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Eosinophilic Esophagitis and Link to Other Allergic Conditions

There are at least 4 major groups of allergic manifestations which are as follows:

The relationship between these 4 conditions has actually been very well studied in a model known as the “allergic march” or “atopic march.”

The allergic march describes how children who have early allergic manifestations, such as eczema or food allergies, are at a higher risk of developing other allergic manifestations, specifically respiratory allergies, later in life.

Researchers at Children’s Hospital of Philadelphia (CHOP) studied the progression of various allergic disorders in a cohort of 130,000 children. They found that children who had eczema and food allergies in early childhood are much more likely to develop respiratory allergies such as allergic rhinitis and asthma later on in life.

Interestingly, their recent analysis also demonstrated that children with skin and respiratory allergies in early childhood are also much more likely to develop eosinophilic esophagitis (EoE) later in life. They also found that children with EoE were at a higher risk of developing allergic rhinitis compared with healthy children.

It is now believed by researchers that eosinophilic esophagitis is also a part of the cascade known as the atopic march. This information is important as it demonstrates that we need to be on the watch for symptoms of EoE in highly allergic children, not just adults.

Eosinophilic esophagitis is an inflammatory disorder involving the esophagus (i.e., food pipe). It occurs in about 1 in 2,000 people. The majority of patients with EoE are atopic (i.e., allergic). In normal individuals, there are no eosinophils (i.e., the “allergy” white blood cells) on the inner lining of the esophagus. In patients with EoE, however, there is an accumulation of eosinophils in the esophagus. The presence of eosinophils in the esophagus causes a chronic inflammation in the esophagus since these eosinophils release chemicals into the surrounding tissue. It is the reaction of the tissue in the esophagus to these chemicals that leads to the unwanted gastrointestinal symptoms of EoE. The symptoms of eosinophilic esophagitis may include difficulty swallowing (especially solid foods), food-getting- stuck-in-the-throat feeling, esophageal reflux, regurgitation of food, abdominal pain, chest pain, weight loss, poor appetite, and in extreme cases, impaction of food in the esophagus. In children, the symptoms may also include vomiting, feeding difficulties, difficulty eating, irritability, and/or failure to thrive.

In many individuals, food allergies play a role. Specific food allergens will act as triggers and thus cause the undesirable symptoms associated with EoE. In eosinophilic esophagitis, it is more challenging to establish the role of foods since the reactions to foods are usually delayed, as they may develop over days, making it more difficult to identify a specific food as the trigger. The most common food triggers for EoE are milk, wheat, egg, and soy.

Environmental allergies to dust mites, molds, pollens, and animals possibly play a role in eosinophilic esophagitis. For some individuals, their EoE seems to worsen during the pollen seasons in the Spring and Fall.

In addition to allergic rhinitis, asthma, food allergies, and eczema, there are other risk factors for the development of eosinophilic esophagitis. EoE is more common in younger adults (i.e., average age of 34 years old) and is also more common in males (i.e., 65% are males). There may be a genetic predisposition towards the condition in some families.

Confirmation of the diagnosis of eosinophilic esophagitis entails endoscopic biopsy of the esophageal mucus membrane by a gastroenterologist with the demonstration of an excessive accumulation of eosinophils. Once the diagnosis is confirmed, the patient should see a board certified allergist such as the ones at Black & Kletz Allergy for food testing. Food testing can be done by skin prick testing and/or blood testing depending on the clinical situation. Skin patch tests may be done in order to detect delayed hypersensitivity to foods. A food elimination diet may be recommended depending on the clinical history. Skin tests to environmental allergens such as pollens may also be performed, especially when the symptoms of EoE exhibit a seasonal pattern.

The treatment of eosinophilic esophagitis may include:

  • Identification of allergenic foods and their restriction in diet
  • Protein pump inhibitor (PPI) medications to reduce acid secretion
  • Swallowed anti-inflammatory medications such as topical corticosteroids
  • Oral corticosteroids may be necessary when the disease is more severe and/or refractory to more conservative treatments
  • Newer anti-inflammatory drugs and biologicals are undergoing research and may be used in the future
  • Dilatation of narrowed portions of the esophagus may be warranted in rare cases of stricture development

The board certified allergy specialists at Black & Kletz Allergy are pleased to answer any questions you may have regarding eosinophilic esophagitis.  Our allergists have been diagnosing and treating EoE and other eosinophilic disorders in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  We have 3 convenient locations in the DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  There is on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call us at any one of our 3 locations.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy is dedicated in providing the most up-to-date diagnostic and treatment modalities in the field of allergy, asthma, and immunology.

