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Allergies to Tree Pollen

This year so far it has been much warmer than usual for Winter. Typically in the Washington, DC Northern Virginia, and Maryland metropolitan area, trees begin to pollinate in March. Over the last few years however, tree pollination began in February. This year, we have seen tree pollen in the air in January and February! For many individuals, tree pollen is the cause for terrible hay fever (i.e., allergic rhinitis) symptoms. In addition to hay fever, tree pollen can and does exacerbate asthma symptoms in those who are allergic to trees and also have asthma. Some of the first trees to pollinate in this area include cedar, maple, elm, alder, birch, and poplar. Later in the Spring season, the principal tree that causes difficulties for people with tree pollen allergies is the oak tree. Other trees that pollinate during this later time frame include walnut, hickory, and pine.

Interestingly, it is not the flowering trees that generally cause allergy symptoms. Most people think that in the Washington, DC area that the cherry blossoms are a major cause of allergies. In fact, cherry blossoms rarely cause allergies but they tend to bloom when other trees that cause allergies in the area pollinate. People either suffer from tree pollen allergies or see others suffer from tree pollen allergies and associate the blooming of the cherry trees with allergies. It is the “ugly” non-flowering trees that tend to cause allergy symptoms. Why, you may ask? Flowering trees (e.g., dogwood trees, cherry trees, redbud trees, magnolia trees) are pretty for a reason. The pollen from flowering trees is relatively heavy. Since the pollen is heavy, it needs the help of bees to help cross-pollinate. The abdomen of the bees land on the pollen of a flower after being attracted to the flower. The bees then land on another flower and the pollen from their abdomen cross-pollinates the other flowers. Non-flowering trees (e.g., maple trees, oak trees, birch trees, hickory trees), on the other hand, have much lighter pollen which is easily wind dispersed. They cross-pollinate by releasing their pollen into the air and having it blow to other trees. It is the result of this wind dispersal that leads to people becoming allergic to tree pollen. Individuals inhale the tree pollen and they may become sensitized to the pollen which manifests itself by the classic allergy or asthma symptoms.

What are the allergy symptoms for tree pollen allergies? The classic symptoms may include runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy roof of mouth, sneezing, sinus congestion, sinus headaches, itchy eyes, watery eyes, puffy eyes, dark circles under the eyes, and/or redness of the eyes. Other less common symptoms may include fatigue, sore throat, snoring, hoarseness, itchy skin, coughing, and/or feeling like you are in a “fog.” Tree pollen can also trigger asthma or even cause asthma symptoms in those who have never had asthma or asthma symptoms. The classic symptoms of asthma may include chest tightness, wheezing, coughing, and/or shortness of breath.

The diagnosis of tree pollen allergies begins with a comprehensive history and physical examination by a board certified allergist. Allergy testing by skin testing or blood testing is often performed in order to determine if the allergies are caused by tree pollens or other allergens such as molds, grasses, weeds, and/or dust mites. In addition to finding out what the patient is allergic to, the degree of the allergy can be ascertained by the severity of the reaction on skin testing or the degree of positivity on the blood tests.

The management of tree pollen allergies begins with avoidance or prevention, if at all possible. Individuals are encouraged to monitor the pollen counts which can be tracked on the top right of our homepage by clicking Today’s Pollen Count. In one’s car, it is advisable to keep one’s windows and sunroof closed and to turn on the air conditioner and change the air filters regularly (about once a month). Use the re-circulate feature in the car so that the air is not coming into the vehicle from the outside. Choose an automobile that has a filter in its air conditioning unit, if possible. Stay indoors wherever possible when the pollen count is high (i.e., generally on dry warmer days). It is important to realize that rain washes away pollen from the air causing pollen counts to be lower on wet cooler days. Since pollen is released in the early mornings, try to avoid exercising during this time. If a person goes outdoors, shower, wash one’s hair, and change one’s clothing before returning home in order to lessen one’s pollen exposure. Avoid drying clothes outdoors when the pollen count is elevated. Avoid yard work and mowing lawns, if possible. If one needs to do yard work, wear a filtration face mask in order to reduce exposure to the tree pollen. Avoid contact lenses which may trap pollen in one’s eyes. Wash one’s pets regularly and avoid close contact with a pet that goes outside during the pollen season since pets carry tree pollen on their coats.

The treatment of tree pollen allergies varies depending on how severe the patient’s symptoms are and if and how the trees affect and alter the desired lifestyle of the individual. Some people do not mind staying indoors in the Spring where others want to participate in outdoor activities such as golfing, jogging, baseball, etc. Oral antihistamines [Clarinex (desloratadine), Allegra (fexofenadine), Zyrtec (cetirizine), Claritin (loratadine), Xyzal (levocetirizine)] and nasal corticosteroids [Flonase (fluticasone), Nasonex (mometasone), Nasacort AQ (triamcinolone), Rhinocort Aqua (budesonide)] are usually the first medications prescribed in individuals that have tree pollen allergies. Oral decongestants [Sudafed (pseudoephedrine)] may be useful in certain patients with nasal congestion assuming there is no contraindication for using them such as hypertension. Other medications may be used and some of these may include oral leukotriene antagonists [i.e., Singulair (monteleukast)], nasal antihistamines [i.e., Patanase (olopatadine), Astelin (azalastine)], nasal anticholinergics [i.e., Atrovent (ipratropium bromide)], and various eye drops. For the treatment of asthma induced by tree pollen, inhaled corticosteroids, leukotriene antagonists, long acting beta 2 agonists, and/or short acting beta 2 agonists are utilized.

