Dark Circles Under Your Eyes?

Along with sneezing, stuffy nose, cough, and sore throat, seasonal allergies can also affect your eyes. Itchy, red eyes may respond to an oral antihistamine, but often they are better treated with a prescription eye drop that prevents the release of histamine (which is what causes the redness and itch to begin with.) Olopatadine ophthalmic solution, brand name Patanol, is applied twice daily, and is generally well tolerated. There is also a newer preparation, Pataday, by the same pharmaceutical company that is only once daily-newer, more convenient, likely more pricey (depends on your insurance.) Both work well.

I find many of my patients try to use over-the-counter eye drops that "get the red out"...only to find that they need more and more of these drops to accomplish the same results. The only time that I recommend these OTC products (with vasoconstrictors to eliminate red eyes) is for extremely short-term use, such as if you are giving a presentation or taking pictures. If you use these products for more than a couple days, you will develop rebound symptoms of increased redness, and risk getting pulled into the cycle of red eyes, use drops, worse red eyes when drops "wear off", more drops, etc.

What about BELOW the eye-those dark black circles that make you look a hundred years old? Those are called "allergic shiners" in the medical world. Congested sinuses slow down return of blood through the small veins under your eyes, causing them to swell and make the skin above them appear purple or black.
What helps? Oral antihistamines, plus or minus a decongestant, will often do the trick if it is mild. For people who suffer for weeks at a time, I'd recommend talking to your doctor and considering prescription nasal steroid sprays. "Spa" treatments like cucumbers and frozen tea bags work very transiently- I'm not sure it isn't just the coldness of these objects that cause vasoconstriction (shrinking of the veins), but they do seem to have non-scientifically proven positive effects, with few to no negative side effects.

BOTTOM LINE: If you have chronic issues with dark circles or "bags" under your eyes, talk to your doctor about treatment options.

Sneeze, Cough, Stuffy Nose...and LOTS of Medicines

Allergy season is in full swing, and there are so many allergy remedies out there. How do you decide what you need? Do you understand the difference between an antihistamine and a decongestant? And where does an expectorant fit in? It's often tough to figure out when to take which drug might help. Here are the basics:

1. Decongestants simply narrow the blood vessels in the lining of the nose, allowing air to pass more easily. Use these when your nose is "stopped up". Caution: do not use if you have high blood pressure, as they can potentially raise your pressure.

2. Antihistamines block the release of histamine, the chemical in your body that cause cells to swell and leak fluid, resulting in itchy eyes, sneezing, and runny nose. Use these to DRY UP (but not when you are simply "stuffy")

3. Expectorants are all medications that include guaifenesin. This drug breaks up mucus, allowing it to drain down from sinuses or be coughed up from your lungs. It wont work if you are dehydrated, so drink extra water- especially if you are also taking an antihistamine, because they DRY UP mucus and that makes it tougher to break up and clear. Use these when you have sinus and ear pressure, or if you have a cold "go to your chest." There is little evidence-based medicine to support the use of these, but clinically I have seen them help a great deal to relieve head congestion, and often avoid the use of antibiotics.

The AAFP a great website with more detail: http://familydoctor.org/online/famdocen/home/otc-center/otc-medicines/857.html

BOTTOM LINE: Don't always grab the "do everything" medicine for your stuffy, sneezy, coughy, itchy symptoms- understand which drug works for which complaint!

April Showers Bring May...ALLERGIES!

Greetings from Austin, Texas, where-ACHOO!-those of us with allergies are collecting sneezing our heads off! In our case, the scant April showers still managed to kick up the MOLD pollens enough to wreak havoc on allergy sufferers, so I thought today I'd talk about seasonal allergies.

What are signs and symptoms of allergies?

At the risk of sounding like an antihistamine commercial, it's sneezing (often in fits of sneezes), itchy eyes, itchy throat, scratchy throat, drainage down the back of your throat (which creates early morning sore throats that often fade mid-morning), stuffy eyes, ear pressure and the lovely dark circles under your eyes.

What is recommended for treatment?

We usually start with the non-sedating antihistamines,which used to be prescription but are now available over the counter (OTC). These include Loratadine (Claritin), Fexofenadine (Allegra), and Cetirizine(Zyrtec), to name a few of the most popular. Which is BEST? In my experience, they are clinically equal. What works for you this year may not work as well next year, and there is not great science to explain why. Antihistamines will DRY you up and STOP ITCH. If you are mainly stuffy, you are better off with just a decongestant such as phenylephrine (Sudafed) or if you have both, grab a combination product.

