Online publication only
As this issue covers the role of inflammation
in several disease aspects, the authors thought it fitting to apply
this topic to seasonal allergic rhinitis, otherwise known as "allergies"
or "hay fever." Seasonal allergic rhinitis, or for that
matter, perennial allergic rhinitis (defined as allergic rhinitis
lasting 9 or more months of the year), is an inflammatory condition
marked by inappropriate immune responses to benign environmental
substances. Of all cases of allergies, the perennial variety occurs
in 40% of all those affected. The allergens in these cases are typically
those with no or little seasonal variation, such as cockroaches,
dust mites, indoor molds, and animal dander (fur, feathers, skin,
urine). Consider the numbers surrounding this inflammatory condition:
· Based on the results of skin
test allergies only, 40 to 50 million Americans are affected with
allergies, making it the 6th leading cause of chronic disease
in the US,1 or 20% of the entire US population.2
· Of those affected by allergy in general, close to 36
million people have seasonal allergic rhinitis,3 leading to 16.7
million visits to health care providers each year.4
· The approximate overall cost of allergic rhinitis in
the US in the year 1996 alone was 6 billion dollars.5
Conventional medical options for this
condition are diverse and include blockage of histamine receptors
(antihistamines) and stabilization of cells that release this compound
(mast cell stabilizers), steroid therapy (nasal and sometimes systemic
steroid preparations), and immunotherapy. Immunotherapy is a particularly
interesting approach; it consists of a preventive and anti-inflammatory
approach to allergies by injecting gradually increasing amounts
of the allergic substance into the person, in hopes that the minute
increases of allergens will lead to a less sensitive immune system.
While this sounds like homeopathy, it is not but does follow a similar
line of thinking in that small substances of offending substances,
when introduced into the body, will stimulate it into overcoming
While all of these approaches have their merits and downsides, they
are not necessarily applicable or entirely curative for all people
suffering from allergic disease. More importantly, those suffering
from one allergic condition are highly likely to be affected by
others such as asthma and eczema. These three conditions, allergies,
asthma, and eczema, are referred to as atopic disease; and the literature
is extensive regarding prevention and alteration of the immune response
in these conditions. Giving due attention to all of these approaches
is best served by addressing them in a larger compendium; the following
are highlights of some of the more popular approaches to allergy
prevention and control. (Please see the May
2004 issue of Townsend Letter
for a look at inflammation and asthma).
Prior to treating allergies, the differentiation between true allergic
responses and sensitivity must be established. Allergy is defined
as an acquired, abnormal immune response to a substance (the allergen)
that does not normally cause a reaction, resulting in a broad range
of immune (inflammatory) responses. Sensitivity is defined merely
as "susceptibility to a substance." More specifically,
this means that a substance (most typically benign as well) may
lead to physiologic perturbations in any number of ways. These include,
but are not limited to, migraines, apthous ulcers (canker sores),
bedwetting, and itching. It is important to make this distinction
because both diagnosis and treatment may be completely different
in this case.
and Food Allergy
While the causes of allergic rhinitis are often obvious (that is,
allergies occur for most people during specific seasonal time periods
associated with plant pollens, and so on), uncovering what makes
the immune system respond in this way is key. One prevailing theory
is that of antigenic load, whereupon it is hypothesized that an
excessive amount of antigenic stimulus overwhelms the immune system,
leading to inflammatory responses. For instance, exposure to small
amounts of allergens may not typically amount to symptoms, until
simultaneous exposure to a number of antigens leads to "spillover"
of symptoms. It is thought that in this manner, the immune system
can deal adequately with substances that it perceives as allergens
when exposed in limited quantities; however, when continually bombarded
by allergens, or presented with several different allergens, the
immune system is overwhelmed, and as such, symptoms appear. Likewise,
repeated chronic immune response to allergens can overwhelm the
immune system when we are tired, stressed, or in otherwise less
than optimal health. And, it may be possible that sensitivities
may contribute to the "load" mentioned here as well. While
much of this is speculative theory, it makes great clinical sense
when confronting allergy symptoms.
