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Eosinophilic esophagitis (EE) is an allergic condition characterized by inflammation of the esophagus (the tube that connects the throat with the stomach). People with this disease have a large number of eosinophils, a type of white blood cell, in their esophagus. The majority of individuals with eosinophilic esophagitis have family histories of allergies and symptoms of one or more allergic disorders such as asthma, nasal allergies, atopic dermatitis or food allergy. Diagnosis Other diseases, including acid reflux, can cause eosinophils in the esophagus. Therefore, it is useful to exclude acid reflux as the cause with a trial of acid suppressive medications. Currently, the only way to diagnose eosinophilic esophagitis is with an endoscopy and biopsy of the esophagus. This is typically coordinated between a gastroenterologist and a pathologist. After the diagnosis of eosinophilic esophagitis has been made, an allergist/immunologist, often referred to as an allergist, is the most qualified physician to determine the role of allergies in the condition. An allergist can provide you, your family and your gastroenterologist with a comprehensive evaluation of the allergic components of eosinophilic esophagitis. Eosinophilic Esophagitis and Allergies Allergies are the result of a chain reaction that starts in the immune system. Your immune system controls how your body defends itself. For instance, if you have an allergy to tree nuts, the immune system identifies tree nuts as an invader or allergen. Your immune system overreacts by producing antibodies called Immunoglobulin E (IgE). These antibodies travel to cells that release chemicals, causing an allergic reaction. Food allergy is a major, yet complex, cause of eosinophilic esophagitis in children, and a probable factor in adult eosinophilic esophagitis. Environmental allergies such as dust mites, animals, pollens and molds may also play a role. Testing Allergy skin tests are useful in determining which allergens are triggering your symptoms. With this painless test, a small amount of allergen is put on your skin by making a small scratch or prick on the surface of the skin through a drop of the allergen extract. If a raised bump or small hive develops within 20 minutes, it indicates a possible allergy. If this does not develop, the test is negative. In certain cases, such as severe eczema, an allergy skin test cannot be done and your allergist may recommend a blood test. Another method for testing for food allergies is a challenge. This is done by feeding the food to find if it causes a reaction. Food patch testing is in another type of allergy test that may be used in the evaluation of EE. This test is used to determine whether an individual has delayed reactions to a food. The patch test is done by placing a small amount of fresh food in an aluminum chamber. The food stays in contact with the skin for 48 hours, is removed and the allergist reads the results at 72 hours. Areas of the skin in contact with the food that have become inflamed indicate a delayed reaction to the food. Treatment Elimination Diet Information about specific food allergies obtained from prick, blood and patch testing can be used to determine if specific food groups should be eliminated from your diet. For many people, this is the only treatment that is required to control eosinophilic esophagitis. In some instances, all sources of protein must be removed from the diet. This approach is generally reserved for individuals with multiple food allergies, or who fail to respond to other forms of therapy Medications No medications are currently FDA approved for the treatment of eosinophilic esophagitis. New forms of therapy are under investigation and may provide significant relief in the future. In the meantime, swallowed steroid from an asthma inhaler or nebulizer is being used effectively, under the care of a physician.

A common allergic reaction often affecting the face, elbows and knees is atopic dermatitis, also known as eczema. This red, scaly, itchy rash is usually seen in young infants, but can occur later in life in individuals with personal or family histories of atopy, meaning asthma or allergic rhinitis (“hay fever”). Eczema may at times ooze, or at times may look very dry. A physician will rarely have difficulty diagnosing atopic dermatitis, based on three factors: an 1) itchy, 2) “eczematous” or bubbly rash in an 3) atopic individual. If one of these three features is missing, your physician should consider other causes. Eczema, or atopic dermatitis, is a common allergic reaction often affecting the face, elbows and knees. This red, scaly, itchy rash is usually seen in young infants, but can occur later in life in individuals with personal or family histories of other allergic conditions – such as asthma or hay fever. In infants, eczema usually appears as tiny bumps on the cheeks. Older children and adults often experience rashes on the knees or elbows (often in the folds of the joints), on the backs of hands or on the scalp. Itching is the hallmark symptom and can sometimes be very intense. Eczema can appear very dry, with flaking skin, or can have lesions that ooze – often a sign of a bacterial infection caused by scratching. Identifying the cause of the itch is essential in relieving the dermatitis. Common triggers include allergens, overheating or sweating, emotional stress, eating certain foods and contact with irritants such as wool, pets, soaps or other agents.

