eMedicine Specialties > Pediatrics: General Medicine > Allergy & Immunology

Mold Allergy: Treatment & Medication

Author: Shih-Wen Huang, MD, Medical Director of Allergy Service, Professor, Department of Pediatrics, Division of Immunology and Infectious Diseases, University of Florida College of Medicine
Contributor Information and Disclosures

Updated: Jun 15, 2009

Treatment

Medical Care

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.

• Allergen avoidance: 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.¹²
  • 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.
• Pharmacotherapy: 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.
  • 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.
  • 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.⁹
    • 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.
  • AFS: A systemic corticosteroid is the treatment of choice. A high-potency intranasal corticosteroid should also be used.
  • 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.¹³
  • EAA: A systemic corticosteroid produces a rapid recovery. It may be supplemented with a bronchodilator.
• Immunotherapy: 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.

Surgical Care

• 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.

Consultations

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.

Diet

• No special diet is indicated for any of the conditions related to mold allergy.

Activity

• Patients should try to remain in mold-free environments. For EAA, susceptible individuals should not work in high-risk environments.

Medication

Various drugs are used for the treatment of upper airway diseases. For allergic rhinitis and conjunctivitis, antihistamine/decongestant and/or intranasal corticosteroid and anticholinergic nose sprays are the treatments of choice. For allergic asthma, short-acting or long-acting bronchodilators, mast-cell stabilizers, antileukotriene agents, corticosteroid inhalers, oral corticosteroids, anticholinergic inhalers, or theophylline may be indicated, depending on the stage of the disease. For allergic fungal sinusitis (AFS), allergic bronchopulmonary aspergillosis (ABPA), allergic bronchopulmonary mycosis (ABPM), and extrinsic allergic alveolitis (EAA), an oral corticosteroid is the treatment of choice; in AFS, it may be supplemented with a corticosteroid inhaler. In ABPA and ABPM, it may be supplemented with a corticosteroid inhaler or theophylline. In EAA, it may be supplemented with a bronchodilator.

Antihistamines, oral

These agents compete with histamine to bind to H1 receptors on the endothelium and smooth muscle. Histamine is a central vasoactive mediator in allergic rhinitis, and prophylactic use of antihistamines typically provides substantial control of symptoms. Dosage of traditional (first-generation) antihistamine classes is limited by the appearance of undesirable adverse effects including sedation, restlessness, dry mouth, urinary retention, constipation, and blurred vision. For this reason, new-generation antihistamines that are mostly free of such adverse effects are welcome options for treatment. Many first-generation antihistamines are available without a prescription, and loratadine, a second-generation antihistamine, is currently available over-the-counter (OTC).

Loratadine (Claritin), cetirizine (Zyrtec), levocetirizine (Xyzal), fexofenadine (Allegra)

Nonsedating second-generation antihistamines. Fewer adverse effects than first-generation medications. Selectively inhibit peripheral histamine H1 receptors.
Loratadine: Available as 10 mg PO or disintegrating tab or syr (5 mg/5 mL).
Cetirizine: Available as 5-mg and 10-mg tab, 5-mg chewable tab, or syr (5 mg/5 mL).
Levocetirizine: Available as 5 mg scored tab.
Fexofenadine: Available as 30-mg and 60-mg immediate release tab or 180-mg SR tab.

Antihistamines with decongestants, oral

Antihistamines are most useful for symptoms of itching, sneezing, tearing, or postnasal drip. Decongestants relieve nasal congestion, reducing symptoms of sniffling. Many are available OTC in various combinations of an antihistamine plus pseudoephedrine.

Loratadine and pseudoephedrine (Claritin-D), cetirizine and pseudoephedrine (Zyrtec-D), fexofenadine and pseudoephedrine (Allegra-D)

Second-generation long-acting antihistamine-decongestant combinations with pseudoephedrine 120 mg or 240 mg. Each available in tab form.

Antihistamine nasal sprays

These agents locally relieve nasal symptoms more effectively than oral antihistamines. They are often used with oral antihistamine.

Azelastine (Astelin)

Aqueous nasal spray to treat seasonal and perennial allergic rhinitis.

Mast-cell stabilizers

These agents prevent mast-cell activation and, thus, degranulation. Degranulation releases mediators (eg, histamine), which causes tissue swelling and chemotactic factors to attract eosinophils to the site. This leads to delayed-phase inflammation. This process is obvious in allergic rhinitis and allergic asthma but may also be involved in other clinical conditions related to mold allergy. Nedocromil may have more anti-inflammatory effect than other agents.

Cromolyn sodium (NasalCrom, Intal)

NasalCrom (5.2 mg per spray, nasal solution) used for mast-cell stabilization in allergic rhinitis. Intal inhaler (0.8 mg per actuation, PO inhaler) used for mild intermittent or mild persistent asthma and especially to prevent asthma. Intal nebulizer solution (20 mg/2 mL, nebulizer solution) used to prevent asthma.

