Is Primatene Mist Good for Asthma?

April 15, 2025 | Black & Kletz Allergy

There are a few over-the-counter (OTC) medications that some patients with asthma and other respiratory conditions occasionally use. One of them is an inhaler called Primatene Mist. Primatene Mist contains epinephrine (i.e., adrenaline) in an inhalable form. Though it is the same drug that is in an EpiPen, Auvi-Q, Adrenaclick, and other self-injectable epinephrine devices as well as the nasal spray, Neffy, used to treat acute allergic emergencies such as anaphylaxis, Primatene Mist does not help in those situations and should not be used. Although Primatene Mist became available in 1967, the FDA took it off the market in 2011, as it contained propellants called chlorofluorocarbons (CFC’s) which are harmful to the environment as they deplete ozone from the atmosphere. However, Primatene mist was recently reintroduced into the market with a newer propellant called hydrofluoroalkanes (HFA’s), which are environment friendly. Primatene Mist temporarily opens up the airways in the lungs thus offering a very short-term relief from shortness of breath and/or wheezing. It is approved only for individuals with an established prior diagnosis of asthma. It is used for the temporary relief of mild symptoms of intermittent asthma in patients aged 12 years or older and should not be used as a replacement for prescription asthma medications. Primatene Mist can do more harm than good if used for a chronic cough, for instance, without a known cause. The risks of Primatene Mist usage include masking of the symptoms without addressing the underlying cause. The symptoms of chest tightness, wheezing, cough, and/or shortness of breath should lead to the proper evaluation in order to establish the reason behind the symptoms. In cases of asthma, the underlying cause could be long-standing inflammation of the lungs. Proper evaluation and management should include the assessment of the lung function in addition to trying to control the causative factors. Uncontrolled inflammation can result in damage to the lung tissues and a reduction in lung capacity over time, which can be irreversible. Several deaths are reported each year in the USA due to uncontrolled asthma. Deaths also occur in cases of mild asthma with acute exacerbations. Primatene Mist is also associated with undesirable side effects such as palpitations, increase in blood pressure, nervousness, etc. In the elderly and in individuals with certain conditions such as heart problems, Primatene Mist may be harmful as epinephrine may worsen their underlying conditions. There is also concern for misuse or abuse. Primatene Mist may make the individual feel better temporarily when in fact the underlying reason for the exacerbation of the asthma goes unchecked, leading to a worse outcome overall because the individual did not seek the proper care. Albuterol, a prescribed alternative medication, is typically used for the quick relief of asthma symptoms. It is a bronchodilator which acts by relaxing the muscles around the airways so that they can open up better making it easier to breath. Primatene Mist is less potent and has a much shorter duration of action than albuterol, and thus not preferred. Primatene Mist is not recommended for severe asthma or as a long-term treatment. It should not be used in children under the age of 12 years old. There is a defined role for albuterol in relieving symptoms while also controls the underlying cause(s) with anti-inflammatory medications. In fact, there is an albuterol inhaler that has a corticosteroid added to it in order to give the medication an anti-inflammatory benefit when treating the symptoms of asthma. This medication is called AirSupra and it contains both albuterol and the corticosteroid called budesonide. It should also be noted that the national and international guidelines by organizations such as the National Institutes of Health (NIH) and the Global Initiative for Asthma (GINA) do not recommend using Primatene Mist. The board certified allergists at Black & Kletz Allergy are always available for our patients to ask any questions that they may have regarding asthma or allergies. We have been treating adult and pediatric patients with asthma for more than 50 years. In addition, we diagnose and treat individuals with allergic rhinitis (i.e., hay fever), allergic skin conditions such as urticaria (i.e., hives) and atopic dermatitis (i.e., eczema), eosinophilic disorders, insect sting allergies, medication allergies, and immune disorders. We have 3 office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices 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 would like to be evaluated today for asthma or any other allergic or immunologic problem, please call us today. You may also click Request an Appointment instead and we will respond to your request within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy pride themselves in providing the highest quality asthma and allergy care in the Washington, DC metro area.

