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Mast cell activation syndrome (MCAS) has been a hot topic in recent years. It seems as though the prevalence is increasing over the last decade.  Mast cell activation syndrome is caused by episodes of the abnormal release of mast cell mediators which can affect any organ system, but tends to involve the skin, nervous system, cardiovascular system, and gastrointestinal tract mostly.  Before delving into the syndrome, it is important to understand the science behind it.

Mast cells are types of white blood cells that generally are found in the connective tissues.  There are granules inside the mast cells that contain chemical mediators such as histamine, heparin, tryptase, prostaglandins, leukotrienes, serotonin, and cytokines.  Many of these mediators are inflammatory in nature.  In addition, mast cells have the allergy antibody, known as IgE, attached to their surfaces.  Mast cells play an important role in initiating and promoting immune responses to pathogens (i.e., bacteria, viruses) and toxins (i.e., mold, flying insect stings) by releasing these chemical mediators   Mast cells are also responsible for immediate allergic reactions.  In an allergic reaction, the IgE on the surface of the mast cells bind to the proteins (i.e., allergens) that cause allergies.  The mast cell is now activated, which causes the granules and their contents to be extruded from the mast cells into the tissues in a process called degranulation.  As a result, the chemical mediators, which include histamine and chemicals that cause inflammation, are released into the tissues.  These chemicals cause the typical symptoms that are generally associated with allergies such as anaphylaxis, itchiness (i.e., pruritus), hives (i.e., urticaria), flushing, swelling (i.e., angioedema), nasal congestion, runny nose, wheezing, chest tightness, coughing, shortness of breath, nausea, vomiting, throat tightness, abdominal pain, abdominal bloating, diarrhea, decreased blood pressure, increased heart rate, lightheadedness, and/or headaches.

The symptoms an individual with mast cell activation syndrome experiences depends on where the mast cells are degranulating.  In general, children are more likely to have dermatologic symptoms whereas adults tend to have symptoms related to other organ systems as well as the skin.  The symptoms associated with the skin may include generalized itching, flushing, hives and/or swelling.  Gastrointestinal symptoms may include abdominal bloating, abdominal pain, throat tightness, nausea, vomiting, and/or diarrhea.  A patient may exhibit respiratory problems such as coughing, wheezing, shortness of breath, and/or chest tightness.  There may be cardiovascular symptoms such as decreased blood pressure, fainting (syncope), lightheadedness, and/or increased heart rate (i.e., palpitations).  Neurological manifestations may cause “brain fog,” fatigue, headaches, sleep disturbances, and/or inability to concentrate.  If the bone marrow is involved, fractures, bone pain, and anemia may ensue.  The lymphatic system may be involved, thus causing swelling of lymph nodes, spleen, liver, and other organs.

There is evidence that mast cell activation can be associated with postural orthostatic tachycardia syndrome (POTS).  Postural orthostatic tachycardia syndrome is a condition where one’s pulse rate increases by a substantial amount, usually greater than 30 beats per minute) upon standing or sitting up.

There is also evidence that mast cell activation can be associated with connective tissue diseases such as hypermobile type of Ehlers-Danlos syndrome (hEDS).  A proportion of individuals with the hypermobile type of Ehlers-Danlos syndrome also have mast cell activation syndrome, leading to the possibility of a link between the 2 conditions.  In one study, 66% of patients with both a high heart rate when standing and Ehlers-Danlos syndrome also had symptoms consistent mast cell activation syndrome.

Sometimes mast cells become defective and release mediators because of abnormal internal signals.  Certain mutations in mast cells can produce populations of identical mast cells (i.e., clones) that overproduce and release more chemical mediators.  These abnormal clones can grow uncontrollably and are quite sensitive to mast cell activation.  Individuals with this condition are said to have a disorder referred to as mastocytosis.  Mastocytosis can be further divided into 2 subgroups:  cutaneous mastocytosis and systemic mastocytosis.

Cutaneous mastocytosis only affects the skin and is more common in children. It is defined by red or brown itchy lesions on the skin. The most common type of cutaneous mastocytosis is called urticaria pigmentosa.

Systemic mastocytosis affects other parts of the body besides the skin such as lymph nodes, bone marrow, stomach, intestines, liver, and spleen.  Very rarely however, mast cell leukemia or mast cell sarcoma can occur in patients with systemic mastocytosis.

The diagnosis of mast cell activation syndrome is somewhat difficult in many patients.  Increases in the chemical mediator tryptase may be found in the blood, but normal levels of tryptase does not rule out the diagnosis.  Tryptase should be drawn between 30 minutes and 2 hours after the beginning of an episode, with a baseline level obtained many days later.  In addition to serum tryptase, elevated 24 hour urine levels of N-methylhistamine, 11B -prostaglandin F2α (11B-PGF2α), and/or leukotriene E4 (LTE4) are useful tests in the diagnosis of mast cell activation syndrome.

The treatment of mast cell activation syndrome should aim to relieve the annoying symptoms that many find maddening.  H1-blocking antihistamines are effective in reducing many of the symptoms in some individuals.  H-2 blockers may work in conjunction with the H1 antihistamines to give better relief.  Leukotriene antagonists [i.e., Singulair (montelukast), Accolate (zafirlukast), Zyflo (zileuton) may also offer additional help in alleviating unwanted symptoms.  These leukotriene antagonists help by blocking the effects of leukotriene C4 (LTC4) or 5-lipoxygenase (5-LPO), depending on the leukotriene antagonist used.  Mast cell stabilizers (i.e., cromolyn sodium) may be useful in that they stabile mast cell membranes, thus reducing degranulation, and causing less of the chemical mediators to be released into the tissues.  Aspirin and NSAID’s (nonsteroidal anti-inflammatory agents) have a role in treatment, particularly of flushing, as they block the production of the chemical mediator prostaglandin D2 (PGD2).  In recalcitr carry a self-injectable epinephrine device (i.e., EpiPen, Auvi-Q, Adrenaclick)) or Neffy, an epinephrine containing nasal spray, as a precaution.  If the epinephrine is used by the patient, the individual should then go to the closest emergency room.   Although not FDA-approved to treat mast cell activation syndrome, Xolair (i.e., omalizumab), a monoclonal antibody that blocks the binding of the IgE molecules to its receptors, has been reported to reduce mast cell reactivity and sensitivity to activation which can reduce anaphylactic episodes.

The board certified allergy specialists at Black & Kletz Allergy treat both adult and pediatric patients.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 of our offices have on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible and the McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line.  You may also click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy has been a fixture in the greater Washington, DC, Northern Virginia, and Maryland metropolitan community for over 50 years for our outstanding services for the diagnosis and treatment of mast cell activation syndrome, allergic rhinitis (hay fever), asthma, eczema (atopic dermatitis), insect sting allergies, food allergies, medication allergies, hives (urticaria), swelling episodes (angioedema), contact dermatitis, eosinophilic disorders, and immunological conditions.

It is that time of the year again. Soon you will be seeing children (and some adults) trick or treating in your neighborhood searching for candy. For children, Halloween is a time to be with their friends, eat a lot of candy, and dress in scary costumes. For millions of parents however, Halloween can also be scary, but for a different reason: Their children have food allergies. According to Food Allergy Research & Education (FARE), approximately 6 million or 1 in 13 children in the U.S. have food allergies. This is about 8% of the U.S. pediatric population which is equivalent to about 2 children per classroom. In addition, more than 26 million adults also have food allergies. Together, there are about 32 million individuals with food allergies in the U.S. which is approximately 10% of the population. What is even more frightening is that the food allergy prevalence among children has increased dramatically within the last 30 years.

To give proper perspective, more than 40% of children with food allergies have experienced a severe allergic reaction to a food such as anaphylaxis. Pediatric hospitalizations for food allergies went up 3-fold in the last 30 years. Every 3 minutes, a reaction to a food causes someone to go to the emergency room, for a total of approximately 200,000 individuals per year requiring emergency care for allergic reactions to a food.

Although there are more than 170 foods that have been identified to cause food allergy reactions in the U.S., approximately 90% of all food allergies are caused by the same 8 common foods which include egg, milk, peanuts, soy, wheat, tree nuts, fish, and shellfish. Sesame seeds are becoming more common as well. The most common food allergies in children are peanut, milk, shellfish, and tree nuts. The most common food allergies in adults are shellfish, milk, peanut, and tree nuts.