Contact Dermatitis refers to a broad range of reactions resulting from the direct contact of an exogenous agent (allergen or irritant) with the surface of the skin. Red, bumpy, scaly, itchy or swollen skin – any of these signs may mean you have a skin allergy. The most common allergic skin conditions are: Eczema Hives and angioedema Allergic contact dermatitis Symptoms of a skin allergy include: A strange rash Red, scaly or itchy skin A swelling of the deeper layers of the skin, such as the eyelids, mouth or genitals Dry, flaking skin Inflamed or blistered skin Skin allergies are painful and unpleasant, but there are things you can do to treat and prevent an allergic skin reaction. Some people are allergic to latex, a substance often found in rubber gloves and balloons. Signs of latex allergy may resemble those of contact dermatitis. But sometimes latex allergy causes a serious reaction called anaphylaxis. This life-threatening condition requires immediate medical treatment. If you think you are having this kind of reaction, call the local Medical Emergency number immediately.

Asthma is the most common serious chronic disease of childhood, affecting nearly 5 million children in the United States. Characterized by coughing, chest tightness, shortness of breath and wheezing, asthma is the cause of almost 3 million physician visits and 200,000 hospitalizations each year. In infants and children, asthma may appear as cough, rapid or noisy breathing in and out, or chest congestion, without the other symptoms seen in adults. Asthma is a chronic disease that affects about 340 million people worldwide. Its primary cause is inflamed airways in the lungs. This inflammation makes the airways smaller, which makes it more difficult for air to move in and out of the lungs. Asthma is the most common serious disease among children. Nine million children in the United States have asthma. Signs that you might have asthma include: Coughing Wheezing Shortness of breath Chest tightness Many people have “allergic asthma,” which means that allergens – like dust mites, mold, animal dander, pollen and cockroaches – make their symptoms worse. Other things that can affect adult asthma include: Pregnancy: Uncontrolled asthma can harm the health of a mother and her baby. Work situations: Fumes, gases or dust that are inhaled at work can trigger asthma. Age: Older people with asthma face unique health challenges. Exercise: Some people may have asthma symptoms when they exercise. Medications: Medications like aspirin and ibuprofen, or beta-blockers (used to treat heart disease, high blood pressure, migraine headaches or glaucoma), may cause an asthma attack in some adults. If you think you have asthma, you should talk to an allergist/immunologist – a doctor with special training to manage allergies and asthma.

Atopy is a term that refers to the genetic tendency to develop the “classical” allergic diseases, namely, allergic rhinitis, asthma and atopic dermatitis. Atopy is typically associated with a genetically determined capacity to mount IgE responses to common allergens, especially inhaled allergens and food allergens

Atopic dermatitis is a chronic or recurrent atopic inflammatory skin disease that usually begins in the first few years of life. It is often the initial clinical manifestation of an atopic predisposition, with many children later developing asthma and/or allergic rhinitis (hay fever). Red, bumpy, scaly, itchy or swollen skin – any of these signs may mean you have a skin allergy. The most common allergic skin conditions are: Eczema Hives and angioedema Allergic contact dermatitis Symptoms of a skin allergy include: A strange rash Red, scaly or itchy skin A swelling of the deeper layers of the skin, such as the eyelids, mouth or genitals Dry, flaking skin Inflamed or blistered skin Skin allergies are painful and unpleasant, but there are things you can do to treat and prevent an allergic skin reaction. Some people are allergic to latex, a substance often found in rubber gloves and balloons. Signs of latex allergy may resemble those of contact dermatitis. But sometimes latex allergy causes a serious reaction called anaphylaxis. This life-threatening condition requires immediate medical treatment. If you think you are having this kind of reaction, call your local medical emergency number immediately.

