Assessment and Management of Patients

With Allergic Disorders

ALLERGY ROLE OF B CELLS

is an inappropriate and often harmful response B cells, or B lymphocytes, are programmed to
of the immune system to normally harmless produce one specific antibody.
substances (allergens). Once encountering a specific antigen, B cells
allergens include: Chemical mediators released stimulate production of plasma cells, the site of
in allergic reactions may antibody production.
1. dust
2. weeds produce symptoms that range ROLE OF T CELLS (T cells, or T lymphocytes)
3. pollen from mild to life-threatening.
assist the B cells.
4. dander
secrete substances that direct the flow of cell
activity, destroy target cells, and stimulate the
SPECIFICITY macrophages.
refers to the specific reaction of an antibody to The macrophages present the antigens to the T
an antigen. cells and initiate the immune response.
They also digest antigens and assist in removing
IMMUNOGLOBULINS
cells and other debris.
Antibodies that are formed by lymphocytes and
plasma cells in response to an immunogenic Antigens are divided into two groups:
stimulus constitute a group of serum proteins. 1. complete protein antigens
2. low– molecular-weight substances.
Grouped into Immunoglobulins can
five classes: be found in the: LOW–MOLECULARWEIGHT SUBSTANCES
1. IgG 1. Lymph nodes
2. IgA such as medications, function as haptens
2. Tonsils
3. IgM (incomplete antigens), binding to tissue or
3. Appendix
4. IgD serum proteins to produce a carrier complex
4. Peyer patches of
5. IgE that initiates an antibody response.
the intestinal tract.
In an allergic reaction, the production of
IgE Immunoglobulins of the IgE class are involved: antibodies requires active communication between
a. in allergic disorders and
cells. When the allergen is absorbed through the
b. some parasitic infections.
respiratory tract, gastrointestinal tract, or skin,
IgE producing cells are located in the allergen sensitization occurs.
respiratory and intestinal mucosa.
MACROPHAGES
Two or more IgE molecules bind together to an
Macrophages process the antigen and present it
allergen and trigger mast cells or basophils to
to the appropriate cells.
release chemical mediators, such as:
These cells mature into allergen-specific
secreting plasma cells that synthesize and
1. histamine
secrete antigen-specific antibodies.
2. serotonin
3. kinins FUNCTION OF CHEMICAL MEDIATORS
4. slow reacting substances of anaphylaxis When mast cells are stimulated by antigens,
5. the neutrophil factor powerful chemical mediators are released,
causing a sequence of physiologic events that
which produces allergic skin reactions, asthma, result in symptoms of immediate hypersensitivity
and high fever. an abnormal physiological condition in which there is an
undesirable and adverse immune response to antigen.
 THERE ARE TWO (2) TYPES OF Eosinophil Chemotactic Factor of
CHEMICAL MEDIATORS: Anaphylaxis
1. Primary mediators - are preformed and are affects the movement of eosinophils (granular
found in mast cells or basophils. leukocytes) to the site of allergens. It is
2. Secondary mediators - are inactive precursors preformed in the mast cells and is released from
that are formed or released in response to disrupted mast cells.
primary mediators. Platelet-Activating Factor
is responsible for initiating platelet aggregation
PRIMARY MEDIATORS
and leukocyte infiltration at sites of immediate
HISTAMINE hypersensitivity reactions. It also causes
released by mast cells vasodilation, broncho constriction, and increased
It is the first chemical mediator to be released in vascular permeability (Frandsen &
immune and inflammatory responses. Pennington,2014)
It is synthesized and stored in high
concentrations in body tissues exposed to Prostaglandins
environmental substances. produce smooth muscle contraction as well as
vasodilation and increased capillary
Histamine’s effects peak 5 to 10 minutes after
permeability.
antigen contact and include the following:
They sensitize pain receptors and increase the
1. erythema pain associated with inflammation.
2. localized edema in the form of wheals induce inflammation and enhance the effects of
3. pruritus mediators of inflammatory response.
4. contraction of bronchial smooth muscle,
Local manifestations include:
resulting in wheezing and 1. erythema
bronchospasm 2. heat
5. dilation of small venules and 3. edema
constriction of larger vessels (Frandsen & Pennington, 2014).
6. increased secretion of gastric and
SECONDARY MEDIATORS
mucosal cells resulting in diarrhea.
LEUKOTRIENES
Histamine action results from :
STIMULATION OF chemical mediators that initiate the
histamine-1 (H1) receptors inflammatory response.
- found predominantly on bronchiolar and Many manifestations of inflammation can be
vascular smooth muscle cells. attributed in part to leukotrienes. In addition,
histamine-2 (H2) receptors found on leukotrienes cause smooth muscle contraction,
gastric parietal cells. bronchial constriction, mucus secretion in the
airways, and the typical wheal-and-flare
reactions of the skin.
Certain medications are categorized by their
Compared with histamine, leukotrienes are 100
action at these receptors
to 1000 times more potent in causing
A. Diphenhydramine (Benadryl) is an example of bronchospasm
an antihistamine, a medication that displays an
BRADYKININ
affinity for H1 receptors.
a substance that has the ability to cause
B. Cimetidine (Tagamet) and Ranitidine (Zantac) increased vascular permeability, vasodilation,
target H2 receptors to inhibit gastric secretions in hypotension, and contraction of many types of
peptic ulcer disease. smooth muscle, such as the bronchi.
stimulates nerve cell fibers and produces pain.
SERATONIN
acts as a potent vasoconstrictor and causes
contraction of bronchial smooth muscle IMMUNE COMPLEX (TYPE III)
HYPERSENSITIVITY TYPE III, OR
HYPERSENSITIIVITY IMMUNE COMPLEX,
an excessive or aberrant immune response to
any type of stimulus (Abbas et al., 2014). It hypersensitivity involves immune complexes
usually does not occur with the first exposure to that are formed when antigens bind to
an allergen. Rather, the reaction follows a re- antibodies.
exposure after sensitization, or buildup of If these type III complexes are deposited in
antibodies, in a predisposed person. tissues or vascular endothelium, two factors
Injurious or pathologic immune reactions are contribute to injury:
classed as hypersensitivity reactions.
Most allergic reactions are either type I or type 1. the increased amount of circulating complexes
IV hypersensitivity reactions and
2. the presence of vasoactive amines.
ANAPHYLACTIC (TYPE I) HYPERSENSITIVITY
The most severe hypersensitivity As a result, there is an increase in vascular
reaction is anaphylaxis. permeability and tissue injury
An unanticipated severe allergic reaction that DELAYED-TYPE (TYPE IV)
is rapid in onset, anaphylaxis is characterized by HYPERSENSITIVITY TYPE IV, OR
edema in many tissues, including the larynx, DELAYED-TYPE, HYPERSENSITIVITY (DTH)
and is often accompanied by hypotension,
bronchospasm, and cardiovascular collapse is an immune reaction in which T-cell–
in severe cases. dependent macrophage activation and
an immediate reaction beginning within minutes inflammation cause tissue injury.
of exposure to an antigen. This type of reaction to the subcutaneous
Primary chemical mediators are responsible injection of antigen is often used as an assay
for the symptoms of type I hypersensitivity for cell-mediated immunity (e.g., the purified
because of their effects on the skin, lungs, and protein derivative skin test for immunity to
gastrointestinal tract. Mycobacterium tuberculosis) (Abbas et
al.2014)
CYTOTOXIC (TYPE II) HYPERSENSITIVITY
TYPE II, OR CYTOTOXIC ASSESSMENT

