By Dr. Paul Ehrlich
Through our social media outreach, we have been told by a particular mother that the family allergist claims that if her daughter goes five to ten years without exposure to her allergens, her body will in essence “forget” that it is allergic. This is a popular theory, but it has its flaws as science. Prolonged avoidance may be followed by tolerance, but don’t count on it. It may appear to work like this for some people, but this is not black-letter immunology. People “outgrow” their allergies for many reasons, only some of which we know. “Forgetting” may just be a coincidence. I offer this as Exhibit A about how long memory can last:
This is the latest episode in what might be the most extensive longitudinal observational study of a single patient in the history of allergy medicine. Readers of our book will recall my encounter with a 15-year-old Hasidic Jew and his Rabbi father many years ago at my Manhattan office. My assistant at the time ordered blood tests for IgE to a routine set of allergens. Unaware that this population is forbidden to eat shellfish, she included a panel of shrimp, crab, and lobster. When the results came back from the lab, one result popped out—a strong reaction to lobster. I did my best to conceal my surprise and the contents of the report from the father, but he was a perceptive man and asked to examine the paper himself. I had no choice but to hand it over. He read it and said words to the effect of “If I understand the process, you have to be exposed to an allergen in order to react to it.” “Yes,” I said.
The father turned to his son and addressed him firmly in Yiddish. After they went back and forth, the father smiled and asked one last question. I was curious about this part of the exchange but I don’t know Yiddish, so when I had a chance I asked the son what the Rabbi had said when he smiled. He answered, “How does it taste?”
Cut ahead many years and a Hasidic Rabbi showed up with his two sons at my office at New York Eye and Ear Infirmary in Williamsburg, Brooklyn, which has a very large Hasidic population. I took up Eye and Ear’s offer to work at this facility on Friday mornings because I wanted to work with more Hasidim on their own turf. Despite the fact that he had a full beard and wore the black hat and suit that normally make Hasidic men indistinguishable from one another in casual observation, there was something very familiar about this new arrival. Finally I said, “Have we ever met before? Did you ever come to my office in Manhattan?” He answered, “I recognized you, too. Are you the doctor who tested me for lobster?”
I said, “I always wanted to know how you ended up eating lobster.” So he told me that one Sunday, he and two friends decided to visit this mysterious place they had heard about—Times Square. They took the subway and got out at 42nd Street and Broadway where they wandered around in awe at the crowds and the lights and the noise, and like teenaged boys everywhere they got hungry. Though they searched high and low, they couldn’t find a kosher restaurant. Finally they settled on a place. Two of them ordered beef hot dogs, and the third decided to play it safe and order a fish sandwich. You must understand that this was the first menu any of them had ever read in English. Our young man ate his food, which was undistinguished in any way except for the price, which seemed inordinately high. It turned out to be a lobster roll—thus the sensitization to a forbidden food.
Not long ago he returned to my office and again I succumbed to my own curiosity. First of all, how did it taste? “Nothing special.” Then I took him aside and asked if I could skin test him to lobster. He was just as curious as I was, so we sent the boys out to the waiting room and he rolled up his sleeve. I scratched his arm and applied the allergen. Oy gevalt! It was a record wheal. This was after 20 years in which I am positive he hadn’t eaten lobster. I am sure he never will again.
*Non-kosher.
Lobster roll from commons.wikimedia.org
Oh yes, I am all too familiar with this myth! An allergist told me, in 2001 when kid #1 was diagnosed with fish allergy, that if he could avoid *any* exposure whatsoever for a few years, his odds of outgrowing the allergy would be greatly increased. It wasn’t easy in our seaside town, but we were exceedingly careful.
And it didn’t work. He’s a teen now and still allergic.
A few years after his initial diagnosis, kid #2’s RAST numbers for peanut were getting pretty low. The good news? She “might” be in the lucky 20% category that outgrows the allergy. I should have been jumping up and down that day. Instead, a couple hours later I found myself breaking down because the other half of the news was this: To maximize her odds of outgrowing, we were supposed to keep her at zero exposure — not a single trace — for “a few years.”
The pressure to live up to this high standard in order to spare her a lifelong debilitating condition left me feeling absolutely overwhelmed. Absolutely zero exposure to peanuts? Way harder than fish. What does zero exposure even mean? I already felt like I was being stalked by the Ubiquitous Peanut. Should we move to Antarctica? My husband and I had made our peace with some reactions being almost inevitable and, for our own sanity, to focus on risk *management* (not risk elimination) and to be prepared. But then we get the marching orders for “zero exposure.” Ugh.
But if there was a way for me to help my daughter outgrow her allergy, by God I was going to do it. And — not to brag or anything — I was quite the Type A achiever in this department. I tried to minimize collateral damage to our social lives and lifestyle, but that was tough. Years later family members and our school community still view me as a pathological obsessive-compulsive with a possible case of Munschausen-by-proxy syndrome.
And all this strict avoidance didn’t have the desired medical outcome. She’s 9 now and a solid Ara h2 positive. Oh well.
I don’t blame the allergists I saw back then for putting my family through this. There were credible studies/articles in credible, peer-reviewed journals in the 90s/early 00s that referred to “strict avoidance” possibly being a route to outgrowing allergies back in the late 90s/early 00s. My understanding is that current research does not support this theory.
Thank you, Dr. Ehrlich, for helping call this out for what it is — one more allergy myth that’s not supported by research.
Great story!!!!
My PA daughters first allergist after having her ANA to peanuts reaction said the same thing. The body is like a camera and after many years the photo will fade and it will forget the allergen. Well, over 10 years went by and we were extremely vigilant and she had no reactions. Peanut challenge was done in our current allergists office and although she reached hour 3 in the challenge, she is still ANA to peanuts!
This is a very timely post, as I just received my daughter’s latest peanut sIgE results and they dropped in half. I was also wondering if this had anything to do with my diligence in keeping her away from any exposure to peanut, basically baby-wiping her entire world, when possible. Perhaps, then, it is just pure coincidence, a maturation of the immune system, a natural desensitization, or a combination of all factors.