Allergies to Molds

Allergies to molds are very common in the U.S. and around the world. Mold allergies are responsible for a great deal of allergic rhinitis (i.e., hay fever), allergic conjunctivitis, and asthma that affects so many individuals. Molds are fungi that grow in the form of multicellular strands called hyphae.  Fungi that propagate in a single celled atmosphere are called yeasts. Molds can cause both annoying symptoms that are bothersome to an individual as well as more severe symptoms that may result in severe consequences to another individual. There are basically 3 major ways in which molds may affect people. They may cause either infections, allergic reactions, or irritant responses.

Molds or fungi can cause infections in certain individuals. Many times the person who gets infected are immunocompromised or have a “low” immunity. They can be immunocompromised for various reasons which may include immune defects (e.g., common variable immunodeficiency, IgG subclass deficiency, hypogammaglobulinemia, Bruton’s agammaglobulinemia), immunosuppressant medications (e.g., corticosteroids, cyclosporine, tacrolimus, azathioprine, biological monoclonal antibodies), cancer, radiation, HIV/AIDS, malnutrition, stress after surgery, and old age, to name a few. Fungi tend to infect the sinuses, lungs, esophagus, brain, bloodstream, eyes, tongue, skin, and nails. One can have a superficial or systemic fungal infection. Systemic fungal infections tend to occur more in immunosuppressed individuals and may be life-threatening. It is important to note that superficial fungal infections of the tongue, nails and skin are common in normal individuals without compromised immune systems. It is the sinuses, lungs, esophagus, brain, bloodstream, and eyes that are more of a problem and tend to occur more in individuals with weakened immune systems. Treatment varies depending on the location and severity of the fungus. Antifungal medications can be given topically, orally, and/or intravenously.

Allergic reactions to molds mainly arise as allergic rhinitis, allergic conjunctivitis, and/or asthma. Allergic rhinitis or hay fever symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy eyes, watery eyes, red eyes, puffy eyes, itchy throat, snoring, sinus congestion, sinus headaches, and/or fatigue. Asthma symptoms generally may include wheezing, chest tightness, shortness of breath, and/or coughing. As a result of mold allergies, it is not uncommon to develop recurrent or chronic sinus infections or nasal polyps. The diagnosis of allergic rhinitis is made by a board certified allergist like the ones at Black & Kletz Allergy and begins with a comprehensive history and physical examination. Afterwards, allergy testing, usually by skin testing and alternatively by blood testing, is performed in order to determine if allergies are present and causing symptoms in the affected individual. For asthmatics, a pulmonary function test is also done in the office in order to evaluate one’s respiratory status. Occasionally, a chest X-ray is ordered to evaluate the lungs, if necessary. Once the allergens are identified, preventing exposure to the allergens is strongly recommended, if one is able to do so. If one is unable to avoid the offending allergens or avoidance does not alleviate the symptoms, there are a host of medications available to help mitigate the bothersome symptoms. The array of medications to treat allergic rhinitis and/or allergic conjunctivitis may include oral antihistamines, oral decongestants, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, topical antihistamines, topical mast cell stabilizers, topical corticosteroids, topical nonsteroidal anti-inflammatory drugs (NSAID), leukotriene antagonists, and/or allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization). Medications used to treat asthma may include inhaled corticosteroids, inhaled beta-agonists, inhaled anticholinergics, leukotriene antagonists, methylxanthines, biologicals [e.g., Xolair (omalizumab), Nucala (mepolizumab), Dupixent (dupilumab)], and/or allergy injections. Allergy shots are very effective and help patients with allergic rhinitis, allergic conjunctivitis, and asthma in 80-85% of the cases. Allergy shots have been utilized in the U.S. for more than 100 years.

Toxic mold syndrome: It should be noted that mold allergies may be responsible for more than half of the cases in the controversial syndrome named “toxic mold syndrome.” The symptoms of toxic mold syndrome range vary greatly and may include runny nose, itchy eyes, red eyes, sore throat, nosebleeds, rash, hair loss, wheezing, chest tightness, shortness of breath, coughing, headaches, nausea, vomiting, abdominal pain, urinary tract infections, dizziness, anxiety, insomnia, shakiness, weight loss, inability to focus, lack of concentration, mood swings, fatigue, loss of appetite, and memory loss. Toxic mold most commonly grow on moist walls and is often accompanied by black, brown, or green patches along with a musty odor. The syndrome sometimes is also referred to as sick building syndrome. Some people feel that toxic mold produces spores and chemicals which are released in the air and when inhaled cause the symptoms mentioned above.