hypersensitivity occurs when the system 1. A comprehensive allergy history and a thorough
mistakenly identifies a normal constituent of the physical examination provide useful data for the
body as foreign. diagnosis and management of allergic disorders.
This reaction may be the result of a cross- 2. An allergy assessment form is useful for obtaining
reacting antibody, possibly leading to cell and and organizing pertinent information.
tissue damage. 3. The degree of difficulty and discomfort
Type II hypersensitivity reactions are experienced by the patient because of allergic
associated with several disorders. symptoms and the degree of improvement in those
For example: symptoms with and without treatment are
assessed and documented.
A. in Myasthenia gravis - the body mistakenly generates 4. The relationship of symptoms to exposure to
antibodies against normal nerve ending receptors. possible allergens is noted
B. in Goodpasture syndrome - it generates antibodies
against lung and renal tissue, producing lung damage and
kidney injury (Grossman & Porth, 2014)
 DIAGNOSTIC EVALUATION 4. Skin Test
Diagnostic evaluation of the patient with allergic Positive (wheal-and-flare) reactions are clinically
disorders commonly includes: significant when correlated with the history,
1. blood tests physical findings, and results of other laboratory
2. smears of body secretions tests.
3. skin tests Skin testing is considered the most accurate
4. the serum specific IgE test (formerly known as confirmation of allergy (Oppenheimer, Durham,
radioallergosorbent test [RAST]). Nelson, et al., 2014)

1. Complete Blood Count With Differential Several precautionary steps must be observed
before skin testing with allergens is performed:
The white blood cell (WBC) count is usually
1. Testing is not performed during periods of
normal except with infection and inflammation
bronchospasm.
(Pagana & Pagana, 2013).
2. Epicutaneous tests (scratch or prick tests) are
Eosinophils, which are granular leukocytes,
performed before other testing methods, in an
normally make up 2% to 5% of the total number
effort to minimize the risk of systemic reaction.
of WBCs. They can be found in blood, sputum,
3. Emergency equipment must be readily available
and nasal secretions. A level greater than 5% to
to treat anaphylaxis.
10% is considered abnormal and may be found in
patients with allergic disorders (Fleisher et al., TYPES OF SKIN TESTS
2013)
The methods of skin testing include:
2. Eosinophil Count 1. prick skin tests
2. scratch tests
An actual count of eosinophils can be obtained
3. intradermal skin testing
from blood samples or smears of secretions.
During symptomatic episodes, smears obtained After negative prick or scratch tests, intradermal
from nasal secretions and sputum of patients skin testing is performed with allergens that are
with allergies usually reveal an increase in suggested by the patient’s history to be
eosinophils, indicating an active allergic problematic.
response (Fleisher et al., 2013). The back is the most suitable area of the body
for skin testing because it permits the
3. Total Serum Immunoglobulin E Levels
performance of many tests.
High total serum IgE levels support the diagnosis A multitest applicator with multiple test heads is
of allergic disease. commercially available for simultaneous
In the majority of cases, the antibody typically administration of antigens by multiple punctures
responsible for an allergic reaction belongs to at different sites.
the IgE isotype. TYPES OF SKIN TESTS
4. Skin Test A negative response on a skin test cannot be
interpreted as an absence of sensitivity to an
Skin testing entails the intradermal injection or
allergen.
superficial application (epicutaneous) of solutions
Such a response may occur with insufficient
at several sites. These solutions contain individual
sensitivity of the test or with the use of an
antigens representing an assortment of allergens
inappropriate allergen in testing.
most likely to be implicated in the patient’s
Therefore, it is essential to observe the patient
disease.
undergoing skin testing for an allergic reaction
even if the previous response was negative
 INTERPRETATION OF SKIN TEST RESULTS MAJOR DISADVANTAGES
Familiarity with and consistent use of a grading The major disadvantages include:
system are essential. 1. limited allergen selection
The grading system used should be identified on 2. reduced sensitivity compared with intradermal
a skin test record for later interpretation. skin tests
A positive reaction, evidenced by the 3. lack of immediate results
appearance of an urticarial wheal (round, 4. higher cost
reddened skin elevation), localized erythema (ASCIA, 2015)

(diffuse redness) in the area of inoculation or

ALLERGIC DISORDERS
contact, or pseudopodia (irregular projection
at the end of a wheal) with associated
erythema is considered indicative of sensitivity There are two types of IgE-mediated allergic
to the corresponding antigen. reactions:
1. atopic disorders
PROVOCATIVE TESTING
2. nonatopic disorders.
involves the direct administration of the
suspected allergen to the sensitive tissue, such ATOPY defined as the genetic predisposition
as: to mount an IgE response to inhaled or ingested
1. the conjunctiva innocuous proteins (Fleisher et al.,2013).
2. nasal or bronchial mucosa Atopic diseases consist:
3. gastrointestinal tract (by ingestion of the 1. asthma
allergen) 2. allergic rhinitis
with observation of target organ response. 3. atopic dermatitis.
- is helpful in identifying clinically significant
allergens in patients who have a large number of All share a common pathogenesis, mediated
positive tests. by IgE, and are frequently present together
MAJOR DISADVANTAGES in the same individual and in families.
Major disadvantages of this type of testing are
The nonatopic disorders lack the genetic
the limitation of one antigen per session and
component and organ specificity 2851 of
the risk of producing severe symptoms,
the atopic disorders (Fleisher et al., 2013).
particularly bronchospasm, in patients with
asthma
LATEX ALLERGY can present as an IgE-
SERUM-SPECIFIC IGE TEST mediated anaphylaxis, type I reaction, or
formerly known as RAST a type IV hypersensitivity referred to as
an automated test performed on blood contact dermatitis.
samples by a pathology laboratory.
ANAPHYLAXIS a clinical response to an
detects free antigen-specific IgE in serum as
opposed to antigen-specific IgE bound to immediate (type I hypersensitivity) immunologic
mast cells in the skin (ASCIA, 2015; Portnoy, reaction between a specific antigen and an
2015). antibody.