The symptoms that a child (or adult) experiences from a food allergy may include nausea, vomiting, abdominal cramping/pain, diarrhea, swelling (i.e., angioedema) of the lips, throat, tongue, or eyes, hives (i.e., urticaria), shortness of breath, worsening eczema (i.e., atopic dermatitis), generalized itching (i.e., pruritus), wheezing. Of course anaphylaxis is a major concern and all food-allergic children and adults should carry a self-injectable epinephrine device (e.g., EpiPen Jr., EpiPen, Auvi-Q, Adrenaclick) or Neffy, an epinephrine-containing nasal spray. The patient should be instructed to go to the closest emergency room, if they use epinephrine.

To help insure that a food-allergic child can take part in Halloween and still have as much fun as a nonallergic child, although nothing is guaranteed, there is a program run by the Food Allergy Research and Education (FARE) organization called the “Teal Pumpkin Project.” This FARE-sponsored international program has been in existence since 2014.  The Teal Pumpkin Project began in Tennessee by the mother of a child with severe allergies.  The project’s aim is to increase awareness of the severity of food allergies as well as to give support to food-allergic children’s families.  In order to participate in the Teal Pumpkin Project, a pumpkin is painted the color teal and then placed on one’s front porch to indicate that “non-food” treats are available at that location on Halloween night.  The color teal was chosen because it represents food allergy awareness.  Classically, “non-food” treats may include toys, stickers, crayons, necklaces, bracelets, rings, balls, whistles, hair accessories, money, bookmarks, finger puppets, glow sticks, vampire fangs, etc.

It is important to mention that the Teal Pumpkin Project is not exclusionary as it still promotes the option of handing out “normal” trick-or-treat candy to children without food allergies.  It however recommends that the “non-food” items be placed in a different bowl or box than that a traditional candy bowl.  FARE provides a “Teal Pumpkin Project Participation Map” on its website so that participating houses can be easily assessed by the parents of food-allergic children.

Whether or not a family or child participates in the Teal Pumpkin Project, reading labels on foods is of the utmost importance. Most families of food-allergic children know how to read labels on foods and avoid those foods that contain ingredients that their children are sensitized to. However, it is important to note that most “fun-sized” candies handed out while trick-or-treating either do not have any labeling at all or they may contain different ingredients than regular sized packages. Children with food allergies should also be instructed to graciously refuse homemade foods such as cupcakes, brownies, and cookies that may be unsafe for them.

Preventing children with food allergies to trick-or-treat without adult supervision as well as avoiding candies without proper labeling can prevent a life-threatening reaction. As mentioned above, it is a highly recommended that food-allergic children (and adults) carry a self-injectable epinephrine device (e.g., EpiPen Jr., EpiPen, Auvi-Q, Adrenaclick) or Neffy, an epinephrine-containing nasal spray while trick-or-treating or while eating Halloween candy.

The board certified allergists at Black & Kletz Allergy hope that everyone enjoys Halloween. We are here to meet your allergy and asthma needs for the people of the Washington, DC, Northern Virginia, and Maryland metropolitan area. We treat both adults and pediatric patients. We have offices on K Street, N.W. in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. There is on-site parking at each of the 3 offices. Our Washington, DC and McLean, VA locations 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 allergies, asthma, sinus problems, hives, or immunological disorders, please call us to make an appointment. You may also click Request an Appointment and we will get back to you within 24 hours by the next business day. Again, we wish you a Halloween.

Immunizations are one of the most effective and safe ways of preventing or reducing the risk of serious illness from various infections.  Vaccinations also prevent infections from spreading from one individual to another, thus protecting the health and well-being of the general population.  One should always check with one’s primary care provider before getting a vaccine.  The CDC recommends vaccines for adults based on a variety of factors which may include age, travel destinations, sexual activity, health history, occupation, lifestyle, and previous vaccinations.  The CDC currently recommends the following immunizations:

All adults should routinely receive the following vaccines:

Special Situations:

Additional Vaccines:

Pneumococcal Diseases:

• Caused by a bacteria known as Streptococcus pneumoniae
• Mild infections:  Ear and sinus infections
• Serious infections:  Pneumonia (lung), bacteremia (bloodstream), meningitis (brain and/or spinal cord)

There are 2 types of pneumococcal vaccines:

How do you know if your immunizations are up to date?

In order to get the information about the immunizations you have already had, talk to your parents, if possible.  Ask them if they have records of your immunizations that you received when you were a child.  You can also check with your primary care provider and/or pediatrician’s office to see if they have your immunization records on file.

In some circumstances, you may need to check with healthcare organizations where you received care when you were younger.  It may be helpful to check with your schools, employers, or military facility who required immunizations.  You can also contact your state health department to see if it has a registry on file that includes adult immunizations.

If you cannot find your records, your primary care provider or immunization clinic may be able to do bloodwork on you in order to see if you are immune to certain diseases that vaccines can prevent.  You may in fact need to get some vaccines again, depending on the results of the bloodwork.

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 field of immunizations/vaccinations.  Black & Kletz Allergy treat both adults and children and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Please call our office to make an appointment or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy has been serving the Washington, DC metropolitan area for more than 5 decades and we pride ourselves in providing excellent allergy, asthma, and immunology care in a highly professional and pleasant setting.

Milk is one of the most common foods to cause allergic reactions.  Almost 3% of children younger than 3 years of age are allergic to milk.  Notwithstanding, a vast majority of children spontaneously outgrow their milk sensitivities.

CAUSES:

In children with milk allergy, the immune system falsely identifies the protein in the milk as potentially dangerous, and as a result, mounts a defensive attack.  The “pre-formed” milk specific antibodies (i.e., immunoglobulin E or IgE) react with the protein in the milk (i.e., antigen), causing release of chemical substances (e.g., histamine, leukotrienes, prostaglandins) into the tissues.  These chemical substances are what causes the symptoms of allergic reactions. Cow’s milk is the most common cause of milk allergy although milk from sheep and goats can also cause allergic reactions in certain sensitized children.  Children are more likely to have a milk allergy if there is a history of a food allergy in other family members.

SIGNS and SYMPTOMS:

Children usually begin manifesting symptoms of milk allergy within a few minutes after consuming milk products.  In some children, however, symptoms can sometimes be delayed for a few hours.

• Skin itching, hives, and/or swelling of soft tissues
• Redness, itching, and/or tearing of the eyes
• Fullness/tightness in the throat, difficulty in breathing and/or swallowing
• Nasal congestion, itching, sneezing, and/or clear runny nose
• Abdominal pain, cramping, vomiting, and/or diarrhea
• Irritability, restlessness, and/or dizziness
• Drop in blood pressure, and/or loss of consciousness

The severity of symptoms can vary from mild to severe life-threatening anaphylactic reactions, depending on the severity of the allergy.

DIAGNOSIS:

• Comprehensive history taking of the milk reaction with focus on the time of exposure to milk, onset time of symptoms, and progression of symptoms.
• Family history of food allergies
• Skin prick testing with a commercially available milk protein antigen with negative and positive controls.  If the wheal diameter of the milk protein is more than 3 mm. than that of the negative control, the test is considered positive, signifying the presence of IgE antibodies to milk.
• A blood test can also be utilized to detect and measure the quantities of milk specific IgE antibodies and should be obtained for more severe milk reactions.
• Oral challenge with incremental exposure to milk beginning with a tiny amount and slowly increasing the amount at regular intervals while closely monitoring for signs and symptoms of a reaction.  These oral challenges should be undertaken only when trained professionals are readily available to identify and treat possible untoward reactions as soon as they occur.

TREATMENT:

• Total avoidance of milk and dairy products
• Read labels and identify the ingredients of packaged foods
• In cases of accidental exposures, antihistamines can be given orally or by injection if the symptoms are limited to hives and/or itching of the skin.
• If the symptoms are rapidly progressing and/or in case respiratory, gastro intestinal, and/or cardiac symptoms, epinephrine should be injected into the muscle on an urgent basis.  Patients should be prescribed a self-injectable epinephrine device (i.e., EpiPen, Auvi-Q, Adrenaclick) and told to go immediately to the closest emergency room if that device is used.
• Oral immunotherapy is a process of desensitization to milk, which reduces the risk of severe reactions after inadvertent exposure to milk products. This process entails ingestion of small quantities of milk protein in a controlled setting to monitor for reactions.  The amount of milk protein will be gradually increased under close medical supervision.
• Xolair (i.e., omalizumab) injections can be given either every 2 or 4 weeks in order to prevent a severe milk allergy, as well as any other food allergy.

