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Viruses cause a variety of illnesses in humans ranging from mild upper respiratory infections (URI’s) to life-threatening pulmonary and extra-pulmonary diseases. Rhinoviruses, adenoviruses, respiratory syncytial virus (RSV), coronaviruses, and influenza are the most common viruses infecting the respiratory tract. Among these rhinoviruses, RSV and influenza viruses are common causes of wheezing in children. Recurrent infections with these viruses may play a role in the development of asthma.

Patients with asthma are more susceptible to contract infections with influenza virus. In addition, they are also more likely to develop serious complications from Influenza. In fact, more than 75% of acute flare-ups of asthma are triggered by infections from either influenza, RSV, or rhinovirus infections.

Influenza infection (i.e., flu) normally occurs in the United States between October and March, although the peak time for infection is between January and March. There are 3 strains of influenza viruses that cause human infections and one other that does not. The ones that cause human infections are known by the names influenza A, influenza B, and influenza C. Influenza D is not known to infect or cause illness in humans and primarily infects cattle.

Influenza A and B are typically associated with seasonal epidemics of disease, known as the flu season. Influenza A is the only influenza virus that has been associated with flu pandemics. There have been several flu pandemics during the 20th century, each with its own severity and outcome. For example, in 1918, the “Spanish flu”, a strain of H1N1 influenza A subtype H1N1, caused between 50 and 100 million deaths worldwide with a mortality rate of 2.5 to 3%. Most of the deaths occurred in adults between the ages of 20 and 40 years. In 1957, the “Asian flu” (influenza A subtype H2N2) caused between 1.5 and 2 million deaths and had a fatality rate of 0.67%. In 1968, the “Hong Kong flu” (influenza A subtype H3N2) has been estimated to have caused between 1 and 4 million deaths and had a mortality rate of less than 0.5%.

Influenza infection begins with invasion of the respiratory epithelium which serves as a site for both viral replication and the host’s immune response. Destruction of the normal airway tissue and a pro-inflammatory immune response are the primary causes of symptoms associated with influenza infection.

The immune response of the host causes many of the symptoms associated with viral respiratory infections and those associated with exacerbations of underlying asthma. Certain individuals seem to be at higher risk for developing infection in the lower airway. The risk of infection increases in children less than 6 months of age, individuals with second-hand smoke exposure, and in people with certain genetic markers. Allergic individuals are also more susceptible to infection due to an impaired immune response.

The classic symptoms of the flu may include:

• Runny nose
• Nasal congestion
• Sore throat
• Cough
• Fever/chills
• Achiness
• Vomiting or diarrhea
• Fatigue/Lethargy

Complications of the flu may include:

• Pneumonia
• Flare-ups of asthma symptoms
• Ear infections
• Inflammation of the heart muscle
• Inflammation of the brain

Treatment of the Flu:

Most cases of influenza are mild and the symptoms usually resolve in 7 to 10 days. Symptomatic relief of fevers, chills, and achiness can be achieved by over-the-counter medications such as acetaminophen (i.e., Tylenol). Antihistamines and decongestants may be utilized to help reduce the unwanted nasal symptoms. Inhaled medications such as albuterol (e.g., Proventil, Ventolin, ProAir) are given to help relieve wheezing, coughing, and/or shortness of breath. Rest and drinking plenty of fluids may accelerate the recovery process overall.

The indications for antiviral medications include patients that are at high risk of influenza-related complications including pregnant women, adults over 65 years of age, immune-compromised subjects, and those with chronic medical conditions such as asthma, chronic obstructive pulmonary disease (COPD), and diabetes. Antivirals should be used if an individual requires hospitalization, if the infection is severe or complicated, and during pregnancy (even in mild disease).

Antiviral treatment works best when begun soon after the flu illness begins. When treatment is started within 2 days of becoming sick with flu symptoms, antiviral drugs can lessen fever and flu symptoms and shorten the duration of illness. They also may reduce the risk of complications such as ear infections in children, respiratory complications requiring antibiotics, and hospitalization in adults.

• Oseltamivir (i.e., Tamiflu) is available as a pill or liquid suspension and is FDA approved for the early treatment of the flu in individuals 2 weeks of age and older who have had flu symptoms for 2 days or less.
• Zanamivir (i.e., Relenza) is a powder that is inhaled and approved for the early treatment of the flu in people 7 years of age and older. Note: Zanamivir is administered using an inhaler device and is not recommended for individuals with breathing problems such as asthma or COPD.
• Oseltamivir and zanamivir are given twice a day for 5 days.
• Baloxavir (i.e., Xofluza) is a pill given as a single dose by mouth and is approved for the early treatment of flu in individuals 12 years of age and older. Note: Baloxavir is not recommended for pregnant women, breastfeeding mothers, severely immunosuppressed individuals, hospitalized patients, or outpatients with complicated or progressive illness.

