for environmental inhalant aeroallergens (pollens, molds, cat, dog, dust mites, cockroach, etc.) for foods when appropriate for drugs/medications when appropriate for stinging insect venoms when appropriate
Traditional allergy shots can provide tremendous long-term relief of allergy symptoms by gradually increasing a patient's tolerance to the pollens, molds, animal dander, and/or insect venom to which they are allergic. We start off with a build-up period, where low doses of the antigens are given, and gradually build up to higher doses over a period of weeks to months as tolerated. Once the patient reaches a maintenance dose, less frequent shot dosings are necessary (generally once a month). The most common reactions are mild, and include itching or swelling at the injection site. Risks include severe life-threatening reactions including death have been reported, but are rare. Allergy shots are administered in the office when an MD is present with a 30 minute minimum wait time in the event of any allergic reaction. Patients generally feel better in a few weeks once starting allergy shots, with substantial improvement in symptoms once they reach the maintenance phase. Most remain on allergy shots for about 3-5 years, depending on symptom response, seasonality, severity of symptoms, adherence to treatment plan, and are able to achieve long-term relief.
In certain special situations, it may be necessary to desensitize a patient to their aeroallergen or venom allergies more quickly than the standard shot schedule. This procedure comes with increased risk of reaction; thus, should be done under the supervision of an allergist in the appropriate setting.
Patients building up to a maintenance dose on allergy immunotherapy should receive their shots on a regular predictable schedule for optimum response and minimal risk of reactions. We do understand that life happens and that occasionally a gap may occur when a patient is unable to receive their shot on schedule. It is important to take this into account when a patient is on allergy shots, so that the dose can be adjusted appropriately. If too long has lapsed since last shot during the build-up period, the patient may need to start over from baseline and build up their dose again to avoid adverse reactions.
Sublingual immunotherapy tablets (SLIT) are an alternative to traditional allergy shots in the treatment of certain aeroallergen sensitivities. Patients receive their dose of antigen under the tongue to boost their tolerance and reduce their symptoms. The first dose is given in the allergist's office with a minimum 30 minute observation time afterward due the the risk of allergic reaction. If well-tolerated, future doses may be taken by the patient at home, generally on a daily basis. Currently, the U.S. Food and Drug Administration (FDA) has approved four allergy tablet products: two for grass pollens, one for short ragweed, and one for dust mites. Grastek® (Merck) is a Timothy grass pollen extract approved for children 5 and up and adults. Oralair® (Greer) is a 5 grass pollen extract approved for children 10 and up and adults. Ragwitek® (Merck) is a short ragweed pollen extract approved for adults. Recently-approved Odactra® (Merck) is a house dust mite extract approved for adults. Symptom improvement is generally seen within 8-14 weeks. Patients generally start SLIT 3-4 months prior to the start of pollen season and continue through the end of the season. Tablets may be taken year-round, with studies showing reduction in symptoms for both grass and dust mite allergies when taken year-round. Patients generally remain on SLIT for 4-5 years, depending on severity of symptoms, tolerance to therapy, and other factors. Patients with asthma that is not well-controlled or patients with eosinophilic esophagitis are not candidates for at-home SLIT. There are no currently FDA-approved SLIT liquid (drops) formulations, and their effectiveness is still under investigation. Most of the SLIT tablets are FDA-approved for use in patients ages 18-65 only. For younger patients, or patients with multiple aeroallergen sensitivities (more than just grass or just dust mites, for example), traditional SCIT (allergy shots) provides a more customized and all-inclusive treatment option.
For patients with allergies to bees, wasps, hornets, yellow jackets, or fire ants, a sting can be extremely dangerous, even life-threatening. Patients with a history of a severe reaction to an insect sting should be tested to definitively determine the causative venom, and initiate immunotherapy to help desensitize them and reduce their risk of anaphylaxis in the event of another sting in the future. Optimal duration of venom immunotherapy (allergy shots) varies with individual patient clinical history, testing results, and anticipated exposure.