ADVANTAGES The reaction results from a rapid release of

The advantages of this test over other tests IgE-mediated chemicals, which can induce
include: a severe, life-threatening reaction.
1. decreased risk of systemic reaction
2. stability of antigens
3. lack of dependence on skin reactivity modified
by medications.
ANAPHYLAXIS
Antibiotics and radiocontrast agents
PATHOPHYSIOLOGY cause the most serious anaphylactic
Anaphylaxis is a type I IgE allergic reaction to reactions.
an antigen, a foreign substance that has Penicillin is the most common medication to
entered the body. cause anaphylaxis.
It is caused by the cross-links of an allergen In a study of an outpatient adult population,
with allergen-specific IgE antibodies found on the prevalence of penicillin allergy was
the surface membrane of mast cells and found to be 12%.
basophils, leading to cellular degranulation. However, only 6% of these patients were
The subsequent release of histamine and referred to an allergist for testing.
other bioactive mediators causes activation of
platelets, eosinophils, and neutrophils. COMMON CAUSES OF ANAPHYLAXIS
Histamine, prostaglandins, and inflammatory
1. Foods
leukotrienes are potent vasoactive mediators
Peanuts
that are implicated in the vascular
tree nuts (e.g., walnuts, pecans, cashews,
permeability changes, flushing, urticaria,
almonds)
angioedema, hypotension, and
shellfish (e.g., shrimp, lobster, crab)
bronchoconstriction that characterize
fish
anaphylaxis.
milk
Smooth muscle spasm, bronchospasm,
eggs
mucosal edema and inflammation, and
soy
increased capillary permeability result.
wheat
Symptoms of anaphylaxis are sudden in onset
2. Medications
and progress in severity over minutes to hours
Antibiotics, especially (penicillin and sulfa
Closely resembling anaphylaxis is an
antibiotics)
anaphylactoid reaction, which is caused by
allopurinol
the release of mast cell and basophil
radiocontrast agents
mediators triggered by non–immunoglobulin E
anesthetic agents (lidocaine, procaine)
(IgE)-mediated events.
vaccines
This nonallergenic anaphylaxis reaction may
hormones (insulin, vasopressin,
occur with medications, food, exercise, or
adrenocorticotropic hormone)
cytotoxic antibody transfusions.
aspirin
The reaction may be local or systemic.
nonsteroidal anti-inflammatory drugs
Local reactions usually involve urticaria and
Other Pharmaceutical/Biologic Agents
angioedema at the site of the antigen
Animal serums (tetanus antitoxin, snake venom
exposure. Although possibly severe,
antitoxin,rabies antitoxin)
nonallergenic anaphylaxis reactions are rarely
antigens used in skin testing
fatal.
3. Insect
Systemic reactions occur within about 30
Stings Bees, wasps, hornets, yellow jackets,
minutes after exposure and involve
ants (including fire ants)
cardiovascular, respiratory,
4. Latex
gastrointestinal, and integumentary organ
Medical
systems.
nonmedical products containing latex
For the most part, the treatment of
nonallergenic anaphylaxis reaction is identical
to that of anaphylaxis
 CLINICAL MANIFESTATIONS PREVENTION
Anaphylactic reactions produce a clinical Strict avoidance of potential allergens is
syndrome that affects multiple organ systems. an important preventive measure for the
Reactions may be categorized as mild, patient at risk for anaphylaxis. Those at risk for
moderate, or severe. anaphylaxis from insect stings should avoid
The time from the exposure to the antigen to areas populated by insects and should use
the onset of symptoms is a good indicator of appropriate clothing, insect repellent, and
the severity of the reaction—the faster the caution to avoid further stings.
onset, the more severe the reaction. If avoidance of exposure to allergens is
The severity depends on the degree of allergy impossible, an auto-injector system for
and the dose of allergen exposure epinephrine will be prescribed.
MILD SYSTEMIC REACTIONS The patient should be instructed to carry
and administer epinephrine to prevent an
consist of peripheral tingling and a sensation anaphylactic reaction in the event of
of warmth, possibly accompanied by a exposure to the allergen.
sensation of fullness in the mouth and throat. People who are sensitive to insect bites and
Nasal congestion, periorbital swelling, pruritus, stings, those who have experienced food or
sneezing, and tearing of the eyes can also be medication reactions, and those who have
expected. experienced idiopathic or exercise-
The onset of symptoms begins within the first induced anaphylactic reactions should
2 hours after the exposure. always carry an emergency kit that contains
Moderate systemic reactions may include epinephrine.
flushing, warmth, anxiety, and itching in The EpiPen and Auvi-Q are auto-injection
addition to any of the milder symptoms. devices that are commercially available for
MORE SERIOUS REACTIONS first aid that deliver premeasured doses of
include: epinephrine
bronchospasm and edema of the airways or Verbal and written information about the
larynx with dyspnea, cough, and wheezing. emergency kit, as well as strategies to avoid
The onset of symptoms is the same as for a exposure to threatening allergens, must also
mild reaction. be provided.
Screening for allergies before a
SEVERE SYSTEMIC REACTIONS
medication is prescribed or first given is an
have an abrupt onset with the same signs important preventive measure.
and symptoms described previously. A careful history of any sensitivity to
These symptoms progress rapidly to suspected antigens must be obtained before
bronchospasm, laryngeal edema, severe administering any medication, particularly in
dyspnea, cyanosis, and hypotension. parenteral form, because this route is
Dysphagia (difficulty swallowing), abdominal associated with the most severe anaphylaxis.
cramping, vomiting, diarrhea, and seizures Nurses caring for patients in any setting
can also occur. (hospital, home, outpatient diagnostic testing
Cardiac arrest and coma may follow. sites, long-term care facilities) must assess
Severe reactions are also referred to as patients’ risks for anaphylactic reactions.
ANAPHYLACTIC SHOCK Patients are asked about previous
exposure to contrast agents used for
diagnostic tests and any allergic reactions, as
well as reactions to any medications, foods,
insect stings, and latex.
 PREVENTION MEDICAL MANAGEMENT
People who are predisposed to Patients at risk for adverse effects include
anaphylaxis should wear medical older patients and those with hypertension,
identification such as a bracelet or arteriopathies, or known ischemic heart
necklace, which names allergies to disease.
medications, food, and other substances. Antihistamines and corticosteroids should not
People who are allergic to insect venom be given in place of epinephrine, may be
may require venom immunotherapy, which given as adjunct therapy.
is used as a control measure and not a cure. Intravenous fluids (e.g., normal saline
The most common serious allergic solution), volume expanders, and vasopressor
reactions to insect stings are from the agents are given to maintain blood pressure
Hymenoptera family, which includes bees, and normal hemodynamic status.
ants, wasps, and yellow jackets. In patients with episodes of bronchospasm or
Venom is an effective treatment for people a history of bronchial asthma or chronic
with systemic reactions to an insect sting. obstructive pulmonary disease, aminophylline
It reduces the systemic reaction, reduces the and corticosteroids may also be given to
risk of future large local reactions, and improve airway patency and function.
improves quality of life. Patients who have experienced anaphylactic
Insulin-allergic patients with diabetes and reactions and received epinephrine should be
those who are allergic to penicillin may transported to the local emergency
require desensitization. department (ED) for observation and
Desensitization is based on controlled monitoring because of the risk for a
anaphylaxis, with a gradual release of “rebound” or delayed reaction 4 to 8 hours
mediators. after the initial allergic reaction.
Patients who undergo desensitization are However, the observation time should be
cautioned to avoid lapses in therapy, individualized based on the severity of the
because this may lead to the reappearance anaphylaxis.
of the allergic reaction when the use of the Longer periods of observation should be
medication is resumed considered for patients who ingested the
MEDICAL MANAGEMENT allergen, required more than one dose of
Management depends on the severity of the epinephrine, had hypotension or pharyngeal
reaction. Initially, respiratory and cardiovascular edema, or have a history of asthma
functions are evaluated.
If the patient is in cardiac arrest, MEDICAL MANAGEMENT
cardiopulmonary resuscitation (CPR) is
instituted. If a patient is experiencing an allergic
Supplemental oxygen is provided during CPR response, the nurse assesses the patient for
or if the patient is cyanotic, dyspneic, or signs and symptoms of anaphylaxis.
wheezing. Airway, breathing pattern, and vital signs are
Epinephrine, in a 1:1000 dilution, is given assessed.
subcutaneously in the upper extremity or The patient is observed for signs of increasing
thigh and may be followed by a continuous edema and respiratory distress.
intravenous infusion. Prompt notification of the rapid response
Most adverse events associated with team, the provider, or both is required.
administration of epinephrine (i.e.,
adrenaline) occur when the dose is excessive
or is given intravenously.
MEDICAL MANAGEMENT DIAGNOSIS AND TREATMENT