The board certified allergists at Black & Kletz Allergy have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and treat both children and adults with tree pollen 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 Washington, DC metro area community for more than 5 decades and we strive to offer the highest quality allergy and asthma care in a compassionate and specialized environment.

Respiratory Syncytial Virus (RSV)

Nearly all children get infected with respiratory syncytial virus (RSV), a highly contagious virus, by their second birthday. RSV has a seasonal predilection, usually from December to March every year. In most instances, it causes mild “cold-like” symptoms and resolves without complications in approximately 1-2 weeks.

Although most cases get better and resolve on their own, respiratory syncytial virus can sometimes lead to severe illness requiring visits to the emergency room. In some cases, hospitalization may be required. The incidence of severe illness due to RSV is especially high during the Winters in the U.S. Surging RSV infections in conjunction with the rise in flu and COVID-19 infections has been termed the “tripledemic.”

RSV is especially severe in very young children and adults over 65 years of age. Predisposing factors to severe RSV infections may also include underlying chronic lung and/or heart conditions as well as having a compromised immune system.

Respiratory syncytial virus is the most common cause of bronchiolitis (i.e., inflammation of the small airways in the lungs) in children younger than 1 year of age. RSV causes approximately 60,000 hospitalizations among children under the age of 5 annually. RSV infection is estimated to cause approximately 15,000 annual deaths in the U.S. in adults over the age of 65. Respiratory syncytial virus is the leading cause of lower respiratory tract infection in children and is a common cause of wheezing in infants and young children. Studies suggest that a severe RSV infection early in childhood is linked to development of asthma later in life.

The infection of respiratory syncytial virus spreads from person to person primarily by contact with respiratory secretions and to a lesser extent by aerosol and droplets. RSV can survive for many hours on hard surfaces such as tables and door handles and lives on soft surfaces such as tissues and hands for shorter amounts of time.

Symptoms:
The symptoms of respiratory syncytial virus usually begin 2 to 3 days after contact with the virus. The initial symptoms usually include nasal congestion and runny nose with clear mucus secretions, an itchy throat and a dry cough. Children can also experience mild fevers, poor appetite, and reduced physical activity.

For babies, thick mucus can clog up the nose and small air passages in the lungs, making it difficult for them to breathe. Narrowed bronchial tubes may also cause wheezing in addition to a severe cough. Respiratory distress requires hospitalization where supplemental oxygen and inhaled medications can be administered.

Older adults, especially those with asthma, chronic obstructive pulmonary disease (COPD), heart diseases, and/or diabetes mellitus can develop pneumonia from an RSV infection. The virus can also aggravate their underlying lung conditions requiring emergency treatment.

Diagnosis:
The diagnosis of RSV is suspected by clinical presentation and can be confirmed by laboratory tests using a nasal mucus swab. Imaging of the lungs may also be needed in order to evaluate the severity of the condition.

Treatment:
The treatment of respiratory syncytial virus is only supportive care in most instances as there is no specific medication available. For young children, nasal saline with gentle suctioning and a cool-mist humidifier may help with their breathing.

In severe cases, intravenous (IV) fluids may need to be given in order to treat dehydration. Oxygen supplementation may be needed to relieve any breathing difficulty.

A medication known as Synagis (palivizumab) is sometimes prescribed in order to minimize or prevent serious RSV disease among high-risk infants and children less than 2 years of age. This drug does not improve symptoms for children already suffering from RSV, nor does it prevent infection with RSV.

Prevention:
People infected with RSV are usually contagious for 3 to 8 days and may become contagious 1 to 2 days before they begin showing signs of the illness.

One of the most effective ways to prevent an RSV infection is to practice good hand hygiene. Frequent hand washing, covering sneezes and coughs, and avoiding direct contact with unclean surfaces are very helpful in minimizing the spread of respiratory syncytial virus.

Effective vaccines and therapeutics to prevent and treat RSV infections are in active development. The research into developing an RSV vaccine began in the 1960’s and this year (2023) RSV vaccines should be on the market. The pharmaceutical companies Pfizer, GSK, and Moderna have been working on such a vaccine and are all close to the final product. Pfizer and GSK announced promising Phase III results in 2022 and they are now both awaiting regulatory approval for the vaccine.

The board certified allergists at Black & Kletz Allergy see both adult and pediatric patients and have over 5 decades of experience in the field of allergy, asthma, and immunology. 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 greater Washington, DC metropolitan area for over 50 years and we look forward to providing you with the highest state-of-the-art allergy care in a friendly and relaxed environment.

Lipid Transfer Protein Allergy

Many fruits and vegetables contain substances called lipid transfer proteins (LPT’s). They are usually present in the skin and seeds of these foods. Lipid transfer proteins are also found in various nuts and some cereals. In the plant, the purpose of the lipid transfer proteins is to move the lipid molecules so the plants develop and maintain their internal and external structures.