If you are suffering regularly in a particular season, or perhaps year-round from something like molds, your doctor may recommend more preventative therapy such as nasal steroid sprays. These sprays are prescription, and they are not "addictive" like the OTC ones. The OTC sprays that give immediate relief are fine for a day or two, but beyond that, you will get rebound nasal congestion and be chasing your tail with symptoms/spray/more symptoms/more spray. Nasal steroids are minimally absorbed (so no turning into Arnold, gaining weight, or weakening your bones.) They are very safe, and decrease swelling while creating kind of protective barrier against entering irritants, so you don't turn on the histamine system that causes allergy symptoms.

What more prevention can you do?

Well, it's May 1st, so like every first of the month, I recommend changing out your home's air filters! That disgusting air filter pictured above came out of our home this morning- yuck!This "central" or "media filter" type should be changed at least three or four times per year, despite manufacturer recommendations of annual replacement. Yes, that is expensive, but cheaper than many allergy medications, and no other side effects! If you look at your filter (set your calendar to remind you) and you see it looking like this- CHANGE it! HEPA air cleans and vacuum bags are of unclear efficacy, but may help. Limit your outside exposure (get on the exercise bike or treadmill indoors.) If you really suffer, consider getting rid of carpet and drapes in your home, and restricting pets to outside the bedroom.

BOTTOM LINE: If you can't stop sneezing or are having other signs of seasonal allergies, schedule an appointment with your doctor and find out what she can do to help! There are many interventions before considering allergy shots- though for severe sufferers, those shots may be an excellent option.

FIRE! Are You Prepared?

The last week has been a challenging one for Central Texas, as FIRES have consumed the majority of Bastrop (still only 70% contained) and several other communities have lost many homes. The landscape looks like a war zone, with burned grounds and few standing brick fireplaces remaining. The scope of the devastation is mind-boggling- not just homes destroyed, but businesses and many livestock as well as family pets. People are suffering financially, emotionally and physically.

There are always lessons to be learned in tragedies such as this, so today I'd simply like to encourage everyone to make sure their smoke detectors are working. Do you check the batteries on the first of each month? Do you have a "fire plan" for your family?

Many of our patients have shared their stories of the 30 seconds they had to run and grab their most cherished possessions before they evacuated their homes. Some grabbed financial papers (deeds, titles & mortgages or insurance papers), many grabbed computers, and all who were able grabbed photos. Thanks to the bravery and efficiency of our central Texas firefighters, very few human lives were lost despite the magnitude of these fires.

What is the medical fall-out? Obviously there will be emotional trauma. Happily, computerized prescription records at pharmacies allowed us to easily refill patients' medications lost in the fires. What we are seeing the most right now, though, is upper respiratory irritation. The smoke particles in the air are creating allergy-like symptoms with nasal congestion, headaches and coughs. Remember to use a decongestant (phenylephrine, like Sudafed) if you are stuffed up, hydrate with extra fluids to keep the mucus thin, and schedule an appointment with your family doctor if your symptoms are not improving.

BOTTOM LINE: Fires can happen EVERYWHERE. Make sure your home has a working smoke detector, and check that battery every month (when you check your air filters!)

Lactose Intolerance & Chocolate Milk...the Conundrum

Does your child tell you they CAN drink chocolate milk, but their stomach hurts after drinking "regular" milk? I'll share that when I told MY parents this, they laughed and thought I was simply asking for more sweets. As an adult, I was often puzzled that certain milk products did not agree with me, while others did. People asked if I was allergic to milk, or whether or not I had lactose intolerance...and I simply said that I do not like milk, because I didn't know the answer.

So, here it is. That kid that can down chocolate ice cream but not skim milk may indeed be lactose intolerant, and she is telling the truth! Lactose intolerance refers to the inability to digest lactose (the main milk sugar). Lactase lives on the inside surface of our intestines. Symptoms typically appear 30 minutes to 2 hours after consuming a product that contains lactose. The degree of symptoms produced (abdominal bloating, cramping, gas and/or diarrhea) depend on several variables:
1. The amount of lactose consumed
2. The level of lactase enzyme present
3. The SPEED of gastric emptying- the faster the gut transit, the worse the symptoms

Higher fat content will SLOW gastric emptying, which reduces the symptoms, so voila! There is your explanation for the chocolate milk. Of course, adding lactase in the form of a powder or capsule will also reduce the symptoms.

Who gets lactose intolerance? 80% of Blacks and Hispanics, nearly 100% of Native Americans and Asians, and roughly 15% of Caucasians develop it. Symptoms usually appear later in childhood or even as an adult. Also, anyone can transiently develop lactose intolerance after a serious bout of diarrhea, because that temporarily strips off the lining of the gut (which houses the lactase). Avoiding dairy products for a few days typically takes care of this type of intolerance.

