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Drug Reaction with Eosinophilia and Systemic Symptoms  (DRESS) Syndrome

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

Causes:

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

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

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

Symptoms:

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

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

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

Diagnosis:

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

Treatment:

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

Prognosis:

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

The board certified allergists at Black & Kletz Allergy will promptly respond to any questions regarding DRESS syndrome, medication allergies, and other allergic or immunologic disorders.  We have been diagnosing and treating allergic disorders for more than 50 years and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We treat both adult and pediatric patients.  All 3 offices at Black & Kletz Allergy offer on-site parking.  Our Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you have had DRESS syndrome, medication allergies, or any other type of allergic condition, please call us to schedule an appointment.  You may also click Request an Appointment and we will respond within 24 hours by the next business day.  At Black & Kletz Allergy, we strive to improve the quality of life in allergic individuals in a professional and compassionate setting.

Summer Allergies

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

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

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

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

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

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

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

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

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating allergies and asthma, for more than 5 decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We treat both pediatric and adult patients. We have officed in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Our Washington, DC and McLean, VA offices are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  The allergy specialists at Black & Kletz Allergy are very familiar about the most current treatment options for patients with allergic rhinitis, allergic conjunctivitis, asthma, insect stinging allergies, and pollen-food allergy syndrome and can promptly answer any of your questions.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC area for more than 50 years and look forward to providing you with exceptional state-of-the-art allergy and asthma care in a welcoming and pleasant environment.

Eosinophilic Esophagitis and Link to Other Allergic Conditions

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

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

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

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

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

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

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

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

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

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

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

The treatment of eosinophilic esophagitis may include:

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

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

Allergies to Molds

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

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

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

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

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

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

Pollen Allergies

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

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

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

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

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

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

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

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

Rhinitis – Is It Due to Allergies or Something Else?

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

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

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

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

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

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

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

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

Pregnancy Rash – Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)

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

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

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

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

 

CAUSES:

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

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

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

DIAGNOSIS:

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

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

TREATMENT:

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

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

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

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

Asthma – What You Need to Know

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

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

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

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

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