Individuals can become sensitized to the lipid transfer proteins. As a result, people can have allergic reactions to them when exposed in the foods we consume. When this occurs, it is called lipid transfer protein allergy. When an individual is allergic to many foods containing lipid transfer proteins, it can be said that that person has lipid transfer protein syndrome. The most common plant foods triggering these reactions include apples, grapes, peanuts, almonds, hazelnuts, walnuts, tomatoes, and dried fruit. Other foods that may also cause symptoms may include mustard seeds, sunflower seeds, chestnut, peaches, strawberry, kiwi, orange, tangerine, pear, banana, lemon, apricot, plum, raspberry, pomegranate, cherry, barley, lettuce, cabbage, corn, mulberry, asparagus, green beans, pea, celery, wheat, durum wheat, lentils, and lupin. Other foods that are known to contain lipid transfer proteins include broccoli, onion, beetroot, parsley, eggplant, parsnip, butter beans, fennel, millet, goji berry, quinces, grapefruit, blueberry, and figs.

Lipid transfer proteins are resistant to heat and to the acid in our digestive tract. This heat and acid resistance make it so that individuals can react to even well-cooked, dried, raw, and/or canned foods. For example, if someone is sensitized to the lipid transfer proteins in a grape, that person should avoid all grape-containing foods such as grape juice, wine, and raisins.

This condition is more common in adults as well as people living in Mediterranean countries. In fact, lipid transfer protein allergy is the most frequent cause of food allergy in southern Europe. It is however interesting to note that lipid transfer protein allergy has been increasingly recognized in other parts of the world.

SYMPTOMS: The symptoms of lipid transfer protein allergy usually begin within 10 to 30 minutes after eating the offending food. The symptoms may include the following:

Itching of the mouth and/or throat
Runny nose
Nasal congestion
Sneezing
Abdominal pain
Nausea and/or vomiting
Skin rashes [i.e., hives (urticaria)]
Swelling of the lips, tongue, and/or throat (i.e., angioedema)
Wheezing
Shortness of breath
Drop in blood pressure
Dizziness/Lightheadedness
Anaphylaxis

Some contributing factors of an allergic reaction due to eating a suspected food with lipid transfer proteins may include physical exertion, alcohol consumption, and certain medications [e.g., nonsteroidal anti-inflammatory medications (NSAID’s) such as ibuprofen or naproxen]. These factors also may delay the onset of the allergic symptoms where the allergic reaction begins after the typical 10 to 30 minute window. Exercise, alcohol, and NSAID’s can also increase the severity of the allergic reaction. There are even cases where someone can eat a plant-based food that contains lipid transfer proteins and has no allergic reaction but when combined with exercise, alcohol consumption, and/or NSAID exposure, that individual may experience an allergic reaction.

DIAGNOSIS: The diagnosis of this condition involves a comprehensive history and physical examination. Special emphasis should be targeted towards getting a detailed record of the patient’s food intake. Maintaining food and symptom diaries are extremely useful in helping to establish the diagnosis. The food and symptom diaries should be supplemented with allergy skin prick testing with suspected food antigens and/or laboratory evaluation when needed.

DIFFERENTIAL DIAGNOSIS: The differential diagnosis includes other food-induced allergic reactions such as pollen-food allergy syndrome (i.e., oral allergy syndrome) and food-dependent exercise-induced urticaria/anaphylaxis (FDEIA).

TREATMENT: Once the diagnosis is confirmed, avoidance of all forms of the plant food including raw, cooked, and processed forms of the food is essential in order to minimize the risk of severe reactions.

Individuals diagnosed with lipid transfer protein allergy will also be prescribed a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) which is to be used in the case of a systemic reaction following an inadvertent exposure to the offending food. It should be stressed that if an individual uses a self-injectable epinephrine device, that person should go immediately to the closest emergency room.

The board certified allergy specialists at Black & Kletz Allergy will promptly respond to any questions you may have regarding food allergies or any other allergic or immunologic disorder. Black & Kletz Allergy has been treating food allergies for many years and we have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have been serving the Washington, DC, Northern Virginia, and Maryland metropolitan area for over 50 years and treat both pediatric and adult patients. All 3 offices at Black & Kletz Allergy offer on-site parking and 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. If you are concerned that you may have a food allergy or sensitivity or any other allergic or immunologic condition such as allergic rhinitis (i.e., hay fever), asthma, sinus disease, medication allergies, flying insect allergies, or hives (i.e., urticaria), please call us to schedule an appointment. You may also click Request an Appointment and we will respond within 24 hours by the next business day. At Black & Kletz Allergy, we strive to improve the quality of life in allergic individuals using state-of-the-art medicine in a professional and compassionate setting.

Update on Dog, Cat, and Other Pet Allergies

In the U.S., dogs are the most common pets. According to the American Veterinary Medical Association, approximately 77 million pet dogs are living in the country spread around roughly 49 million homes. This means that each dog-owning household has an average of 1.5 dogs. The most common breed of dog is the Labrador Retriever. The second most common pets are cats. According to the American Veterinary Medical Association, there are about 32 million homes in the U.S. with cats comprising of approximately 59 million cats in total. Thus, the average cat-owning home has an average of 1.8 cats. The most common breed of cat is the Ragdoll. Fish, birds (e.g., parakeets, cockatiels, parrots), reptiles (e.g., lizards, turtles, snakes, geckos), rabbits, poultry (e.g., chickens, ducks, turkeys, geese), hamsters, guinea pigs, and ferrets round off the top 10 most common pets in the U.S. in that order. Overall, about 70% of homes have at least one pet. The number of pet-owning households continues to rise compared with ownership in the past.

