Mold Allergy Treatment & Management
- Author: Shih-Wen Huang, MD; Chief Editor: Harumi Jyonouchi, MD more...
The most important aspect of patient care is providing information to the patient and, if the patient is a child, the parent. Successful treatment depends on the patient understanding the nature of the disease and that it may be a lifelong ailment. Successful treatment of symptoms largely depends on the cooperation of the patient. Books or pamphlets can often be helpful.
The measures below can be applied to any of the 6 clinical conditions related to mold allergy.
Symptoms can be alleviated by decreasing exposure to the specific allergens. For mold allergy, the local environment should be kept dry, and dense vegetation around the house should be eliminated. The affected individual may also find that avoiding raking leaves or engaging in other activities likely to stir up mold spores in the immediate atmosphere is helpful. Eliminating other local irritants as much as possible is also helpful.
The importance of a nonsmoking environment cannot be stressed enough.
Humidifiers and vaporizers are sources of indoor mold growth if they are not well maintained. A dehumidifier may be useful if the house is located in a humid environment. Roof leaks or wet walls can be sources of mold infestation in the house. A report indicated that an air-conditioned car can be a potential source of fungal allergens. A study in Kansas City indicated that fungal allergens were highest in the homes of children with asthma.
In occupation-related mold allergy leading to allergic bronchopulmonary aspergillosis (ABPA), allergic bronchopulmonary mycosis (ABPM), or extrinsic allergic alveolitis (EAA), the allergen can sometimes be removed from the environment. Otherwise, individuals perhaps should not work in that environment. Eliminating exposure helps control the disease in affected individuals and may prevent sensitization in unaffected but exposed individuals.
Simply altering the moisture content in the air and temperature can help. Avoiding or reducing the proliferation of normal airborne microbial contaminants that invariably occurs in the stagnant collection of water in air systems is crucial. Biocidal sterilizing agents must be considered for their low intrinsic toxicity and sensitizing potency. Recirculating filtered air is most economic but requires a high level of maintenance to decrease the load of respirable microbial allergens.
A study that examined in-home high fungal concentrations (>90th percentile), measured once within the first 3 months of life, as predictors of doctor-diagnosed allergic rhinitis in the first 5 years of life in 405 children in the Boston area indicated high measured fungal concentrations and reports of water damage, molds, or mildew in homes may predispose children with a family history of asthma or allergy to the development of allergic rhinitis.
A study was conducted to evaluate the use of high efficiency in-duct air cleaners in patients with asthma triggered by fungal exposure. The results indicate the use of the system provide an effective means of controlling allergen levels not only in single room, like a portable air cleaner, but the entire house. The findings are useful for evaluating potential benefits of high efficiency in-duct filtration system.
In Cincinnati, Ohio, a study was conducted to determine whether mold exposure at the ages of 1 and/or 7 years was associated with asthma at the age of 7 years. Mold was assessed by a DNA-based analysis for the 36 molds that make up the Environmental Relative Moldiness Index (ERMI) at age 1 and 7 years. They found children living with a high ERMI-value (>5.2) home at age 1 year had more than twice the risk of developing asthma than those in low-ERMI value home (< 5.2). The study also showed air-conditioning at home reduced the risk of asthma development. This may be the first study that predicts the early exposure to molds at age 1 year would have significantly increased risk of asthma at age 7 years.
Avoiding mold allergens all of the time is not easy. Therefore, pharmacotherapy remains a mainstay of medical management of all conditions related to mold allergy. Details of drug management for each condition are discussed further in Medication.
Pharmacotherapy - Allergic rhinitis and/or conjunctivitis
Antihistamines with or without decongestant, eye drops, and steroid nose sprays are available. Combined use of these drugs depends on the severity of the disease.
Pharmacotherapy - Allergic asthma
Depending on the severity of the disease according to the classification of the National Guideline of Asthma Education and Management, patients may receive one or more of the following agents: mast-cell stabilizer, short-term bronchodilator, long-term bronchodilator, leukotriene antagonists, inhalation corticosteroid, systemic corticosteroid, and theophylline.
Patients with moderate-to-severe asthma who react to perennial allergens despite using inhaled corticosteroids may benefit from omalizumab treatment.
