Hair loss Treatment Center

What exactly does an allergist do and what kinds of tests can you expect to get if you go to see one?  Here to explain are two doctors who specialize in this field.  We have Dr. Morris Nejat, who is the director of the Division of Pediatric Allergy and Clinical Immunology at Bellevue Hospital Center.  He is also a clinical professor of pediatrics at NYU Medical Center.  Dr. Nejat, thanks for joining us.

We also have Dr. Heidi Zafra, who is the head of Pediatric Allergy at St. Christopher's Hospital for Children in Philadelphia.  She is also an assistant professor of pediatrics at the MCP Honneman School of Medicine.  Dr. Zafra, we appreciate your time as well.

Dr. Nejat, let's begin with you.  When a patient first exhibits symptoms of an allergy, or what he or she believes to be an allergy, when is it appropriate for the patient to go beyond just a primary care physician and see a specialist?  And can most primary care physicians diagnose and treat allergies well?

MORRIS NEJAT, MD:  Most primary care physician do a very good job at treating mild to moderate allergies, especially if there are classic allergy symptoms like itchy nose, itchy eyes, sneezing.  By going to an allergy specialist, the patient gets somebody who specializes in only the treatment of allergic disorders, like allergic rhinitis, allergic conjunctivitis, allergic asthma, eczema, hives, food allergies.  It's to get the allergy specialist's wide array of experience.

The allergy specialist is very familiar with both over-the-counter allergy products as well as prescription allergy products.  They also can help diagnosis specifically what the patient's allergic to, and by identifying these things, they can help the patient avoid these things, which will help decrease the patient's symptoms, and the medication requirements.

PAUL MONIZ:  Dr. Zafra, you deal mostly with children.  Do you find that some children come to you, and they've been treated by a primary care physician, and that physician has been treating them for something other than what they're really allergic to?

HEIDI ZAFRA, MD:  A lot of children will present with a cough that won't go away, a runny nose that won't go away, and it'll be treated as a virus or just as a cold.  The mother will say that the cold is there forever and has been there for months and months and months.  Or the coughing, especially coughing at night, the pediatrician will just give a cough suppressant.  We try to determine if it is allergy related or not, or if it could be treated with other medications like asthma medications, and not just some cough preparation.

PAUL MONIZ:  Do you find that a lot of the patients are coming in over-medicated on over-the-counter substances?

HEIDI ZAFRA, MD:  Yes, they try everything in the decongestant, cough suppressant aisle, some of them, before they come to me.

PAUL MONIZ:  Let's talk about how one person would go about finding an allergist.  Is it a referral?  Should you talk to friends?  Should you look in the phone book?  What do you recommend?

MORRIS NEJAT, MD:  I recommend that patients find somebody that is familiar with a particular allergist, be it friends and family, or their primary care physician who has worked with this particular allergist and is comfortable with them.  Then you would call, make an appointment, and before you go see the allergist, you should try and stay off your antihistamines for at least 48-72 hours.  In case the allergist wants to do skin testing, you can do it right then and there; you don't have to come back for a followup visit.

PAUL MONIZ:  You should stay off those because --?

MORRIS NEJAT, MD:  Because they can suppress the results of the skin testing.  Because the allergy specialist, what they'll do, is actually do testing on your body to help determine what exactly you're allergic to.

PAUL MONIZ:  We have certainly heard a lot about allergies lately, this time of year, going into spring.  What kinds of things are you seeing more of, at this moment?

HEIDI ZAFRA, MD:  At this time, for children, it's mostly a virus that's causing the runny nose or the chronic cough.  Also indoor mold is a problem.  The pollens are really not around yet.  Indoor allergens such as dust mites.  Pet dander, also.  Or cockroach allergen in cities can also cause problems this time of the year.  These are allergens that are all year round, and the pollens are only during the seasonal times, spring, summer, fall.

PAUL MONIZ:  A patient makes the decision to go to an allergist, perhaps on the advice of his or her primary care physician.  What can the patient expect when they get there? MORRIS NEJAT, MD:  The patient will come in, and the allergist will first do a detailed history.  Going into the patient's symptoms, the duration of symptoms, how it affects the patient.  Then they'll probably go into a very detailed environmental history.

What is the patient's environment?  Do they have pets?  Do they have stuffed animals on their bed, if it's a child?  Do they have rugs in the bedroom, feather pillows or a down comforter?  They'll also see what triggers a patient's symptoms.  Do they sneeze when they're cleaning?  When they're playing with the cat or dog?  When they go to school, when they come home, when they go in the basement?  All these will help determine which tests to do on the patient, and what things the patient should avoid.

PAUL MONIZ:  Skin testing is one of the most common tests that's done.  We also have some video.  Maybe you can walk us through a patient actually having some of those tests.  What happens when they go in for this testing?

