Allergies affect up to 21 million people in the UK – one of the highest incidence levels in the world, according to Allergy UK. Some 5-8 per cent of children have a food allergy, an estimated 10m adults have more than one allergy and seven million people have allergies severe enough to need specialist allergy care. 

“We now know that around a third of adults and up to half of children will be affected by an allergy at some time in their lives,” says Allergy UK specialist allergy nurse Margaret Kelman. “There are lots of theories on the causes of the allergy epidemic, but no defined answers. There have been many changes in our environment and lifestyle in the last 40 years, with urbanisation, pollen and climate change all playing a role. All these can affect our immune system, making us more prone to an allergy developing.”

We know that allergies have a psychological impact too. A study by Allergy UK revealed that 53 per cent of people living with allergies regularly avoid social situations, while 52 per cent feel they have to downplay their allergies due to fear of judgement. Parents of children with food allergies are particularly affected, with 54 per cent feeling anxious about their child having an allergic reaction when eating out. 

“Having an allergic condition impacts on all aspects of your life, including work, school or hobbies, with anxiety, a sense of isolation, and loss of self-esteem and confidence common. Pharmacy teams can play a role in offering information, advice and reassurance,” says Ms Kelman.

Sue Swift, Numark UK drug tariff and information technician adds that allergy is an important category for community pharmacy. “Over the last couple of years there has been an increase in individuals requiring support for allergy symptoms,” she says. 

Contact dermatitis

“Contact dermatitis is a localised form of eczema caused by direct or indirect contact with substances in a person’s environment,” explains British Skin Foundation spokesperson and consultant dermatologist Dr Derrick Phillips. “There are two types of contact dermatitis – irritant and allergic. Irritant contact dermatitis occurs when the skin encounters irritating substances such as solvents, detergent soaps or hot water. These substances damage the outer layer of skin by stripping away natural oils, causing dryness and irritation. Allergic contact dermatitis occurs when a person develops an allergy to substances that have been in contact with the skin. Common allergens include fragrances, preservatives, hair dye, rubber, and nickel.” 

Skin will look dry, red or scaly. In severe cases, blisters can form. Itching is the most difficult symptom to treat. 

Dr Phillips suggests asking customers the following questions to help find out if they have contact dermatitis: Is the skin itchy or sore? Is there cracking of the skin? Are there red/dark brown or scaly patches? Are there small fluid filled blisters? Is there golden yellow crusting? “Most contact dermatitis is irritant in nature,” he says. “Patients with dry, sensitive skin are more susceptible. Occupations involving wet work, exposure to irritants and repeated hand washing are at increased risk. Allergic contact dermatitis is more likely to develop with repeated exposure to high concentrations of allergens. This can occur in occupational settings and is more common in patients with impaired skin barrier function.”

How pharmacy staff can help

“Most cases of contact dermatitis are irritant and can be managed with conservative advice. Moderate to severe cases should be referred to a doctor. Most patients will not need patch testing. This is only performed when allergic contact dermatitis is suspected,” says Dr Phillips. 

“For contact dermatitis, pharmacy teams can help customers select the correct creams,” adds Ms Swift. “Since it can be caused by ingredients in washing powders, soaps and fragrances, pharmacy staff can ensure customers do not use any creams which also have the potential to cause an allergic reaction.” 

Treatment

Emollients are essential for rehydrating dry skin, says the Eczema Society. Advise customers to avoid soaps and detergents and use soap substitutes instead. Topical steroids can reduce inflammation during flare-ups.

Prevention tips to pass on

• Avoid irritants and allergens as far as possible
• Wear gloves to protect hands when doing wet work or using chemicals
• Use emollient as a hand wash soap substitute, then rinse off
• Reapply emollients frequently and avoid alcohol-based gels
• Avoid wearing rings when doing household tasks or using chemicals.

Pet allergy

“We know that around one in 10 people have an allergy to animals, and most common is cat allergy,” says Ms Kelman. “Symptoms are similar to rhinitis, but it can induce an asthma flare-up in people with asthma, so they should be referred to their GP.” 

Pet allergy is the second most common cause of indoor allergy after dust mites, and some 35 per cent of Brits who own a pet have an allergy to it. Pet allergy of all types is caused by the protein in a pet’s saliva, urine or dander. It is a major risk factor in the development of asthma or allergic rhinitis.

