Darrell Rebouche (Host): Hello and welcome to Health on Point, presented by Willis Knighton Health. In this episode, Dr. Caroline Caperton, an allergist, immunologist, and public health professional, will attempt to demystify the rapidly evolving world of food allergy management. Dr. Caperton, thank you for joining us.

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Thank you so much for having me, Mr. Rebouche.

Host: It feels like the prevalence of food allergies is growing, expanding all the time worldwide. We hear more and more about this. Can you explain, A, is that true? And, B, if so, why do you think it is?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: It is true. And we were kind of scratching our heads and trying to figure this out for a while. There's a couple of things that are highest on the list of differential diagnoses like we as physicians like to say. One of which maybe, we're too clean. So back in the day, our immune system would be too busy fighting off microbes, parasites, viruses, bacteria, trying to not die from cholera. And it's kind of bored now, we're really, really clean. So, those little cells are still doing that to keep us safe and healthy as much as possible.

However, they've kind of shifted their goals. Instead of sitting around twiddling thumbs, they say, "Hmm, you know what? Maybe. I haven't seen a helminth recently. What is that? Is that a peanut?" So, the hygiene hypothesis where we don't see as much dirt as we used to. So, a bored immune system kind of starts to look for different kind of things to act against is one theory.

Another theory is that we use those wet wipes. So, I'm Cajun. So back in the day, my grandma used to wipe the kitchen counter with that wash rag from the kitchen and it had all the food particles on it, and God knows what else. And then, she'd wash our faces, right? So, you had this introduction to this amazing array of antigens, good and bad in food particles, but you were also eating the food that she would prepare. She wasn't preparing all these pouches or anything. We would eat what she would eat. There wasn't a specific decree from American Academy of Pediatrics that said, "Hey, withhold these allergenic foods like peanut until the age of one," because especially if you're an eczema kid, we don't know, like maybe you'll get a food allergy or maybe that's going to worsen your eczema or something.

So when that advice came out based on a level of evidence, like we have these grades of evidence, the big like randomized, systemic controlled, like Cochrane Reviews of these systemic clinical trials that we look at. And then, the lowest form of evidence is like expert opinion, somebody like me. So, expert opinion said we should withhold these foods. So, that's another reason why we think this prevalence of food allergy has gone up. We didn't eat these foods, for our babies, until they were about one-year of age. And I said, "Hey, you know what? About 2015 came around, we looked at food allergy eczema kids, people who maybe had a higher risk, like their sibling had a food allergy, this baby has eczema. Yeah, we're going to feed them peanut at like four to six months of age. We're going to introduce peanut to the diet, keep it in the diet early and often," and then versus these other kids and say, "Hey, don't eat it until one," standard of care at the time. Look two had an EpiPen style food allergy to peanut at age of five, 80%—8-0 percent—reduction in the allergy of peanut at the age of five for the kids who introduced early. So, four to six months of age, introduction of peanut, do not withhold. That's LEAP study, Learning Early About Peanut.

So, we know now, don't withhold this. This is standard of care. Introduce peanuts and in a form that's not obviously a choking hazard early and often to the diet so that that kid knows, "This is a food. This is a food. This is a food." Because otherwise, if you're using these baby wipes on a compromised skin barrier, like eczema, and then you are not ingesting that protein, but the first source of exposure to that protein, to that food is through the skin, and then you're not eating it, so your body's like, "I don't know what this is. Let's freak out," right? Instead of your innate immune system, having that early often introduction, "Chill out. It's a food. It's a food."

Host: Okay. You said we're too clean. I mean, you have two daughters. Do you encourage them to go play in the yard and play in the dirt? How does that manifest itself just from the standpoint of a parent?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: We use the five-second rule if it's not sticky or wet, you know what I mean? If the cookie fell on the floor and it's not the airport or the bathroom, we're pretty clean. But yeah, it's hard as a mother, right? Like, your first instinct is to be like, "Oh, don't eat it, "or like, "Hey, let me wipe that for you. Let me Purell those hands. Let me do all the hand sanitization." And you want to do those things, right? You want to be clean, you don't want to have the dog lick the pacifier before you stick it back in the other kid's mouth.

