SCRATCH ’N SNIFF

You know the symptoms of allergies well enough. What you may not know is the impact that environmental allergens have on your sleep, cognitive ability and general wellbeing. Here’s why the condition is nothing to sniff at and how to get it under control.

Why allergic rhinitis is nothing to sniff at – and how to get a handle on environmental allergens

A‘ g, it’s my allergies’ is a tired phrase I’ve been employing for years, having long since accepted that I’d have to live with the symptoms of allergic rhinitis, of which hay fever, a seasonal allergy, is a common form: a sometimes runny, sometimes congested nose; itchy, watery eyes; a scratchy throat; and sneezing. Over the years I’ve tried to pin down which seasons ramp up my symptoms (they all do) and whether they’re worse inside or outside (affirmative on both fronts). I also discovered I’m allergic to cats (not a fan, so that I can live with). So I assumed my allergies were hereditary – my mother is a champion sneezer and almost all my cousins have asthma, hay fever, eczema or all three – and

I thought that every allergen in the air was my nemesis. Case closed. What I didn’t expect was that I could do something about it. And so can you.

that every allergen in the air was my nemesis. Case closed.

Not even steadily worsening symptoms when I moved to a 100-year-old house set between the mountain and the sea deterred me from my assumption that snotting and sneezing were my normal. My thinking was I’d dose myself with antihistamines, not have pets or flowers in the house and vacuum regularly – all of which I did; none of which helped. I felt frazzled during a flare and drained after.

The turning point came earlier this year when I was stationed in Pretoria for a month for work.

I had 12-hour days ahead of me, so heading to the office without a cache of tissues and antihistamines was not an option – yet to my amazement, it was! Not a sniffle, sneeze nor a scratch! I also no longer looked like I was nursing a hangover: my usually irritated eyes were clearer, the circles under them were less Marilyn Manson-esque, my nose wasn’t red, and where was all this energy coming from?

Then I returned to Cape Town, and all hell broke loose. My symptoms were back with a vengeance, so much so that my husband and I were contemplating relocating to Gauteng. What was setting me off in Cape Town? I decided to see Dr Adrian Morris at the Allergy Clinic to find out once and for all. He did an allergy skin prick test, which exposes you to various allergens to determine the ones that affect you (more about that later). House dust mite, Cladosporium mould spores; Timothy, African indigenous and Bermuda grass pollens; and cat and dog dander all made a showing. Pretty much what I expected

– what I didn’t expect was that I could do something about it. And so can you.

IT’S NOT JUST A RUNNY NOSE

Recognising that allergic rhinitis is a chronic condition that needs to be managed is a good place to start. ‘It is one of those conditions that people tend to trivialise,’ says Dr Candice Royal, a paediatrician and allergist at the Kidsallergy centre in Pinelands, Cape Town. ‘We think it’s just a bit of a nuisance, but people don’t realise what an impact it has on their ability to function.’

In his 2005 paper ‘The burden of allergic rhinitis’, published in the journal Current Allergy & Clinical Immunology, Professor Robin J Green of the University of Pretoria writes that the Rhinoconjunctivitis Quality of Life Questionnaire – which measures the functional problems most troublesome to adults – has highlighted in many clinical trials the harmful effects of rhinitis. ‘Despite the relatively small effects of treatment on primary nasal symptoms, differences in areas such as sleep, activity and emotional function were profound, suggesting that even relatively minor illnesses can have important deleterious effects on quality of life,’ he writes.

Quality of life is disturbed mainly by poor sleep, which results in daytime lethargy. ‘You’re having micro arousals the whole night, so you’re not quite waking up but hanging around in a light sleep,’ Dr Royal explains. ‘That causes you to feel tired the next day rather than rested and restored.’ This is often made worse by sedating antihistamines, which many think will help them sleep better. But these medications actually disturb the regular sleep cycle.

Your concentration also takes a hit – and that goes for kids too. Various studies have looked at children with a grass pollen allergy who take exams during the grass season; if they have untreated allergic rhinitis, their scores are dramatically lower. ‘Many parents assume they just have a snotty child,’ says Dr Royal. ‘Yet untreated allergic rhinitis has an impact on their sleep, concentration and behaviour. They develop irritating mannerisms like sniffing or wiping their nose all the time, or making funny noises. There’s also the impact of having a blocked nose, which causes them to breathe through their mouth – that can cause facial changes in the long term; it can give you a very long face with a high-arched palate as well as dental problems.’

What is worse, allergic rhinitis is often compounded by allergic disorders like asthma and eczema that tend to cluster together. In fact, the Allergy Foundation states that allergic rhinitis occurs in 20-30% of South Africans, and 40% might also have asthma, often undiagnosed. ‘Eczema is often the first manifestation of allergic disorders,’ says Dr Royal. ‘It usually starts in babies; later on allergic rhinitis and asthma could occur in childhood.’

ARE OUR GENES TO BLAME?

That’s the question everyone is trying to answer. The prevalence of allergies is increasing so rapidly that while there is a genetic role, it’s more likely that our allergic genes are being expressed more prominently because of changes in our microbiomes.

‘Our environment has changed the kinds of bugs we’re carrying on our skin, in our noses and respiratory tract – that’s allowing allergy to be expressed at an increasing rate,’ explains Dr Royal. ‘All the things that make our environment “too clean” – antibiotic exposure, being born by C-section, not being exposed to animals – swing things towards developing an allergic response.’ There’s also a transgenerational risk: studies have shown that babies of mothers who smoke during pregnancy have an increased risk of asthma – and that risk is carried on to the grandchildren regardless of whether or not the child smoked. So the short answer is: it’s complex.