Asthma is a chronic disease that affects about 340 million people all over the world. Its primary cause is inflamed airways in the lungs. This inflammation makes the airways smaller, which makes it more difficult for air to move in and out of the lungs. Asthma is the most common serious disease among children. Nine million children in the United States have asthma. Signs that you might have asthma include:   Coughing   Wheezing   Shortness of breath   Chest tightness Many people have “allergic asthma,” which means that allergens – like dust mites, mold, animal dander, pollen and cockroaches – make their symptoms worse. Other things that can affect adult asthma include:   Pregnancy: Uncontrolled asthma can harm the health of a mother and her baby.   Work situations: Fumes, gases or dust that are inhaled at work can trigger asthma.   Age: Older people with asthma face unique health challenges.   Exercise: Some people may have asthma symptoms when they exercise.   Medications: Medications like aspirin and ibuprofen, or beta-blockers (used to treat heart disease, high blood pressure, migraine headaches or glaucoma), may cause an asthma attack in some adults. Childhood Asthma Children with recurrent cough, wheezing, chest tightness or shortness of breath may have one or more forms of asthma. Left untreated, asthmatic children often have less stamina than other children, or avoid physical activities to prevent coughing or wheezing. Sometimes they will complain that their “chest hurts” or that they can not “catch their breath.” Colds may “go straight to their chest.” They may cough when sick, particularly at night. Asthma has multiple causes, and it is not uncommon for two or more different causes to be present in one child. Asthma is not just “wheezing.” Coughing, recurrent bronchitis and shortness of breath, especially when exercising, are also ways that asthma appears. Diagnosis Diagnosing the precise cause of asthma is sometimes difficult because two or more causes may be present in one child. Unfortunately, there is not a single test that provides all the answers. An allergist/immunologist, often referred to as an allergist, has specialized training and experience to determine if your child has asthma, what is causing it and develop a treatment plan. Your child’s allergist will want to learn how often episodes of wheezing/coughing/other symptoms occur, and how bad they are. It is important to understand what triggers your child’s symptoms, and what (including medications) makes them go away. An understanding of your family history and environment (smoking, pets, etc) is useful, so your physician may ask. Infants may need extra attention during the diagnostic process because asthma symptoms can be caused by many things in this age group, some of which need very different therapies. When an infant has asthma symptoms, it is sometimes called “reactive airway disease.” The two most common triggers of asthma in children are colds and allergens. After infancy, allergies become particularly important, and therefore asthmatic children should have an allergy evaluation to help diagnose and manage their asthma. Avoiding the allergens to which your child is allergic may help improve his or her asthma. If your child is older than 5 years, he or she may be asked to perform pulmonary function testing to learn how air flows in his or her lungs. Other tests that your physician may discuss with you include measures of inflammation, a chest x-ray and tests for some of the less common causes of asthma-like symptoms. Management The most important part of managing asthma is for you and your child to be very knowledgeable about how and when asthma causes problems, how some of the triggers can be avoided and how to use medications. The causes of asthma and best treatment for it in your child may be quite different than for another child. Your allergist will help you develop an asthma management plan, and it is wise to share it with other caregivers. This plan outlines what medications to take, and when and how to increase the doses or add more medication if needed. It also includes advice about when to call your physician. An asthma management plan puts you in control for detection and early treatment of symptoms. Inhaled medications come as metered dose inhalers (sometimes called pumps), nebulizer solutions (delivered as a mist by a machine) and dry powder inhalers. It is important to learn how to use the type of medications prescribed for your child, or they might not work well. Another brochure in this series, Inhaled Asthma Medications, offers helpful information. Asthma medications include inhaled rescue medications (quick relievers) to treat symptoms and long-term controller medicines (inhaled as well as oral) to control inflammation that commonly causes the asthma. If your child’s asthma is more than a rare minor problem, a controller medication will probably be prescribed. Our knowledge about asthma and its therapy is constantly changing. An ongoing relationship with your child’s physician is key to determining what will work best for your child, now and throughout childhood. Answers to Commonly Asked Questions   Will my child outgrow his/her asthma? Many babies who wheeze with viral respiratory illnesses will stop wheezing as they grow older. If your child has atopic dermatitis (eczema), allergies or if there is smoking in the home or a strong family history of allergies or asthma, there is a greater chance that asthma symptoms will persist. Can asthma be cured? Not yet. However, for most children and adults, asthma can be controlled throughout life with appropriate diagnosis, education and treatment. Should my child exercise? Once a child’s asthma is controlled, (usually with the help of proper medications) exercise should become part of his or her daily activities. Children with asthma certainly can and do excel in athletics. Many Olympic athletes have asthma. How can symptoms be controlled at school? You, your family, physician and school personnel can work together to prevent and/or control asthma. Share your child’s asthma management plan with the school nurse and any coaches who oversee your child. With

Angioedema is a swelling of the deeper layers of the skin and often occurs with hives. Angioedema itself is not red or itchy and most often occurs in the body’s soft tissue, such as the eyelids, mouth or genitals. Angioedema is called “acute” if the condition lasts only a short time (minutes to days) and does not recur. This is commonly caused by an allergic reaction to medications or foods. Chronic recurrent angioedema occurs when the condition returns over a long period of time. Chronic recurrent angioedema most often does not have an identifiable cause.