But by kid two rolls around and you're like, "Hey, hey, the dog got it first. It looks pretty clean to me," you know? So, there was that kind of, I guess, maturity as an adult, as a mother, as a physician. I've become a better physician now that I'm a mother, I can tell you that much, because I used to just say, "Just make him use his inhaler, Shirley. Just make him use it twice a day." And now ,I'm just like, "What you're going to do is negotiate with terrorists." So, no, you do what you can when you can. And sometimes you dig your heels in and they do too. And my husband comes in and he is like, "Ladies, ladies." So, it's a compromise, right? And it's what you feel comfortable with as a parent."

And that being said, in the good of your child, right, you make the best decisions for your kids with the information you have at the time. And that being said, we can't be like woefully ignorant and willfully ignorant about the data that exists around us, and where you're getting that data. I think it's lamentable that we have to pay for a journal article that's peer-reviewed and published in medical literature, but misinformation is freely available on TikTok and other sources, and no one vets those sources. And there's no accountability to these professionals who have a wellness agenda and also something to sell you. So, just be wary of those sorts of sources.

Host: Can we make a distinction between food intolerance and food allergies? And we hear a lot about lactose intolerance or maybe gluten intolerance, but that may be different from being allergic to something.

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Absolutely. So if you have an intolerance, maybe it doesn't sit right with you, right? Maybe you have that enzyme. You don't have this lactase to digest the lactose and you just replace the enzyme. And then, you're able to digest that protein, that sugar, lactose, lactase. But if you have an allergy to the milk, there's kind of a different types of allergies. One is that immediate style allergy, where pretty quickly after you eat it, you're going to have symptoms of immediate shortness of breath or hives or swelling of the lip, tongue, throat, vomiting, diarrhea, or drop in blood pressure. That's allergy, right? So, you cannot tolerate even lactose-free milk. Those kids have issues with lactate, because it's not the lactose, it's the casein protein or the whey protein. So, dairy allergies are tricky, and that's one of the ones that I really respect and I'm fearful of, because milk allergy is something that is really hard to avoid in a lot of foods, even medicines.

Host: We've talked about peanuts and we've talked about milk, but there are other food allergens out there. Is there, for instance, a sports-style top 10 list that we need to know about?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Yes. There are the big eight—now the big nine—that they cause 90% of those type 1-mediated what we call hypersensitivity reactions. There's kind of four types of main types of allergies, but the type 1 hypersensitivity is IgE-mediated, meaning you have this antibody, it sits on your allergy cells, and that receptor kind of waits on them. And then, you have the peanut or whatever it may be, and it explodes like a landmine receptor.

So, those top eight, nine foods that set off that type of reaction would be milk, egg, wheat, soy, fish, shellfish peanut and tree nuts. And then, kind of they get emerging as like seeds, like sesame. And those kind of enjoy a status, I would say, amongst the food allergy community. And if you have a really unique rare food allergy to a spice or something, it's really hard to avoid. Because those are the ones that are labeled, at least in the United States, that you could read labels to actively avoid your allergens. But if it says spice and you have an issue with, I don't know, like thyme, for example, it's not as easily avoidable. There's insidious exposures in certain things, especially in Louisiana with our Cajun cooking. So, our patients have a little bit of a harder time trying to read labels "to avoid," "may contain" shared lines, things like that.

Host: You talked a lot about children, pediatric patients, I'm speaking to a physician. But there are also now adult-onset allergies, food allergies, which seems to be a relatively recent development, at least in terms of my perception. So, what's the trigger there? I mean, how do you deal with these adult-onset allergies?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: It's tricky. You think you're going well through life, and then 45 hits like a ton of bricks, perimenopause, all the hormonal changes, thyroid stuff, rheumatologic stuff, autoimmune things. And then, the breaks kind of start going weird and the lug nuts come off, at least that's my experience. But hormonal fluctuations can do a lot with the way that we react to not only ourselves, autoimmunity, but the world around us immunologically.