Two pivotal, 52-week, phase III trials were conducted in 1071 patients aged 12-76 years. The coprimary endpoint was mean asthma exacerbations per patient. Patients were randomly selected to receive subcutaneous omalizumab or placebo every 2-4 weeks. Inhaled corticosteroid doses were kept stable over the initial 16 weeks (stable-steroid phase) then tapered over 12 weeks (steroid-reduction phase). As add-on therapy to inhaled corticosteroids, omalizumab reduced exacerbations by 33-75% and 33-50% during the stable-steroid and steroid-reduction phases, respectively. The reductions were confirmed by improvements in other measurements of asthma control, including symptom scores (eg, nocturnal awakenings, daytime asthma symptoms).
The use of antifungal treatment for severe asthma with fungal sensitization was not well known. a study recently showed addition of itraconazole was beneficial. The study concluded severe asthma with fungal sensitization responded to oral antifungal therapy as judged by large improvement in quality of life in about 60% of patients.
Pharmacotherapy - AFS
A systemic corticosteroid is the treatment of choice. A high-potency intranasal corticosteroid should also be used.
Pharmacotherapy - ABPA and ABPM
A systemic corticosteroid is the treatment of choice. When indicated, supportive therapy may include the use of a high-potency inhaled corticosteroid, adrenergic agonists, nedocromil, or theophylline. The results of trials with antifungal agents have not been convincing.
Several reports appeared sporadically about the success of treating ABPA by using antifungal agents. The antifungal treatment ranged from the use of a combination of oral erythromycin and fluconazole, the use of oral itraconazole alone, or inhalation of amphotericin B alone. At the initial stage, most studies reported the concomitant use of a corticosteroid and these antifungal agents. However, these are only case reports.
A single dose of 300 mg of the anti-IgE antibody, omalizumab, resulted in a dramatic and rapid improvement of symptoms and lung function in a 12-year-old girl with cystic fibrosis and ABPA. . Another recent report also showed good response for 2 pediatric patients with CF and ABPA after an injection with omalizumab. Their admission number was significantly decreased. Additionally, their free IgE level decreased by 87.9% in one and by 95.6% in the other. The authors suggested free IgE measurement is useful for monitoring the clinical response.
Pharmacotherapy - EAA
A systemic corticosteroid produces a rapid recovery. It may be supplemented with a bronchodilator.
For patients with allergic rhinitis and/or conjunctivitis, immunotherapy may offer lasting relief of symptoms. In general, results have not been as positive as those for patients with pollen allergy. Likewise, immunotherapy for allergic asthma due to mold allergy is not highly recommended. Immunotherapy has not been useful for patients with AFS, ABPA, or ABPM.
However, in a recent review by Hall and deShazo, after reviewing several studies of immunotherapy on AFS, they found evidence that allergen immunotherapy is effective in the treatment of symptoms of AFS and may decrease the rate of postoperative exacerbation and further operation. There was no evidence that it induces immune complex disease. Thus, they concluded allergen immunotherapy could be a useful adjunctive therapy for AFS. However, they cautioned that if the therapy is administered before the removal of fungal contents, it could worsen sinusitis. More studies are pending on this issue.
There is also a published report that the efficacy of sublingual specific immunotherapy (SLIT) in patients with respiratory allergy to Alternaria alternata is confirmed. Fifty-two subjects with a mean age of 20 +/- 9 years were studied. Clinical improvement was seen in 97% of the SLIT group, in contrast to 27% of the control group. The authors concluded SLIT, based on the blinded, controlled, 3-year study, should be considered for future therapy for respiratory allergy to fungi.
The only clinical disease caused by mold allergy that is benefited by surgery is AFS. Surgical removal of the allergic mucin that obstructs sinus drainage opens the sinus ostium and removes the mucin, which is laden with fungi.
Other surgical procedures are related only to the adverse effects of the primary disease. For instance, an otolaryngologic surgery may be indicated for a patient with allergic rhinitis who develops chronic ear effusion, adenoid hypertrophy, or chronic adenoiditis.
An allergist/immunologist and/or a pulmonologist should be consulted for the diagnosis and long-term follow-up care of patients with any conditions related to mold allergy.
An allergist/immunologist can offer advice on how to avoid allergens and may perform skin tests or initiate a course of immunotherapy in patients with allergic rhinitis or conjunctivitis if clinically indicated.
Pulmonologists can offer valuable expertise on the care of patients with ABPA, ABPM, or EAA, especially if the patient progresses to chronic stage or end-stage lung disease.
An otolaryngologist can help with the surgical removal of allergic mucin or mucus plugging that obstructs the ostium of sinus tracts in patients with AFS.
A radiologist can help identify sinusitis or adenoid hypertrophy.
No special diet is indicated for any of the conditions related to mold allergy.
Patients should try to remain in mold-free environments. For EAA, susceptible individuals should not work in high-risk environments.
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