It should also be noted that approximately 4 million households’ own horses. Horses do not normally live in people’s homes, but they still may be rather allergenic. In recent years, it has become fashionable to own miniature horses, which in some cases, do live in their owner’s home. Living with a horse in one’s house is probably not a good idea, but for those who are allergic to horses, it is especially ill-advised.

Whereas Wyoming is the top state for pet ownership at 71%, Idaho residents have the greatest number of dogs owners at approximately 59%. In contrast, Washington, DC has the least number of pet-owning households at 39%. Of note, 46% of Vermont residents have cats in their home making it the highest in the nation.

In general, a pet allergy is caused by an allergic reaction to specific proteins that are only found on the pet in question. The classic symptoms of pet allergies may include sneezing, runny nose, nasal congestion, post-nasal drip, sinus congestion, itchy nose, itchy throat, itchy eyes, watery eyes, red eyes, chest tightness, coughing, wheezing, and/or shortness of breath. The diagnosis of a pet allergy is done by taking a comprehensive history and physical examination of the patient in combination with allergy testing (i.e., blood tests, skin tests). Once the diagnosis is made, the best approach is prevention. If an individual can avoid being exposed to the pet, no other treatment is generally needed. If they must be exposed or refuse to avoid the animal, then the treatment may consist of oral antihistamines, oral, decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, ocular antihistamines, ocular mast cell stabilizers, inhaled bronchodilators, inhaled mast cell stabilizers, and/or inhaled corticosteroids. For those who decide to live with their pet, allergy shots (allergy immunotherapy, allergy injections, allergy desensitization, allergy hyposensitization) may be indicated. Allergy injections are very effective as they work in 80-85% of individuals who take them. They have been given to patients for over 100 years and they are generally given for a period of 3-5 years.

People who are allergic to dogs usually have a reaction to the major protein called “Can f 1,” which is found on dogs. Specifically, the dander of dogs contains this major dog protein, Can f 1. It should be noted that the furry hair of a dog, which is not allergenic, may also transport other allergens (i.e., dust, pollens) to sensitive allergic individuals causing them to be exposed to more dust and pollens. The dander of a dog can stick to an individual’s clothing, bedding, carpeting, etc., but with less affinity. In addition to the dog’s dander, the Can f 1 protein is also found in a dog’s saliva and urine. It is important to note that a dog allergy will cause perennial symptoms, unlike pollen allergies which generally affects individuals in certain seasons.

Individuals with cat allergies have a very similar situation to those with dog allergies, however, the major proteins responsible for the allergic reaction are named “Fel d 1” and “Fel d 4.” These proteins are found in the sebaceous glands of the skin (i.e., dander), the saliva, and the urine of cats. The dander of a cat tends to “stick” to things such as walls, bedding, carpeting, clothes, etc. Even with professional cleaning, it still takes a long time (i.e., up to several months) for the levels of cat protein to decrease to tolerable levels. Thus, removing a cat from one’s home for a few weeks is not long enough to determine if the cat is the problem. One misconception that is quite common is that there are “hypoallergenic cats.” All cats have the capacity to induce allergic symptoms to cat-sensitive individuals. Some patients feel that they can tolerate short-haired cats better than long-haired cats, but studies do not support this theory. Brushing and bathing your cat regularly will however reduce the cat protein levels that cause allergic symptoms and of course is advisable.

Bird and rodent allergies are similar to other pet allergies except that in addition to the dander, the proteins responsible for the allergic reaction are also found in the urine, fecal, and feather particulates in birds and in the urine, saliva, and fecal droppings in rodents (e.g., hamsters, guinea pigs, mice, rats, gerbils, chinchillas). It is important to point out that in addition to allergies, both birds and rodents pose another threat to one’s health. Exposure to birds can cause more than 60 infections and diseases. Some of these may include avian flu, avian tuberculosis, psittacosis, salmonellosis, allergic alveolitis, campylobacteriosis, giardiasis, Newcastle disease, histoplasmosis, and cryptosporidiosis. Exposure to rodents (e.g., mice, rats) can cause many diseases as well such as the hantavirus pulmonary syndrome (HPS), tularemia, leptospirosis, salmonellosis, bubonic plague, rat-bite fever (RBF), Lassa fever, and lymphocytic choriomeningitis.

Allergies to reptiles are not common. There have been reports of allergies to snakes, and of course there is always the possibility of an allergic reaction to the venom of certain snakes. There have also been reported cases of allergies to various reptiles, particularly iguanas. In addition to the typical allergy symptoms that occur with other pets, there seems to be more skin irritation with reptiles than with other pets.