Prevention of the Flu:

Staying home and avoiding contact with others will reduce the risk of acquiring influenza infection.

Routine annual influenza vaccination (i.e., flu shot) is recommended for all persons 6 months of age and older. Many types of flu vaccines are licensed by the FDA this year with varying indications based on one’s age group and health status. Please click on the following CDC link for more information: cdc.gov/flu/prevent/keyfacts.htm

The board certified allergists at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding the flu, asthma, and/or allergies. We have 3 offices with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer on-site parking. In addition, the Washington, DC and McLean, VA offices are accessible by Metro. There is also a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Kindly make an appointment by calling one of our 3 offices. Alternatively, you may click Request an Appointment and we will answer your inquiry within 24 hours by the next business day. Black & Kletz Allergy treats both children and adults and we are proud to serve the Washington, DC metro area residents for which we have done for more than 5 decades.

Sleep apnea is a condition in which breathing is repeatedly interrupted which results in an individual to not get enough deep sleep that is required to rejuvenate the body. Excessive daytime sleepiness or falling asleep at inappropriate times are the classic symptoms of this disorder.  It can be very serious and is a potentially fatal condition. Other common symptoms may include snoring, fatigue, decreased memory, decreased ability to learn, depression, decreased productivity at school and/or work, and a decreased quality of life. It is interesting to note that allergic rhinitis (i.e., hay fever) has also been linked to many of the same symptoms.  The combination of allergic rhinitis and sleep apnea can have deleterious effects such as an increased risk for motor vehicle accidents, stroke, heart disease, and/or sexual dysfunction. As a result, sleep apnea should not be taken lightly. Although approximately 25 million adults have sleep apnea in the U.S., the actual numbers are probably much higher since cases are underdiagnosed due to a variety of reasons. It should be noted that many individuals with sleep apnea are just unaware that they have the condition.

Sleep apnea may be classified as either “obstructive sleep apnea” or “central sleep apnea.” The severity is categorized into 3 classifications: mild, moderate, and severe. The severity is based on the number of episodes or events of apnea (i.e., complete stoppage of breathing for at least 10 seconds) or hypopnea (i.e., shallow breaths for at least 10 seconds) that occur per hour of sleep. Sleep apnea is deemed “mild” when there are 5-14 episodes of apnea or hypopnea per hour. It is considered “moderate” when there are 15-29 episodes of apnea or hypopnea per hour. Likewise, it is called “severe” when there are 30 or more episodes of apnea or hypopnea per hour. In obstructive sleep apnea, the breathing is obstructed by the blockage of air flow. It is often caused by the tongue sliding back in the throat, in combination with a relaxed airway which changes shape to a more oval shape which gives way to less room for air to be able to get to infiltrate the lungs from the nose or mouth.  In a sense, the muscles of the throat relax and fail to hold the airway open during sleep. In central sleep apnea, the normal unconscious breathing simply stops, usually due to the brain not sending the normal signals to the muscles that control breathing. Central sleep apnea is much less common than the obstructive variety and not associated with allergies, so we will only be discussing obstructive sleep apnea in this blog article.

Individuals with allergic rhinitis (i.e., hay fever) have worse sleep apnea overall than those without allergic rhinitis. The apnea episodes are more frequent and longer in duration. Allergic rhinitis is also a risk factor for snoring. Snoring is one of the most common findings in individuals with sleep apnea. Individuals with allergic rhinitis often have nasal congestion which causes the upper airway to narrow.  Individuals with hay fever also are more prone to sinus infections.  Most individuals with sinus infections also have concurrent nasal congestion as part of their symptoms.  The upper airway narrowing that occurs due to nasal congestion in allergic individuals increases the likelihood of snoring and obstructive sleep apnea. Some other risk factors for obstructive sleep apnea include obesity, large neck circumference, enlarged tonsils, deviated septum, males, age over 40, and gastroesophageal reflux (GERD).

