Practical Allergy and Immunology for the Busy Pediatrician by qga16183

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									Cecilia Mikita, MD, MPH
 FAAAAI, FACAAI, FAAP

 CAP Conference 2009
•I have no relevant financial relationships with
 the manufacturers of any commercial
 products and/or provider of commercial
 services discussed in this CME activity

•I do intend to discuss an
 unapproved/investigative use of a
 commercial product/device in our
 presentation
   Discuss management plan for atopic
    dermatitis
   Introduce recent advances in food allergy
   Identify treatment options for allergic
    rhinitis
   Describe clinical presentation of
    eosinophilic esophagitits
Atopic Dermatitis

 ↑ incidence in industrialized nations
  15-20% of school-aged children affected
  1-3% of adults affected

 Majority develop disease before 5 yo
  45% pts develop sx in first 6 months of life
  60% pts develop sx in first year of life
  85% pts develop sx by 5 years of age



           Leung D. Ann Allergy, Asthma, Immunol 2004;93:S1-21.
           Akdis C., et al. J Allergy Clin Immunol 2006;118:152-69.
Triggers
 Allergens
  Environmental, foods, personal care products,
   meds
 Chemical irritants
  Acids, alkali, solvents, plastic, smoke
 Physical irritants
  Scratchy or occlusive clothing
  Scratching or vigorous scrubbing
  Extremes of environmental temp or humidity
  Hot water
 Internal changes
  Infection, stress, hormonal changes
   History and physical exam
    ◦ Dry, pale, pasty skin
    ◦ Distribution of lesions
   Labs
    ◦   Serum IgE level
    ◦   ImmunoCAP RAST specific IgE
    ◦   Skin biopsy
    ◦   Skin culture
   Skin tests
    ◦ Prick skin tests aeroallergens
    ◦ Atopy patch test – foods, dust mite
   Treat skin barrier
   Treat inflammation
   Avoid triggers
   Education
   At least one bath or shower per day
   Warm water, 10-20 min
   Avoid scrubbing skin
   Pat away excess water
   Immediately apply topical medications and
    emollients (< 3 min)
   Addition of oatmeal or baking soda to bath
    ◦ Soothing anti-pruritic effect
    ◦ No increase in water absorption

                        www.nationaljewish.org
   Minimal defatting activity
   Neutral pH
   Avoid products with perfumes and dyes

   Cetaphil skin cleanser
   Soap bars - Dove, Oil of Olay, Eucerin, Basis,
    Oilatum, Cetaphil, Neutrogena, or Aveeno
   Creams and ointments best, no lotions
   Apply continuously, even when no lesions
   Most are available on core formulary
   Patient/family preference
   Cetaphil, Vanicream, Aquaphor, Eucerin,
    Moisturel
   Vaseline, Crisco, Baby oil
   Good occlusives to seal in water
   Do not contain water, do not moisturize skin
   Only good after soaking bath
   Helps recover epidermal barrier function
   Face and/or body
   Bottom layer wet, upper layer dry
    ◦   Gauze for extremities
    ◦   Washcloths for face
    ◦   Socks and gloves
    ◦   One piece pajamas for full body
   Apply after “Soak and Seal”
   Re-wet or remove when wraps dry out
   Topical corticosteroids
    ◦ Low potency to face
      Hydrocortisone 1% or Desonide 0.05%
    ◦ Mid to high potency to body
    ◦ Twice daily x 7 days, daily x 7 days to QOD
    ◦ Aim for “rare flares”
   NO systemic steroids
   Topical calcineurin inhibitors
    ◦ >2 years old
    ◦ Not for acute flares
   Ex: 70 kg adult

   Whole body application QD = 30g (1 oz)
    ◦ Cetaphil cream 16 oz = 453g
      One tub will last approx 2 weeks


   Face only BID = 4g
    ◦ Desonide 0.05% cream = 60g
      Large tube will last approx 2 weeks



                Lynfield YL, Schechter S. J Am Acad Dermatol. 1984;10:56-9.
Emollients        Barrier Creams        Topical           Topical
                                        Corticosteroids   Calcineurin
                                                          Inhibitors
Vaseline $0.38    CeraVe cream $0.96    TAC 0.1% $3.60    Pimecrolimus
($0.18)                                 ($2.00)           1% $82.00
                                                          ($41.26)
Cetaphil $0.83    TriCeram $8.80        Desonide 0.05%    Tacrolimus
($0.66)                                 ($1.31)           0.03% $102.00
                                                          ($44.95)
Vanicream $0.84   Mimyx $31.00          HC 2.5% $9.99
($0.36)                                 ($1.25)

Aquaphor $1.06    Atopiclair $32
($0.31)           ($28.88)