Horse allergies are not that uncommon. Individuals that are allergic to horses typically have similar symptoms as people with cat and/or dog allergies. The dander is the most common way in which horses cause allergic symptoms in humans. The horse’s saliva, urine, and the fecal material dropped by horse mites are other ways that people are exposed to the allergenic proteins of horses. 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 3 animals.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating pet allergies in both adults and children in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years. Black & Kletz Allergy has 3 offices in the Washington, DC metropolitan area with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. If you suffer from a pet allergy or are not sure if you do, please call us to and make an appointment at one of our conveniently located offices. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy are confident that we will be able to help you with your furry friends.

New Indications for Biological Medications

Most of the medications used for treating diseases are chemically synthesized in a laboratory. Some newer medications, however, are derived from a variety of natural sources such as humans, animals, or microorganisms. These newer medications, often referred to as “biologicals,” are typically produced by using biotechnology and/or other cutting-edge methodologies. Biologicals represent a breakthrough advance in therapeutics as they may offer the most effective means to treat a variety of medical illnesses and conditions that presently have no other treatments available.
Most allergic and immunological disorders have chronic uncontrolled inflammation as the primary underlying mechanism of the disease. This chronic inflammation often leads to organ dysfunction and the unwanted symptoms associated with such inflammation. The inflammatory process is mediated by various chemical substances such as antibodies and cytokines. The biological medications (i.e., biologicals) target these inflammatory mediators and suppress or block their actions resulting in better control of the disease.

XOLAIR (i.e., omalizumab) was the first biological approved by the FDA for the treatment of asthma. It was initially approved for adults in 2003 and later approved for children in 2006. Xolair acts by blocking the “allergy” antibody, commonly called IgE, which acts as a mediator of many disorders of immediate hypersensitivity.
Xolair is used for adult and pediatric patients who are 6 years of age and older with moderate to severe persistent asthma, whose symptoms are inadequately controlled with inhaled corticosteroids, who have a positive allergy skin test or an in vitro (i.e., in the test tube) reactivity to a perennial aeroallergen such as dust mites. It is administered by subcutaneous (SQ) injections on a regular basis (i.e., every 4 weeks). The dose and frequency of administration depend on the IgE level and the weight of the patient. The IgE level is determined by a blood test.
After getting the approval for the treatment of moderate to severe persistent asthma, Xolair subsequently was also approved for the treatment of chronic idiopathic urticaria (i.e., chronic hives) in patients ≥ 12 years of age who remain symptomatic despite H1 antihistamine (e.g., Clarinex, Claritin, Allegra, Zyrtec, Xyzal, Benadryl) treatment. Xolair has helped numerous individuals suffering from chronic hives.
More recently, Xolair has received an additional indication for the add-on maintenance treatment of nasal polyps in adult patients ≥ 18 years of age who have an inadequate response to nasal corticosteroids (e.g., Flonase, Nasonex, Nasacort AQ, Rhinocort AQ, Qnasl)
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NUCALA (i.e., mepolizumab) is a biological drug that blocks a cytokine called IL-5. It was approved in 2015 as an add-on maintenance treatment for patients with severe eosinophilic asthma aged 6 years and older. The approved recommended dosage is 100 mg once every 4 weeks given as a subcutaneous (SQ) injection.
Later, Nucala also was approved for:
- Add-on maintenance treatment of chronic rhinosinusitis with nasal polyps (i.e., CRSwNP) in adult patients 18 years of age and older with an inadequate response to nasal corticosteroids
- Treatment of adult patients with eosinophilic granulomatosis with polyangiitis (i.e., EGPA)
- Treatment of adult and pediatric patients aged 12 years and older with hypereosinophilic syndrome (i.e., HES)
FASENRA (i.e., benralizumab) is indicated for the add-on maintenance treatment in patients with severe eosinophilic asthma aged 12 years and older. It acts by rapidly depleting eosinophils which cause tissue damage when excessively activated and accumulated. The maintenance dose is 30 mg. injected subcutaneously (SQ) under the skin every 8 weeks.
DUPIXENT (i.e., dupilumab) acts by blocking 2 pro-inflammatory cytokines called IL-4 and IL-13. It is administered every 2 weeks as a subcutaneous (SQ) injection under the skin.

It is used to treat:

Adults and children 6 months of age and older with moderate to severe eczema (i.e., atopic dermatitis) that is not well controlled with prescription therapies used on the skin (i.e., topical), or who cannot use topical therapies
With other asthma medications for the maintenance treatment of moderate to severe eosinophilic or oral steroid-dependent asthma in adults and children 6 years of age and older whose asthma is not controlled with their current asthma medications
With other medications for the maintenance treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP) in adults whose disease is not controlled
Adults and children 12 years of age and older, who weigh at least 88 pounds (i.e., 40 kg), with eosinophilic esophagitis (EoE)
Adults with prurigo nodularis (PN)

TEZSPIRE (i.e., tezepelumab) is the most recent biological medication that was approved by the FDA for treatment of asthma. It is a medication that blocks the cytokine TSLP, a cytokine which plays a prominent role at the top of the inflammatory pathway. It is indicated for the add-on maintenance treatment of adult and pediatric patients aged 12 years and older with severe asthma.
Tezspire can be used without checking for any biomarker levels such as IgE. It can also be used in most phenotypes of asthma and is not restricted to only be used in eosinophilic asthma as with some other biologicals. It is administered as an injection subcutaneously (SQ) under the skin in a single dose of 210 mg. every 4 weeks.