Note:  “Lactose intolerance” is sometimes confused with milk allergy.  Intolerance in this case signifies a difficulty in processing and digesting the sugar in the milk (i.e., lactose) as the enzyme that is needed to break it down (i.e., lactase) is lacking in sufficient quantities.  This process does not involve the immune system and the symptoms are usually limited to the gastrointestinal tract. The typical symptoms may include abdominal bloating, abdominal pain, diarrhea, nausea, and/or vomiting.  These children will be able to tolerate lactose-free milk and dairy products.

PREVENTION:

• Milk allergy itself may not be preventable, due to a genetic predisposition and susceptibility.
• Diligent avoidance of milk and dairy products such as cream, cheese, butter, ice cream, and yogurt may prevent severe reactions.
• Having a self-injectable epinephrine (e.g., EpiPen, Auvi-Q, Adrenaclick) device readily available at all times can reduce the risks of life-threatening anaphylactic reactions.

Close monitoring by a board certified allergist, like the ones at Black & Kletz Allergy, as well as testing for milk allergy at regular intervals, may identify the children who outgrow their milk allergy.  At this point, milk and dairy products may possibly be gradually reintroduced into their diets.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing milk and other food allergies in both adults and children for over 50 years.  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.  The allergists are able to test for milk allergy and most foods which can be done by either blood tests or allergy skin tests.  We offer onsite parking at each one of our locations 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.  If you feel you may have a milk allergy, other food allergy and/or a food intolerance, please call us today to schedule an appointment. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy are eager to help you find out if you are allergic to milk or other foods.  This will allow you live in less fear as you will be able to avoid the offending food as well as have a detailed plan on what to do if you would accidentally ingest the given food.

Generalized itching (i.e., generalized pruritus) is a condition which can be quite annoying.  It is when an individual has diffuse itching of the body usually without an associated rash.  Approximately 20-25% of the general population experiences generalized pruritus at least one time in their life.  The itching may be intermittent or it may be chronic in nature.  “Acute” itching is when the itching has been present for less than 6 weeks.  “Chronic” itching is defined by having it for 6 or more weeks.  The itching may last for years in certain individuals.  The severity of the itching may vary from very mild to very severe where it can interfere with one’s quality of life.  If the itching becomes chronic, it is important to see a board certified allergist, like the ones at Black & Kletz Allergy, so that a cause of the itching can hopefully be identified.  Note that generalized itching may also be associated with hives (i.e., urticaria) and/or swelling (i.e., angioedema).

There are many causes of generalized itching.  Allergies are a very common cause of itching.  Allergies to oral and topical medications, foods, cosmetics, fragrances, metals, shampoos, nail polish, latex, poison ivy, poison oak, and poison sumac are just some of the common allergies that may cause itching.  Contact dermatitis and eczema, (i.e., atopic dermatitis) are 2 other allergic conditions that may cause itching.   Although allergies may be the cause of a lot of individual’s itching, it by no means the only reason for the pruritus.  There are a variety of underlying conditions that may cause a person to have itching even though it may not be the most common symptom of the disease.  Some of the underlying conditions that can cause itching may include diabetes mellitus, hepatitis B, hepatitis C, kidney disease, thyroid disease, malignancy, iron deficiency anemia, dyshidrotic eczema, HIV, folliculitis, ringworm, seborrheic dermatitis, neurodermatitis, shingles, xerosis (i.e., dry skin), psoriasis, bed bugs, parasitic infections, pregnancy, as well as many others.  It is important that a cause be identified so that either the allergen is avoided or the management can be focused on the underlying condition responsible for the itching.

The diagnosis of generalized itching begins with a comprehensive history and physical examination.  By performing a comprehensive history, the allergist is trying to ascertain the cause of the itching.  It is common for a patient to forget or not bring up pertinent information that can help the allergist figure out the cause, so it is important for the allergist to ask a variety of questions in order to try to establish a cause or trigger of the pruritus.  Asking questions such as, “Have been on any recent antibiotics or new medications?” or “Do you take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)?” are good questions because many patients will not volunteer this information because they do not feel that it is important enough to mention to the physician.  In reality, antibiotics, new medications, aspirin, and NSAIDs use are very common reasons for generalized itching.  If no obvious allergen can be identified and the itching has lasted 6 weeks or more, looking for an underlying condition is the next step.  This is usually done by blood tests.

The treatment of generalized itching is directed at avoiding the offending agent.  If for example a new medication appears to be causing the itching, the medication should be stopped or changed to another appropriate medication.  If it is a certain cosmetic or a specific food, then obviously the cosmetic or food should be avoided.  In addition, using oral H1 blockers (i.e., antihistamines) is the most common treatment.  Sometimes, adding an H2 blocker and/or a leukotriene antagonist to the Hi blocker is needed.  Rarely, oral corticosteroids are needed for severe cases.  Topical creams/ointments have been used with limited success.  In most cases, medications may only be needed for 1 or 2 weeks, but can be necessary is some individuals for several years.  If the itching persists for more than 6 weeks and bloodwork is obtained in order to rule out underlying conditions, then treating the underlying condition may in fact get rid of the itching.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating generalized itching for more than 50 years.  We treat both pediatric and adult patients.  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.  To schedule 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 generalized itching, hives, swelling episodes, or any other allergic condition, the allergy specialists at Black & Kletz Allergy are happy to help you.  We are dedicated to providing you with the highest quality allergy care in a relaxed, considerate, and professional environment.

Anaphylaxis is an acute, severe, and life-threatening allergic reaction.  The most common triggers for anaphylaxis include allergenic foods, medications, and insect stings.  Symptoms usually begin within a few minutes of exposure of the triggering agents.  Initially, the symptoms characteristically involve the skin which typically causes itching and hives followed by swelling of the soft tissues.  Unless treated, the reaction may rapidly progress and may involve other organ systems (e.g., respiratory, gastrointestinal, cardiovascular) resulting in symptoms such as shortness of breath, wheezing, coughing, nausea, vomiting, abdominal pain, dizziness, drop in blood pressure, and/or loss of consciousness.

The only effective treatment for anaphylaxis is epinephrine.  If given early in the process, it can stop the reaction from progressing and can be life-saving.  As anaphylactic reactions can occur after accidental exposures anywhere and at any time, it is recommended to have epinephrine readily available at all times for those at risk for anaphylaxis.

Until now, the only form of epinephrine available was an injectable form.  The epinephrine is injected into a muscle either with a syringe and a needle or with an autoinjector device.  There are a few autoinjectors available in different shapes and sizes and dome of the brand names include EpiPen, Auvi-Q, and Adrenaclick.  Autoinjectors are preloaded with different doses of epinephrine suitable for adults and children.  One problem with autoinjectors is that some patients and parents of children at risk for anaphylaxis are not comfortable in using them because they are squeamish about needles.  As a result, a hesitancy in the use of epinephrine can lead to a delay in administering the needed treatment in a life-threatening situation which can be detrimental.

On August 9, 2024, the Food and Drug Administration FDA) approved a new form of epinephrine that is delivered into the nostrils by way of a nasal spray device.  It is called Neffy and it uses the same delivery device used to administer other medications into the nasal cavity such as Narcan, a drug useful in reversing the effects of opiates.

Neffy delivers 2 mg. of epinephrine into the nasal cavity. (Epipen is available in 0.3mg. and 0.15mg. dosage strengths).  In clinical trials, Neffy resulted in comparable blood levels of epinephrine to injectable forms, with a shorter onset of action.  It also showed that it can increase the blood pressure and heart rate rapidly, which are indicators for the reversal of the reaction.

This nasal epinephrine formulation is approved for adults and children weighing 30 kg. (66 lbs.) and above.  Neffy is a single dose nasal spray administered into one nostril.  It is available as a 2-pack, which is similar to injectable forms.  It is recommended to administer the second dose on Neffy from a different device into the same nostril if the anaphylactic symptoms persist 5 minutes after the initial dose.

