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Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox and I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, everybody. My name is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to talk about urticaria sometimes also referred to as hives or welts. Luke, what's urticaria?

Dr. Johnson: Well, urticaria is hives. Medical term for hives is urticaria. I have also heard people refer to them as welts or welps sometimes, but I think most people call them hives. And there's a type of white blood cell called a mast cell that is responsible for these things showing up on your skin.

Mast cells are all full of histamine and stuff like histamine, and various things can cause them to basically explode and release their innards all over and those innards contain histamine and some other stuff. And that causes the blood vessels to get swollen, which causes the skin to get swollen in that area, which is why hives are pink and sort of raised up.

Dr. Tarbox: And what kind of things can cause hives, Luke?

Dr. Johnson: Many things can. In children, the most common cause is just a viral infection. Usually, something mild like a cold. So if you have a child and they get a bunch of hives, you don't need to get too excited. The most likely explanation is that they have a viral infection, especially if they have some kind of other symptom like if they have a runny nose or a cough or something like that, it's probably what's going on.

Sometimes the hives can be the only thing that the kids have, even if they also have a virus. They're just otherwise healthy but have some hives, it's related to their immune system, getting extra excited about what's going on not necessarily to the virus specifically, and just tends to go away on its own.

Another common cause of hives is medications. Again, the immune system sometimes gets excited about things that it doesn't necessarily need to get excited about, and medications are the most common cause of hives in adults probably because they take more medications and their immune systems are a little bit more mature and a little bit more used to the viruses that can cause the hives in kids, but kids can also get hives from medications and adults can also get hives from viruses though it's a lot less common.

Dr. Tarbox: Some of the most common medications that can cause hives include penicillin, aspirin, ibuprofen, naproxen, and blood pressure medications.

Dr. Johnson: There's also a large category of hives that end up being idiopathic.

Dr. Tarbox: Wah wah.

Dr. Johnson: And idiopathic is the medical term for, we don't know why. And we made up a term idiopathic so that we didn't sound by saying, well, we don't know why.

Dr. Tarbox: We say we say idiopathic, so we don't sound like idiots.

Dr. Johnson: Right. But the good news is that even though we can't always figure out what's causing the hives, we can usually treat them safely and effectively. We can talk about that later.

Dr. Tarbox: There's also some other small categories of hives. Some people will get them related to hormonal changes. Women will sometimes get them in pregnancy, things that kind of perturb the immune system in one way or another can create hives. Some people even get at hives from sunlight.

Dr. Johnson: It's true, very rare. And of course, allergies can cause hives. I'm sure there are people out there who've gotten hives after they've been exposed to a dog or a cat or rolling around in the grass or something.

And then there's what we call physical urticaria. So there are various what we refer to as physical stimuli, things that happen to your skin that can cause it to develop a hive. So there are these very rare patients who can get highs from sunlight, some people get hives from vibration on their skin, some people get hives when their skin gets cold or when it gets wet. The most common of these physical urticarias is dermographism.

Dermographism literally means skin writing, and that's because when you scratch the skin, you create a hive and the exact line where you scratched. So if you were so inclined, you could scratch your name onto the back of somebody who has dermographism, and then your name would show up in hives.

Dr. Tarbox: Yeah. About 2% to 5% of the population has dermatographism, so if you don't personally have this unique human trick, you probably know somebody who does, who can really make a little billboard out of their back.

Dr. Johnson: And usually people aren't really bothered by it though sometimes they can be. And then sometimes people can get dermatographic even if they normally aren't if they have like a viral infection, for example. So the same things that can just caught as hives can also just make your mast cells extra twitchy and make you dermatographic.

There are other pretty rare causes of hives. Like there are some things that you can come into contact with, then you get a hive. That's pretty uncommon. We call that a contact urticaria. And then the ones that are kind of scary is that every so often, hives can mean that there's something a little bit more going on in your body. So sometimes people who have an autoimmune disease can get hives and sometimes certain infectious diseases can cause hives, but don't let your brain go there right away. If you've got hives or your kid has hives, it's most commonly a virus or a drug or it's idiopathic.

Dr. Tarbox: About 10% of the population will experience hives at some point in their life so it's relatively common. The good news is most of the time it goes away. About, you know, a small percentage of patients will have hives that last a little bit longer. When they last more than six weeks, we call that chronic urticaria and then we start getting more serious about trying to figure out exactly what's causing the problem. But what can people do about their hives, Luke?

Dr. Johnson: Well, hives are mostly caused by histamine, and the good news is we have medicines that are antihistamines. There's a lot of them and they're over the counter. There are some that are sedating, means they tend to make people sleepy. And then there are some that are not sedating, meaning they don't tend to make you sleepy. So generally, we recommend that you take a non-sedating antihistamine in the morning and a sedating one at night. Do you have some favorites, Michelle?

Dr. Tarbox: I do. My actual favorite one for hives is Allegra or fexofenadine. It comes in the 180-milligram dose over the counter. It's important that you don't need the decongestants. So you don't need an Allegra-D, Just plain Allegra is the medicine that I prefer the most for urticaria for the non-sedating antihistamines. For the sedating antihistamines, we have a couple of options that we can use.

Dr. Johnson: Benadryl's the most common example of a sedating antihistamine. The generic name is diphenhydramine. It's a fine choice for the evening, as long as it doesn't make you groggy in the morning. There's also a prescription version of Benadryl called hydroxyzine that you make have seen occasionally. Other non-sedating antihistamine, there's a lot of them. The brand names are things like Xyzal and Zyrtec. The generics are levocetirizine, and cetirizine, they're also all good choices.

Dr. Tarbox: Some patients can get a little bit sleepy with cetirizine and levocetirizine, more cetirizine which is Zyrtec. About 25% of the time, it actually crosses the blood-brain barrier and can cause some fatigue. So if you're one of those patients, you would choose a different non-sedating antihistamine to help aid things. So we talked about Benadryl as a sedating antihistamine being helpful for itch. What about topical Benadryl, Luke?

Dr. Johnson: Well, before we move on to topicals, Michelle, I want to just talk about what to do. If you're itchy, you take an Allegra or something in the morning, a Benadryl or something in the evening, and you still got these hives, well, you can increase the dose.

So we know that taking up to four times the normal daily doses of these antihistamines is safe and is usually what we do if people don't get better with kind of the normal dosing. So for example, you could take three Allegra fexofenadine throughout the day, and then a Benadryl diphenhydramine at night. And if that's still not controlling your hives and you're miserable, well, that would be a good time to reach out to us. Though as you say, there are topical options as well.

Dr. Tarbox: Yeah. So when we were talking about topical products and we talked about oral Benadryl for as a sedating antihistamine, we were going to say, what do you think about that topical Benadryl?

Dr. Johnson: I hate topical Benadryl.

Dr. Tarbox: Why do you hate it?

Dr. Johnson: Well, Benadryl's a brand, and so if it's topical diphenhydramine, which is the oral antihistamine. It doesn't work if you put it on your skin and strangely it can actually make you allergic to it. So don't use diphenhydramine cream. I think it's possible that the brand Benadryl also makes a hydrocortisone cream just to confuse things, and a hydrocortisone would be a good thing to put on your hives. It can help the inflammation calm down.

