Household experience the more live-threatening or costly complication of allergy,

including recurrent or chronic rhinosinusitis and asthma.

The patient directly controls environmental management. Once of history of allergy
testing strongly suggest the causative allergen, the physician must convert the
importance of environmental management to the success of allergy control.
Families vary widely in their commitment to the implementation of environmental
control, their personal financial resources, energy level, demand on time, and other
factor that are critical to the success avoidance treatment. The patients allergist can
advice and support, but difficulty of compliance with the limiting and sometimes
expensive implementation of environmental control must be considered individually.
Prevention of allergy
Allergic symptoms do not occur with primary exposure. Immunoglobulin E (IgE) to
the allergen is not generated until after one or many exposure to the allergen. Only
when sufficient IgE has been produce to occupy mast cell can the patient manifest
the symtoms. Which occur when the allergen cross-link the IgE molecule present on
the mast cell, causing the granulation. In the child who is at high risk for
development of allergy because of present of allergy in both parent. Environmental
control should be instituted, ideally before the born of the child. Hide at al . in
randomized control trial showed that environmental control for dust mites during at
first 12 months of life in high risk children prevent the development of allergic
rhinitis at 12 months and 24 months, compare with control subject. The children
treated with strict environmental control had a significant decrease in positive skin
prick reaction compare with the children in home without environmental control in
place.
Allergen sensitivity may be increase with exposure to multiple factor independent of
allergen. Especially concomitant exposure tu environmental tobacco smoke. Linford
et al. in prospective study of 189 asthmatic children showed that the risk of
sensitization to cat is low (9%) is there no household cat, whereas the incidence of
cat sensitization increase proportional to cat exposure but is dramatically increased
if, in addition to cat there is house dampness and environmental tobacco smoke,
with 80% of these children showing IgE sensitivity to cat.
The other area where prevention of allergy should be strongly considered is the
patient involve with laboratory animal such as mice, rodent and rabbits. This
animal are highly allergenic, and the incidence of the sensitization in patient who
fail to prevent sensitization through the use of gloves and masks is as high as 46%,
substantially greater than the 20% incidence of allergies in the general
population(4). It is far easier to prevent sensitization than it is to deal subsequently
with the results of sensitization.
ENVIRONMENTAL CONTROL IN SENSITIZED PATIENTS

The first focus of environmental management should be on the bedroom because

this usually is the area of the house where inhabitant spend the most time. This
approach also ensure the achievement of highest yield from effort and money
spend for environmental control.
Three basic control principles apply for all inhalant allergens :
1. Remove this source of allergen if possible
2. Remove accumulated allergen
3. Prevent the return of allergen
With indoor allergens, management consist of decreasing the presence of the
allergens, management principles emphasize cocooning the patient to avoid
exposure. The following section deal with pollen, mold, dust mite, pet (cat and
dog), rodent, cockroach, and tobacco smoke individually.
Pollen
Allergenic pollen range from 15 to 50 m in size (e.g., ragweed, 23 m
diameter). Indoor pollen exposure is reduced by keeping windows close during
times of high pollen counts, by the use of air conditioning to filter air, the
avoidance of inward-directed windows fans. More aggressive measure include
removing allergic plant and trees that are immediately adjacent to the dwelling,
and the use of room or house air filtration devices. Wilson et al. shows that
particle more than 10 m in diameter are too large to reach the lower air ways
and are primarily responsible for upper airway disease (i.d. allergic rhinitis)(5). It
still is possible for fragments of pollen (approximately 7 m) to reach the lower
air and cause asthma symtoms (6).
Although staying indoors during specific pollen season may provide considerable
relief, it also is socially restrictive and becomes ad increasing hardship if the
patient is allergic not only to trees, for example, but also to grasses, molds,
and weeds. This would essentially restrict the patient to the indoors for at least 6
months of the years in the northern climates and year round in the more
southern areas of the United States.
Pollens are most prevalent in the air in the morning as the sun rises and the air
warms. Staying indoors at this time reduces pollen exposure at the most critical
period of the day. Regional pollen counts are published in major newspapers and
provided by television weather forecasters in the area. When pollen levels are
exceptionally high, the pollen-allergic patient should plan one spending more
time indoors. When it is necessary to go outside, patients should choose calm
days when the air is still, or within 2 hour of a rain. Most pollen is washed from
the air during a rain. Wearing a hat, glasses, and a mask limits outdoor exposure
to pollen. After outdoor activities, patients should remove clothing immediately
and shower and shampoo to remove pollen from the skin and hair. Control of

