Chronic Cough

Coughing is a protective “reflex” given to us by nature as part of our body’s vital defense mechanisms.  It forcibly expels harmful bacteria, viruses, foreign objects, and excessive mucus from the respiratory tract protecting our lungs from irritation, inflammation, and infections.


There are 4 stages in a cough reflex:

  1. An initial deep inspiration filling the lungs with air.
  2. Closure of epiglottis [the flap over the opening of the windpipe (i.e., trachea)].
  3. Forcible contraction of the muscles of the chest and abdomen which pushes up the diaphragm causing compression of the lungs.
  4. As the pressure builds up, the epiglottis is forced open allowing the air to rush out at a high speed producing a whooping noise.

Coughing can be a voluntary act, conscious action, or more commonly an involuntary uncontrollable process.  The reflex is initiated by stimulation of the nerve fibers in the respiratory tract by various substances such as smoke, cold air, allergens, microbes, and tumors, as well as from irritation by normal secretions such as mucus and/or stomach acid.

All of us cough from time to time.  It is very common during colds (i.e., upper respiratory infections), which are usually viral in nature.  Coughing also is common during acute bronchitis and pneumonia (i.e., lower respiratory infections involving mainly the lungs).  It should be noted that following infections, a cough may linger for a few weeks before it subsides.

A cough that lasts for months (and sometimes years) is described as “chronic” and is one of the most common reasons why healthcare providers are consulted.  A cough may interrupt sleep resulting in daytime somnolence and affect school and work performance. Vigorous coughing may also cause physical effects such as urinary incontinence and rib fractures.


  1. Smoking:  Most cigarette smokers eventually develop a “smoker’s cough”. Irritation by noxious chemicals is the predominant cause.  Smoke also plays a significant role in causing chronic bronchitis, emphysema, and lung cancer.
  2. Post-nasal Drip:  In addition to aiding in the perception of smell, the nose also protects the lungs by filtering, warming, and humidifying the air entering the lower respiratory tract.  It accomplishes this by secreting warm, moist, and sticky mucus. When the nose is irritated by chemicals, allergens, microbial organisms, etc., it secretes excessive mucus which is usually thin and watery.  When these copious secretions run down the back of the throat, they irritate the nerves in that area, cause a tickling sensation which may trigger a cough reflex. A post-nasal drip can often be controlled by avoiding exposure to known triggers and stimuli.  Medications such as antihistamines, decongestants, and nasal sprays may help relieve the cough caused by a postnasal drip. Home remedies such as steam inhalation and saline nasal irrigation also may play a role in treatment.
  3. Asthma:  Chest tightness, wheezing, and shortness of breath usually accompany cough in individuals with asthma.  However, in a variant of this condition, a cough may be the only presenting manifestation.  This is called cough variant asthma. The diagnosis is established by pulmonary function testing (sometimes after inhalation of a chemical (e.g., methacholine) that can trigger symptoms which can then be relieved by a medication that opens up the airways).  Occasionally, a therapeutic trial of anti-inflammatory inhaled medications (i.e., inhaled corticosteroids) on a regular basis for a few weeks is helpful in arriving at the diagnosis.
  4. Gastroesophageal Reflux Disease (GERD):  When stomach acid travels up the food pipe (i.e., esophagus), it usually causes heartburn, belching, sore throat, and/or hoarseness.  However, in one third of patients it manifests only as a chronic cough without the other symptoms. Confirmation of the diagnosis is established by placing a probe in the esophagus and monitoring the pH for acidity for 24 hours.  A simpler approach is to empirically treat the individual with lifestyle modifications (e.g., avoiding alcohol, spicy foods, citrus fruits, bulky meals, and carbonated beverages). If the symptoms persist, medications to neutralize the acid and/or reduce acid secretion may be utilized.
  5. Chronic Bronchitis:  Prolonged inflammation of the tissues in the lungs from chemical irritants and pollutants can cause a chronic cough.  Imaging studies are sometimes needed to rule out anatomical and structural abnormalities. Some patients may need long term anti-inflammatory inhaled medications (e.g., inhaled corticosteroids) to control a chronic cough.
  6. ACE inhibitors:  These medications [e.g., lisinopril (Prinivil), enalapril (Vasotec), benazepril (Lotensin), quinapril (Accupril), ramipril (Altace)] are often used to treat high blood pressure and/or heart failure.  Up to 20% of people receiving these medications may develop a cough after a few weeks, which is a known side effect of these types of medications. They may need to discontinue these medications and begin taking an alternative medication in order to get relief from their cough.
  7. Heart Disease:  Congestive heart failure can cause either a dry cough or a productive cough associated with a frothy, thin, white sputum.  Leg swelling (i.e., edema), fatigue, and exercise intolerance are other common symptoms of congestive heart failure.
  8. Aspiration:  When food finds its way into windpipe (i.e., trachea) instead of food pipe (i.e., esophagus), it triggers a recurrent cough.  This is more common in patients with strokes and other chronic neurological disorders.
  9. Lung Cancer:  It is a rare cause of chronic cough in non-smokers, and more common in smokers.
  10.  Stress:  “Psychogenic” coughing increases at times of stress and usually disappears or diminishes during sleep.
  11.  Chronic sinusitis:  It is fairly common for individuals with a chronic sinus infection (i.e., chronic sinusitis) to experience a chronic cough.  In some cases, it is the only symptom of their sinus condition.  In others, it may be accompanied by symptoms such as nasal congestion, decreased ability to smell and/or taste, post-nasal drip, discolored nasal discharge, sinus pressure, and/or sinus headaches.

