July Summer Vacation Allergy Injection Hours

Please Note the Following Changes to our allergy injection hours for July only We will not be giving injections on Wednesday, July 24, 2024, or Thursday, July 25, 2024


What is Histamine?

Histamine is the nemesis of people with allergies and the allergists that care for them.

Think of any allergic symptom and it is probably caused by histamine.  Histamine in the nose causes itching, sneezing, dripping, and congestion.  In the gastrointestinal system, it causes cramping pain, diarrhea, and vomiting.  In the skin, it causes itching, flushing, swelling, and hives.   
Where does the histamine come from? The answer is one of the more perplexing facts in medicine.  We make histamine.

We make histamine.

Histamine is manufactured and stored in a white blood cell called the mast cell.  In allergic reactions, the mast cells release histamine into the tissue or bloodstream.  The result is hives, hay fever, food allergy, and asthma.

Mast cells are part of our immune system and the primary job of our immune system is to protect us from invading viruses, bacteria, and parasites.   So then, why do our mast cells release a flood of histamine when we mow our grass lawn?  Or pet the cat?   Or eat a peanut?  The allergic reaction is a sophisticated, orchestrated, militaristic response to harmless elements in our environment, or in our food, or the medications we take, with potentially life-threatening consequences.  In all this, the primary weapon is histamine. 

Mast cells do play an important role in protecting us from pathogens.  They are very numerous in tissues that are exposed to the environment such as the respiratory tract, the skin, and the intestines, and have the ability to respond to dangerous elements such as infectious organisms and injury.  In this way, they play a role in what is called the innate immune response.  The sensors and response programming of the mast cell are hard-wired and ready to act even before birth.  The mast cell sensors can respond to certain “danger signals’ the first time it encounters it.  

It would be like a baby on the day it is born being able to act on an SOS in morse code by calling the coast guard.

When the mast cells sense danger they release a variety of chemicals stored inside the cell.  In addition to histamine, these chemicals begin the early inflammatory response, preparing the tissue and recruiting many other cells to the area that will complete the task.  Investigators have recently discovered evidence suggesting that mast cells may play a role in protecting us from honeybee, snake, lizard, and scorpion venoms.  

It may be that the powerful mast cell and histamine weapon system that now seems only to cause allergy problems may once have been crucial to the survival of our ancestors as they dealt with a more complex and threatening environment. 

sesame seed bun

Sesame Seed Allergy

Sesame seed is a common ingredient in our diet. It is also one of the most common causes of serious allergic reactions, particularly in children.

When thinking of sesame seed one of the first images to come to mind are the tiny seeds added to bread, buns, and crackers. An estimated 75% of Mexico’s sesame crop goes to McDonald’s to be used in their sesame seed buns.

Cheeseburger with sesame seed bun
Cheeseburger with sesame seed bun

Sesame seed is also the main ingredient in many foods that many do not know contain it. For example, it is commonly known that hummus is made from chickpeas, however, another main ingredient in hummus is Tahini, a sauce made from toasted ground sesame seed. Tahini is also used in halva and falafel and is commonly used in Middle Eastern restaurants as a side dish or as a garnish.

Traditional Greek Food: Hummus and Falafel
Traditional Greek Food: Hummus and Falafel

Sesame allergy is the 9th most common food allergy in the U.S. and its prevalence appears to have increased significantly over the past several years. Although sesame allergy frequently causes severe allergic reactions, it is less well known than other allergenic nuts and seeds.

Sesame allergy is the 9th most common food allergy in the U.S

Since 2004, the FDA has required that manufacturers label foods for 8 major allergens including milk, eggs, fish, shellfish, tree nuts, wheat, peanuts, and soybeans. Importantly, because the FDA does not include sesame in its list of major food allergens, food manufacturers are not required to list it as an ingredient. A year ago the FDA asked for comments regarding adding sesame to the list of major allergenic foods. To date, nearly 5,000 votes have been received overwhelmingly in favor of making the change.

Find out if you are allergic

A history of suspected sesame seed allergy can be easily confirmed with an allergy skin test. Currently, the only treatment is careful avoidance. It is important to ask about ingredients when eating out, particularly if Middle Eastern dishes are on the menu. Anyone with a history of a serious reaction should carry self-injectable epinephrine such as an EpiPen at all times.

Over The Counter Allergy Medications

You feel miserable!