The board certified allergy doctors at Black & Kletz Allergy see both adult and pediatric patients and have over 50 decades of experience in the field of allergy, asthma, and immunology. 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 greater Washington, DC metropolitan area for over 50 years and we look forward to providing you with the highest state-of-the-art allergy care in a friendly and approachable environment.

Cold Weather Allergies

Cold Weather Allergies Now that it is turning cold in the Washington, DC, Northern Virginia, and Maryland metropolitan area, some allergic individuals are happy because they have a respite from their pollen (e.g., trees, grasses, weeds) allergies which tend to bother them in the Spring, Summer, and/or Fall. Others however, are not as happy, as they either continue to have their allergy symptoms or develop their allergy symptoms only in the colder weather. These individuals are allergic to other allergens such as dust mites, molds, pets, or cockroaches, to name a few.

Dust mites, molds, pets, and cockroaches are allergens that are generally considered “indoor” allergens; however, molds are found both indoors and outdoors. Molds are particularly a problem in the Washington, DC metro area as Washington, DC was built on a swamp and the mold counts tend to be high in the area throughout the year. The 2 most common conditions caused by these allergens are allergic rhinitis (i.e., hay fever) and allergic conjunctivitis (i.e., eye allergies). The classic symptoms of allergic rhinitis may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, sinus congestion, sinus headaches, and/or snoring. The typical symptoms of allergic conjunctivitis may include itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. Another common malady that can arise from these allergens is asthma. Asthmatics typically complain of wheezing, chest tightness, coughing, and/or shortness of breath. Reducing one’s exposure to dust mites, molds, pets, and/or cockroaches is generally the first step in managing allergic rhinitis, allergic conjunctivitis, or asthma in most individuals. It should be noted that exposure to cockroaches is a fairly common cause of asthma exacerbations in inner city asthmatic children. Medications are also frequently utilized in order to better control the unwanted allergy or asthma symptoms. Allergy immunotherapy (allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) is a staple in the treatment of all 3 conditions. Allergy immunotherapy has been around for more than 100 years and it is effective in 80-85% of individuals who take allergy shots.

There is a subset of individuals who are bothered just by the cold air and not the allergens associated with the Winter. These patients have vasomotor rhinitis and may experience hay fever-like symptoms (i.e., runny nose, nasal, congestion, post-nasal drip) with just the exposure to cold air. Vasomotor rhinitis is a nonallergic condition that is caused by irritants such as cold air, strong scents, chemicals, pollutants, etc. In addition to these hay fever-like symptoms, the cold air may contribute to nose bleeds (i.e., epistaxis), watery eyes, and redness of the eyes.

The cold air does not only affect the eyes, nose and lungs when it comes to allergic and nonallergic conditions that are diagnosed and treated by board certified allergists like the ones at Black & Kletz Allergy. The skin is affected by the cold quite often and can be extremely annoying and even serious for some individuals. There are 4 cold-related conditions that fall under a similar category that affect the skin. These diseases are similar, but differ mainly by their severity. These 4 disorders include cold-induced pruritus, cold-induced urticaria, cold-induced angioedema, and cold-induced anaphylaxis. In cold-induced pruritus, the cold air will cause an individual to have itchy skin. A person with cold-induced urticaria will develop hives with cold exposure. People with cold-induced angioedema will develop swelling episodes when exposed to the cold. Lastly and most seriously, some individuals may develop life-threatening anaphylaxis when they are exposed to the cold. It is important that a patient be prescribed a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) for patients with cold-induced angioedema and/or cold-induced anaphylaxis. It is also important to note that any individual who needs to use a self-injectable epinephrine device should go immediately to the closest emergency room after using the device.

In addition to the 4 cold-related conditions mentioned above that affect the skin, some individuals may experience a change in the color of their skin with associated coldness, numbness, and stinging sensation. The color change is typically a whitish or bluish color. These individuals may have either Raynaud’s disease (i.e., primary Raynaud’s) or Raynaud’s phenomenon (i.e., secondary Raynaud’s) depending on whether there is an underlying medical problem. Raynaud’s disease is not associated with an underlying medical disorder and is more common than Raynaud’s phenomenon, which is associated with an underlying medical condition. The medical conditions most commonly associated with Raynaud’s phenomenon include connective tissue diseases (e.g., systemic lupus erythematosus, Sjögren’s syndrome, scleroderma, rheumatoid arthritis), smoking, injuries to the hands and/or feet, carpal tunnel syndrome, atherosclerosis, and certain medications (e.g., beta blockers, ADHD medications, migraine headache medications).

The board certified allergy doctors at Black & Kletz Allergy will promptly respond to any questions regarding cold-induced disorders and any other allergic or immunologic disorders. We have been treating cold-indued disorders for over 50 years and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We treat both adult and pediatric patients. All 3 offices at Black & Kletz Allergy offer on-site parking and 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. If you are concerned that you may have a cold-induced condition or any other allergy, asthma, sinus, skin, or immunology problem, please call us to schedule an appointment. You may also click Request an Appointment and we will reply within 24 hours by the next business day. At Black & Kletz Allergy, we strive to improve the quality of life in allergic individuals in a professional and welcoming setting.

