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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.

Spring Allergies

Historically, March is the month that many trees begin pollinating in the Washington, DC metropolitan area. This year, trees have begun to pollinate in February, as the temperatures in the metro area have been higher than normal for a typical Winter. We will begin to see tree pollen marked by a yellowish coating on our automobiles soon. For many allergic individuals, this represents a tumultuous time for those who are sensitized to tree pollen. Birch, cedar, ash, oak, elm, cottonwood, hickory, and maple are the predominant trees producing pollen in our area during the Spring. This time of the year is the reproductive season for the trees. As a result, the tree pollen grains are released into the atmosphere in order to fertilize the ovules of other trees. This process is called pollination. Pollen is produced and then dispersed by the wind throughout the day, however, the tree pollen counts are highest during the morning hours.

Pollen grains are not harmful or noxious when inhaled, unless an individual’s immune system mistakes the pollen as potentially hazardous and subsequently mounts a defensive attack on them. This process is called allergic sensitization and results in the release of certain chemical mediators such as histamine and leukotrienes, which are mediators of the annoying symptoms of allergic rhinitis (i.e., hay fever) and allergic conjunctivitis (i.e., eye allergies).

Over the past decade, several scientists have noticed a steady increase in the tree pollen counts across the country. Many scientific researchers believe, although controversial, that climate change is contributing in part to this trend of increasing pollen counts. Carbon dioxide is the primary gas needed for the growth and development of trees, (along with sunlight, water, and nutrients), and increasing levels of carbon dioxide are being documented every year. These changes in the climate may impact the pollen season of not only trees, but in addition, may affect the pollination of both grasses and weeds. Climate change may cause an increase in the amount of pollen produced as well as cause an extension of the duration of the pollen seasons.

What are the symptoms of Spring allergies?
The most common symptoms of Spring allergies may include sneezing, clear runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy eyes, watery eyes, red eyes, puffy eyes, cough, itchy ears, clogged ears, sinus headaches, sinus congestion, sinus pressure, snoring, and/or fatigue. In asthmatics, the pollen can also trigger chest tightness, coughing, wheezing, and/or shortness of breath.

How are Spring allergies diagnosed?
Spring allergies are diagnosed by board certified allergists such as the allergy specialists at Black & Kletz Allergy who first take a comprehensive history and perform a detailed physical examination. Allergy testing is often done either by skin testing or occasionally via blood testing in order to identify the offending allergen. Once the allergens are known, preventive measures are recommended in order to reduce exposure to the allergens.
Some preventive measures to reduce exposure to pollen and to minimize symptoms may include the following:

Track the local pollen counts on the homepage on our website, www.bkallergy.com by clicking Today’s Pollen Count and avoid outdoor activities on days where the pollen count is high, especially in early morning hours.
Go outdoors shortly after it rains, as the water keeps the pollen from blowing from place to place.
Change and clothes after wearing them worn outside.
Leave shoes outdoors in order to help prevent bringing pollen into the home.
Wipe down a pet’s fur and/or wash the pet before he/she comes indoors.
Shower off the pollen from skin and hair before going to bed.
Close the windows in automobiles and at home to keep the pollen out.
Run the air conditioner in automobiles and at home.

How are Spring allergies treated?
Begin using antihistamines and nasal corticosteroid sprays early in the season. They are more effective if begun before the onset of symptoms and if taken daily throughout the season. Other common types of prescription medications may include decongestants, leukotriene antagonists, nasal antihistamines, nasal anticholinergic agents, eye drops, inhaled corticosteroids, and inhaled beta-agonists. In cases of persistent or severe symptoms, consider allergy desensitization (i.e. allergy shots, allergy immunotherapy, allergy injections, allergy hyposensitization) to the pollen, which usually provides a long-term benefit and reduces the need for medications. They are effective in 80-85% of patients. They are generally taken for 3-5 years.

The board certified allergists at Black & Kletz Allergy have 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Our 3 office locations have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. Our McLean office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line. The allergy specialists at Black & Kletz Allergy diagnose and treat both adult and pediatric patients. To schedule an appointment, please call our office directly or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy have been serving patients with hay fever, asthma, sinus disease, hives, eczema, insect sting allergies, food allergies, medication allergies, and immunological disorders for more than 50 years. If you are bothered from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.

