Fifty million people in the U.S. have allergies. Sometimes it feels like all of them live in Central Texas. For my husband, it’s cedar. For me, it’s oak. But in this corner of the state, with rivers and lakes that hold in moisture, with south and north winds that whip across the wide open fields and with relatively few hard freezes, some part of Mother Nature is usually in bloom.
Every day, both on the website for Allergy Asthma Center and on its Facebook page, pollen counts are listed for the Waco area. The January day when I interviewed Dr. Neil Amar, one of three board-certified allergists who practice at the clinic, I knew mountain cedar was at 2,801. What I didn’t know was that the number wasn’t generated by an algorithm. Someone actually counted the pollen grains.
“There’s a rod on top of our building that collects pollen,” Amar said. “That morning we’ll take that pollen and look at it under a slide, and then we count — we physically count — the pollen. That’s the numbers you’re reading there.”
Because this process is done by hand, the number posted is actually for the previous day’s pollen. Amar says that for any number above 25, someone who is allergic to that specific trigger will show symptoms. A reading of 50 is high. So 2,801 means that even people who don’t usually suffer from allergies may feel a little out of whack.
Amar grew up in Waco, the child of two physicians, allergist Dr. N.J. Amar (with whom Amar practices) and endocrinologist Dr. Meera Amar.
“I went to Midway my whole life, then the last three years I switched to Vanguard,” he said.
Amar attended medical school at The University of Texas Medical Branch in Galveston (UTMB) and completed his residency in internal medicine at Baylor College of Medicine in Houston. He followed that up with a fellowship in allergy and immunology at UTMB. The decision to come back to Waco and join his father’s practice was not something Amar initially considered. His wife, Dr. Ashley Amar, a psychiatrist, led that charge.
“My wife is from South Dakota, a small town, 100 people,” Amar said. “We met in residency in Houston, and it was way too big to her. She wanted to live in Waco. She thought, ‘Oh, yeah, it’s perfect! It has a Walmart!’”
After settling on a ranch outside of town, Amar agrees that coming home was the right decision. “I enjoyed coming back,” he said.
All four Amar doctors work at the same address. Amar’s wife and mother share a waiting room.
“There are four Amars in the building,” he explained. “We get to see each other every day.”
Amar and his wife have a 15-month-old daughter, Divya, and they hire a babysitter to stay with her at the clinic so that both parents and the grandparents get to spend time with her.
Back in 2010 the Wacoan interviewed Amar’s parents for an article on medical marriages — marriages in which both spouses are physicians. At that time Amar was in residency in internal medicine. I asked why he went on to study allergy and immunology.
“I did internal medicine because I didn’t know what I wanted to do yet. From internal medicine you get to specialize. I actually thought about doing endocrine, like my mom. My mom does a lot of thyroid biopsies — I just really wanted to treat patients,” Amar said. “Allergy is completely different because you don’t go to the hospital at all, and that’s one of the biggest benefits. I don’t like hospitals. And I’m totally OCD. I write these detailed notes, and no one can really read them.”
Unlike internal medicine, which serves mostly adults, Amar likes the blend of adults and children in allergy and immunology.
“This is one of the few specialties where you get to see half kids and half adults. Adults have more nasal allergies; kids have more asthma. I kind of like the blend. We [allergists] don’t get bored as easily. Kids do silly things. They make me laugh.”
One reason allergists see so many kids is that allergies tend to run in families.
“Almost always there’s a family history — 90 percent of the time there’s a family history of allergies. So we always ask,” Amar said.
He explains that four types of allergic conditions run in families and can grow and change into one another: food allergies, eczema, asthma and nasal allergies.
“If you have one of those conditions, there’s a 50 to 75 percent chance that you have the others of them as well,” Amar explained. “You’ll have a history of eczema or food allergies. What happens is that’ll get better, then you’ll start developing asthma. Then that usually gets better around age 10, and then you’ll start seeing nasal allergies.”