Dr. Tarbox: Yeah, I think that that would actually potentially be beneficial. So topical steroids like topical hydrocortisone or prescription topical steroids can sometimes be beneficial for itching. So do we need to get super excited about figuring out what's causing this?

Dr. Johnson: Usually not. And I know it's frustrating to not know what's causing the hives, but if they get better with antihistamine and then they just go away and don't come back, I am comfortable living in ignorance.

So if you've got hives for just a short period of time, like less than six weeks, that's what we consider short. And especially if the antihistamines control them and they go away, I don't think you need to knock yourself out trying to figure out what's going on.

But situations where you might want to try to figure out what's going on as the hives have been going on for a long time, like more than six weeks, especially if antihistamines are not sufficient to control them.

If you think it's obviously related to some kind of trigger, especially like a food, especially in like a little kid. So if somebody eats peanut butter and they get hives five minutes later, don't eat any more peanuts and you got to make sure you know exactly what's going on there because you can have these dangerous anaphylactic reactions to stuff like that.

But if you just have some hives and it's not obviously related to a food, most likely it's not the food that you ate last night or for breakfast or whatever.

If you have some other funny symptoms that are unexplained, like you've just been getting fevers for no reason, you feel crappy, you also have hives, we should figure that out. And if the hives are just miserable, you know, you've tried antihistamines, they're not better, you're itchy as heck, you're hating life, we should help.

Dr. Tarbox: I like it. So in terms of what doctor people should see to help them when they do get to that state where they're just miserable and they need some help, I actually feel particularly qualified to talk about this because both myself and my husband's specialties treat urticaria. So I am a dermatologist, my husband is the allergist, and both of us are capable of taking care of patients with urticaria.

We have a relatively similar toolkit, although we sometimes use it a little bit differently. If there's a suspicion that there is an inciting element like a pet or food, it might be more helpful to go see an allergist because they can do something called prick testing.

Prick testing allows us to test for the kind of allergy that can cause hives as well as the kind that causes sneezing. If you're having other symptoms that involve the skin, a dermatologist may be more able to help you. But the real answer is when you get urticaria, usually you get it quickly and usually you're pretty uncomfortable. So really whoever you can get in with first is probably the one that you would choose so that they can get you on the road to recovery.

Dr. Johnson: Our first step is usually these antihistamines plus maybe some topical steroids, but if those aren't controlling your hives, know that there are powerful prescription medications out there that can help.

And I think that's all we've got time for. So thanks for hanging out with us today, guys. Thanks to our institutions. Thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us, Michelle. If you would like to hear more of Michelle and I talking, you can listen to our other podcast.

Dr. Tarbox: Our other podcast is called "Dermasphere." That podcast's a bit longer. It's about an hour-long and it's actually aimed at people who take care of the skin. So we call it the dermatology podcast by dermatologists for dermatologists and the dermatologically curious. We invite anyone to come listen though. If you want to learn more about the science behind skin, it's a place that you can take a deep dive.

Dr. Johnson: Thanks for hanging out and feeling hiver with us today. We'll see you guys next time.

Dr. Tarbox: Hello, and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. This is Michelle Tarbox. I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello. This is Dr. Luke Johnson. I am a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: Today, we're going to talk about atopic dermatitis, more commonly known as eczema. Luke, as a pediatric dermatologist, I know you see a lot of patients with this condition, so what is it?

Dr. Johnson: I sure do. It's an itchy red rash, and it's common. There are a lot of things in the world of dermatology that could be described as itchy red rashes, so there are a few things about eczema that look distinct to a skin doctor, but maybe not so much if you don't spend all your days looking and thinking about skin.

It tends to be scaly. It tends to be what we call ill-defined, so it's kind of hard to tell where the rash necessarily starts and stops. It tends to show up in specific areas of the body, and those are a little bit different depending on how old you are, but it's especially common in babies and little kids. There are some medical data that says about one in five babies can get it. And then it's common in other age groups as well.

Dr. Tarbox: Yeah, the literature is about 15% to 20% of kids can have atopic dermatitis. The words eczema and atopic actually are kind of fun. So eczema comes from a Greek word ekzein, which is to boil over or breakout, and atopic means out of place. But really, it's just this eruptive, pruritic rash, this itchy rash, that little kids can get, and it can be so disruptive to their little lives, and as well to the family.

So what causes it, Luke?

Dr. Johnson: Well, what I sometimes tell the families who come in to see me is that if you look in a dermatology textbook about what causes eczema, you find a huge list of things. And you just told me that you wrote a chapter in a textbook about what causes atopic dermatitis. So not only is there a huge list of things, there's an entire chapter about it.

But I tell people that, in my opinion, the most important thing is that can cause it is that the skin is leaky. So one of the most important functions of the skin is to be a barrier between your insides and the outside. And in people with eczema, it's leaky, so it's not as good a barrier. And because it's leaky, water can evaporate away. So people with eczema tend to get dry skin, and then other stuff can get in through those leaks that's irritating and creates the itchy red rash that we see as eczema.

Dr. Tarbox: I love that explanation, Luke. And I think that that's such a nice way to encapsulate it for families. We know from looking at the science that it's caused, in some patients, by a mutation in a gene that helps make the outside of our skin more waterproof. If we lose that waterproofing and we do have leaky skin, we have to remember that water always flows downhill, even microscopically. There's more water in our skin than there is in the surrounding air, and so we lose water through our skin to the air and then other things get in.

Things that can make that worse are an even more dehydrated internal air environment, like what happens in the wintertime when we turn on the heaters and the air becomes dehydrated, as well as a contaminated environment with lots of particulate dust.

Dr. Johnson: And I sometimes have people say, "Well, why does my child have this leaky skin whereas other people don't?" And the unsatisfying answer that I give to a lot of people who have questions about why this happened to them is, "Well, mostly it's bad luck." But what it probably is, is a combination of genes and probably some other factors as well that just came together in this particular configuration, sadly in your child, so that he or she has eczema.

It's not a traditional genetic disorder, so it's not like, "Oh, my dad has it and my grandpa has it. Now I have it." It's more like there is a combination of genes, and if somebody in particular happens to get the right combination, then they are more prone to this kind of issue.

Dr. Tarbox: We also find that some things that mess up what we call our skin barrier, that waterproofing of the outside of our skin, can make eczema worse. Harsh detergents can do this either in clothing or in the products that we use to cleanse skin. Sometimes things that we apply in an effort to improve the eczema can cause problems if it's got irritating chemicals or things that we're allergic to in them.

And then we also wonder about immune dysregulation. Have you seen some flares of eczema in kiddos that have had to deal with the COVID virus?

Dr. Johnson: I don't know about the COVID virus in particular, but it's pretty well known that if kids get a cold, just like an upper respiratory tract infection, their eczema tends to get worse for sure.

Dr. Tarbox: The immune system plays a role. The environment plays a role. And then patients' contact with any kind of chemicals or anything that makes an irritation to the skin also plays a role.

Dr. Johnson: There are other skin diseases that can sometimes be mistaken for eczema: psoriasis and, of course, there are lots of others as well. So I admit I did not know what psoriasis was until I went to medical school. I kept getting it confused with cirrhosis, which sounds the same, but it's completely different. That's a liver disease. And so sometimes I have patients who come in and tell me they have psoriasis and, actually, they have eczema.