                                   Adapted from Schneider L. AAAAI 2009.
   Avoid common irritants
    ◦   Products with fragrance or dyes
    ◦   Some soaps, toiletries, detergents, chemicals
    ◦   Abrasive or heavy clothing (eg. wool)
    ◦   Occlusive, tight fitting clothing
   Laundry
    ◦   Launder new clothing before use
    ◦   Liquid, fragrance and dye-free laundry detergent
    ◦   Second rinse cycle
    ◦   Avoid fabric softeners
   Open weave, loss-fitting, cotton-blend fabrics
   Control extremes of temp and humidity
   Minimize aeroallergen exposure
   Keep fingernails trimmed short to minimize
    skin trauma from scratching
   Cover hands when sleeping
   Control emotional stress
   Food sensitive pts – eliminate food
   > 95% have colonization (5-30% nonatopic)
    ◦ S. aureus or S. pneumoniae
    ◦ 50-60% produce toxins with superantigenic
      properties

   Decrease S. aureus colonization
    ◦ Antibacterial cleansers
         Lever 2000
         Chlorhexidine, antiseptics
    ◦   Bleach baths – ½ cup bleach in full tub
    ◦   Short course oral antibiotics
    ◦   Topical antibiotics for mild lesions
    ◦   Intranasal mupirocin BID x 5-7 days
   Seborrheic areas of skin and scalp
    ◦ Trichophyton rubra
    ◦ Malassezia species (30-68%)
    ◦ Candida albicans
   Anti-fungal therapy
    ◦ Itraconazole 100 mg daily x 7 week then 200 mg
      daily weekly
    ◦ Effective in subgroup of pts
   Moderate-severe atopic dermatitis
    ◦ Up to 1/3 have food allergy
    severity of AD,  risk of food allergy
    Allergic and non-allergic mechanisms
    Responsible foods
    ◦ Eggs, milk, peanut, soy, wheat
   <2% adults have food allergy triggers


            Sicherer S, Sampson H. J Allergy Clin Immunol. 1999;104:S114-22.
            Disease management of atopic dermatitis; an updated practice
            parameter. Ann Allergy, Asthma, Immunol. 2004;93:S1-23.
   Increasing prevalence
    ◦ 6-8% children
    ◦ 1-2% adults
   National Electronic Injury Surveillance System
    ◦   Two month period (Aug-Sept 2003)
    ◦   20,000+ ER visits for food-related adverse events
    ◦   2,300+ episodes of anaphylaxis
    ◦   520 hospitalizations for food allergic reactions
   Fatalities: 150-200 deaths/year



                     Ross, et al. J Allergy Clin Immunol 2008:121:166-171.
Most Common Food Allergens
   Children               Adolescents
    ◦ Milk                  ◦ Peanuts
    ◦ Egg                   ◦ Tree nuts
    ◦ Peanuts               ◦ Fish
    ◦ Tree nuts             ◦ Shellfish
    ◦ Soy                   ◦ Fruits and
    ◦ Wheat
                              vegetables

    ◦ Increased incidence in peanut,
      sesame, and kiwi allergy
Oral Allergy Syndrome
(Pollen-Food Allergy Syndrome)
   Assoc with seasonal allergic rhinitis
   Oropharyngeal itching, occas angioedema
   Associated with ingestion of fresh fruits,
    vegetables, or nuts
    ◦ Birch - apples, celery, cherry, pear, hazelnut,
      carrot, potato, kiwi
    ◦ Ragweed – melons, banana
    ◦ Grass – melon, tomato, orange
    ◦ Mugwort – melon, apple, peach, cherry

   Tolerate cooked or processed fruits,
    vegetables
Food Allergy Evaluation

   History and physical exam
   Skin tests
    – Prick skin tests
   Labs
    – Serum IgE level
    – ImmunoCAP RAST specific IgE
Testing for Specific IgE
– Prick Skin tests
   – High sensitivity (>90%)
   – Modest specificity (50%)
   – 50% PPV
   – 95% NPV
– Serum ImmunoCAP RAST tests
   – Certain foods with good PPV and NPV


                     Food Allergy: A Practice Parameter.
                     Ann Allergy Asthma Immunol. 2006;96:S1-68.
ImmunoCAP Levels
Correlating With Clinical Reactivity
 Food       95% positive                95% negative
           predictive value            predictive value
               (KU/L)                       (KU/L)
  Egg              6                      0.6 (90%)
  Milk           32                          0.8
 Peanut          15                      <0.35 (85%)
Cod Fish         20                          0.9
  Soy         65 (50%)                        2
 Wheat       >100 (75%)                       5
           Sampson H, Ho D. J Allergy Clin Immunol. 1997;100:444-51.
   Trial elimination diet
   Graded oral food challenge
   Epinephrine auto-injectors
   Food allergy action plan
   Nutrition consult
   Education
   Yearly allergist follow-up
   108 egg-allergic children
   Challenged to raw and heated egg products
   Tolerate moderate doses of egg in
    extensively heated foods (eg. baked goods)
    ◦ Egg white ImmunoCAP useful for predicting
      reaction to raw egg
    ◦ Ovomucoid ImmunoCAP useful for predicting
      reaction to heated egg
   More data needed to evaluate whether eating
    baked eggs promotes tolerance
   Peanuts
    ◦ 20% will outgrow
    ◦ 8% incidence of recurrence of allergy
   Tree nuts
    ◦ 9% will outgrow
   Milk and eggs
    ◦ 80-85% will outgrow
   Seafood
    ◦ 15-20% will outgrow