Rapid initiation of emergency measures (e.g.,

Early diagnosis and adequate treatment are
intubation, administration of emergency
essential to reduce complications and relieve
medications, insertion of intravenous lines,
[Link] allergic rhinitis is induced by
fluid administration, and oxygen
airborne pollens or molds, it is characterized by
administration) is important to reduce the
the following seasonal occurrences.
severity of the reaction and to restore
cardiovascular function.
Early spring—tree pollen (oak, elm, poplar)
The patient who has recovered from
Early summer—grass pollen (Timothy, Redtop)
anaphylaxis needs an explanation of what
Early fall—weed pollen (ragweed)
occurred, instruction about avoiding future
exposure to antigens, and how to administer
Each year, attacks begin and end at about the
emergency medications to treat anaphylaxis.
same time.
The patient must be instructed about
antigens that should be avoided and about
Airborne mold spores require warm, damp
other strategies to prevent recurrence of
weather. Although there is no rigid seasonal
anaphylaxis.
pattern, these spores appear in early spring, are
All patients who have experienced an
rampant during the summer, then taper off and
anaphylactic reaction should receive a
disappear by the first frost in areas that
prescription for auto-injectable epinephrine
experience dramatic seasonal temperature
devices.
variation.

ALLERGIC RHINITIS
In temperate areas that do not experience
Allergic rhinitis (hay fever, seasonal allergic freezing temperatures, these allergens, especially
rhinitis) is the most common form of respiratory mold, can persist throughout the year
allergy, which is presumed to be mediated by
ALLERGIC RHINITIS
an immediate (type I hypersensitivity)
immunologic reaction. PATHOPHYSIOLOGY

Symptoms are similar to those of viral rhinitis but Sensitization begins by ingestion or inhalation
are usually more persistent and demonstrate of an antigen.
seasonal variation. On reexposure, the nasal mucosa reacts by
Rhinitis is considered to be the allergic form if the the slowing of ciliary action, edema formation,
symptoms are caused by an allergen-specific IgE- and leukocyte (primarily eosinophil) infiltration.
mediated immunologic response. Histamine is the major mediator of allergic
Approximately one third of patients with rhinitis reactions in the nasal mucosa.
have associated conjunctivitis, sinusitis, and Tissue edema results from vasodilation and
asthma. increased capillary permeability
The proportion of patients with the allergic form
of rhinitis increases with age. It often occurs with CLINICAL MANIFESTATIONS
other conditions, such as asthma, and cystic
The four major signs and symptoms of allergic
fibrosis.
rhinitis include:
If symptoms are severe, allergic rhinitis may
1. copious amounts of serous nasal discharge
interfere with sleep, leisure, school, and overall
2. nasal congestion
quality of life.
3. sneezing
4. nose and throat itching.
 CLINICAL MANIFESTATIONS AVOIDANCE THERAPY
In avoidance therapy, every attempt is made to
5. Patients may experience post-nasal drip, itching,
remove the allergens that act as precipitating
watery eyes, headache, and hyposomnia.
factors.
6. Bronchial asthma is more persistent in patients
Simple measures and environmental controls are
with chronic rhinitis than in those with allergic
often effective in decreasing symptoms.
rhinitis.
Examples include the use of air conditioners, air
7. The symptoms of this chronic condition depend
cleaners, humidifiers, and dehumidifiers; removal
on environmental exposure and intrinsic host
of dust-catching furnishings, carpets, and window
responsiveness.
coverings; removal of pets from the home or
8. Allergic rhinitis can affect quality of life by also
bedroom; the use of pillow and mattress covers
producing sleep disturbance, impairment of daily
that are impermeable to dust mites; and a smoke-
activities, and missed school and work
free environment.
Additional measures include changing clothing
ASSESSMENT AND
when coming in from outside, showering to wash
DIAGNOSTIC FINDINGS
allergens from hair and skin, and using an over-
Diagnosis of seasonal allergic rhinitis is based on the-counter nasal irrigation device or saline nasal
history, physical examination, and diagnostic test spray to reduce allergens in the nasal passages
results.
PHARMACOLOGIC THERAPY
Diagnostic tests
ANTIHISTAMINES
nasal smears
peripheral blood counts classified as H1 receptor antagonists (or H1
total serum IgE blockers), are used in the management of mild
epicutaneous allergic disorders.
intradermal testing H1 blockers bind selectively to H1 receptors,
serum-specific IgE preventing the actions of histamines at these
nasal provocation tests. sites.
Results indicative of allergy as the cause of rhinitis They do not prevent the release of histamine
include increased IgE and eosinophil levels and from mast cells or basophils. The H1 antagonists
positive reactions on allergen testing. have no effect on H2 receptors, but they do
have the ability to bind to nonhistaminic
MEDICAL MANAGEMENT receptors.
Oral antihistamines, which are readily absorbed,
The goal of therapy is to provide relief from are most effective when given at the first
symptoms. occurrence of symptoms, because they prevent
Therapy may include one or all of the the development of new symptoms.
following interventions: avoidance therapy, The effectiveness of these medications is limited
pharmacologic therapy, and immunotherapy. to certain patients with hay fever, vasomotor
Verbal instructions must be reinforced by rhinitis, urticaria (hives), and mild asthma.
written information.
Knowledge of general concepts regarding Oral antihistamines
assessment and therapy in allergic diseases is The major side effects are drowsiness and
important so that the patient can learn to drymouth.
manage certain conditions as well as prevent Additional side effects include anxiety,
severe reactions and illnesses. agitation, urinary retention, blurred vision,
anorexia, nausea, and vomiting.
 Oral antihistamines PHARMACOLOGIC THERAPY
MAST CELL STABILIZERS
Antihistamines are contraindicated during
pregnancy, in nursing mothers and newborns, in In addition, it inhibits macrophages, eosinophils,
children and older adults, and in patients with monocytes, and platelets involved in the
hypersensitivity to the drugs whose conditions may immune response.
be aggravated by muscarinic blockade (e.g., Cromolyn interrupts the physiologic response to
asthma, urinary retention, open-angle glaucoma, nasal antigens, and it is used prophylactically
hypertension, prostatic hyperplasia). (before the exposure to allergens) to prevent
Second-generation or nonsedating H1 receptor the onset of symptoms and to treat symptoms
antagonists are newer types of antihistamines. once they occur