So, I've seen patients outgrow like a peanut allergy in adolescence when they hit that growth hormone spurt. I've also seen patients where, after pregnancy, all of a sudden they start to have issues with eating crawfish or shrimp and starting to develop itching in the mouth or ears or having increasing intolerance—not intolerance, but an allergy where they start to develop like swelling of the lips or things. It's just unfortunate, right? So, the things that—it doesn't happen to everyone, but there are certain things that we think that ways that people become sensitized. Allergies can develop as we get older and certain fluctuations in our hormones. Certain, you know, becoming pregnant or having a growth hormone spurt in adolescents. So, sometimes they'll outgrow their peanut allergy or a woman becomes pregnant and thereafter starts to have issues with eating shellfish, a shrimp.

Also, there is a cross-reactivity between dust mites, shrimp, crawfish lobster. Don't think about it too hard, but they share a homology, tropomyosin protein. So even in patients that don't eat shellfish, we've seen allergies to that on skin testing or blood testing, because of that cross-reactive dust mite allergy. So, they think maybe, perhaps, a dust mite sensitivity might predispose someone to developing shellfish allergy later in life. But that's kind of just a hunch.

Host: This is Health on Point presented by Willis Knighton Health. Our guest is Dr. Caroline Caperton, an allergist to immunologist and a public health professional at Willis Knighton Health in Shreveport. Dr. Caperton, we've talked a lot about these allergies. But you, as a clinician, need to identify the allergies. You need to figure out what your patients are allergic to. There are a number of ways to test this. I know about pricking the skin. There's also blood draws. Can you tell us what the most common ways of determining what the allergies are?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Yes. So, I sit with patients for a good deal of time and I try to listen to their history. Because 99% of the time, your history is going to tell me everything I need to know, and we're just doing confirmatory testing at that point. If you've had a history of eating something and then pretty quickly thereafter, within 30 to 60 minutes, having a rapid onset of the symptoms of immediate allergy, such as like swelling of the lips, tongue, throat, vomiting, hives, shortness of breath, drop in your blood pressure, those sorts of things, then I have a pretty good hunch, especially if it's reproducible upon every exposure, or it's happened since then.

If you've eaten it subsequent to that issue, it's not that food, I'm just not even going to test you to it. If you're sitting there drinking a sippy cup of milk, lugging it down, living your best life, no symptoms, I don't care what the test shows, you're not allergic to that food. And so, there are blood tests to look for a specific IgE level, that landmine kind of on the allergy cell, that may or may not be detectable in the blood. And what's more sensitive is skin prick testing, where we take a little bitty, teeny tiny bit of that food, either in the real form or a commercial extract, and then prick, either a scratch or with a needle, or there's little plastic toothpicks now with no needles. And by introducing a teeny tiny amount of that food to the skin, it can tell you really within 10, 15 minutes, make a little hive, "I don't really like that" or not. The problem is there's false positives there too. I can skin test you with bleach and you'll make a little hive. It doesn't mean you're allergic to it, but it's an irritant reaction, especially on patients with compromised skin such as an eczema baby.

The dirty secret of today's insurance reimbursements is we get paid by what we do to patients instead of what we do for patients. So, there's a financial incentive to skin prick someone to many foods, which may be positive on a skin test, or, say, you have a really highly allergic patient, either allergic rhinitis or asthma or eczema. And that total IgE is very high in the blood. With the tide, all the ships will rise. So, you'll get a non-specific, everybody's screaming at recess kind of thing. And who's really hurt? "Well, Tommy broke his leg last week," right? "Well, I know when my kid ate shrimp or something, then reproducibly he's getting hives. He's getting hives. Can we confirm the shrimp allergy?" Yeah, that's Tommy who broke his leg, right? So, I'm really going to pay attention to the IgE to shrimp, lobster crab in the blood, but he eats fish fine. Don't test fish. He's eating it just fine.