The gold standard for the diagnosis of sleep apnea is an overnight sleep study. Allergy testing by allergy skin tests or blood tests are performed by a board certified allergist like the ones at Black & Kletz Allergy in order to identify potential allergens that are causing their allergic rhinitis symptoms (e.g., nasal congestion, runny nose, post-nasal drip, itchy nose, sneezing, snoring, fatigue, itchy throat, itchy eyes, watery eyes, redness of the eyes, sinus pressure, sinus headaches).

The most effective treatment of obstructive sleep apnea is the use of CPAP (continuous positive airway pressure) while sleeping. CPAP machines are used to distribute a constant flow of pressure which in turn forces open the airway obstruction. CPAP can be delivered by the use of nasal pillows or prongs, a nasal mask, or a full face mask. The use of mouth or dental devices are controversial but may help alleviate symptoms in individuals with mild obstructive sleep apnea. Surgery can also be performed in order to improve obstructive sleep apnea, although it is also somewhat controversial in its efficacy. A uvulopalatopharyngoplasty is one of the most common surgical procedures for treating obstructive sleep apnea although not necessarily the most effective. It is performed in order to remove excess tissue in the throat such as the uvula, tonsils, adenoids, and parts of the soft palate. It should be noted that the largest obstacle in the treatment of sleep apnea is compliance, as more than 50% of individuals do not adhere to the recommended usage of CPAP.

The board certified allergy specialists at Black and Kletz Allergy have been diagnosing and treating allergies and asthma for more than 5 decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area. In our allergy practice, we treat both adults and pediatric patients. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have on-site parking at each of our 3 locations. Our Washington, DC and McLean, VA offices are Metro accessible. Black & Kletz Allergy offers a free shuttle service between our McLean, VA office and the Spring Hill metro station on the silver line. If you suffer from sleep apnea, snoring, fatigue, allergies, sinus problems, asthma, hives, or immunological disorders, please call one of our offices to make an appointment. You may also click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy is dedicated in providing the most advanced allergy treatments in a warm, caring, and professional environment.

Asthma is a chronic condition that causes inflammation of the lungs. Inflammatory swelling of the tissues in the walls of the bronchial tubes and excessive mucus secretion within the lumen of the bronchial tubes cause blockage to the free flow of air in and out of the lungs during normal respiration. In some instances, asthma is a genetically determined condition which can be aggravated by environmental factors such as exposure to allergens (e.g., dust mites, molds, pollens, pet dander, cockroaches) and/or irritants (e.g., cigarette smoke, strong scents, air pollution, increased humidity, cold air). The usual symptoms of asthma may include coughing, chest tightness, shortness of breath, and wheezing.

The course of the disease varies widely in individual patients depending on the severity of the condition. Some individuals have symptoms all of the time and their asthma is labeled persistent while others only have symptoms sporadically and thus their asthma is categorized as intermittent. Physical exertion and both upper and lower respiratory infections may increase the frequency and severity of asthma symptoms in susceptible patients. Asthma usually begins in childhood although it may begin in adulthood. Asthma is usually associated with other allergic disorders such as hay fever (i.e., allergic rhinitis) and/or eczema (i.e., atopic dermatitis).

Chronic obstructive pulmonary disease or COPD is a common, preventable, and treatable condition that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. Chronic bronchitis and emphysema are the two most common conditions that fall under the umbrella of COPD. Persistent coughing associated with expectoration and increasing difficulty in breathing as well as effort intolerance are the usual symptoms.

COPD is a progressive condition and it is very common to have increasing severity over time. COPD symptoms typically begin after the age of 40, although symptoms may appear earlier. The symptoms may vary from day to day, but they are chronic even with treatment. Most individuals with COPD also have a history of smoking or smoke exposure.

Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with both asthma and COPD. ACOS is therefore identified in clinical practice by the features that it shares with both asthma and COPD. Individuals with ACOS may experience wheezing, breathing difficulties, fatigue, and/or excessive mucus that often responds to bronchodilators (i.e., medications that open airways such as albuterol). Patients with asthma-COPD overlap syndrome also seem to experience more shortness of breath than individuals with COPD or asthma alone. “Persistent airflow obstruction with features of asthma” is a common way that this condition is defined. They tend to be younger in age than patients with COPD alone. However, because this condition is still being studied, experts do not yet agree on a single way to define the syndrome.

ACOS generally involves these 3 features compared with people who have COPD alone:

• more of a response to inhaled bronchodilators
• increased reversibility of airflow
• bronchial and systemic inflammation from eosinophils (i.e., a type of white blood cell that is often elevated in allergic conditions).