PHARMACOLOGIC THERAPY PHARMACOLOGIC THERAPY

ADRENERGIC AGENTS CORTICOSTEROIDS

Adrenergic agents, which are vasoconstrictors Intranasal corticosteroids are indicated in more
of mucosal vessels, are used topically in nasal severe cases of allergic and perennial rhinitis
(Afrin) and ophthalmic (Alphagan P) that cannot be controlled by more conventional
formulations in addition to the oral route medications, such as decongestants,
(pseudoephedrine [Sudafed]) antihistamines, and intranasal cromolyn.
The topical route (drops and sprays) causes Examples of these medications include
fewer side effects than oral administration; beclomethasone (Beconase, Qnasl), budesonide
however, the use of drops and sprays should be (Rhinocort), flunisolide (AeroSpan), and
limited to a few days to avoid rebound triamcinolone (Nasacort) (Comerford, 2015).
congestion.
Adrenergic nasal decongestants are applied PHARMACOLOGIC THERAPY
topically to the nasal mucosa for the relief of LEUKOTRIENE MODIFIERS
nasal congestion.
Topical ophthalmic drops are used for
Leukotrienes have many effects on the
symptomatic relief of eye irritations caused by
inflammatory cycle.
allergies.
Leukotriene modifiers, such as zafirlukast
Potential side effects include hypertension,
(Accolate) and montelukast (Singulair), block
dysrhythmias, palpitations, central nervous
the synthesis or action of leukotrienes and
system stimulation, irritability, tremor, and
prevent the signs and symptoms associated
tachyphylaxis (acceleration of hemodynamic
with asthma .
status).
Leukotriene modifiers are for long-term use,
and patients should be advised to take their
PHARMACOLOGIC THERAPY medication daily.
MAST CELL STABILIZERS Patients take appropriate “rescue”
Intranasal cromolyn sodium (NasalCrom) is a medications for symptom exacerbation but
spray that acts by stabilizing the mast cell continue to take the leukotriene 2866 modifier
membrane, thus reducing the release of on a daily basis.
histamine and other mediators of the allergic
response.
 IMMUNOTHERAPY
IMMUNOTHERAPY SUBLINGUAL IMMUNOTHERAPY.
CONTRAINDICATIONS
Administration of SLIT includes a buildup phase
The use of beta-blocker or angiotensin- that is followed by a treatment plan of three
converting enzyme inhibitor therapy,which may times per week with a rapid dissolving tablet or
mask early signs of anaphylaxis liquid containing allergen extracts.
Presence of significant pulmonary or cardiac Recent studies show comparable efficacy of
disease or organ failure Inability of the patient to SLIT with SIT. Systemic side effects are rare but
recognize or report signs and symptoms of a have been reported in patients who also report
systemic reaction systemic reactions with SIT.
Nonadherence of the patient to other Side effects include irritation, minor swelling or
therapeutic regimens and nonlikelihood that the itching inside the mouth, and stomach upset
patient will adhere to the immunization schedule and nausea
(often weekly for an indefinite period)
IMMUNOTHERAPY
Inability to monitor the patient for at least 30
EPICUTANEOUS IMMUNOTHERAPY.
minutes after administration of immunotherapy
Absence of equipment or adequate personnel to EPIT represents an alternative allergen
spond to allergic reaction if one occurs. immunotherapy with delivery of the allergen to
the epidermis. Because the epidermis is less
IMMUNOTHERAPY vascular, there is reduced risk of systemic
SUBCUTANEOUS IMMUNOTHERAPY allergic side effects due to inadvertent
intravascular allergen delivery.
The most common method of treatment is SIT, Reports from the completed trials of EPIT may
which consists of the serial injection of one or find potential application in the management of
more antigens that are selected in each IgE-mediated allergies, but more research is
particular case on the basis of skin testing. needed to define an optimal regimen that
This method provides a simple and efficient balances clinical efficacy and safety
technique for targeting IgE antibodies to
specific antigens.
NURSING PROCESS
Specific treatment consists of injecting extracts
THE PATIENT WITH ALLERGIC RHINITIS
of the allergens that cause symptoms in a
ASSESSMENT
particular patient.
Injections begin with very small amounts and The examination and history of the patient
are gradually increased, usually at weekly reveal sneezing, often in paroxysms; thin and
intervals, until a maximum tolerated dose is watery nasal discharge; itching eyes and nose;
attained. lacrimation; and occasionally headache.
Maintenance booster injections are given at 2- The health history includes a personal or family
to 4-week intervals, frequently for a period of history of allergy.
several years, before the maximum benefit is The allergy assessment identifies the nature of
achieved, although some patients will note early antigens, seasonal changes in symptoms, and
improvement in their symptoms. medication history.
Long-term benefit seems to be related to the The nurse also obtains subjective data about how
cumulative dose of vaccine given over time the patient feels just before symptoms become
obvious, such as the occurrence of pruritus,
breathing problems, and tingling sensations. In
addition to these symptoms, hoarseness, wheezing,
hives, rash, erythema, and edema are noted.
 PROMOTING UNDERSTANDING OF ALLERGY
DIAGNOSIS
AND ALLERGY CONTROL
NURSING DIAGNOSIS