Pollen Food Allergy Syndrome Revisited

April 10, 2025 | Black & Kletz Allergy

Tree Pollen Allergies Update in the Washington, DC Area

March 25, 2025 | Black & Kletz Allergy

Spring is here!  This means that quite a few Washingtonians will be pretty miserable as they will be suffering from hay fever (i.e., allergic rhinitis).  In the early Spring, tree pollen is mostly to blame for the annoying symptoms that cause hay fever.  Other than tree pollen, molds are also a common environmental allergen that plays havoc with allergy sufferers.  It should be noted that tree pollen can exacerbate asthma as well as cause allergic eye symptoms (i.e., allergic conjunctivitis). In the Washington, DC, Northern Virginia, and Maryland metropolitan area, trees typically begin to pollinate at the end of February, peak in mid- to late-April and continue to pollinate through late May and occasionally through early June.  The first trees to pollinate in the Washington, DC metro area cedar, birch, maple, poplar, elm, and alder.  Later in the Spring season, the principal tree that causes difficulties for people with tree pollen allergies is the oak tree.  In addition to oak tree, however, other tress that pollinate during the same time as oak trees include hickory, walnut, and pine trees. Tree pollen, as well as other pollens (e.g., grasses, weeds), pollinates by releasing its pollen into the air.  In general, most non-flowering trees have pollen that is light in weight.  When the pollen in released into the air, it is carried by the wind and the pollen grains land on other trees.  It is this cross-pollination that allows trees to reproduce.  Although it is good for the trees, it is not so good for allergy patients.  If outdoors when tree pollination takes place, a tree-sensitive individual will breathe in the pollen-infested air which will cause that person to exhibit allergic rhinitis symptoms. The symptoms of tree pollen allergy may include sneezing, runny nose, nasal congestion, post-nasal drip (which may cause a sore throat or cough), itchy throat, itchy nose, itchy eyes, watery eyes, red eyes, puffy eyes, sinus pressure and/or pain, snoring, chest tightness, wheezing, cough, and/or shortness of breath.  Tree pollen as well as other environmental allergens (e.g., grasses, weeds, molds, dust mites, pets, cockroaches) may also exacerbate asthma in patients with this condition. An interesting fact regarding flowers or flowering trees is that they generally do not cause hay fever symptoms because the pollen is too heavy, and as a result, the pollen is not wind-disbursed.  If they are too heavy to be transported in the air to other flowering trees, then one generally does not become sensitized to the pollen because they are not breathing in this heavier pollen.  It is thought that the flowers are an adaptation over millions of years in order to attract bees.  By design, bees have taken over for cross-pollinating flowering trees by landing on the flowers and then flying to other flowering trees.  When the bee lands on the flower, tree pollen gets stuck to their abdomen.  When they fly to another flowering tree, the pollen on its abdomen rubs off on the flowers allowing cross-pollination of that species of tree. The diagnosis of tree pollen allergy begins with a comprehensive history and physical examination.  Allergy skin testing or blood testing (in select individuals) is usually performed in order to identify a tree allergy. Once a diagnosis of tree pollen allergy is confirmed, avoidance of tree pollen and prophylactic measures should be tried, if at all possible.  If one goes outside, take a shower, wash one’s hair, and change one’s clothing when returning home in order to lessen pollen exposure.  It is wise to turn on the air conditioner and change air filters regularly (approximately once a month).  In addition, close one’s windows and sunroof and re-circulate the air in the car in order to avoid outside air from entering the vehicle.  At home, avoid mowing one’s lawn and yard work.  If these tasks must be done, where a filtration mask to lessen exposure to tree pollen.  Also avoid close contact with a pet that goes outside since they carry tree pollen on their coats.  If they go outdoors, wash the per regularly.  Check pollen counts every day and click Today’s Pollen Count on our website to see the daily pollen count.  Stay inside whenever possible during the Spring, especially when the tree pollen count is high.  If you must go outside, try to avoid exercising outdoors in the early mornings because pollen tends to be released more during that time frame.  Avoid wearing contact lenses which may trap the tree pollen in one’s eyes.  It is important to know that rain washes tree pollen from the air causing the pollen counts to be lower on wet cooler days. The treatment of tree pollen allergy, other than trying to avoid exposure, usually begins with taking allergy medications.  There are also a multitude of medications available that may help diminish allergy symptoms.  Some of these medications may include antihistamines, decongestants, leukotriene inhibitors, nasal corticosteroids, nasal antihistamines, nasal mast cell stabilizers, nasal anticholinergics, ocular antihistamines, and/or ocular mast cell stabilizers.  Allergy shots (i.e., allergy immunotherapy, allergy desensitization, allergy hyposensitization) are a very efficacious treatment modality in patients with all types of environmental allergies, including tree pollen allergies.  They work in 80-85% of patients that take them.  It is also helpful in the treatment of allergic conjunctivitis as well as asthma. The board certified allergy specialists at Black & Kletz Allergy have been treating individuals with tree pollen allergies for over 50 years.  If you suffer from any of the symptoms above in the Spring, please call our office for an allergy consultation in order for us to determine if you have tree or other allergies that may cause any of the symptoms above.  We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area with office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Black & Kletz Allergy specializes in treatment of both adult and pediatric patients.  Alternatively, to schedule an appointment, 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 pride themselves in providing superior allergy and asthma care in a specialized and caring environment.

Food Protein-Induced Enterocolitis Syndrome (FPIES)

March 20, 2025 | Black & Kletz Allergy

Food protein-induced enterocolitis syndrome (FPIES) is a rare condition that causes gastrointestinal symptoms several hours after consumption of certain foods by an individual who has an intolerance to that food.  The prevalence rate in the United States is approximately 0.5%. The most common types of food allergy in children and adults are mediated by an antibody called IgE. Food allergies may result in adverse reactions which in some cases may be very severe and even life-threatening in some that may occur within minutes of ingestion of the offending food.  The IgE antibodies are specific to the food that causes the reaction.  However, in individuals with FPIES, the intolerance to the food is not caused by IgE antibodies and the symptoms are usually delayed in onset.  It should however be noted that on occasion, FPIES may coexist with IgE mediated classic food allergies. In infants and children with FPIES, the most common foods that trigger gastrointestinal symptoms are milk, soy, oats, rice, and eggs.  For exclusively breastfed infants, FPIES reactions generally only begin when other foods are added to their diet.  For bottle-fed infants, FPIES reactions may begin in the first few months of life.  The most common trigger in adults with FPIES is seafood, particularly shellfish. Symptoms:

