Yeah, I know.  Some of you may have written in and suggested that I am too sarcastic; my cynicism about our profession is too great; that my satire on the allergy profession is too biting, that I am too bitter.  But hey, you could think of me like that ice-cold shower you take on the morning after a long night out--painful, hard-to-take, but in a way refreshing, and it gets the job done.  Nevertheless, there may be some merit in what you say, so...well, I hear ya, Ralph.  So I'm turning over a new leaf.  No more Mr. Bad Guy.  So here goes:  I would request that all of you allergists take a moment from your busy lives and please--pretty please, if you will--clear your desks (and minds) of your asthma inhalers, asthma patient education booklets, asthma medication samples, asthma peak flow meters and color charts, asthma guideline protocols, asthma posters, asthma questionnaires, asthma textbooks, asthma journals, asthma-tips-for patients brochures, asthma controller meds, asthma semi-controller meds, asthma ultra-controller meds, and begin to think about a topic too rarely discussed amongst colleagues and friends in our own little bronchospastic let's-control-asthma world--a topic so radical it's almost beyond bearing: 

allergy.

yes, allergy.  allergy  on another mucosal surface.  

Oops.  Sorry.  ...And I promised to turn over a new leaf...but hey...I've got liftoff, so I feel great...

  But honestly, In our eagerness to examine the respiratory tract, how many of us really take an allergy history with an emphasis on vaginal pathology?  I have.  For 26 years.  And I have to say it's been an eye-opening 26 years. You see, basically, the vaginal mucosa responds to same 3 things that the respiratory tract mucosa does:  allergens, irritants, and infections.  And these 3 items are not mutually exclusive, and may co-exist together.  Keeping this concept in mind has helped me in achieving perspective in observing  allergic vaginitis in my allergy patients.   The following observations have come from listening to patients, testing them, and following their treatment.

1.  True atopic sensitivity to Candida antigen exists. Allergic vaginitis may exist by itself, in clinical "isolation"  (like the child who "just" has rhinitis) but many times in my experience it is associated with coexisting respiratory tract disease.  Suspect allergic vaginitis with Candida sensitivity  when a woman has positive immediate (not delayed) reactivity to Candida antigen on prick or intradermal testing, and when she has a history of vaginal pruritis with repeated negative gynecological exams.  Often a woman will complain to her gynecologist of intense itching or burning but be subsequently told she that has "just a few yeast cells" (or none at all) on exam, and told she "shouldn't worry."  She then may use an OTC antifungal vaginal cream with some relief. If she has a seasonal component to any traditional allergic illness, she may note that the vaginal symptoms flare the same time as her respiratory tract flares. 

2.  The vaginal lining may be reactive to food antigens.   Typically, food yeast, dairy and wheat are frequent offenders in the allergic vaginitis patient, but just like with other target organs in the body, virtually any food may play a potential aggravating role.  And, just like the respiratory mucosa, if an allergic response goes on for a long enough time, subsequent infection can ensue.  For example, I have a nurse I've treated who could eat citrus in limited quantities--a small amt would give leukorrhea, and 3 successive days would result in a documented yeast vaginitis episode on multiple separate occasions. Remember that small amounts of food antigen can be present in semen (see Part I of this series for the reference on the case of a woman sensitive to walnuts who had anaphylaxis on one occasion after having sex with her husband who had ingested walnuts prior to intercourse).  Thus, the vaginal mucosa is getting exposure to small amounts of food antigens in a woman having intercourse with her partner.  If a female allergic patient has a severe food reaction (like to peanuts) it is critical that her sexual partner avoid eating this food prior to intercourse! 

3.  Seasonal allergic vaginitis exists:   Many women who have a seasonal flareup of their respiratory condition in the spring/summer may have a flare-up of yeast vaginitis as well at the same time.     

4.  There is an allergic "triad" of Candida-mold-food yeast hypersentivity:  Just like there is the "hyperlipidemia-hypertension-cardiac disease" triad, we have a triad of "mold-Candida-yeast" triad for our profession.  For example, Airola et al last year described "clustered sensitivity" in a patient with documented reactions between multiple molds and baker's yeast.  Savolainen et all in Allergy in 1988 pointed out "atopic patients primarily sensitized by C. albicans and S. cerevisiae may develop allergic symptoms by exposure to other environmental yeasts due to cross-reacting IgE antibodies" .  Clinically, when you encounter a patient with documented sensitivity in one of these three areas (i.e., mold, yeast, Candida), --be sure to check out the other two.    In my experience, you will be richly rewarded diagnosticaly if you do this.  There is an intimate relationship between mold exposure and allergic vaginitis:  For example, patient X, a biology teacher, is one of my patients.  After being outdoors and digging in the dirt collecting mushroom samples with her studies, she returned back to the classroom with her students.  She was astonished to find that  within minutes after the mushroom exposure she had intense vaginal pruritis and burning.  This was accompanied by mild (and more tolerable) nasal congestion symptoms. I have one other patient with an identical story.   

5.  Vaginal symptoms with protected intercourse may be related to latex condom sensitivity:  warn your latex sensitive female patients about latex condom useage in their partners!   

6.  Antihistamines may be helpful for allergic vaginitis:  Just as for allergic rhinitis, I have occasionally found that routine systemic antihistamine medications may be helpful for allergic rhinitis.  I have also have used custom-compounded cromolyn sodium in coca butter intravaginally applied to be helpful on rare occasions.  There is a case report by Dhaliwal et al on allergic vaginitis due to ragweed, in which no success was obtained with antihistamines for controlling symptoms, and for which prednisone was provided for the ragweed season, with complete control of symptoms. 

7.  SLIT immunotherapy for offending allergens can greatly help the woman with allergic vaginitis and reduce the incidence of yeast vaginitis: Over the years, I have employed treatment for allergic vaginitis in the same protocol as I use for treating allergic rhinitis or asthma:  Identify the precipitating allergens, irritant, and infectious factors, and treat appropriately, with emphasis on SLIT for allergenic sensitivity issues.  This has been a rewarding experience for my patients, as well as myself, since treatment of allergic vaginitis can symptomatically help the patient, as well as reduce the incidence and severity of recurrent yeast infections...