Many children develop rashes with fever and bacterial infections, for which they may be prescribed antibiotics such as penicillin, amoxicillin, or Augmentin. It can be difficult to tell which came first, the rash or the medication. We are able to provide skin testing and oral challenge in the office to determine whether the medication allergy truly exists or remains, and provide a great relief in opening up a whole class of medications to the patient in the event they need to receive that drug in the future. Penicillin is the only FDA-approved drug/medication skin testing and challenge currently available; however, there are a plethora of verified published protocols in the medical literature on a wide variety of medications which we are able to test to. Obtaining medications used in testing is usually coordinated with the patient or prescribing or consulting physician, or from pharmacy if inpatient. Drug/medication testing is generally done on a separate day from the initial consultation to allow for proper protocols and time in administration.
In the event that the patient does have a true allergy to a medication, and it is determined that the patient absolutely needs the medication and there are no alternatives available, upon consultation by prescribing physician, we are able to perform medication desensitization. Aspirin desensitization can be done in clinic. Depending on the nature of the drug or medication, and the inherent risks during the procedure, drug desensitization may require hospitalization in ICU with prior authorization from insurance and an accepting admitting physician (i.e., for chemotherapy). This would be discussed at initial clinic consultation.
Certain skin rashes are more than meets the eye. When the diagnosis is in question or review by a pathologist is warranted, a very small piece of skin and underlying dermis can be sampled in the office for review. This involves a local numbing anesthetic and a small piece of skin (less than the size of a pencil eraser) being taken, followed by a small stitch to enhance healing and reduce scarring. The suture or stitch can be removed generally one week later in the office when the patient returns for the biopsy results, or by the patient's primary physician.
Pumonary Function Testing (PFTs) are helpful in diagnosis and management of certain obstructive and restrictive lung conditions, mainly asthma. By monitoring the lung function, we can track the improvement or decline in asthma control even if the patient is not perceiving symptoms.
It is very important to have an Action Plan with your health. Printable Asthma and/or Anaphylaxis Action Plans are prepared with Dr. Caperton during your visit so you have an actionable plan of "what to do" when symptoms arise for optimal health outcomes.
A relatively small number of foods cause a large majority of food allergy reactions (cow’s milk, hen’s egg, soy, wheat, peanut, tree nuts, fish, and shellfish); however, patients can experience symptoms with any foods. Patients with symptoms consistent with a history of immediate-type food allergy can be tested and if appropriate, challenged in office for tolerance. Oral food desensitization is currently under investigation as a way to promote induction of oral tolerance. The mainstay of current treatment is avoidance, watch for risk of cross-contamination, and education on use of epinephrine. Some children do outgrow their food allergies; thus, monitoring blood levels and performing additional testing over months to years is very useful in helping to predict their chances of eventually tolerating the foods.
Patients with itchy rashes in either a specific spot, or over the whole body may be suffering from an allergy to something with which they are coming into contact in their daily lives. The process of discovering which "something" is causing the symptoms is often quite frustrating for the patient. Patch testing offers patients the possibility of discovering which chemicals or metals they may be sensitized to, and in-depth history with the allergist can be helpful in determining which of these chemicals may be the culprit in their current itchy rash. Bringing in hygiene, cosmetic, and beauty products from home can help us "super-sleuth" any products that may be more insidious than others. Armed with knowledge of their allergens and safe product alternatives, patients are often relieved to finally achieve relief of their symptoms.
Certain patients with frequent infections or need for hospitalizations, or long-term, high-dose antibiotic therapy to control infections, or recurrent diarrhea, or near-constant sinusitis, or growth of atypical bacteria or fungus or virus warrant further investigation into the status of their immune system to determine whether it is functioning appropriately. Patients may have a family history of immunodeficiency disorders, while for others, they are the only family member affected. Patients with primary immunodeficiency diseases can have a higher risk of developing autoimmune disorders or even cancers, so proper diagnosis and management with an Allergist/Immunologist in coordination with other appropriate specialists including Rheumatology, Pulmonary, Infectious Disease, ENT, Oncology, Hematology, and Geneticists can be extremely helpful in managing the health of the entire patient.