One of the most direct ways to lighten the antigenic load is by
identifying and removing food allergens. A subject unto itself,
food allergies and sensitivities play a key role in resolving many
physical symptoms in people, including allergic responses. When
we look at foods as a culprit, this makes complete sense, as they
comprise the largest pool of antigenic challenges to the immune
system.6 (Please see the Townsend Letter
on food allergies). Additionally, food groups are very consistent
in the majority of people, as diets rarely vary from 10 different
food types on a weekly basis. Continuous exposure to sensitivities
or allergies in this fashion is an understatement. Food sensitivities
and allergies themselves set up the immune system for even more
reactivity toward other substances.
Allergic/inflammatory processes become active in the gut; transportation
of food proteins across the intestinal wall becomes altered resulting
in increased permeability and motility of the intestine.7 Coupled
with other conditions such as intestinal infections/flora imbalance,
and decreased secretory IgA, this may lead to further intestinal
compromise and increased antigen-immune interaction. Thus we may
hypothesize that not only will increasing the antigenic load in
the form of food allergy/sensitivity increase the food allergy problem,
it will also overburden the immune system, possibly leading to overreaction
against airborne or other seasonal allergens.
Milk is an interesting food to look at while on the subject of food
allergy. Commonly thought of as an allergen (especially incorrect
in those with lactose-intolerance) because of its ability to increase
mucus secretion, its status as such was evaluated in one interesting
study. Investigators looked at people's sensations and symptoms
immediately after drinking milk and a placebo beverage.8 The study
went like this: 169 subjects, 70 of whom believed that milk leads
to increased mucus production, were enrolled in a randomized, double-blind
trial of a "flavored" cows' milk drink and a similar-appearing
and -tasting soy milk drink. In a pretest of 185 people, the researchers
claim that the two drinks were indistinguishable. A survey was administered
to each subject in both groups asking them to rate 14 milk-mucus
indicator variables; only 3 of the 14 variables were elevated in
both groups. They were: "coating/lining over the mouth, throat
or tongue," "need to swallow a lot," and "saliva
thicker, harder to swallow than before." Investigators concluded,
in their oft-quoted study, that milk does not increase mucus, and
the sensation of increased mucus production can be duplicated after
consuming a soy drink as well, thereby negating the claim that milk
leads to increased mucus production.
What is most interesting about (and the biggest flaw in) this study
is that researchers looked only at immediate reactions to mucus
production, and not at longer-term outcomes (hours to even a day
later). Clinically, many people with allergies are averse to milk,
as are people like athletes, singers, and speakers, or for that
matter anyone whose performance may be affected by excess mucus
production. Another study looking at mucus production hours after
milk consumption is in order here.
Preventing the allergic response is, of course, our first line against
this condition. Preventive approaches can take place as early as
gestation and throughout infancy. While prevention always makes
the most sense, there are other treatment strategies for adults
with allergies as well.
A discussion about inflammation, especially allergic, is not complete
without mention of the Hygiene Hypothesis. The central tenet of
this hypothesis states that increases in hygiene have led to an
immune system left unchallenged. The widespread use of antibacterial
cleaners and the intense methods in which children are prevented
from encountering "germs" may have led to an increase
in atopic disease. The hypothesis was created after patterns of
risk factors for allergic disease in Europe; apparently hygienic
practices have removed a protective influence against allergic disease
by reducing the number of infectious challenges early in life.9
That is, as young children are exposed to and become infected by
various agents, the immune system is kept "busy" combating
these infections. Now that modern medicine and intense hygiene (food
that falls on the floor is never eaten, hands are washed several
times a day, and great alarm occurs if dirt, rocks, or other "unclean"
items go into a child's mouth) have removed much of the infections
that previous generations suffered, the modern immune system now
reacts against typically benign environmental substances, such as
animal dander and pollens.
This theory poses an interesting question, especially when considering
the upcoming discussion of probiotics. Can allowing young children
to exist in a less-sanitary environment prevent some allergic disease?
