Relentless Allergies

Hello Everyone!

Welcome to another edition of the monthly 'Amuse-Bouche' series. Like a morsel compliments of the chef, these small but critical scientific bites are created to stimulate your thinking about health and occasionally provide some comic relief. Prior editions.

Imagine some beautiful, barbed balls snagged on the membranes of the eyes, nose and airways. Welcome to the Willamette Valley with the verdant landscapes we love so much, and what translates directly into protracted pollen exposure. Not to mention that we produce roughly two-thirds of the nation’s cool-season grass seed. Tree pollen arrives as early as January and continues into early spring. Grass pollen dominates late spring and early summer. Mold contributes year-round to the region’s delightful, damp climate. Allergy symptoms here reflect a sustained assault, not brief seasonal spikes. If that wasn’t enough, we can be allergic to just about any of the zillions of molecules in our environment, food, and medications.

Allergies affect over 100 million people in the United States and cost us billions of dollars. The impact is not only medical but functional—sleep disruption, fatigue, reduced concentration, and poor quality of life. People would feel much better if their pesky allergies were taken care of.

Tilting At Windmills

Why do allergies occur? Allergies occur because the immune system misclassifies a harmless substance (allergen) as a threat and mounts an exaggerated and misguided inflammatory response (allergy). This differs from an infection, where viruses or bacteria actively invade tissue. An allergic response unfolds in stages:

1. Sensitization (first exposure)

• You inhale or ingest something harmless (e.g., pollen, dust mite debris, pet dander)

• The immune system generates a response and produces allergen-specific IgE antibodies

• IgE binds to mast cells in tissues (nose, lungs, skin)

• At this stage, there are no symptoms

2. Re-exposure (trigger phase)

• The same allergen enters again

• It binds to IgE on mast cells.

• This cross-linking activates the mast cell with a rapid release of histamine and other chemicals.

This produces:

• itching, sneezing (nerve activation)

• congestion (blood vessel leakage)

• mucus (gland stimulation)

3. Amplification (late phase)

• The immune system recruits eosinophils and other inflammatory cells

• These sustain inflammation for hours to days

• This leads to persistent congestion, tissue swelling, and increased sensitivity

Not everyone develops allergies. Susceptibility is influenced by several factors:

• genetic predisposition (family history of allergies)

• barrier dysfunction (skin, airway, or gut allowing greater allergen exposure)

• environmental exposure (high and repeated exposure, as seen in this region)

• immune miscalibration (a pathway originally designed for parasites redirected toward harmless proteins)

Dark Circles Under the Eyes

For many people, allergy season brings more than sneezing and itchy eyes. It can also cause dark, puffy circles under the eyes, commonly called allergy shiners (periorbital hyperpigmentation).

These are not cosmetic. They result from nasal congestion and inflammation in the nasal passages and sinuses. When this tissue is swollen, it slows venous drainage from the area under the eyes. Blood pools in these small veins, giving the skin a darker, bluish appearance.

Chronic nasal congestion affects breathing patterns. When nasal airflow is impaired, people tend to shift toward mouth breathing. This alters normal coordination of the face, tongue, and airway, and can contribute to the structure of the face, it’s bones and muscles.

Over time, persistent mouth breathing and altered airflow can affect tongue position, swallowing, and airway mechanics. In children, this may influence facial development and orthodontic outcomes. In both children and adults, it can contribute to orthodontic failure, sleep disruption and sleep-disordered breathing.

Addressing the underlying nasal inflammation is therefore not just about symptom relief. It helps restore normal airflow, improve sleep, and prevent downstream effects on airway and facial function.

System Under Siege

Allergic inflammation is not confined to one site. In the nose, swelling narrows airflow and slows mucus clearance. In the sinuses, drainage is impaired, leading to pressure and sinusitis. In the eyes, inflammation causes redness, tearing, and itching. Mucus contributes to post-nasal drip, throat clearing, and cough.

The same immune pattern can affect multiple systems. In the airways, it contributes to cough, wheezing, and asthma. In the skin, it can present as eczema or hives. In other patients, the gastrointestinal tract is involved—eosinophilic esophagitis is one example, causing difficulty swallowing.

Serious allergic reactions

Some allergy symptoms are localized, but in some cases the same immune pathway can produce more severe reactions.

Angioedema: This is deeper swelling beneath the skin, often involving the lips, eyelids, tongue, or throat. It can occur with or without hives. When it involves the airway, it is a medical emergency as it can interfere with breathing and requires immediate evaluation.

Anaphylaxis: This is a systemic, rapidly progressive allergic reaction involving multiple organ systems. Symptoms may include difficulty breathing, throat tightness, wheezing, low blood pressure, dizziness, and widespread hives. This is a medical emergency.

Diagnosis: What’s Useful

Allergy diagnosis starts where it should: with the story. When do symptoms happen? What makes them worse? How consistent is the pattern? Getting a good clinical history is invaluable.

Allergy tests show sensitization - meaning the immune system recognizes the allergen. They don’t automatically prove it’s causing the symptoms. A positive test without matching symptoms doesn’t mean much, and a negative test doesn’t rule things out. There are skin tests, blood tests and oral/airway challenges.

Avoid nonvalidated testing such as IgG food panels, hair analysis, electrodermal or “bioenergetic” testing, applied kinesiology, or grocery store testing. Major medical organizations recommend against them.