It's also not an allergy. So I feel like I have lots of patients and parents who feel that their eczema or their child's eczema represents an allergy to something. And it's true that kids with eczema have more allergies than kids without eczema, but the eczema itself is not an allergy.

Dr. Tarbox: And some of you may know that Mr. Dr. Tarbox is an allergist, so we spend a lot of time talking about this particular interplay of different kinds of medical conditions. When we're talking about a rash from food allergy, that's usually something that makes hives. Some people call them welts. Sometimes we call it urticaria. This is a different kind of rash than eczema is. It's more come-and-go very quickly type of rash than eczema is. So foods can cause a rash but not specifically eczema. What about . . .

Dr. Johnson: There's been a lot of research into food and eczema. So I find that it's pretty common for parents to wonder if it's something about the diet that affects the child's eczema. And again, there's been a lot of research and the general answer is no, there's nothing about the diet that affects their eczema, which I know in some ways is kind of disappointing because we can control our diet.

And I think one reason that there are a lot of people who really want the diet to play a role is because eczema is by its nature uncontrollable. It comes and goes, sometimes for a good reason, like it's dry in the wintertime, and sometimes for no good reason, it's just there. And there's a tendency to want to say, "Oh, well, it's because of something I did," like feed him peanuts yesterday, or whatever. But really, it was just a coincidence.

And while we can control our diet and it doesn't help, we can control what we put on the skin, the sorts of soaps and stuff we use, and other things that we'll discuss. But I do want to reassure people that in the vast majority of cases, the child's diet or the breastfeeding mother's diet is not related to the eczema.

Dr. Tarbox: Now, one thing parents can be in control of that can influence the severity of eczema is cigarette smoking in the house, especially because the particulate debris that can come out from smoking and the contaminants that can end up in the clothing fibers and on the carpet and on the child's skin have been proven to potentially exacerbate eczema.

So if you do have a child with eczema, trying not to smoke around them and trying to keep any clothing contaminated with cigarette smoke away from them could be beneficial.

Dr. Johnson: Eczema is also not anyone's fault. It's not because of something that you did or didn't do during pregnancy, or something that you did or didn't do while taking care of your baby. There are things that can make it worse, like smoking, and there are things that can make it better, like moisturizing the skin. But to current medical knowledge, there's really nothing you could have done to have prevented this.

Dr. Tarbox: So, Luke, when a parent comes to you with a small child that has eczema and they're looking at you with that look of desperation in their eyes, that question that's unasked, "Is it always going to be this hard to take care of this kid's skin?" what do you tell them?

Dr. Johnson: It's definitely a lot of work. And when I have a child with bad eczema and then they're better at follow-up, I make sure to tell the parents a lot of the reason that they are better is because of your hard work. It's definitely hard work.

The good news is that about 50% of kids outgrow it at some point. The earliest that tends to happen is around age 2, though for most patients, it's more like middle school age, so maybe age sort of 10 to 12 they start to outgrow it.

And the genes don't change. So what is it that changes that makes some people outgrow it? Well, we're still sorting that out as doctors. We don't really know. But because the genes haven't changed, if you were prone to eczema as a kid, there's probably something about you that's still prone to it even later in life.

So it's not uncommon that I have an adult patient come in or a teenager and it looks like they have eczema and they say, "Well, yeah, I think I had eczema when I was 3, but I haven't had it for 20 years. What's the deal now?" And to them, I say, "I'm sorry, I don't have an answer as to why this suddenly came back, but it is something that we see."

Dr. Tarbox: One reason we think that kids outgrow eczema is that there's this compound that gets formed in the outside layer of the skin that's appropriately named natural moisturizing factor. And small children don't form it well in all areas of their skin, specifically the areas where they tend to get bad eczema like their cheeks. So it takes them a while to start forming that uniformly over their skin.

And it's formed from that same gene that sometimes gets messed up in patients that have atopic dermatitis or eczema, which is called filaggrin. And whenever this is present, it improves the health and quality of the skin. So researchers are actually looking at replacing it synthetically to try and help improve the skin in patients that have atopic dermatitis.

Dr. Johnson: Finally, I want to point out that we cannot diagnose eczema with any kind of test. The good news is we generally don't need to. Eczema generally looks pretty obvious to most skin doctors and probably a lot of pediatricians and other sorts of doctors as well. So we don't need testing to diagnose it.

You can take a biopsy of the skin where you cut out a little piece and look at it under the microscope. That's not necessary in the vast majority of cases because, usually, eczema looks like eczema and we can figure it out.

But just like the fact that it's not an allergy, we can't do allergy testing, for example, to sort out eczema or to figure out whether or not your child has eczema.

So the best test is to have a doctor look at you or look at your child and listen to the history and figure out if it looks and sounds like eczema.

Dr. Tarbox: One of the good things too is that we know more about it now than we have ever before in history and we have more therapeutic options than we did previously.

So on our next episode of "Skincast," we're going to discuss ways to help treat patients that have atopic dermatitis or eczema.

Dr. Johnson: Stay tuned for that, and thanks so much for hanging out with us today, guys. And thanks to the University of Utah for supporting the podcast, and to Texas Tech for lending us Michelle.

If you are a super dermatology nerd, you might be interested to know that Michelle and I have another podcast. It is called "Dermasphere." It's really intended for other dermatologists and people practicing dermatology, but again, if you're a super dermatology nerd, maybe you'll find it fun as well.

We'll see you guys next time.

Interviewer: You've tried the sprays and the pills for your seasonal allergies, but they just don't seem to work. So what are the next steps to finding allergy relief?

Dr. Gretchen Mae Oakley is a nose and sinus expert at U of U Health. She's really good with allergies too. So in our previous conversation with Dr. Oakley, we talked about managing those symptoms with prescription and over-the-counter sprays and other medications. If you haven't listened to that podcast, be sure to check that out first. But Dr. Oakley, if those sprays and pills aren't working, what are the next steps that you would take with a patient?

Dr. Oakley: The main next step that we generally talk about with patients is allergy testing, and that is identifying what the patient is specifically allergic to or the things, you know, they're specifically allergic to. And the goal behind doing that allergy testing and the reason we don't necessarily do that upfront is because the main goal is kind of a step towards the immunotherapy option. And this is a treatment for allergies that can be very effective for a lot of patients who, you know, are still struggling after medical therapy. And the idea behind it is basically desensitizing your immune system to the allergies, so it's less reactive to that allergen or those allergens.

Interviewer: And it seems like most people I talked to that have allergies, they'll be like, "Oh, I need to go get my allergies tested." In their mind, it's the first thing that you do. Do you find that to be common?

Dr. Oakley: I do. Yeah. I get that question actually a lot, "Should I be allergy tested?" And it's certainly satisfies our curiosity in many cases of, you know, what we're allergic to, but it doesn't necessarily change the treatment if we haven't done those medical management steps yet, because if, you know, whether you're allergic to this specific pollen or that specific, you know, weed, or this tree, or that grass, you're still going to be using those as, you know, your earlier steps. You're still going to be using, you know, those nasal steroids sprays first or the oral antihistamines first and the antihistamine sprays first, because that has, you know, a broader effect, you know, on all of those.

So that's what we generally don't do that upfront, because it doesn't necessarily change our first couple steps and, you know, the treatment. But it does affect, you know, our later steps. If we're thinking of immunotherapy, we need to know what we're specifically treating for that to work. And so that's kind of where it comes in and the point behind the testing, you know, at that stage generally.