CRITTERS & CULPRITS

Allergens are either perennial (year-round) or seasonal. Dust mites, animal dander, cockroaches, indoor mould and occupational allergens are perennial, while outdoor mould spores and grass, tree and weed pollen are seasonal.

Remember that 100-year-old house I lived in? Well, lovely as it may have been to look out across the ocean and up at the mountain, it was essentially a powder keg of allergens, Dr Morris revealed: dust mites (critters that thrive in humid coastal regions), indoor mould and damp (commonly found in old homes) and mould spores (from the sea as well from fynbos blowing off the mountain) were all behind my persistent allergic state.

Dust mites are a major problem in the Western Cape. These microscopic, temperature-sensitive creatures feed on dead skin flakes and so penetrate bedding, carpets and upholstery. They need an indoor temperature of 25°C and 70% humidity to survive. (That explained Pretoria: it’s inland, so less humidity means few to no dust mites.) According to Dr Morris, their faeces contain the protein Der p1, which is the allergy trigger; if you consider that up to 10 000 mites can colonise a mattress in three months, that’s a lot of poop! The same goes for cockroaches: their faeces contain allergy-provoking particles. Maize and tree pollen are the main triggers in inland regions like Gauteng. Tree pollen is generally at its worst in autumn/spring, and grass pollen in spring/summer. Not in the Western Cape, though. ‘The grass season is thought to be spring and summer,’ Dr Royal says. ‘But grass pollen may occur at high levels outside of spring and summer, so it’s possible to have symptoms year-round.’

FIGURE OUT YOUR TRIGGER/S

First the medical stuff. When an allergen, like pollen, enters the body, it triggers the immune system to make immunoglobulin E (IgE) antibodies, which attach to the allergy cells (mast cells). When the allergen enters the body again, it comes into contact with IgE. This causes the mast cell to burst and release chemicals, one of the most important being histamine, which tries to usher the allergen out of your body. So you sneeze/ scratch/blow your nose, whatever to get the imposter out. Your body’s ‘overreaction’ is what gives you symptoms, which many then try to curb with an antihistamine.

The allergy skin prick test

This simple, safe procedure takes 15-20 minutes and produces immediate results. The test is looking for those IgE antibodies. Drops of various allergen extracts are placed on the skin, usually along the arm, and small pricks are made to allow the allergens to penetrate the skin’s surface. If you have IgE, histamine will be released and a weal will form – a 3mm weal is significant (my reaction to dust mites and mould spores produced an 8mm weal!).

The test relies on histamine release, so you have to stop taking antihistamines three days prior to it. Oral cortisone medication also needs to be stopped, though asthma inhalers and intranasal sprays can continue to be used.

A blood test is also a reliable option, though the skin prick test is slightly cheaper and more

sensitive. The only drawback of the skin test is that severe eczema may result in false positives.

ALLERGIES, AWAY!

So now you know what’s setting you off. But what if your best friend has a cat? Do you avoid her house, as well as her? (Interestingly, cat dander can be transferred, so if she has it on her clothes, it may set you off.) And if the pollen count is high, do you batten down the hatches and stay indoors? Where exposure is unavoidable, flares are best managed by keeping track of pollen counts and having your medication on hand, says Dr Royal.

The meds

Intranasal steroid nose spray is a preventative treatment that has the greatest efficacy, because by treating allergic inflammation in the nose, congestion as well as other symptoms like itchy eyes and sneezing are also curbed. Eye drops may also be prescribed to help with allergic inflammation. ‘We also suggest doing regular saline irrigation (using a neti pot) to wash out the allergen in the nasal passages,’ says Dr Royal. ‘It also helps to remove the mucus so the medication can be taken up better.’

For those with difficult-to-treat allergic rhinitis, especially people who also have asthma or who are dead set against saying farewell to their pet, immunotherapy may be an option. This involves the patient being exposed to the allergen every day for about three years in order to induce tolerance to it. ‘It’s safe and effective, but not widely available in South Africa, so we have to bring vaccines in on a patient-by-patient basis,’ says Dr Royal.

So long, suckers

When it comes to critters, there’s a lot you can do to alleviate your symptoms. Unlike dust mites that need humidity, cockroaches have to find food and water to survive, so fill cracks in the house and see to damp areas; also pack food away.

As for dust mites, Dr Morris suggests taking some of the following measures:

• Change your pillows every year (this alone made a HUGE difference for me)

• Encase pillows and mattresses in a mite-impermeable microporous barrier covers that can be zipped.

• Water-wise measures notwithstanding, wash bedding and linen protectors at 60°C weekly. Hot tumble-drying and ironing the covers further reduce mite levels.

• Sunlight kills mites, so put your bedding outdoors in direct sunshine for four hours a week.

• Steam-clean mattresses, carpets and bedding every six months.

• Vacuum floors, curtains, carpets and furniture twice a week, as well as mattresses. Keep mite-allergic kids out of the room during cleaning and for three hours afterwards. Your vacuum cleaner should have high-power suction (1 500 watts), and be fitted with a HEPA microfilter (which removes microscopic particles) and double-thick bags, otherwise mites will pass through.

• Air rooms regularly to reduce indoor humidity. A dehumidifier may also help, as will an air purifier, which traps allergens.

• Machine-wash soft toys monthly, then place in a plastic bag in the freezer overnight to kill mites.