Molds may also bother individuals by causing an irritant reaction. To many individuals this irritant reaction mimics an allergic reaction, however, it is not an immunologic reaction and cannot be treated by allergy shots. An irritant reaction occurs when the mold is irritating to a patient, but no allergy exists. Examples of irritant reactions include watery eyes from freshly cut onions or a runny nose after eating hot peppers. In cases of irritant reactions to molds, the best treatment is prevention by avoiding molds. If this cannot be achieved, there are some medications that may help reduce the symptoms of this nonallergic rhinitis. Such medications may include oral decongestants, nasal antihistamines, nasal corticosteroids, and/or nasal anticholinergics.

The board certified allergists at Black & Kletz Allergy diagnose and treat mold allergies in both children and adults and have been doing so for more than 50 years.  Our 3 offices are conveniently located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have parking at each location and the Washington, DC and McLean, VA offices are Metro accessible.  If you suspect mold allergies or have hay fever, eye or skin allergies, or asthma, please call us to schedule an appointment.  Alternatively, you can click Request an Appointment and we will respond back to you within 24 hours of the next business day. The allergy specialists at Black & Kletz Allergy hope to serve your allergy and asthma needs in our state-of-the-art medical facilities while continuing to provide you with a friendly and welcoming environment.

Pollen Allergies

Pollen is comprised of a powdery substance whose individual grains contain the male part (i.e., anthers) of seed-bearing plants. The pollen causes the female part of the same type of flower to produce seeds. Pollen is carried to other plants via the wind or by insects. It is when the pollen is dispersed by the wind that individuals are exposed to it by breathing in and inhaling the pollen-infested air. As a result, certain individuals become sensitized and develop allergies to pollen. People who develop pollen allergies may manifest their symptoms in various manners. Some individuals develop allergic rhinitis (i.e., hay fever) and suffer from mostly nasal symptoms. Others are affected mostly around and in their eyes and acquire a condition termed allergic conjunctivitis. Still other people can develop asthma as a result of the exposure to pollen.

The amount and type of pollen released into the air is dependent on various weather factors as well as the time of year. The air temperature, humidity, rain, and wind speed can and do affect the amount of pollen in the air. Pollen counts are highest on dry, warm, and windy days. The pollen counts tend to be the highest in the early mornings. The amount of pollen in the air at a given time can be measured and is published to the public as the pollen count. You can find out today’s pollen count in the Washington, DC Northern Virginia, and Maryland metropolitan area by clicking “Today’s Pollen Count” at the top right of our website. The time of year also is a major factor in determining the type of pollen that is in the air. In general, tree pollen is present in the early Spring, while grass pollen is present in the late Spring. Ragweed and other weed pollen are prevalent in the late Summer and early Fall. In the Washington, DC metro area, the trees begin to pollinate in late February, peak in mid- to late-April, and end in late-May or early-June. The grasses begin to pollinate in late-April to early-May, peak in late-May or early-June, and end in August. Ragweed, the principal weed to affect most sensitive individuals, generally begins to pollinate in mid-August, peak in late September, and end in late-October coinciding with the first frost.

In the Washington, DC metro region, there are specific species of trees, grasses, and weeds that are endemic to that area. The most common tree pollens in the area include birch, maple, oak, cedar, hickory, ash, beech, cottonwood, poplar, sycamore, alder, elm, and mulberry. Common grass pollens include Timothy, Bermuda, Johnson, Kentucky bluegrass, meadow fescue, and rye. Similarly, the most common weeds in the Washington, DC area include and ragweed, lamb’s quarters, English plantain, pigweed, cocklebur, mugwort, and sorrel. Of course, there are other varieties of trees, grasses, and weeds in the Washington, DC region but these other varieties are not as prevalent as the ones mentioned above.

It is interesting to note that the “pretty” trees (i.e., flowering trees and plants) generally do not cause allergies when compared to the “ugly” trees (i.e., non-flowering trees and plants). The reason this is true is that “pretty” trees (e.g., cherry, dogwood, magnolia, eastern redbud) have pollen that is heavy in weight and thus are not dispersed into the air as much as the lighter pollens found with “ugly” trees (e.g., birch, maple, oak). If the pollen is not in the air, individuals do not become exposed and thus sensitized to it and allergies to the pollen do not occur. “Pretty” trees consequently need to rely on bees to cross-pollinate since the wind is unable to efficiently disperse their heavy pollen. They have flowers in order to attract bees. Bees will land on the flowers and the pollen sticks to their abdomens. The bees then fly to another tree and land on a new flower and simultaneously cross-pollinates this flower. On the other hand, “ugly” trees have adapted to having no flowers by having pollen that is light in weight. They depend on the wind to cross-pollinate. It is through exposure to the light-weight pollen in the air that sensitive individuals will develop their allergies.