Based on the assessment data, major nursing 2. The nurse informs and reminds the patient of
diagnoses may include: the importance of keeping appointments for
desensitization procedures, because dosages are
1. Ineffective breathing pattern related to allergic usually adjusted on a weekly basis, and missed
reaction. appointments may interfere with the dosage
2. Deficient knowledge about allergy and the adjustment.
recommended modifications in lifestyle and 3. Patients need to understand the difference
self-care practices. between rescue medications for allergy
3. Ineffective coping with chronicity of condition exacerbation and seasonal flares (e.g.,
and need for environmental modifications. antihistamines) and
medications used for allergy control throughout
COLLABORATIVE PROBLEMS/POTENTIAL the year (e.g., inhaled corticosteroids, leukotriene
COMPLICATIONS modifiers).
4. Patients also need to understand that
Potential complications may include the following:
medications for allergy exacerbation and
1. Anaphylaxis Impaired breathing
seasonal flares should be used only when the
2. Nonadherence to the therapeutic regimen
allergy is apparent.
PLANNING AND GOALS
COPING WITH A CHRONIC DISORDER
The goals for the patient may include restoration of
Although allergic reactions are infrequently life-
a breathing pattern that provides adequate
threatening, they require vigilance to avoid
ventilation, increased knowledge about the causes
allergens and modification of the lifestyle or
and control of allergic symptoms, improved coping
environment to prevent recurrence of
with alterations and modifications, and absence of
symptoms.
complications.
Allergic symptoms are often present year-round
NURSING INTERVENTIONS and create discomfort and inconvenience for
the patient. Although patients may not feel ill
IMPROVING BREATHING PATTERN during allergy seasons, they often do not feel
The patient is instructed and assisted to modify well, either.
the environment to reduce the severity of allergic The need to be alert for possible allergens in
symptoms or to prevent their occurrence. the environment may be tiresome, placing a
The patient is also instructed to reduce exposure burden on the patient’s ability to lead a normal
to people with upper respiratory tract infections. life.
Adherence to medication schedules and other Stress related to these difficulties may in turn
treatment regimens is encouraged and reinforced increase the frequency or severity of symptoms.
To assist the patient in adjusting to these
PROMOTING UNDERSTANDING OF ALLERGY
modifications, the nurse must have an
AND ALLERGY CONTROL
appreciation of the difficulties encountered by
the patient.
1. Instruction includes strategies to minimize
The patient is encouraged to verbalize feelings
exposure to allergens and explanation about
and concerns in a supportive environment and
desensitization procedures and correct use of
to identify strategies to deal with them
medications.
effectively
MONITORING AND MANAGING POTENTIAL CONTACT DERMATITIS
COMPLICATIONS
a type IV delayed hypersensitivity reaction, is
Anaphylaxis and Impaired Breathing.
an acute or chronic skin condition caused by
Respiratory and cardiovascular functioning can
contact with an exogenous substance that
be significantly altered during allergic reactions
elicits an allergic response.
by the reaction itself or by the medications used
to treat reactions.
The respiratory status is evaluated by monitoring THERE ARE FOUR BASIC TYPES:
the respiratory rate and pattern and by assessing 1. ALLERGIC
for breathing difficulties or abnormal lung 2. IRRITANT
sounds. 3. PHOTOTOXIC
The pulse rate and rhythm and blood pressure are 4. PHOTO ALLERGIC.
monitored to assess cardiovascular status
regularly or any time the patient reports Skin sensitivity may develop after brief or
symptoms such as itching or difficulty breathing. prolonged periods of exposure, and the clinical
In the event of signs and symptoms suggestive of picture may appear hours or weeks after the
anaphylaxis, emergency medications and sensitized skin has been exposed.
equipment must be available for immediate use.
CLINICAL MANIFESTATIONS
Nonadherence to the Therapeutic Regimen.
Knowledge about the treatment regimen does Symptoms include itching, burning, erythema,
not ensure adherence. skin lesions (vesicles and papules), and edema,
Having the patient identify potential barriers and followed by skin thickening, hardening, and
explore acceptable solutions for effective scaling.
management of the condition (e.g., installing tile In severe responses, hemorrhagic bullae may
floors rather than carpet, not gardening in the develop.
spring) can increase adherence to the treatment Repeated reactions may be accompanied by
regimen. thickening of the skin and pigmentary changes.
Secondary invasion by bacteria may develop in
MONITORING AND MANAGING POTENTIAL
skin that is abraded by rubbing or scratching.
COMPLICATIONS
Educating Patients About Self-Care. ASSESSMENT AND DIAGNOSTIC FINDINGS
The patient is instructed about strategies to
minimize exposure to allergens, the actions and Determining allergens responsible requires a
adverse effects of medications, and the correct history, physical examination, and patch testing.
use of medications. Assessment should include the date of onset,
The patient should know the name, dose, and any identifiable relationship to work
frequency, actions, and side effects of all environment and skin care products.
medications taken. The location of the lesions, distribution of the
Instruction about strategies to control allergic dermatitis, absence of other etiologies, and the
symptoms is based on the needs of the patient history of exposure aid in determining the
as determined by the results of tests, the condition.
severity of symptoms, and the motivation of the Patch testing and environmental history of
patient and family to deal with the condition exposure to contact allergens are required to
verify the diagnosis. Patch testing is indicated in
cases in which inflammation persists despite
avoidance therapy.
ASSESSMENT AND DIAGNOSTIC FINDINGS MEDICAL MANAGEMENT

