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Healio
Issue: March 2011
March 01, 2011
6 min read
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Avoiding allergy-related illness during spring break travel takes preparation

Patients without allergy histories also benefit from physicians’ proactive counsel.

Issue: March 2011
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Spring break travel for patients with established allergies — and even those without — can be safer and more enjoyable if they are prepared for common allergy-related contingencies.

“Certain destinations are potentially more likely to create problems with allergies than others,” Matthew Greenhawt, MD, assistant professor, University of Michigan Medical School, Health Systems Division of Allergy and Clinical Immunology, told Infectious Diseases in Children.

Food allergies

There are 1,443 to 1,503 anaphylactic deaths in the United States each year, according to a report published in a 2007 issue of Clinical Pediatric Emergency Medicine. Of the anaphylaxis-related ED visits reported annually, 35% are food-related, according to a 2009 study in the Journal of Travel Medicine. However, researchers of a 2010 study in the Journal of Allergy and Clinical Immunology concluded that number may be underestimated.

“The number of US emergency department visits for food-related acute allergic reactions may be significantly higher than estimated in previous reports,” the investigators wrote.

One-third of children with atopic dermatitis also have a food allergy, according to research presented at the recent American Academy of Dermatology 69th Annual Meeting in New Orleans.

“Food allergy is more likely to be a factor in children with moderate to severe atopic dermatitis,” Greenhawt said.

Allergic reactions from cashews and from the skins of mangoes are common in patients with histories of poison ivy, oak and sumac dermatitis because of the antigen urushiol, according to findings published in a 2010 issue of the Journal of Travel Medicine. Photodermatitis (when not caused by a reaction to an ingredient in sunscreen) can occur with sunlight exposure after contact with limes, lemons, celery or parsley, according to a report published in a 2007 issue of Clinical Pediatric Emergency Medicine.

“This tends to be more from contact with the skins and shells of these foods, not the actual eating of them, which means it’s the preparation of the food that’s the issue,” said Andy Nish, MD, of the Allergy and Asthma Care Center in Gainesville, Ga.

“It’s difficult to anticipate when someone will develop a food allergy, or react to a food. But if you know your patients already have a food allergy, before they leave on their trip, remind them to always have their self-injectable epinephrine when they travel,” Greenhawt said. “It also might not be a bad idea to recommend that your patients look up the location of the hospital emergency department nearest to where they will be staying, just in case.”

Referencing a study published in a 2010 issue of Pediatrics, which concluded that children at risk for food-related anaphylaxis should keep two doses of self-injectable epinephrine within reach at all times, Greenhawt said, “It’s never a bad idea to prescribe ‘twin-packs’ of an auto-injector to patients at risk for anaphylaxis.”

Insect bites

Insect bites and stings account for up to 15% of all annual ED visits in the United States, according to a study in the Journal of Travel Medicine. US poison control centers reported more than 75,000 insect bite poisonings in 2005 from bees, wasps, yellow jackets, fire ants, ticks, scorpions and spiders — all found in warmer climes where patients may spend their spring breaks.

“Most patients are not allergic to insect stings, but there can be considerable swelling and pain from a bite or sting that doesn’t result in an allergic reaction. These are generally localized reactions that require low-scale treatment. Benadryl (diphenhydramine, McNeil Consumer) is usually a good choice for itching and swelling,” Greenhawt said.

Up to 60% of patients with histories of severe systemic reactions to insect stings are likely to have an anaphylactic reaction if stung again, researchers wrote in a 2005 issue of the Journal of Allergy and Clinical Immunology.

“Localized reactions to insect stings are generally viewed as good predictors that patients are not likely to have a future severe systemic reaction,” Greenhawt said. “But if a patient has a known history of severe reaction to an insect bite or sting, and they end up being evaluated in an ED, then remind them to make their history known. Medical alert jewelry can help facilitate prompt identification of such relevant medical information.” Patients should seek emergency treatment if they experience difficulty breathing or swallowing, and if the pain is disproportionate and sustained.