So, you have to, in the context of the history, interpret the blood and/or skin testing. But if the kid is eating and tolerating, do not test skin or blood because it clouds the picture. And then, that parent or that patient is never going to truly believe me when I tell them, "You're eating it, you're fine. You're not allergic. Just non-specific happens to be there, but you're not having a problem with it."

Host: Let's talk about an oral food challenge. What is that? When do you do that? What is the indication that leads you to that decision?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: So, you may have gotten told back in the day when you had eczema or something and someone did a bunch of skin testing or blood testing, and you had a detectable level. So thereafter, you avoided it or you had an actual clinical scenario where you ate that protein or you were exposed to it and had this legitimate reactivity afterwards, or an allergic reaction.

And so, over time, sometimes that can go down. Sometimes you can outgrow an allergy. So, I watch for that pretty aggressively in patients and see whether or not those specific IgE levels are going down in the blood, whether or not the skin test wheal flare, the hive, is getting smaller, whether or not they've had any accidental exposures in the interim. if all those parameters are good and Mercury's not in retrograde, and it's not a full moon, we'll come in and we'll do an observed oral food challenge where we give incremental doses of that food until you eat an age-appropriate serving, and then we watch you usually for an hour thereafter. If you have no symptoms within that timeframe, go home. "Don't eat anymore tonight. We'll call you tomorrow." "Hey. You good?" "Hey, I'm good." Fantastic. Incorporate that food back into the diet. And so, you're doing it in an environment that is well-equipped to monitor for the signs or symptoms of anaphylaxis to treat if necessary. And we're right here next to Willis Knighton South, if anything, God forbid, should go down.

Host: Okay. You mentioned anaphylaxis. That is the scariest risk I know about for food allergy. So, explain what anaphylaxis is and explain the appropriate ways to respond to it in the moment.

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: This is so important. So, pretty quickly within if it's a food, if it's a medication, if it's a bee, wasp, sting, fire ant, if you have exposure to something that you are allergic to—and this may be the first-time you realize it—pretty quickly, usually within 30 to 60 minutes or shorter than that, a patient may experience basically that landmine went off and the preform mediators inside your mast cell or basophil will release histamine. It makes you itch, right? You may get hives. And then, your blood vessels may dilate and that juice may come out. And so, you may get the swelling of the lips, swelling of the throat, tight throat, trouble swallowing, itching, hives—and it doesn't have to be all of these—shortness of breath, wheezing. You may have nausea, vomiting, diarrhea, a drop in your blood pressure, an impending sense of doom they call this, or a combination of these symptoms. I had one patient, all she had was uterine cramps. But it was after an allergy shot and we acted quickly.

So, those sorts of symptoms where your body's like, "Get this out of me," you should pay attention to those things. The appropriate treatment for anaphylaxis, which is one of those systemic symptoms or if you're having mild symptoms from more than one area. So you're having shortness of breath and hives, you're having swelling of the lips and you vomited, that's anaphylaxis.

Two system involvement for which the treatment is epinephrine, epinephrine, epinephrine, epinephrine. It's not Benadryl. It's not diphenhydramine. It's not cetirizine or Zyrtec. It's not loratadine or Claritin. If you have mild symptoms from one area, you can treat and watch. However, mild symptoms from more than one area like that, or a major symptom, you should inject or administer epinephrine. If you are completely responsive after that first dose, you don't have any underlying cardiac issues, you never had a history of anaphylactic shock, you have an adult with a second epi device available, EMS can get to you within 10 minutes or so, you don't necessarily have to activate 911 after that first administration of epinephrine in a change to previous guidelines if those things in place. However, if the symptoms are not completely resolved after the first epi, within three to five minutes, administer the second epinephrine and call 911.

