The Environmental Aspects of Ear, Nose, and Throat Disease: Part II William J. Rea, MD, FACS, Dallas, TX, Director, Brookhaven Environmental Unit; Clinical Associate Professor of Thoracic Surgery, Southwestern Medical School, University of Texas Health Science Center.

Abstract: There are many methods now available to help the clinician to define changes in the body homeostatic mechanisms that occur upon exposure to offending agents. These include measurements of eosinophils, IgG level, serum complement, T and B lymphocytes, blastogenesis, C-reactive protein, IgE, IgA, IgM, and Ig D, and leukocyte inhibitory factor. Tests available include the cytotoxic food test and challenge test, skin tests, and inhalant testing. The best treatment in all allergies is avoidance, to as great a degree as possible, of offending agents.

Source: J.C.E.O.R.L. & Allergy, 41 (8/9):41-54, 1979. 81979 Medical Digest, Inc.
 
 

LABORATORY

Many parameters are now available to help to define changes in the body homeostatic mechanisms when exposure to incitants occurs. Not all are specific, but these measures sometimes can be an aid in confirming the diagnosis of environmentally triggered disease. Eosinophils Total body eosinophil count is readily available and usually present in a depressed state in people with environmentally triggered disease. In analysis of over 300 consecutive patients presenting to our Unit with a food and chemical susceptibility problem, 90% had depressed or absent eosinophils below 35 mm3. The 10% of the patients with eosinophilia were usually those with asthma or dermatitis, and they were definitely in the minority of patients presenting with those conditions. Once the patient was in the basal state and his peripheral eosinophils had returned to normal, incitant challenges were done. Frequently, the patient=s eosinophils were depressed on serial blood specimens drawn during the reaction. If eosinophils were depressed on admission, they would be depressed upon challenge, and if they were elevated upon admission, they would go up on challenge. Our normal laboratory range is between 50 and 200 mm3. IgG Peripheral IgG has been noted to be depressed on admission in 15% of our patients. Usually, it returns to control of over 800 mg per dilution without treatment other than avoidance. Often depression occurs upon challenge. The reason for this is unexplained, because there is usually such a large pool of IgG in the body. Complement Total hemolytic serum complement CH50 and CH100 has been measured in over 300 of our patients, as have the C3 and C4 components. Thirty-five percent of the patients appear to have complements out of the two standard deviation ranges of 80 to 120%. The majority of these are in the range of below 70% of control. Incitant challenge depresses the total complement. The C3 level, when abnormal, may be depressed, while C4 has usually been elevated.

All nine components have been assayed in 75 patients who presented with initial depression of their total complements. Frequently, C2 was also depleted. Ten percent of the patients in this category had very low terminal components. Seventy-five percent of the depressed complements returned to control levels by the time patients attained an adequate, consistent avoidance program.

T and B Lymphocytes The T lymphocytes were measured by the E rosette method while the B lymphocytes were measured by the EAC sheep blood cells method. B lymphocytes were rarely out of the normal range of 20 to 40%, while 50% of the patients had depressed lymphocytes below the 60% range, the majority having an absolute T lymphocyte count below 1,000. T lymphocytes appear to be sensitive indicators in these patients and frequently go down on challenge. Blastogenesis Lymphocyte transformation due to stimulation with pokeweed mitogen and phytohemagglutinin has been measured in over 200 patients. Different concentrations have been found to be important in assessing sensitivity, as stimulation may occur only at different levels. Ten and 50 dilutions have been used. Of our patients, 20% have low stimulation. These patients are the most difficult to work with and the slowest to respond to treatment. However, as treatment progresses the response gradually increases their transformation. C-Reactive Protein

This substance is elevated in 10% of our patients and often returns to normal as the inflammation subsides.

IgE

This substance, since it was isolated by Ishizaka, has been treated as the mechanism for allergy. IgE has been measured in over 400 patients with a food and/or chemical problem. Ten percent have an elevation of over 100. Although this is popularly thought to be elevated in individuals with pollen, dust, and mold problems, it appears to be of much less significance in overall assessment of the patient with environmentally triggered problems. Certainly, when IgE is elevated, skin tests will be positive and RAST tests will be elevated; the patient responds to injection therapy. These patients usually are very easy to treat by hyposensitization, and skin tests can be best worked out by serial dilution titration to find the optimum dose.