Anticipating allergens

If traveling patients have dust mite allergies that are mitigated at home by using hypo-allergenic bed linens, Nish said they should pack their pillow cases to use while away.

“The best way to address allergies is to avoid them, but sometimes you can’t do that, so coping strategies can help,” he said. Greenhawt added that patients should also, “consider pre-treating themselves with an antihistamine such as cetirizine (Zyrtec, McNeil Consumer), loratadine (Claritin, Schering-Plough) or Benadryl and having albuterol available if pet dander is a known asthma trigger.”

If a patient with pet dander allergies will be visiting a household with a cat or dog, usually just moving the pet out of the house when the patient arrives is not enough because dander can remain for months, Nish said.

“It might be reasonable for the host to consider having a room available to the patient where the pet isn’t allowed to enter. In some cases, it might be worth recommending that patients bring a HEPA filter with them, or asking the host to provide one, as they tend to be cumbersome,” he said.

More than 70% of people with asthma also have allergies, and 10 million Americans suffer specifically from allergic asthma, according to the American Academy of Allergy Asthma & Immunology (AAAAI). In a correlative study between pediatric asthma exacerbations and the weather, researchers wrote in a 2009 issue of the Annals of Allergy, Asthma & Immunology that fluctuations in humidity and temperature increased the number of children presenting to EDs with exacerbated asthmatic symptoms.

If patients are traveling to locations where the weather is warmer and tree pollen season is already under way, Nish said he prescribes seasonal allergy medications prophylactically.

“Let’s say a patient lives in Maine but is traveling to Georgia, where tree pollen season has already started. While there is some benefit to taking their allergy medications, such as nasal steroids, as needed, they can be more effective if patients start taking them a few weeks earlier than they normally might, since they can take a while to kick in. It’s better to take them regularly, and on a daily basis,” Nish said.

Over-the-counter allergy relief

For patients who do not typically take prescription allergy medications but who experience allergic reactions while on vacation, Greenhawt said, “There are a number of over-the-counter options that once were prescription-only. The range of options is generally good, since the efficacies are already proven.”

“Loratadine is a good non-sedating antihistamine. Cetirizine is also a good antihistamine,” said Nish. Because they can cause drowsiness in some patients, Nish recommended patients take these medications at bed time.

For acute symptoms, Nish said he recommends the nasal antihistamines olopatadine (Patanase, Alcon) and azelastine (Astepro, Meda Pharmaceuticals). These can also be used prophylactically, Nish said. “If a person knows they are going to be exposed to something that affects them, such as a cat, they can use these nasal antihistamines ahead of time.” For allergic conjunctivitis, Nish said he suggests olopatadine (Pataday, Alcon). “For acute symptoms, I would suggest using either oral or nasal antihistamines, or a combination of the two, along with Pataday for eye symptoms, if there are any. Overall, I think nasal steroids should be used regularly, as the foundation. The others can be used as needed; they kick in quickly,” said Nish.

“Patients should keep in mind that over-the-counter is not a pseudonym for safe medication,” Greenhawt said. “Patients need to take these medications at the right doses. There is the potential for unwanted side effects. For example, contraindications for antihistamines, like Benadryl, include certain kinds of heart conditions; however, drowsiness is the main side effect.”

Recommendations for traveling allergy sufferers

“Physicians might want to consider providing an extra prescription of allergy medications if they think access to care for patients with allergies will be an issue for them while traveling,” Greenhawt said.

Recommendations from the AAAAI for traveling allergy sufferers include keeping all medications in their original packaging to avoid running afoul of the Transportation Security Administration, and packing them in carry-on luggage if patients are traveling by air, train or boat. – by Whitney McKnight

For more information:

Disclosures: Drs. Greenhawt and Nish report no relevant financial disclosures.

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