Cough Medications

  1. Dextromethorphan is a commonly used, partially effective cough suppressant.  Prescription medications containing codeine and its derivatives are more effective but have more undesirable side effects and may be habit-forming.
  2. Guaifenesin is the most commonly used expectorant which may be useful in thinning out viscous secretions which ultimately help the mucus drain more easily.

Warning Signs:  One should consult his or her physician as soon as possible if one experiences any of the following symptoms:  bloody sputum, fever, weight loss, night sweats, breathlessness, excessive fatigue, and/or chest pain.

The board certified allergy doctors at Black & Kletz Allergy have a great deal of experience in diagnosing and treating both adults and children with a chronic cough.  It is important to find the underlying reason for a cough in order to treat it appropriately.  At Black & Kletz Allergy, we search for a cause beginning with a comprehensive history and physical examination.  Breathing tests, X-rays, blood tests, and/or allergy skin tests may be performed depending upon each individual’s history and physical, as it is tailored to each person’s own situation.

The allergists at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Our 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 one of our offices or alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC area for more than 50 years and we look forward to providing you with excellent state of the art allergy care in a welcoming and professional environment.

Reactions to Food Additives

More and more natural and artificial chemicals are being added to our food as preservatives, flavor enhancers, and coloring agents.  The U.S. Food and Drug Administration (FDA) lists close to 4,000 substances as food additives.

Despite widespread use of these chemicals in food, adverse reactions are fortunately uncommon.  Most cases are described in the literature as single case reports or reports of a small cluster of patients.


Sulfites:  These chemicals in the gaseous form can cause lung irritation and may trigger asthma in sensitive asthmatics.  They are commonly found in liquid form in processed cold drinks and fruit juice concentrates in order to extend their shelf lives.  Sulfites are also added to most wines and sprayed onto cut foods in order to keep them fresh and prevent discoloration or browning. They are used to preserve smoked and processed meats, dried fruit (e.g., apricots), and salads.  In its solid form, sulfites can cause hives when ingested.

Benzoic acid (i.e., benzoate) and Parabens:  Benzoates and parabens have antibacterial and anti-fungal properties in order to help with the prevention of food spoilage.  These agents are added to pharmaceutical and food products such as drinks (e.g., sugar-free cola). They occur naturally in prunes, cinnamon, tea, and berries.  These substances may cause urticaria (i.e., hives), asthma and angioedema (i.e., swelling) in sensitive individuals.

Antioxidants:  Synthetic phenolic antioxidants [e.g., BHA (butylated hydroxyanisole) and BHT (butylated hydroxytoluene)] are typically added to processed foods such as dry cereals and potato flakes in order to prevent the fats and oils in these foods from turning rancid when exposed to air.  Unfortunately these antioxidants may trigger asthma, rhinitis, and urticarial in some sensitive individuals.

Flavor Enhancers:

Aspartame (e.g., NutraSweet, Equal), a low-calorie sweetener, can occasionally trigger itchy hives and swelling of the body.  It is also important to note that individuals with genetic condition phenylketonuria should avoid aspartame. Aspartame breaks down into an essential amino acid called phenyalanine which is toxic to individuals with phenylketonuria since these patients are unable to metabolize phenyalanine.


Azo dyes [e.g., tartrazine (i.e., yellow dye #5)] and Non-azo dyes (e.g., erythrocine) can trigger hives, asthma, and generalized allergic reactions.

Nitrates and Nitrites give meat a pink color to look more attractive.  These food colorings are typically found in bacon, salami, and frankfurters.

Monosodium Glutamate (MSG) may trigger the “Chinese Restaurant Syndrome” which causes individuals to experience headaches as well as burning and/or tightening of the chest, neck, and face.  MSG may be found in soups, pot noodles, and instant drinks, among other foods.

Naturally Occurring Substances:

Vasoactive amines: Natural histamine, serotonin, and tyramine occur in some ripe cheeses, fish, cured sausage, red wine, chocolate, and pickled vegetables and may induce cramping, flushing, headache, and palpitations in a dose-related manner.  Of note, there is a condition known as “scombroid poisoning” which occurs in individuals who eat spoiled fish. In this condition, there are abnormally high quantities of histamine in the fish due to improper storage or processing.  The typical fish effected may include tuna, mackerel, herring, sardine, anchovy, marlin, and bluefish. The symptoms may include flushing, headache, generalized itching, blurred vision, abdominal cramps, and/or diarrhea. Scombroid poisoning is often wrongly diagnosed as a fish allergy since similar symptoms may be associated with a true fish allergy.  One key factor to look for is to see if other individuals eating the same piece of fish exhibited symptoms. If so, it is more likely to be scombroid poisoning due to eating spoiled fish as opposed to a fish allergy.