However, caution should be used when treating a patient with low IgE levels and negative RAST results. These patients may well be extremely sensitive to inhalant antigens, probably through an abnormality in another as yet undefined mechanism. Many patients in the Unit had severe rhinitis, sinusitis, vascular headaches, salivary gland swellings, and numerous other entities that were triggered by pollen, dust, and mold. They also had total IgE levels in the range of 0 to 50, and the selective IgE level was low when the Fadal-Nalebuff scoring system was used on the RAST. A prospective ongoing study under super-controlled conditions has revealed that over 50% of the patients we see are initially skin-test negative, but are extremely sensitive to inhalation challenge with pollen, dust, and mold (Table 7). It should be pointed out that 30% of our patients, although immediately skin test positive, are IgE negative, which suggests another mechanism.

Table 7

Results in Initially Skin-Test Negative Patients upon Inhalation Challenge

Class
T-lymphocytes
IgE
Skin Reactivity
Systemic Reaction
% Patients
I
Normal or Low
High
High
Low
10
II
Normal or Low
Low
High
High
50
III
Normal or Low
Low
Delayed from 6-48 hours
High
10
IV
Normal or Low
Low
Absent
High
30

 

IgA

Reports are available that low surface IgA occurs. In the series reported, less than 1% of our patients had low IgA levels. At present, we have not been able to correlate its apparent depletion with clinical entities as some authors have. IgM and IgD

No correlation has been seen in over 400 patients in whom these immunoglobulin levels were determined.

Tests for Leukocyte Inhibitory Factor

These tests have been done on over 400 patients with environmentally triggered disease using the food to which a patient is sensitive on challenge. Food is placed in the patient=s fresh blood and the number of leukocytes it inhibits after incubation is counted. But based on results in a number of patients, this test appears to be only about 60% accurate. Cytotoxic Food Test Correlation with incitant challenge still leaves the cytotoxic food test not completely reliable. In some individuals the correlation is almost 100%. In others, it seems to have little correlation. Heavy reliance on this test would appear to be unwise at this time as the test seems to fall into the same category as the leukocyte inhibitory factor test. Challenge Test Challenge tests under controlled conditions are very reliable and reproducible. Once can now show serial blood changes in various parameters as the patients are reacting to the various challenges presented to them.
 
 
METHODS OF DIAGNOSIS Traditionally, diagnosis is made by withdrawal and challenge; however, in many cases quantitative skin tests can be used for diagnosis. Pollen, Dust, Mold Skin tests have been used to diagnose and treat patients with this problem more precisely. These tests, along with the RAST, appear to be definite aids in diagnosis and treatment.

However, as has been previously mentioned, over 50% of the patients who were tested in the Environmental Unit were sensitive to these inhalants even though they had no skin whealing. Actually, most of these patients were supersensitive. Serial dilution titration certainly adds to the preciseness of the tests and allows for more rapid achievement of the optimal tolerated dose of any one substance in the individual patient.

Foods Withdrawal and challenge is still the best way of diagnosing food sensitivity. The use of the four- to seven-day rotary diet aids one in pinpointing incitants much more precisely. This method may also be used as a form of treatment. However, rotation alone often will not do the job. Intradermal neutralization of Lee and Miller=s technique is an effective aid in the diagnosis and treatment of food problems. When comparing skin whealing with food challenge in the Environmental Unit, there is a high degree of correlation (70 to 80%) if one includes delayed skin whealing. If systemic reactivity is included, such correlation may go as high as 95%.

The latter two categories are rather difficult to assess in the physician=s office, particularly if his environment is contaminated and the patient is chemically sensitive. Certainly, there appears to be a 95% correlation of positive skin tests occur. One must be extremely careful, however, in saying that a person does not have food problems just because the skin test is negative. To be certain of that statement, negative oral challenge after at least four days of avoidance must be proven in these possibly sensitive individuals.

Inhalants and Ingested Chemicals The most rapidly growing number of environmental incitants are synthetic and natural chemicals are synthetic and natural chemicals in the air and food. This is becoming the number one problem in attempting to clear patients with environmentally triggered diseases.

Unfortunately, skin testing is not too rewarding in defining the extent of the chemical problem. Usually only phenol and ethanol are available. Occasionally, formaldehyde can be assessed by the whealing or sublingual method. Testing should be done under controlled conditions, using a stainless steel booth. The patient is placed in the booth and allowed to clear. Then challenge is carried out, allowing time to breathe the odors at the ambient dose to which he is exposed daily. These substances may include chemical fumes, phenol, alcohol, formaldehyde, pesticide, cigarette smoke, perfumes, polyester, and fumes from natural gas and other synthetics. In this way the physician can more properly assess a person=s sensitivities. These tests can all be done in a double-blind manner.