Unusual and Uncommon Allergies

Most everyone is aware of the classic and common allergies that many individuals suffer from routinely. Allergies to dust mites, molds, pollens, pets, and/or cockroaches usually manifest themselves as symptoms of allergic rhinitis (i.e., hay fever), allergic conjunctivitis (i.e., eye allergies), and/or asthma. Food allergies are not uncommon and it commonly known that the most common food allergens are milk, egg, soy, wheat, peanuts, tree nuts, fish, and shellfish. When people think of allergies of the skin, they often think of atopic dermatitis (i.e., eczema), allergic contact dermatitis (i.e., poison ivy, poison oak, poison sumac, cosmetic allergy), and hives (i.e., urticaria). All of these allergies are relatively common but there are a number of allergies that are uncommon and/or unusual that are very interesting. It is some of these more unusual and uncommon allergies that we will explore in the following paragraphs.

Uncommon Food Allergies:

Oral Allergy Syndrome (Pollen Fruit Syndrome; Pollen/Food-Associated Syndrome): An allergic reaction in the mouth usually causing itching that occurs in certain allergic individuals that have certain pollen allergies. Classic examples include birch tree allergies and reactions to raw apples, kiwi, apricots, cherries, peaches, plums, pears, avocados, celery, and/or carrots. Ragweed allergies and reactions to melons, cucumbers, zucchini and bananas. In this disorder, the raw fruit or vegetable looks similar structurally to the pollen and the body “thinks” that the food is the pollen and an allergic reaction (e.g., itchy mouth) occurs. Interestingly, if the food is cooked and or processed, the individual can usually tolerate the food without any symptoms.

Mammalian Meat Allergy: Some individuals that are bitten by a Lone Star tick may develop a meat allergy due to the development of an antibody to a carbohydrate called galactose-alpha-1,3-galactose (i.e., alpha-gal). This carbohydrate is found on all mammalian meat (e.g., beef, pork, lamb, venison, whale). When an individual with the alpha-gal antibody eats any mammalian meat, the meat triggers the release of the chemical called histamine. It is the histamine that causes the allergic symptoms which usually appear 4-8 hours after the consumption of the meat. Symptoms may include generalized itching (i.e., pruritus), hives, and/or swelling (i.e., angioedema).

Chamomile Tea: Chamomile is related to ragweed and some ragweed-sensitive individuals may also react to chamomile tea and chamomile lotions. Symptoms can range from allergic rhinitis symptoms to anaphylactic shock, although it is rare to have such a violent reaction.

Gelatin Allergy: Some individuals are allergic to gelatin; however, this allergy is rare. Gelatin is a protein formed when connective tissue from animals is boiled. Some individuals are allergic to this protein and when exposed, they can have an allergic reaction that may also be quite severe. Gelatin may be found in chewy candies, frosted cereals, and in some vaccinations such as the flu shot.

Wine: Certain individuals are hypersensitive to sulfating agents used in processing certain foods, beverages, and drugs. Sulfur dioxide and several forms of inorganic sulfites that release sulfur dioxide when used as food ingredients are known collectively as sulfating agents. The preservative sulfite is used in the production of wine and other foods. Some individuals, especially asthmatics, are sensitive to sulfites and should avoid certain foods that may contain sulfites such as sauces, gravies, soups, wine vinegar, processed meats, dried/frozen/canned fruits and vegetables, and occasionally salad bars.

Hot Dogs and Deli Meats: Hot dogs and various deli meats are highly processed foods that contain many additives. An allergic reaction after eating these meats could be due to any of these added ingredients. It is believed however that nitrate and nitrite additives are generally the cause in most instances.

Water: Yes, individuals can be allergic to water. It is quite rare, however, there are some individuals who have a condition called aquagenic urticaria. If one has this malady, the contact with water will cause itching and hives. There is no optimum treatment for this disorder at the present time

Uncommon Non-Food Allergies:

Latex Allergy: Latex or natural rubber allergies can range from a mild irritation of the skin to a severe anaphylactic reaction. Common latex products include latex gloves, condoms, dental dams, adhesive bandages, balloons, waistbands, tires, and pacifiers, to name a few. It is interesting to note that there are similar proteins in natural rubber latex and certain foods (e.g., avocados, chestnuts, papaya, bananas, kiwis), so cross-reactivity can occur.