Treatment

Untreated allergies lead to persistent inflammation. Over time, the system becomes more reactive. Early treatment prevents deterioration.

1. Intranasal steroids

• Daily intranasal steroid (fluticasone/Flonase, Nasonex, Nasocort and others)

• Reduces underlying inflammation, swelling, and mucus

• Most effective treatment for congestion and sinus pressure

• Requires consistent daily use; effect builds over several days

2. Oral antihistamines

• 2nd-generation antihistamine (cetirizine or Zyrtec, loratadine or Claritin, fexofenadine or Allegra)

• Helps itching, sneezing, runny nose, eye symptoms by blocking histamine receptors

• Works best when taken daily during exposure

• Talk to your doctor as they can be taken in higher doses if necessary to control symptoms

3. Intranasal antihistamines

• Like azelastine nasal spray

• Works directly in the nasal lining

• Rapid onset (often within minutes)

• Useful for breakthrough symptoms or in combination with nasal steroids

• May cause a bitter taste or mild sedation in some patients

4. Eye drops (eye symptoms are often undertreated)

• Antihistamine eye drops (e.g., olopatadine or Pataday, ketotifen) can reduce itching and redness

• Work locally and act quickly

• Avoid frequent eye rubbing (worsens inflammation)

• Artificial tears can help dilute and clear allergens from the eye surface

5. Supportive measures

• Saline irrigation to clear pollen and breakdown thick mucus

• Shower and change clothes after outdoor exposure

• Keep windows closed during peak pollen periods

• Use air purifiers/filters

When To Escalate Care

If symptoms are not well controlled by the measures outlined above or a serious allergic reaction has occurred, a referral to an allergist-immunologist is recommended. Further treatment modalities include:

• Mast cell stabilizers like montelukast or Singulair

• Epi-pen on hand

• Immunotherapy (allergy shots or tablets) - gradual allergen exposure that shifts the immune response over time and reduces long-term sensitivity.

What To Avoid

• First-generation antihistamines (diphenhydramine or Benadryl, chlorpheniramine, hydroxyzine):  Benadryl is the most well known in this class and others are found in Advil or Tylenol PM type products for sleep. They cross the blood-brain barrier and produce sedation, cognitive impairment, slowed reaction time, dry mouth, and increased fall risk. They are not recommended due to these potentially dangerous side effects especially in older people.

• Vasoconstrictors temporarily shrink blood vessels to reduce congestion for a few hours but do not resolve the underlying inflammation. Oral versions like Sudafed or nasal sprays (like oxymetazoline or Afrin) are not recommended as they cause worse rebound congestion as they wear off, cause habituation and increase blood pressure. There are similar products for eyes and skin which should also be avoided.

Practical Approach to Managing Allergies

People are not just under-treated, but they often start late. Start treatment 2–3 weeks before allergy season starts. Use a daily nasal corticosteroid as the foundation. Add an antihistamine daily and do not skip doses. Supplement with saline rinses and allergen avoidance measures. If symptoms persist, complications like chronic sinusitis, asthma develop or you have serious allergic reactions, obtain a referral to an allergist.

Chronic allergies or inflammation disrupts normal mucociliary clearance, the mechanism by which the airways clear pollen, debris, and pathogens. When this system slows, drainage is impaired, creating an environment where infections, particularly sinus and respiratory infections, develop more easily. Not to mention fatigue, poor sleep, mouth breathing, concentration issues…. the list goes on.

Early, consistent treatment of allergies is very accessible, prevents continuous drain on the body and avoids complications from an unnecessary immune response. The American Academy of Allergy, Asthma & Immunology (AAAAI) provides guidance on finding board-certified specialists.

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Medical disclaimer: These op-ed articles are for general informational purposes only and do not constitute the practice of medicine and no doctor/patient relationship is formed or implied. The use of information on this site or materials linked from this site is at the user’s own risk. The content of this article or site is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.

Proof of Life: Work along with Play

It has been one year since I started my solo independent concierge-style practice.

This transition has been shaped by building something from the ground up, caring for patients in a way that feels aligned, writing the Amuse-bouche series, and forming a remarkable new community. I am close with colleagues from my prior practice, and I have found a new group of generous, independent physicians and friends who have made this genuinely fulfilling.

“Amuse-bouche” has grown fast with readers from over 15 countries! My goal is to spotlight issues that are less understood, relatively simple but can have a powerful impact. Things that more people deserve to know about. It is a responsibility and I work very hard to put out something decent each month Many of you read them and write back. Those exchanges have been very encouraging. Please keep writing!

My goal is to always educate myself and create conditions for learning. I recently began hosting small physician gatherings, “Peer to Peer,” in my office. Once a month, physicians, surgeons, and dentists come together for dinner, a presentation and interdisciplinary discussion. Our recent session on leg swelling and lymphedema, presented by Dr. Toshio Nagamoto (Inovia Vein), brought together primary care, surgical specialties, and physical therapy. The next one will focus on the dental origin of maxillary sinusitis, an often overlooked and common cause of treatment failure, presented by Dr. Ashish Bhandari (Clive Endodontics).

I am deeply grateful to all of you who have been part of this journey, and to the patients who have trusted me with their care. The work continues. Cheers!