Patch testing and environmental history of Treatment of patients with atopic dermatitis must
exposure to contact allergens are required to be individualized.
verify the diagnosis.
identification and avoidance of contact with
Patch testing is indicated in cases in which
the offending agents.
inflammation persists despite avoidance
elimination of inflammatory disorders and
therapy.
infections.
The patch test most commonly used is the Thin-
prescription of topical corticosteroids and non-
layer Rapid.
steroidal anti inflammatory agents.
Use Epicutaneous (T.R.U.E.) test
preservation and restoration of the stratum
corneum layer.
prescription of anti puritic agents, oral
antibiotics, and oral immunosuppressants for
severely affected patients.
ATOPIC DERMATITIS Itching can be decreased by wearing cotton
Atopic dermatitis is a type I immediate fabrics; washing with a mild detergent;
hypersensitivity disorder characterized by humidifying dry heat in winter.
inflammation and hyper reactivity of the skin. maintaining room temperature at 20°C to
22.2°C (68°F to 72°F);
a chronic pruritis inflammatory skin disease. using antihistamines such as diphenhydramine;
avoiding animals, dust, sprays, and perfumes.
Keeping the skin moisturized with daily baths to
hydrate the skin and the use of topical skin
moisturizers is encouraged.
topical corticosteroids are used to prevent
inflammation, and any infection is treated with
antibiotics to eliminate Staphylococcus aureus
when indicated.
The term is used synonymously with atopic The use of immunosuppressive agents, such as
eczema (AAAAI, 2015). cyclosporine (Neoral,Sandimmune), tacrolimus
Other terms used to describe this kind of (Prograf, Protopic), and pimecrolimus (Elidel),
disorder include atopic eczema, atopic may be effective in inhibiting T cells and mast
dermatitis, and atopic dermatitis/eczema cells involved in atopic dermatitis
syndrome (AEDS).
Increased serum IgE levels have been indicated NURSING MANAGEMENT
in 80% of the patients with a family history of
Patients who experience atopic dermatitis and
type 1 allergies, allergic rhinitis, and asthma.
their families require assistance and support
This disorder affects 15% to 30% of children and
from the nurse to cope with the disorder.
2% to 10% of adults in developed countries.
The symptoms are often disturbing to the
Most patients have significant elevations of
patient and disruptive to the family.
serum IgE and peripheral eosinophilia. The
The appearance of the skin may affect the
eosinophil count may be increased depending
patient’s self-esteem and their willingness to
on concomitant respiratory allergies.
interact with others.
 DERMATITIS MEDICAMENTOSA
NURSING MANAGEMENT
(DRUG REACTIONS)
Instructions and counseling about strategies to
This is a common condition with
incorporate preventive measures and
approximately 10% to 20% of people having
treatments into the lifestyle of the family may
one episode during their lifetime.
be helpful.
Urticaria is most commonly instigated by
The patient and family need to be aware of
infections, allergic reaction to food, insect
signs of secondary infection and of the need to
stings, and medications (American
seek treatment if infection occurs.
Osteopathic College of Dermatology.
The nurse also educates the patient and family
Each hive remains for a few minutes to
about the side effects of medications used in
several hours before disappearing. They
treatment
usually fade within 24 to 48 hours, but new
lesions may be developing simultaneously at
DERMATITIS MEDICAMENTOSA
other skin sites.
(DRUG REACTIONS)
The condition usually resolves in 3 weeks.
Dermatitis medicamentosa, a type I However, if this sequence continues for
hypersensitivity disorder, is the term applied to longer than 6 weeks, the condition is called
skin rashes associated with certain medications. chronic urticaria.

Although people react differently to each MANAGEMENT OF THE CONDITION INCLUDES

medication, certain medications tend to induce
eruptions of similar types. This disorder is the 1. eliminating the causative drug or food.
leading cause of fatal anaphylaxis, comprising 2. avoiding the use of nonsteroidal anti-
43% of deaths from anaphylaxis. inflammatory drugs (NSAIDs);
All routes of administration are potentially fatal, 3. minimizing potential aggravators, including
but drugs given parenterally incur the greatest heat, stress, alcohol, and tight clothes.
risk. 4. administering antihistamines, and possibly a
Cutaneous rashes are among the most common short course of corticosteroids (Prednisone).
adverse reactions to medications and occur in
approximately 2% to 3% of hospitalized
patients ANGIONEUROTIC EDEMA

DERMATITIS MEDICAMENTOSA
(DRUG REACTIONS)
Urticaria (hives) is a type I hypersensitive
allergic reaction of the skin that is
characterized by the sudden appearance of
edematous, pink or red wheals of variable
size from 2 to 4 mm, and general pruritus.
They may involve any part of the body,
(i.e., angioedema) involves the deeper layers
including the mucous membranes
of the skin, resulting in more diffuse swelling
(especially those of the mouth), the larynx
rather than the discrete lesions characteristic
(occasionally with serious respiratory
of hives.
complications), and the gastrointestinal
tract.
ANGIONEUROTIC EDEMA
HEREDITARY EDEMA
CLINICAL MANIFESTATIONS
It is manifested by non-pruritic, brawny,
nonpitting edema with well-defined margins and When skin is involved, the swelling usually is
erythema similar to urticaria. diffuse, does not itch, and usually is not
Urticaria and angioedema often occur together. accompanied by urticaria.
The regions most often involved in angioedema Gastrointestinal edema may cause abdominal
are the lips, eyelids, cheeks, hands, feet, pain severe enough to be incapacitating.
genitalia, and tongue; the mucous membranes of Typically, attacks last 2 to 4 days and resolve
the larynx, bronchi, and gastrointestinal canal without intervention; however, attacks can
may also be affected, particularly in the occasionally affect the subcutaneous and
hereditary type. submucosal tissues in the region of the upper
On occasion, this reaction covers the entire airway and can be associated with respiratory
back. obstruction and asphyxiation.
Swellings may appear suddenly, in a few
HEREDITARY EDEMA
seconds or minutes, or slowly in 1 or 2 hours.
MEDICAL MANAGEMENT
In the latter case, their appearance is often
Attacks usually subside within 2 to 4 days, but
preceded by itching or burning sensations.
during this time the patient should be observed
Seldom does more than a single swelling appear
carefully for signs of laryngeal obstruction, which
at one time, although one may develop while
may necessitate tracheostomy as a lifesaving
another is disappearing.
measure.
Infrequently, swelling recurs in the same region.
Epinephrine, antihistamines, and corticosteroids
Individual lesions usually resolve in 24 hours.
are usually used in treatment, although their
On rare occasions, swelling may recur with
success is limited.
remarkable regularity at intervals of 3 to 4
weeks.
COLD URTICARIA
HEREDITARY ANGIOEDEMA

Hereditary angioedema is a rare, potentially

life threatening, autosomal dominant disorder.

Although not an immunologic disorder in the

usual sense, this condition is included because
of its resemblance to allergic angioedema and
because of the potential seriousness of the
condition.
Familial atypical cold urticaria (FACU) and
Symptoms are caused by edema of the skin,
acquired cold urticaria (ACU) are additional
the respiratory tract, or the digestive tract.
diseases within the spectrum of urticaria
Attacks may be precipitated by trauma, or they
induced by temperature exposure.
may seem to occur spontaneously.