CASE REPORTS AND SERIES IN EAR, NOSE, AND THROAT DISEASES Often, patients presenting to the physician with ear, nose, and throat symptoms are early in the disease spectrum. They can be diagnosed and treated by simple measures. The temptation is always present to treat symptomatically with antihistamines and allow the patient to go his way. However, this should not be the case today, as so many other tools are now available to stop the disease process totally. Covering up symptoms and allowing the disease to become more complicated should be a procedure of the past. It is now clear that neglected ear, nose, and throat sensitivities will result in either end organ irreversibility or spread of the sensitivities to other smooth muscle systems throughout the body, thus heralding the onset of many untreatable inflammatory diseases in affected individuals.

Of 100 consecutive patients seen with advanced environmentally triggered disease in our Unit, 71 had ear, nose, and throat symptoms prior to onset of the other symptoms. The majority had been treated by otolaryngologists with little effect. According to various authors, no etiology can be found in many patients with recurrent sinusitis, laryngeal edema, or Meniere=s disease. These conclusions were based primarily on skin testing and Vivonex fasting. Etiology had to be determined on many of these individuals by placing them in the Environmental Unit. The patients have much more widespread sensitivities than those who can be treated in the office. The following case histories are illustrative:

Salivary Gland Malfunction A woman age 69 entered with a chief complaint of inability to talk because of lack of salivation. This condition had progressed gradually over the last 10 years to the point where her speech was almost incomprehensible. There was swelling in the parotid glands, as well as spontaneous bruising, petechiae, peripheral and periorbital edema, and Raynaud=s phenomenon. The patient had received injection hyposensitization therapy from two different allergists for six months at a time without success.

Physical examination revealed parotid swelling, extremely dry mouth, and noticeably dry eyes. The skin of the extremities had many petechiae and bruises. There was mild periorbital and digital edema. The hands and feet were blue. Laboratory results are shown in Table 8A.

Table 8A

Laboratory Results in Patients with Environmentally Triggered Disease

A. Laboratory Data

HB
136
AB lymph

(E. Rosettes)

576

(1800 " 200)

MIF-pork
35.0%
 

HCT

39
T -Lymph

(E. Rosettes)

374

IgE (mg/dl)

IgM

192

(10-200)

(60-280)

WBC
6000
C3 (mg/dl)
81

(80 - 120)

IgG

IgA

1030

194

(800-1800)

(90-450)

THSC

(CH100)

80.0%
C4 (mg/dl)
32
IgD
3.6
 

 

90-98.0%

 

(20 - 40)

 

 

 


 
 
  The patient was placed in the Environmental Unit and fasted for five days without any medications. At the end of this period, she could salivate profusely and talk without impediment. Her skin was clear. As the challenge tests were performed, eight foods produced stoppage of salivation while eight others produced the petechiae, bruising, peripheral edema, and cyanosis. Three chemicalsCnatural gas, cigarette smoke, and insecticideCalso stopped salivation. The patient cleaned up her home and went on a rotary diet. She also had neutralization with food injections. She has done well over the last year and a half.

Other patients have been seen with malfunction of the salivary glands who presented similar courses of treatment (Table 9). It should be noted that one patient was a beautician and her main sensitivity was fumes from the hair dressings. This case illustrates the fact that chemical sensitivity should be ruled out before classifying the disease as nonallergic.

Table 9

Salivary Gland Malfunction

Patient*

(Age, years)

 

WBC

mg.dl

EOS

CH100

THSC (%)

mg/dl

C3

mg/dl

C4

E Rosettes

T-Lymphocytes

mg/dl

IgE

mg/dl

IgG

69
6000
70
80
87
32
378
5
1032
34
4000
35
94
80
31
1038
65
1115
49
5800
123
77
76
44
1247
25
770
41
11200
334
52
66
26
990
120
1530
55
5100
53
80
97
74
460
C
1540
36
6900
18
96
98
38
1901
190
1350
58
3000
35
80
85
19
350
5
1950
Notes:

*All patients were white women.

Laryngeal Edema

Several patients with recurrent laryngeal edema have been seen in our Unit (Table 10). The following is an illustrative case.