The most common symptoms of pollen allergies may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy eyes, watery eyes, redness of the eyes, itchy throat, sinus pressure, sinus headaches, snoring, fatigue, wheezing, chest tightness, coughing, and/or shortness of breath. It is not uncommon for allergic individuals to develop sinus infections as a result of their allergies.

The diagnosis of pollen allergies is performed by a board certified allergist such as the ones at Black & Kletz Allergy. The diagnosis begins with a comprehensive history and physical examination. Allergy testing by skin testing or blood testing is usually done in order to ascertain the cause of the allergy. Depending on the patient, pulmonary function tests may be performed if symptoms of asthma are present.

The treatment of pollen allergies depends on the type and severity of symptoms. Treatment usually begins with prevention (i.e., avoiding the offending allergen, if possible). A wide array of medications is available to treat pollen allergies. They include antihistamines, decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, nasal decongestants, eye drops, inhaled bronchodilators, inhaled corticosteroids, inhaled anticholinergics, and biologicals. Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are very effective as they work in 80-85% of individuals with allergic rhinitis, allergic conjunctivitis, and asthma. Most individuals are on allergy shots for 3-5 years. Note: Allergy shots are even more effective for insect sting venom allergies (e.g., bees, wasps, yellow jackets, hornets).

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating pollen-induced allergies such as allergic rhinitis, allergic conjunctivitis, and asthma for many years in both adults and children.  Black & Kletz Allergy has 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area. Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of the offices have on-site parking.  In addition, the Washington, DC and McLean, VA locations are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call us or alternatively you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy specialists of Black & Kletz Allergy are always ready to help you with your allergy, asthma, sinus, dermatological, and immunological needs.  Black & Kletz is dedicated to providing outstanding allergy care to you and your family as we have been doing in the Washington, DC metropolitan area for more than 50 years.

Rhinitis – Is It Due to Allergies or Something Else?

Rhinitis is a term that means inflammation of the mucus membranes of inside the nose. It is a very common condition. Rhinitis can either be acute or chronic. Acute rhinitis is inflammation of the mucus membranes of the inner nose that lasts up to 4 weeks in duration. It is not uncommon for acute rhinitis to last a few days as in the case of the common cold. Chronic rhinitis, on the other hand, is inflammation that lasts more than 4 weeks in duration. The symptoms of rhinitis may include runny nose, nasal congestion, post-nasal drip, and/or sneezing. Rhinitis can be classified into allergic rhinitis and nonallergic rhinitis. For the paragraph below, nonallergic rhinitis is further divided into rhinitis caused by infections and by other nonallergic stimuli.

The inflammation of rhinitis may be caused by any of the following:

  • Allergies – Allergic rhinitis due to dust mites, molds, pollens (e.g., trees, grasses, weeds), pets, cockroaches, etc.
  • Infections – Viral, bacterial, or parasitic
  • Other Nonallergic Stimuli
    • Foods – Gustatory rhinitis due to spicy foods, alcohol, or other foods
    • Hormonal imbalance – Thyroid disease, pregnancy, menstruation, etc.
    • Medications – Rhinitis medicamentosa due to oxymetazoline and phenylephrine nasal sprays; other medication-induced rhinitis due to nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen, meloxicam), beta blockers (e.g. metoprolol, propranolol, carvedilol), alpha blockers (e.g., doxazosin, terazosin, tamsulosin), diuretics, antidepressants (e.g., chlorpromazine, risperidone, amitriptyline), aspirin, oral contraceptives, calcium channel blockers (e.g., amlodipine, nifedipine, verapamil), erectile dysfunction medications (i.e., phosphodiesterase 5 inhibitors such as sildenafil, vardenafil, and tadalafil)
    • Emotional issues – Stress
    • Asthma – There is a higher association of rhinitis with asthma
    • Exercise – May act as a trigger of rhinitis
    • Airborne Irritants – Air pollution, strong scents, cigarette smoke, smog, etc.
    • Pregnancy – Probably as a result of hormonal changes
    • Gastroesophageal Reflux Disease (GERD)
    • Decreased Blood Flow – Atrophic rhinitis in mostly elderly individuals
    • Environmental Changes – Change in barometric pressure, temperature, and/or humidity
    • Structural Defects – Deviated septum, enlarged nasal turbinates, tumors, enlarged adenoids, nasal polys, etc.
    • Inflammatory/Immunologic Disorders – Sarcoidosis, granulomatous infections, Wegener granulomatosis, Churg-Strauss, amyloidosis, midline granuloma, relapsing polychondritis, etc.
    • Cerebrospinal Fluid Leak – Cerebrospinal fluid rhinorrhea is caused by the leaking of brain fluid out of the nose. Some of the causes may include head trauma, tumor, congenital birth defect, and increased intracranial pressure.
    • Nonallergic Rhinitis with Eosinophilia (NARES) – A syndrome that has symptoms consistent with allergic rhinitis but without evidence of atopy as allergy skin testing is negative. In addition, nasal cytology demonstrates more than 20% eosinophils. Anosmia (i.e., lack of the ability to smell) is a prominent feature which is usually not seen with allergic rhinitis.
    • Obstructive Sleep Apnea – Allergic rhinitis increases the risk of developing obstructive sleep apnea.