Anaphylaxis (an-a-fi-LAK-sis) is a serious allergic reaction that happens to some people who have allergies to food, insect stings, drugs or latex. Anaphylaxis happens very quickly and affects your entire body. Signs usually start within 5 to 30 minutes of coming into contact with the thing to which you are allergic. But it may take more than an hour for you to notice anaphylactic symptoms. Warning signs may include:   A red rash, with welts, that is usually itchy   Swollen throat or swollen areas of the body   Wheezing   Passing out   Chest tightness   Trouble breathing   A hoarse voice   Trouble swallowing   Vomiting   Diarrhea   Stomach cramping   A pale or red color to the face and body Anaphylaxis requires immediate medical treatment. Who is at risk? Anyone, especially those allergic to foods such as peanut, tree nut, seafood, fin fish, milk, or egg, or to insect stings or bites, natural rubber latex, or medications. When can it happen? Within minutes, anytime the allergic person comes in contact with his or her trigger. How do we know? Several symptoms occur at the same time, such as: itching, hives, flushing, difficulty breathing, vomiting, diarrhea, dizziness, confusion, or shock. Where can it happen? Anywhere; for example, home, restaurant, school, child care or sports facility, summer camp, car, bus, airplane. What should we do? Self-inject epinephrine (Adrenaclick, EpiPen or Twinject), call 911 or your local emergency medical services number, and notify the individual’s family (in that order)! Act quickly. Anaphylaxis can be mild, or it can be fatal. Why is follow-up needed? Anaphylaxis can occur repeatedly. The trigger needs to be confirmed, and long-term preventive strategies need to be implemented.

Allergic conjunctivitis is the most common allergy affecting the eyes. The conjunctivae—the thin membranes covering the eyelids and the exposed surface of the eyes—is an active tissue of the immune system that responds to allergies caused by airborne particles, or allergens. Allergic conjunctivitis can appear in two forms: seasonal and perennial. The seasonal version is much more common, and is related to exposure to specific airborne allergens, such as grass, tree and weed pollens and molds. The perennial form persists throughout the year and is usually triggered by dust mites, animal dander and feathers. EYE ALLERGY: CAUSES AND TREATMENT Conjunctivitis is an inflammation of the conjunctiva. This is the mucous membrane covering the white of the eyes and the inner side of the eyelids. If something irritates this clear membrane, your eyes may water, itch, hurt, or become red or swollen. In some people, conjunctivitis is due to an allergy. In these instances, the condition is called either allergic conjunctivitis or ocular allergy. It can occur alone, or it may be associated with nasal allergy symptoms. Unlike conditions such as pink eye, allergic conjunctivitis is not contagious. A recent study reported by Leonard Bielory, MD, FAAAAI, states that ocular allergies may be more common than nasal allergies in some areas, especially in the southern United States. And, while most people treat nasal allergy symptoms, they often ignore their itchy, red, watery eyes. CAUSES AND TRIGGERS If you have an allergy, your immune system identifies something as an invader or allergen. Your immune system overreacts by producing antibodies called Immunoglobulin E (IgE). These antibodies travel to cells that release chemicals, causing an allergic reaction. This reaction usually causes symptoms in the nose, lungs, throat, sinuses, intestinal tract or the eyes. The most common allergen is pollen, which is seasonal. People with seasonal allergic conjunctivitis, or rhinoconjuntivitis will experience symptoms at certain times during the year – usually from early spring, into summer, and even into autumn (fall). Those with perennial allergic conjunctivitis are susceptible at any time of year. These irritations may be triggered by perfumes, cosmetics, skin medicines, or environmental allergens such as air pollution or second-hand smoke. SYMPTOMS Most people suffering from allergic conjunctivitis have problems in both eyes. Symptoms may appear quickly, soon after the eyes have come into contact with the allergen. The most common symptom occurs when the eyes become irritated, the capillaries (small blood vessels) widen and the eyes become pink or red. Some people experience pain in one or both eyes. Other symptoms include swollen eyelids, a burning sensation, sore or tender eyes. TREATMENT According to Dr. Bielory, about 50% of conjunctivitis cases seen by primary care physicians are actually allergic in nature. There are many different treatment options, depending upon the severity of the symptoms. As with any allergy, the first approach for successful management of seasonal or perennial forms of eye allergy should be prevention or avoidance of the allergens that trigger your symptoms. The AAAAI Outdoor Allergens brochure offers tips on avoiding triggers. However, avoidance of airborne allergens isn’t always possible. That is when medications may be helpful. Over-the-counter (OTC) eye drops and oral medications are commonly used for short-term relief of some eye allergy symptoms. However, they may not relieve all symptoms, and prolonged use of some OTC eye drops may actually make your symptoms worse. Prescription eye drops and oral medications can also treat eye allergies. Prescription eye drops provide both short- and long-term targeted relief of eye allergy symptoms, and they can be used to manage eye allergy symptoms in conjunction with an oral antihistamine that might be taken to manage nasal allergy symptoms. Any medication placed in the eye should be kept in the refrigerator.