He adds that nasal allergies, although more commonly found in adults, can be diagnosed in infants.
Because the immune system is still developing in children, it can be difficult for parents to know when to make an appointment with a pediatrician and when to consult an allergist.
“Allergies are actually going up in the world. It’s mainly in developed countries,” Amar said. “The reason why is the hygiene hypothesis, that we’re too clean as a people. They’ve done studies on people that grew up on farms, and they have fewer allergies. It’s because in the very first six months of life they’re exposed to more allergens, so they produce more antibodies. People who grow up in an ICU [intensive care unit], it’s too clean an environment.”
He adds that all those antibacterial soaps and wipes — “which I love to use, even though I know better,” Amar said — probably aren’t doing our immune systems any favors.
That being said, even if you do live on a farm with lots of critters, Waco is a particularly bad place for allergies. There are four main allergy seasons, and they pretty much cover the calendar year.
“The four main ones in our area are mountain cedar in the winter; then spring, oak; summer, grasses, and grass season can be up to 8 months long; and fall, ragweed,” he said. “That’s why we’re the allergy capital because we don’t get a break.”
If you are allergic to any of those four, or if you have a combination of allergies, as many people do, Amar says you may be a candidate for allergy shots.
“Our bread and butter is nasal allergies, allergic rhinitis — that’s the most common patient we see. Usually we do skin testing for that. It’s more sensitive than blood testing,” he said. The clinic uses different tests, or panels, for different patients. “There’s different panels: one for kids, one for adults, one for infants. Same with food allergies, the same process.”
About half of patients with allergies also have asthma. Those patients will also receive a breathing test (actually two tests — one before being given the medication albuterol and then another one afterward) to see if they improve.
“One of the criteria to have asthma is reversibility. With albuterol, you should be back to normal, for the most part. If you have COPD [chronic obstructive pulmonary disease], you won’t see the change,” Amar said.
Asthma affects more than 20 million Americans and at least 7 million children. It can be triggered by smoke, cold air, exercise and stress as well as typical nasal allergies. That means controlling asthma can be complicated.
“Some people with severe asthma, you can never get their asthma under control unless you control their nasal allergy,” Amar said.
But how do you control nasal allergy? Amar says patients can get confused about how to properly take even prescription allergy medicine. When it comes to over-the-counter remedies, there’s a lot of misunderstanding, especially about antihistamines versus decongestants.
“We worry about decongestants — they’re a huge deal. I wish they were not over-the counter. Decongestants are things like Sudafed, but the problem with those is they only work for a short period of time. If you use them longer than a week, they don’t work when you take them, so you take more,” Amar said. He adds that the decongestant nose sprays sold in grocery stores are addicting and can cause permanent nasal damage.
Amar recommends people start with antihistamines.
“Nose sprays, like Flonase and Nasacort, are better when used every day — not used as needed. They’re more preventative medicines. They prevent things from getting bad,” he said. Antihistamine pills, like Allegra, Claritin and Zyrtec, work differently.
“The thing is they don’t work for prolonged periods of time. If you keep using Zyrtec every single day, it becomes less effective, so they work better as needed,” Amar said.
He prefers these second-generation antihistamine pills, which come in non-drowsy, long-acting formulas, to first-generation antihistamines, like Benadryl.
“It’s short-acting and knocks everybody out. People say it doesn’t, but it does, just like a drink of alcohol. Even one drink makes you a little sleepy,” he said.
He says expectorants, like Mucinex, can be helpful to break up mucus. Nasal saline rinses can be used in conjunction with antihistamine nose sprays.
“A lot of our patients are just on the rinses and shots because they don’t want to take any medications,” Amar said. He recommends the squeeze bottle rinses over the pot type because they are easier to use and more effective.
Despite several patient inquiries about allergy drops, he does not like them.
“Allergists kind of frown upon them,” Amar said. “It’s a marketing thing. They’re not FDA-approved. We think it’s kind of bogus.”