Some complications of rhinitis may include sinusitis, middle ear infections, nasal polyps, and/or an interruption of daily activities at home, school, and work due to being less productive since rhinitis is known to decrease the quality of life. After the “common cold,” rhinitis is the second most common cause of missed school or work days.

Prevention of the offending triggers of rhinitis will help to mitigate one’s symptoms. Although it is not always possible to avoid the triggers of rhinitis, one can do their best to try to evade them. It is important not to use over-the-counter nasal decongestants as they just cause a temporary improvement in nasal symptoms. Continued use of nasal decongestants [e.g., Afrin (oxymetazoline)] may cause “rebound” nasal congestion. This “rebound” nasal congestion occurs when an individual suddenly discontinues the use of nasal spray. The nasal congestion that occurs as a result of stopping the medication tends to feel worse than the initial nasal congestion before the nasal decongestion was used. The instructions on oxymetazoline nasal spray clearly states that it should not be used for more than 3 days. This paradoxical condition is called rhinitis medicamentosa. In addition to avoiding triggers and avoiding nasal decongestants, vaccines for viruses (e.g., influenza, measles, rubella) and bacteria (e.g., diphtheria, Bordetella pertussis, Streptococcus pneumoniae, Haemophilus influenzae) may help reduce the likelihood of infectious agents that will cause rhinitis.

The diagnosis of rhinitis is best made by a board certified allergist such as the ones at Black & Kletz Allergy. A comprehensive history and physical examination are important to diagnosing rhinitis. Allergy testing via skin tests and/or blood tests are also typically performed. A CT scan of the sinuses may be necessary to diagnose chronic sinusitis in some individuals who do not improve with standard treatments.

The treatment of rhinitis largely depends on the cause of the rhinitis. It is important for the allergist to determine the cause as treatment is usually tailored to the cause. Some treatment modalities for rhinitis may include saline irrigation, nasal corticosteroids, oral antihistamines, nasal antihistamines, oral decongestants, nasal anticholinergics, and leukotriene antagonists. Allergy shots (i.e., allergy immunotherapy, allergy desensitization, allergy hyposensitization) are a very effective therapy for the treatment of allergic rhinitis and asthma. Allergy shots have been used for more than 100 years in the U.S. and are effective in 80-85% of individuals who take them. They are usually taken for 3-5 years.

The board certified allergists at Black & Kletz Allergy have expertise in diagnosing and treating rhinitis, as well as all other types of allergic conditions and asthma. We treat both adult and pediatric patients and have been doing so in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from rhinitis, we are here to help alleviate or hopefully end your bothersome symptoms so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

Pregnancy Rash – Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is the most common skin disease of pregnancy. This polymorphic (i.e., different shapes and forms) skin eruption occurs in approximately 0.5% or 1 in 200 pregnancies. The cause of this condition is generally unknown.

Individuals with this condition exhibit a very itchy (i.e., pruritus) rash that usually begins in the last trimester, but can began earlier in the pregnancy. The rash usually begins in stretch marks on the abdomen, but spares the area around the umbilicus (i.e., belly button) and within a few days begins to spread to the legs, feet, arms, neck, and/or chest. It tends to spare the face, palms, and soles. Skin distension (i.e., stretching) is thought to be a possible trigger for this condition.

It is more common to occur in a first pregnancy than in subsequent pregnancies. Likewise, it is more common to occur in pregnant women who are carrying a male fetus, pregnant with multiple births (e.g., triplets more than twins), and/or who have gained excessive weight during their pregnancy.

Initially the rash presents as red, hive-like (i.e., urticarial) bumps (i.e., papules) and later may develop into larger red, swollen patches (i.e., plaques). In lighter-skinned individuals, the rash may appear to be surrounded by a thin, white halo.

 

CAUSES:

The exact cause of pruritic urticarial papules and plaques of pregnancy is not exactly known.

One theory hypothesizes that when the skin of a pregnant woman is stressed or stretched, the connective tissues can be damaged. This damage causes inflammation which can result in a red, swollen rash.