It is hoped that the nasal spray would remove some barriers for early usage of epinephrine (i.e.  the fear of injections) and thus would meet an unmet need.  The manufacturer says that most commercially insured patients will pay approximately $25 as copay for a 2-pack, while also offering assistance for patients who are not insured.  The medication has a shelf-life of about 30 months and is stable at wide temperature ranges.

Neffy was also studied in patients with nasal congestion due to allergies and infections and it was shown to be well absorbed from the nasal cavity without losing its efficacy.  Note however that Neffy was not studied in patients with nasal polyps and in patients after nasal surgeries, so its efficacy in these patients is currently unknown.

The side effects observed in clinical trial participants included throat irritation, tingling sensation in the nose, runny nose, nasal congestion, headaches, jitteriness, and dizziness. Neffy should also be used with caution in patients with a history of allergic sensitivity to sulfites.

Neffy is expected to be available in the pharmacies in October 2024.

The board certified allergists at Black & Kletz Allergy see bothadult and pediatric patients and have over 5 decades of experience in the field of allergy, asthma, and immunology.  Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We look forward to providing you with the newest cutting edge allergy care in a welcoming and relaxed environment.

As the Summer marches on and we are now in the month of August, many allergy sufferers are about to get ready for another foe, namely ragweed. Usually about August 15th of every year, ragweed pollen begins to blanket the Washington, DC, Northern Virginia, and Maryland metropolitan area like clockwork. The dissemination of ragweed pollen generally comes to an end in our region in late October during the first frost. With the rising temperatures and rising carbon dioxide (CO₂) levels, the ragweed season is now longer than it has been historically and it now may begin as early as early August. Ragweed is a flowering plant and considered a weed. Ragweed is widespread in the U.S., particularly in the Midwestern and Eastern and regions of the U.S. Though many weeds (e.g., cocklebur, mugwort/sagebrush, pigweed, Russian thistle) pollinate in the Fall, ragweed is the most common and predominant allergen in our geographical area. The only state without ragweed is Alaska.  It is typically found in fields, on the side of roads, in vacant lots, and near riverbanks. There are at least 17 species of ragweed in North America. Even though each ragweed plant lives only 1 season, it can produce approximately 1 billion pollen grains, plenty enough to cause havoc amongst allergy sufferers. Increased humidity in conjunction with warm weather and wind enhances the release of ragweed pollen. The ragweed pollen, like other pollens, is transported by the wind and can travel hundreds of miles due to its light weight. The wind causes the ragweed to become airborne for days which provides an easy way for individuals to become sensitized to the ragweed pollen. The ragweed pollen count is typically lowest in the early morning and it tends to reach its highest in the midday.

When a previously sensitized individual has been is exposed to ragweed again in the air, the ragweed proteins trigger specialized cells in the immune system to release increased levels of histamine and other chemical mediators which are responsible for numerous allergic symptoms which is known by the names allergic rhinitis (i.e., hay fever) and/or allergic conjunctivitis (i.e., eye allergies). Some of these symptoms may include runny nose, sneezing, nasal congestion, post-nasal drip, itchy nose, sinus congestion, headaches, itchy throat, fatigue, snoring, itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. In asthmatics, coughing, chest tightness, wheezing, and/or shortness of breath may also occur.

In some ragweed-sensitive individuals, consuming certain fresh fruits or vegetables may cause itching and tingling of mouth, tongue, and throat. This condition is called “oral allergy syndrome” or “pollen-food allergy syndrome” and is a result of the cross-reacting proteins in the pollen and fresh fruits or vegetables. The syndrome is caused by allergens in foods that are derived from plants. Thus, only foods that come from plants can cause the syndrome.  Ironically, when the fruit or vegetable is canned or cooked, the protein is denatured and destroyed which usually prevents the allergic reaction from happening. Most of the time, individuals can tolerate canned and/or cooked fruits or vegetables.

Avoidance is the key to combatting ragweed, if at all possible. Some avoidance measures may include the following:

• Keeping the windows and doors at home as well as the windows in automobiles closed and use air-conditioning.
• Decreasing outdoor activities, especially in the early morning hours when the pollen counts tend to be at their highest.
• Showering to remove ragweed pollen from the skin and hair after coming indoors.
• Washing clothes upon returning from outdoors.
• Nasal irrigation can wash the ragweed pollen from the nasal passages.
• Washing the fur and coats of one’s pets after being outside.

If it is impossible to avoid ragweed using the avoidance measures listed above or one still develops those annoying allergy symptoms, there are some medications available in order to prevent or minimize the symptoms of ragweed allergy. They include oral antihistamines, oral decongestants, leukotriene antagonists, nasal antihistamines, nasal decongestants, nasal anticholinergics, nasal corticosteroids, ocular antihistamines, ocular decongestants, ocular anti-inflammatory agents, and/or ocular mast cell stabilizers. For those patients who have asthma, the treatment may include short-acting beta 2 agonists, long-acting beta 2 agonists, inhaled corticosteroids, leukotriene antagonists, monoclonal antibody injections, and/or oral corticosteroids in more severe cases. In addition to the medications listed above, allergy shots (i.e., allergy immunotherapy, allergy injections, allergy desensitization, allergy hyposensitization) are a very effective tool in the treatment of allergic rhinitis, allergic conjunctivitis, and asthma. They have been given to patients in the U.S. for more than 100 years. Allergy shots work in 80-85% of patients who undergo them. They are typically given for 3-5 years. Allergy immunotherapy will offer the most effective long-term relief of symptoms and can reduce or eliminate the need for medications.

The board certified allergists at Black & Kletz Allergy have 3 office locations in the Washington, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. The McLean office has a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. The allergy specialists at Black & Kletz Allergy diagnose and treat both pediatric and adult patients. For an appointment, please call one of our offices or alternatively, 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 helping patients with hay fever, asthma, sinus disease, hives, eczema, insect sting allergies, food allergies, medication allergies, and immunological disorders for more than 5 decades. If you suffer from allergies, it is our mission to improve your quality of life by reducing or preventing your unwelcome and irritating allergy symptoms.

Contact dermatitis is an inflammation of the skin triggered by a physical exposure to an allergen. These allergens are usually either chemicals or plants. There are 3 plants, (i.e., poison Ivy, poison oak and poison sumac) which account for a vast majority of plant-based allergens. The active allergen is the sap oil (i.e., urushiol) in the roots, stem, and the leaves of the plants.

About half the adult population in the United States develops contact dermatitis after exposure to these plants. Approximately 10 to 50 million people in the U.S. suffer from this condition every year. Certain professions who work outdoors, such as construction workers, farmers, landscapers, and firefighters are at a higher risk to develop plant-induced contact dermatitis than other professions where workers are primarily based indoors. Individuals who have active lifestyles outdoors or who have a hobby or passion that involves the outdoors are also more prone to developing poison Ivy, poison oak and/or poison sumac.

On exposure to one of these plants, the sap oil urushiol penetrates the skin and cause inflammation. The uruahiol can also spread to different parts of the body by direct contact. Pets and other animals can also transfer the allergen from the plants to the human skin. In addition, contact with plant-exposed clothing or garden tools can also result in contact dermatitis.

Symptoms:

The symptoms of poison ivy, poison oak, and/or poison sumac typically begins with a reddish and itchy rash that develops over the exposed area of the skin approximately 1 to 2 days after the exposure. Note that the rash may take up to 2 weeks in some individuals to develop after the first exposure, however, as mentioned above, it typically begins within the first day or two. The rash is usually intensely itchy and may cause a burning sensation in some individuals. In severe cases, fluid-filled blisters may develop and they are usually arranged in linear streaks, a pattern that can be explained by the contact with a branch of leaves touching the skin. The symptoms usually increase in intensity over the next week and the whole episode gradually resolves after 2 to 3 weeks.

Management:

The whole body should be washed with soap and water as soon as possible after exposure to these plants. The oily urushiol should be removed from everywhere before it has a chance to get absorbed. Clothing and other items that were exposed to the plants should be thoroughly washed as well. It is also prudent to bathe any pet that was exposed.

