In this guest article from allergist Dr. David S. Mazza, learn more about managing allergy problems and understanding the way your body responds to common allergens.
Singing is an art that demands total body involvement. First and foremost is the utilization of the essential elements: eyes, ears, nose, throat, and lungs. The main target organs of most allergies also involve these same elements. So, controlling allergies is critical to the professional singer.
In my many years of teaching and practicing allergy medicine, I have found that patient understanding of the nature of their disease and the rationale behind the treatments is key to their acceptance and compliance with treatment regimens. We also want to avoid side effects that will interfere with performance. With that in mind, the first principle I always teach my patients is “What does it mean to be allergic? What happens when you have an allergic reaction?”
Everyone has allergy cells, which are mast cells, basophils, and eosinophils. However, as you know, not everyone has allergies. What makes the allergic person different is that their allergy cells have, on their surface, receptors that are directed very specifically at the molecular level to the antigen to which they’re allergic—be it dust mites, cats, dogs, trees, grass, etc. When an allergic reaction takes place, the allergy cells release a plethora of chemicals into the blood stream directed at the tissues of the target organ. One of these chemicals is histamine. Thus, antihistamines and decongestants are the “go to” treatment for most patients.
However, this is only one of the myriad chemicals that are released, and the most successful treatment for the allergic patient is to stop this cascade of chemicals from being activated in the first place. It is best to think of allergies as an inflammatory disease; when an “allergy attack” takes place, this involves inflammation. In the respiratory tract the body’s response to inflammation results in swelling and increased mucus production—all key elements that one needs to control for singing. Swollen nasal passages, throat, vocal cords, and lungs together with copious amounts of mucus can have a marked effect on the ability to sing. Review the mast cell schematic of this process for clearer understanding.
As I previously mentioned, it is important for the singer to be able to identify the target organs for each allergen. For example, I have patients who are allergic to tree pollen in the spring, which causes sneezing. In the fall, they are allergic to weeds but their only symptom may be itchy eyes. Each patient is different, so it is important when you visit an allergist to know what symptoms you experience around each allergen or season so your doctor can specifically tailor your treatment.
Medications can be categorized as either symptomatic controllers or anti-inflammatory. Symptomatic drugs control some of the overt manifestations in your allergic reaction. Anti-inflammatory drugs address the inflammatory response that is occurring. If you can control the inflammation, then you can be like the person who has allergy cells but no allergies.
Environmental Controls
The first treatment is to assess how much of the environment you can control to diminish your exposure to allergens—i.e., environmental controls. If you have seasonal allergens to trees, grass, or weeds, performing in an indoor space where the air is filtered through HEPA filters lowers your allergen exposure. Also be cognizant in what part of the world you will be performing and in what season. Seasons south of the equator are the exact opposite of those north of the equator. For example, if you are performing in Australia in the North American spring and you only have spring allergies in the U.S., then singing in Australia may not require any medication. If you are allergic to dust mites—which live in mattresses, pillows, rugs, curtains, and fabric furniture—it doesn’t matter in what part of the world you are performing, for the most part.
Steps usually need to be taken when you will be staying in some facility other than your own home. (Information for hotels that offer accommodations for allergy sufferers can be found at https://www.sylvane.com/traveling-with-allergies-infographic.html.) If your accommodations are going to be with a volunteer of the organization for which you are performing, learn ahead of time whether there are pets, rugs, or smokers, etc.. in the residence. This can save you much angst when you arrive.
What about your own home environment? Do you have pets even though you are allergic to them? Do you have dust mite precautions in your own living space if you have dust mite allergy, etc.? Allergy treatment starts in the home for those allergic to indoor allergens.
Symptomatic Treatment
Antihistamines are a good start for patients with mild allergies and symptoms such as sneezing or an itchy or runny nose. Allergies are classified as mild, moderate, or severe. For the mild- to low-moderate patient, this may be all that is needed. Certainly, non-sedating antihistamines are the best choice in this category. Luckily, science has come a long way in this field since the days when Benadryl was the antihistamine of choice. Benadryl is effective but unless you are using this as a sleep aid, the side effects of drying the mucus membranes and sedation, in most cases, makes this antihistamine not the drug of choice.
The drug I recommend for singers which has the least drying effect and sedation is fexofenadine (Allegra is one of the brand names). This drug is available in 60 and 180 mgs. For the adult patient, a 180 mgs daily or as needed is the usual dose. (Please note that if this dose doesn’t control the above symptoms adequately, then doubling the dose is an option, but consult first with your allergist and/or primary care doctor to take into consideration other medications that you may be taking.) Other medications in this same category are loratadine (Claritin), cetirizine (Zyrtec), desloratadine {Clarinex), and levocetirizine (Xyzal).