All cats produce the cat allergen Fel d 1, but at differing levels. Intact male cats produce more than females, while neutered males produce the same levels as female cats. The Fel d 1 protein is produced in the cat’s mouth and skin, which is then spread through the hair as it grooms itself. 

Symptoms

A reaction can start immediately or some time after exposure to animals. Signs include sneezing, runny nose, coughing, breathing difficulties, wheeze, watery and itchy eyes, skin rash/hives, eczema flare-up and, in severe cases, anaphylaxis.

Treatment

Apart from avoiding exposure to the pet as much as possible, you can recommend the following to customers:

• Non-sedating antihistamines
• Antihistamine and steroid nasal sprays
• Eye drops
• An asthma inhaler (if appropriate)
• Allergen barrier balm
• Saline nasal douching 
• Immunotherapy for moderate to severe cases (via referral to an allergy clinic)
• For cat owners, a specific cat food that neutralises the Fel d 1 and reduces the active allergen load can help. 

Prevention advice

“Keep pets out of bedrooms and use a washable blanket to cover sofas and chairs where pets may sit,” advises Ms Kelman. “Use a vacuum with a pet filter and vacuum regularly.” 

“Giving pets a weekly bath, coupled with the use of a vacuum cleaner to remove pet hair, can prove useful for sufferers. Additionally, using a clean air filter is useful,” says Ms Swift. 

Natural management

In recent research into allergy prevalence, Scope Healthcare found that 85 per cent of people use antihistamines to treat their symptoms. However, 64 per cent do not use other products to treat their allergies, despite not being fully satisfied with antihistamines. Some 95 per cent were interested in using natural and preservative-free treatments.

Food allergy and intolerance

Up to 10 per cent of adults and children have a food hypersensitivity, but not always an allergy. A food allergy causes hives, itching and swelling, and in serious cases breathing difficulties and anaphylaxis. It can also affect the gut. An allergy is caused by an abnormal immune system reaction, called IgE mediated allergy. 

“Pharmacy staff should understand the difference between food allergy and intolerance so they are able to help customers. With this knowledge, they are better placed to understand the symptoms and give them the best advice,” says Naresh Rallmil, Numark’s lead information pharmacist.

“Whether food allergy is increasing or we are better at recognising it is hard to know,” says Laura Philips, Allergy UK clinical dietetic advisor. “A recent BMJ article looking at immediate IgE allergy has shown hospital admissions for anaphylaxis do indicate food allergy is on the rise, especially in the 0-14 year age group.

“Common food allergens include eight types of foods responsible for 90 per cent of reactions: milk, egg, peanut, tree nuts, fish, shellfish, soya and wheat. However, it is possible that any food has the potential to cause allergic reactions. Some more novel allergens that have caused recent concern in much lower numbers include peas, coconut, oats and fruits.”

A food intolerance is more common and is not caused by the immune system. It does not cause a severe or life threatening reaction. Symptoms commonly affect the digestive system, skin and respiratory system. 

Digestive symptoms include abdominal pain, diarrhoea, bloating and constipation. Skin symptoms include flushing, urticaria and eczema flares. Respiratory symptoms include rhinitis, breathing difficulties and wheeze.

“In instances where a customer is unsure of whether they have an allergy or intolerance, pharmacy teams should encourage them to keep a food diary and document if and how particular components of their diet affect them,” says Vinay Patel, Alphega UK services and contract pharmacist.

Food allergy vs intolerance

“It is important that the cause of an IgE-mediated food allergy is recognised and diagnosed as soon as possible, as this has the potential risk of a severe allergic reaction,” says Allergy UK. 

The customer should be referred to their GP. Referral to a dietician is advisable if a food intolerance is suspected, for advice and guidance on food avoidance and replacement. 

Top food allergens

Celery, cereals containing gluten, crustaceans, egg, fish, milk, molluscs, mustard, tree nuts, peanuts, sesame seeds, soya and sulphur dioxide.

Top food intolerance culprits

• Lactose (milk and dairy)
• Gluten (bread, pasta, cereals, cakes, biscuits)
• Food additives and chemicals such as benzoates (in soft drinks, jams, pickles), caffeine, alcohol, monosodium glutamate.

Pollen food syndrome

Pollen food syndrome is an increasingly common condition where the person has immediate allergic symptoms in their lips, mouth and throat when eating certain raw fruits and vegetables. Itching and tingling are the most common signs, and there may also be swelling. It is usually only raw food that causes a reaction, as cooking changes the structure of the protein responsible. 