Sex: There are individuals that have a disorder called seminal fluid hypersensitivity whereby they are allergic to the seminal fluid of a particular person. It is generally an allergy to a specific man’s seminal fluid and not necessarily to all men. The symptoms can range from just a minor irritation on the skin, to hives, to anaphylaxis. Symptoms can be avoided with the use of condoms. Many times, in vitro fertilization is needed in order for the couple to conceive without risk to the allergic individual.

Sunlight: A small percentage of the population have a sensitivity to sunlight where they may develop hives, itchy skin, rash, nausea, and/or headache. Solar urticaria is a condition where hives form upon exposure to sunlight.

Exercise: Exercise may trigger a generalized itching, hives, swelling, asthma, and/or anaphylaxis, depending on the person. These conditions are called, exercise-induced pruritus, exercise-induced urticaria, exercise-induced angioedema, exercise-induced asthma, and exercise-induced anaphylaxis respectively. In some instances, an individual must exercise in the cold air for symptoms to occur. In others, a specific food must be eaten a few hours before exercise in order for there to be an allergic reaction. This is called food-dependent-exercise-induced urticaria. An example of this is a person who can eat celery without problems and they can exercise without problems. However, if they eat celery within 2 hours before exercise, they will develop hives. Patients with these conditions should never exercise alone and if they exercise, should always stop exercising at the first sign or symptom of their allergy.

Cold: Cold can be a trigger for some individuals to develop generalized itching, hives, swelling, asthma, and/or anaphylaxis. The names of the corresponding conditions are cold-induced pruritus, cold-induced urticaria, cold-induced angioedema, cold-induced asthma, and cold-induced anaphylaxis respectively. Similar to exercise above, these patients should avoid the cold, if possible.

Money: Individual with nickel allergy may develop allergic contact dermatitis from handling coins. Metal allergy is not that uncommon, but having reactions to holding coins is fairly uncommon. Obviously, the condition is more prevalent in individuals who handle money more often such as bank tellers and cashiers.

Scratches: Some individuals have a disorder called dermatographism where a simple scratch or pressure on the skin will cause the affected area to develop hives in a linear pattern to match the scratch. The name dermatographism means “skin writing” so it is possible to write a word on the individuals’ skin just by writing the word using a fingernail on the skin. Approximately 5 minutes later, the word is visible in a reddish and raised fashion.

There are more uncommon allergies than mentioned above, but the ones listed above give some indication of the diversity of unusual allergies. Individuals can be allergic to almost anything. It is a combination of the patient’s awareness of their symptoms and situation in conjunction with the allergist’s knowledge that is needed in order to diagnose and then prevent and/or treat such unusual allergies.

The board certified allergists at Black & Kletz Allergy have 3 office locations in the Washington, Northern Virginia, and Maryland metropolitan area. The allergy doctors at Black & Kletz Allergy treat both pediatric and adult patients. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. The McLean office has 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. The allergy specialists at Black & Kletz Allergy have been helping patients with hay fever, asthma, sinus disease, eczema, hives, insect sting allergies, immunological disorders, medication allergies, and food allergies for more than 50 years. If you suffer from any allergy, whether unusual or not, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.

Keratoconjunctivitis and Eye Allergies

Keratoconjunctivitis is term used to describe inflammation of the cornea and conjunctiva. Keratitis specifically is the inflammation of the cornea (i.e., the transparent dome that covers the pupil and the iris of the eye). Conjunctivitis, on the other hand, is the inflammation of the conjunctiva [i.e., the thin membrane covering the sclera (i.e., the white of the eye) as well as the lining of the inner part of the eyelids]. It is more commonly referred to as “pink eye.” Keratoconjunctivitis is one of the most common causes of red and irritated eyes as millions of individuals visit doctors for this condition every year.

Most of the cases of keratoconjunctivitis and conjunctivitis are due to allergies. Conjunctivitis due to allergies is referred to as allergic conjunctivitis. Infections are another common cause of keratoconjunctivitis and conjunctivitis with viruses accounting for most of the infections across all age groups. Of note, conjunctivitis caused by bacteria is more common in children. Other infectious agents may include a parasite or a fungus. It should also be noted that an injury to the eye can inflame the cornea or conjunctiva without a secondary infection.

Types of Keratoconjunctivitis:

Keratoconjunctivitis sicca is also commonly known as dry eye syndrome. Dry eye occurs when either the eye does not produce enough tears or when the tears evaporate too quickly. It can also occur when there is an imbalance in the tear mixture. Tears are comprised of water, fatty oils, and mucus. Individuals need the correct mixture of all three of these ingredients in order to properly nourish one’s eyes. Some of the more common causes may include allergies, contact lens use, pregnancy, meibomian gland (i.e., glands in eyelids that excrete oil into the tears) dysfunction, and certain medications such as (e.g., antihistamines, some blood pressure medications, hormone replacement therapy, antidepressants).