Interviewer: Yeah, so your patients that you take at that point to the testing stage, I'd imagine they're just not finding any sort of relief from the first steps, or their allergies are just so terrible. I mean, what kind of patient then makes it to the testing stage usually? You're able to . . . I would imagine the medical things that you do first, the sprays and the pills take care of a lot of what patients experience.

Dr. Oakley: Yeah. I would say the patients that generally get to that next stage are those that are getting either really severe or really bothersome seasonal allergies that are refractory to the medical therapy. And they just don't want to, you know, suffer every summer, all summer or every spring, all spring. Those are good candidates for immunotherapy. They're getting breakthrough symptoms despite those, you know, medical treatments.

Other patients will have year-long allergies because they may be allergic to, you know, dust mite, and it's all around them. It's in their house. And, you know, there are things they can do, like, you know, try cleaning their house really well. However, we've not seen that those things will fix the problem in a noticeable way. They'll still get their symptoms. And so, you know, those patients are suffering all year, and, you know, there are immunotherapies that can help with those perennial allergies.

An additional option, for example, would be a patient who has a cat that they're allergic to, but they're very, you know, emotionally connected to their cat. It would be distressing for them to get rid of their cat, or it's a partner's cat and, you know, they can't necessarily avoid it. It's not so easy to always get rid of a pet. So that'd be another case where immunotherapy may, you know, play a good role for that patient.

Interviewer: When you get to that point, you do some of the testing, and then after you get the results, how do you proceed to the immunotherapy and how does that work?

Dr. Oakley: So generally, we're identifying the allergies that are causing, you know, the sensitivities that the patients have based on how they respond to, for example, skin prick testing, which would be the most commonly used allergy testing upfront. It can be done, you know, in the office. Patients are tested for multiple allergies at once usually on their arm. You're using a grid system to see what skin responses are the most significant to determine what they're, you know, most allergic to. And those are the allergies that you target, you know, their worst reactions with the immunotherapy. And the idea behind the immunotherapy is giving them very small but ramping up doses of that thing that they're allergic to, to just gradually desensitize the immune system to it.

Interviewer: I remember getting those as a kid. I've had more success with the first line of defense in later life, with some of the new medications that came out, I don't know, probably 20 years ago now, but I say new. So like my experience was the immunotherapy didn't really help me. Do a lot of people experience success with it?

Dr. Oakley: It's generally considered to be 80% to 90% effective. But, you know, it's not 100% effective, as you said. So some people don't get that response. It's generally very effective, but it is a commitment. It's very much a time commitment. You know, it's a three to five-year treatment where patients are coming in anywhere from a weekly to a . . . or I should say anywhere from a twice weekly to a monthly basis for injections, you know, to get that benefit.

Interviewer: Yeah. I remember it was twice a week I'd go in and get those allergy shots. So if immunotherapy doesn't work then, then it sounds like the last option is surgery, and I didn't even know there were surgical methods for allergies. Talk about that.

Dr. Oakley: Well, I should clarify because surgery is more of an assistive option.

Interviewer: Oh, okay.

Dr. Oakley: So not so much a treatment. It doesn't specifically cure or treat allergies. It helps with the symptoms, but in and of itself would not be sufficient. It goes along with these other treatments. So surgery can address some of the more bothersome nasal obstruction symptoms. For example, well, let's just say specifically from anatomical factors, like a deviated septum or enlarged turbinates, which are, you know, shelves of tissue in the nose that warm and humidify the air but can get quite enlarged with allergies. So treating some of those anatomic, you know, factors can improve symptoms of nasal congestion, but you need to treat the trigger as well, the ongoing allergy trigger. So that's that medical management or immunotherapy as well. So the surgery helps, but it's not a treatment in and of itself.

Interviewer: If somebody is listening to this and you just would want them to take away one thing after we're done with our conversation, what would that be?

Dr. Oakley: The main thing I would say is don't suffer in silence. This is a really common problem with many options for treating it. We know from, you know, research study after research study that there is a significant improvement in quality of life when these allergies are managed appropriately in patients rather than just struggling with really bothersome and really distressing, you know, symptoms on a day-to-day or seasonal or yearly basis. You know, try some of these easier steps. Don't hesitate to come in and get some, you know, formal consultation and talk about other options that can really, really benefit you.

Interviewer: There is no cure for allergies. Really the best you can do is manage the symptoms, and the first step to doing that is to avoid the things that give you allergy symptoms, but that can be hard. A lot of times you can't do that. So then the next step are sprays, pills, and eye drops.

Dr. Gretchen Mae Oakley is a nose and sinus expert at U of U Health. She's also an allergy expert, and she's going to take us through the process of trying to figure out how to manage those symptoms and then maybe help us understand when you might need to get professional help. So Dr. Oakley, let's first start with allergy sprays.

Dr. Oakley: There are a couple main nasal sprays that work really well and have great evidence behind them for the treatment of allergies. Our first-line treatment based on the literature and just how well it works in patients is nasal steroid sprays, and fortunately they're all over the counter. Some of those sprays would be, if I were to name some, Fluticasone nasal spray, Mometasone, Budesonide. Those are probably some of the three most common. There're a couple others in that, you know, similar family and those work really well.

You can use them up to twice a day, more than that is not going to help anymore, but once or twice a day use. They're very reliant on regular consistent use, and they have a bit of a slower ramping up effect, so you really want to use them for at least, you know, a few weeks on a daily basis just very regularly to get their full effect rather than, you know, here and there when your symptoms bother you.

Interviewer: If the over-the-counter stuff doesn't work, are their prescription ones that are very different from that, or is most of them over the counter nowadays?

Dr. Oakley: There's an antihistamine spray that is a prescription that can actually work great for a lot of patients too, either as their primary treatment or as a, you know, secondary, an additional treatment if the corticosteroids sprays alone don't work enough for them. That antihistamine spray is called Azelastine, and it works particularly well for those let's call them the wet allergy symptoms, which is, you know, more of those like sneezing, runny nose, itchy, watery eyes, that kind of tickle sensation that we can get with allergies. They work okay for the nasal congestion symptoms, but the steroid sprays work better for that.

Interviewer: What is it that makes it so different from person to person that perhaps maybe a steroidal spray would work for one person but not another, they'd have to use, you know, an antihistamine spray? Is it just the difference in us as humans?

Dr. Oakley: We don't always know exactly why some patients respond better to some sprays, you know, versus others. It may just be a severity of their symptoms. You know, they may get 75% better with the steroid sprays, but it may just not quite be enough. Whereas somebody else where their symptoms are maybe moderate rather than severe, they may do great, and that's all they need.

Some patients may be a little more bothered by like the runny nose and the sneeze, whereas, you know, in those cases antihistamine sprays would work better for them. So sometimes we just get different presentation of our allergies, different symptoms and different severities. But you're right that the other factor is we're all just a little bit different and we respond just a little bit different to certain treatments.

Interviewer: It can be a little frustrating as an allergy sufferer sometimes because I think sometimes as patients we think, "Well, I'm going to go in and the doctor's going to give me the cure," right? But with allergies it sounds like, you know, sometimes you have to do some experimenting on what's going to work best for that individual person.