The condition usually occurs in people who get hayfever – especially those who react to birch pollen and grass pollen. The proteins in pollen are similar to those in raw fruit and vegetables. The similarity means the person’s immune system mistakes food for pollen. Symptoms are usually mild. “You should still refer customers with pollen food syndrome symptoms to their GP to confirm a diagnosis,” says Allergy UK specialist allergy nurse Margaret Kelman.

Product news

• Thea Pharmaceuticals has launched Zaspray, a preservative-free spray to relieve itchy and dry eyes caused by allergies. It contains 0.2% hyaluronic acid and 4.5% Per-Lip complex, which includes liposomes. It can be used alongside antihistamines. 
• Scope Healthcare is supporting its new hayfever range Fusion Allergy with a national marketing campaign this summer. It includes TV advertising to raise awareness of key symptoms, while highlighting the natural and preservative-free benefits of Fusion Allergy nasal spray. 

Anaphylaxis update

“Community pharmacists have a role in supporting patients by teaching them how to use their adrenaline auto-injector (AAI) and what to do in an emergency,” says a spokesperson for Anaphylaxis UK. “Also reiterating key messages, such as making sure they are carrying their two AAIs at all times and how best to store the devices. Pharmacists should also signpost customers to www.anaphylaxis.org.uk for further information and advice.”

The main anaphylaxis danger signs to watch out for are:

• Airway: Persistent cough, vocal changes, difficulty swallowing, swollen tongue
• Breathing: Difficult or noisy breathing, wheezing (like an asthma attack)
• Consciousness/Circulation: Feeling lightheaded/faint, clammy skin, confusion, unresponsive/unconscious.

Other less severe signs include widespread flushing of the skin, hives, swelling of the skin, abdominal pain, nausea and vomiting.

Views of the P3pharmacy category panel

“For an allergic reaction, customers want immediate attention and treatment. Most queries are about skin reactions. Pet allergy queries are less common, but that’s often because customers don’t know what is causing their allergy. We go through an elimination process of what they’ve been exposed to. Oral antihistamines are the most popular treatments. For an itchy rash, we also recommend hydrocortisone cream such as Eurax HC or HC45, or a generic alternative. If rash is on the face, we recommend Eurax cream or Anthisan. If rash gets worse or doesn’t improve, we refer them to their GP.”

Lila Thakerar, Shaftesbury Pharmacy, Harrow

“We have a year-round offer on purchases of more than two packs of once-a-day generic antihistamine tablets. Our offer promotes repeat custom as well as saving the customer money. When it comes to contact dermatitis, we make sure we have a good stock of 1% hydrocortisone and Eumovate 0.05% cream for those needing something stronger. The message that you must take antihistamines for perennial or pet allergy prophylactically is getting through. We are also seeing an increase in customers requesting unlicensed use hydrocortisone 1% cream for their face or for a child on recommendation from their GP.”

Gareth Evans, Wansford Pharmacy, Peterborough

“Allergies are very important and everyone who works in the pharmacy should have a constant awareness of them, especially when recommending or handing out certain products which patients may be allergic to, such as ibuprofen, aspirin and some penicillin antibiotics. There have been occasions where patients present with an allergic reaction and it is our role to distinguish between the need for urgent referral or self care treatment. If the reaction can be self treated, antihistamines are a popular choice. Fexofenadine is now available OTC as the brand Allevia, which has provided an extra option.” 

Ellis Nugent, Davies Chemist, Gurnos, Swansea

Improve your allergies category

The total allergy category is worth £123.7 million (IRI Dec ’21) and has grown 5 per cent year on year. Tablets are the largest sub category, followed by nasal sprays.  

“Since the allergy category holds about 7 per cent of the total medicines category, it’s important to build a well-stocked category offering a range to suit various ages and requirements,” says Cathy Crossthwaite, Numark OTC business development executive. “Keep in mind there is a general move towards natural remedies, with the introduction of several natural nasal sprays. This opens up a wider customer base. Staff should remember it can take several attempts for the customer to find the remedy that suits their symptoms, so it’s important to provide ongoing support.”

Alphega Pharmacy’s Vinay Patel adds that it’s important to stock key brands as well as generic alternatives. “During the main allergy season, move your allergy products to a more visible location and, if available, also use your counter impulse units,” he says. “Take advantage of any PoS supplied by manufacturers.”