Caffeine found in foods, medication, tea, coffee, and carbonated beverages induces dose-dependent agitation, palpitations, nausea, and/or tremors.

Salicylates (i.e., aspirin-like naturally occurring chemicals) may induce urticaria, asthma, and/or nasal polyp growth.  They are found in curry powder, paprika, oranges, apricots, ginger, honey, berries, fruit skins, tea, and almonds.  Salicylate sensitive individuals also tend to have adverse reactions to benzoates and tartrazine.


The precise mechanism how food additives cause reactions is not well understood in many instances.  The IgE antibody, which plays a crucial role in immediate-type (i.e., Type I) allergic reactions to food, is usually not involved in adverse reactions caused by food additives.

Skin prick tests and allergy blood tests are not helpful in identifying the food additive culprit in most cases.  Careful observation and maintaining food and symptom diaries are sometimes useful in narrowing down the offending additive. Oral challenges under close monitoring in controlled environments may be needed to arrive at a specific diagnosis.


Avoidance of the suspected food additive is the only certain way of preventing adverse effects.  One should be vigilant about reading food labels and asking restaurants about ingredients and cooking methods.

If there is a history of anaphylaxis, carrying an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) is extremely helpful in emergency treatment.  It is important to emphasize that if a self-injectable epinephrine device is used, one should go immediately to the closest emergency room.

The board certified allergists at Black & Kletz Allergy have been diagnosing food additive sensitivitis, food allergies, and food intolerances routinely for many years on both adults and children.  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 by the next business day.  The allergists of Black & Kletz Allergy are eager to help you with your allergy, asthma, sinus, and immunology needs.  We are dedicated to providing excellent care and service to you as we have been doing in the Washington, DC metro area for more than 5 decades.

Fatigue Can Be Due to Allergies?

In the hectic days we live in, many individuals feel fatigued or exhausted.  Fatigue is a very common symptom that can be either chronic or intermittent. Many people seek help by seeing a physician in order to find out the cause of their fatigue, as there are many potential causes.  Despite the numerous causes of fatigue, underlying allergies is a fairly common reason for fatigue in many individuals.

Usually patients with allergic rhinitis (i.e., hay fever) and allergic conjunctivitis exhibit many of the classic symptoms of allergies which may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy ears, clogged ears, itchy eyes, watery eyes, redness of the eyes, puffy eyes, sinus pressure, and/or sinus headaches.  The typical symptoms in individuals with asthma may include wheezing, chest tightness, shortness of breath, and/or coughing.  It should also be noted that food allergies can cause fatigue in certain individuals in addition to the more typical abdominal symptoms (e.g., abdominal pain, diarrhea), skin symptoms (e.g., hives, itching, swelling), lung symptoms (e.g., wheezing, shortness of breath, coughing), and of course anaphylaxis.  Even though the symptoms listed above are the “more typical” symptoms associated with allergies, asthma, and food allergies one should realize that fatigue is not an uncommon symptom that occurs in allergic individuals. There are in fact people that only complain of fatigue and do not have any of the more typical symptoms of allergies.  You may be asking: How do you know if your fatigue is due to allergies?  It should be noted that there are a whole host of conditions and/or reasons that can cause fatigue.  Likewise, it is important to rule out these “other” causes of fatigue before declaring one’s fatigue is due to allergies.

What are some common causes of fatigue besides allergies?  Here are some of the more common reasons/conditions that may cause fatigue, but keep in mind that there are numerous other conditions or reasons that may cause fatigue that are not listed below:

  • Thyroid disorders (e.g., hypothyroidism)
  • Anemia
  • Sleep apnea
  • Heart disease
  • Lack of sleep
  • Infection (e.g., hepatitis, mononucleosis, urinary tract infection)
  • Diabetes mellitus
  • Autoimmune disorders (e.g., systemic lupus erythematosus, Sjögren’s syndrome)
  • Fibromyalgia
  • Anxiety/Depression
  • Dehydration
  • Chronic obstructive pulmonary disease (COPD)
  • Medication side effects

Fatigue Can Be Due to Allergies?Assuming that there are no other reasons for one’s fatigue, seeing a board certified allergist in the Washington, DC, Northern Virginia, and Maryland metropolitan area is important in order to rule out allergies as a cause.  In fact, even if you have another condition that can cause fatigue, it is still possible that some or all of your fatigue may be coming from allergies.  The board certified allergists at Black & Kletz Allergy are experts in the field and can find out if you have allergies via blood and/or skin testing.  It is first important for the allergist to perform a comprehensive history and physical examination.  Allergy testing is done in order to identify if, what, and how allergic one is to specific allergens. Once an allergy is identified, preventive measures are discussed in order to minimize one’s exposure to the offending allergens.  In addition, the use of allergy medications are usually beneficial in alleviating those unwanted allergy symptoms which also includes fatigue. Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy hyposensitization) may be utilized to treat the underlying allergies as they are very efficacious and are beneficial in 80-85% of individuals who take them.  Most individuals are on allergy shot for 3-5 years.

