This is part of Moms’ Call the Doctor series, where we peek behind the medical privacy curtain and get to know the people we entrust our health with, including their motivation, research, career goals, and daily work.
It’s itchy-sneezy-rashy season across the United States. If this season feels worse than ever, feel free to blame climate chaos. “We know that climate change—global warming—has made allergens more potent, whatever pollen, whether it’s grass or tree or ragweed, there’s really good evidence to suggest that,” says Dr. Mansi Kotwal, a pediatric allergy doctor at Children’s National in Washington, DC. She mostly sees patients between six months and 21 years old with asthma, seasonal allergies, food allergies, and eczema, plus hives and drug allergies.
But it’s not just pollen making you miserable; it’s also a shift in seasons. “There’s more heat days, more frost-free days, and with that, you have longer allergenic seasons,” she adds. This alone has increased the number of patients coming to Dr. Kotwal complaining of seasonal allergies. “I’ve been seeing lots of patients who say that their allergies have gotten worse over the past several years or they’ve never had issues and all of a sudden they’re having issues during fall or spring or summer,” she notes.
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Asthma presents unique concerns
Photo courtesy of Mansi Kotwal.
All of this is of great interest to Dr. Kotwal, who vice chairs the environmental health committee of the American Academy of Allergy, Asthma, and Immunology. When it comes to increased incidences of just asthma during allergy season, the link to climate is less linear. There is good research to show that climate change impacts asthma (as well as allergenic rhinitis), but there are many other complex triggers too. “Asthma is so multifactorial that I can’t say for sure that I’ve seen a huge uptick. A lot of the patients I see have poor asthma control, issues with managing their asthma in general.”
Her patients are mostly from lower socioeconomic status populations. “So it could be related to medications not getting approved by insurance. It could be issues with compliance because they have a lot of different caretakers. They don’t have enough inhalers. It could be their home environment,” she says, mentioning possible triggers like mold, floods, water damage, smoke exposure, and pets. All of these things can compound asthma effects she’s also seeing with climate change. “Air pollution, particulate matter, ozone, anything that’s affecting air quality already impacts asthma patients and increases the risk of going to the emergency room,” she says.
What worries parents most
Dr. Kotwal doesn’t automatically discuss the links between allergies and the climate crisis with her patients, despite clear research. “Some of the families that I take care of have many other things that they’re thinking about and are basically trying to make ends meet on a day-to-day basis. So I don’t necessarily bring it up,” she admits, adding, “Until there’s belief from our government that climate change is real, some of the things, they can’t control. They can’t control where they live. They can’t control the pollution that they’re surrounded by. They can’t control the temperature.”
But when families bring up climate and environmental concerns directly, seeking her help on figuring out air quality, for example, she gets into it. “We’ll talk about apps that are available. Some people say, Do you think we should keep our kids inside right now because of recent fires? Or whatever,” she says. She’s always happy to weigh in.
Recent complaints
Feeling generally itchy is on the rise. Dr. Kotwal has noticed an increase in patients coming in with itch as a primary complaint. “There’s actually a lot of research going on into that. We have eczema, we have other kinds of skin conditions, psoriasis, and there’s a lot that are managed by dermatologists. And there’s now also people who have generalized itch.”
Researchers are trying to figure out what is going on. Dr. Kotwal is also witnessing a rise in chronic urticaria—patients coming in with random episodes of hives for more than six weeks at a time. “I can’t say that I know 100% this is climate change related. But there’s no identifier trigger. So there’s no food, no environmental stuff the patient could think of, no new pet. There’s just these random episodes,” she says, adding there’s reason to believe that there’s some association with climate because weather—warm, humid, hot, and even cold—can lead to hives.
Skin allergies and air pollutants
There’s also reason to believe skin exposed to air pollutants can be negatively impacted. “Let’s talk about the microbiome. Basically, bacterial communities lie on your body,” she says. While the majority of research on the gut microbiome focuses on brain and respiratory health, skin is one of the biggest parts—if not the biggest—of an immune system. An imbalance between good and bad bacteria on the skin can lead to issues including developing and controlling eczema. “Think about rashes, whether it’s contact dermatitis or hives, your immune cells on your skin are responding to the environment. And then kind of saying, This is not a friend,” she explains. Skin causes inflammation to keep anything “unfriendly” out of the body.
Research is ongoing about the various things that can alter skin bacteria composition. They don’t just lead to increased rates of eczema, but also asthma and food allergy. “There is a correlation with eczema being a risk factor for food allergy development. So when you’re looking at climate change affecting the skin bacteria composition, that alteration will increase your risk for eczema, make your eczema potentially worse, and then ultimately in turn, that could have a downstream effect of making food allergy more. Whether that will pan out, I don’t know,” she says.
As this research continues, Dr. Kotwal is personally seeking to broaden the ways she can help allergy patients—not just the ones who can come see her. She wants to focus on targeted education to families in as broad a way as possible, from YouTube videos to getting involved with educational organizations to policy and advocacy work. “That’s hopefully on the horizon.”
Tell Congress: Hold Zeldin Accountable for Corrupting EPA’s Mission