Treatment:

• Wet compresses may help to reduce inflammation and pain.
• Soothing agents such as calamine lotion, zinc oxide, and/or oatmeal baths can reduce irritation and discomfort.
• Topical corticosteroid creams/ointments will help control inflammation and can reduce blistering and itching.
• If more than 20% of the body surface area is involved and/or in case of a severe rash over the face, hands, genitals, etc., systemic corticosteroids (e.g. oral prednisone) may be helpful.
• Antihistamines can offer some marginal relief from itching. First generation antihistamines are usually more effective but should not be used when one needs to be fully alert and awake as they may cause drowsiness and fatigue.
• Occasionally, antibiotics are necessary to treat secondary infections that can occur.

Prevention:

• Identifying and avoiding exposure to poison ivy, poison oak, and/or poison sumac is the only definitive way in preventing plant-induced contact dermatitis.
• Wearing long sleeves, long pants, boots, and gloves before gardening and other outdoor activities can reduce direct exposure to the plant oils.
• Barrier skin creams such as Ivy Block or IvyX applied over the skin before possible exposure may offer some additional protection.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating poison ivy, poison oak, and poison sumac for more than 50 years.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at each location and the Washington, DC and McLean 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.  Please call us today to make an appointment at the office of your choice.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergists at Black & Kletz Allergy pride themselves in delivering the highest quality allergy care in the Washington, DC metropolitan area in conjunction with providing excellent customer service in a welcoming and friendly environment.

Now that it is Summer, mosquitoes are becoming more prevalent in the Washington, DC, Northern Virginia, and Maryland region. Mosquitoes are flying insects that tend to be more widespread where there is standing water. They are more active early in the morning and early in the evening. Female mosquitoes typically lay their eggs in stagnant water. Only the female mosquito bites and feeds on human blood, as they need this blood in order to produce their eggs. Male mosquitoes, on the other hand, feed on water and nectar.  Mosquitoes are considered pests and they are a nuisance to almost everyone who comes in contact with these annoying insects. When a person is bitten, the mosquito injects its saliva into the skin which contains proteins that prevent the human blood from clotting. This allows the blood to be transferred to the mosquito’s mouth without clotting. For the most part, mosquitoes bite people and animals without any symptoms or only very mild local symptoms. For many others however, a mosquito bite can cause a great deal of misery, mostly consisting of irritation, itching, redness, and/or swelling at the site of the bite. In very sensitive individuals, the swelling and redness can become quite large. Occasionally this redness and swelling is accompanied by bruising and/or blisters.

The typical localized itching, swelling, and/or redness of the skin that results from the bite is not directly due to the bite itself, but rather caused by the body’s immune response to the proteins in the mosquito’s saliva. In extremely rare occurrences, an individual with a true mosquito allergy, which by itself is rare, may develop a classic systemic allergic reaction (i.e., anaphylaxis) whereby the bite can trigger a life-threatening allergic reaction. An “allergic reaction” to a mosquito bite is when there is a severe immune reaction against the salivary proteins of the mosquito. As emphasized above, this is very uncommon but these mosquito-allergic individuals may experience generalized itchiness (i.e., pruritus), hives (urticaria), wheezing, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, throat closing sensation, lightheadedness, dizziness, fainting, increased heart rate, and/or drop in blood pressure. A self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) should be prescribed for any person with a true mosquito allergy who have exhibited systemic symptoms in the past. It is important to note that if one uses a self-injectable epinephrine device, they should go immediately to the closest emergency room. Individuals with anaphylaxis or systemic reactions from a mosquito bite should also be referred to a board certified allergist like the ones at Black & Kletz Allergy.

The development of a true allergic reaction from mosquitoes usually progresses as follows:

• Individuals who have never been exposed to a particular species of mosquito do not usually develop reactions to the initial bites from such mosquitoes.
• Subsequent bites result in delayed local skin reactions.
• After recurrent mosquito bites, immediate wheals (i.e., hives) may develop.
• With additional exposure, the delayed local reactions diminish and eventually disappear, although the immediate reactions persist.
• Individuals who are repeatedly exposed to mosquito bites from the same species of mosquito eventually also lose their immediate reactions. They become tolerant to the mosquito bite. This is in essence what happens when an allergy patient receives allergy shots to environmental allergens. The allergy injections cause the individual who may be allergic to dust mites, molds, pollens, or pets become less bothered by these allergens since they develop antibodies to the allergens.

In addition to local and systemic reactions to mosquitoes, one must be concerned about the mosquito-borne diseases that may result from a simple mosquito bite. Some of the diseases that are known to be transmitted by mosquitoes include malaria, West Nile virus, dengue fever, encephalitis, chikungunya, yellow fever, Eastern equine encephalitis filariasis (i.e., elephantiasis), St. Louis encephalitis, Japanese encephalitis, Western equine encephalitis, Zika virus-related illnesses, Venezuelan equine encephalitis, Ross River fever, Rift Valley fever, and La Crosse encephalitis.

Avoiding exposure to mosquitoes is the best solution to prevent mosquito bites. Even if you stay indoors, it is recommended that one install screens in the windows and doors in order to help prevent mosquito exposure. Unfortunately, it is not always easy to avoid them if you plan to leave the house. If you venture outdoors, stay clear of free-standing water as mosquitoes tend to congregate and breed there. Avoid going outside from dusk until dawn, if possible, as mosquito bites occur more often during this time. Wear permethrin-treated clothing as well as light-colored long-sleeved clothing and hats. Use a bed net if sleeping outdoors. Use citronella-scented candles when at outdoor events. Use insect repellent that preferably contains a 10-25% concentration of DEET (N,N-diethyl-3-methyl-benzamide or N,N- diethyl-meta-toluamide). Alternatively, one can use insect repellents containing either picaridin or oil of lemon eucalyptus.

The treatment of run-of-the mill local reactions from mosquito bites vary depending on the severity of the reaction. Applying a cold pack or ice to the affected area is sometimes helpful. Using various creams (e.g., calamine lotion, anti-itch creams, topical antihistamines, corticosteroid creams) topically often give some relief. Oral antihistamines may offer additional relief in certain individuals. As mentioned above, anyone who has had a systemic reaction to mosquito bites should be prescribed a self-injectable epinephrine device and referred to a board certified allergist.

The board certified allergy specialists at Black & Kletz Allergy see patients of all ages and have over 50 years of experience in the field of allergy, asthma, and immunology. Mosquito bites as well as other insect bites (e.g., bees, wasps, yellow jackets, hornets, spiders) are common occurrences that we routinely diagnose and treat. Black & Kletz Allergy has 3 offices 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 and all locations have on-site parking. Our Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To make an appointment, please call us or alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day. The allergists at Black & Kletz Allergy are happy to answer any questions or concerns you may have about any allergic, asthmatic, or immunologic issue.

Grass pollen allergy is a very common environmental allergy. Grass pollinates in at different time of the year depending on where in the U.S. one is located. In the Northeastern and Mid-Atlantic regions of the U.S., grass pollinates from the Spring through the Summer. In the Washington, DC, Northern Virginia, and Maryland metropolitan area specifically, grass predominantly pollinates begins in April and generally lasts until the end of August, however, the peak pollination tends to be from May through the end of June. It should be noted that in some parts of the U.S. (e.g., the Southern U.S.), grass pollinates all-year long. It is a perennial allergen. Approximately 10-30% of the U.S. population is allergic to grass pollen. There are many species of grasses in the U.S. and many of them cross-react with each other, meaning that if you are allergic to one species of grass, you are likely to be allergic and bothered by other species of grasses.

There are many types of grasses and they are categorized by what family and subfamily of grasses they encompass. In the grass family Poaceae, there are several subfamilies that contain highly allergenic grasses. Pooideae is the largest subfamily of the grass family Poaceae. The common grasses associated with this subfamily include Orchard, Timothy, Kentucky blue, Sweet vernal, Red top, Meadow fescue, and June grasses. The common cereal grasses (e.g., rye, barley, oat, wheat) are also members of the grass family Poaceae. Panicoideae is a subfamily of Poaceae too and is comprised of many grasses with the most notable allergenic grasses being Bahia and Johnson grasses. Chloridoideae is also a subfamily of Poaceae and the most allergenic grass from this subfamily is Bermuda grass. Bermuda grass, however, tends to grow and pollinate primarily in the Southern U.S. where there are warmer temperatures.