• Vomiting, typically occurring 1 - 4 hours after ingestion
• Diarrhea
• Blood and mucus in the stools
• Dehydration
• Fatigue
• Changes in blood pressure and body temperature

Diagnosis:

• In most cases, allergy skin prick and/or allergy blood tests will be negative, as this condition is not mediated by the IgE antibody.
• The diagnosis is most often established based on a comprehensive history and physical examination, after excluding other common conditions.
• Blood tests usually reveal the immune system’s response to stress, such as infections.
• Confirmation of the diagnosis often requires an oral challenge with the suspected food under close monitoring in a controlled environment in an attempt to trigger the symptoms.

Treatment:

• Children can rapidly become dehydrated following vomiting and diarrhea which may lead to a shock-like condition. Immediate rehydration intravenously and/or orally can be lifesaving.
• Zofran (ondansetron), an oral medication that controls nausea and vomiting, is sometimes useful in older children and adults.
• Breastfeeding infants, who begin exhibiting FPIES symptoms when solids are introduced into their diets, may need to continue exclusive breastfeeding for several more months.
• Infants who have reacted to dairy and/or soy-based infant formulas often need to be switched to hypoallergenic or elemental formulas.
• Oral corticosteroids may sometimes be prescribed in order to reduce the immune reaction as a short term measure.
• In older children and adults, eliminating one or more foods based on the clinical history and/or oral challenges may be warranted for prolonged periods.
• Foods are gradually reintroduced into the diet, one at a time, based on the results of oral challenges.

Prognosis:

• Many children outgrow FPIES and will be able to tolerate the foods spontaneously by the age of 3.
• Dairy is usually tolerated much earlier than rice and other cereals. Seafood may take several years to outgrow.
• Some children continue to experience FPIES symptoms into adolescence and into adulthood.
• As the underlying pathology is not yet fully understood, no curative treatments are available at this time.

The board certified allergy doctors at Black & Kletz Allergy have 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.  The allergists at Black & Kletz Allergy are very knowledgeable regarding FPIES as well as food allergies.  We diagnose and treat both adult and pediatric patients.  In addition, we treat hay fever (i.e. allergic rhinitis), asthma, and patients with medication, skin, and skin allergies.  We also diagnose and treat sinus disease, eosinophilic esophagitis, mast cell disorders, and immunological disorders.  To schedule an appointment, please call any of our offices or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 5 decades and we look forward to providing you with all-inclusive state-of the-art allergy care in a welcoming and professional environment.

Update on Angioedema (Swelling Episodes)

February 13, 2025 | Black & Kletz Allergy

Some individuals have episodes of swelling or “angioedema” of various tissues that may occur without any known rhyme or reason.  They may have 1 episode or they may have multiple or recurrent episodes.  Most people with this condition are very surprised and nervous when they notice an area of their body swelling up right in front of their eyes.  The swelling can occur on any part of the body or even internally.  They may occur by themselves or they may be accompanied with hives (i.e., urticaria) and/or generalized itching (i.e., pruritus).  The severity of the swelling can range from very mild to extremely severe.  The swelling occurs because there is seepage of fluid through small blood vessel walls which in turn results in soft tissue swelling. The allergic causes of angioedema are varied and may include the following:

• Allergies to Food – Peanuts (legumes), tree nuts, fish, shellfish, eggs, milk, etc.
• Insect Sting Allergies – Honey bees, wasps, yellow jackets, hornets, fire ants, etc.
• Medication Allergies – Penicillin, sulfa, erythromycin, tetracycline, aspirin, nonsteroidal anti-inflammatory drugs (NDAIDS), vaccines, etc.
• Natural Rubber Latex – Gloves, balloons, condoms, catheters, dental dams, etc.

The nonallergic causes of angioedema are also varied and may include the following:

• Autoimmune Disorders – Rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s syndrome, polymyositis, scleroderma, Grave’s disease, Hashimoto’s thyroiditis, etc.
• Certain cancers
• Infections – Hepatitis B, syphilis, etc.

Nonallergic reactions to some medications may cause angioedema and some of these medications may include:

• Angiotensin II Receptor Antagonists - Diovan (valsartan), Cozaar (losartan), Atacand (candesartan), Micardis (telmisartan), Benicar (olmesartan), Avapro (irbesartan), etc.
• Proton Pump Inhibitors - Prevacid (lansoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Prilosec (omeprazole), Aciphex (rabeprazole), Protonix (pantoprazole), etc.
• Angiotensin Converting Enzyme (ACE) Inhibitors - Altace (ramipril), Vasotec (enalapril), Zestril (Lisinopril), Capoten (Captopril), Lotensin (benazepril), Accupril (quinapril), etc.
• Selective Serotonin Reuptake Inhibitors (SSRI’s) - Lexapro (escitalopram), Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), etc.
• Statins - Zocor (simvastatin), Lipitor (atorvastatin), Pravachol (pravastatin), Crestor (rosuvastatin), Lescol (fluvastatin), Mevacor (lovastatin), etc.