Your eyes are so itchy that you have rubbed them raw and you have fits of sneezing so violent you are afraid you have permanently damaged your ears.  Mucous drips on your keyboard while you try to work and you can’t sleep or taste your food because your nose is plugged shut.   Your mouth is so dry from mouth breathing that it feels like a small furry mammal has taken up residence.

You need relief but you are too busy to get in to see a doctor or the next available appointment is not until the allergy season will be long over.

You might be asking: “What can I get at a local Walgreens, CVS, or Costco that will give some relief?”

Here are a few suggestions:


Get Zyrtec 10 mg (cetirizine) or Allegra 180mg (fexofendine).  Do not get the “D” version of either.

Zyrtec is best but can make you a little drowsy so be careful at work or school or if you will be driving.  Allegra works well and will not make you drowsy but is a pretty big pill to swallow.  These will help the sneezing and itching and to some degree the dripping.   They will not unstuff your nose.

Nasal Steroids

Yes it’s a steroid…however it is topical with very little systemic side        effects, and is the only thing that will safely unplug your nose.   (Read more about steroids)

No nasal steroid works quickly; it will be several days to a week before you see improvement and you have to use them every day.   Flonase (fluticasone) and now Rhinocort (budesonide) are the best.  They both have a smell but neither is deal breaker.  All nasal steroids can cause burning and possible a bloody nose with regular use.  They should not be used in children under 12 without checking with a doctor first.

Eye Drops

Naphcon A works quickly and will temporarily relieve the itching and redness.  Any topical medication with a decongestant (like Naphcon) can cause rebound issues if you use it daily for more than about a week.   For symptoms lasting longer than that, you are much better off getting a prescription eye drop.

Oral Decongestants

Decongestants have issues.  For any but short term, as needed use, the side effects can outweigh the benefits.   There are only two decongestants still on the market: pseudoephedrine and phenylephrine. Pseudoephedrine (Sudafed) is considerable more effective than phenylephrine, which many believe to be so under dosed in the OTC products that it is not much better than placebo.  Pseudoephedrine is now a controlled medication so you can only get a few at a time and you have to sign for what you get.  Oral decongestants can cause cottonmouth, raise your blood pressure and heart rate, keep you up at night, and make it hard to pee (particularly if you happen to have a prostate).

In my opinion, decongestants are more helpful for cold and sinus symptoms.  In fact, OTC medications that use the words, “cold and sinus”, typically contain a decongestant and medications that use the word “allergy” usually contain an antihistamine.

If medications are not helping or if you are wondering if there is an alternative to having to take medications (OTC or otherwise) for the rest of your life, it is time to make an appointment with an allergist.

I just might know one to recommend.

Ahwatukee Oak Alley

I attended medical school in New Orleans.  Along with great food, music and the rich culture and history, one of my fondest memories was the magnificent Southern Oak trees.

These ancient giants, some dating back to the Civil War, with trunks the size of a Volkswagen beetle, hanging with moss, framed an idyllic image of the old south.  They are beautiful trees but they are also one of the major causes of spring allergy problems throughout the south.

When I moved to Arizona and started an allergy practice, I was sure of one thing:  I would not have to worry about Southern Oak allergy problems in Phoenix!

I was wrong.

I have known that there are several varieties of Oaks native to Arizona, the majority of which live at higher elevation in the state, and rarely in Phoenix.  But certainly, there were no trees resembling the Oaks I knew from the south, growing in a typical, low water use, desert landscaped yard in Ahwatukee!

Souther Oak Trees Lining Lakewood Drive in Ahwatukee

Oak Tree Pollen

And yet, if you take a drive around the lakes of Lakewood, in Ahwatukee, (as I did on my bike a few weeks ago), you will find the entire seven mile stretch lined with mature Southern Oak trees.  No hanging moss or women in antebellum dresses swinging on porch swings, but most definitely full of pollen.

Exercise Induced Bronchospasm: Treatment

As every athlete involved in an aerobically taxing sport knows, effective breathing can be key.  Muscles will not keep working  (and you won’t keep going) if you can’t breath. Oxygen delivery to working muscles depends on several factors, but the ability to rapidly move a large volume of air in and out of the lungs is critical.   When oxygen demand exceeds supply, an effort can continue for only a short period before you must slow down or stop.   No gas, no go. That’s the law!