The classic symptoms that an allergic individual who has allergic rhinitis (i.e., hay fever) to grass pollen may experience are the same symptoms that one would experience with any other pollen, dust mite, mold, or pet allergy. The characteristic symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, snoring, hoarseness, sinus headaches, sinus congestion, itchy ears, clogged ears, itchy eyes, watery eyes, redness of the eyes, puffy eyes, chest tightness, wheezing, coughing, and/or shortness of breath. In allergic individuals who are very allergic, contact with grass may cause hives and itchy skin. It should be noted that in extreme cases, it has been reported that very sensitive grass-allergic individuals can develop anaphylaxis upon scraping their skin with grass. This unusual anaphylactic reaction tends to occur while playing certain sports that are played on grass such as soccer, football, and baseball.

In addition to the above allergic rhinitis symptoms, some individuals with grass pollen allergies may experience itching of the mouth, throat, tongue, and/or lips due to a reaction to a protein in certain fresh fruits, vegetables, and/or nuts. The protein in the fresh fruits, vegetables, and/or nuts looks very similar to the allergenic protein found in grass pollen. The most common fruits and vegetables that cause these symptoms in grass-allergic individuals include melons (e.g., cantaloupe, honeydew, watermelon), tomatoes, and potatoes. These individual’s immune systems “see” the protein in these foods as the same protein found in grass pollen even though they are not actually the same proteins. As a result, the grass-allergic patient reacts to the food proteins because it is so similar to the grass pollen protein. This condition is called oral allergy syndrome or pollen food allergy syndrome. Note that if the food is cooked (i.e., heated), the protein of the food is denatured (i.e., broken down), and as a result, the individual can tolerate the food without having the mouth, throat, tongue, and/or lips symptoms. It is also interesting to note that oral allergy syndrome also occurs in individuals with tree pollen and ragweed pollen allergies.

The diagnosis of grass pollen allergy begins with a board certified allergist like the ones at Black & Kletz Allergy performing a comprehensive history and physical examination from the patient. Allergy skin testing or blood testing is usually done in order to identify specific allergens as the cause of the allergy symptoms. Pulmonary function tests may also be performed if one’s symptoms are indicative of asthma or the patient has a history of asthma.

The treatment of grass allergies begins with prevention and avoidance. The patient should try to avoid contact with grass by minimizing yardwork and lawn mowing, if possible. Removing one’s clothing and shoes when coming indoors after being outside may be helpful. Taking a shower after being outdoors for a prolonged period of time is also recommended. Wiping down or washing the fur of one’s pets after they are outside is also suggested.

Medications are usually the next step in the treatment of grass pollen allergy. Oral medications may include antihistamines, decongestants, and leukotriene antagonists. Nasal medications may include corticosteroids, antihistamines, and anticholinergics. Ocular medications may include antihistamines, decongestants, and mast cell stabilizers. Ocular corticosteroids are only used for severe ocular allergy symptoms due to the potential for long-term side effects. Oral corticosteroids may also be utilized but again reserved for recalcitrant and difficult to treat allergy symptoms. As with ocular corticosteroids, oral corticosteroids can also cause long-term side effects and are used judiciously.

Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) is often used to treat pollen allergies as well as dust mite, mold, and pet allergies. They are effective in 80-85% of the patients who take allergy shots. The average length of time on allergy immunotherapy is typically 3-5 years.

The board certified allergists at Black & Kletz Allergy have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and treat both children and adults with grass allergies. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Black & Kletz Allergy offers on-site parking at each of their 3 office locations and the Washington, DC and McLean, VA offices are also Metro accessible. There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To make an appointment, please call our office or you can click Request an Appointment and we will respond within 24 hours on the next business day. Black & Kletz Allergy has been serving the allergy and asthma needs of the Washington, DC metro area community for more than 5 decades and we strive to offer high quality allergy and asthma care in an empathetic and professional atmosphere.

In order to understand conjunctivitis, one must first understand a little about the anatomy of the eye as well as a little physiology of the way eyes become lubricated. The conjunctiva is the thin transparent membrane that lines the inside of the eyelids (i.e., palpebral area) and the front of the eyeballs (i.e., bulbar area). The lacrimal glands, which are located in the outer corners of the eyes, secrete tears which lubricate the eyes. These tears then drain into the nose via tear ducts from the inner corners of the eyes. Inflammation of the conjunctival membrane is called conjunctivitis. There are several conditions which cause inflammation of the conjunctiva which are as follows:

Viral infections – Viral infections are the most common cause of conjunctivitis. Several types of viruses can cause infections of the eye. Most viral infections are highly contagious and spread by contact with the infected individual’s eye secretions. The most common viruses that cause “cold-like” symptoms are primarily responsible for the majority of conjunctival infections. It should be noted that eye infections and upper respiratory infections often co-exist.

The symptoms of viral conjunctivitis may include redness (i.e., “pink eye”), watery discharge, feeling of grittiness, and/or a burning sensation in the eye. Occasionally the discharge becomes mucus-like and the eyelids can stick together with dried and crusted secretions primarily in the mornings. The symptoms usually begin in one eye and then may spread to the other eye after approximately 1 to 2 days.

The symptoms usually become progressively worse for 2 to 3 days and then begin to gradually decrease in intensity over the next 4 to 5 days. It may take 1 to 2 weeks for total resolution of the symptoms to occur.

The treatment of viral conjunctivitis may include the application of an eye drop containing an antihistamine and/or decongestant which is typically used 2 to 3 times a day for no more than 3 to 4 days at a time. Oral antihistamines and analgesics may also be helpful if respiratory symptoms are also associated. Warm or cool compresses can help to relieve any accompanying discomfort. Despite any relief these medicines may bring, these measures do not reduce the duration of the illness, as there is no specific curative treatment for the virus which is the causative agent in viral conjunctivitis.

Bacterial infections – Bacterial infections causing conjunctivitis are also highly contagious spreading by contact with conjunctival secretions and transmitted through objects (i.e., fomites). Usually, several members of a family or several children in a school are infected at the same time. Bacterial conjunctivitis is more common in children than in adults.

The most common symptoms of bacterial conjunctivitis include redness and a thick discharge from one eye, although both eyes can become infected. The discharge may be white, yellow, or green, and it usually continues to drain throughout the day. The affected eye often is “closed shut” in the mornings.

The treatment of bacterial conjunctivitis may include the application of an antibiotic eye drop or antibiotic ointment several times a day. It is also important to maintain good hand and eye hygiene so that it will not spread to the other eye or to other individuals. Ointments are preferable in children and should be applied in the space between the lower eyelid and the eyeball.

The ocular symptoms usually improve on their own even without treatment, but topical antibiotics can reduce the duration of the illness in some individuals. Vision may be blurred for up to 30 minutes after the application of the ointment as the ointment is thick. Contact lens wearers should avoid using their lenses for a few days.

Allergic conjunctivitis – Allergic conjunctivitis caused by the contact of aeroallergens in the environment with the eyes. The symptoms may include severe itching, redness, watery eyes, and in severe cases, blurring of vision and swelling of the eyelids. These symptoms are made worse by rubbing the eyes, however, allergic conjunctivitis is not contagious.

Allergic conjunctivitis can be “seasonal” (i.e., caused by tree and grass pollens in the Spring and/or weed pollens in the Fall) or “perennial” (i.e., caused by indoor allergens such as dust mites, mold spores and/or animal allergens). The symptoms may also be acute or chronic. Allergic conjunctivitis may also be associated with other atopic conditions such as hay fever (i.e., allergic rhinitis) and/or eczema (i.e., atopic dermatitis).

The treatment of allergic conjunctivitis may include the application of an eye drop containing an antihistamine and/or vasoconstrictor which is usually instilled 2 to 3 times a day for relief of the itching and redness. It should be noted that these drops should not be used for more than 3 to 4 days at a time. Eye drops that have both antihistaminic as well as mast cell stabilizing properties may be used for a longer course of treatment, if needed. Very severe symptoms not responding to these agents may require treatment with a corticosteroid eye drop for a few days.

Oral antihistamines can help relieve other associated symptoms such as itching and excessive sneezing. Lubricant eye drops are also useful in moisturizing the eyes while simultaneously reducing discomfort due to dry eyes.

Avoiding exposure to the pollen in the Spring and Fall, as well as employing environmental controls in order to minimize exposure to indoor allergens (e.g., dust mites, molds, animals) will help reduce the severity of both allergic conjunctivitis and allergic rhinitis symptoms. It should be pointed out that most patients will experience long-term benefit with allergen desensitization (i.e., allergy shots, allergy injections, allergy hyposensitization) treatments by building up a tolerance to the common allergens. Allergy shots are effective in 80-85% of the patients that take them. The average length of time that an individual is on allergy injections is 3 to 5 years.