The allergists at Black & Kletz Allergy see both pediatric and adult patients and have over 50 years of experience in the field of allergy, asthma, and immunology.  Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC metropolitan area for over 5 decades and we look forward to providing you with the highest state-of-the-art allergy care in a friendly and comfortable environment.

Non-Allergic Rhinitis

Non-Allergic RhinitisSymptoms such as nasal congestion, clear runny nose, and itchy throat are most commonly due to sensitivity to common “allergens” in the environment (e.g., pollens, dust mites, mold spores, animals).  Our immune system mistakes them as potentially harmful and thus mounts a defensive attack on these substances when it encounters them.  During this process, there is a release of chemical substances (e.g., histamine, prostaglandins, leukotrienes) into the tissues inside the nose and eyes and these chemicals are responsible for the symptoms of allergies.

The symptoms may be relieved with medications that block the actions of these chemicals which can be utilized to make allergic individuals more comfortable.  The symptoms may also be prevented either by avoiding the exposure to the allergens, by environmental controls, or by getting desensitized to the allergens by allergy immunotherapy (allergy shots, allergy injections, allergy desensitization, allergy hyposensitization).  Sensitizing allergens can vary from person to person and allergy tests obtained by skin or blood testing are needed to identify the offending allergen in order to consider specific environmental controls and/or desensitizing treatments.

What if one has all the symptoms suggestive of “allergies” but all the tests are negative?  You may have a condition called vasomotor rhinitis or more appropriately called non-allergic rhinitis.

The symptoms of non-allergic rhinitis may include:

  • Nasal congestion
  • Runny nose
  • Sneezing
  • Mucus (i.e., phlegm) in the throat (e.g. post-nasal drip)
  • Cough

These symptoms can be long term or may last only a short period of time.  They can come and go all year-round.  Itching of the nose, eyes, and/or throat are not present in non-allergic rhinitis as they are more likely to be features of allergic rhinitis (i.e., hay fever).

The exact cause of non-allergic rhinitis is not known.  The effect is widening of the blood vessels inside the nostrils and leakage of fluids into the tissues resulting in excessive mucus and swelling of the mucus membrane linings and nasal turbinates.

The common triggers of non-allergic rhinitis are:

  • Environmental or occupational irritants: Dust, smoke, pollutants, strong odors, perfumes, colognes, potpourri, chemical sprays, fumes, etc.
  • Weather changes: Fluctuations in temperature and humidity.
  • Food: Hot and spicy foods, certain alcoholic beverages.
  • Infections: Viral infections such as the common cold or influenza (i.e., the flu)
  • Medications: Aspirin, Ibuprofen, certain blood pressure medications (e.g., beta-blockers ACE inhibitors), sedatives, antidepressants, and oral contraceptives.
  • Rhinitis medicamentosa: Prolonged and/or overuse of over-the-counter decongestant nasal sprays (e.g., Afrin, Neosynephrine) can cause rebound congestion and habituation.
  • Hormonal changes: Pregnancy, menstruation, and hypothyroidism.
  • Stress: Emotional or physical stress.
  • Other triggers: Sleeping posture, sleep apnea, acid reflux, etc.


  • Nasal polyps: These are soft, benign growths that develop on the lining of the nose or sinuses due to chronic inflammation.  Small polyps may not cause problems, but larger ones may block the airflow through the nose, making it difficult to breathe.  They also increase the likelihood of recurrent sinus infections.
  • Sinusitis: Prolonged nasal congestion due to non-allergic rhinitis may increase the chances of developing sinusitis, an infection or inflammation of the membranes that line the sinuses.
  • Middle ear infections: Increased fluid and nasal congestion may lead to middle ear infections.
  • Interrupted daily activities: Non-allergic rhinitis may affect focus and concentration and in turn impact learning at school and/or productivity at work.

The diagnosis is established when one presents with the classic symptoms of rhinitis and when the skin tests and/or blood tests fail to identify specific environmental sensitivities.  Common infections of the nose and sinuses also need to be ruled out by examination and imaging tests. There are no confirmatory tests for non-allergic rhinitis and it is usually an exclusion diagnosis.


Avoidance of the common triggers is the first step in the management of non-allergic rhinitis.  When avoidance is not possible or when it does not work, the following actions may be helpful.

