1-Good allergy practice:
- Allergy specialty has multiple interactions with other organ specialties.
- Teamwork by:
- A specialist with approved higher medical training in a field related to allergy/immunology
- Nurses and qualified dietitians are essential.
- The investigation of allergic diseases includes:
* Tests for food allergy.
*Specialized laboratory for investigations such as measurements of specific IgE antibodies and other immunological tests as appropriate.
* Spirometry (including peak flow measurements).
2-Areas covered by Allergy & immunology specialists:
- Seasonal rhinitis (seasonal)
- Perennial rhinitis (all year around)
- Allergic conjunctivitis (seasonal; all year around)
- Allergic asthma (including occupational asthma), Spirometry (including peak flow measurements).
- Allergy to stinging insects (especially Wasps & Bees)
- Allergy to medications
- Allergy related skin disorders namely, urticaria, angio-oedema, atopic eczema, and contact dermatitis.
- Food allergy and intolerance.
- Hereditary and acquired angio-edema.
- Diseases of the immune system (primary and secondary immune deficiencies, humoral and cellular).
- Primary and congenital immunodeficiency.
- Hypereosinophilia and related syndromes.
- Allergic bronchopulmonary aspergillosis.
- Hypersensitivity pneumonitis.
3-When to refer patients for specialist allergy advice:
*For investigation and management of allergic rhinitis, conjuctivitis and asthma.
*For investigation and management of anaphylaxis.
*If the diagnosis of allergy is in doubt (for example, discordance between clinical history and the results of skin prick testing or the radioallergosorbent test.)
*If food allergy is suspected (for assessment and expert dietic input).
*If occupational allergy is suspected.
*In case of urticarial, especially if chronic (>6 weeks)
*For consideration of immunotherapy (in cases of severe rhinitis, allergic asthma, allergy to venom from stinging insects).
*To exclude allergy as a cause of non-specific illness.
*Recurrent respiratory, skin or other infections.
4- Diagnosis approaches by allergist/immunologist:
- Performing skin test. (The gold standard of allergy diagnosis)
*Always check that the patient is not taking antihistamines.
*Always include positive (histamine) and negative (allergen diluents) control test.
*Oral corticosteroids do not significantly inhibit allergen skin prick tests.
*Dermographism may confound results (although it is evident as a positive response at the negative control site).
*Skin prick tests should not be performed if the patient has severe eczema.
*Measurement of allergen specific IgE concentrations (radio-allergosorbent test (RAST) is an alternative if skin prick tests cannot performed.
- Indications for Bronchial provocation testing to a diagnosis of occupational asthma:
*Diagnosis uncertainty despite adequate prior investigation.
*Impracticability of serial peak flow.
*Uncertainly about which of several potential agents may be implicated.
(Note: provocation testing is not indicated solely for medico legal purposes).
- Measuring Total IgE
- Specific serum IgE dosage, indicated by allergist/immunologist and its interpretation.
- Epicutaneous Patch test to diagnose a contact & atopic eczema.
- Food allergy: – Skin prick testing (with extracts or fresh fruits…)
-Confirmation with oral or nasal food challenge.
5-Summary of guidelines on specific allergen injection immunotherapy:
*Use only high quality standardized allergen extracts.
*Administer in specialized clinics only.
*Doctors should have appropriate experience and training in immunotherapy.
*Adrenaline should always be immediately available.
*Ready access to resuscitative facilities; attendant staff should be trained in resuscitative techniques.
*Patients should be kept under close observation for the first 15 minutes after each injection.