FACU is an autosomal dominant condition,

inherited from one affected parent, and
symptoms usually begin at birth within the first 6
months of life.
ACU most frequently affects children and young
adults.
 COLD URTICARIA FOOD ALLERGY
CLINICAL MANIFESTATIONS
More than 170 foods have been reported to
Patients with FACU break out in hives (i.e., cause IgE-mediated reactions (Sampson,
urticaria) when exposed to cold. Aceves, Brock, et al., 2014).
The urticaria may be prompted by exposure to Almost any food can cause allergic symptoms.
cold weather or cold water or after coming in Any food can contain an allergen that results in
contact with cold objects. anaphylaxis.
Lesions occur within a few hours and usually The most common offenders are seafood
subside in 2 days. (lobster, shrimp, crab, clams, fish)
Symptoms include fever, chills, conjunctiva peanuts, tree nuts, berries, eggs, wheat, milk,
infection, sweating, headache, and arthralgia. and chocolate
During the attack, the patient may develop Peanut and tree nut (e.g., cashew, walnut)
leukocytosis, an increase in the erythrocyte allergies are responsible for the most severe
sedimentation rate (ESR) and raised C-reactive food allergy reactions.
protein levels There is insufficient evidence that maternal diet
during pregnancy or lactation affects the
COLD URTICARIA development of food allergies later in life.
MEDICAL MANAGEMENT

Prevention involves avoidance of cold stimuli. FOOD ALLERGY

Treatment involves bed rest, warmth, and
CLINICAL MANIFESTATIONS
corticosteroids to treat an acute attack.
All patients with any form of cold urticaria Food allergy is the most common trigger for
should carry an autoinjectable epinephrine anaphylaxis. Symptoms occur in a few minutes
device for emergency use because hives can to hours from exposure.
progress to anaphylaxis. The clinical symptoms are classic allergic
symptoms
FOOD ALLERGY 1. urticaria
2. dermatitis
3. wheezing
4. cough
5. laryngeal edema
6. angioedema
gastrointestinal symptoms
1. itching
2. swelling of lip, tongue, and palate
IgE-mediated food allergy, a type I 3. abdominal pain
hypersensitivity reaction, occurs in about 2% 4. nausea
of the adult population; it is thought to occur 5. cramps
in people who have a genetic predisposition 6. vomiting
combined with exposure to allergens early in 7. diarrhea
life through the gastrointestinal or respiratory
tract or nasal mucosa.
 FOOD ALLERGY LATEX ALLERGY
ASSESSMENT AND DIAGNOSTIC FINDINGS

A careful diagnostic workup is required in any

patient with suspected food hypersensitivity.
Included are a detailed allergy history, a
physical examination, and pertinent diagnostic
tests.
Skin prick testing is used to identify the source
of symptoms and assists in identifying specific
foods a causative agents Latex allergy—the allergic reaction to natural
rubber proteins—has been implicated in
FOOD ALLERGY rhinitis, conjunctivitis, contact dermatitis,
MEDICAL MANAGEMENT urticaria, asthma, and
anaphylaxis.
Therapy for food hypersensitivity includes
elimination of the food responsible for the
The prevalence has been steadily declining,
hypersensitivity.
possibly because of the use of nonpowdered
Pharmacologic therapy is necessary for
latex and latex-free gloves.
patients who cannot avoid exposure to
Natural rubber latex is derived from the sap of
offending foods and for patients with multiple
the rubber tree (Heveabrasiliensis).
food sensitivities not responsive to avoidance
The conversion of the liquid rubber latex into
measures.
a finished product entails the addition of
Medication therapy involves the use of H1
more than 200 chemicals.
blockers, antihistamines, adrenergic
The proteins in the natural rubber latex (Hevea
agents, corticosteroids, and cromolyn
proteins) or the various chemicals that are
sodium
used in the manufacturing process are
thought to be the source of the allergic
FOOD ALLERGY reactions.
NURSING MANAGEMENT
LATEX ALLERGY
In addition to participating in management of CLINICAL MANIFESTATIONS
the allergic reaction, the nurse focuses on
preventing future exposure of the patient to Irritant contact dermatitis, a nonimmunologic
the food allergen. response, may be caused by mechanical skin
If a severe allergic or anaphylactic reaction to irritation or an alkaline pH associated with
food allergens has occurred, the nurse must latex gloves.
instruct the patient and family about strategies Common symptoms of irritant dermatitis
to prevent its recurrence. include erythema and pruritus. These symptoms
Patients’ food allergies should be noted on can be eliminated by changing the brand of
their medical records, because there may be gloves or by using powder-free gloves.
risk of allergic reactions not only to food but The use of hand lotion before donning latex
also to some medications containing similar gloves can worsen the symptoms, because
substances. lotions may leach latex proteins from the
gloves, thus increasing skin exposure and the
risk of developing true allergic reactions
 LATEX ALLERGY LATEX ALLERGY
CLINICAL MANIFESTATIONS MEDICAL MANAGEMENT

Delayed hypersensitivity to latex, a type IV The best treatment available for latex
reaction mediated by T cells in the immune allergy is the avoidance of latexbased
system, is localized to the area of exposure and products, although avoidance is often difficult
is characterized by symptoms of contact because of the widespread use of such
dermatitis, including vesicular skin lesions, products.
papules, pruritus, edema, erythema, and Patients who have experienced an
crusting and thickening of the skin. anaphylactic reaction to latex should be
These symptoms usually appear on the back of instructed to wear medical identification.
the hands. Antihistamines and an emergency kit
This reaction is thought to be caused by containing epinephrine should be provided to
chemicals that are used in the manufacturing these patients, along with instructions about
of latex products. It is the most common emergency management of latex allergy
allergic reaction to latex. symptoms.
Patients should be counseled to notify all
LATEX ALLERGY health care workers, as well as local paramedic
ASSESSMENT AND DIAGNOSTIC FINDINGS and ambulance companies, about their allergy.
Warning labels can be attached to car
The diagnosis of latex allergy is based on the
windows to alert police and paramedics about
history and diagnostic test results.
the driver’s or passenger’s latex allergy in case
Sensitization is detected by skin testing; serum-
of a motor vehicle crash.
specific IgE, EIA, or ELISA; or
the level of Hevea latex-specific IgE antibody LATEX ALLERGY
in the serum. Testing for the chemicals found in
NURSING MANAGEMENT
the rubber production that makes latex is
performed using the patch test. The nurse can assume a pivotal role in the
management of latex allergies in both patients
and staff.
Skin patch testing is the preferred method for
All patients should be asked about latex
patients with contact allergies.
allergy, although special attention should be
given to those at particularly high risk (e.g.,
The T.R.U.E. test and other skin tests should be patients with spina bifida, patients who have
performed only by clinicians who have undergone multiple surgical procedures).
expertise in their administration and Every time an invasive procedure must be
interpretation and who have the necessary performed, the nurse should consider the
equipment available to treat local or systemic possibility of latex allergies.
allergic reactions to the reagent. Nurses working in operating rooms, intensive
care units, short procedure units, and EDs need
LATEX ALLERGY
to pay particular attention to latex allergy.
MEDICAL MANAGEMENT

The best treatment available for latex

allergy is the avoidance of latexbased
products, although avoidance is often difficult
because of the widespread use of such
products.