Rhinoconjunctivitis is inflammation of the lining of the nose and eyes due to allergy.  It causes a blocked, runny and itchy nose, sneezing and itchy running eyes.

Hay fever is allergic rhinitis due to grass allergy and is mostly during spring/summer.

Allergic rhinitis due to dust mite lasts year round and can be worse overnight, in the mornings or around vacuuming or dusty environments.  Certain houses or a dusty old bach might set you off.  Cat/dog allergy can also cause year round symptoms.

For some people bad rhinitis can be associated with asthma so it is hard to breathe at the time.

In the case of allergic rhinitis, the specific allergen (the thing that you are allergic to) may be identified by skin prick tests. This involves placing a drop of the allergen on your skin and then scratching your skin through the drop. If you are allergic, your skin will become red and swollen at the site.

Skin tests are only of value if interpreted with respect to a careful history of a patient’s clinical symptoms. They are not a diagnosis by themselves. 

When the correct allergy is identified, desensitisation can be a very effective long term treatment for allergic rhinoconjunctivitis.

Before an appointment with us, it is good to avoid all antihistamines for 4 days prior, so we can do this testing if needed.

We can work to improve your symptoms by:

– identification and minimisation of the allergen

– best medical therapy options

– desensitisation – a treatment that makes you less allergic and has sublingual and subcutaneous forms

This is episodic swelling of the lips, tongue or around the eyes that is usually painless. For some it can cause shortness of breath, voice change, or a sensation of tightness around the neck.  

Angioedema can be due to allergy or have other causes. Again, carefully listening to a patient’s symptoms can help distinguish the causes.  Sometimes further tests are needed.

Anti-inflammatories (NSAIDs) are a commonly missed cause, as are ACE inhibitors (a blood pressure medication). Angioedema can also occur in association with non-allergic causes such as infection or chronic spontaneous urticaria.

If breathing or voice change, or large tongue swelling has occurred an adrenaline autoinjector such as Anapen and Epipen should be considered, and an action plan must be provided.

If you think you may get angioedema it is useful to take a photo of any tongue swelling, eye swelling, lip or hand/feet swelling, as well as a photo of any rashes, and bring these photos to the clinic.

Patients who are sensitive to aspirin may need aspirin desensitisation. There are two main groups of patients who need this:

1. Those who have had reactions to aspirin but need to take it as a regular medication (e.g. for their heart)
2. Patients with asthma/sinusitis/polyps/aspirin sensitivity (also known as AERD / Samter’s Triad).

Aspirin desensitisation is an effective treatment for the right patient group.  We are happy to review these issues and see if it is right for you.

Urticaria (hives) is an itchy rash which comes and goes. It can cause small bumps or large patches over 15 cm. Causes of urticaria hives include not only allergy but also non-allergic causes. 

Carefully listening to a patient’s symptoms and history is the key to distinguishing what causes hives / urticaria, and is essential for proper management.  Stress, low mood, illness, fever, exercise, temperature change and anti-inflammatories (NSAIDs) are a few of the non-allergic causes, and testing for allergy is necessary in some cases but not others.  Chronic Spontaneous Urticaria is an immune mediated (non-allergic) cause of regular urticaria/hives and has a specific range of treatment options. This can cause angioedema (swelling) as well.

Hives can be associated with dermatographism (also known as skin writing) in which a raised red itchy line appears on scratching the skin. Urticaria / hives is actually quite common, with one in four people getting hives at some stage in their lifetime. Sometimes urticaria is associated with angioedema (swelling of the lips, tongue and eyes).

Treatment of urticaria involves addressing the underlying cause and this is different in each case. Antihistamines are often necessary, as well as minimising precipitants.

For those with bee or wasp allergy, reactions can range from mild, through to life threatening. Bee or wasp allergy can cause anaphylaxis. 

There is a fatality approximately once every 2 – 3 years in New Zealand from bee or wasp anaphylaxis. For those who have had anaphylaxis, the chance of a severe reaction with each bee sting in future is about 75%.