exposure to seasonal pollen can be relatively simple but not practical in most
situations.
Seasonal variation in pollen counts
Peak pollination, unfortunately, occurs when people most want to be outside. In
temperate climates, tree pollen is the earliest pollen of the year. Trees primarily
pollinate in the spring, starting as early as February in some parts of the country.
One species of tree may pollinate for a few weeks, followed by pollination by
others species. There is considerable overlap in tree pollination and the season
may last until June, depending on the geographic area, temperature, and rainfall.
Summer is the peak pollination season for grasses, but it frequently overlaps
the tree pollination season to some degree as well as extending into the fall
weed pollination season. In some areas, grasses pollinate throughout the year.
Fall is primarily weed pollination season, starting in august and continuing until
the first frost, although timing and duration vary geographically. In addition,
widespread distribution of pollen through high winds over grade distances is
possible (7).
Patients often are unaware of the appearance of the tree, grass, or mold that in
causing their symptoms and may mistakenly attribute their symptom to a pollen
they can readily see, such as pine, which is much less allergenic than the more
buoyant pollens that are less apt to coat the ground. In extreme situation,
removal of the shrub or plant from close proximity to the house can be
undertaken. Keeping the grass cut short can minimize pollination from grass.
Nevertheless, pollen can still be blown great distances and the pursuit to remove
allergenic pollinating plants from the environment must be tempered with this
knowledge. Mary Jelks has written an excellent, well illustrated short book on
allergy plants that cause sneezing and wheezing. It is a valuable tool for the
education of patients(7).
MOLD
Mold is present year round. Outdoor mold counts are highest during the warmer
months and usually lower after first frost. Mold spores range from 5 to 50 m but
in general are larger than most pollen grains. The same strategies for avoiding
outdoor mold exposure as for the pollens can be pursued. The reduction of
exposure to indoor mold should be pursued vigorously.
The most commonly identified indoor molds are Aspergilus, Penicilium,and
Rhizopus. This is in contradistinction to the high outdoor counts, in which
Alternaria, Cladosporium, and Helminthosporium predominated. Regardless of
the species present, environmental control measure are the same because all
molds grow better in damp areas.

Outdoor molds peak in the evening hours when the temperature drops at sunset.
an avoidable common exposure to molds is lawn work. Patient who complaint of
severe allergies when mowing the lawn frequently are not allergic to grass
because lawn grasses do not pollinate when kept closely mowed. Rather they are
reacting to the molds and smut that are present in the grass roots and become
airborne when the grass is mowed. Mold-allergic patient should either avoid lawn
work or wear a facemask. The same goes for raking leaves or piles of cut grass.
Rain usually clears the air of pollen, but mold spores are be released and
frequently peak approximately 2 hours after the rain. During this time, moldallergic patients should stay indoors.
An occupational hazard for farmers is mold exposure from molds and smuts
growing on grains stables and barns frequently are moldy, with mold growing on
animal droppings, litter, hay, and feed. Decaying vegetation promotes heavy
mold growth, and the compost pile should not be close to the house.
Indoor mold exposure occurs on indoor plants, shower curtains, and in areas of
dampness in basements and garages, drip pans beneath refrigerators and
freezers, and around condensers. Old books, bird droppings, firewood, and piled
newspapers frequently are moldy. Christmas tree allergies frequently are not a
tree allergy but a mold allergy because the trees have been cut and packed in
the presence of snow and frost that, with warming, provide the humidity that
allows prolific mold growth.
The best method of environmental management of indoor mold is too keep
humidity law and prevent wet areas on walls and carpets. Maintaining the
humidity below 50% reduces the growth and germination of molds significantly.
A humidity gauge can be used to assess humidity levels.
Chemical fungicides include chlorine bleach and specific mold-inhibiting
preparations. Soap and water also can reduce mold and mildew for a short time.
Irritating, harsh chemicals should be avoided. A dehumidifier should be placed in
the basement. Carpeting should be avoided in the basement. If a basement
smells like basement, it almost certainly has mold growing in it.
DUST AND DUST MITES
House dust is a combination of over two dozen identified or suspected allergens.
The potency depends largely on the age of the dust. Older dust is more
allergenic. House dust is generated in any living environment and include
degenerating residues of upholstery, carpets,.