Another theory of the cause of PUPPP is that it is due to an immune response to fetal cells. During pregnancy, some cells from the fetus migrate throughout the mother’s body. It is these fetal cells that can trigger an immune response in the mother, which in turn causes the rash.

DIAGNOSIS:

The diagnosis is usually established by the history and appearance of the rash and its association with intense itching. There are no specific diagnostic tests and skin biopsy usually reveals non-specific findings. A skin biopsy is sometimes done in order to differentiate the rash from similar rashes caused by herpes gestationis, prurigo of pregnancy, and atopic dermatitis (i.e., eczema).

Rarely, the baby can be born with a mild form of the rash of pruritic urticarial papules and plaques of pregnancy, but this rash soon fades. It should be noted that PUPPP does not cause any other problem for the baby.

TREATMENT:

Pruritic urticarial papules and plaques of pregnancy continues until delivery then usually resolves within 1–3 weeks. Rarely, it may persist for longer. In some cases, this relates to retained placental products.

There is no curative treatment for PUPPP, apart from delivery. Symptoms can be controlled using the following:
⦁ Emollients (i.e., moisturizers) applied liberally and frequently as required
⦁ Topical steroids applied thinly once or twice daily to the red itchy patches
⦁ A short course of systemic steroids (e.g., prednisone) in severe PUPPP
⦁ Antihistamine tablets appear safe in late pregnancy, although they may make the baby drowsy upon delivery

It is very uncommon for pruritic urticarial papules and plaques of pregnancy to recur. If it recurs, it is likely to be a milder case. It should also be noted that there is no long-term risk for either the mother or unborn child despite frequently severe itching.

The board certified allergists at Black and Kletz Allergy have over 5 decades of experience in diagnosing and treating all types of allergic skin conditions.  We treat both pediatric and adult patients, and of course pregnant patients.  Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the Washington, DC, Maryland, and Northern Virginia metropolitan area for many years and we look forward to providing you with the utmost state-of-the-art allergy care in a warm and pleasant environment.

Asthma – What You Need to Know

Asthma is a fairly common disease in the U.S. Asthma is a chronic disease that causes inflammation of the bronchial tubes (i.e., breathing tubes) resulting is symptoms that may include chest tightness, wheezing, shortness of breath, and/or coughing. According to the Centers for Disease Control and Prevention (CDC), approximately 25 million people in the U.S. have asthma which equates to 1 in every 13 individuals or 7.7% of the population. Note that 7.5% of children in the U.S. have asthma. Asthma is more common in adult women (9.1%) compared with adult men (6.2%), however, in children, boys are affected more than girls (8.3% vs. 6.7% respectively). Regarding race and ethnicity, asthma prevalence in the U.S. decreases in the following order: Native American (10.5%) > African American (9.6%) > White (8.2%) > Hispanic (6.0%) > Asian (4.7%). The fatality rate per million in individuals with asthma in the U.S. decreases in the following order: African American (21.8%) > Native American (11.3%) > White (9.5%) > Asian or Pacific Islander (8.5%) > Hispanic (6.3%). From the above statistics, one can see that the fatality rate is not based on the prevalence. It should also be noted that the asthma prevalence has been increasing over the last few decades even though there are more treatment modalities available now than ever before.

Asthma is characterized by the class it is designated. Asthma is categorized as follows: mild intermittent, mild persistent, moderate persistent, and severe persistent. The classification depends on how often one experiences symptoms, how often symptoms are causing nighttime awakenings, if the symptoms are disrupting normal activities, and how often one uses their rescue inhalers. In addition to these categories, asthma can also be classified as exercise-induced asthma, cough-variant asthma, nocturnal asthma, occupational asthma, asthma with associated COPD (i.e., chronic obstructive pulmonary disease), cardiac asthma (i.e., not actually asthma but congestive heart failure and other heart disease that masquerades as asthma since the symptoms are very similar to asthma), allergic asthma (i.e., an older classification which is not used anymore), nonallergic asthma (i.e., an older classification which is not used anymore).

In addition to asthma, there are several conditions that mimic asthma in its presentation and some of them are as follows: cardiac asthma (mentioned above), vocal cord dysfunction and/or paralysis, GERD (i.e., gastroesophageal reflux disease), sinusitis, upper respiratory tract infections (i.e., URI’s), COPD (e.g., chronic bronchitis, emphysema), bronchiectasis, cystic fibrosis, thyroid gland tumors, lung or chest tumors, pulmonary embolism, anxiety, pneumonia, and food aspiration.