For bee or wasp allergy, we can assess, test and diagnose the allergy.  I can provide an emergency management action plan for you and educate on Epipen use. I can identify if you have had anaphylaxis, or are at risk of anaphylaxis and what to do about that. If you have had a large localised reaction (spreading to the tissues from the sting site) I can provide a management plan for future stings.

Desensitisation is very beneficial if you have had anaphylaxis to a bee or wasp sting and is an option to consider.  The treatment has several different protocols, with frequent injections in the initial days/weeks but then monthly injections for 5 years after that.  The risk of an allergic reaction after doing desensitisation is <5%.

I can discuss if desensitisation is right for you, and if it is I will refer you to ADHB Immunology at Auckland City Hospital to be considered for the desensitisation program there.

ADHB Immunology would usually get your dose up to a regular monthly dose after several weeks of appointments, and then have your GP do the ongoing injections for the next 5 years on a monthly basis.

At our Takapuna clinic we provide desensitisation treatment for dust mite allergy, grass allergy, tree pollen allergy (birch), cat and dog allergy and plantain (a weed).  These are the most common hay fever / rhinitis and asthma allergies in New Zealand.  

Desensitisation (also known as immunotherapy) is an excellent treatment for allergic rhinitis or rhinoconjunctivitis (hay fever), and asthma.  Dust mite desensitisation treatment has benefit for some selected patients with eczema as well.  Desensitisation is a common treatment in hospitals and private medical clinics in Europe and the United States.  It is funded by the public health system in many parts of Europe.

Desensitisation involves giving you an increasing amount of a substance you are allergic to.  Done in specific ways/doses, this makes the immune system become tolerant to it, so that you become more tolerant / less reactive.  Skin testing and an accurate review of your symptoms is essential first to definitively diagnose the allergen.  

We prescribe both sublingual desensitisation (tablets/sprays under the tongue) and allergoid subcutaneous desensitisation (small injections under the skin).  

Our subcutaneous allergoid version is an injection once monthly for three years.  Recent advances in the treatment mean the injections are monthly from the start, so do not require the initial weekly injections that previous protocols needed.

Our sublingual versions are Actair, Oralair and Oraltek, and involve sprays or tablets under the tongue, daily for three years, and these courses are taken at home, except for an initial supervised first dose at our clinic.

The benefit of desensitisation treatment for hay fever rhinitis and asthma allergies is that the improvements when the course finishes are often long term.  It is the only treatment that offers the possibility of long term remission of your symptoms.  The most common response is a significant partial improvement in symptoms, with some long term benefit continuing after the treatment finishes.

Simone Stephens, our specialist nurse, has been involved with setting national standards on desensitisation and her extensive experience is an invaluable asset. 

For long term treatment of significant allergy, desensitisation is the treatment of choice.

A 2013 analysis by the US Department of Health examined all the evidence for desensitisation to dust mite, grass, cat and dog hair, for asthma and hay fever (rhinitis).  The conclusion was there is very clear scientific evidence from multiple studies that desensitisation gives significant benefit in improving asthma, hay fever, allergic rhinitis and allergic conjunctivitis as well as quality of life.  Click here to find out more about the scientific evidence for desensitisation in asthma and hayfever.

Desensitisation has costs for the product and for any appointments needed.  Some aspects can be covered by health insurance, but often the products themselves you would need to pay for.

Samter’s triad – Aspirin Exacerbated Respiratory Disease (AERD)

Some people develop a running, blocked nose in early adult life that may progress to asthma and sinusitis.  Some of these people turn out to have nasal polyps.  This is known as Samter’s triad.

The complete combination is:

• rhinitis (constant or frequent running nose)
• asthma
• nasal polyps (and sinusitis)
• aspirin or anti-inflammatory (NSAID) sensitivity.

Treatment of Samter’s triad can be started with nasal sprays, sinus rinses however many people require surgery such as polypectomy.

Furthermore, some people with these symptoms can have adverse reactions when they take aspirin or anti-inflammatories. 

Aspirin desensitisation is an important treatment in this scenario.

Aspirin desensitisation has the following benefits:

• improved asthma symptoms
• fewer episodes of sinusitis
• slower polyp regrowth (from average 3 years to 10 years)
• less steroid medication required.
• fewer hospitalisations.