This is of course, a charged discussion, especially with the prevailing
media endorsement of household cleaning agents as well as media
exposés of the many germs found in dishcloths and on restaurant
tables. The majority of such "germs" found in these frightening
stories are commensal organisms that exist practically everywhere,
including in and on our bodies.
The current progressive increase in frequency of atopic disease
(asthma, allergies, and eczema) appears throughout the modern Western
world. Probiotics, or cultures of beneficial, commensal bacteria
that typically dwell in the gut, have been researched as potential
primary inhibitors of the atopic process.
There are many recent investigations of the effects of supplementation
with probiotics on the prevention and treatment of allergic disease,
with promising results. Despite its wide acceptance as the best
source of nutrition for the infant and its role in optimizing infant
health, breast-feeding as a protection against allergic disease
remains elusive today with both pro and con studies.10 However,
studies investigating the effects of probiotics both in the ante-
and postnatal periods have also produced fascinating results in
this area; however, they mainly focus on eczema.
In a study of 62 mother-infant pairs, administration of probiotics
to the mother both during pregnancy and in lactation increased the
immunoprotective properties of the breast milk as assessed by the
amount of transforming growth factor beta2 (TGF-beta2) in the milk.11
Infants whose mothers took probiotics had a significantly reduced
risk of atopic eczema development in their first 2 years of life,
compared with the infants whose mothers were not supplemented. The
risk for eczema development was 15% in the mother-supplemented babies
and 47% in the non-supplemented-mother infants. It was revealed
further that maternal atopy was a clear risk factor for eczema in
the infant, and those most likely to benefit from maternal probiotic
supplementation were those who had an elevated umbilical cord blood
concentration of immunoglobulin E (IgE), a primary mediator of allergy.
Administration of probiotics during pregnancy and breast-feeding
appears to offer a safe (no side effects were reported in any of
the probiotic studies) and effective tool for protection against
atopic disease early in life. More needs to be learned about the
preventive role of probiotics in seasonal allergic rhinitis, or
a tendency toward its development.
A popularly prescribed allergy treatment is Urtica dioica, or stinging
nettle. Nettle has long been the subject of much herbal lore regarding
allergy treatment. Nettles have been subjected to surprisingly little
scientific scrutiny in relation to their anti-allergy affect. While
some amount is known about this plant in this regard, it does provide
interesting insight into its allergy-preventive effects. Nettle
is known to contain histamine, serotonin, and acetylcholine in the
stinging portions of the leaves.12,13 While using a plant containing
the very substances that standard allergy medication works against
(antihistamines), it seems strange to use this botanical medicine
for allergy treatment. However, histamine has been used to treat
several different types of allergic conditions, including seasonal
allergic rhinitis.14 Surprisingly, it had been demonstrated that
high serum levels of histamine do not accompany some allergic responses;
rather, low amounts of plasma histamine have been associated with
more severe reactions to inhalation of known allergens.15
One double-blind, placebo-controlled study tested the efficacy of
nettle in allergic rhinitis.16 A total of 69 patients completed
the study, with 59% rating nettle as effective in treating symptoms
compared with 37% of the placebo group finding relief as well. Other
descriptive actions relating to older herbal texts describe nettle
as "astringent to the mucous membranes" and a "histamine
Ammi Visnaga (Khellin)
This herb has many applications in preventing symptoms of allergic
disease; it is available as a commercially produced bronchial inhaler,
nasal inhaler, and opthalmic solution. While relatively far removed
from its natural state, khellin is altered and its commercial preparations
are referred to as sodium cromoglycate. This medicine is useful
for treating asthma, allergic rhinitis, and allergic conjunctivitis
as a preventive medicine. Khellin is known to stabilize mast cells
(the main producers of histamine in allergic reactions), thereby
blocking the release of inflammatory and allergic mediators. When
applied in the above-mentioned forms, it is used frequently to disallow
mast cell degranulation in the allergic cascade. Used in this manner,
both early- and late-phase allergic reactions are avoided, and development
of inflammatory processes are quelled as well.