  • An over-the-counter nasal saline spray or homemade salt water solution to flush the nose of irritants and help thin the mucus and soothe the membranes inside the nose.
  • Corticosteroid nasal sprays (e.g., fluticasone, triamcinolone, budesonide) may help reduce the congestion due to their anti-inflammatory effect by shrinking the swelling and reducing excessive mucus production.
  • Antihistamine nasal sprays (e.g., azelastine, olopatadine) are more helpful than oral antihistamines in relieving the symptoms of non-allergic rhinitis.
  • Anticholinergic nasal sprays (e.g., ipratropium bromide) can help to dry up the excessive nasal secretions and relieve runny nose and post nasal drip.
  • Oral decongestants (e.g., pseudoephedrine, phenylephrine) can help relieve nasal stuffiness by shrinking the blood vessels and reducing mucus buildup. Side effects of these medications however may include elevated blood pressure, rapid pulse, restlessness, sleep disturbances, palpitations, and/or tremors.


A recent small study showed that eating oily fish (e.g., herring, mackerel, salmon) at least once a week may reduce the risk of rhinitis.  However more studies are needed to confirm this finding.

The board certified allergists at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  The allergy specialists at Black & Kletz Allergy are extremely knowledgeable regarding non-allergic rhinitis as well as allergic rhinitis.  We diagnose and treat both pediatric and adult patients.  In addition, we treat patients with food, medication, insect sting, and skin allergies, asthma, eosinophilic esophagitis, sinus disease, and immunological disorders.  To schedule an appointment, please call any of our offices or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years and we look forward to providing you with comprehensive state-of the-art allergy care in a friendly and professional environment.




Does Eating Local Honey Help Treat Allergies?

honey treating allergiesDoes eating local honey help treat allergies?  This question has been asked for decades.  Many individuals swear that consuming local honey does help alleviate their seasonal allergy symptoms known as allergic rhinitis (i.e., hay fever).  Beekeepers generally also agree with this theory.  In order to answer this question, another important question to ask is “how does local honey help allergies?”, if in fact it does help.

The theory behind this hypothesis is rooted in the fact that when bees land on flowering trees and plants, the pollens that are on the flowers stick to the bees’ abdomens.  When bees make honey, the pollen that is on their abdomen is incorporated in the honey.  Local honey contains the pollen of these flowering trees and plants.  Processed honey that you would typically buy at a grocery store is usually micro-filtered and pasteurized.  These processes generally remove the pollen from the honey.  The thought is that local “raw” honey contains pollens from local trees and plants and by eating the honey, an individual will develop a “resistance” to the pollens that are in the local honey.  This would then lead to less or no allergic symptoms when exposed to these local pollens.  In theory, this sounds good, but in fact, there are flaws in this concept which are as follows:

The first fault in this idea is that individuals suffering from seasonal allergies in the Spring are allergic to non-flowering trees such as maple, birch, elm, hickory, cedar, ash, beech, and oak trees.  They are not generally allergic to the pollen from flowering trees and plants such as cherry trees, Bradford pear trees, redbud trees, dogwood trees, and forsythia bushes.  The reason for this is fairly simple.  The pollen of flowering trees and plants are heavy in weight and thus are not wind-dispersed.  Since the pollen is heavy, through evolution, these types of trees and plants had to develop flowers in order to attract bees so that they could cross-pollinate and thus reproduce.  The bees land on a flower and the pollen then sticks on the abdomen of the bees.  The bees then fly to another same species flowering tree or plant and when they land on these flowers, the pollen on their abdomen gets distributed on this new flower and hence cross-pollination occurs.  The fact that the pollen is heavy and not wind-dispersed means that individuals do not inhale the pollen and therefore do not become sensitized or allergic to these pollens.  Unlike flowering trees and plants, the non-flowering tree pollens are light in weight and are wind-dispersed, thus able to cause sensitization and allergy symptoms to allergic-prone individuals.  This translates into the fact that eating local honey (which is composed of flowering tree pollens) will not reduce one’s allergies in the Spring because it does not contain the correct types of pollens that cause hay fever.

In addition, the amount of pollen in local honey is not consistent between different bottles of honey from the same beekeeper yet from different beekeepers.  It is not standardized.  The idea of allergen desensitization (i.e., allergy immunotherapy, allergy hyposensitization) is to give a very low tolerable dose and increase the amount slowly over time, so that an individual can become tolerant to that allergen (e.g., tree pollen).

Another major flaw in this theory is that there have been no good scientific studies showing any advantage in using local honey to treat allergies.  There are a few studies that are flawed in the manner the studies were done as well as the number of participants are too small to make a general correlation between consuming local honey and its effects on allergies.  The use of honey to treat allergies is also not endorsed by either the American Academy of Allergy, Asthma & Immunology or the American College of Allergy, Asthma & Immunology.

Honey does have some advantages however.  It is not uncommonly used to help alleviate coughs and of course, it tastes good!  It is also interesting to point out that honey does not spoil.  This is thought to occur because organisms cannot survive long enough within a jar of honey due to the very low moisture that exists in a jar of honey and thus does not have the chance to spoil.