There is a genetic cause of angioedema which is in a category all by itself: Hereditary angioedema is a condition that is genetic that will cause swelling episodes.  In this disorder, there is an inherited abnormal gene that causes a deficiency of a normal blood protein called “C1 esterase inhibitor.”  If an individual has this deficiency, they may have repetitive swellings which may last for 1 to 2 days in duration.  Hereditary angioedema usually begins to cause swelling episodes in patients after puberty.  These swelling episodes are not accompanied by hives (i.e., urticaria) whereas with allergic causes of angioedema, hives are quite commonly associated with the swelling episodes.   The episodes of swelling in individuals with hereditary angioedema can be spontaneous or they may be triggered by alcohol, physical or emotional stress, and/or hormonal factors. If no cause of the angioedema can be identified, the individual is said to have idiopathic angioedema.  Idiopathic means that an unknown reason is causing the swelling episodes, however many causes have been ruled out as a cause. The diagnosis of angioedema begins with a comprehensive history and physical examination.  Allergy testing and bloodwork may be necessary depending on the history and physical examination findings.  Allergy skin tests are often performed to rule out food, medication, insect sting, or latex, or allergies.  Blood testing is usually done if the swelling episodes become more chronic in nature, (more than 6 weeks), in order to rule out underlying conditions that may be causing the angioedema. The treatment of angioedema depends on the severity and length of time of the swelling episodes. In mild to moderate acute angioedema, taking an oral antihistamine and/or corticosteroid may be beneficial in curtailing and eliminating the swelling.  Alternatively, intramuscular administration of an injection of epinephrine can be performed along with an intramuscular injection of an antihistamine and/or a corticosteroid. Severe acute angioedema is treated similarly, however, keeping the airway open is the main objective.  In order to maintain an open airway, intramuscular epinephrine is often used, particularly if the angioedema occurs in the throat or respiratory tract.  In such patients, a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, adrenaclick) should be prescribed and used if the throat or respiratory tract is involved.  The patient should also go immediately to the closest emergency room if the self-injectable epinephrine device is used.  The treatment of chronic recurrent angioedema often involves the use of oral antihistamines, leukotriene antagonists, H2-blockers, and/or corticosteroids. Hereditary angioedema management typically involves the use of intravenous C1 inhibitor concentrate, the deficient enzyme causing the condition.  The C1 inhibitor concentrate can also be infused prophylactically about 1 hour before a surgical procedure in order to prevent swellings due to physical trauma.  It should be noted that hereditary angioedema generally does not respond well to antihistamines.  There are also various complement system blockers that can be used via injection to treat acute symptoms.  Newer medications such as Kalbitor (ecallantide) and Firazyr (icatibant) may also be used to treat this genetic condition. The board certified allergy doctors at Black and Kletz Allergy have over 5 decades of experience in diagnosing and treating angioedema.  We treat both adult and pediatric 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 friendly and professional environment.

The Quademic

February 11, 2025 | Black & Kletz Allergy

Four viral infections are surging in the country this year.  Three of them are respiratory viruses and one is a gastrointestinal infection. Influenza (“flu”) usually tends to peak in the Winter.  The Centers for Disease Control’s (CDC) statistics reveal that more than 30% of the lab tests were positive for the flu in January of this year and the numbers are climbing.  16 deaths related to influenza were reported, bringing the total to 47 deaths so far this season. Respiratory syncytial virus (RSV) numbers peaked in January of this year and are slowly dropping in case numbers. COVID-19 cases have not peaked yet as they did in the previous years but there could be an upsurge in the coming weeks. Norovirus, which causes gastrointestinal infections, circulates all year round, with an uptick in the number of cases during the Winters. The symptoms of all the 3 respiratory viral infections mentioned above are usually similar.  In order to diagnose an infection with each of the viruses, laboratory tests are needed to confirm the diagnosis.  The viruses usually begin as upper respiratory infections with symptoms such as nasal congestion, runny nose, itchy eyes, sore throat, and/or cough.  As the infection progresses, people may also experience fever, achiness, fatigue, headache, and/or shortness of breath.  Norovirus infections, in addition to the upper respiratory symptoms listed above, may cause nausea, vomiting, and/or diarrhea. Though one can have more than one infection at the same time, it is very unlikely to have all 4 viruses.  Most cases tend to be mild and only require symptomatic treatment.  Anti-viral medications, to be optimally effective, need to be started in the first few days after the onset of symptoms. RSV infections usually peak in the months of December and January every year.  Almost all children are affected with respiratory syncytial virus in the first 5 years of life. Although most cases are mild and only cause cold-like symptoms for a few days, it should be noted that RSV infections can be severe and dangerous in infancy, the elderly, as well as in immunocompromised individuals. The stomach and intestines are typically inflamed by norovirus infections.  When this occurs, people tend to say they have the “stomach flu.”  It is highly contagious and can survive on surfaces for a long period of time, as in days or weeks.  Outbreaks of norovirus are quite common in cruise ships and other crowded places such as college dormitories and nursing homes.  Drinking contaminated water, eating contaminated food, being in close contact with a person who has a norovirus infection, and touching one’s hand to one’s mouth after the hand has been in contact with a contaminated object or surface are common ways in which an individual may get a norovirus infection.  As a result of being infected with norovirus, it is not unusual for individuals to become dehydrated which can occur rapidly.  In such individuals, rapid oral or intravenous (IV) rehydration is often necessary. Vaccinations are available for influenza, RSV and COVID-19.  It should be stated that vaccines are not perfect.  Immunized individuals can and do get infected with the virus that they have been immunized against.  The benefit of the vaccination is that the symptoms associated with the virus tend to be less severe and less likely to lead to serious complications.  In addition to protecting the individual, vaccines also reduce the chances of the infections spreading to others, thus benefiting the community at large.  It occurs when a sufficient percentage of the population has become immune to an infection, whether by vaccination or previous infection.  This is known as herd immunity. The board certified allergy doctors at Black & Kletz Allergy have expertise in diagnosing and treating many types of viral and bacterial infections, as well as all types of allergic conditions, asthma, and immune problems.  We are board certified to treat both pediatric and adult patients and our allergists 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 recurrent viral or bacterial infections, environmental allergies, sinus-related symptoms, asthma, eczema (i.e., atopic dermatitis), hives (i.e., urticaria), generalized itching (i.e., pruritus), swelling episodes (i.e., angioedema), insect sting allergies, food allergies, medication allergies, and/or immune disorders, we are here to help you sort out your allergies and find a way to combat and control your 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 comfortable, considerate, and professional environment.