After you’ve traveled the over-the-counter route and still feel miserable, that’s when it’s time to consider seeing an allergist.
“When your symptoms are not controlled with medication, that’s when you need to come in,” Amar said.
And if you have asthma and have never seen an allergist, it might be a good idea to make an appointment anyway. Amar describes asthma as “an allergy in your airway.”
“It’s the same mechanism that causes both of them [allergies and asthma]. Asthma has two parts to it: the inflammation part of it, and that’s a similar mechanism to allergy,” he said. “For a lot of people allergy is the trigger for their asthma. What happens in your nose happens in your airway. We treat asthma in the airway and not the lungs. Pulmonologists treat the lungs.”
He says most people with asthma need two medicines: one for the inflammation, which is an inhaled steroid, like Advair or Flovent. The other is a medicine like albuterol to address construction in the airway.
“You have muscles around your airways, and they constrict [in asthma]. Albuterol only works on the muscle part,” Amar said. “Albuterol can only do so much.”
The child of a family friend of the Amars died from asthma. He was using his albuterol as a rescue inhaler, but Amar suspects he also needed to be on a medication to control the inflammation from asthma.
Fundamentally, allergies are part of the immune system. The website of Allergy Asthma Center, texasallergist.com, says, “An allergic reaction occurs when the immune system overreacts to an allergen.” If an allergic reaction is just the immune system overreacting, then why do we feel so terrible?
“We have different antibodies that fight infection. Immunodeficiency, that’s part of allergy and immunology. We’re trained in that as well,” Amar said.
He explains that there are good antibodies and bad antibodies. An antibody called IgG protects the body from infections — it’s the good one. Then there’s IgE.
“There’s an antibody called IgE, and it causes allergies. It was initially there [in our bodies] because it does fight parasitic infections, but otherwise it’s known to cause allergies. That’s what overreacts; it’s not the good antibody — it’s the IgE.”
When the IgE binds to the allergen and then to a cell called a mast cell, histamine is released.
“That’s the bad guy that causes all allergic reactions. That’s why you take antihistamines,” Amar said.
Allergy shots can be a useful tool in building the body’s immune system.
“When you’re on allergy shots, you’re getting a small amount of what you’re allergic to, and you get higher and higher doses. You produce less IgE antibodies, the bad ones, so therefore, you have less allergies,” Amar said. “It’s like a spectrum. Your body can only make a certain amount of antibodies, so which is it going to make?”
Being an allergist does not keep Amar from struggling with allergies. Mountain cedar bothers him, especially when he’s around one of his dogs — a Rottweiler and a German shepherd he describes as “really spoiled.” The dogs have their own room for times when the weather is especially hot or cold. Like most canine pets, they’re inside and outside. And that back and forth brings in a lot of pollen.
“It’s because the dog is like a carpet, so [the pollen is] highly concentrated,” Amar said, especially on days when the pollen count is high.
He says sometimes people mistake a dog allergy for what is actually an allergy to pollen in the dog’s hair.
“People don’t realize that if they’re having symptoms around their dog, it’s probably pollen on their dog,” he said, adding, “There’s no such thing as a hypoallergenic dog.”
However, cat allergies are another story.
“Cat is one of the strongest allergens there are. You could be across the restaurant from the cat lady and have symptoms,” he said. “If you have a cat in your house, and it’s hardwood [floors], you can clean the whole house. You can change as many filters in the house as you like — the cat dander can still last up to six months.”
If you suspect you have allergies of any type — pollen, pets, skin, food, even drug allergies — learning more about what kinds of allergens trigger a reaction and when they are likely to cause problems can help you know how to handle them. Sometimes it comes down to avoidance.
“If you can avoid something, that’s the easiest way. Sometimes that’s also the hardest, but there’s avoidance techniques you can do,” Amar said. “I think once you fail medicine in general, that’s when we recommend you see an allergist and get tested and figure out what you’re allergic to.”