Exercise induced bronchospasm (EIB) causes tightening of involuntary muscles surrounding medium to small airways.  This narrowing of thousands of tiny airways limits the rate at which air can be moved into and out the lung.  The “button” that turns on brochospasm in susceptible athletes is a receptor in the lining of the airways that respond to rapid changes in the temperature and humidity of the airway, conditions that frequently occur with such sports as running and biking out of doors.   Rapidly breathing cold, dry air is a particularly strong trigger.  Fortunately, the airways not only have an “on” button that when pushed tells the airway muscles to tighten, but also an “off” button that will relax the tightened airways, relieving the obstruction and allowing air to flow freely.  This muscle- relaxing button is called a beta-receptor.   Not only are these beta-receptors found throughout the airways, but also in the heart and nervous system where, as you might imagine, they have different effects.

The most important medication used in the treatment of asthma is albuterol, a beta agonist.  In other words albuterol “pushes” beta-receptor buttons causing rapid relaxation of the airway muscles and bronchodilation.  Because of the beta-receptors in the heart and nervous system, albuterol can also cause an increase in heart rate and a sensation of nervousness.

Not surprisingly, the most frequently used treatments for EIB is albuterol.   Two inhalations of albuterol fifteen minutes prior to an exercise cession will provide prevent bronchospasm for up to four hours.   Albuterol can also be used when needed to provide rapid relief of asthma symptoms such as wheezing, chest tightness, and shortness of breath within five minutes.   Albuterol is so effective in preventing exercise-induced bronchospasm that response to treatment with albuterol is often used as a test to confirm EIB.   If a patient is suspected of having EIB but does not improve with albuterol before exercise, an alternative diagnosis should be considered.

Albuterol is very effective in preventing symptoms of EIB but it does have limitations.  In athletes who train daily, albuterol can become less effective over time so that, not only does it become less effective in preventing EIB but can also become less effective during an asthma attack.  This is unlikely to be a problem if albuterol is not used daily.

Because of the concerns associated with daily use of albuterol, it is suggested that an athlete with EIB who exercises daily use an inhaled corticosteroid in addition to the albuterol.  Although steroids are not bronchodilators, they are very effective controllers of inflammation and are felt to maintain the effectiveness of albuterol after several weeks of daily use; inhaled steroids may also effectively control EIB without the need for albuterol.

Another medication that has been used for EIB is monteleukast or Singulair.   Monteleukast is preferred by many because it is a tablet (chewable for children) rather than an inhaler, can be used daily, and does not have the concerns associated with an inhaled steroid.  It does not benefit all who use it and many find it significantly less effective than albuterol or an inhaled steroid.

Albuterol is called a short-acting-beta agonist (SABA) because of it relatively short (four-six hours) duration of action.  Long-acting-beta agonists are also available which provide protection from EIB for up to 10 hours.   This would seem to be ideal for many athletes although because of the concern about loss of effectiveness with daily use and the possibility that this kind of medication could mask a worsening asthma attack, it has been recommended that LABAs not be used without the concomitant use of an inhaled corticosteroid.  Fortunately, there are several products available that combine an inhaled corticosteroid with a LABD including Advair, Serevent, and Dulera.   The LABD in Serevent and Dulera can work as quickly as albuterol and can therefore be used as a very effective daily treatment for EIB.

Several non-pharmacologic treatment options may be effective in some with EIB. These include warming up slowly before a hard workout to create a “refractory” state in the airways, preventing bronchospasm and wearing a mask to limit exposure to cold, dry air.

For patients with allergies who also have EIB, adding an antihistamine may be helpful.

“My Worst Allergy Spring Was the Winter I Just Spent in Arizona”: Part Two

Arizona Ash Flower

While walking my dog several weeks ago, I noticed something unexpected; a number of ash trees in full bloom.   This was unexpected because it was the first week of February and ash trees usually pollinate later in the month.  It was also unexpected because this was near a school in the Foothills of Ahwatukee were the ash trees are supposed to be of a less allergenic variety.   This is in distinction from the Arizona Ash, Fraxinus velutina, which is notorious for it’s prolific production of allergenic pollen. For this reason landscapers have been discouraged from planting Arizona Ash trees for a number of years although they are very numerous in older communities such as the Warner Ranch area as well as old Ahwatukee and Tempe.