Update on Hives

January 16, 2025 | Black & Kletz Allergy

Hives, also known as urticaria, is a very bothersome problem for those affected. They are usually quite itchy although they do not have to be. A hive is typically a raised welt, wheal, or bump on the skin that may have an accompanying red blotch surrounding the bump. Hives however can be flush with the skin in some cases. The shape and size of a hive is very variable, ranging from pinprick-looking dots to large irregularly-shaped blob-like skin lesions. Not only can hives occur anywhere on the skin, but in some cases, they may be in the soft tissues (e.g., throat, tongue, lips, eyelids) or internally such as the gastrointestinal system (e.g., stomach, intestines). If the hives occur in the throat, the individual may experience a throat-tightening sensation. If the hives affect the tongue, lips, or eyelids, the person may develop localized swelling in these tissues. On the other hand, if they occur in the stomach, the patient may experience abdominal cramping, abdominal pain, nausea, and/or vomiting Usually, multiple hives occur at one time, but it is also possible to just have 1 isolated hive appear from time to time. A hive generally resolves within 24 hours, but may last longer. Hives tend to come and go and generally do not stay in one place for days, week, or months as is common with some other skin disorders such as eczema (i.e., atopic dermatitis). The causes of hives are numerous. Some of the more common causes may include allergies to a medication (e.g., aspirin, nonsteroidal anti-inflammatory drugs, antibiotics), food, (e.g., peanuts, tree nuts, egg, wheat, fish, shellfish, soy, milk), or flying insect sting (e.g., bee, wasp, yellow jacket, or hornet sting). Some other causes of hives may include personal care products, environmental agents, infections (e.g., viral, bacterial, fungal, parasitic), inflammatory conditions (e.g., vasculitis), autoimmune disorders (e.g., systemic lupus erythematosus, Sjögren’s syndrome, giant cell arteritis, polyarteritis nodosa, scleroderma, polymyositis, dermatomyositis), physical stimuli (e.g., cold, heat, exercise, vibration, pressure, solar exposure, water exposure), and/or rarely cancer. Hives can be categorized into 2 basic types - acute and chronic. “Acute” urticaria is defined as one having hives for less than 6 weeks. “Chronic” urticaria, on the other hand, is defined as one having hives for 6 or more weeks. Approximately 20-25% of the U.S. population will have hives at some point in their life. Acute urticaria is much more common than chronic urticaria, although chronic urticaria is not that uncommon. It should be noted that it is not uncommon for someone who has either the acute form or the chronic form of hives to also have associated swellings (i.e., angioedema). These swellings may occur in conjunction with one’s hives or they may occur separately from one’s hives. The diagnosis of hives is generally made after an allergist performs a comprehensive history and physical examination. In many cases, bloodwork, urinalysis, allergy skin tests, chest X-ray, and/or skin biopsy may be needed, particularly when a diagnosis of chronic urticaria is made. In these cases, it is important to rule out an underlying condition that may be the cause of the hives. If such a condition is identified, treatment of the underlying disorder may be all that is necessary in order to free the person of their hives. The treatment of hives primarily relies on the use of antihistamines. Since histamine is the primary chemical that is responsible for the development of hives, most cases of hives are responsive to antihistamines which block the action of histamine on the skin. In some individuals, avoidance of a particular food or medication is all that is needed. For others, there are a variety of treatment options, some of which include antihistamines [e.g., Claritin (loratadine), Clarinex (desloratadine), Allegra (fexofenadine), Zyrtec (cetirizine), Xyzal (levocetirizine) leukotriene antagonists [e.g., Singulair (monteleukast)], histamine-2 blockers [Pepcid (famotidine)], corticosteroids, immune modulators, and “biologicals” [e.g., Xolair (omalizumab) injections] or various combinations of the above-mentioned medications. The board certified allergy specialists at Black & Kletz Allergy have more than 50 years of experience in diagnosing and treating hives, as well as swelling episodes. They also diagnose and treat allergies, asthma, generalized itching, eczema, insect sting allergies, medication allergies, food allergies, eosinophilic disorders, mast cell activation syndrome, and immune disorders. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA and offer on-site parking at all locations. The Washington, DC and McLean, VA offices are Metro accessible and we provide 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 or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy is proud to provide high quality allergy care to the Washington, DC, Northern Virginia, and Maryland metropolitan area residents in a welcoming and professional setting.