The easiest way to tell if you have lactose intolerance is to eliminate it from your diet, and see if your abdominal complaints disappear. Remember, though, to read labels carefully, looking for "milk sugar, whey, or curd" as well as plain "milk". Note, too, that many prescription and OTC medications also use lactose as a base. Typically, however, even a lactose intolerant person is fine with SOME lactose (roughly 12 g) so it is not necessary to eliminate lactose 100% to see results.

If you are lactose intolerant, remember you will still need calcium to protect your bones, so talk with a registered dietician to be sure you are getting all you need.

BOTTOM LINE: Lactose intolerance is all about degrees, not simply "yes, you have it" or "no, you don't". Try a simple lactose elimination diet for a few days if you are concerned about abdominal complaints and think you may have lactose intolerance.

Where Did My Favorite Cold Medicine Go?

Today the FDA (US Food & Drug Administration) is removing many allergy, cough and cold products from the shelves of your pharmacy. If you have a favorite that has worked for you, perhaps you should stock up. What's going on? Well, it turns out that there are a ton of drugs out there that lack FDA approval, yet doctors and patients alike are unaware.

Why does it matter? Our FDA actually does a great job of collecting and reacting to adverse events related to medications, acting swiftly to remove products that could cause danger. Though there are not oodles of reports with this group of products, there are enough, especially considering that because most are over-the-counter, adverse events are much less likely to be reported.


Frankly, as I went through the list, I was very surprised that some drugs that I have previously written prescriptions for (like Entex PSE and Bromfed) are NOT FDA approved. The main reason I don't routinely recommend herbal treatments is their lack of FDA regulation, which means there is no guarantee of the amount of ACTIVE product in each tablet or capsule. Turns out, this could be true for any of these allergy, cough & cold remedies as well. Additionally, in the past couple of years, pediatric recommendations have changed greatly, especially for kids younger than two years. Many of these medications do not issue any such precautions.

Here are a few, but go to the FDA website for a full list: Accuhist DM, Aerohist, Allerx, Aquatab, Bromfed, Biotuss, Brovex, Carbodex, Deconamine, Duravent, Entex, Guaifenesin, Histex, Lodrane, Rescon, Ru Tuss, ZCof, etc.

Note that the Triamic brand and Robitussin brand are NOT on the list.

BOTTOM LINE: Go to the FDA WEBSITE and scan the list to be sure YOUR upper respiratory medicine of choice is NOT on the list!

Food Allergies

How many times have you heard someone say that they are allergic to a specific food? Food allergies are indeed common, affecting roughly 8% of kids and around 4% of adults. A true food allergy is an immune reaction to a food protein. There are many food REACTIONS (such as lactose intolerance, for example) that are not true allergies.The most common allergens are PEANUT, FISH, SHELLFISH and other TREE NUTS.

What are signs and symptoms? Food allergies show up within minutes to a couple hours after exposure to even small amounts of the offending protein. Itchy, red rashes, swelling, flushing, nausea, abdominal cramping and diarrhea, stuffy nose, wheezing, racing heart and metallic taste in your mouth are some of the possible presentations.

How do we diagnose food allergies? Mainly by history, to be honest. We combine the history with either skin or blood testing for more accuracy. Skin testing CAN be helpful, but there are many false-positives (which means the test says there IS an allergy, but there is not.) NEGATIVE results on a skin test, however, are very accurate that there is NO food allergy, so that can be very reassuring. Blood tests are also poorly predictive, being accurate only roughly half of the time. We do know, though, that high levels of blood tested antibodies are very suggestive of an allergy to that food.

We do not have a CURE for food allergies, but we can use antihistamines and epinephrine to treat acute reactions.
Of course, the mainstay of treatment is prevention through avoidance of that food protein.

BOTTOM LINE: If you think you may have a true food allergy, discuss it with your doctor and consider additional testing before permanently restricting your diet.

Change Your Air Filters Today!

Happy February 1st! On the first day of each month, I try to remind my patients (and most importantly for me, my wonderful husband) that it's time for that special monthly chore- changing the air filters. Especially here in Austin, where pollens are crazy year-round, it's really important to change the filters to reduce allergens in your home. You'll be amazed twenty-four to forty-eight hours later when you wake up breathing easily and headache-free.
How do you pick an air filter? Easy- kind of like choosing a wine off a menu where you don't recognize the vineyards. You don't want the cheapest, but you don't need the most expensive, either. Choose a filter that is corrugated. If you have the deluxe models that you need to take outside and wash periodically, make the first of each month your wash day.

BOTTOM LINE: Tired of waking up with headaches, sneezing, and/or stuffy nose? Change your filter the first of every month!