Nedocromil sodium (Tilade)

Used for mild intermittent and mild persistent asthma. Metered-dose inhaler provides 1.75 mg per actuation. Nebulizer solution available as 11 mg/2 mL.

Antihistamine and mast cell stabilizer eye drops

Although oral antihistamines are useful for allergic conjunctivitis, ophthalmic drops offer immediate relief of eye symptoms from allergies (eg, itching, tearing, conjunctival swelling). Not indicated to relieve an acute asthma attack.

Olopatadine (Patanol 0.01%)

Ophthalmic antihistamine solution indicated for temporary prevention of ocular itching due to allergic conjunctivitis. Inhibitor of histamine release from mast cells and devoid of effects on serotonin, alpha-adrenergic, muscarinic, and dopamine receptors.

Corticosteroid nasal sprays

Corticosteroids are potent anti-inflammatory agents that affect activation of many cells (eg, mast cells, eosinophils, macrophages, lymphocytes) and effect of mediators (eg, histamine, eicosanoids, interleukins [ILs], cytokines) that are important in allergic inflammatory process or hypersensitivity reactions. Therefore, they are important for treatment of the various diseases attributable to mold allergy.

Mometasone (Nasonex)

Demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulate pretranscriptional mechanisms. Reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells). Available as aqueous nasal spray of 50 mcg per spray.

Fluticasone propionate (Flonase) and fluticasone furoate (Veramyst)

Used to treat allergic rhinitis. Delivers 50 mcg per spray. Available as aqueous nasal spray. The propionate delivers 50 mcg per actuation, whereas the furoate delivers 27.5 mcg per actuation. Fluticasone furoate is well tolerated compared with the older propionate version, particularly in children.

Budesonide (Rhinocort Aqua)

Inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, may decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. Has extremely potent vasoconstrictive and anti-inflammatory activity. Alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Used for treatment of allergic rhinitis.

Flunisolide (Nasarel)

Inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, may decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes, and reversing capillary permeability. Does not depress the hypothalamus.

Ciclesonide (Omnaris)

Corticosteroid nasal spray indicated for allergic rhinitis. Prodrug that is enzymatically hydrolyzed to pharmacologic active metabolite C21-desisobutyryl-ciclesonide following intranasal application. Corticosteroids have a wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in allergic inflammation. Each spray delivers 50 mcg. Well tolerated in children.

Bronchodilators, short term

Short-term bronchodilators are beta2-agonists that act to relieve bronchospasm by elevating cyclic adenosine monophosphate (AMP) in cells. They are used for acute relief of bronchospasm and for prophylaxis, especially prior to exercise.

Albuterol (Proventil, Ventolin), pirbuterol (Maxair), levalbuterol (Xopenex)

Following list of Proventil products are for acute relief of asthma in various stages. Most commonly used alone in intermittent asthma or as prophylaxis, especially before exercise: tab: 2 or 4 mg, Repetabs: 4 mg SR, syr: 2 mg/5 mL, hydrofluoroalkane (HFA) MDI: 90 mcg per actuation, inhalation solution for nebulization: 0.083% (0.83 mg/mL, 2.5 mg/3 mL) or 0.5% (5 mg/mL).
Maxair Autohaler provides 200 mcg per actuation (breath activated) for relief of bronchospasm and asthma.
Xopenex inhalation solution for nebulization (0.31 mg/3 mL, 0.63 mg/3 mL, 1.25 mg/3 mL, 1.25 mg/0.5 mL) for prevention and treatment of reversible obstructive airway disease.

Bronchodilators, long-acting

One of the advantages of long-acting beta-agonists is prolonged relief for patients with obstructive lung disease (eg, asthma). They are especially useful for patients with nocturnal cough.

Salmeterol (Serevent Diskus)

Indicated for maintenance therapy for asthma. Prevents bronchospasm in reversible obstructive airway disease, including nocturnal asthma.

Corticosteroid oral inhalers

These are potent anti-inflammatory agents because of their effects on several cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and on the production and secretion of mediators (eg, histamine, eicosanoids, leukotriene, cytokines) in inflammatory process. Inhalers listed below are valuable for the treatment of mild-to-moderately persistent or severe forms of allergic asthma and are used as supplemental therapy for ABPA, ABPM, and EAA. Oral inhaled corticosteroids allow avoidance of severe adverse effects associated with systemic corticosteroids.

Corticosteroid oral inhalers are also available as combination products with long-acting beta2 agonists (eg, fluticasone propionate and salmeterol [Advair HFA, Advair Diskus], budesonide and formoterol [Symbicort]).¹⁴

Fluticasone (Flovent)

Indicated for maintenance and treatment of asthma as prophylaxis; also used in patients requiring long-term systemic corticosteroid treatment to attempt gradual tapering and discontinuation of PO corticosteroids: Available as Flovent MDI (44, 110, 220 mcg per actuation), Flovent Rotadisk (50, 100, 250 mcg per actuation), and dry powder in blister packs for inhalation with inhalation device.