Hypereosinophilic Syndrome

January 9, 2025 | Black & Kletz Allergy

An eosinophil is a type of white blood cell that has a role in fighting against parasitic infections and responding to allergens.  Eosinophils normally constitute about 5 to 8% of the white blood cells in one’s bloodstream.  Their absolute numbers range from 100 to 500 eosinophils per microliter of blood. In individuals who are atopic, (i.e., people with a higher incidence of allergic disorders), there will be a higher number of eosinophils in the blood.  When there are higher number of eosinophils in the blood than normal, the condition is called eosinophilia.  In a disorder named hypereosinophilic syndrome (HES), there are much higher numbers of eosinophils in the blood.  Individuals with hypereosinophilic syndrome usually have more than 1,500 eosinophils per microliter in their blood for 6 months or more, and the cause cannot be identified. In addition to being located in the bloodstream, the eosinophils in hypereosinophilic syndrome may also accumulate in various tissues.  This excessive eosinophil deposition into the tissues may lead to tissue damage and loss of function. Many organs including the heart, lungs, brain/nervous system, kidneys, stomach/intestines, bone-marrow, and skin may be affected in hypereosinophilic syndrome.  Untreated, this condition can be life-threatening, however, early diagnosis and specific treatments can protect the organs from getting damaged. Fortunately, hypereosinophilic syndrome is a rare condition.  It has a predilection for the male gender, with a male to female ratio of approximately 8 to 1.  It occurs most commonly in individuals between 20 and 50 years of age, although it can affect anyone of any age. Causes of Hypereosinophilic Syndrome: The exact cause of hypereosinophilic syndrome is not well understood, however, some patterns are known to occur as below:

• Some types of hypereosinophilic syndrome tend to run in families.  There are some abnormalities in the genes coding for eosinophils in certain individuals.
• Higher than normal levels of a protein called Interleukin-5 (IL-5), a growth factor for eosinophil growth and differentiation, may be found.
• Some types are associated with certain kinds of cancers such as myeloproliferative disorders.  These disorders are characterized by excessive blood cell production in the bone marrow.
• May be associated with certain infections (i.e., parasitic)

Symptoms of Hypereosinophilic Syndrome: The symptoms of hypereosinophilic syndrome are dependent on the organs primarily affected.  Some of the symptoms associated with the syndrome may include:

• Skin rash, pruritus (i.e., itching)
• Cough, shortness of breath
• Dizziness
• Fatigue
• Fevers
• Abdominal pain, diarrhea
• Joint stiffness, joint pain
• Mouth sores
• Memory loss
• Tingling and numbness of the extremities
• Blurred vision, slurred speech

Diagnosis of Hypereosinophilic Syndrome: It is important to rule out other conditions with similar symptoms since the symptoms of hypereosinophilic syndrome are quite common.  Some of these conditions may include allergic diseases, parasitic infections autoimmune disorders, and drug reactions.  Below are some standard recommended diagnostic tests that may help diagnose the syndrome:

• Blood counts:  Absolute eosinophil count greater than 1,500 per microliter on at least 2 occasions
• Anemia:  Found in more than 50% of patients
• Serum tryptase levels:   Elevated in some genetic variations
• Bone marrow biopsy:   May be needed in specific situations
• Electrocardiography (EKG)
• Echocardiography
• Troponin levels
• Pulmonary function tests (PFT)
• Tissue biopsy:  May be required to demonstrate eosinophilic infiltration

Treatment of Hypereosinophilic Syndrome:

• In all patients without a genetic mutation, glucocorticoids are the first-line therapy.
• Interferon-alpha and hydroxyurea are the recommended second-line drugs.
• For third-line therapy, high-dose (400 mg/d) imatinib (i.e., Gleevec) is the treatment of choice.
• For patients with a genetic mutation, imatinib (i.e., Gleevec) is the drug of choice.
• In 2020, the U.S. Food and Drug Administration (FDA) approved mepolizumab (i.e., Nucala) for adults and pediatric patients aged 12 years and older with hypereosinophilic syndrome.  Mepolizumab is a humanized monoclonal antibody specific for interleukin-5 (IL-5), and is the first treatment shown to reduce disease flares.
• In refractory cases, particularly those resistant to imatinib (i.e., Gleevec) therapy, hematopoietic stem cell transplantation (HSCT) has been shown to reverse the organ dysfunction.

Monitoring Hypereosinophilic Syndrome:

• Peripheral blood eosinophil count and serum troponin levels every 3 months.
• Echocardiograms and pulmonary function tests every 6 months.

The board certified allergy specialists at Black & Kletz Allergy see both adult and pediatric 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, Northern VA, and Maryland metropolitan area for over 50 years and we look forward to providing you with the highest state-of-the-art allergy care in a welcoming and relaxed environment.