Dr. Oakley: Exactly. There's definitely some trial and error there to try to get it just right for that patient. The third thing in terms of nasal treatments I didn't mention, that I'd be remiss if I didn't mention, is very straightforward, and it's just some saline in the nose, saline irrigations specifically. Those can work really well as an adjunct treatment. It's not going to in and of itself fix your allergies, but it can help with some of the symptoms along with some of these other treatments by mechanically washing, you know, those allergens, those irritants, those pollens out of the nose so they're not just sitting, you know, on the lining of the nose inflaming it. So it can help, you know, in some of those ways as well.

Interviewer: So do you normally go nasal spray first and then oral medication? Is that how that usually goes?

Dr. Oakley: I would say, in general, yes. I like to give people topical treatments over oral treatments if possible, just because your side effects tend to be lower. The other thought in that however, that I'll talk to patients about, is that certain oral treatments, like oral antihistamines specifically, those tend to work similarly to a nasal steroid spray, have similar effectiveness, but sometimes patients will have symptoms that are not just in the nose. They'll have, you know, maybe some dermatitis that they get with their allergies that bother them or, you know, symptoms like that that are elsewhere, and sometimes the systemic therapy, an oral therapy in that case can be a little bit more helpful than a localized therapy.

Interviewer: So oral medications, let's talk about over the counter first. What are kind of the choices there?

Dr. Oakley: I would say the main one, the front runner are those oral antihistamines. So the newer versions that tend to work better for patients with fewer side effects are those medications like Loratadine and Cetirizine and Fexofenadine. Those are the main kind of newer generation oral antihistamines. The older generation antihistamines would be, you know, what we know as Benadryl, which can work too but has, tends to have higher side effects and be more sedating for patients. So we generally recommend those newer generation, non-sedating medications. And they have great evidence behind them, they work well, and those are over the counter.

Interviewer: And then itchy eyes is another symptom that a lot of people have with allergies. I used to suffer terribly, and then I was prescribed some eye drops, which now I think I can just get over the counter because I've bought them. I think they're the same thing, which makes all the difference in the world. Can you talk about some of the eye drops you might want to look for if itchy eyes are part of your allergy symptoms?

Dr. Oakley: Yeah, eye drops can actually help a lot, and it is generally an antihistamine eye drop. There are a couple different ones. One that's popping into my mind is Olopatadine. That can actually help patients significantly because a constant itchy eye will drive you crazy.

Interviewer: And just like all the other things, the nasal sprays, the oral medications, I had to try a couple of different antihistamine eye drops before I found the one that really kind of worked for me. So you know what, I started out thinking, well, let's see if we can give people, you know, some things they can try on their own, but then you start talking about how, you know, this combination isn't proven to work as well as that combination, and it can get really complicated really fast. So I'm starting to think maybe if like the first nasal spray doesn't work, maybe go see a doctor to try to figure out what combinations of stuff because that does get complicated pretty fast, doesn't it?

Dr. Oakley: It does get complicated pretty fast. It is certainly reasonable to try a couple over-the-counter meds on your own. I personally, you know, if I were in the patient's shoes, I would start a nasal spray and give that a few weeks personally. If that didn't work, you know, I'd maybe try an oral antihistamine for a couple weeks and see how I do. But after that, I don't see a lot of sense in just suffering. I think it's worth going in and talking to your doctor about some alternative options that may help quite a bit rather than just being miserable.

Dr. Gellner: Insects bites and allergic reactions, what's a myth and when to worry is today's topic on The Scope. I'm Dr. Cindy Gellner.

Announcer: Keep your kids healthy and happy. You are now entering The Healthy Kids Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: We see a lot of bug bites especially in the spring, summer, and fall, and they can cause quite a lot of swelling. It may look shocking if your child has a very large lump where they were bit. This means they're allergic to that bug, right? Not in the sense that we worry about an allergy. That's an old wives' tale. The size of the swelling can vary from a small dot to a few inches in diameter, and the larger size does not mean that your child is allergic to the insect. In fact, take the example of mosquito bites near the eye. They can usually cause enough swelling to close the eyelid almost shut for two to three days, and some mosquito bites in sensitive children form hard lumps that can last for months.

Children who have allergies or eczema can have a larger reaction than other kids do. Why? It's just because their immune systems are ramped up to attack anything it deems a threat, and more histamine is released. Histamine is the chemical in our bodies that causes allergic reactions. A bug bite triggers a local histamine reaction, but we don't say that people are allergic to mosquitoes or other common biting insects. A true concerning allergic reaction to an insect bite would involve excessive swelling, difficulty breathing, hives, and maybe even vomiting or passing out. Bees are an insect many people are allergic to, and these are the symptoms that concern us and why people who are allergic to bees carry epinephrine injections.

If your child just has a localized reaction, whether it's hot, tender, or swollen, try hydrocortisone cream along with an over-the-counter antihistamine. These medicines will help keep your child from scratching. Now, if the swelling continues after a few days especially with treatment or you notice red streaks from the site of the swelling or your child starts acting sick with a fever, then it's time to see your child's doctor to make sure they're not developing a skin infection as a result of the bite.

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Announcer: Have a question? Ask it. Send your listener question to hello@thescoperadio.com.

Interviewer: It's time for another listener question and we're here with Dr. Kirtly Parker Jones. Dr. Jones, the question sent in was, "Could my baby be allergic to my breast milk? I've noticed that he's not really absorbing it, he's not really taking it, but he's fine with formula milk."

Dr. Jones: To start at the beginning, babies cannot be allergic to your breast milk.

Interviewer: The answer is just no?

Dr. Jones: The answer is no. However, there are proteins in what you eat that are absorbed into your bloodstream that then come out in the breast milk, and certainly there are flavors in what you eat that come out in the breast milk. In fact, there are flavors of what you eat when you're pregnant that flavor the amniotic fluid, and the baby is already kind of drinking your garlic or your hot sauce, or whatever it might be. The babies will not be allergic to your breast milk. Newborns don't actually form an allergic response. So it takes a while for babies to be able to even form an allergic response.

So, if newborns are throwing up, you start to really worry that maybe they have a problem with their stomach. So sometimes babies actually have a weakness in their stomach that allows the fluid to come back up. So some babies actually have to be fed kind of thickened milk or have to be slept tilted like people who have reflux. So babies can have reflux and newborns can have reflux until they're a little older. So babies can have reflux and that can make them throw up, and it's not they're allergic, it's just that they can't keep the fluid down.

Secondly, there are some babies with congenital malformations that cause a blockage in the esophagus. This is very rare and it's devastating. So there's a blockage in the esophagus and the fluids go down into their lungs. This is called a TE, a tracheoesophageal fistula. Once again, it's the baby that's not actually absorbing because it's going down the wrong way.

Now, let's take babies a little bit older. They actually can be allergic and develop an allergy to things that are in your food, and the most common is milk. So milk proteins in milk, of course, when . . . oh, cow's milk, there is something called casein and this is a protein that a mom might actually have in her blood and that the baby might actually develop an allergy to. That being the case, babies might get a little distended, they might be a little uncomfortable, and sometimes, they may even have a rash around their rear where it's kind of irritating.