The diagnosis of asthma requires a comprehensive history and physical examination in conjunction with a pulmonary function test. Additional measures may be needed depending on the history and physical examination and may include allergy skin or blood tests, chest X-ray, other types of bloodwork, sweat chloride test, CT scans, and others. The treatment of asthma is catered to each specific patient based on the frequency and severity of their symptoms. A host of medications may be utilized and range from just a rescue inhaler (i.e., short acting beta 2 inhalers) for intermittent asthma to biologicals (i.e., Xolair, Fasenra, Nucala) for more moderate-to-severe cases. Other therapeutics utilized to treat asthma may include inhaled corticosteroids, long acting beta 2 inhalers, combination inhalers of corticosteroids and long acting beta 2 inhalers, leukotriene antagonists (e.g., Singulair, Accolate, Zyflo), methylxanthines (e.g., theophylline), and oral corticosteroids. The prevention of asthma symptoms can usually be achieved through allergy immunotherapy (i.e., allergy shots, allergy injections, allergy hyposensitization, allergy desensitization) as well as to attempt to avoid triggers that can exacerbate one’s asthma.

The board certified allergists at Black & Kletz Allergy have had more than 50 years of experience in diagnosing and treating asthma in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We treat both children and adults and have office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at all of our office locations. The Washington, DC and McLean, VA offices are also Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call one of our offices or alternatively you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy are happy to help you diagnose and treat your asthma as well as any other allergy-related or immunological condition that you might have.

What Can Be Done for Hives?

Hives (i.e., urticaria) are a fairly common occurrence which is usually very annoying to the individual who suffers from them. They are often called “welts” by the general public and “wheals” by allergists. Hives are itchy, red blotches on the skin that are usually raised. Some affected individuals may experience a burning sensation while others notice a stinging sensation. Hives, in some instances, may be flat and not raised. The size of an individual hive may range from very small to rather large. They can also coalesce with other hives to create giant “plaques” of hives. Hives can be various shapes and are usually not symmetrical. They often look like mosquito bites but without the actual bite. They can occur anywhere externally on the body (e.g., face, neck, extremities, back, abdomen) or be located internally (e.g., throat, intestines). When they are internal, symptoms such as swelling of the throat, abdominal pain, or diarrhea may ensue. When hives occur on the lips, tongue, eyes, or ears, it is not uncommon for the individual to notice only swelling of these body parts. This swelling is termed angioedema. Angioedema is essentially a hive that is in the deeper tissue layers. As a result, the lesion appears as a swelling, opposed to a hive. Either way, both are bothersome to the person who is afflicted with either or both of them.

Hives are basically grouped into two main categories, although there are actually more than two. The first category is referred to as acute urticaria. Acute urticaria is a condition where the hives occur for 6 weeks or less. If hives linger on and persist for more than 6 weeks, they are called chronic urticaria. Some cases of hives may last for months and even years in a small percentage of patients. Approximately 25% of the general population in the U.S. develop hives at some point in their lives. Each episode of hives generally last less than 24 hours in duration but may last for days or weeks in certain circumstances.

The diagnosis of hives begins with a comprehensive history and physical examination by a board certified allergist such as the allergists at Black & Kletz Allergy. The workup for hives will vary depending on what was discovered in the history and physical examination in conjunction with how long the hives have been present. For many individuals, a medication allergy is to blame. For others, a food may be the culprit. For those who present with chronic urticarial (i.e., hives that have persisted for more than 6 weeks), bloodwork is generally needed in order to rule out a multitude of diseases and conditions that are known to cause hives. Despite all of the bloodwork done on a patient with chronic urticaria, approximately 95% of these individuals will have normal test results. If the workup is completely negative, the term idiopathic chronic urticaria is used as a diagnosis. This basically is a fancy way of saying that no identifiable cause was discovered to cause the hives of that individual. Some of the conditions that are known to be associated with chronic urticaria include thyroid disorders, autoimmune disorders (e.g., systemic lupus erythematosus, Sjögren’s syndrome, rheumatoid arthritis), hepatitis B, other infections, cancers, complement disorders, and physical elements (e.g., heat, cold, pressure, exercise, vibration), to name a few.

The treatment of hives can range from avoidance to using medications. Antihistamines are usually the first line of defense of most cases of hives. Beta-2 agonists such as Pepcid (famotidine) are often utilized to enhance the effect of the antihistamine when an antihistamine alone is not enough to prevent hives. Leukotriene antagonists [e.g. Singulair (montelukast)] are often added to the regimen is difficult-to-treat hives. In recalcitrant disease, oral corticosteroids may be used to bring the hives under control for a short time since the use of long-term steroids is not ideal because of the risks and many side effects that may develop. Xolair (omalizumab) injections are used for idiopathic chronic urticaria in patients where other therapy is unsuccessful. Xolair injections Xolair are very effective in the management of chronic hives.