Epidemic keratoconjunctivitis (EKC) is an eye infection caused by a specific virus called the human adenovirus. It is also known as “adenoviral keratoconjunctivitis” or just “viral keratoconjunctivitis.”

The incubation period of EKC is long and it is very contagious. It tends to spread quite easily especially when individuals are in close quarters (e.g., dormitories, hospitals, schools, arenas, movie theaters).

There’s no specific treatment for EKC. Symptoms typically last a few weeks in duration before abating. Adenoviruses may also target the digestive, respiratory, and genitourinary tracts.

Vernal keratoconjunctivitis (VKC) is a recurrent, chronic allergic inflammation of the eyes. It generally results in small, round bumps known as giant papillae underneath the eyelid. VKC generally affects the upper eyelids more than the lower eyelids. The symptoms are much more common in the Spring with the arrival of pollen, particularly tree and/or grass pollen.

The cause is thought to be an allergic disorder, but may also involve genetic and/or immune system disorders. It is more common in tropical environments and is more common in boys than in girls.

Atopic keratoconjunctivitis (AKC) is a chronic inflammatory disease of the eye that usually affects patients with a history of atopic dermatitis (i.e., eczema). Males are affected with AKC more often than females, and it is more likely to involve the lower eyelids more than the upper eyelids.

Symptoms characteristically worsen in the Winters. Without treatment, AKC may lead to serious complications such as:

Ulceration
Keratoconus (i.e., thinning and bulging cornea)
Corneal vascularization (i.e., growth of new blood vessels into the cornea

Herpetic keratoconjunctivitis is an infection caused by the herpes simplex virus, particularly Type 1. Touching one’s eyes after touching a cold sore may transfer the virus to the eyes.

Allergic keratoconjunctivitis refers to any keratoconjunctivitis caused by an allergen. Vernal keratoconjunctivitis and atopic keratoconjunctivitis, for example, are included in this group. The allergies can be seasonal or perennial in nature.

Symptoms of Keratoconjunctivitis:

Symptoms range from mild to severe. The symptoms may vary depending on the cause. Some symptoms associated with keratoconjunctivitis may include:

Redness
Itchiness/Burning
Puffy eyelids
Discharge from the eyes (i.e., watery eyes)
Stickiness of the eyes (i.e., eyes become “glued shut”)
Light sensitivity (i.e., photophobia)
Dryness
“Foreign body” sensation in the eyes
Blurry of vision (usually mild)

Diagnosis of Keratoconjunctivitis:

The diagnosis can be made based on the medical history, symptoms, and visual inspection of the eyes. Depending on the initial findings, a physician may also want to examine:

Visual acuity
Under the eyelids
Ocular pressure
Pupillary reactions
Discharge of the eyes
Corneal sensation

In some cases, one may need to be tested for:

Allergens
Viruses
Autoimmune disorders
Genetic conditions

Treatment of Keratoconjunctivitis:

Treating the symptoms:

One may need a combination of therapies which may include:

Topical antihistamines or mast cell stabilizers
Preservative-free lubricating gels and ointments
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Topical corticosteroids

In cases of severe keratoconjunctivitis sicca, punctal plugs may be inserted to reduce the drainage of the tears into the nose.

Treating the underlying condition(s):

Some viral infections, such as herpes, may require treatment with topical or oral antiviral medications. Any underlying autoimmune or genetic conditions may also need specific treatments.

Black & Kletz Allergy has board certified allergists in 3 convenient locations in the greater Washington, DC, Northern Virginia, and Maryland metropolitan area. The allergists are trained and very familiar with allergic eye disorders such as mentioned above. The allergy specialists at Black & Kletz Allergy diagnose and treat both adults and children. We offer on-site parking in our Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA locations. The Washington, DC and McLean, VA offices are Metro accessible and the McLean office has a free shuttle that runs between the McLean office and the Spring Hill metro station on the silver line. If you are experiencing what appears to be allergy symptoms associated with your eyes, please call us to schedule an appointment. Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been serving the needs of allergy and asthma sufferers in the Washington, DC metro area for more than 5 decades.

Eczema Exacerbations

What are some of the causes?