Now, what about the baby that seems to be fine with formula and not so well with breast milk? Well then, the questions is, is the baby getting better suckling with the nipple . . . the formula? Is there something in the mother's food that's flavoring her breast milk? Meaning is she eating a lot more garlic, or is she eating spicy things that are getting through and the baby doesn't like the taste? And then the question is, is the mother putting anything on the nipple that the baby doesn't like the taste of? So we put all these lotions on our bodies and women put lotions and Bag Balm, which doesn't really taste very good. Bag Balm is something they put on nipples of cows when the nipples break down with nursing cattle, and so that may not taste very good.

So what are you putting on the skin and the answer is nothing, is the baby actually latching on well? So sometimes the baby has to struggle getting the whole nipple in their mouth, but it's easy to put the nipple from the bottle. There are many cultural norms about what you should and should not eat because of what goes in your breast milk, like don't eat cabbage because it will make your baby bloated. Well, unfortunately, cabbage won't make your baby bloated. It might make you bloated, but not your baby.

Of the things that they worry about, cow's milk is the first and about 2% to 3% of babies might actually be allergic to the cow's milk that their mother has in their food. And if a baby seems like it's not absorbing or is irritated by the breast milk, the question is what is it? And you have to kind of take things away. The top ones are peanut, soy, and cow's milk, but there may be other things. So moms need to eat carefully. The baby may not like garlic in their breast milk. By the way, wine goes right through the breast milk, too, so be careful.

So the long and the short of it is the baby is not allergic to your breast milk, but it can be allergic to what you're eating. There are lots of cultural superstitions about what mom should and shouldn't eat, and what should go in the breast milk. There's not much science, but if you take away one thing at a time and see if the baby does better, you might figure out what it is. And of course, your pediatrician can really help you work this out.

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Interviewer: What are the symptoms of food allergies? We'll examine that next on The Scope.

Announcer: This is "From the Frontlines" with emergency room physician Dr. Troy Madsen on The Scope. On The Scope.

Interviewer: If you're listening to this right now, you probably suspect you might have a food allergy and you're curious to know for sure if that could be the case. Probably have a lot of questions and so do I so we're going to talk to Dr. Troy Madsen. He's an emergency room physician at University of Utah Health Care. So symptoms of food allergies, how do I know if I have a food allergy? What are some of the common symptoms? And there's a difference between food allergies and food sensitivities?

Dr. Madsen: Exactly, yeah and that's often a point of confusion, but allergies are like any other kind of allergy. If you have a food allergy, it can range from mild, so maybe some itching, little bit of a rash; to more severe, where you have some throat tightness, some lip tingling, to really severe cases where you just can't breathe. So those are what we think of with allergies.

Interviewer: With food allergies. And is it possible for me to just be minding my business, I'm eating something I've eaten my whole life and now, all of a sudden, my throat's swollen, like I've reacted that quickly and that severely?

Dr. Madsen: It is possible and, surprisingly, it's not uncommon. People I've known who have had eaten shellfish for years and then sometime in adulthood, eat some lobster or some shrimp, and just suddenly develop itching and facial swelling and trouble breathing. So it's entirely possible. You could've eaten this food for years and then, later in life, develop a food allergy.

Interviewer: All right. And if you start having these symptoms, what should you do?

Dr. Madsen: If they're mild symptoms, like a rash, maybe just a little bit of itching, you're probably okay just to take some Benadryl. But if it's more severe, anything that involves the airway, any lip swelling, tongue swelling, throat tightness, trouble breathing, that's where I would even call 911. I mean, you've got to get to the ER because those things can develop really quickly and be life-threatening, just very, very severe reactions.

Interviewer: So those symptoms again, lip swelling, tongue swelling, tingling?

Dr. Madsen: Tingling, I would get to the ER and, again, if you're . . . any concerns about your airway, call 911.

Interviewer: All right. Don't mess around with that.

Dr. Madsen: Exactly.

Interviewer: I feel like we only talked for a few seconds here about this topic. Have we covered it all? Is that pretty much it?

Dr. Madsen: Well, like you mentioned, there's also the issue with food sensitivity versus allergies. So again there, we're talking about very different things, some people may have concerns about gluten or other things in foods. There, they may have some more abdominal cramping, maybe some nausea, diarrhea. That's not a true allergy. Again, the allergies are the things we think of with any sort of allergy: itching, rashes, airway issues, much more concerning in terms of getting to the ER.

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Dr. Gellner: Like all food allergies, milk allergy can be difficult to manage in a child. How can you help your child when milk is a common ingredient in so many foods? I'm Dr. Cindy Gellner with some tips for this tricky food allergy on today's Scope.

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kids Zone with Dr. Cindy Gellner on the Scope.

Dr. Gellner: A milk allergy is not the same as lactose intolerance. Lactose intolerance only affects the digestive tract and it cause symptoms such as bloating, gas, and diarrhea. A milk allergy is a reaction by your child's immune system to the protein in milk. Our immune systems normally respond to bacteria or viruses that attack the body, but sometimes the body's immune system mistakenly believes that a harmless substance such as the proteins found in milk are harmful.

In order to protect the body, the immune system goes on attack with antibodies against that food. And the next time you eat that food, your immune system releases huge amounts of histamine to protect the body against the evil food proteins. That is what causes the symptoms that make us so miserable.

Casein is the main protein found in milk. It is found in the solid part of milk called curd when the milk goes sour. Whey, which is the liquid that remains once the curd is removed, contains the rest of the proteins. Your child can be allergic to the proteins in the curd, the whey, or both.

In very young children, cow's milk is the leading cause for allergic reactions. Milk is one of the eight foods that are responsible for food allergies in children. The other foods include eggs, soy, peanuts, tree nuts, wheat, fish, and shellfish. The good news is that most kids outgrow milk allergy by two or three years of age.

If you think your child is allergic to milk, dairy products, or any other food, it is important to get a diagnosis from your pediatrician or an allergist. Usually the history of the reaction is all we need to determine the allergy. But there are blood tests to confirm for some of these foods.

Milk allergies are typically discovered very early in formula and breast-fed babies. If a mother drinks cow's milk, the milk protein also comes out in her breast milk. The symptoms seen in milk allergy depend on whether or not the child has a slow or rapid reaction to milk.

The slower reaction is more common and the symptoms develop over time. Symptoms that occur slowly over several hours or sometimes days include diarrhea, often with streaks of blood, wheezing, rashes like eczema flares, and failure to grow very well. Symptoms that occur rapidly within seconds to hours may include severe wheezing, vomiting and hives.

If a mom is nursing, the pediatrician will most likely recommend avoiding milk products to the mom and taking calcium and vitamin D supplements instead. If your baby is formula fed, sometimes pediatricians will recommend a soy-based formula. These formulas contain soybean proteins, vitamins and minerals. The switch to soy formula helps for about half of the baby's allergic to milk. For those babies who still have reactions to milk proteins, pediatricians recommend hypoallergenic formulas. There are two types.

Hydrolyzed formulas contains proteins that have been broken down so they are easily digested and less likely to cause a reaction. These include Nutramigen, Alimentum and Pregestimil. Elemental formulas have proteins in their simplest form and are used when hydrolyzed formulas continue to cause symptoms. These include Neocate and EleCare.

The only treatment for a child with a milk allergy is to completely avoid milk and foods that contain milk products. Many processed food and restaurant foods contains milk or processed milk products. And you will need to change the way you shop and prepare foods.