The board certified allergists at Black & Kletz Allergy have had more than 50 years of experience in diagnosing and treating asthma in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We treat both children and adults and have office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at all of our office locations. The Washington, DC and McLean, VA offices are also Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call one of our offices or alternatively you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy are happy to help you diagnose and treat your asthma as well as any other allergy-related or immunological condition that you might have.

New Treatments for Chronic Cough

Why do we cough? Coughing is a natural defense mechanism to expel excessive mucus, microbes, and irritant substances from our airways which acts to protect our lungs from the potential damage caused by them. Coughing, however, can also be a bothersome symptom and is one of the most common reasons why patients consult their doctors.
The sound of a cough is produced after forcible expiration (i.e., breathing out) against a closed glottis (i.e., voice box) as the air flows out when the glottis suddenly opens. A cough is defined as “acute” when it persists for less than 3 weeks, subacute when the duration is between 3 and 8 weeks, and chronic if it continues to be present for longer than 8 weeks.

Approximately 12% of U.S. population experiences a chronic cough at some point in their lives. It is more common in women than in men and generally peaks between the 5th and 6th decades of life. A chronic cough can be very bothersome which may negatively impact one’s quality of life. A severe cough may lead to vomiting, broken ribs, bleeding, incontinence, sleep disturbance, social distress, and/or depression.

Common causes of a chronic cough:

  • Asthma
  • Medications such as ACE (angiotensin converting enzyme) inhibitors and some diabetes mellitus medications
  • Upper airway cough syndrome (e.g., post-nasal drip)
  • GERD (i.e., gastroesophageal reflux disease) – Also known as acid reflux.
  • Environmental irritants
  • Tobacco use
  • Eosinophilic bronchitis
  • Tumors

Initial evaluation begins with obtaining a comprehensive history, which includes:

  • Duration of the condition
  • Characteristics of the cough
  • Triggers for the cough (e.g., environmental, dietary)
  • Medications taken (e.g., over-the-counter, herbal, prescriptions)

“Red flags” in the history suggesting a serious illness may include:

  • Coughing up blood (i.e., hemoptysis)
  • Chronic smoking with a new cough
  • Difficulty in breathing
  • Persistent hoarseness
  • Difficulty in swallowing
  • Vomiting
  • Fever
  • Weight less
  • Swollen hands and/or feet
  • Abnormal examination
  • Abnormal chest X-ray

Treatments:

  • Upper airway cough syndrome: Post-nasal drip is usually a result of inflammation of the nose and throat either from allergens or irritants. This condition frequently responds to either antihistamines or nasal sprays or the combination of both antihistamines and nasal sprays.
  • Asthma: Cough may be the only symptom of asthma (e.g., cough variant asthma) and can be controlled with inhaled corticosteroids and/or oral leukotriene modifiers (e.g., Singulair, Accolate, Zyflo)
  • Non-asthmatic eosinophilic bronchitis: A trial of oral corticosteroids such as prednisone for 1 to 2 weeks is usually helpful in relieving the cough.
  • GERD: Approximately 10% of the population report frequent “heartburn” from acid reflux. Lifestyle modifications and medications to reduce acid secretion (e.g., Prilosec, Nexium, Prevacid) for 4 to 8 weeks will usually result in a substantial improvement of the cough.
  • Speech evaluation and speech therapy may be useful in certain situations.

If the cough does not respond to the above treatments at the correct dosage for a sufficiently long duration, it is termed a chronic refractory cough.
New medications which target the neurological pathways and block the cough reflex are actively being investigated and are as follows:

  • Sodium channel blockers: Similar to local anesthetics such as lidocaine.
  • Neurokin-1 (NK-1) receptor antagonists (e.g., Orvepitant, Aprepitant)
  • Purinergic receptor antagonists: Gefapixant is the name of one of the most promising drugs currently in development which exhibited significant efficacy in controlling a refractory cough. It is undergoing phase 3 clinical trials at this time. It is given by mouth twice a day. Side effects reported so far include taste disturbances.

The board certified allergists at Black & Kletz Allergy have been treating coughs in adults and children in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  Black & Kletz Allergy provides on-site parking at all of their convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA locations are Metro accessible and there is a complementary shuttle that runs between our McLean office and the Spring Hill metro station on the silver line.  Please call any one of our offices to schedule an appointment for your allergy, asthma, or immunology needs. Alternatively, please click Request an Appointment and we will respond within 24 hours on the next business day.