Decongestants are another symptomatic treatment available over the counter. The most common one is pseudoephedrine (Sudaphed). The main symptoms that this drug treats are nasal congestion, postnasal drip, and sinus headache. This drug or similar is often combined with the above antihistamines and has the suffix D at the end to indicate their presence (e.g., Claritin D). However, I prefer not to take these combination products but to treat the individual symptoms. One of the main side effects of decongestants is drying of the mucus membranes excessively. Some patients cannot tolerate decongestants because of their tendency in some people to cause anxiety, increased blood pressure and heart rate, and insomnia.
For some patients, a particular allergen may target only one organ such as the eyes causing tearing, swelling of the eyelids, or the experience of something in your eye. Although a complete discussion of eye drops is beyond the scope of this article, please be aware that there are many OTC medications that are now available and, depending on your symptom, some may be better suited to you.
A common antihistamine eye drop is azelastine (Optivar). It is important to realize that you get approximately 600 times the concentration of an antihistamine in your eye with an eye drop as opposed to using an oral antihistamine pill. There are also anti-inflammatory eye drops such as ketorolac (Acular), mast cell stabilizer eye drops and antihistamine ketotifen (Zaditor), and decongestant eye drops naphazoline (Visine Advanced). Steroid eye drops are available only through a prescription and a patient should have their eyes examined by an ophthalmologist before taking this type of medication.
In the best of all worlds, given the degree of severity of your symptoms, it is better to prevent the allergic reaction from occurring in the first place. If this is accomplished, very little symptomatic medication (such as antihistamines, decongestants, or eye drops) will be needed. To do this we have to address the reaction at its core, namely the inflammation that is occurring.
Anti-inflammatories
One of the best in the category of anti-inflammatories is the drug montelukast (Singular), which was originally released as a treatment for asthma. Since it is an oral pill, it can also have anti-inflammatory effects on any target organ of the allergic reaction. It was subsequently approved by the FDA for not only asthma but also allergies of the upper respiratory tract such as the nose. This drug is great for some people, but it is so targeted to a particular part of the inflammatory cascade—so if your inflammation is not primarily caused by this specific part of the inflammatory cascade, it will have little effect. Its major advantage is it is nonsteroidal with minimal side effects. This drug is prescription, but the safety profile is excellent. This medication is not taken as needed but rather daily during the period that your allergies are present.
The drug regime that really changed the treatment of allergies in a major way is the topical use of steroids. These are a powerful class of drugs, but using them topically avoids the major side effects of oral steroids. Topical steroids are available now OTC for the most part. Examples of these medications are fluticasone (Flonase), budesonide (Rhinocort), and triamcinolone (Nasacort). These medications for the most part take 4 to 7 days to reach maximum effectiveness. So, for example, if you find that you are always very allergic in the spring, then you would begin these medications daily starting at the end of winter and take them until the end of the spring. If you do have breakthrough symptoms such as infrequent episodes of sneezing, itching, runny nose, nasal congestion, or sinus headache, then the symptomatic medications such as antihistamines and/or decongestants can be used on an as needed basis as an adjunct.
Inhaled steroids, in addition to their use in treating the upper respiratory tract, have also revolutionized the treatment of the lower respiratory tract (e.g., asthma). Although a full discussion of the treatment of asthma is also beyond the scope of this article, it is important for the singer to be aware of this ailment since 60% of asthma is driven by allergic disease.
For some patients whose allergies are not controlled by the above medications and environmental controls, allergen immunotherapy offers an opportunity to control or eliminate their allergic disease. These treatments are available both through allergy injections and oral tablets (oral is currently available only for grass, ragweed, and dust mite). For all the other allergens—such as dogs, cats, mold trees, grass, and weeds—subcutaneous allergy treatment (allergy shots) has been used since the 1940s, although they have been greatly improved upon since those early days.
These treatments consist of injecting or taking orally the substances to which you are allergic. Gradually your body becomes less allergic and, in some cases, no longer reacts to the allergen. This result can persist for years. Subcutaneous allergy injections take 6 to 9 months of weekly visits to get up to levels that provide desensitization, followed by monthly injections for a period of 3 to 5 years.
Please refer to the decision tree graphic for your use in planning your allergy treatments. This is best accomplished by first seeing a board-certified specialist in allergy who has a minimum of 2 years’ training in this specialty beyond their 3-year residency in pediatrics or internal medicine. Great resources for allergic disease in general can be found at the American College of Allergy, Asthma, and Immunology (ACAAI.org) and the American Academy of Allergy, Asthma, and Immunology (AAAAI.org). They provide information that is based on scientific evidence that has been studied and analyzed before recommendations are made.