As we enter into the season of colder days and nights in the Washington, DC metropolitan area, we are exposed to colder and drier air. The cold and dry air in conjunction with lower humidity levels predispose individuals to flare-ups of eczematous skin conditions.

Layers of clothing during outdoor activities and returning to overheated homes can trigger a cycle of sweating, itching, scratching, and irritation. Dry heat from our furnaces will evaporate the normal protective oils of one’s skin which may lead to cracking of the skin.

The smoke emitted by indoor fireplaces and wood burning stoves in combination with exposure to dust and dust mites may cause exacerbations of allergies, eczema, and asthma in individuals predisposed to these conditions. Parched air can dry up the normal moisture in the mucus membranes leading to nose bleeds as well as a burning sensation in the eyes.

The pile of wet leaves in people’s yards create a breeding ground for the molds to grow and their spores may trigger allergic rhinitis (i.e., hay fever), asthma, and eczema (i.e., atopic dermatitis) in sensitized individuals. The wool in one’s sweaters can irritate sensitive skin and cause itching (i.e., pruritus) and rashes.

Other common triggers of eczema may include hot water, smoke, sweat, extreme temperatures, perfumes, colognes, cleaning solutions, scented laundry detergent, scented candles, scented soaps, scented shampoos, scented dryer sheets, fabric softeners, pets, molds, pollens, skin infections, stress, and certain foods in people with known food sensitivities.

What can be done in order to improve the situation?

Thorough and regular moisturizing of the skin with emollients (e.g., creams, ointments, lotions, gels) is the best protection against flare- ups of individuals with eczema. Thick oil-based creams and/or ointments generally help protect the skin from excessive dryness better than water-based lotions. “Soak and seal” methods are efficacious in helping prevent the loss of moisture from the skin.

Direct exposures to sources of dry heat (e.g., radiant warmers) should be avoided. If the HVAC system does not have a central humidifier, an ultrasonic water vaporizer in the bedrooms, especially during nights, will reduce excessive dryness of the mucus membranes and the skin.

Long, hot showers can strip the skin of its natural oils. Shorter, lukewarm showers or baths are skin-friendly. Milder soaps, detergents, and shampoos without fragrances are kinder to the skin.

Woolen and synthetic clothes can irritate the skin and cause itching when they are in direct contact with skin. Natural fabrics such as cotton and cashmere are less likely to cause flare-ups of itching and rashes while in direct contact with skin.

In spite of above measures, if eczema does flare-up, one may need to use medications in order to control eczema. Below are a list of several medications used to treat eczema:

1.) In order to manage eczema, it is very common to use topical anti-inflammatory medications (e.g., topical corticosteroids) for a short period of time.

2.) The itching usually responds well to first generation antihistamine medications.

3.) Second generation antihistamines may also help and have the advantage of being generally non-sedating.

4.) Eucrisa (crisaborole) ointment 2% is a nonsteroidal cream that is quite efficacious in the treatment of eczema and has very few side effects. The most common side effect is a mild burning or stinging sensation of the skin where the ointment is applied. Eucrisa ointment 2% is indicated in the treatment of eczema in children ages 2 years of age and older as well as in adults.

5.) Topical immunosuppresants are commonly used in both children and adults. The two most common medications in this class include Protopic (tacrolimus) ointment and Elidel (pimecrolimus) ointment. They are both fairly effective and are steroid-free. Protopic can be used in children 2 years of age and older as well as in adults. Elidel is approved for children 3 months of age and older as well as for adults.

6.) Rarely, a short course of oral corticosteroids may be necessary during severe exacerbations of eczema, although the use of oral corticosteroids is generally avoided due to the potential side effects that corticosteroids can produce.

7.) If all else fails, there is a class of medications called “biologicals” that may be utilized and has been very effective in the treatment of eczema. Dupixent (dupilumab) is currently the only biological that is FDA-approved to treat moderate-to severe-eczema. It is currently approved for adolescents (12 years of age and above) as well as for adults. Of note, Dupixent also is approved for the treatment of asthma in patients 12 years of age and older, as well as in adults with chronic rhinosinusitis with nasal polyps (CRSwNP).

The board certified allergy specialists at Black & Kletz Allergy have expertise in diagnosing and treating eczema as well as other skin conditions [i.e., hives (urticaria), contact dermatitis, poison ivy]. We are board certified to treat both pediatric and adult patients and have been doing so in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than a half a century. 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 directly or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from eczema or other skin-related disorder, we are here to help alleviate or hopefully end these unwanted symptoms that have been so bothersome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a friendly and professional environment.