Newer Medications for Atopic Dermatitis

December 13, 2024 | Black & Kletz Allergy

Atopic dermatitis (i.e., eczema) is a chronic inflammatory disorder of the skin. The symptoms usually begin in infancy and early childhood, although less commonly, they may begin later in life.  Genetic predisposition is the underlying reason for most cases, however environmental factors and allergic sensitization to foods and aeroallergens may trigger and/or aggravate the condition. The face and extensor regions of the extremities are usually affected in infants and young children, whereas the flexural areas, especially in the bends of elbows and knees, are more commonly involved in older children and adults. The symptoms of atopic dermatitis may range from mild dryness and itching of the skin to moderate thickening and discoloration of the skin, excessive creasing and cracking of the skin, and oozing in severe cases.  It should be noted that inflamed skin is more susceptible to bacterial and fungal infections than skin that is not inflamed.  More and more body surface area is involved as the disease progresses and this can have a huge negative impact on one’s quality of life. Though there is no cure for the genetic abnormalities that are responsible for atopic dermatitis at this time, many treatments are available to help reduce the ongoing inflammation and minimize the aggravating symptoms.  Until 2015, the only FDA-approved treatments for atopic dermatitis were topical corticosteroids and topical calcineurin inhibitors [e.g., Protopic (tacrolimus) ointment, Elidel (pimecrolimus) ointment].  Since then, many newer medications have been made available for the treatment of atopic dermatitis.

1. Eucrisa (i.e., crisaborole) topical ointment 2% - Approved by the FDA in December 2016 for mild-to-moderate atopic dermatitis in adults and children aged 2 years and older.  In March 2020, the FDA expanded the indication to include infants and children aged 3 months and older.
2. Dupixent (i.e., dupilumab) - A monoclonal antibody approved in 2017 for adults with moderate-to-severe atopic dermatitis which is not adequately controlled with topical prescription therapies.  It is the first biologic medication for atopic dermatitis and it is administered as a bi-weekly injection subcutaneously (SQ) or under the skin.  In 2019, this indication was expanded to include adolescents aged 12 years and older.  In 2020, it was further expanded to include children as young as 6 years of age.
3. Adbry (i.e., tralokinumab) - A monoclonal antibody that inhibits interleukin 13 (IL-13).  It was FDA-approved for the treatment of moderate-to-severe atopic dermatitis for adults whose disease is inadequately controlled with topical therapies.  In December 2023, the approval was expanded to include children 12-17 years of age.  This biologic is also given as a subcutaneous (SQ) injection every other week.
4. Rinvoq (i.e., upadacitinib)  - This oral JAK1-selective inhibitor was approved for the treatment of refractory moderate-to-severe atopic dermatitis in patients aged 12 years and older whose disease is not adequately controlled with other systemic drug products, including biologics.  It is taken daily in either 15mg. or 30mg. doses.
5. Cibinqo (i.e., abrocitinib) -An oral JAK1 inhibitor that is taken once a day that is indicated for the treatment for patients aged 12 years and older with moderate-to-severe atopic dermatitis.  It is dosed at 100mg. per day.
6. Opzelura (i.e., ruxolitinib) cream 1.5% - The first topical JAK inhibitor, which gained FDA approval, for short-term and non-continuous long-term treatment of mild-to-moderate atopic dermatitis in non-immunocompromised adults and adolescents whose disease is not adequately controlled with other topical prescription therapies.  It is applied twice daily to the affected areas of the skin.
7. Zoryve (i.e., roflumilast) topical cream – It got FDA approval for mild-to-moderate atopic dermatitis in adults and children aged 6 years and older in July 2024.  It is applied once a day to the affected areas as a 0.15% cream.
8. Ebglyss (i.e., lebrikizumab) - A monoclonal antibody that binds to IL-13 and inhibits the release of proinflammatory cytokines, chemokines, and IgE.  In September 2024, it was approved by the FDA for moderate-to-severe atopic dermatitis in patients aged 12 years and older who weigh at least 40 kg. (88 lbs.) in cases when the disease is not adequately controlled with topical prescription therapies.  It can be used with or without a topical corticosteroid.

Additional treatments:

1. In January 2015, the World Allergy Organization recommend the use of probiotics in pregnant and lactating women and their breastfed infants to prevent the development of atopic dermatitis.
2. Acyclovir, an anti-viral medication is effective in treatment of atopic dermatitis complicated by herpes virus infections (i.e., eczema herpeticum).
3. Excessive colonization of the affected skin by bacteria such as Staphylococcus and clinical infection in patients with atopic dermatitis can usually be controlled by antibiotics.
4. Phototherapy can be very effective in certain clinical scenarios of atopic dermatitis.
5. Immunosuppressive medications such as azathioprine, cyclosporine, mycophenolate, and methotrexate are effective in very severe cases of atopic dermatitis, but systemic toxicity limits their regular usage.
6. Antihistamines such as hydroxyzine may offer relief in individuals with atopic dermatitis from intense itching, but sedation is a common side effect.
7. Hydration of the skin with regular use of emollients such as Vaseline petroleum jelly can improve excessive dryness and itching in patients with atopic dermatitis.
8. A cool mist humidifier may help in reducing dryness in individuals with atopic dermatitis.
9. Soaps and detergents should be mild and non-irritating in patients with atopic dermatitis.