Host: What are your recommendations for parents and for the patients about managing this? I mean, you've got to travel, sometimes you got to get out in groups, sometimes you're going to go eat out, you're going to be in social situations. I mean, do you give advice about managing this on a day-to-day basis?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Absolutely. And there's a lot of anxiety that is comorbid around food allergies and just allergies in general. Patients that are asthmatic and scared to go to the mall, because they may have perfumes sprayed around them, or even church. So, we don't live in a bubble. We don't want them to live in a bubble. We acknowledge and validate that feeling of anxiety. However, I do want them to always be prepared. And I think that ignoring something and never, ever going anywhere, and missing out socially on a lot of these things affects their quality of life, not only for the patient but their families, their siblings,

And so, to pretend that you're in a peanut-free environment ever is a mistake, whether it be a peanut or milk or whatever it is that you're allergic to, right? But being prepared and having an action plan in place with anticipatory guidance is how I empower patients. And we go over it every time. We say, "Hey, where's your epi? You got two? Great. Don't leave them in the car. You can degrade them. So if you have these signs or symptoms, how are you going to use it?" Right?

So, they feel. By using these drills and doing those things that they know, "If I'm somewhere, I'm in charge of what goes in my mouth. And if I should have any of these signs or symptoms, I have drilled this to where I'm going to administer epinephrine. If I'm not completely responsive, I'm going to do the second and call 911." And then, that fear, that anxiety, kind of goes down a little bit with that empowerment. There's also more options available, I'll say nowadays to where strict avoidance and epi carriage is not the only option anymore for these patients.

Host: So, patients typically aren't going to go directly to you. Parents are going to take their kids to the pediatrician, adults are going to go to their primary care physician. So, what are the triggers that those primary care physicians should be on the lookout for to say, "Hey, I got to send this patient to an allergy specialist"?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Right. I would say if they have an underlying cardiovascular issue to where maybe they have very high blood pressure, they've had a previous stroke, and now they're developing issues, like immediate issues like we talked about when they're eating shellfish or something. And then, there's no contraindication to the administration of epinephrine in anaphylaxis, period. But you do want to call 911 in those scenarios, right? But you have some comorbidities that you may need to navigate or is this an allergy? I have a patient who was coming off of a viral illness and/or the kid had strep throat. And we gave penicillin and they developed a rash subsequently. Is it viral illness or was it the penicillin? Oh, we also started to feed them eggs. So, we can help to kind of suss out those details. And we have the privilege of time with the patient a little bit more as specialists than the primary care does, because they're fixing about 17 things in one 15-minute visit. And we have a teensy bit more time where we could just focus on what happened during that period of time, and then do some targeted testing to try to like see who done it, if you will.

Host: How does immunotherapy come into play? I think there's a lot of talk out there, a lot of chatter about it. Is that something you recommend or is there something about that that people misunderstand?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: This is probably my favorite aspect of what I do as an allergist. So, we can desensitize the immune system's response to an allergen. We do it with allergy shots. We've been doing it for a very long time that way. It's where we introduce teeny tiny amounts of the allergen to the system without setting off the landmine. So, that IgE receptor on your cell, we just kind of put a pinky toe— oh, pinky toe, two toes, three, and then are pressing down that landmine. And as long as you have that exposure to the antigen, you're not going to react when you get more on there, right? But if you go too long without exposure to that antigen, the next exposure you could have an issue.

So, desensitization is this bibbidi-bobbidi-boo temporary state of tolerance, right? I'm putting scotch tapes over your allergy spells, and then I'm gradually maybe putting a pin in and letting a little bit pinky toe rash, I'm good with as long as you're tolerating your food, your peanut, your pollens, your cat, your chemotherapy, your penicillin. So in those scenarios where we need to desensitize to a medication that is vital to your care at that point, "Oh, you tried to have a major life-threatening reaction to penicillin. The skin testing is positive." "Yeah, that guy's allergic, but he is going to die without it. We need you." Okay, fine. So, there's very few times the allergist goes into the hospital, white coat blazing red. So, that's one of them, where we absolutely cannot use an alternative medicine. We are able to administer that medication in very incremental, teeny tiny little steps until we get it desensitized.