The commercial form, sodium cromoglycate, is poorly absorbed on
a systemic basis (thereby necessitating direct application to mucous
membranes) rather than oral administration. It is well tolerated
with very few side effects, the most often-reported being headaches.17
There are no associated drug or herb interactions, and its efficacy
is comparable to prescription antihistamines and intranasal corticosteroids.
It is most effective with prophylactic use.
Acupuncture can be a useful adjunctive therapy for treating allergies.
While the authors do not practice acupuncture clinically, both have
observed rather impressive results in patients using acupuncture
as part of their treatment of seasonal allergic rhinitis. While
a discussion of acupuncture and allergies are beyond the scope of
this article, it is recommended that those suffering from allergic
symptoms seek acupuncture as part of their treatment plan. One interesting
study looked at the effects of real versus sham acupuncture on cytokine
levels in patients with allergic rhinitis.18 Cytokine levels were
markedly lower after the real acupuncture treatment, whereas they
remained elevated and unchanged following the sham acupuncture treatment.
This is one of many fascinating studies that endorses the use of
acupuncture for treatment of many conditions, allergies being yet
Prevention and treatment of the inflammatory cascade in seasonal
allergic rhinitis is an extremely large topic; this article only
briefly addressed a few methods and theories. Natural medicine encompasses
an enormous array of treatment methodologies for addressing not
only allergic disease but inflammation as well. As practitioners
of natural medicine, we must also incorporate the wisdom of these
additional therapies and lifestyle approaches:
· nutrition: Vitamins and minerals
(vitamin C, B6, magnesium), and fatty acid modification using
essential fatty acids;
· bedroom hygiene: removing carpeting and drapery, frequent
changing of sheets (avoidance of dust mite allergens);
· saline nasal rinse: saline is a weak mast cell stabilizer
· washing hair and face before retiring at night (removes
accumulated pollens and other allergens encountered during the
· homeopathic remedies;
· other botanical medicines: Euphrasia officinalis, Achillea
millefolium, Cochlearia armorica, Hydrastis canadensis, and others;
· energetic-based allergen removal, including Nambudripad
allergy elimination technique (NAET) and related forms.
1. American Academy of Allergy, Asthma and Immunology (AAAAI). The
Allergy Report: Science Based Findings on the Diagnosis & Treatment
of Allergic Disorders. 1996–2001.
2. American Academy of Allergy, Asthma and Immunology. Task Force
on Allergic Disorders. Executive summary report. 1998.
3. Natahn RA, Meltzer EO, Selner JC, Storms W. Prevalence of allergic
rhinitis in the United States. J Allergy
Clin Immunol. 1997;99:S808–S814.
4. US Centers for Disease Control and Prevention. National Center
for Health Statistics. Vital and Health
5. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures
for sinusitis in 1996: contributions of asthma, rhinitis and other
airway disorders. J Allergy Clin Immunol.
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6. Buckley RH, Metcalfe D. Food allergy. JAMA. 1982. Nov 26;248(20):2627–2631.
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J Diarrhoeal Dis Res. 1997 Dec;15(4):211–223.
8. Pinnock CB, Arney WK. The milk-mucus belief: sensory analysis
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12. Collier HOJ, Chester GB. Identification of 5-hydroxytryptamine
in the sting of the nettle. British J Pharmacol.
13. Saxena PR, Pant MC, Kishor K, Bhargava KP. Identification of
pharmacologically active substances in the Indian stinging nettle,
Urtica parviflora (Roxb.). Can J Phys Pharmacol.
14. Horton BT. The clinical use of histamine. Postgrad
15. Zimmerman I, Ulmer WT. Effect of intravenous histamine, allergen
(Ascaris suum extract) and compound 48/80 and inhaled allergen aerosol
on bronchoconstriction and histamine release. Respiration.
16. Mittman P. Randomized, double blind study of freeze dried urtica
dioica in the treatment of allergic rhinitis. Planta
17. Meltzer EO; NasalCrom Study Group. Efficacy and patient satisfaction
with cromolyn sodium nasal solution in the treatment of seasonal
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IL-10 in patients of chronic allergic rhinitis treated with acupuncture.
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