The board certified allergy specialists at Black & Kletz Allergy have been diagnosing and treating atopic dermatitis for more than 50 years. We treat both adults and children.  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 atopic dermatitis, other skin allergies and/or any other allergy symptoms, we are here to help lessen or hopefully end these unwanted symptoms that have been so bothersome, so that you can enjoy a better quality of life.  Black & Kletz Allergy is devoted to providing the highest quality allergy care in a comfortable, considerate, and professional environment.

Winter Allergies Are Almost Here

December 6, 2024 | Black & Kletz Allergy

If pollens are generally a problem in the Spring and Fall, why do so many people experience allergy symptoms in the Winter?  What allergens are causing individuals to feel so lousy during the coldest time of the year?  The answer is not a simple one.  There are many allergens that may wreak havoc on sensitive allergic individuals during the Winter.  The most common allergens responsible for Winter allergies may include dust mites, molds, pets, and/or cockroaches. As far a dust mites are concerned, in the Washington, DC metro area, the 2 common species of dust mites are Dermatophagoides fariniae (i.e., American dust mite) and Dermatophagoides pteronyssinus (i.e., European dust mite).  Both of these species are quite allergenic.  In fact, it is the fecal particles and exoskeleton that are the allergenic components of the dust mites.  Dust mites are usually found indoors in places such as in bedding (i.e., pillows, mattresses, box springs), carpeting, and upholstered furniture.  They are microscopic in nature and look similar to cockroaches except they cannot be seen with the naked eye.  They are approximately 0.25 mm. in length.  Dust mites survive by eating the dead skin that habitually sloughs off of humans each night, hence they are commonly found in bedding.  Dust mites flourish in high humidity, warm, moist climates.  They do not survive if the temperature is over 130° F or when the altitude is greater than 1 mile (5,280 feet).  Dust mites are known to be a common cause of allergic rhinitis, allergic conjunctivitis (i.e., eye allergies) and asthma in many sensitive individuals.  Dust mites can be killed with the application of miticide products, however these products have not been shown to be that efficacious.  Encasing one’s pillows, mattresses, and box springs in allergy-proof encasings are a fairly effective way to minimize one’s exposure to dust mites. In the Winter, many people close up their homes by keeping the windows closed and recirculating the air.  As a result, indoor allergens such as dust mites, molds, pet dander, and cockroach become trapped in the home causing an individual to breathe in more allergen than during other times of the year when the windows tend to be open more often. Cockroach allergy is common particularly in major cities such as Washington, DC and New York City.  They are potent allergens.  Many apartments, condos, homes, restaurants, and public buildings in inner cities are infested with cockroaches, even though they may not be visible during the day to most people.  It is important to make sure that traces of food are not left on countertops and floors, as this entices cockroaches.  There is also a strong association between cockroach allergy and childhood asthma in inner city populations.  Cockroach allergies may cause allergic rhinitis, allergic conjunctivitis, and/or asthma symptoms in sensitive allergic individuals. Pet allergens from the dander and saliva tend to be worse in the Winter due to the closed up nature of a typical house.  People who are allergic to pets but refuse to give them up should at least not allow the pet to venture into their bedroom, if at all possible.  This will give the individual a “pet-free” zone in the bedroom, where people tend to spend the most time. Mold allergy is also prevalent during the Winters in the Washington, DC metropolitan area.  Washington, DC was built on a swamp and as a result the abundance of mold is commonplace.  Similar to dust mite, cockroach, and pet allergies, mold is an indoor allergen, however, unlike dust mite, cockroach, and pet allergies, mold is also found outdoors.  This double whammy makes mold allergy a unique allergen in that it affects people both indoors and outdoors.  It is recommended that people keep the relative humidity in their homes to be below 33%. In a perfect world, avoidance of the offending allergen is obviously the best option to prevent environmental allergies.  In reality however, it is very difficult, if not impossible, to avoid contact with some of these ubiquitous allergens.  So if one is unable to avoid these allergens, there are numerous medications that can be used by allergy doctors to treat dust mite, mold, pet, and cockroach allergies.  In addition to various antihistamines, decongestants, nasal sprays, and allergy eye drops, allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization) are a very effective tool that board certified allergy specialists use to treat individuals with these allergies, as well as pollen allergies.  Allergy injections are effective in 80-85% of the patients.  Allergy shots have been used in the U.S. to treat allergies and asthma for over 100 years.  The average length of treatment is 3-5 years. The board certified allergy specialists of Black & Kletz Allergy have been treating pediatric and adult patients with allergies and asthma for over 5 decades.  Black & Kletz Allergy has 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We have convenient offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Our offices in Washington, DC and McLean, VA are Metro accessible with free shuttle service between the Spring Hill metro station and our McLean office.  All 3 locations offer on-site parking.  To make an appointment, please call us, or alternatively you can click Request an Appointment and we will respond within 24 hours on the next business day.  The allergists at Black & Kletz Allergy strive to manage your allergy and asthma to your utmost satisfaction in a professional caring atmosphere.