Now, here's the fun part. So, we'll spend six hours to eight hours in the ICU doing that. And then, the night shift will call and they said, "Hey, Doc, you said in six hours, just administer it over 30 minutes." I'm like, "Yeah, he is good. We scotch taped it." She's like, "I'm sorry, what?" I'm on night shift, you know w. I said, "Yeah, we're good. We're still at the ball. We're still dancing. But if he goes home, he can transition to oral antibiotics," totally fine on that same type of penicillin or whatever it was we desensitized to. But depending on the half-life of the drug, depending on the food, depending on whatever it is that we desensitized too, or how long it's been since your last allergy shot, your immune system kind of forgets, right? The antigen falls off the receptor, and then you turn back into a pumpkin. Two weeks later, you need a course of antibiotics, boom, you will react. So, that's something that we really have to define. So, you're inducing a temporary state of tolerance. But if you go without exposure to that antigen on that receptor for a specific period of time, and we're trying to define how long that is, upon re-exposure, you may actually have symptoms versus you outgrew that allergy versus you have remission of that allergy, right? Versus sustained unresponsiveness, which is all these like nomenclature that we're like now developing.

So for venom allergies, we're trying to define how long of a period of time we can go between maintenance doses up to eight to 12 weeks now, between maintenance doses of venom, wherein a patient, if he gets stung in the interim, we'll have protection against one to two bee stings or hornet stings, whatever it may be.

Host: Prevention, remission, tolerance, desensitization, all words you've used. The word I've not heard you say is cure. So, tell me, what is a realistic expectation for the vast majority of allergy patients?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Yeah. Cure would be just like heaven. That'd be great, right? No. But unfortunately, cure is something that we are hesitant to use, because we're kind of retraining the immune system to think a different way about an allergen. And so, we are learning more—and every patient's different, every patient's immune system is different, what they're going through the exposures.

And so, if you're able to outgrow that allergy, is it something that we did to manipulate that versus did you do that on your own? And I'm hesitant to take credit for things, but there are certain ways where you had childhood asthma or you were a little wheezer, right? Fifty percent of kids that wheezed before the age of four may not ever develop asthma, but they had a reactive airway, they might've had RSV, and they wheezed a little bit. But now, they kind of grew out of it, haven't ever used an albuterol forever. Is that cured versus they grew out of it?

So, currently, the state of food allergy is that there's not a cure, so to speak. And interestingly, there's organ transplant recipients who got an organ from a patient who had a food allergy and subsequently developed an allergy to that food and started being reactive to it. So, it's interesting. There's something inherent in the way our genes are programmed and that makes us more prone to developing an allergy or not. And then, it's nature versus nurture—the exposures that we have, the interventions that we can do to try to intervene, and make someone able to tolerate it at least.

Host: We've talked about mostly food allergy today because that's our topic. And I would take a point of personal privilege here to ask you about one of the weirdest allergies, I've ever heard about my son is allergic to nickel. What in the world? How does one become allergic to a metal?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: So, exposure, you could go one of two ways. You could develop this tolerance to it versus you have an abundance of it and you just start to develop. Your body's like, "Nope. I had enough."

So, we talked about kind of four different main types of allergic reactions. The immediate type, EpiPen type 1; what you're talking about is a type 4, where it's mediated by T cells and it's a delayed sometimes reaction. It's not going to be an EpiPen style. But it's going to be quite itchy. Maybe he has a history of eczema that impairs skin barrier. I'll oftentimes, I'll see it on the button behind the jeans where that little jeans button will make a little rash right under the belly button, or those fun earrings that you wear if they had nickel in them, you'll start to develop issues with the earrings and things for kids. Sometimes we'll see it necklaces and fun jewelry. And even iPhones now, but I don't know who uses a naked iPhone—but I'm always scared—but iPads and things like that, the Apple watches.