Other causes of conjunctivitis may include adverse reactions to medications and preservatives, as well as a foreign body in the eye.

Preventive measures recommended in order to reduce the spread of conjunctivitis include avoidance of sharing handkerchiefs, tissues, towels, pillows, and sheets with uninfected people, as well as using frequent and proper hand-washing techniques and/or using alcohol-based hand rubs.

The board certified allergists at Black & Kletz Allergy have 3 locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. The McLean office has a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. The allergy doctors of Black & Kletz Allergy diagnose and treat both adult and pediatric patients. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy have been helping patients with allergic conjunctivitis, hay fever, asthma, sinus disease, eczema, hives, insect sting allergies, immunological disorders, medication allergies, and food allergies for more than 5 decades. If you suffer from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.

Summertime in the metropolitan Washington, DC, Maryland, and Northern Virginia area, brings a lot of allergies for allergy sufferers. For most of us, we see the coming of Summer as a beautiful event every year because of the warmer weather and longer days it brings us. People with allergies however see the coming of Summer as a mixed bag of good and bad. Even though they may be happy with the advantages of warmer weather and daylight savings time, they are not so happy with the allergy symptoms that also occur at the same time.

In the Washington, DC metro area, tree pollens are released in the early Spring and may persist until early-June. In fact, the beginning of the tree season has come earlier and earlier over the last decade. Tree pollen is often detected in mid-February and occasionally has been seen as early as January in the Washington, DC regional area. Grass pollen usually begins to be seen in May and typically can be found throughout the Summer lasting until August. In addition, molds are seen throughout the Summer, particularly in the Washington, DC area which was built on a swamp. The humid weather is an aggravating factor for allergies and a “friend” of mold growth. Also keep in mind that normal indoor allergens such as dust mites, pet dander, and cockroaches are still present in the Summer and thus still play a major role in affecting allergic individuals in the Spring, as well as the rest of the year.

The allergies that individuals have in the Summer are referred to as allergic rhinitis (i.e., hay fever) and/or allergic conjunctivitis (i.e., eye allergies). These allergy symptoms may include sneezing, runny nose, itchy nose, nasal congestion, post-nasal drip, itchy throat, sinus congestion, sinus headaches, fatigue, snoring, itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. Hay fever is an interesting name because individuals with hay fever do not get a fever and they are not necessarily allergic to hay. It was initially called hay fever because hay is typically harvested in the Fall and many people had allergy symptoms in the Fall. It just so happens that ragweed pollinates at the same time that hay is harvested in the Fall, so the words hay fever actually refer to ragweed allergies in the Fall. Likewise, the words rose fever refers to tree pollen allergies. Similarly to the term hay fever, patients with rose fever had no fevers and they were not allergic to roses. It just so happens that roses bloom in the Spring when trees and grasses pollinate. Thus, rose fever refers to the Spring allergies caused by the release of tree and grass pollen.

Asthmatic individuals may experience chest tightness, wheezing, coughing, and/or shortness of breath in the Summer. In addition to the increased humidity found in the Washington, DC metropolitan area, more exercise, excessive heat, and increased air pollution (i.e., smog) are factors that occur more often in the Summer than that of other seasons. These factors may trigger or exacerbate asthma in certain sensitive individuals.

The diagnosis and treatment of Summer allergies and/or asthma begins with a comprehensive history and physical examination. Allergy skin testing or allergy blood testing is frequently done in order to identify the aeroallergen responsible for causing the annoying allergy symptoms. Medications are usually prescribed which may include oral antihistamines, nasal corticosteroids, oral decongestants, leukotriene antagonists, nasal antihistamines, nasal anticholinergic agents, eye drops, inhaled corticosteroids, and inhaled beta-agonists. In cases of perennial, multi-seasonal, and/or severe symptoms, allergy injections (i.e. allergy shots, allergy immunotherapy, allergy desensitization, allergy hyposensitization) to the responsible allergens usually provide long-term benefits and reduces the need for allergy or asthma medications.  Allergy shots are effective in 80-85% of patients and are generally taken for 3-5 years.

In addition to environmental allergies (i.e., pollens, molds, dust mites, pets), venomous stinging insect reactions are more common in the Summer than that of other months. Honey bees, yellow jackets, wasps, yellow-faced hornets, and white-faced hornets are the stinging insects native to the Washington, DC metro area. In other warmer and more southern areas of the U.S., the fire ant is a stinging insect that may also cause serious anaphylactic reactions. Anaphylactic reactions to individuals with insect sting allergies may be life-threatening and it is important to see an allergist if one has a reaction to a venomous flying insect sting. The board certified allergist, like the ones at Black & Kletz Allergy will evaluate the stinging victim with allergy testing to the stinging insects and then recommend a course of treatment. This treatment may range from a prescription for a self-injectable epinephrine device (i.e., EpiPen, Auvi-Q, Adrenaclick) to a prolonged course of allergy shots with insect sting venoms (i.e., venom immunotherapy) depending on the patient’s reaction history.

The board certified allergy specialists at Black and Kletz Allergy have been diagnosing and treating allergies, asthma, and insect sting allergies for more than 5 decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We see 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 allergies, asthma, and/or insect sting allergies, please call one of our offices to schedule 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 treatment modalities in a amiable, considerate, and professional environment.

Asthma is a chronic inflammatory disorder affecting the lower respiratory tract. The lower respiratory tract includes the muscular tubes that carry air in and out ofthe lungs as well as the tissues in the lungs where gas exchange takes place. The inflammation found in individuals with asthma is usually associated with inflammation of the upper respiratory tract, which includes the nose and the sinuses.

The symptoms of asthma may include a feeling of chest tightness or heaviness in the chest, wheezing (i.e., high-pitched whistling type of noise during breathing), coughing, and/or shortness of breath/difficulty in breathing. The frequency of these symptoms varies depending on the severity of the asthma. The symptoms can be intermittent or persistent. The severity is also classified as either mild, moderate, or severe. Asthma usually begins in childhood, although it can also be diagnosed for the first time in adulthood. The course of asthma is variable. The symptoms can be mild, moderate, severe, frequent, infrequent, intermittent, and/or persistent at various times throughout one’s life.

The underlying cause for most cases of asthma is a genetic predisposition. However, several factors in the environment play a role in determining the frequency and severity of asthma symptoms. These external factors “trigger” flare-ups or exacerbations of the condition in most individuals.

Common triggers of asthma:

1. Infections: Both upper and lower respiratory infections, especially the ones caused by viruses, are notorious for triggering and aggravating asthma leading individuals to visit emergency departments. In some cases, hospitalizations are required in order to treat the patient effectively. Several viruses such as rhinoviruses, adenoviruses, myxoviruses, and coronaviruses are well-known to exacerbate asthma. Frequent hand washing, avoiding exposure to “sick” people, and timely immunizations to viruses and bacteria (e.g., influenza, coronavirus, respiratory syncytial virus (RSV,) shingles, pneumococcus) can minimize the risk of asthma flare-ups.

2. Allergens: In sensitized individuals, exposure to indoor allergens (i.e., molds, dust mite, animal dander, cockroaches), and outdoor allergens (i.e., tree pollen, grass pollen, weed pollen) could set off more frequent and more severe asthma symptoms. Environmental controls and allergy desensitization with allergen injection therapy (i.e., allergy shots, allergy immunotherapy, allergy hyposensitization) is very helpful to better control and prevent asthma symptoms, as they are effective in 80-85% of the patients that take them.

3. Irritants: Dry air, cold air, excessive humidity, smoke, pollution, chemical aerosol sprays, fragrances, colognes, and other strong odors may irritate the airways of the lungs and result in exacerbations of asthma. As these irritants cannot be “desensitized” by traditional allergy immunotherapy, avoidance is the key to reducing the risks of more severe asthma when irritants are the trigger.

4. Physical Exertion: Exercise can trigger acute attacks of asthma in certain individuals. Proper conditioning, regular use of preventive maintenance medications, and receiving bronchodilator inhaled medications prior to exercise can all help to reduce asthma exacerbations that are caused by physical exertion.

