Diagnostic Approach and Management of Allergic Conditions

Introduction to Allergic Conditions

The American Academy of Allergy, Asthma, and Immunology recommends diagnosis of allergic conditions through demonstration of specific IgE antibodies via skin testing or in vitro testing that correlate with clinical symptoms and allergen exposure history 1, 2
Skin prick testing is the preferred diagnostic method, with approximately 70-75% sensitivity compared to specific IgE immunoassays 1
Select allergens for testing based on patient age, geographic location, occupation, and symptom timing—not random panels 1
Positive allergy tests without correlation between allergen exposure and symptoms indicate nonallergic disease, even with positive IgE results 1

The American Thoracic Society recommends inhaled corticosteroids as the most consistently effective long-term control medication at all steps of care for persistent asthma, and improve control more effectively than leukotriene receptor antagonists or any other single agent 3
Long-acting beta-2 agonists serve as adjunctive therapy with inhaled corticosteroids for patients requiring step 3 or higher care 3
Leukotriene receptor antagonists are alternative but not preferred therapy for mild persistent asthma 3
Short courses of oral systemic corticosteroids are used to gain prompt control, while long-term oral corticosteroids are reserved for severe persistent asthma requiring step 6 care 3

The American Academy of Allergy, Asthma, and Immunology recommends considering allergen immunotherapy for patients with demonstrable specific IgE antibodies to clinically relevant allergens when symptoms remain inadequately controlled despite pharmacotherapy and avoidance measures 2, 4
Immunotherapy is effective for pollen, animal allergens, dust mite, mold/fungi, and Hymenoptera hypersensitivity (Strength A recommendation) 4
Plan for minimum 3 years of treatment for optimal clinical benefit and disease modification, including prevention of new sensitizations 4

The American Academy of Allergy, Asthma, and Immunology recommends epinephrine as the only first-line treatment for anaphylaxis—there is no substitute 8
Administer intramuscular epinephrine in the anterolateral thigh rather than subcutaneous injection for more rapid plasma concentrations 8
10-20% of individuals require more than one dose of epinephrine; repeat dosing every 5-15 minutes as needed for ongoing or progressive symptoms 8
Antihistamines are not a substitute for epinephrine and their use is the most common reason for failing to administer epinephrine, placing patients at significantly increased risk 8

The American Academy of Allergy, Asthma, and Immunology recommends referring patients with inadequate response to pharmacotherapy with or without environmental controls to an allergist-immunologist 9, 4
Children with allergic rhinitis should be referred to an allergist-immunologist for potential preventive role of immunotherapy in reducing new sensitizations and asthma development 6, 7
Patients with nasal polyps requiring specialized medical management should be referred to an allergist-immunologist 6, 7
Patients with suspected immunodeficiency, cystic fibrosis, fungal sinusitis, or granulomatous diseases should be referred to an allergist-immunologist 6, 7