The first step is to learn how to read labels and become familiar with ingredients that contains milk or dairy products. Always ask about ingredients if you are not sure. Foods and ingredients that contain milk include milk from other animals such as a goat, as well as yogurt, cheese, cottage cheese, cream, anything with casein or whey, butter and sadly chocolate. And also be careful of any ingredients that begin with "lac" such as lactose, lactate, lactalbumin, and lactic acid, and also fat replacers such as Simplese.

Reading labels to avoid allergens has become a lot easier. Foods that contain common allergens must be listed in plain language on the ingredient list. There are still some things to watch out for when reading food labels. Watch out for the words "may contain". Milk may not be an ingredient but the food may be made in a factory which also produces foods made with milk. If you see the words "may contain," there may be very little of the allergen or there may be a large amount.

A common question from parents is how to avoid cross contamination. Avoid battered or fried foods. The oil is often used for many different items, some of which may contain milk. Separate cooking utensils, cutting boards, and dishes used to prepare dairy products from those used to prepare food for your child.

Your child can still have a healthy diet as well as continue to enjoy some kid favorites. The main nutrients found in milk are protein, calcium, vitamin D and riboflavin. It is important to either take supplements or eat foods that are high in these elements. There's a lot of protein in milk, poultry, pork, fish, beans, nuts, and seeds. Ask your pediatrician about calcium and vitamin D supplements. Good sources of riboflavin are meat and eggs, whole grain or enriched cereals, and dark green leafy vegetables. Many foods such as bread and orange juice are now supplemented with calcium and vitamin D.

There are several brands of soy and rice milks that are enriched with calcium. They can be used for drinking and to pour on cereal. If milk is part of a recipe just to provide liquid, you can substitute water. Soy and rice milk, as well as fruit juice works well when substitutes baking. Oils, milk-free margarines, and soy butter can take the place of butter.

You can also visit foodallergy.org where there are many other helpful tips. Prepare your child's lunch at home. Talk with teachers about your child's needs. Ask the teachers to keep an eye out and explain the situation to other children if needed. Have the teacher call you if there is a special event or party planned so that you could bring a few modified treats that your child enjoys and can share with other kids. Make a card that lists foods and ingredients that should be avoided and give one to the teacher.

Living with food allergies is possible. I'm proof of that. By making others aware of your child's food allergy, you will keep your child safe. If your child is old enough, even as young as three or four, make sure they are aware of their food allergy. This will empower them to be in charge of their own health.

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Dr. Gellner: Latex allergy is more common than you might think. I have it, and it's one of the main reasons latex is not found in medical offices anymore. How do you known if your child is allergic to latex or not, and what should you do about it? I'm Dr. Cindy Gellner on The Scope.

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kids Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Latex is a substance made from a milky fluid that comes from the rubber tree. With a latex allergy, the body treats certain proteins in latex as if they were harmful and triggers an allergic immune response. This may happen when products made from latex touch your child's skin, mouth, or even if they are just inhaled. Children who have chronic diseases, such as spina bifida, or have a lot of surgeries, may be exposed to latex from the medical procedures. They may become sensitive to it.

Children who have allergies to certain foods may also develop a latex allergy. Both the foods and the latex have some of the same proteins. These include fruits such as bananas and kiwis, vegetables including avocadoes and tomatoes, tree nuts, peanuts, and shellfish. If you think your child is allergic to latex, it is important to get a diagnosis from your health care provider or allergist.

Symptoms of a latex allergy can develop over several hours, or they may be immediate and severe. The most common reactions are skin reactions, such as hives and eczema flares. If latex is around the mouth or inhaled, your child may have wheezing, trouble breathing, itching and swelling around the mouth, and a rapid heartbeat.

It is possible to have an allergic reaction called anaphylactic shock. This is a serious reaction that is sudden, severe, and can involve the whole body. It can cause swelling of the mouth and throat, dangerously low blood pressure, and trouble breathing. This type of reaction is an emergency. It is treated with antihistamines and injectable epinephrine. Usually, parents or caregivers of children who have severe allergic reactions carry their own epinephrine in case of an emergency. If epinephrine is used, or your child has a reaction, and epinephrine is not available, call 911 immediately.

Many things contain latex, including baby bottle nipples and pacifiers, rubber bands, balloons, Band Aids, IV tubing and catheters, many kinds of medical gloves, and dental dams used in dental procedures. In general, any item that can be stretched may contain latex. There are many things that can be used instead of things that contain latex. These are made from vinyl, plastic, or silicone.

If your child has been diagnosed with a latex allergy, teach your child to known and avoid latex products. Make sure your child wears a medic alert bracelet or necklace. Know what to do in case of an emergency. Ask your child's health care provider about a prescription for injectable epinephrine in case of emergency.

Finally, be sure to tell all dentists, health care providers, teachers, daycare providers, babysitters, friends, and family members that your child has a latex allergy. Anyone your child's going to be spending time with needs to know about this. Something as simple as going to a birthday party with latex balloons can trigger a serious reaction. Be sure you are always prepared for your child.

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Dr. Gellner: Anaphylaxis is a frightening thing to see your child have. What is it and how can you be prepared if your child has a severe allergic reaction? I'm Dr. Cindy Gellner for The Scope.

Announcer: Keep your kids healthy and happy. You are now entering The Healthy Kids Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: A severe allergic reaction is called an anaphylactic reaction. It is an immediate, severe reaction, usually due to a bee sting, medication, or food. The symptoms begin within 30 to 60 minutes and include wheezing, trouble breathing, tightness in the chest or throat, and the voice may even change, dizziness or passing out, the skin may become blue, swelling of the lips, tongue, or throat, and widespread hives, swelling or itching. They can also have significant vomiting, diarrhea, or stomach cramps. If your child has hives, swelling, or itching, but these symptoms do not occur with the symptoms we just mentioned, your child is probably having an allergic reaction but not an anaphylactic reaction.

So what should you do if your child has a severe allergic reaction? Remain calm. Call 911 immediately, especially if your child is having trouble breathing, trouble swallowing, or any serious symptom. Have your child lie down with their feet elevated to prevent shock, and if your child stops breathing, start CPR.

If your child has a known anaphylactic reaction to something, make sure you have a prescription for injectable epinephrine in a form called an EpiPen. If you have an EpiPen, give your child the shot of epinephrine immediately. It can save your child's life. Inject it into the thigh muscle. You should be trained by your pediatrician or pharmacist as to how to use this when you get the prescription. Don't hesitate to give epinephrine. If your child has had a life-threatening reaction in the past and now has been re-exposed to the same allergic substance, for example peanuts or a bee sting, give the EpiPen before your child develops symptoms. Again, it could save his or her life.

Your child will feel the effects of epinephrine. He or she may vomit. They will feel shaky, have heart palpitations, and a headache. Your child will need to be monitored for a few hours after the epinephrine to make sure that their blood pressure is stable and that they don't have symptoms of anaphylaxis come back after the epinephrine has worn off. For that reason, EMS will transport your child to the hospital.

If your child has been stung by a bee and is allergic to bee stings, treat the sting by making sure you remove the stinger. Do this by scraping the stinger off with a credit card, rather than squeezing it.