MORRIS NEJAT, MD:  After doing a history exam, then we do a physical exam, to see what kind of allergy signs a patient has.  What the patient does is, the way I do a skin test is, I like to do it on a patient's arm, if possible.  Initially, the patient rolls up their sleeve.  You clean off the area with alcohol.  What you would do then is actually make specific marks, specific scratches with different antigens, on the patient's arm, then wait 20 minutes to see if there's a reaction to these substances.

PAUL MONIZ:  You can actually get a result in 20 minutes?

MORRIS NEJAT, MD:  Yes.  I tell the patients I'm using their body as a laboratory.

PAUL MONIZ:  What kinds of things are you testing for?

MORRIS NEJAT, MD:  What I do usually is a panel of indoor and outdoor allergens that patients in this region of the country are allergic to, including dust, roaches, dogs.

PAUL MONIZ:  What are we seeing here, the lines and then the pokes?

MORRIS NEJAT, MD:  I do the lines just to guide where I'm doing the actual pokes.  When you do the scratch tests, you just scratch the most superficial.

PAUL MONIZ:  Some of the items here, soy, peanut, wheat, egg white.

MORRIS NEJAT, MD:  Those are the most common food allergens.  The main thing when patients have respiratory symptoms, though, is we do aeroallergens.

PAUL MONIZ:  Is this painful, this test?

MORRIS NEJAT, MD:  It's a little prick.

HEIDI ZAFRA, MD:  It's more uncomfortable than painful.  It's itchy.  There's an initial pain, but it goes away right away.  Like a little bug bite.

PAUL MONIZ:  What does the patient do for the 20 minutes while he or she is waiting for the results?

MORRIS NEJAT, MD:  Usually in our office, we sit them down, they watch an instructional video.

PAUL MONIZ:  There's some swelling here.  Does this mean the patient is allergic in those spots?

MORRIS NEJAT, MD:  This is a positive skin test.

PAUL MONIZ:  How allergic is this particular patient?

MORRIS NEJAT, MD:  This patient, it's tough to tell just from the skin testing how allergic.  You combine their skin test --

PAUL MONIZ:  What's happening there?

MORRIS NEJAT, MD:  I just gave him an antihistamine to make him more comfortable, after the reading of the skin test.

PAUL MONIZ:  And now?

MORRIS NEJAT, MD:  I just gave him some cortisone cream to decrease the reaction.

PAUL MONIZ:  The antihistamine also will do the same?

MORRIS NEJAT, MD:  Exactly.

PAUL MONIZ:  Now what are we seeing?

MORRIS NEJAT, MD:  When we do skin testing, sometimes the substance is negative on the scratch test, so we inject a higher amount under the layer of skin.  It is called intradermal testing.

PAUL MONIZ:  So this is really an insurance policy, right?  To make sure you haven't missed anything?

MORRIS NEJAT, MD:  Exactly.  For the sake of completeness.

PAUL MONIZ:  Again the results take about the same amount of time?

MORRIS NEJAT, MD:  About 20 minutes.

PAUL MONIZ:  Is it possible that you may be missing something when you do these tests?  In other words, you're testing for the most common things.  What happens if the patient still is allergic?

MORRIS NEJAT, MD:  That's why we try to do a detailed history, to see what exactly trigger the patient has.  There are times where we will test them for something unusual, just based on their reactions.  Like say, I don't usually test for hamsters unless the patient's exposed to hamsters in school.

PAUL MONIZ:  Do you find, generally, that patients and, in your case, Dr. Zafra, that the parents of these patients actually think their kids are allergic to things other than what they actually are?

HEIDI ZAFRA, MD:  When I do the testing, I do pretty detailed testing.  Like I just don't do one tree, I do several trees, several grasses, several weeds, different kinds of molds, and two different kinds of dust mites.  It's really very, very wide; it's a wide range.  If I don't find anything, I basically just tell parents, if you're negative, more likely the chances of you being a true negative is high.  If you're positive, you have to correlate it with your clinical symptoms.

You may have a patient who has a lot of positives, but clinically they're not really reactive to anything.  They don't really scratch their nose, they don't really rub their eyes, and they don't really have a cough.  It's more reliable to have a negative than a positive.  You can have what we call a false positive.

PAUL MONIZ:  There are other tests that you perform as well.  One of them is the pulmonary function test, and we have some pictures of that.  What is happening in that test?

MORRIS NEJAT, MD:  When a patient comes in with respiratory symptoms relating to the lower airways, coughing, wheezing, we'll often do a pulmonary function test to get a measure of the lung function.  This is particularly useful in patients who have asthma, because it's very easy to diagnose asthma after doing this test.  It also helps us follow patients in the long run, to see their asthma and make sure it gets better.

PAUL MONIZ:  What is the patient doing, blowing into that device?

MORRIS NEJAT, MD:  He's blowing into this device as hard as he can, and then inhaling back in.