                        Fleischer et al. JACI 2004;114:1195-201.
   Consultation with allergist
    ◦ Repeat specific ImmunoCAP and/or skin testing
    ◦ History of accidental ingestions and reactions
   Peanut food challenge
    ◦ ≥ 4 years old, no recent reactions
      ImmunoCAP < 0.35 KU/L, 76% successful
      ImmunoCAP < 2 KU/L, 50% successful
   Milk and egg food challenge
    ◦ Any age, no recent reactions
    ◦ ImmunoCAP < 0.35 KU/L, 68% successful
   Conducted in setting equipped to handle
    acute anaphylaxis
   Several small trials underway
   Milk, peanuts, tree nuts
   Most with reactions during therapy
    ◦ Usually mild, several requiring epinephrine
   Increase in amount of food tolerated
   Transient effects or tolerance?
   Pregnancy
    ◦ Maternal dietary restrictions during pregnancy does
      not play a significant role in the prevention of
      atopic disease in infants


   Lactation
    ◦ Antigen avoidance during lactation does not
      prevent atopic disease, with the possible exception
      of atopic dermatitis




                   Greer, et al. Pediatrics. 2008;121:183-191.
   High risk infants
    ◦ Exclusive breastfeeding for 4 months decreases
      incidence of atopic dermatitis and milk allergy in
      first 2 years of life
    ◦ Exclusive breastfeeding for at least 3 months
      protects against wheezing in early life
      Does not protect against allergic asthma beyond 6 yo
    ◦ Formula fed infants fed extensively or partially
      hydrolyzed formula may delay or prevent atopic
      dermatitis
    ◦ No convincing evidence for the use of soy based
      formula for allergy prevention


                   Greer, et al. Pediatrics. 2008;121:183-191.
   No current convincing evidence that delaying
    solid food introduction beyond 4-6 months
    has a significant protective effect on the
    development of atopic disease




                Greer, et al. Pediatrics. 2008;121:183-191.
   Intranasal corticosteroids
    ◦ Nasal congestion
   Second-generation antihistamines
    ◦ Allegra is the only NON-sedating antihistamine
   Ocular meds
    ◦ Patanol – antihistamine + mast cell stabilizer
   Leukotriene antagonists
    ◦ Safe, effective
   Nasal saline lavage
    ◦ AHLTA order – “Sinus” – NeilMed sinus rinse
   Aeroallergen immunotherapy - “allergy shots”
   On the horizon…

   Shows promise as a safe, effective alternative
    to “allergy shots”
   Better for individuals with limited sensitivities
   Not currently FDA-approved
   Not currently available in local MTFs
   EPR-3 guidelines
   Consider aeroallergen immunotherapy in pts
    with allergic triggers
   Difficult to manage pts
    ◦ DDx includes vocal cord dysfunction,
      gastroesophageal reflux, chronic sinusitis
   Omalizumab (Xolair) limited role for specific
    patients
   Isolated, severe eosinophilic infiltration of
    esophagus

   Signs and Symptoms
    ◦   Failure to thrive
    ◦   Feeding aversion/intolerance
    ◦   Vomiting/regurgitation
    ◦   Epigastric or chest pain
    ◦   Dysphagia
    ◦   Food impaction/foreign body impaction
   ≥15 eos/hpf in 1 or more biopsy specimens
   Lack of responsiveness to high dose proton
    pump inhibitor (up to 2mg/kg/day) x 8
    weeks OR
   Normal pH monitoring of distal esophagus




                   Furuta G, et al. Gastroenterology. 2007;133:1342-63.
   CBC with diff
  ◦ 20-60% pts have peripheral eosinophilia
 IgE increased in 20-60% pts
   High dose PPI
   Allergy evaluation
    ◦ Food prick skin tests, and/or RAST
    ◦ Food atopy patch tests
   GI consult
    ◦ pH monitoring
    ◦ Endoscopy
   Corticosteroids
    ◦ Swallowed
    ◦ Systemic
                              Furuta G, et al. Gastroenterology. 2007;133:1342-63.
                      Spergel J., et al. J Allergy Clin Immunol. 2002;109:363-368.
                  Spergel J., et al. Ann Allergy Asthma Immunol. 2005;95:336-343.
   Food Allergy and Anaphylaxis Network
    www.foodallergy.org
   American Academy of Allergy, Asthma, and
    Immunology
    www.aaaai.org
   Asthma and Allergy Foundation of America
    www.aafa.org
   National Institute of Allergy and Infectious
    Diseases
    www.niaid.nih.gov
   Cecilia Mikita, MD, MPH
cecilia.mikita@us.army.mil
            202-782-8498

								
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