Cat, Dog, and Other Pet Allergies

Twenty percent of the U.S population have cat allergies and 10% of the population have dog allergies. In the U.S., the most common pet are dogs, which are followed by cats as the second most common pet. Approximately 70% of homes having at least one pet. This is a higher percentage of homes with pets than in the past as more and more families are acquiring pets. In addition to cats and dogs, some other common pets include birds (e.g., parakeets, parrots), fish, rabbits, rodents (e.g., guinea pigs, hamsters, gerbils, chinchillas, rats, mice) reptiles (e.g., snakes, lizards, turtles, geckos), hermit crabs, ferrets, horses, and spiders. Horses normally do not live in people’s homes, but they may be rather allergenic. In recent years, there is a fad of owning miniature horses which in some cases do live in their owner’s house. This is probably not a good idea in general, but for those who are allergic to horses, it is especially unwise.

Allergies to pets are in fact really an allergy to the specific proteins that are produced by a particular pet. In dogs, the major protein responsible for allergies to dogs is called “Can f 1.” This protein produced by dogs is most commonly found in the dog’s dander, saliva, and urine. In cats, the major proteins associated with allergies are known as “Fel d 1” and “Fel d 4.” These two proteins are responsible for most of the suffering in individuals with cat allergies. Similarly, most of the proteins that cause allergies in cats are concentrated in the sebaceous glands in the skin (i.e., dander), the saliva, and the urine. Unlike dogs, cat dander tends to “stick” to things such as walls, carpeting, clothing, bedding, etc. and is commonly transported from the home to home or home to work environments. If the Fel d 1 protein is measured on a cat owner’s clothing, bedding, or upholstered furniture at work, it is likely that the protein will be found. In addition, it may take months for these proteins to dissipate and become undetectable, despite a thorough cleaning of the home, due the stick-to-itiveness of cat dander. Note that since the protein is also found in urine, cat litter boxes are a rich source of these proteins and allergic individuals should avoid exposure to litter boxes. In dogs, fortunately the protein Can f 1 is not as “sticky” as the cat proteins, but still can adhere to walls, clothing, carpeting, bedding, etc. Interestingly, there is an increased incidence of horse allergy in some individuals that have cat and/or dog allergies due to a common protein that is shared between all three animals. In rodents, in addition to the allergenic protein being present in the urine, dander, and saliva, certain rodents such as mice contain allergenic proteins in their mouse droppings.

In addition to pet allergies, there are additional potential medical hazards to consider when owning certain pets. Mice and rats carry many diseases such as the bubonic plague, Hantavirus pulmonary syndrome (HPS), leptospirosis, tularemia, rat bite fever (RBF), lymphocytic choriomeningitis, salmonellosis, and Lassa fever. Exposure to birds can cause infections and diseases such as psittacosis, salmonellosis, allergic alveolitis, campylobacteriosis, avian flu, avian tuberculosis, Newcastle disease, cryptosporidiosis, and giardiasis. Reptiles can irritate one’s skin. Snakes can cause life-threatening allergic reactions from the venom that is introduced from a snake bite.

As a general rule, if an individual is allergic to a specific pet, it is advisable not to own that pet. Even though this seems pretty obvious, a majority of individuals still choose to either acquire a pet or keep an existing pet that they own despite that the pet causes unwanted allergy symptoms. This is understandable, although not advisable, since a pet becomes a member of the family and often causes great happiness.

One myth to debunk is that there are “hypoallergenic” cats and dogs to get if one is allergic to such a pet. While some pet-allergic individuals feel that they have reduced allergic symptoms around short-haired cats and/or dogs that do not shed (e.g., poodles), most scientific studies do not support this phenomena.

Obviously, the best way to combat pet allergies is to completely avoid them as mentioned above. If this is not an option, one can take some measures to reduce their exposure to the allergens that cause pet allergies. Brushing your cat or dog frequently and bathing your cat or dog often will help reduce the levels of cat and proteins. It is also advisable to prevent the pet from entering your bedroom.

The symptoms of pet allergies are similar to any other type of environmental allergy. The symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy eyes, watery eyes, redness of the eyes, puffy eyes, headaches, sinus congestion, itchy skin (i.e., pruritus), hives (i.e., urticaria), wheezing, chest tightness, coughing, and/or shortness of breath.