All in all, honey has its merits, but treating allergies is not one of them.  If you suffer from allergies, please contact Black & Kletz Allergy so that you can see one of our board certified allergists in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  After a comprehensive history and physical examination, allergy testing may be done and the appropriate avoidance measures will be discussed.  Depending upon each individual’s results, medications and/or allergy shots (i.e., allergy immunotherapy) may be prescribed.  Allergy shots have been prove to be effective in 80-85% of patients undergoing injections and they have been given in the United States for over 100 years.  Unlike consuming local honey, there are numerous studies demonstrating the efficacy and benefits of allergy immunotherapy when administered in the proper way.

The allergy doctors 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 of the 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 and Northern Virginia community for over 50 years for our exceptional services for the diagnosis and treatment of allergic, asthmatic, and immunological conditions.

Allergy Shots for Eczema?

Allergy shotsEczema (i.e., atopic dermatitis) is a genetically determined condition which causes long term inflammation of the skin which may result in itching, thickening, redness, and occasionally ulcerations of the skin.  A similar appearance can sometimes be seen in other chronic skin conditions.

Eczema or atopic dermatitis affects an estimated 7% of the population with varying degrees of severity.  It often begins in early childhood and may wax and wane throughout a lifetime.  The severity can vary from mild dryness and/or excessive creasing of the skin to a severe debilitating illness presenting with painful sores and/or skin infections.  The intractable itching often does not respond to medications and may lead to loss of sleep, inability to focus on work and/or school, and/or emotional problems.

Unfortunately there is no known cure for the condition yet.  The flare-ups of this disorder are typically treated with topical and/or oral corticosteroid medications, which usually offer only short-term relief.  The numerous topical corticosteroids available vary in potency and should be prescribed based on the severity of the eczema as well as the location of the eczema on the body.  The side effects of the corticosteroid medications can also be worrisome, so it is important to use them sparingly and to avoid excessive use.  A few new non-steroidal topical medications and injectable biological medications have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of atopic dermatitis.  It is important to note that the response rates to these medications are highly variable.  There are also side effects one should be aware of regarding the biological medications in particular.

Allergy shots (i.e., allergen immunotherapy, allergy injections, allergy desensitization, allergy hyposensitization) is a systematic treatment option which helps the immune system to develop tolerance to the offending allergens that cause allergy symptoms.  As a result, individuals have less or even no allergy symptoms when subsequently exposed to these allergens.  This method has been practiced for over 100 years in the United States and is highly effective in reducing the symptoms and lessening the need for medications for patients with respiratory and eye allergies such as hay fever (i.e., allergic rhinitis), asthma, and allergic conjunctivitis.

Despite the fact that allergy immunotherapy is so efficacious in allergies of the respiratory tract and eyes, allergy immunotherapy has not been studied extensively in patients with eczema.  A case-study, however, presented at a recent annual scientific meeting of the American College of Asthma, Asthma & Immunology, offers hope.

In this case-study, a 48 year-old man who had suffered from severe eczema involving a large part of his body since his childhood was observed.  He had tried many therapies for years including both mild and high-strength topical corticosteroid creams, other topical anti-inflammatory creams, and topical moisturizer creams without adequate relief.

Since he also had respiratory allergy-related symptoms, his doctors tested him for environmental allergies and diagnosed him with sensitivity to dust mites, molds, animal dander, trees, grasses, and weeds.  In fact allergic rhinitis, asthma and eczema constitute the “atopic triad” and share a similar genetic predisposition.

Because his allergies could all be treated with allergy shots, his doctors thought that treating his allergies may also be beneficial for his eczema.  After one year of allergy shots, he reported significant improvement of his eczema symptoms.  Once he reached a maintenance dose on his allergy shots, he no longer needed high dose corticosteroid treatment for his eczema.

There is a need for more extensive controlled studies investigating the benefits of allergy shots for individuals with moderate to severe eczema.  If further studies substantiate the data observed in this patient, allergy shots have the potential to benefit thousands of people with severe recalcitrant eczema.

The board certified allergists at Black & Kletz Allergy see patients of all ages and have over 50 years of experience in the field of allergy, asthma, and immunology.  In addition to allergic rhinitis, allergic conjunctivitis, and asthma, skin disorders such as eczema, contact dermatitis, poison ivy, poison oak, poison sumac, hives (i.e., urticaria), generalized itching (i.e., pruritus) are common skin ailments 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.  The 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 concern.




Less Common Seasonal Allergy Symptoms

Seasonal AllergiesAs we enter the Spring season in the Washington, DC, Northern Virginia, and Maryland metropolitan area, many allergy sufferers will begin to experience the classic hay fever (i.e., allergic rhinitis and allergic conjunctivitis) and/or asthma symptoms.

The typical hay fever signs and symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, a horizontal crease at the bottom third of the nose, itchy nose, itchy eyes, watery eyes, redness of the eyes, puffy eyes, dark circles under the eyes, a line or fold in the skin below the lower eyelids, itchy mouth and throat, itchy ears, clogged ears, coughing, itchy skin, and/or sinus pressure.  In the Spring in the Washington, DC metro area, the tree and grass pollens as well as molds are generally to blame for these annoying allergy symptoms.  In the Fall, ragweed and molds are generally the culprits when it comes to causing hay fever symptoms.  Ragweed generally begins to pollinate in mid-August and is typically ends at the first frost which is usually at the end of October.