The only way to prevent an allergic reaction is to avoid contact with the food, drug, or other item that causes the problem. It is very important to learn to read food labels if your child has a food allergy. Since the reactions can be fatal, you should keep emergency kits containing epinephrine at home, school, and in a backpack if you're traveling. Educate others about your child's allergy. Tell all pharmacists, healthcare providers, and dentists who treat your child about any allergies he or she has. This goes for school personnel as well. Your child will be able to keep epinephrine at school. You will just need to have a form completed by your pediatrician, so that the epinephrine can be kept at the school nurse's office or with the secretary and can be used if needed at school.

Your child should have a medical ID bracelet or necklace that tells the insect, drug, or food allergy as well. Remember, if your child is not with you and he or she has an anaphylactic reaction, they may not be able to speak. The medic alert ID will speak for them and provide crucial information to others that could save your child's life. Anaphylactic reactions are serious. If your child is old enough, teach them what they are allergic to so they can help avoid their triggers as well.

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Dr. Miller: Hives, what are they? How do we get them? And what do we do about them? This is Dr. Tom Miller on Scope radio. We're going to talk about that next.

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Dr. Miller: Hi, I'm here with Dr. Mark Eliason. And he is a professor of dermatology here at the University of Utah. And Mark is going to tell us a little bit about hives. What are hives? What's a hive? I think of a beehive but I don't know if that's what a hive is.

Dr. Eliason: This is the right state for that. No, well a hive is simply... the easiest way to think about it is like a bug bite. Imagine a mosquito bite. Something that's raised, it itches, and it bothers you. Most all hives will itch. And there are a lot of things that will cause them as well. But generally speaking, they're raised areas on the skin that are red and usually they will draw your attention to them.

Dr. Miller: I mean, do they happen rarely? Do some people get them and others don't? I mean, who get's a hive?

Dr. Eliason: So, we know that anyone who spends any time outside, especially in the morning or in the evening during mosquito season certainly knows what hives are. You can get a lot from the environment. But beyond just the hives that come from insects that bother you, a number of people develop hives spontaneously. And that can be because they have an allergy to something that they've taken, or something that they've eaten. Or they can also get hives sometimes without anything that they've done wrong, so to speak. Their body sometimes just makes their own hive.

Hives are interesting things to think about because it's an old reflex that our bodies have built into it that draws our attention to a part of us. And if you think about it, when something hurts, we pull away from something. Hurting is a way for our bodies to say, "Stop what you're doing." Itching and hives are a way to tell us that we need to pay attention to a part of our body.

Dr. Miller: Like a mosquito bite. You're near mosquitoes, move away from them.

Dr. Eliason: Right, or something is in us that's itching. Pull that thing out of us. And so it's sort of an opposite built in reflex that sometimes gets turned on inappropriately if something triggers it when it shouldn't.

Dr. Miller: Now, I think our audience might actually be interested in the spontaneous hives, because I've had patients who come in and they describe hives as being something that just pops up in an area that they didn't have any insect bite. So tell me about that a little bit. Because I think if people have hives that are due to, say mosquitoes, they kind of know what's caused that. But sometimes they just don't know.

Dr. Eliason: Sure, and hives can be scary. Because sometimes you get one or two little spots that will show up on your skin and that's not too much of a problem. But people will come in sometimes, they can be covered in hives. And not only are they just uncomfortable because they're itching like crazy, but it's frightening. Some people will feel parts of their body swelling. Like their lips can swell. They can feel like, sometimes they get nervous. Their breathing can be affected too. Hives can become something very worrisome.

Dr. Miller: But more rarely, correct?

Dr. Eliason: That's correct. I should be careful to tell you that most of the times hives that happen on the outside of the body, don't actually cause problems with breathing. But it is one of the things that people watch out for. The number one rash that people go into the emergency room for are hives.

Dr. Miller: So let's talk about that for a second. So let's say a person has never had hives before and they develop one or two episodes, do they need to see a physician? Or should they just maybe not worry about it so much?

Dr. Eliason: That's a great question. And a lot of it depends on what the hives are doing to them. People that are developing a handful of hives, some that are bothersome but they're not affecting at all the way that they're working or their ability to do the things they do during the day, usually don't necessarily need to see a physician until they've tried some of the over the counter products that are available to treat hives easily.

Dr. Miller: And what would those be?

Dr. Eliason: Of course assuming that people don't have any reasons why they couldn't take them, simple things like Benadryl or some of the non-sedating antihistamines with names like Zyrtec or Allegra. Or of course the generic equivalents of those are very safe things for people to start to just try to treat their hives and see if you can get them to go away easily.

Dr. Miller: Is one better than the other? The non-sedating versus the sedating? Because some people will take Benadryl and fall asleep at work, which is bad. Or if they're operating expensive dangerous machinery. That could be a problem.

Dr. Eliason: Right. That's a great point because any medicine that you give someone, if you give them enough of it, you can get side effects with it. So during the day I usually advise patients to consider using things like Zyrtec or Allegra because those are non-sedating. And most people do great with them.

Dr. Miller: Now how often do you find a reason for someone to have spontaneous urticaria? Aside from an insect bite.

Dr. Eliason: Yeah, this is a hard question. And with the spontaneous or acute urticaria, that's the kind that just shows up. It's only around for a couple of weeks. We don't always find the causes. In children it's usually related to an infection. And so it doesn't mean you have an infection that's creating your hive. You could have an infection like a common cold. You could have strep throat.

Dr. Miller: A virus.

Dr. Eliason: Exactly.

Dr. Miller: Or a bacterial pharyngitis.

Dr. Eliason: Precisely.

Dr. Miller: Sore throat.

Dr. Eliason: Those infections can, they don't cause hives, but your body's response to the infection accidentally creates hives on you. It's almost like your body makes a little bit of a mistake while it's cleaning out the infection and incidentally creates hives in the process.

Dr. Miller: Well when should that patient find their way to your office?

Dr. Eliason: We like to see patients when it bothers them. And so for some people that means that they get hives and they have a chance to try some of the over-the-counter antihistamines. And they don't work. In which case we certainly want to help them because there's a lot of other things that we have access to, prescription-wise, that can be stronger.

Dr. Miller: Do you have a definition of, sort of, mild, moderate, or severe hives in terms of how often they occur or how extensive they might be? Maybe that would help our audience know when they should seek medical advice.

Dr. Eliason: A lot of this isn't necessarily with the frequency but more of the severity. Hopefully I can make that make sense. When hives are developing and they aren't preventing people from doing what they normally do during the day, and they also are not causing any changes where parts of their body are swelling, then usually people can try over-the-counter products without having a worry that they need to rush in to see a physician for it.

If people are developing hives where they are getting swelling in their skin, so like I mentioned, lips can swell, ears can swell, or they can just have big welts. Their wrist gets too large. And it looks kind of doughy sometimes. Those are reasons to get into be seen by a physician sooner. Of course if people are having any difficulty breathing, it's a trip to the emergency room very quickly.

Sometimes when hives present, and they cause changes in breathing, people don't necessarily feel like they can't breathe. But they just start coughing sometimes. And those are things to watch for. Of course, you don't ever delay in that case. If you ever feel, if people ever feel like they can't breathe normally, it's straight to the ER.

Dr. Miller: Thank you very much. This is very helpful Mark.

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updated: August 21, 2018
originally published: February 23, 2015