The treatment of pet allergies begins with avoidance of the offending pet as previously mentioned. Medications used for the management of pet allergies may include antihistamines, decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, and/or asthma inhalers. Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are very effective in treating pet allergies as they are also very efficacious in the management of dust mite, mold, and pollen allergies. They work in 80-85% of patients with allergies and have been used in the U.S. for more than 100 years.

The board certified allergists at Black & Kletz Allergy have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and treat both adults and children with pet allergies. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Black & Kletz Allergy offers on-site parking at each of their 3 office locations and the Washington, DC and McLean, VA offices are also 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 make an appointment, please call our office or you can click Request an Appointment and we will respond within 24 hours on the next business day. Black & Kletz Allergy has been serving the asthma and allergy needs of the DC metro area community for more than 50 years and we strive to offer high quality allergy and asthma care in a compassionate professional environment.

Is It the Common Cold or Allergies

As we are in the Fall season and approaching Winter, many individuals may experience a clear runny nose, post-nasal drip, sneezing, sore throat, nasal congestion, sinus pressure, headache, coughing, and/or fatigue. The question to many becomes, “Do I have a common cold or do I have Fall/Winter allergies? It is a common question to an even more common complaint. How does someone know if they are having allergies rather than the common cold? Well, if someone does not have a history of allergic rhinitis (i.e., hay fever) and they develop the above-mentioned symptoms, they probably are not experiencing allergies, unless these symptoms persist for several weeks or more. If the symptoms persist, one should consult a board certified allergist like the ones at Black & Kletz Allergy. The allergy specialist can help identify if one has allergies vs. are the symptoms a result of a lingering cold or a secondary bacterial infection (e.g., sinus infection, upper respiratory infection, pneumonia)?

The common cold is caused by a variety of viruses (e.g., rhinovirus, human coronavirus, influenza viruses, parainfluenza virus, human respiratory syncytial virus (i.e., RSV), enteroviruses other than rhinovirus, and adenoviruses). There are over 200 viruses associated with the common cold, although rhinovirus accounts for most of them. In addition, approximately 25% of colds are caused by unknown factors, which are presumed to be due to unidentifiable viruses.

Of particular importance to infants and young children is the human respiratory syncytial virus which can be fairly severe in these age groups and cause life-threatening illness in approximately 1-2% of infants and young children who get the virus. RSV may also cause serious symptoms in individuals whose immune systems are compromised, as well as in individuals with chronic heart or lung disease. Most of the time, RSV has a mild self-limited course in children and adults resulting in a cold-like illness. In fact, almost all children get RSV by the age of 2. It is only this 1-2% of infants and young children, some individuals whose immune systems are compromised, and some people with chronic heart or lung disease who go on to develop more serious symptoms which may include pneumonia (i.e., infection of the lungs), and/or bronchiolitis [i.e., inflammation of the bronchioles (small breathing tubes in the lungs]. Infants and young children with this more severe course often require intravenous antibiotics and fluids, oxygen, and sometimes need to be placed on a ventilator for a short period of time in order to help them through the respiratory distress that can accompany this virus. In addition, infants and young children that develop complications from RSV may be more likely to develop asthma in the future.

While discussing the common cold, there is a common myth to debunk regarding the development of the common cold and environmental factors. It is a myth that being out in the cold weather will cause a cold. The traditional theory is that a cold can be “caught” by the prolonged exposure to cold weather, which is probably how the disease got its name. It is much more likely that in the Fall and Winter months, when it happens to be cold outside, some of the viruses that cause the common cold occur more frequently during this time period. If these viruses are more prevalent during this time period, it stands to reason that we are exposed to more of these viruses at this time and therefore are more likely to “catch” a cold in these colder months. One other factor to consider is that once a few individuals develop colds, since it is easily transmissible, more and more people who are in close contact will then develop colds. This process becomes exponentially larger and before you know it, “almost everybody” has a cold.

What about someone who does have a history of allergies? If they develop the classic symptoms of a cold in the Fall or Winter as mentioned in the first paragraph, is it their allergies or a common cold? The same basic formula applies to them. If the symptoms are present for a week or two, one is to assume it is a common cold. However, if the symptoms last several weeks or more, then one is to assume that their allergies are playing a role. The allergens that typically cause allergic rhinitis symptoms in the Fall and Winter include dust mites, molds, pets, cockroaches, and other animals such as rodents. Allergy testing can be done via skin or blood testing. If an environmental allergy is identified, it is important to try to prevent exposure to the allergens. If that does not relieve the symptoms, then there are host of medications that can be utilized in order to help mitigate one’s allergy symptoms.