PAUL MONIZ:  And this chart?

MORRIS NEJAT, MD:  We get printout from the computer, which tells us the readings.

HEIDI ZAFRA, MD:  It tells us lung function, what's going on in their large airways and in their small airways.  Even children can do it, children over six can do it, and we can, I actually am able to tell mothers whether there is some mild form of asthma or not, in children who have registered for pulmonary function.

PAUL MONIZ:  Is it possible that all of the initial skin tests could be negative, but when you do the pulmonary test, you find something fairly significant?  Or is that rare?

HEIDI ZAFRA, MD:  It is possible.  It's possible that you have non-allergic components to asthma, and especially with children, there are other causes of asthma besides allergies.  There are irritants like cigarette smoke, there are viruses, there are chemical sprays, cleaning agents, stuff like that.  For things that are not allergens, you can still have episodes of wheezing.

PAUL MONIZ:  The next step would be what?  For treatment or diagnosis, you actually, once you find out what's going on, you start giving shots?

MORRIS NEJAT, MD:  You find out.  The main thing, when you find out what's going on, is to advise the patient how to avoid these allergens.

PAUL MONIZ:  Avoidance is first?

MORRIS NEJAT, MD:  Avoidance is the key thing in allergy disease.

HEIDI ZAFRA, MD:  For any allergy, avoidance is the main way to prevent symptoms.

PAUL MONIZ:  But if you can't avoid, or if you're so allergic, then what?

MORRIS NEJAT, MD:  Then you would give the patient medicines to help control their symptoms, and then you may want to supplement that with allergy immunotherapy.  What you do is, you give patients injections of what they're allergic to.  You start out at very small doses, and gradually build up on a weekly basis, until the patient gets to a maintenance level.

PAUL MONIZ:  We have some pictures of that as well, of some of the video shots and allergy shots.  What are we seeing here?

MORRIS NEJAT, MD:  Here are different patient serums that we give to patients as we try to desensitize them.  Here's one of our patients receiving an allergy shot, which is a very small injection into the subcutaneous tissue in the back of the arm.  Following the shot, the patient will wait about 20 minutes, to make sure they don't have any type of reaction.  Then they would go home, and they come back the following week.

PAUL MONIZ:  How often would a patient come?  Every week for how long?

MORRIS NEJAT, MD:  Depending on how allergic they are, we usually start out once a week for six to nine months.  Then we follow that with every two weeks, and then eventually every three weeks.  Then we conclude with once a month maintenance immunotherapy.  We want to do that for at least three to five years, the maintenance.

PAUL MONIZ:  So this is a long haul for people, especially those that are really allergic?

HEIDI ZAFRA, MD:  It's a commitment.

MORRIS NEJAT, MD:  Sure.

PAUL MONIZ:  Is this generally covered by insurance?

HEIDI ZAFRA, MD:  Yes, depending on the insurance company, of course, but yes.

MORRIS NEJAT, MD:  Almost always, it's covered.  The insurance companies have seen that allergy immunotherapy is a very effective and cost effective way.

HEIDI ZAFRA, MD:  It's very cost effective.

PAUL MONIZ:  Are there a lot of people who are missing work because of their allergies, would you say?

MORRIS NEJAT, MD:  I think studies have shown that productivity, allergies and asthma cause about $2-10 billion a year worth of lost productivity.  There's 10 million school days per year missed because of allergies.

PAUL MONIZ:  So it has a tremendous impact?

MORRIS NEJAT, MD:  Of course.

HEIDI ZAFRA, MD:  In children, especially if they can't sleep because their nose is so stuffy, they lose days from school.  They can't understand their lessons well.  Basically they're absent from school all the time.  So from giving them the proper medication and maybe immunotherapy, their quality of life improves.

PAUL MONIZ:  Dr. Zafra, what is the correlation between allergies and asthma?  If someone is subject to these allergens, are they more likely to get asthma?

HEIDI ZAFRA, MD:  It depends.  Some people are prone to become asthmatic.  They have, along with the allergies in the nose, they have what we call twitchy airways.  For those who have the predisposition to become asthmatic, they also develop some inflammation in their airways.  A lot of times the inflammation is triggered by allergies in the environment, allergies to things in the environment.

PAUL MONIZ:  Dr. Nejat, let's give you the final word on diagnosing these allergies.  What would you suggest to our audience?

MORRIS NEJAT, MD:  In our society, oftentimes people trivialize allergic diseases, because it's rarely fatal, especially respiratory allergies.  It does cause a lot of problems, especially with children, and it's very important to identify what you're allergic to.  After identification, you want to avoid it and, if possible and necessary, you need to treat it to improve both your child's and your quality of life.

PAUL MONIZ:  All right.  Dr. Morris Nejat, we appreciate your time.  Some very good information as well.  Dr. Heidi Zafra.