Tuesday, January 11, 2011

A close-up look at immunotherapy

January's issue of the Journal of Allergy and Clinical Immunology is dedicated to immunotherapy. To be honest, the first time I heard of immunotherapy, I thought it was a quack treatment (it didn't help that what I'd heard of was sublingual immunotherapy, and the point of the author was that because the FDA hadn't yet approved it in the US, it must be too effective). But the more I learn about it the more I find that it is a long-established therapy with proven results. You should read the issue's editorial, which summarizes immunotherapy over the past 100 years.

What did I learn from this issue? (Not: what is news to everyone; what was news to me.) First, it seems that immunotherapy is largely directed at allergic rhinitis, or hay fever, caused by grass pollen; that, in the US, the standard method is repeated injections over a long period, from four months to three years; that sublingual immunotherapy is widely practiced in Europe, and appears safe and effective; and that trials of therapies for other allergens such as cat dander and dust mite droppings are being conducted and show promise.

For now let's leave aside the issue that doctors don't seem to be prescribing immunotherapy for eczema patients. Say it were available. What then?

The problem for me is that I don't know for sure what allergens cause my eczema. I know that my skin prick test, 10 years ago, showed that I reacted to a bunch of things including cat (at least, one cat allergen), egg white, and rye grass. But does that guarantee that, say, rye grass pollen is a major factor in my eczema during the period that rye grass pollen is in the air? Everything I've read regarding food allergies says that skin prick tests are not diagnostic, and that the gold standard is to lay off the offending food and see if the problem goes away. There's no good way to try an avoidance diet with pollen or dust mites.

An aside: the reaction I get in the spring and summer, which I attribute to pollen, is quite different from the eczema I experience on my hands, arms, scalp, etc. In the summer, on both east and west coasts, I get red, inflamed skin on my face in a butterfly pattern. It's distinctive, and out there in the open for everyone to see. I saw the same pattern once on someone else's face.

One thing I am sure of: Claritin and Allegra, the over-the-counter antihistamines marketed for hay fever, do absolutely nothing for me.

Would I undergo injection immunotherapy, a long, arduous, and (in the US) expensive procedure, in the hope that 1) the thing I'm getting injected with is a major contributor to my eczema and 2) the therapy works for me? No, I wouldn't. And I do suspect that at least one form of pollen gives me trouble.

But I would take a course of immunotherapy tablets orally (or sublingually). That would not seem like a waste of time, nor would it be hard to get a kid to take them. One good thing is that grass pollens are, apparently, "cross-reactive," which I read as meaning their allergens are similar enough that if you induce tolerance to one, you induce tolerance to the rest of them. So you don't have to take more than one type of allergen as immunotherapy.

Reading the editorial, I did learn that grass pollen tablets are not effective if you take them as only one component of a mix of allergens in immunotherapy. Here's another difference between the US and Europe: in the US, a multiallergen mix is a common approach, while in Europe, immunotherapy for a single allergen at a time is the norm. (Any experts or Europeans are free to correct me on this.) So, it does appear that the US is lagging Europe in easy, effective immunotherapy.

When will we see immunotherapy applied to eczema? Is there anywhere in the world where it already is?

8 comments:

  1. Thank you for this post, I get so frustrated with my seven year old's scratching- especially when the eczema seems to be retreating. But to hear from an adult how uncontrollable the urge to scratch is-- well, it's enlightening. Do you have any suggestions for how to help a child not scratch??

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  2. No sure answer to this! The itch urge is so powerful it's hard to break. I'd suggest applying a cold pack (frozen peas OK), and then once the itch has temporarily subsided, trying to get your kid involved in a relaxing, repetitive activity that requires concentration--such as practicing a musical instrument, or playing a card game, or the kiddie equivalent of tai chi or yoga. Maybe art, like painting or drawing. Something with which it's nearly impossible to become frustrated. Good luck.

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  3. I have had atopic dermatitis/eczema since I was born, but it was dormant from middle school to high school. I got it back at 17 and over the course of 3 years, my allergies were out of control. I grew up with cats, dogs, rabbits, and every other pet under the sun. I had an allergy test at 20, which noted I was highly allergic to cats, several trees and pollens in the area, and dust mites. Since then, I have been out of my parent's house, however, I have also developed an allergy to dogs.

    I have noticed I have not had typical symptoms of seasonal allergies, but my eczema is currently terrible, going on a few weeks now. These flare ups come out of nowhere.

    I have accepted my life with eczema. However, it still sucks to be 26 and have red welts all over my visible skin.

    Is it worth to try allergy shots?

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  4. Florida Girl, another thought-- video games!

    ...if you're OK with it, I bet playing something like Tetris (I'm dating myself) that is a bit addictive and requires a lot of concentration would distract your kid from scratching.

    Chelsea--it's a hard call because there is no guarantee immunotherapy would work. I'd say get the allergy test again, and ask the allergist for a professional opinion whether your eczema is related to allergies. If everything makes sense and there seems to be a major contributor that you cannot avoid, like grass pollen, AND you are the type of person (such as myself) who can actually commit to a long disciplined course of injections, then I would do it.

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  5. Thanks for that-- we have a "fiddle toy" he holds at school so his hands are busy.

    Just read your new post and I have a few things to say about that-- so I will... over there.

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  6. Dear Spanish Key,

    Thanks for this article, I live in Hong Kong which is a nightmare for Eczema sufferers: Hot humid weather 10 months per year, high air pollution levels, and lots of agriculture creating allergens in the air.

    I want to respond to Chelsea as I wish for her to know that she's not alone.

    I have a lot of little tricks that I use to keep the flare ups down.

    My girlfriend made a lavender and tea tree alcoholic spray for me that keeps the irritation down when things get itchy. I also put watered down vicks vaporub in a small spray bottle with me when I go out. These both are good short term solutions to soothing my skin when things get really itchy.

    One major step I took was getting a gym membership at the club next to my work. I don't work out that much, but it is a great place for me to pop in and take a nice cold shower should my eczema get bothersome during my mon-fri 9 to 5.

    Overall, I think it's the scratching and irritation that causes the most trouble (another reason to keep a nail clipper and file at work and on my bedside table); I don't have any miracle cures, but I hope these little tricks I have will help you out.

    Also, I use an emoliant shower gel. That really helps keep my skin nice and moist/oily to avoid further flare ups.

    Hope this helps; you're not alone, Chelsea!

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  7. I was reviewing data on immunotherapy and eczema for my daughter and stumbled on this blog. It is not that purpose of your article but as a MD I would be very concerned with what you describe as a butterfly shaped rash on your face during summer. This is VERY concerning for Lupus. I suggest you see your primary care physician and bring a picture or describe this rash so he/she can get the appropriate blood tests to rule out Lupus as a cause of your summer rash.

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  8. Thanks, Dr. Spears.

    I will bring that up with my GP the next time I see him.

    I had a look at the Lupus Foundation of America website and considered the classic symptoms of lupus. I don't have any of them apart from seasonal patches on my face. (And I'm outside year-round in California.) I see now that I originally wrote "butterfly pattern" but really they're just two separate patches on my upper cheeks with no connection over the nose. I looked at the Google Images for lupus (and boy, do I wish I hadn't) and what I occasionally experience doesn't match up.

    However, you're the first to bring up the topic. I appreciate your advice and will get it checked out.

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