If you are suffering from a prolonged “cold” and/or are not sure if your symptoms may be due to allergies and you would like to be seen at one of Black & Kletz Allergy’s 3 convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), or Manassas, VA, please call us to make an appointment. Alternatively, you can click Request an Appointment and we will get back to you within 24 hours by the next business day. We offer parking at each office location and we are Metro accessible at our Washington, DC and McLean, VA locations. We also offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Black & Kletz Allergy provides a friendly and caring environment for you to get the top quality allergy, asthma, and immunology treatment that we have been providing the community for more than 50 years.

Mast Cell Disorders

A mast cell is a component of the immune system that is involved in the allergic response. Mast cells contain histamine and other chemical mediators. These chemicals are released into the bloodstream and then into the surrounding tissues during an allergic reaction.

In a disorder called “mastocytosis,” individuals harbor excessive numbers of mast cells in the bone marrow and other organs. It is important to note that this condition may occur both in children and adults. Individuals with mastocytosis frequently experience generalized itching, flushing, skin rashes, abdominal cramps, nausea, vomiting, diarrhea, shortness of breath, dizziness, and/or passing out (i.e., syncope).

Children are more likely to have symptoms limited to the skin whereas the majority of adults have systemic symptoms which usually involve multiple organ systems. These symptoms are similar to that of anaphylaxis. In addition, these individuals are more sensitive to various triggers such as temperature changes, certain medications, spicy foods, alcohol, bee stings, etc. Occasionally they suffer anaphylaxis spontaneously without exposure to any obvious trigger(s).

The first step in the diagnosis of this condition is a comprehensive history taking note of the specific symptoms, as well as their onset, progression, and severity. Physical examination sometimes reveals freckle-like skin lesions called “urticaria pigmentosa” which typically appear over one’s thighs, abdomen, etc. These spot-like skin lesions can lead to hives (i.e., urticaria) upon stroking the skin (also known as Darier’s sign), as well as after exposure to temperature changes (e.g., taking hot showers). This occurs as a result of the compression of mast cells.

The most helpful diagnostic laboratory test is a serum tryptase level, which is usually elevated in systemic mastocytosis. Urine examination also can be useful in detecting higher levels of metabolites of various chemical mediators of allergic reactions. Confirmation of the diagnosis usually requires a skin biopsy, bone-marrow examination, evaluation of organ functions, and occasionally genetic studies.

The usual course of treatment of this condition is avoidance of exposure to the known triggers of mast cell activation in order to prevent acute symptoms. There are several medications that are utilized in order to treat this condition. Antihistamines block the effects of histamine, which is one of the most common mediators of allergic reactions. As a result, antihistamines [e.g., Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine)] are the most commonly used medications to treat mast cell disorders. A medication called cromolyn is helpful to alleviate the gastrointestinal symptoms (i.e., abdominal cramping, nausea, vomiting) that may occur with mast cell disorders including. Aspirin, ketotifen and leukotriene modifiers [e.g., Singulair (montelukast), Accolate (zafirlukast), Zyflo (zileuton)] are also sometimes employed in the treatment of mast cell disease.

It is important to note that individuals with mast cell disorders are also at risk for fractures due to osteopenia and/or osteoporosis, and bone health needs special attention. More aggressive forms of systemic mastocytosis may require interferon, immune modulators, and/or chemotherapeutic agents.

All patients with established mast cell disorders need to have ready access to epinephrine auto-injectors (e.g., EpiPen, Auvi-Q, Adrenaclick) at all times to be used at the onset of symptoms suggestive of anaphylaxis. Once used, it is important for the individual to go to the closest emergency room. It is also important for patients with mast cell disorders to make surgeons and anesthesiologists aware of their mast cell disorder in case a surgical procedure is needed, as surgery can also be a trigger systemic symptoms.

The board certified allergists at Black & Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area and are very experienced in the diagnosis and treatment of mast cell disorders. Black & Kletz Allergy treat both adults and children and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible. There is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please call our office to make an appointment or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been serving the Washington, DC metropolitan area for more than 50 years and we pride ourselves in providing excellent allergy and asthma care in a professional and pleasant setting.