Egg Allergy

Egg allergy is second only to milk allergy in prevalence among infants and young children. It affects about 1 to 2 % of young children overall. It is also the most common food allergy in children with eczema.

Proteins found in egg whites are generally responsible for causing allergic reactions in egg-allergic individuals. Although the ovalbumin is the most abundant protein in egg white, it is the protein ovomucoid that is generally responsible for egg allergy in most children. Ovalbumin is heat labile. The heating process denatures the protein ovalbumin and as a result of heating, the new heated protein is structurally different. Since the heated proteins are structurally different, the majority of egg-allergic children will not react to baked egg products that have been heated during the baking process. This suggests that children who have specific IgE antibodies primarily to ovalbumin are likely to tolerate heated forms of egg. On the other hand, the protein ovomucoid, which is also found in egg white, is not altered by extensive heating and thus is responsible for most of the egg allergies in children.

Clinical Manifestations:

Immediate hypersensitivity (Type I or IgE antibody mediated) reactions are the most common type of allergic reaction that occurs in egg-allergic individuals. Symptoms usually begin within minutes of egg exposure. Skin manifestations such as itching, rashes, hives, and/or soft tissue swellings are the most common symptoms. Respiratory symptoms such as chest tightness, coughing, wheezing and/or shortness of breath can rapidly progress in severity. Allergic reactions to eggs can also result in gastrointestinal symptoms such as abdominal pain, abdominal bloating, nausea, vomiting, and/or diarrhea.
Egg allergy most commonly manifests itself in the second half of infancy.
Egg allergy can be potentially life-threatening (e.g., vocal cord swelling can rapidly lead to difficulty in breathing and loss of consciousness)
Food-dependent, exercise-induced anaphylaxis with egg as the trigger has been reported. In other words, an individual can eat an egg and then exercise within a certain period of time (i.e., usually within 2 hours) and then develop anaphylaxis as a result of the combination of egg plus exercise. It is interesting to note that this individual may be fine just eating an egg or just exercising, but when done sequentially, anaphylaxis may occur.
Bird-egg syndrome is a condition where the primary sensitization is to airborne bird allergens and there is secondary sensitization or cross reactivity with the protein albumin in egg yolk. These patients experience respiratory symptoms (i.e., runny nose, nasal congestion, post-nasal drip, sneezing, itchy eyes, watery eyes, puffy eyes, redness of the eyes, chest tightness, coughing, wheezing, shortness of breath) with bird exposure and allergic symptoms with egg ingestion.
Egg allergy can present as infantile atopic dermatitis (i.e., eczema). Children with eczema and asthma are at increased risk for more severe reactions.
Egg allergy is one of the common triggers of symptoms in certain gastrointestinal disorders such as eosinophilic esophagitis (EoE) and food protein induced enterocolitis (FPIES).

Diagnosis:

A comprehensive history of one’s exposure to egg products (both cutaneous and oral), time of onset of specific symptoms after exposure, rapidity of progression, duration of the reaction, and resolution of symptoms are all necessary to help make the diagnosis of an egg allergy.
Skin prick tests (SPT) with egg white and egg yolk antigens
Laboratory tests for blood levels of specific IgE antibodies to egg
Oral food challenge (OFC), a gold-standard for the confirmation of the diagnosis of food allergy.

Treatment:

The most straightforward approach in managing any food allergy is the complete avoidance of the culprit food. Eliminating egg white and egg yolk from the diet can be difficult and can pose nutritional as well as quality-of-life concerns.
The evaluation of the allergy followed by an oral food challenge to extensively heated egg is an option since a majority of those with egg allergy will tolerate egg in extensively heated (baked) products, such as a muffin.
Oral immunotherapy (OIT) is a promising treatment method, though not yet FDA-approved.
Epinephrine auto-injectors are prescribed for use in the case of a reaction following inadvertent exposure to egg products. Some of the more common names of epinephrine auto-injectors may include EpiPen, Auvi-Q, and Adrenaclick. It should be noted that if an individual uses their auto-injector, that person should go immediately to the closest emergency room.
Children with egg allergy should be monitored for the resolution of the allergy since most will outgrow the allergy in childhood. Monitoring for resolution includes assessing the history of any accidental exposures and reactions and serial testing for sensitization using laboratory tests, skin prick testing, and/or oral food challenges.

Immunizations:

Children with egg allergy should not receive yellow fever vaccinations due to an increased risk of allergic reactions since the vaccine is produced using chicken embryos.
Egg-allergic children can safely receive the influenza and MMR (mumps, measles, rubella) vaccinations despite the use of egg-based technology since the amount of egg protein is incredibly small. It is recommended however that the vaccination be given in a doctor’s office and observed for 30 minutes after the injection. There are also a couple of influenza vaccines that do not contain any egg protein that are available.