Budesonide (Pulmicort Flexhaler)

Inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, may decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. Has extremely potent vasoconstrictive and anti-inflammatory activity. Alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Used for treatment of allergic rhinitis.
Available as Pulmicort Turbuhaler (90 mcg per actuation or 180 mcg per actuation delivers 80 mcg per inhalation or 160 mcg/inhalation) and dry-powder MDI; Pulmicort Respules inhalation susp (0.25 mg/2 mL, 0.5 mg/2 mL) inhalation susp

Triamcinolone (Azmacort)

Indicated for maintenance and treatment of asthma as prophylaxis; also used in patients requiring long-term systemic corticosteroid treatment to attempt gradual tapering and discontinuation of PO corticosteroids. Available as Azmacort (75 mcg per actuation) and MDI with an attached Aerochamber device.

Systemic corticosteroids

These are potent anti-inflammatory agents because of their effects on many cell types (eg, mast cells, eosinophils, neutrophils, macrophages, basophils, lymphocytes) and on the production and secretion of mediators (eg, histamine, eicosanoids, leukotrienes, cytokines) in inflammation. Many conditions related to mold allergy (eg, allergic asthma, ABPA, AFS, ABPM, EAA) require systemic corticosteroids from the onset of disease.

When disease activity decreases, reducing the dose to the lowest effective level and trying to further taper it to an every-other-day schedule are advisable. Also, a oral inhaled corticosteroid may be used to replace a systemic steroid to reduce adverse effects.

For allergic asthma, systemic corticosteroids are indicated when patients have a severe form of asthma resistant to other forms of therapy.

Prednisone (Deltasone, Prelone), prednisolone (Pediapred)

Prednisone remains mainstay PO systemic corticosteroid. Starting doses in each condition or different stages of same disease may differ. Main concerns with systemic corticosteroids, especially with long-term use, are adverse effects, which are more apparent than those of PO inhaled corticosteroids. Various tab strengths and liquids available to customize doses and ease tapering.

Leukotriene antagonists/5-lipoxygenase inhibitors

In asthma, leukotriene is an important mediator released in the airway that causes constriction of smooth muscle. This is most apparent in a delayed-phase reaction. Therefore, use of leukotriene antagonists is an important part of treatment to control asthma. These agents are indicated for forms of asthma ranging from mild intermittent to severe. For children, it is a valuable treatment for the night cough or wheeze. Inhibition of lipoxygenase reduces production of leukotriene at peripheral tissue and achieves results similar to those of leukotriene antagonists.

Montelukast (Singulair)

Leukotriene receptor antagonist indicated for long-term treatment of asthma. Available as 4-mg and 5-mg chewable tabs, 4-mg granules, 10-mg PO tabs.

Zafirlukast (Accolate)

Indicated for prophylaxis and long-term treatment of asthma. Leukotriene receptor antagonist.

Zileuton (Zyflo)

Indicated for prophylaxis and long-term treatment of asthma. 5-lipoxygenase inhibitor.

Theophylline derivatives

These agents directly relax smooth muscles of bronchial airways and pulmonary blood vessels, acting as bronchodilators and smooth muscle relaxants. They are used to supplement other asthma drugs, typically in moderately severe or severe asthma. Their effects in other forms of pulmonary diseases (eg, ABPA, ABPM, EAA) are unknown, though anecdotal evidence indicates that they have been tried in the chronic stage of the diseases.

Theophylline (Slo-bid, Slo-Phyllin)

Wide variety of dosage forms (tab, cap, extended release [ER], sprinkles, liquids) enables ease of dosing. Indicated for treatment of asthma, especially moderate-to-severe form as supplement to other anti-inflammatory drugs.

Monoclonal antibodies

These agents bind selectively to human IgE on the surface of mast cells and basophils.

Omalizumab (Xolair)

Recombinant, DNA-derived, humanized IgG monoclonal antibody that selectively binds to human IgE on surface of mast cells and basophils. Reduces mediator release, which promotes allergic response. Indicated for moderate-to-severe persistent asthma in patients who react to perennial allergens in whom symptoms are not controlled by inhaled corticosteroids.

Anticholinergic nasal sprays and oral inhalers

An increase of local production of acetylcholine may cause tissue reaction in the case of hypersensitivity. This is most common in IgE-mediated hypersensitivity. Anticholinergic agents may be useful for allergic rhinitis or allergic asthma.

Ipratropium bromide (Atrovent)

Available as 0.03% (21 mcg per spray) or 0.06% (42 mcg per spray) nasal spray. Suitable for allergic rhinitis. Also available as PO inhaler (18 mcg per actuation) indicated for moderate persistent or severe persistent asthma.

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