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Month: May 2021

New Treatment for Eczema

Eczema, eczematous dermatitis or atopic dermatitis is a chronic inflammatory condition affecting the largest organ of our bodies, the skin. It is a common long-term disorder which affects about 10-12% of children and 1-2% of adults. In 60% of the cases, onset occurs during the first year of life. The incidence of eczema seems to be increasing in the past few decades and it is more prevalent in developed countries compared with developing countries. Atopic dermatitis is strongly associated with other atopic disorders, such as allergic rhinitis and asthma, with 50-80% of children exhibiting concurrent atopic manifestations.

Genetic factors are predominantly implicated in the causation of eczema, but environmental factors such as allergic sensitivity to certain foods and aeroallergens can play a role in aggravating the condition. In most individuals with eczema, the disease follows a remitting and relapsing course throughout one’s life. Exposure to heat, humidity, and other physical factors may also trigger a flare-up of disease activity.

The hallmark of this condition is a disturbance of epidermal-barrier function due to recurrent skin inflammation, which leads to dry skin, pruritis, and IgE-mediated allergen sensitization. Skin lesions may then lead to increased risks of secondary bacterial and/or viral infections.

In addition to generalized dryness of the skin and scattered rashes over the trunk and extremities, incessant itching is usually the most bothersome symptom. It adversely affects the school performance in children and productivity at work in most adults. Uncontrolled atopic dermatitis may also interfere with nighttime sleep and in general, may have a negative impact on one’s quality of life.

Though there is no cure yet for atopic dermatitis, several treatment options are available to control the activity of the disease process and minimize the intensity of symptoms. Traditional management approaches include:

  • Emollients – These are moisturizing lotions which hydrate the skin in order to relieve the dryness. They need to be applied all over the body when the skin is still wet after a shower or a bath. They seal the moisture into the skin.
  • Topical creams/lotions/ointments – Given in order to reduce inflammation. Corticosteroids are the most common topical anti-inflammatory medications used to reduce the severity of the rash. These agents are available in various strengths and forms. Generally low to medium strength steroids are preferable in order to minimize the side effects such as thinning of the skin and susceptibility to infections. Ointments are preferred to lotions as they can remain on the skin for longer periods. Typically, they are applied twice a day over the affected area for only up to 10 days duration in order to minimize the risks of adverse effects. Ideally, they should not be used over sensitive areas of the body such as the face or groin where they can cause more troublesome side effects such as hypopigmentation. Corticosteroid use in such sensitive areas may also cause higher systemic absorption.
  • Non-steroidal topical anti-inflammatory medications – Protopic (i.e., tacrolimus) and Elidel (i.e., pimecrolimus) are non-steroidal topical anti-inflammatory ointments which are alternative medications to topical steroid medications in the treatment of eczema. They can be used long-term but carry a “black box” warning, as some tumors were noted in rodents exposed to these agents.
  • Eucrisa – A topical agent approved for the treatment of atopic dermatitis. It is available as a 2% ointment and it can be safely used over the face, as it does not cause steroid-related side effects.
  • Dupixent – A biological injectable medication approved for the treatment of uncontrolled asthma as well as atopic dermatitis uncontrolled with topical agents. It works by blocking inflammatory mediators such as IL-4 (i.e., interleukin 4) and IL-13 (i.e., interleukin 13), which contribute to the severity of the disease. The medication is injected under the skin every 2 weeks. The first injection is usually administered in a physician’s offices under close observation and patients are then trained for self-administration of subsequent doses at their homes. Side effects of this Dupixent may include redness and watering of the eyes.
  • Antihistamines – Usually utilized for the control of itching in individuals with eczema. First-generation antihistamines [e.g., Benadryl (i.e., diphenhydramine), Atarax (i.e., hydroxyzine)] are generally more effective at relieving the pruritus (i.e., itching) but they are more likely to cause sleepiness. Second-generation antihistamines (e.g., Claritin, Allegra, Zyrtec) are generally not as effective as the first-generation ones for itching but are less sedating and can be dosed once a day.
  • Oral corticosteroids – Prednisone, an oral corticosteroid, is occasionally used for short-term bursts to control acute flare-ups of the disease. They are not suitable for long-term use due to the risks of adverse side effects.
    Systemic immunosuppressants – Cyclosporine, azathioprine, and methotrexate are immunosuppressants that are rarely used. They are occasionally utilized in order to control severe disease activity; however, their toxicity limits their utility.

As we understand the mechanisms of inflammation in atopic dermatitis in more detail, we are able to target more chemical mediators of disease activity in order to reduce the severity of the symptoms.

Recently, Janus kinase inhibitors or JAK inhibitors have emerged as a novel therapeutic intervention for inflammatory diseases. JAK are intracellular secondary enzyme messengers that transmit extracellular cytokine signaling to the STAT pathway. Inhibition of the JAK-STAT pathway can suppress inflammation and inhibit immune cell activation.

Some of these novel medications which inhibit JAK are currently being used for rheumatological diseases such as rheumatoid arthritis. They are being studied for control of severe atopic dermatitis and clinical trials are revealing very promising results. These JAK inhibitor medications are small molecule agents that are available in both oral [upadacitinib (i.e., Rinvoq), baricitinib (i.e., Olumiant)] and topical [tofacitinib (i.e., Xeljanz)] formulations.

Though none of these medications are yet approved by FDA for the treatment of atopic dermatitis, they remain a promising new therapeutic modality for patients with eczema. They are shown to rapidly and significantly relieve itching as well as reduce the severity of skin lesions.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating eczema 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 locations 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 eczema or other allergic skin conditions, allergies, asthma, or immune disorders, we are here to help alleviate these undesirable symptoms that have been so troublesome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

Tinnitus – Can It Be Caused by Allergies?