I had a baby that had a seizure disorder and they had that nickel metal alert bracelet and exactly right where that little alert bracelet was, developed a pure little ring of a rash right there. And it's just ironic that we did that to him. I was like, "Get a silicone one." But nickel can be sensitizing. So, it's one of those metals, just like formaldehyde can be, certain chemicals in baby wipes, even fragrances, parabens, some of these things that are contained in our daily things that we come across.

So, I guess, we tested that differently than a skin prick test where we find out in 10, 15 minutes. Patch testing is where we put a little bitty bit of those chemicals in little squares on your back and stickers. So, we'll usually put those on. And then, 48 hours later, we'll take them off. And we'll look to see if you have any little itchy rashes on that spot. And sometimes it can be pretty dramatic, almost like a poison ivy blistering rash. Sometimes you can get reactivation of the dermatitis where it occurred on your earrings or on that nickel, that wrist.

So, we usually will check again at 96 hours for any final reactions and anything that's an irritant should decrescendo by that Friday. We usually do Monday, Wednesday, Friday. And then, true allergic reactions, those T cells, they take a while to get there. I like to think of them like ladies. So, they're not fast, but they're going to get there. And then, upon subsequent exposures, they can come harder and faster. And so, they're going to be like telling you, "Uh, nuh-uh, it's nickel again. I'm coming. I'm getting my purse. I'm getting my lipstick. You wait, you wait, but I'm coming." So, subsequent exposures, you get worse reactions: poison ivy, nickel, some of the things we come into contact with.

Host: Okay. What excites you about the future of your specialty? What is the next thing on the horizon that's really going to help people?

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: I love my specialty. I'm so privileged to practice allergy and immunology. I love being able to desensitize someone to something they're allergic to, be it bee, wasp, hornet, pollen, cat, dog, dust mite, grasses, to be able to play in the grass, and foods. I think that is such a neat concept that we're able to tell the immune system to, "Chill out, buddy. Like, let my patient live their life and not have to have such crazy avoidance or all these medications." We are using more and more targeted biologics. And that doesn't necessarily mean immune suppressing at all. We're learning more about distinct pathways within the immune system that start down this just awful pathway to overabundance of allergic symptoms that we could say, "Hey, let's just cut that road off. Let's roadblock." Nope, not going to do that."

And so, we've heard of medications like dupilumab or other things that stop eosinophils to where it does not hurt the rest of your immune system. And as young as six months of age, babies are able to be treated with dupilumab for eczema. And you see it's this remarkable clearing of their skin. It's just stopping interleukins 4 and 13 from continuing on this bad pathway to that inflammation. So, you're stopping it at the source rather than treating the skin topically and trying to do all these other things.

We even have a really cool landmine blocker for that IgE sitting on this allergy cell, and this omalizumab kind of stops that right there and it kind of blocks the landmine from blowing off. And so, that treatment's now been approved for allergic asthma for probably over 20 years. But it's also approved for hives, nasal polyps, and now food allergies. So, it's interesting what we could do now that we know the mechanisms behind the allergic reactions and those pathways and say, "Hey, that's a target. Let's block that guy and see what happens." And we're having a lot of success in that and not having as much collateral damage as just like blowing everybody up with the prednisone or some systemic steroid that's going to have its own deleterious effects.

Host: You have been so generous with your time, your wit, and your immense knowledge. We are grateful for you, Dr. Caroline Caperton. Thank you.

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: I appreciate you. Thank you so much. And the cool thing is I like to talk about food oral immunotherapy because it's not just "hold your epi and avoid everything in all scenarios." If you want to become bite-proof against a food, there's ways that we can do that nowadays that fit into your lifestyle. And we can get you to eating like two peanut M&Ms a day, kind of like a multivitamin. So, that's also an option for patients.

Host: This is Health on Point, presented by Willis Knighton Health for Dr. Caroline Caperton. I'm Darrell Rebouche. Thank you for being with us.

Caroline Caperton, MD, MSPH, FAAAAI, FACAAI: Thank you so much for having me.