The diagnosis of asthma-COPD overlap syndrome requires a comprehensive history and physical examination. Pulmonary function tests (i.e., spirometry) are also usually obtained. One may also need imaging studies such as a chest X-ray and/or CT scan.

The treatment of ACOS generally includes:

• Avoidance of allergens and irritants
• Total cessation of smoking
• Medications which usually consist of daily maintenance inhaled corticosteroids which are anti-inflammatory, in combination with inhaled long-acting bronchodilators to keep the airways open, and short-acting bronchodilators to provide quick relief from symptoms during flare-ups
• Regular immunizations such as Influenza and pneumonia vaccinations
• Pulmonary rehabilitation (i.e. breathing exercises and healthy eating habits)

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 asthma and asthma-COPD overlap syndrome. We also work in concert with any pulmonologist on patients with COPD. Black & Kletz Allergy treat both children and adults and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location. The Washington, DC and McLean, VA offices are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. 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 exceptional allergy and asthma care in a professional and caring environment.

It is mid-August in the Washington, DC, Northern Virginia, and Maryland metropolitan area, so that means that ragweed is beginning to pollinate. For those who are bothered by ragweed allergies, this means that it is time to stock up on tissues and over-the-counter medications. Ragweed allergy is common as approximately 10% of the U.S. population suffers from ragweed pollen. It has been estimated that ragweed causes about half of all pollen-associated allergic rhinitis (i.e., hay fever) in North America. Ragweed also causes allergic conjunctivitis (i.e., eye allergies) and asthma in a multitude of sensitive individuals.

Ragweed is very prevalent in the U.S., particularly in the Eastern and Midwestern regions of the U.S. The only state without ragweed is Alaska. There are at least 17 species of ragweed in North America. Each ragweed plant lives only 1 season but can produce approximately 1 billion pollen grains. The pollen is even more widespread in rural areas. It typically is found along the side of the road, in fields, in vacant lots, and along riverbanks. The warm weather in combination with increased humidity and wind enhances the release of ragweed pollen which tends to begin in mid-August, peak in mid-September, and end with the first frost which usually occurs in late October in the mid-Atlantic region. The pollen released from the ragweed plant can travel hundreds of miles, so most of the U.S population is exposed. The ragweed pollen count tends to peak during the midday and is the lowest in the early mornings.

For those who suffer from ragweed allergy, you are very knowledgeable with respect to the symptoms that you develop. For others who are not familiar with ragweed allergy, here are some of the typical symptoms that you may expect: sneezing, itchy nose, runny nose, nasal congestion, post-nasal drip, itchy eyes, watery eyes, red eyes, puffy eyes, fatigue, snoring, sinus pressure, sinus headaches. In some individuals, ragweed may cause asthma symptoms such as chest tightness, coughing, wheezing, and/or shortness of breath. In asthmatics, it is not uncommon for ragweed to exacerbate one’s asthma. In addition, ragweed may also increase the likelihood of sinus infections (i.e., sinusitis) in some prone individuals.

One fairly common but not well known to the public nuance regarding ragweed allergies is its association with foods. There is a condition known as oral allergy syndrome (i.e., pollen-food allergy syndrome) is a type of food allergy where the patient must have a pollen allergy even if they are not aware of it. It is characterized by an itchy mouth, throat, and/or lips in response to eating certain raw or uncooked fruits, vegetables, and nuts. Occasionally, people will experience itching of their hands when touching the raw foods. The syndrome is caused by allergens in foods that are derived from plants. Thus, only foods that come from plants can cause the syndrome. Extra caution needs to be taken in cases where nuts cause symptoms because many individuals can have nut allergies that are not associated with plants and as discussed above, may be life-threatening. Ironically, when the fruit or vegetable is cooked or canned, the protein is denatured and destroyed which usually prevents the allergic reaction from occurring. In most cases, individuals can tolerate cooked and/or canned fruits and vegetables. Some examples of foods associated with ragweed pollen allergy include melons (e.g., cantaloupe, honeydew, watermelon), banana, chamomile tea, white potato, cucumber, zucchini, artichoke, dandelion, and sunflower seeds.