Do you hear ringing, roaring, clicking, buzzing, humming, or hissing sound in your ear or ears? If the answer to this question is yes, then you suffer from a condition called tinnitus. Tinnitus is a disorder in which one classically hears a “ringing” of the ears. As mentioned above, the ringing may also be described as roaring, clicking, buzzing, humming, or hissing. The noise level may be anywhere from very mild to fairly severe. The noise heard is not an external sound but rather in internal sound, not heard by others. Tinnitus affects between 10-20% of the population. It is generally described as a very annoying symptom to those who have had it. Tinnitus is more common in the elderly and can affect one ear or both ears. It can be constant or intermittent. It is more common in the elderly and usually occurs in the presence of another underlying condition such as hearing loss. Some of the underlying conditions that are known to cause tinnitus may include:

  • Hearing loss – Usually caused by loud noises and due to broken hair cells in the inner ear. The hair cells usually move when sound waves are transmitted to the ear. Broken hair cells will interfere with the brain’s interpretation of the sound heard.
  • Ear infections – Fluid build-up will increase the pressure in the ear which can cause tinnitus.
  • Clogged ears – The pressure in the ear can increase from clogged ears due to a foreign body which is not uncommon in children, high altitudes, diving, Eustachian tube dysfunction, acoustic neuroma, or ear wax (i.e., cerumen).
  • Acoustic neuroma – A noncancerous tumor that grows on the main nerve between the ear and the brain.
  • Muscle spasms in the inner ear – The muscles in the inner ear can spasm for unknown reasons that may cause tinnitus.
  • Otosclerosis – Hardening of the bones of the middle ear can lead to tinnitus.
  • Sinus infections – Fluid build-up in the ears or increased pressure of the ears as a result of a sinus infection.
  • Eustachian tube dysfunction – When the Eustachian tube becomes partially or fully blocked, one may develop an ear fullness sensation as well as popping or clicking of the ears. As a result, tinnitus may develop.
  • Ménière’s disease – A build-up of fluid in the compartments of the inner ear, called the labyrinth, is thought to be the cause of this malady. Individuals develop tinnitus, vertigo/dizziness, and hearing loss.
  • Allergies [i.e., allergic rhinitis (hay fever)] – Allergies cause tinnitus usually by causing fluid in the ear or by causing blockage of the Eustachian tubes. In addition, allergic individuals are more likely to have sinus disease.
  • Temporomandibular joint (TMJ) conditions – The TMJ shares some ligaments and nerves with the middle ear. The chewing muscles are also near some of the muscles that insert into the middle ear. Together, these factors may affect hearing.
  • Heart disease – Certain heart problems can increase the blood flow pressure and cause one to have tinnitus.
  • Blood vessel disease – High blood pressure, atherosclerosis, and abnormalities of the blood vessels can cause a higher pressure in the blood vessels which can lead to tinnitus. Pulsatile tinnitus is a condition where one hears their own heartbeat.
  • Thyroid dysfunction – Both overactive and underactive thyroid glands are known to cause tinnitus in some individuals.
  • Medication side effects – Multiple medications are known to have the side effect of tinnitus including aspirin, nonsteroidal anti-inflammatory agents or NSAIDs (e.g., ibuprofen, naproxen), loop diuretics [e.g., furosemide (Lasix)], ACE inhibitors (e.g., lisinopril, enalpril), Accutane, anti-malarial drugs (e.g., chloroquine, hydroxychloroquine), and certain antibiotics (e.g., tobramycin, gentamicin)
  • Hormonal changes – Abnormal estrogen levels have been associated with tinnitus.  Premenstrual syndrome (PMS), perimenopause, menopause, and pregnancy have all triggered tinnitus. As mentioned above, abnormal thyroid levels may also cause tinnitus.

Despite the many causes of tinnitus, some underlying conditions cannot be treated very easily, while others, such as allergies, are easier to treat. Hay fever (i.e., allergic rhinitis) is quite common, as 25-30 million individuals in the U.S. suffer from it. Individuals with allergic rhinitis are more likely to be afflicted with tinnitus. In addition, people with allergic rhinitis are more likely to be bothered with sinus infections, ear infections, clogged ears, and Eustachian tube dysfunction, all of which are additional risk factors for tinnitus. The treatment of allergic rhinitis and/or its associated complications (i.e., sinus infections, ear infections, clogged ears, Eustachian tube dysfunction) can prevent, alleviate, or eliminate tinnitus in many individuals. Medications often used to treat allergic rhinitis may include antihistamines, decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, and/or nasal anticholinergics. Allergy shots (i.e., allergy immunotherapy, allergy desensitization, allergy injections, allergy hyposensitization) are a very effective tool in the management of allergic rhinitis and asthma and are effective in 80-85% of the patients that take them.

The treatment of tinnitus due to non-allergic underlying conditions may also focus on treating the underlying condition. Examples may include stopping a medication if the tinnitus was caused by a side effect of the medication, hormone therapy in cases of hormonal changes causing tinnitus, or a dental consultation in cases where TMJ is the cause of the tinnitus. It should be noted that treating recalcitrant cases of tinnitus may entail the use of hearing aids, white noise machines and devices, and/or behavioral therapy.

The board certified allergists at Black & Kletz Allergy have been seeing patients with tinnitus for many years. Black &Kletz Allergy has 3 convenient 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 which all offer on-site parking. The Washington, DC and McLean, VA locations are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please call us to make an appointment or you can click Request an Appointment and we will reply within 24 hours of the next business day. The allergists of Black & Kletz Allergy are eager to help you with your tinnitus or other allergy, asthma, or immunology needs. We are committed to providing excellent care and service to you as we have been doing in the Washington, DC metro area for more than 50 years.