Table 10

Laryngeal Edema

Patient*

(Age, years)

 

WBC

mg.dl

EOS

CH100

THSC (%)

mg/dl

C3

mg/dl

C4

E Rosettes

T-Lymphocytes

mg/dl

IgE

mg/dl

IgG

27
4200
18
20
78
45
C
83
1670
47
3500
0
106
64
22
842
5
4000
36
6900
18
96
98
48
1901
190
1350
72
6400
53
90
102
50
537
C
1440
Notes:

*All patients were women and Caucasian with the exception of the youngest, who was an Oriental.

A Caucasian woman age 36 entered with these complaints: throat closing, seizure-like episodes resulting in partial paralysis accompanied by spontaneous bruising, petechiae, and abdominal bloating with severe distention. She had been examined in a physician=s office and found to be sensitive to some foods and inhalants. Her clinical course steadily deteriorated in spite of injection therapy for inhalants and some food avoidance. Admission to the Environmental Unit showed a well-developed female in moderately acute distress with shortness of breath and stridor. Other positive findings showed multiple bruises over the extremities accompanied by petechiae, cyanosis, and mild-pitting edema.

Laryngoscopy and bronchoscopy done after the patient was clear revealed normal cord, larynx, and trachea.

Biopsy of the petechia showed non-necrotizing lymphocytic infiltrate around the vessel wall with edema of associated tissue. Other laboratory findings are shown in Table 8B.

Table 8B

Laboratory Results in Patients with Environmentally Triggered Disease

B. Laboratory Data: Laryngeal Edema

HB
12.5
AB Lymph

(E. rosettes)

2924

(1800 " 200)

MIF-beef
50%
 

HCT

39.9
T Lymph

(E. rosettes)

1901

IgE (mg/dl)

IgM

190

240

(10 - 200)

(60 - 280)

WBC
6900
C3 (mg/dl)
98

(80 - 120)

IgG

IgA

1350

290

(800 - 1800)

(90 - 450)

THSC

(CH100)

96.0%
C4 (mg/dl)
38
IgD
4.7
 

 

(90 - 98%)

 

(20 - 40)

 

 

 


 
 
  It was found that the patient was sensitive to 13 foods and two chemicals. It was interesting to note that five foods caused the laryngeal edema, nine caused seizure-like episodes, and nine caused the bloating. There was obvious overlap of symptoms on many challenges. The recommendation to this patient was that she clean her house thoroughly and avoid the chemicals as much as possible.

The author has now worked up 81 patients in the Unit with recurrent sinusitis. These patients usually had combinations of inhalant, food, and chemical sensitivity. They could not be cleared without detailed attention to the food and chemical sensitivity problem. All had previously been given standard medical therapy without help.

Meniere=s Disease Some patients with Meniere=s disease appear to be environmentally triggered, as occurred in the following patient: A woman, age 41, entered with dizziness of five year=s duration. The patient noticed this condition to be worse in the spring and fall. For the past three years she had had onset of vertigo in early October, becoming severe by mid-October. Over the past year the patient had become increasingly more incapacitated by this problem. She had almost constant ringing in her ears, tended to fall to the left, and had increased left-sided deafness. Her throat would swell to the point that she could not breathe, and she had severe sinus congestion. Throat swelling developed about every two to three months for the past three to four years. She had been treated with cortisone to keep this under control. The patient had been receiving injection therapy for pollen, dust, and mold for the past five years without success. Attempts at dietary control had not been successful, nor had surgical interference with the vestibular apparatus. The patient was admitted to the Environmental Unit and was fasted on a safe water until she reached a basal state. Challenge with chemically less contaminated foods produced no symptoms. She was then challenged with commercial food, and after one meal her symptoms were reproduced (see laboratory results in Table 8C). All six chemicals tested also reproduced her symptoms. The patient has since removed inciting agents from her environment and is doing quite well. Headaches Headaches are the problems that one encounters most frequently. Basically, they are of the type that have been discussed under sinusitis, or are tension-produced or vascular in nature. In a series of 100 patients with predominately tension and vascular headaches due to food and chemical triggering, the majority could be cleared and remained clear with either avoidance or a combination of avoidance and food injections. These former unsalvageable entities now have a large degree of salvageability. TM Joint

The following is another example of an environmentally triggered disorder:

A woman age 30 entered with severe nausea and vomiting of blood. She also reported a continuous headache of low degree. In the past nine months, the headaches had become more severe with pain in back of her eyes and on the right side of her face. With this flare-up of right-sided face pain, severe pain also developed in the right upper molars. Root canal work was done but was unsuccessful, and the tooth was extracted. She continued to have pain in the adjoining tooth, which was also then extracted. On examination of the teeth no pathology was found. Neurologic evaluation was negative. Her throat swelled frequently, and she had difficulty swallowing. She had frequent earaches with ringing in the ears and minimal hearing loss, as well as rhinorrhea, nosebleeds, loss of sense of smell, and frequent bleeding of the gums.

