Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
What is the utility of remibrutinib or other tyrosine kinase inhibitors in MCAS?
MCAS can be due to clonal (mastocytosis) or non-clonal (IgE and non-IgE mediated mast cell activation or idiopathic) etiologies. Remibrutinib is a btk inhibitor, currently only approved for chronic spontaneous urticaria, but not for MCAS. Btk is involved in IgE receptor signal transduction. In patie...
How do you reassure families that no allergy testing is needed for urticaria?
I explain to them that it is an immunologic phenomenon (inside job) and not allergic (outside job).
With emerging therapies, what is your general treatment ladder for chronic spontaneous urticaria (CSU)?
Antihistamines remain the first-line therapy for chronic spontaneous urticaria (CSU), and doses should be optimized before turning to other therapies. If patients fail a trial of adequately dosed first- and second-generation antihistamines, montelukast is a reasonable adjunct. For patients with high...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Does switching arms enhance the efficacy of subcutaneous allergen immunotherapy?
I wish we knew. Many of us switch arms with immunotherapy doses routinely to try to minimize local reactions and "spread out allergen evenly," so to speak. It is the latter concept that is relevant to the question. I do not know of any data as it pertains to allergen immunotherapy. However, there is...
Do you use skin prick testing wheal size/grade or serum IgE levels when deciding what dose of allergen immunotherapy to start a patient on?
Generally, regardless of the degree of sensitization, I start my patients' immunotherapy with a 1:1000 dilution and build up to 1:1 over several months. However, I may consider the degree of sensitization when writing the extract prescription. I typically dose in the lower range for allergens with m...
How long do you apply patch testing before interpreting the results?
In most instances, patches are removed after 48 hours (2 days). This timeframe is specifically chosen to allow sufficient time for the allergen to penetrate the stratum corneum and trigger a T-cell-mediated response, while simultaneously reducing the potential for significant skin irritation that ca...
What data exist regarding treatment for facial erythema from dupilumab in children <5 years of age?
In AD patients >6 years, the incidence of facial erythema for dupilumab was 1% vs placebo 0.7% (Paller et al., PMID 41163262). The placebo-controlled LIBERTY AD PRESCHOOL trial (Paller et al., PMID 36116481) and the subsequent open-label trial up to 2 years (Paller et al., PMID 41926052) for 6-month...
How reliable are the expiration dates of patch test allergens?
An AI search of this question revealed the following: "Expiration dates for patch test allergens are generally considered reliable and should be strictly honored to ensure diagnostic accuracy. While some allergens remain stable for years, others degrade rapidly, and using expired materials significa...
How do you approach selection of systemic treatment in a patient with atopic dermatitis with severe itch?
The good news is we have 6 approved options here, 4 biologics and 2 small molecules, and all of these therapies have excellent itch data. Selecting a systemic therapy needs to take other comorbid conditions, medications, delivery preference (pill or injection), lifestyle, and other patient attribute...