In addition to ragweed allergies, it should be noted that other allergens may play a significant role in Fall allergies. Some of the other allergens that may contribute to an individual’s Fall allergies may include dust mites, molds, pet dander, and cockroaches. It should also be pointed out that these allergens are perennial in nature and may cause allergic rhinitis, allergic conjunctivitis, and asthma symptoms throughout the year, and not only during the Fall season.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating ragweed allergies and other Fall allergies for more than 5 decades. We treat both pediatric and adult patients. If you suffer from allergies and/or asthma, please call Black & Kletz Allergy to schedule an appointment with one of our board certified allergists. We have 3 offices in the Washington, DC, Northern VA, and Maryland metropolitan area. Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible, with a free shuttle between the McLean office and the Spring Hill metro station on the silver line. Black & Kletz Allergy has been providing high quality allergy, asthma, and immunology care to the Washington, DC metro area for many years. Please call us for an appointment today or alternatively, you can click Request an Appointment and we will respond within 24 hours on the next business day.

DRESS syndrome is a rare but serious allergic reaction to medications.  Though the true incidence of this condition is unknown, it is estimated to occur in 1 in 1,000 to 1 in 10,000 drug exposures.  In addition to affecting the skin, it may damage the function of many internal organs. It is extremely dangerous and is one form of the 5 severe cutaneous adverse reactions that may occur when an individual is exposed to a medication.  The other 4 severe cutaneous adverse reactions from drugs include:  Stevens-Johnson syndrome, toxic epidermal necrolysis, Stevens–Johnson/toxic epidermal necrolysis overlap syndrome, and acute generalized exanthematous pustulosis.

Causes:

Theoretically any drug may trigger DRESS syndrome, but the medications most commonly implicated are drugs that are used to treat seizures (e.g., carbamazepine, phenytoin, phenobarbital), gout (e.g., allopurinol), antibiotics (e.g., especially penicillin), and many anti-viral medications (e.g., boceprevir, telaprevir, abacavir, nevirapine)

The exact mechanism of the hypersensitivity to drugs causing this condition is not clearly understood.  It does not involve the antibodies that cause immediate allergic reactions, but is rather mediated by lymphocytes which cause delayed hypersensitivity.

Genetic factors are also important.  The risk of DRESS may be as high as 25% for individuals who have a first degree relative who has experienced this syndrome.

Symptoms:

The symptoms of DRESS syndrome usually begin about 2 to 6 weeks after the initiation of treatment with the offending drug.  The first symptom to occur is usually a low-grade fever, followed by a reddish rash on the skin.  The rash usually begins on the face and neck and gradually extends to involve the trunk and extremities.  In severe cases, multiple blisters, sores, and denudation of the superficial layers of the skin may occur.

As the condition progresses, the lymph nodes become swollen and patients may also experience fatigue, achiness, and general malaise.  The immune system also adversely affects the functioning of the liver, kidneys, thyroid gland, and rarely the heart and lungs.

There is an excessive accumulation of eosinophils (i.e., a type of white blood cell often associated with allergic diseases). When the number of eosinophils reach very high levels, tissue damage and subsequent organ injury occurs.

Diagnosis:

The diagnosis of DRESS syndrome requires a high index of suspicion.  The onset of new clinical features as described above about 2 to 6 weeks after a person begins using a new medication should prompt blood tests to detect high eosinophil numbers.  There are no allergy skin prick or patch tests to confirm the diagnosis.

Treatment:

The immediate cessation of the suspected drug is essential to limit the damage to the skin and internal organs that may be caused by DRESS syndrome.  Most affected individuals also need treatment with anti-inflammatory medications such as systemic corticosteroids for at least several weeks.  Supportive care is generally the only other treatment modality available for the treatment of DRESS syndrome.

Prognosis:

DRESS syndrome is a relatively serious disease with a high mortality rate of approximately 5-10%.  Prolonged use of corticosteroids may also cause systemic side effects.  Some of the surviving patients may develop other autoimmune disorders in later life.

The board certified allergists at Black & Kletz Allergy will promptly respond to any questions regarding DRESS syndrome, medication allergies, and other allergic or immunologic disorders.  We have been diagnosing and treating allergic disorders for more than 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.  Our 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 have had DRESS syndrome, medication allergies, or any other type of allergic condition, 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 in a professional and compassionate setting.

We have all heard about Spring and Fall allergies. The severity of the pollen seasons is always predicted as we enter Spring and Fall and there are numerous news articles and television pieces on the subject. You may seem like an expert on these seasonal allergies, but do you know that Summer brings its own allergy annoyances. Summer allergies are generally not discussed much in the media or amongst ordinary people. They are in fact quite bothersome to individuals who suffer from them however.

In the Summer, there are a multitude of allergic conditions that affect the population. Some of these may include allergic rhinitis (i.e., hay fever), allergic conjunctivitis (i.e., eye allergies), asthma, insect sting allergies, and pollen-food allergy syndrome (oral allergy syndrome).

