Opinion - Whatcom View

POSTED: Sunday, Jun. 21, 2009

Hayfever at its peak in Whatcom County

The sneezing, itching and coughing many of us are experiencing now is due to a medical condition called seasonal allergic rhinoconjunctivitis or SARC, and better known as hayfever. Mid-May through mid-July is considered the most important time of year for allergy sufferers in our area due to high concentrations of grass pollen.

Low levels of grass pollen begin to circulate in the air in mid-May as the seed head forms at the top of the tall grass. Early on, when the pollen counts are low, very few symptoms are noted. However, the few pollen grains that do make their way into the nasal passages begin an inflammatory process called priming. This silent immune "activation" sets up the mucous membranes for a major second wave of localized immune activity occurring weeks later, the seasonal inflammatory "awakening" known as hayfever. As the pollen counts rise, the sensitivity of the nose and eyes increase, and ongoing exposures lead to severe allergic reactions including sneezing, nasal congestion, runny nose, itchy eyes and throat, and in some, cough and wheezing.

Within the mucous membrane lining the nose and surface of the eyes, histamine literally explodes from certain immune cells called mast cells with each contact with a pollen, leading to the allergic reaction. However, histamine is only part of the problem. Soon after release, these allergy cells then send out molecular "magnets" recruiting more mast cells and other immune cells to the site of exposure, leading to an intense and persistent inflammatory condition known as SARC.

In moderate to severe SARC, the problem is not just localized to the site of activity, but spills over into one's general health and quality of life. Significant side effects of this inflammation include sleep disruption, headache, malaise and fatigue, and difficulty concentrating. These problems pose a major burden for patients as well as families of allergic children. Recent estimates indicate that in the U.S. there are 3.5 million lost workdays and 2 million lost school days annually because of allergic rhinitis.

Some hesitate to enjoy the outdoors due to severe and bothersome symptoms.

Although the diagnosis of SARC this time of year is straightforward, associated cough and sinus symptoms can present a challenge when diagnosing asthma or sinus infection.

Allergy skin testing is the most sensitive evaluation to confirm allergy and may be helpful in identifying those who have skin test reactivity to year-round allergens also. Many allergic patients tend to ignore less bothersome fall-winter allergic rhinitis, which may be an important contributing factor in severe seasonal symptoms.

Treatment for those with mild symptoms typically involves daily antihistamine therapy, such as loratadine (Claritin), an over-the-counter medication. Cetirizine (Zyrtec) is another option but may be sedating for some. Several prescription antihistamines are also available. This class of medication however has minimal impact on the priming and inflammation described above, and therefore, prescription anti-inflammatory nasal sprays are advised for those with moderate to severe symptoms. Optimally, such medication should be started in early May to block the early, "silent" priming process, and used daily to inhibit the subsequent build up of allergy cells in the mucous membrane. Newer prescription antihistamine nasal sprays are often helpful for breakthrough symptoms. Ketotifen (Zaditor), available over the counter, can help reduce eye symptoms. Prescription eye drops are also effective. Nasal and eye saline products are available to rinse the affected tissues. This can help remove pollens, irritants, some allergy cells and histamine and has been shown to be beneficial. Immunotherapy, or allergy shots, is very effective and a good option for those who do not respond well or desire an alternative to the usual therapy. A buildup phase is required before this becomes effective, and the routine must be continued for three to five years or more.

Allergic rhinoconjunctivitis can be treated and controlled successfully using the right combination of therapy and treatment recommendations. However, success often requires a more "labor intensive" approach than other medical conditions. Effective communication with your health care provider is also essential in achieving optimal control of this common, yearly malady.

For more information on seasonal allergy, visit AAAAI.org.

Dr. William Anderson is a specialist in allergy-immunology at the Asthma & Allergy Center of Whatcom County. This column is one of an occasional series on health care issues written by members of the Whatcom County Medical Society. If you have a column suggestion for the doctors, send it to wcms@hinet.org