5. Occupational Asthma: Hairstylists, bakers, farmers, welders, seafood processors, textile workers, carpenters, pharmaceutical workers, chemical manufacturers, food processors, animal handlers, metal workers, painters, and adhesive handlers are at increased risk for asthma flare-ups as they may inhale harmful gases, fumes, chemicals, dyes, plastics, metals, enzymes, dust, animal proteins, and/or other particulates. These substances are known to cause wheezing, coughing, and/or shortness of breath in certain occupations, as well as exacerbations in asthmatics in individuals who work there.

The diagnosis and treatment of asthma begins with the allergist performing a comprehensive history and physical examination. The diagnosis is further enhanced by obtaining a pulmonary function test. Occasionally a chest X-ray may be needed to rule out other respiratory diseases. Allergy skin testing or blood testing is often done since both indoor and outdoor aeroallergens are often a trigger in many asthmatics. The treatment of asthma begins with prevention. It is advisable for an asthmatic individual to try to avoid triggers that are known to cause or exacerbate their asthma symptoms. Medications are utilized in the management of asthma in most asthmatics. Every asthma patient should have a short-acting beta2 agonist rescue inhaler rescue medication (e.g., albuterol, ProAir, Proventil, Ventolin, Xopenex, levalbuterol, pirbuterol, Maxair, AirSupra) on hand to use if symptoms develop or to use prophylactically before exposure to a known trigger such as exercise. In addition, many patients will need other medications in order to control their asthma symptoms. Some other medications used to treat asthma may include, inhaled corticosteroids, inhaled long-acting beta2 agonists, oral leukotrienes, oral phosphodiesterase inhibitors, oral beta2 agonists, and biologicals . Allergy injections, as mentioned above may also be beneficial in the treatment of asthma as it helps reduce and prevent allergic triggers such as dust mites, molds, pollens, pets, and cockroaches. It is important to note that the treatment of asthma is individualized as it differs with each individual depending on the patient’s symptoms, frequency of symptoms, severity of symptoms, triggers, medications tried in the past, and the patient’s underlying conditions.

The board certified specialists of Black & Kletz Allergy always strive to keep abreast of new developments in the field of Allergy, Asthma, and Immunology in order to offer new and emerging diagnostic and therapeutic modalities, as soon as they are available. Black & Kletz Allergy has 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA and offer on-site parking at each location. In addition, the Washington, DC and McLean offices are Metro accessible. There is a free shuttle that runs between the McLean office and the Spring Hill metro station on the silver line. The allergy doctors of Black & Kletz Allergy see both children and adults in the Tysons Corner, VA, McLean, VA, and Manassas, VA areas and we have been serving the greater Washington metropolitan area for over 50 decades. Please call one of our convenient offices to make an appointment or alternatively, you can click Request an Appointment and we will reply within 24 hours by the next business day.

As we enter into Spring, not only should allergy-sensitive individuals be on the lookout for those annoying pollen allergy symptoms, but they should be aware of their surroundings for venomous flying insects. In the Washington, DC, Maryland, and Northern Virginia metropolitan area, the most common venomous flying insects are honey bees, wasps, yellow jackets, white-faced hornets, and yellow-faced hornets. The summer months are the peak months that insect stings occur. In the U.S., about 3% of the population experience allergic reactions to the venom of flying insect stings. Approximately a half a million individuals seek emergency room care every year for insect sting reactions in the U.S. Unfortunately, there are roughly 50 deaths reported each year from these insect sting reactions.

Honey bees live in “honeycombs” or colonies that are found in crevices of buildings or in hollow trees. Yellow jackets, on the other hand, generally nest underground and are rarely seen in the cracks in buildings or in trees. Hornets produce brown or grey oval-shaped nests above the ground which are typically located in the branches of trees or in shrubs. Wasps make nests that are made up of a paper-like material which may also be found in shrubs, but are also common under eaves and behind window shutters.

Honey bees, wasps, yellow jackets, white-faced hornets, and yellow-faced hornets all inject their venom into their subjects when they sting their prey. If a sensitive individual has an allergic reaction to a sting, they may develop either a local reaction or they may develop a more serious systemic reaction. A local reaction usually entails redness, itching, and/or swelling at the site of the sting. A systemic reaction, on the other hand, may include generalized itching, hives, swelling, chest tightness, shortness of breath, wheezing, throat tightening, abdominal cramping, fainting, and/or a drop in blood pressure. Patients with reactions are prescribed self-injectable epinephrine devices (e.g. EpiPen, Auvi-Q, Adrenaclick) so that they can be used immediately. A person who has used a self-injectable epinephrine device should immediately go to the closest emergency room.

After a sting, in some instances, an individual may have toxic (i.e., non-allergic) reaction instead of an allergic reaction, particularly if stung by several insects at once. In a toxic reaction, the body reacts to the venom as if it was a poison. This typically occurs because the individual is exposed to an over-abundance of venom at one time. A toxic reaction may cause symptoms similar to those of an allergic reaction, but in addition, may cause non-allergic symptoms such as nausea, fever, and/or seizures.

It is interesting to note that of all the venomous flying insects mentioned above, only the honey bee leaves the sting in the victim. If you are stung by a honey bee and notice the stinger stuck in your skin, you should not pull it out, as doing so may cause more of the venom to be introduced into your body. The recommended way to remove the stinger is to scrape it off with something like your fingernails, a credit card, or other flat surface. It should also be noted that honey bees will die after stinging their victims because their stingers have barbs. After stinging, as the bees try to withdraw their stingers from their prey, their abdomens rupture causing a large hole which causes the demise of the bees. It is also interesting to be aware that, in general, bumblebees do not sting. They can sting but it is uncommon. They tend to sting only when the feel threatened. Since a bumblebee’s stinger has no barbs and is therefore smooth, it does not die after stinging its prey, since their abdomens are not ruptured after stinging. Another interesting fact is that only female bumblebees can sting, as their stingers are used as a modified egg-laying device which is only present in females.

One other well-known venomous insect to bring up is the fire ant. Fire ants bite their victims. The typical reaction to a fire ant is that of a local burning pain with an accompanying red bump that can turn into a white fluid-filled pustule within a day or two. Occasionally individuals are very sensitive to the venom and will manifest systemic symptoms such as generalized itching, hives, swelling, chest tightness, shortness of breath, wheezing, throat tightening, abdominal cramping, fainting, and/or a drop in blood pressure, just like with venomous flying insects. Fire ants of course do not fly. In addition, they do not pose a large threat to residents of the Washington, DC metro area because they live in the warmer climates of the southern U.S., although they have been found in Virginia and Maryland. At least for now, fire ants are not prevalent as far north as Washington, DC, but who knows what will happen in the future, especially if global warming takes more of a stronghold.

The diagnosis of a venomous insect sting allergy is performed by board certified allergy specialist like the ones at Black & Kletz Allergy. The allergy doctor will complete a comprehensive history and physical examination. Depending on the patient’s history, allergy testing to flying insects is usually the next recommended step. Allergy testing is usually performed by allergy skin testing, although blood testing is occasionally done depending on the patient’s history.

The treatment of venomous flying insect sting allergy consists of venom immunotherapy (i.e., allergy desensitization, allergy shots, allergy injections). If the results of the skin testing are positive to any of the stinging insect venoms, it is highly recommended that the patient complete a course of venom allergy immunotherapy as it is extremely effective in preventing further anaphylactic reactions from venomous flying insect stings. Venom allergy immunotherapy involves receiving increasingly greater doses and volumes of insect venom to the patient weekly over a period of 10 weeks, then every 2 weeks for 1 dose, then every 3 weeks for 1 dose, then a maintenance dose every 4 weeks for 1 year, and then the maintenance dose can be reduced to every 6 weeks for several more years. This maintenance dose is roughly equivalent to the amount of venom in an actual sting of a flying insect. In addition to venom immunotherapy, all patients who are allergic to any of the venomous flying insects should carry a self-injectable epinephrine devices (e.g. EpiPen, Auvi-Q, Adrenaclick) as mentioned above. A patient who has used a self-injectable epinephrine device should immediately go to the closest emergency room.

The board certified allergists at Black & Kletz Allergy have expertise in diagnosing and treating venomous flying insect allergies. We are board certified to 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 insect sting allergies, Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a comfortable, thoughtful, and professional environment.