Prevention:

The early introduction of egg can provide protection against egg allergy for at least some children who are at high risk for developing an egg allergy. Children at risk may need to undergo a comprehensive evaluation to see if the early introduction of eggs in the diet is appropriate.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing egg allergy and other food allergies in both adults and children in patients in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years. Black & Kletz Allergy has 3 offices in the Washington, DC metro area with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. If you think or know you have a food allergy, please call us to make an appointment at one of our conveniently located offices. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy are confident that we will be able to help you identify your food allergies and any other allergy you may have. The allergists at Black & Kletz Allergy are dedicated to providing you with the best quality allergy, asthma, and immunology care in a professional and caring environment.

Latex Allergy Update

Natural rubber latex is the milky white sap that comes from the Brazilian rubber tree. The Brazilian rubber tree is scientifically referred to as Hevea brasiliensis. The tree is mainly found in Southeast Asia and Africa. The sap is collected from rubber trees much in the same manner that maple syrup is extracted from maple trees. In order to give latex its elastic characteristic, several chemicals are added to the milky sap during the manufacturing process. The latex is then further refined into rubber for commercial use. This natural rubber should not be confused with synthetic rubber which is made from chemicals. Synthetic rubber products are not made with natural rubber latex and do not cause allergic reactions in individuals who are allergic to natural rubber latex.

Latex allergy is a condition in which a sensitive individual develops an immunological reaction against the allergenic proteins found in natural rubber latex. This allergic reaction usually begins within 30 minutes, but can develop later, and can range in severity from mild to life-threatening. Approximately 1-2% of the U.S. population has a latex allergy. Latex allergies are much more common in certain groups of individuals such as children with spina bifida, rubber industry workers, patients who have had multiple surgeries, patients who have had recurrent catheterizations of their bladder, and health care workers.

Approximately 70% of children with spina bifida have latex allergies because they have not one but 2 risk factors for latex allergies: multiple surgical procedures and the use rubber urinary catheters. Both of these factors make these children more susceptible to latex allergy mainly because they come in contact with natural rubber latex more than most individuals. Since they are exposed to latex more than the average person, they are more likely to develop an allergy to latex.

The allergic reaction that occurs in an individual due to a latex allergy can be different in each person. The allergic reaction can be either an immediate-type (i.e., Type I) hypersensitivity reaction or a delayed-type (i.e., Type IV) hypersensitivity reaction. In addition to a true allergic reaction, a non-allergic irritant contact dermatitis may also occur. In an immediate-type or Type I allergic reaction, the allergic individual usually has allergy symptoms within 30 minutes after exposure to the allergen (i.e., mold, dust mite, pollen, food, bee venom). The allergic reactions to latex usually occur after a number of exposures to latex, however, the severity of the reactions can worsen with repeated exposures. The symptoms of an immediate-type (Type I) allergic reaction due to a latex allergy may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy eyes, watery eyes, redness of the eyes, wheezing, shortness of breath, chest tightness, coughing, generalized itching, hives (i.e., urticaria), abdominal cramping, throat tightening (i.e., angioedema), nausea, dizziness, rapid heart rate, feeling faint, and/or drop in blood pressure. In severe cases, anaphylaxis can occur which can be life-threatening. A self-injectable epinephrine device may be prescribed to an individual with a history of a systemic reaction to latex. If such a device is used, they are to go immediately to the closest emergency room.

Physical contact with latex can also cause soreness and blistering of the skin which usually begins 2 to 3 days of exposure. This type of reaction is a delayed-type (Type IV) reaction and is called allergic contact dermatitis. It is similar to the reaction that is caused by poison ivy, poison oak, and poison sumac. As mentioned above, a non-allergic irritant contact dermatitis may also occur. Patients with this type of reaction may develop itchy, red, dry, flaky, peeling, and/or cracked skin after topical exposure to latex. Blisters may also develop in certain individuals.

The diagnosis of latex allergy is made by a comprehensive history and physical examination. Blood tests can be done to confirm a diagnosis. Allergy skin testing can also be performed in individuals where the blood test is negative but there is a high index of suspicion for latex allergy.

The treatment of latex allergy is to avoid exposure to natural rubber latex. Individuals should avoid all products containing latex, some of which may include: latex gloves, condoms, dental dams, balloons, rubber bands, select toys, tires, erasers, elastic clothing waistbands, nipples used on baby bottles, pacifiers, baby bottles, soles of shoes, athletic shoes, certain fruits and vegetables (see below). Many medical and dental devices (e.g., gloves, stethoscopes, dental dams, catheters, and airway and IV tubing. It should be noted that synthetic rubber products such as house paint are not made with natural latex. Patients who are allergic to latex should wear a medical alert bracelet and carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) and know when to use it. As mentioned above, if the self-injectable epinephrine device is used, the individual should go immediately to the closest emergency room.

It should also be noted that certain fruits and vegetables cross-react with latex as they share similar proteins and should be avoided in individuals who have a latex allergy. Approximately 30-50% of people with latex allergy have reactions to these fruits and vegetables. Some of the more common cross-reacting fruits and vegetables may include apples, avocados, bananas, chestnuts, carrots, celery, kiwi, melons, papayas, potatoes, and tomatoes.

The board certified allergists at Black and Kletz Allergy have over 50 years of experience in diagnosing and treating latex allergies. We treat both pediatric and adult 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 greater Washington, DC metropolitan area for many decades and we look forward to providing you with the utmost state-of-the-art allergy care in a warm and pleasant environment.