A patient’s father recently asked me an insightful question about allergy immunotherapy. Allergy shots had been recommended for his son to treat his seasonal allergy and asthma symptoms and he wanted to know how we decided what allergens to include in the serum.

In some cases, as I explained, the answer is fairly straightforward. If his son had year round allergy symptoms that worsened when he was home on weekends, a very strong reaction to cat dander on allergy testing, and lived in a home with six cats, desensitizing to cat would definitely be a high priority.

More often, the decision is a little more involved but we start with the  following questions:
1. What is the patient sensitive to on allergy testing? When we read an allergy test, a positive reaction is defined as an increase in wheal size (raised area) of 3 mm or greater compared with a negative control or redness around the test site of 10 mm or greater. Skin test reactions are often much larger, however for an allergen to be considered clinically significant, it only has to reach the minimum size.

2. Is the patient currently exposed to the allergens that show positive on the allergy test?  The answer to this can be a bit tricky. For example, a number of people show positive reactions to House Dust Mite on allergy testing. And yet, most experts agree that House Dust Mite levels in the typical Arizona home are too low to cause significant symptoms. This is because House Dust Mites need an indoor humidity level of at least 50% for most of the year to thrive and the majority of homes in the Phoenix area rarely have indoor humidity levels this high. When there is a question, a simple test is to measure the indoor humidity levels in various rooms in the home with an inexpensive hydrometer. Unless the hydrometer readings are above 50%, we may not need to include Hose Dust Mite in the serum mix. However, if a patient frequently travels to more humid climates (anywhere but the South Western United States) and has increased symptoms on these trips, treatment for House Dust Mite may be recommended.

Why would you react to an allergen on an allergy test if you are not exposed to it?   There are several possible explanations. Your allergic sensitivities  may have developed when you were living in an area where the allergen is more prevalent. For example, if you lived in New Orleans for a number of yeas before moving to Arizona, you might have a strong sensitivity to House Dust Mite on an allergy test because of the high level of mite exposure on the Gulf Coast, but mites would be an unlikely cause of allergy problems in your new home in the desert. Cross reactivity is another reason that you may show a positive test to an allergen that you  have never been exposed to.   For example, the major allergenic protein in House Dust Mite is also found in a number of other insects and is also present in the muscles of  shellfish. If you are allergic to shellfish, you may show a positive reaction to House Dust Mite on testing, even though you have never lived in an area where dust mites are prevalent.

Cat and dog dander exposure is another issue. Several studies have shown that animal dander in school classrooms and work places may reach levels high enough to cause allergy symptoms in sensitized people, even if they do not have pets. It is also possible to bring enough dander home from school or work on your cloths for levels in your home to reach symptom-causing levels!

3. Can the allergen be avoided or eliminated from the environment? If a patient has significant allergy problems caused by an indoor pet and that is the only thing they are allergic too, relocating the pet from the home might be the best solution.   This is certainly true in principle but relocating a family pet from the home is frequently not an option and so management with allergy injections may be the only long term solution.

4.  Is the allergen available for immunotherapy? If you developed allergy problems soon after bringing home a pet llama from your travels to Machu Picchu, appropriate material for desensitization may not be readily available.  Because of cost restraints, the companies that provide the material for making allergy immunotherapy extracts limit choices to items that are frequently used.  Even though Phoenix is the 5th largest city in the US, the percentage of people that are exposed to the unique allergens of the Sonoran Desert is small compared with other regions.  For this reason, some allergens that may be important for those living in our area may not be available. For example, Palo Verde, the state tree of Arizona, is not generally available for allergy immunotherapy.