Allergic rhinitis and allergic conjunctivitis symptoms may include runny nose, nasal congestion, itchy nose, post-nasal drip, sneezing, itchy eyes, watery eyes, redness of the eyes, puffy eyes, sinus congestion, sinus headaches, snoring, and/or fatigue. Individuals with allergic rhinitis and allergic conjunctivitis may exhibit physical markings around their faces which may indicate to allergists that they are atopic. Such signs may include:

• Allergic shiners: Dark circles under the eyes that result from chronic nasal congestion
• Dennie’s lines or Dennie-Morgan folds: Lines or folds in the skin just below the lower eyelids which appears a wrinkle in the skin
• Nasal crease: This is also called the allergic salute or nasal salute and is formed from the repetitive upward rubbing and wiping of the nose using the palm of one’s hand. Over time, a horizontal white line is formed at the junction of the lower one-third and upper two-thirds of the nose. This nasal crease is more common in children.
• Long face syndrome: A disproportion of facial features that includes a narrow face, large chin, and an open bite (i.e., lack of contact between the front teeth). It can be caused by chronic nasal congestion in children which leads to mouth breathing. This in turn leads to a high-arched palate which subsequently causes a change in the facial features in this condition. The face appears droopy and tired looking. Orthodontic treatment is usually necessary to treat these structural abnormalities.

The causes of allergic rhinitis and allergic conjunctivitis in the Summer are mostly due to exposure to molds and pollens, particularly grass pollen in the beginning of Summer and ragweed pollen towards the end of Summer. In addition, allergy sufferers can still be bothered by the usual perennial allergens such as dust mites, cockroaches, and pets.

Asthmatics may experience wheezing, chest tightness, coughing, and/or shortness of breath in the Summer. Exposure to the Summer environment may mean exposure to more mold and pollens, increased humidity, more exercise, excessive heat, and increased air pollution (i.e., smog) than that of other seasons. These factors may trigger asthma in certain sensitive individuals.

In the Summer, one must be extra careful about stinging insects. Honey bees, wasps, yellow jackets, white-faced hornets, and yellow-faced hornets are the stinging insects indigenous to the mid-Atlantic region of the U.S. In other warmer areas of the U.S., fire ants are another stinging insect that can cause serious anaphylactic reactions. Anaphylactic reactions to individuals with insect sting allergies may be life-threatening and it is important to see a board certified allergist like the ones at Black & Kletz Allergy if you have had a reaction to an insect sting. Allergy testing to the stinging insects and possible subsequent treatment with an epinephrine autoinjector and/or allergy shots to venoms (i.e., venom immunotherapy) may be utilized.

There is also a condition called pollen-food allergy syndrome (i.e., oral allergy syndrome) that is an allergic reaction in the mouth and throat to certain raw fruits, vegetables, and some tree nuts. The symptoms may include an itchy mouth or throat, and/or swelling of lips, tongue, mouth, or throat. The reaction is caused by cross-reacting allergens that are found on both pollens and the associated food. These foods have proteins that are structurally similar to specific pollens and the body “thinks” that the proteins in these foods are in fact pollen and as a result, mounts an immunologic or allergic response. Local itching and swelling are usually the result, although systemic reactions may occur in very rare circumstances. It is important to note that when these foods are cooked, the protein is denatured and no longer looks like the pollens. Thus, individuals may be able to eat these cooked fruits and vegetables without symptoms, in most cases. An allergist may prescribe an epinephrine autoinjector in those individuals with more severe symptoms.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating allergies and asthma, for more than 5 decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We treat both pediatric and adult patients. We have officed in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Our Washington, DC and McLean, VA offices are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  The allergy specialists at Black & Kletz Allergy are very familiar about the most current treatment options for patients with allergic rhinitis, allergic conjunctivitis, asthma, insect stinging allergies, and pollen-food allergy syndrome and can promptly answer any of your questions.  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 area for more than 50 years and look forward to providing you with exceptional state-of-the-art allergy and asthma care in a welcoming and pleasant environment.

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

• Atopic dermatitis (i.e., eczema)
• Food allergy
• Asthma
• Allergic rhinitis (i.e., hay fever)

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

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

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

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

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

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

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

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

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

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

The treatment of eosinophilic esophagitis may include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CAUSES:

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

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

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

DIAGNOSIS:

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

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

TREATMENT:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.