NASHVILLE — Although more than 50 million Americans have been diagnosed with allergic diseases, the American College of Asthma, Allergies, and Immunology has estimated a 7% decline in number of practicing allergists by 2020.

This decline will increase the number of allergy-related conditions being treated by primary-care clinicians, according to a poster presented at the American Association of Nurse Practitioners 2014 meeting.

“Studies indicate a 50% chance of misdiagnosing allergy and prescribing a medication when none was necessary,” wrote Kevin Letz, DNP, RN, FNP-C, ANP-BC, PNP-BC. “New testing and treatment modalities make it possible for primary-care [practitioners] to deliver evidence-based allergy and asthma care.”

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Guidelines on allergic rhinitis and asthma suggest testing for allergies when symptoms are persistent and have a significant impact on a patient’s quality of life. Letz named immunotherapy as solution to desensitizing patients to allergens.

Testing methods

Patient history and exam alone may lead to an incorrect diagnosis. Allergy testing can rule out potential misdiagnoses and can cut down return-visits, medication costs, and incorrect pharmacology treatments. Letz suggested in vitro and skin allergy testing options for primary-care clinicians to diagnose allergic conditions.

In vitro allergy testing has no risk of immediate side effects, anti-histamines do not need to be discontinued, and results are quality-controlled.  However, in vitro testing is more expensive and is less specific compared with skin testing.

Skin allergy testing runs the low risk of systemic reaction, and antihistamines must be discontinued three to five days prior to testing. Although skin testing is less invasive compared with in vitro testing, patients may prefer one blood draw to multiple skin pricks, noted Letz.


The practice of exposing patients to a specific allergen in order to promote tolerance and control a sustained decrease in reaction has been around for a 100 years, according to Letz. Immunotherapy aims to sustain immune response after discontinuation of treatment.

Subcutaneous immunotherapy continues to be the most popular allergy treatment method in the United States. Allergen immunotherapy consists of two phases of build-up and maintenance.

Build-up involves increasing one to two weekly doses of extract until a therapeutically effective maintenance dosage is reached. After the maintenance dosage is reached, the interval between dosages is gradually increased, and maintenance therapy continues for three to five years in duration for the best long-term benefits after discontinuation.

“About 30% of patients seen in a primary-care setting present with ‘allergy-like’ symptoms,” wrote Letz. With the projected decrease in allergists, the researcher suggests 80% of allergic conditions can be treated in primary-care settings. Educating PCPs on allergy testing and treatments can alleviate the growing need for allergy care.


  1. Letz K. #142. “Allergy Testing and Immunotherapy.” Poster presented at: AANP 2014. June 17-22, 2014; Nashville, Tenn.