In asthmatics, the characteristic symptoms that may occur include chest tightness, wheezing, shortness of breath, and/or coughing.  The most common allergens that cause an increase of these asthma symptoms include tree pollens in the early Spring, grass pollens in the late Spring, and molds, which occur throughout the Spring.  It is important to know that molds are prevalent throughout every month of the year and are present both indoors and outdoors.  As mentioned in the paragraph above, ragweed, along with molds are the principle allergens that cause asthma exacerbations in the Fall.

It is interesting to note that there are a variety of other rarer symptoms that some individuals may notice in the Spring and Fall.  In fact, these symptoms may be perennial in nature which can be confusing since they can signify other medical conditions.  These less common allergy symptoms may include fatigue, “fogginess” feeling of the head, ringing of the ears (i.e., tinnitus), joint achiness, headaches, itchy mouth, abdominal pain, diarrhea, sore throat, behavioral issues (e.g., moodiness, hyperactivity, inability to concentrate), snoring, and/or rashes.

Note that the combination of fatigue, achiness, runny nose, nasal congestion, and sneezing can easily be misconstrued for the common cold.  One should be aware that the common cold is caused by a virus, and that in general, “colds” usually last no more than 7-10 days.  This means that if an individual is experiencing “cold” symptoms for a long period of time (i.e., greater than 2 weeks) and/or if he or she is experiencing recurrent “cold” symptoms every Spring or Fall, then allergies should be seriously considered and one should make an appointment with a board certified allergist such as the ones at Black & Kletz Allergy.

A few words about some of the less common seasonal allergy symptoms are discussed below:

  • Fatigue: Usually occurs due to poor quality or quantity of sleep as a result of poorly controlled allergies.  In some individuals, this fatigue can be rather severe.
  • “Fogginess” feeling of the head: May be due to increased sinus pressure.
  • Ringing of the ears: Usually due to blockage of the Eustachian tube which stems from sinus congestion.
  • Joint achiness: May be due to inflammation caused by allergies
  • Headaches: Seasonal allergic headaches are usually due to increased nasal and sinus congestion.  They tend to be in the forehead and cheek regions of the face.
  • Itchy mouth, Abdominal pain, and/or Diarrhea: Some pollen-allergic individuals have a condition called oral allergy syndrome (i.e., pollen-food allergy syndrome) whereby they have a local reaction in the gastrointestinal tract (i.e., mouth, esophagus, stomach) to certain foods (usually fresh fruits and/or vegetables).  Usually these individuals will experience an itchy mouth or throat from eating these raw fruits and vegetables, however, sometimes more severe gastrointestinal reactions may occur such as abdominal pain and/or diarrhea.  Some common cross-reactive foods and pollens include:  birch tree pollen – apples, pears, peaches, celery, carrots; ragweed pollen – melons, bananas, kiwi.
  • Sore throat: Usually associated with a post-nasal drip but can also be caused by excessive dryness due to the use of antihistamines.
  • Behavioral issues: Usually die to poor quality or quantity of sleep.
  • Snoring: Usually due to increased nasal congestion.  Note that an increase in nasal congestion may also worsen obstructive sleep apnea and thereby cause an increase in snoring.
  • Rashes: Seasonal allergies can cause a flare-up of eczema (i.e., atopic dermatitis).  Some allergic individuals may develop itching and rashes when they come in direct contact with an allergen such as grass.


The board certified allergy specialists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC metro area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices have on-site parking.  For further convenience, our Washington, DC and McLean, VA offices are Metro accessible.  Our McLean, VA office location offers a complementary shuttle that runs between this office and the Spring Hill metro station on the silver line.  For an appointment, please call one of our offices or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  If you suffer from allergies or asthma, it is our mission to help alleviate or end your undesirable symptoms, so that you can enjoy a better quality of life.  We have been serving the community’s allergy and asthma needs for more than 50 years.  Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a caring, relaxed, and professional environment.

Itchy, Red Eyes: Allergy or Infection?

The most common cause in the Washington, DC, Northern Virginia, and Maryland metropolitan area for itchy, red eyes in the Spring and Fall high pollen seasons is inflammation of the thin membrane covering the eyeballs (i.e., conjunctivae).  This inflammation is triggered by allergen exposure to susceptible individuals.   However, inflammation to the conjunctivae can also be caused by infections by microorganisms such as viruses, bacteria, and rarely fungi and parasites.

It is very important for a board certified allergist to distinguish the difference between these two conditions as the treatment options are determined by the causative factors and differ greatly.

Though it is not always possible to differentiate the conditions by symptoms alone, the following information can be a helpful beginning.itchy eyes

If the discharge from the eye(s) is anything more than normal tears, it is more likely to be something more than allergies.  Though allergies also can cause much discomfort, pain in the eye(s) is more indicative of an infectious process.