Ash trees are in the same family as olive trees, possible the most allergenic tree in Phoenix, and so people who are allergic to one will be allergic to the other

So the ash trees are pollinating a full two to three week early this year, probable because of the warm weather.  This along with large amount of Arizona Cypress and Juniper pollen in the air is creating a very difficult winter for people with allergies.

“My Worst Allergy Spring Was the Winter I Just Spent in Arizona”

When we think of allergy season, fall and spring comes to mind, but not so much winter.  Yet this December, January, and now into February, patients have been coming into our allergy clinic in the suburbs of Phoenix complaining of some of the worst allergy symptoms all year.  Typical complaints include sneezing, itchy nose, and particularly, very itchy eyes.

Alligator Juniper

Alligator Juniper Payson, Arizona

When patients undergo testing for allergies, many show sensitivity to a number of different allergens such as plant pollen, mold, foods, and animal dander.  However, in the case of the winter allergy sufferers, the majority show sensitivity to only one thing: juniper, or more specifically, Cupressaceae.

The Cupressaceae are a family of evergreen conifers found throughout the world. Arizona is home to a number of native species of cupressaceae including Rocky Mountain Juniper (Juniperus scopulorum), Utah Juniper (Juniperus osteosperma), One Seed Juniper (Juniperus monosperma), Alligator Juniper (Juniperus deppeana) and Arizona Cypress (Cupressus arizonica).

Although Phoenix has a number of ornamental varieties of Cupressaceae used in landscaping, the majority are found at 3000-7000 feet elevation and cover millions of acres surrounding Phoenix on all sides.    When conditions are right, a large amount of cupressaceae pollen finds its way into the valley.  One of the chief offenders is Arizona Cypress which is very prevalent in the higher areas surrounding the valley and produces  pollen November through March.

The pollen produced by the different varieties of Cupressaceae cross react with one another, which means that if you are allergic to one you will be allergic to all.  Mountain cedar (Juniperus ashei) is the leading cause of respiratory allergy in South Texas and affects so many with severe allergy symptoms that it has been given it’s own diagnosis, “cedar fever” .

Olive Tree (Olea europaea)

Untitled design (22) (1)The olive tree is native to the Mediterranean, Asia, and Africa and has been cultivated for it’s fruit for thousands of years.  It is a hardy, drought and disease resistant tree, well suited for the harsh conditions of the Sonoran desert.  It is an evergreen tree which can grow to 30 ft and has an attractive gray, often gnarled and twisted trunk gaining character with age.  Some trees are hundreds of years old.  The olive tree produces a small,  inconspicuous pale, white flower which is wind pollinated and produces volumes of airborne pollen in the spring.   Olive tree pollen is one of the most potent and sensitizing of the allergenic plants of Arizona.  Because of it’s association with severe springtime allergy symptoms, the city’s of Phoenix and Tucson have banned the planting of fruiting Olive trees since the 1960s.  More

Mistaken asthma

There is a common saying among doctors that treat asthma: “Not all that wheezes is asthma and not all asthma wheezes”.   This is to remind us to be on the look out for conditions that look like asthma but may not be.

One of the most common asthma mimickers is a condition known as vocal chord dysfunction.  When we speak or sing, the vocal chords tighten and vibrate as a small about of air passes through the narrow opening.   The vocal cords are relaxed during normal breathing, allowing air to easily pass through the trachea.  In a condition called vocal cord dysfunction, the vocal cords and surrounding structures close together, or constrict, during one or both parts of the breathing cycle, partially blocking the windpipe and creating a sensation of not getting enough air.   The symptoms of vocal chord dysfunction are very similar to asthma: shortness of breath, chest tightness, and wheezing.  In fact, patients with vocal chord dysfunction are frequently treated with strong asthma medications including steroids for years before the proper diagnosis is made.

So what causes the vocal cords to tighten during normal breathing?  In many, vocal cord dysfunction is a type of involuntary stress reaction.  The vocal cords tighten during periods of stress.  This may be the case even though an individual does not feel particularly stressed or anxious. Vocal cord dysfunction had recently been recognized a frequent cause of exercise induced shortness of breath, particularly in children involved in school sports.  A child, who has a strong internal drive to win or feels pressure from a coach or parents to do better, may exhibit vocal chord problems.

The most important step in managing vocal chord dysfunction is suspecting it in the first place, particularly in someone who has been diagnosed and treated for asthma but is not responding to typical medications.    Effective treatment includes education and speech therapy.