Patients with Primary Immunodeficiency Diseases such as Hypogammaglobulinemia, Common Variable Immunodeficiency (CVID), X-linked Agammaglobulinemia (XLA), among others often suffer from frequent severe infections. The severity and frequency of infections may be reduced with immunoglobulin replacement therapy, either at home or in an infusion center. Monitoring of immunoglobulin levels and overall clinical health is paramount with patients with immunodeficiency diseases.
Certain patients with severe asthma as well as year-round allergies (to dust mites, animal dander, or cockroach) may benefit from Xolair® (omalizumab; Merck) every 2-4 weeks, approved for children 6 and up and adults. It is also used every 4 weeks to treat chronic idiopathic urticaria (hives) in children 12 and up and adults. Nucala® (mepolizumab; GlaxoSmithKline) is a monthly injectable medication that works by reducing the number of eosinophils (allergy cells) in asthma patients 12 and older. These are injections given in the allergist's office due to risk of allergic reaction, with mandatory wait period after administration. Patients often experience dramatic reduction in severity of symptoms while on treatment. Need for continued therapy is evaluated at periodic follow-up intervals.
Food Allergy Allergy, Nut Allergy, Peanut Eosinophilic Esophagitis - Child Sulfite Intolerance Sulfite Sensitivity Cow's Milk Allergy (IgE-mediated) Egg Allergy (IgE-mediated) Food Allergen Avoidance Food Allergen Cross-reactivity Food Allergens in Medications Food Allergy Monitoring and Natural Course Food Protein-Induced GI Syndromes Histamine Intolerance and Scombroid Managing Food Allergy at School Meat Allergy and Alpha Gal Oral Food Challenge Procedure Pollen Food Allergy Syndrome or Oral Allergy Syndrome Seafood Allergy Sesame Seed Allergy Spice Allergy Sulfite Sensitivity Vaccination in Egg Allergy
Atopic Dermatitis - Child Atopic Dermatitis - Adult Acute Eczema Seborrheic Dermatitis Seborrheic Keratosis Bleach Baths Dupilumab (Dupixent)
Asthma-Adult Asthma-Child Pediatric Wheezing Severe Asthma Asthma-living with Reactive Airway Disease—Adult (RAD) Exercise-induced Bronchoconstriction (EIB) Reflux (Gastrointestingl) Vitamin D Vocal cord dysfunction Allergic Bronchopulmonary Aspergillosis Omalizumab (Xolair) Mepolizumab (Nucala)
Allergic Rhinitis Aeroallergen Avoidance Allergic Eye Disease Aspirin Hypersensitivity and Aspirin-Exasperated Respiratory Disease (AERD) Common Cold >URI Cough Hay Fever Nasal Polyps Obstructive Apnea Sleep Apnea Snoring Sore Throat Viral Rhinitis Viral Sore Throat
Angioedema (hives) Acute Urticaria Chronic Urticaria Chronic Urticaria Treatment Flushing Mast Cell Disorders Physical Urticaria Urticarial Vasculitis Omalizumab (Xolair)
Penicillin Allergy Aspirin Hypersensitivity and Aspirin-Exasperated Respiratory Disease (AERD) Cephalosporin Allergy Contrast Media DRESS Drug Challenge and Desensitization Drug Rashes (Delayed) Food Allergens in Medications Local Anesthetic Allergy Perioperative Drug Allergy Sulfonamide Allergy Vancomycin Hypersensitivity others among upon consultation
Pediatric Immunization Schedule Vaccination in Egg Allergy Management of Vaccine Adverse Reactions Vaccinations for Adults with Asthma and COPD Vaccines Contraindicated in Immunodeficiency
Pregnancy & Asthma Progesterone Hypersensitivity and Catamenial Anaphylaxis Teratology Society - Pregnancy Medication Fact Sheets LactMed - Lactation Medication Database
Primary Immunodeficiency Syndromes Acquired Immune Deficiency Syndromes Chronic Granulomatous Disease (CGD) Common Variable Immunodeficiency Diagnostic Vaccination for Immunodeficiency Evaluation Elevated IgE Hyper-IgE Syndromes Immunodeficiency Warning Signs IVIG and Subcutaneous Ig Vaccines Contraindicated in Immunodeficiency