A definitive diagnosis can only be made by examination and testing by trained and experienced professionals.

Allergies are not contagious to others but infections can easily spread from person to person or from one eye to the other eye.  The signs and symptoms of eye allergies (i.e., allergic conjunctivitis) are more likely to occur in both eyes, whereas infections are more likely to develop in one eye initially, although both eyes may be affected.


Prevention and Treatment:

Allergic Conjunctivitis:

Prevention should include reducing one’s exposure to known allergens by restricting outdoor activities on high pollen days, keeping windows closed, keeping pets out of the bedrooms, and using air purifiers and dehumidifiers to minimize dust mite and mold growth.

Treatment involves using over-the-counter eye drops containing antihistamines and mast cell stabilizers.  These are often helpful in relieving the itching and redness that are characteristic of allergic conjunctivitis.  They can be supplemented with oral medications (e.g., antihistamines) especially if nasal and sinus symptoms are also present.  Over-the-counter artificial tears also can help keep eyes moistened and flush out allergens.  In case of persistent symptoms, certain nasal corticosteroids, but not all, have the indication to help alleviate the allergic eye symptoms that may be extremely bothersome to the allergic individual.  Though they are more efficacious, the risks of adverse effects are also higher.

Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) is very effective in treating individuals with allergic conjunctivitis whether they have associated hay fever (i.e., allergic rhinitis) or not.

Infectious Conjunctivitis:

Prevention should entail avoiding exposure to people battling viral and bacterial infections to the best of their ability.  In addition, frequent hand washing can reduce the risks of contracting and spreading infectious eye conditions.

The treatment of infectious conjunctivitis varies depending on the microorganism.

Most viral infections resolve after a few days without any specific antiviral medications.  Lubricating eye drops and cold compresses can help relieve the discomfort and facilitate recovery.

Bacterial infections need antibiotic eye drops, instilled several times a day for about a week in order to treat the infections.  Rarely infections can also be caused by fungi and/or parasites.  In these rare cases, anti-fungal and anti-parasitic medications can be administered.

If eye infections are mistakenly self-treated with over-the-counter allergy medications, one can run the risk of damaging the eyes.

Other Ocular Allergies:

Of note, there are 3 other forms of ocular allergies that are more severe than allergic conjunctivitis which include the following:

Vernal keratoconjunctivitis (VKC):  A chronic inflammatory swelling of the outer lining of the eyes due to an allergic reaction.  It typically affects boys and young males who live in hot dry climates in a seasonal manner, most often occurring in the Spring and/or Summer.  It usually occurs in patients with a family history of allergies.  The classic symptoms may include watery eyes, itching, redness, and/or increased sensitivity to light (i.e., photophobia) of both eyes.  The treatment is similar to that of allergic rhinitis (see below), but in addition, individuals with severe cases may need topical corticosteroids, cyclosporine, or tacrolimus.  Rarely, oral corticosteroids may be necessary in recalcitrant cases.  It should be noted that rarely, VKC can lead to corneal scarring and vision loss if not properly treated.

Atopic keratoconjunctivitis (AKC):  A genetic disorder that is more common in adults (men more than women) where the immune system produces higher amounts of antibodies in response to a given allergen.  Although AKC is perennial in nature, the symptoms may worsen in the Winter.  Individuals usually have a history of eczema (i.e., atopic dermatitis).  The typical symptoms may include red eyelids, burning, itching, watery eyes, and/or increased sensitivity to light (i.e., photophobia) of both eyes.  The treatment is similar to that of VKC.  It should be noted that rarely, AKC can lead to corneal scarring and vision loss as mentioned above with VKC.  This complication however occurs more often in individuals with AKC than with VKC.

Giant papillary conjunctivitis (GPC):  A disorder that causes inflammation in the inside part of the eyelid.  It is most often caused by a reaction to eyelid movement over a foreign substance such as contact lenses.  It can develop at any time after wearing contact lenses.  An allergic reaction is thought to be one of the causes of GPC.  Some individuals are allergic to either their contact lenses or the chemicals used to clean them.  An allergic reaction between the skin of the eyelid and the contact lenses or chemicals may be a cause.  Other causes of GPC may include repetitive rubbing of the eyes, eye implants, and/or sutures in the eyes from a previous eye surgery.  The symptoms may include watery eyes, redness, burning, itching, and/or pain.  Treatment includes changing one’s contact lens regularly and limiting the time of wearing them to a few hours per day.  Disposable contact lenses may be of some benefit as well.  In more severe cases, the individual should stop using contact lenses altogether.

The board certified allergy specialist physicians at Black and Kletz Allergy have over 50 years of experience in diagnosing and treating all types of eye conditions whether allergic or infectious.  We treat both pediatric and adult patients.  Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC metropolitan area for many decades and we look forward to providing you with the utmost state-of-the-art allergy care in a welcoming and pleasant environment.