The patient was admitted to the Environmental Unit and her symptoms cleared after seven days of fasting on safe water. The patient was then challenged with chemically less contaminated food, and eight foods reproduced her symptoms as did five chemicals. The laboratory data are shown in Table 11.

Table 11

Laboratory Findings in Patient with TM Joint Dysfunction

HB
12.4
AB Lymph

(E. rosettes)

4046

(1800 " 200)

IgE (mg/dl)
25
(10 - 200)
HCT 
34.4
T Lymph

(E. rosettes)

1659
IgM
106
(60 - 280)
WBC
7900
C3 (mg/dl)
104

(80 - 120)

IgG
740
(800 - 1800)
THSC

(CH100)

107%
C4 (mg/dl)
58
IgA
200
(90 - 450)
 

(90-98%)

 

20 - 40

IgD
5.4
 

  The patient was discharged on safe water and a rotary diet, and given information on how to make her environment more tolerable. The patient had adhered to this program and has remained almost totally asymptomatic. Treatment The total patient should be considered for over a period of years. Many measures, though satisfactory on a short-term basis, may be detrimental to the patient over the long-term. It is becoming increasingly apparent that, if treated early, allergic diseases can be prevented from developing into measurable end-stage inflammatory disease. It is being shown that patients may do well for a few months to several years with injections therapy for pollen, dust, mold, and food sensitivities, and then suddenly start deteriorating. They may lose their food sensitivity but develop a chemical sensitivity problem. It is not certain why this spreading phenomenon occurs, but it appears to be due to an overload of synthetic chemicals. Pollen, Dust, Mold Avoidance TechniquesCCertainly, avoidance is the best method of dealing with these problems, but injection therapy usually must be used simultaneously. Cleanliness in the home is most important. Most cleansing agents should be nontoxic. Bon-Ami, Borax, and baking soda are the primary safe cleaners. Nontoxic soaps (e.g., Ivory, Basis, Catille, Neutrogena, and old-fashioned lye soap) are available. Antidust sprays should not be used. Antimold treatment (e.g., washing the room with formaldehyde and keeping some in the room) is mentioned only to condemn.

Plastic mattresses and covers are also mentioned only to be condemned. Although they decrease the amount of dusts and molds in the environment, they increase the risk of the allergic patient to the development of chemical sensitivity because of the constant fuming of the plastic. It is much better to strip the bed to the springs and then build up the area with cotton blankets and cover with a close knit cotton made from surgical barrier cloth. In this way, dust, mold, and chemicals can be managed. The mattress can be taken apart at any time and washed thoroughly.

If cotton mattresses are already available, one can place the barrier cloth over the mattress, as a cover. One should be sure that the mattress is not fireproofed with a chemical retardant or mildew proofed.

HyposensitizationCUsually pollen, dust, and mold hyposensitization is used conjunctively with the aforementioned precautions. Serial dilution titration appears to be the best method for finding the initial optimum dose. It allows one to start at safer higher doses and more rapidly reach ultimate optimum doses. When the RAST is positive and specific IgE level is elevated, the use of the Fadal-Nalebuff scoring system appears to be a significant advance in the treatment of inhalant sensitivity. This may also be used to effect the maximum dose rapidly. The optimum dose is occasionally difficult to attain, and in some patients the Lee and Miller neutralization technique using specific doses of pollen, dust, and mold has been useful.

Sensitivity to phenol and glycerine appears to be an increasing problem. It has been the author=s experience that many patients who have been intolerant to phenol or glycerine can be treated if these substances are left out of the injections. Of course, the extracts are more precarious in that they have to be kept frozen except when in use.

Food Avoidance TechniquesCFoods should be used on a rotary diversified diet both as a treatment and prophylaxis. A five-day rotation will be adequate for some individuals. However, others may have to be on a seven- to 10-day rotation. Still others will have to rotate up to 30 days with some foods. Some foods must be totally avoided.

NeutralizationCFood neutralization injection therapy as advocated by Lee and miller seems to be an excellent adjunct to the rotary diet. In our Unit there is a high correlation between challenge testing and skin whealing in moderately sensitive patients (Table 12). After neutralization approximately 75% of the foods could be included in the rotary diet at least once every seven days. Some foods could be eaten with impunity, but more often, repetition leads to loss of tolerance for that particular food.

Table 12

Food Neutralization Results in 25 Patients

Pt
No effect
Improved
Months Follow-up
Avg. No. Foods Neutralized
Stopped Injections Briefly
Worse
Improved with Restitution of Injection
25
1
24
12
16
10
10
10

 
 
  Although this series is small and testing was not done in a double-blind manner, it is clear that repeated challenge resulted in food reactions each time. When daily injections of the neutralizing dose of a food were given, the patient could eat the food on rechallenge. This was done under controlled conditions so as to define the parameters clearly. When the injections were withheld, food sensitivity rapidly occurred.

Physicians have been using neutralization techniques for foods for a long enough time to realize that injection therapy may fail at any given time. This is because of myriad problems. Chemical overload in food-sensitive patients appears to be the prime reason for injection therapy failure. Patients tend to do only what they must in order to get by environmentally. As our environment steadily deteriorates, the problem of chemical sensitivity increases. We now have had the opportunity to see patients who have been on injection therapy for foods up to seven years. These patients were followed by competent physicians who noted that an individual would suddenly become intolerant to his injections. The endpoints would constantly shift and could not be maintained. These patients were ultimately found to be intolerant to the phenol and glycerine in their injections. However, simple removal of these components was not enough. They had to decrease their chemical load further by cleaning their houses, often removing the gas heat and carpeting, and stopping the use of extermination products. The patients then were given frozen saline extracts until tolerance was regained. We have now observed this phenomenon in over 60 patients who have come through our Unit.
 
 

CHEMICALS Treatment for chemical sensitivity is complex, because most treatment consists of avoidance. Some individuals respond intermittently or briefly to neutralization therapy with phenol, ethanol, formaldehyde, and various other synthetic extracts; but these appear to be only Acheater doses@ and will hold only for a few hours.

Principles of chemical avoidance will be discussed only briefly here. Those who wish more details can consult Human Ecology Susceptibility to the Chemical Environment, by Theron Randolph, MD; Clinical Ecology, by Lawrence Dickey, MD; and The Management of Complex Allergies, by Natalie Golos. The latter is a manual that is a Amust@ for every physician and patient.

Patients must use safe water. Usually charcoal-filtered water is adequate if all devices are made of stainless steel. The filter will not remove fluoride, however. Frequently, one of the many spring waters is best. This must be kept in glass containers, however, or the sensitive patient will not tolerate it. There are some patients who tolerate distilled water but fewer than the aforementioned. Approximately, 1% of the chemically sensitive patients can tolerate no water. These individuals are extremely difficult to manage.

Chemically less contaminated food is extremely important for those with chemical susceptibility. There are now enough patients in all major United States cities with this problem to be able to band together to form cooperatives. We have found it necessary to contract with farmers to grow chemically less contaminated foods in order to have a constant and safe supply. Reliance upon health food stores is difficult, because many foods sold there are contaminated.

The home environment is the most important place to maintain. Guidelines for construction of an environmental unit are applicable to the home and should be followed as closely as possible. There should be no gas appliances in the house. If petroleum products or coal are used, they should be kept away from the house, using boilers for heating; then, the hot water can be pumped into the central system and heat blown throughout the house. Lower temperature electric heat appears to be one type tolerated by many.

The bedroom should be the maximum oasis. Bedding should be 100% cotton or linen, as previously described. Carpets should be removed and a tolerable flooring applied. Window coverings should be either 100% cotton or metal blinds. Closets and dressers should be stripped of all clothing, except that which the patient can tolerate. Articles remaining in the bedroom and/or attached bath should be kept at a minimum; all plastics, cosmetics, and cleaning agents should be removed.

All clothing should be of washable cotton, linen, or silk. Formaldehyde is often used in sizing new cottons, and care should be taken to process new clothing before it is worn. A vinegar soak followed by laundering with sodium bicarbonate is the best method for removing sizing and chemical treatment of cotton. In the sensitive patient this process may have to be repeated several times.

Finally, no pesticides, herbicides, fertilizers, and the like should be used in or around the home.