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New Treatment for Eczema

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

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

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

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

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

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

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

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

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

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

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

Tinnitus – Can It Be Caused by Allergies?

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

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

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

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

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

Mast Cell Conditions

Mast cells are a type of white blood cells. They are an important part of our immune system as they help us fight off infections and other invaders. Mast cells contain granules which contain a variety of chemical substances (e.g., histamine, heparin, tryptase, serotonin, leukotrienes, prostaglandins, cytokines). These chemical substances have effects on the body such as inflammation and allergic symptoms.

Mast cells play a crucial role in defending us against infections and aiding in wound healing. Despite these important functions, they can also cause diseases when too many of them are produced (i.e., mastocytosis) or when they become overactive (i.e., mast cell activation syndrome). These fairly uncommon conditions occur in approximately 1 in every 150,000 individuals.

Cause:

The exact cause of these mast cell conditions is unknown. It is however thought that abnormal genes inherited from parents could play a role in the development of mast cell disorders.

Symptoms:

Mast cell disorders can affect various organs in the body:

1. Skin: The skin is the largest organ in our bodies. When excessive numbers of mast cells are deposited in the skin, they cause a condition called urticaria pigmentosa, which manifests as light brown, itchy, and raised patches over various parts of the body. If the patches are rubbed, they become redder, swollen, and may result in blisters (i.e., Darier’s sign). Some individuals also develop dermatographism, which is a condition where one is able to write on the skin with a blunt object. Urticaria pigmentosa is more prevalent in children and usually improves with age. Frequent episodes of flushing, especially over the face, is a common symptom. Generalized itching (i.e., pruritus) can be a very bothersome symptom, interfering with both sleep and work. In addition, the localized accumulation of mast cells can present as nodules.
2. Gastrointestinal: Abdominal pain, bloating, discomfort after eating, heartburn, nausea, vomiting, pale stools
3. Cardiovascular: Decreased blood pressure, lightheadedness, fainting
4. Bone Marrow: Anemia, bone pain, fractures.
5. Respiratory: Wheezing, shortness of breath, coughing
6. Neurologic: Headache, tremors, numbness
7. Lymphatic: Swelling of lymph nodes, liver, spleen and other organs

Triggers:

A number of factors can trigger symptoms of mast cell disorders:
1. Physical: Heat, cold, friction, sunlight, fever, fatigue, physical exertion
2. Emotional stress
3. Food: Cheese, spices, shellfish, food preservatives (e.g., MSG), food additives (e.g., flavorings, colorings)
4. Infections: Bacteria, viruses, fungi
5. Drugs: Aspirin, antibiotics, anesthetics, opioids, alcohol
6. Insect bites or stings
7. Irritants: Strong odors, perfumes, other chemical irritants
8. Surgery

Diagnosis:

1. Blood tests: Measure tryptase levels at the baseline (i.e., before flare-up) and during a flare-up when tryptase levels are more likely to be elevated.
2. Urine tests: Measure the metabolic end products of tryptase
3. Bone marrow biopsy: Microscopic examination of the bone marrow for evidence of mast cell deposition
4. Skin biopsy: Microscopic examination of skin lesions
5. Genetic tests: Looks for gene abnormalities
6. Chest and bone X-rays or scans
7. Skin prick tests: Detects specific IgE antibodies to environmental and/or food allergens, if suggested by history of flare-ups on exposure

Treatment:

Unfortunately, there is no cure for these disorders but various manifestations can be treated in order to help relieve the symptoms as well as help preserve the function of organs systems.

1. Acute severe systemic reactions (i.e., anaphylaxis) are treated with an immediate epinephrine injection. Patients should to carry an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) and wear a medical alert bracelet. If used, it is important for the individual to go to the closest emergency room.
2. Itching, flushing, and other skin allergy symptoms can be controlled by using H1-blocking antihistamines such as Claritin (loratadine), Allegra (fexofenadine), and Zyrtec (cetirizine) in combination with H2-blockers such as Tagamet (cimetidine) or Pepcid (famotidine).
3. Medications which stabilize the mast cells such as cromolyn, nedocromil, and ketotifen can help prevent from degranulation of the granules inside mast cells and thus help prevent the release of chemical mediators into the tissues and the bloodstream. These medications are often used to treat gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping.
4. Digestive symptoms caused by mast cell disorders can also be improved with proton pump inhibitor (PPI) medications such as Prilosec (omeprazole), Prevacid (lansoprazole), and Nexium (esomeprazole).
5. Albuterol inhalers will help open the airways and help wheezing, coughing and/or shortness of breath in individuals with respiratory symptoms.
6. Anticholinergic medications may be used to reduce the motility of the bowels which may help control diarrhea.
7. Anti-inflammatory medications such as corticosteroids (e.g., prednisone) and leukotriene antagonists [e.g., Singulair (montelukast), Accolate (zafirlukast), Zyflo (zileuton)] are sometimes used to help control systemic symptoms. Topical corticosteroid creams or ointments, as well as phototherapy can improve localized skin lesions.
8. Surgical removal of the spleen can help improve severe symptoms in some individuals.
9. Immune modulating medications such as interferons may be used in more severe cases of systemic mastocytosis
10. Bone marrow transplant may be necessary in severe cases of systemic mastocytosis.
11. Stem cell therapy may be necessary in severe cases of systemic mastocytosis.

Prognosis:

Most cases of localized mast cell disease can persist for many years as nodules on the skin. In rare instances, cancers can develop which require constant monitoring.

Systemic mastocytosis tends to be persistent at a low level for decades, requiring treatment to control symptoms. Occasionally, however, it can become aggressive and even life-threatening.

Avoidance of exposure to the known triggers, as best as possible, can help minimize the symptoms and reduce the need for medications.

The board certified allergy specialists at Black & Kletz Allergy treat both adult and pediatric patients. We have been diagnosing and treating mast cell diseases for many years. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking. In addition, 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. To schedule an appointment, please click Request an Appointment and we will respond within 24 hours by the next business day. The allergists at Black & Kletz Allergy have been the trusted allergists in the greater Washington, DC and Northern Virginia community for over 50 years. We pride ourselves for our outstanding services we provide for the diagnosis and treatment of mast cell disorders as well as other conditions in the fields of allergy, asthma, and immunology.

Spring Cold or Spring Allergies?

Spring is in the air and many individuals are suffering. Although many are experiencing the signs and symptoms of hay fever (i.e., allergic rhinitis), not all of these individuals are allergic to the Spring pollens. In a typical Spring hay fever patient, the symptoms are generally due to an allergy to either tree pollen, grass pollen, or molds. In some individuals however, they may still exhibit the same annoying symptoms as an allergic person, but when skin tested by a board certified allergist, they are negative. In these individuals, they are irritated by pollens or molds as opposed to being allergic to them. This condition is called nonallergic rhinitis or vasomotor rhinitis. For the sufferer, it does not much matter because they may feel awful, but from a treatment standpoint, it does matter because some of the medications used to treat allergic individuals will not help alleviate the nonallergic irritant effects caused by these particles. Still further, there are people who have a viral infection such as the common cold who exhibit many of the same symptoms as an allergic individual, but should again be treated differently from the previous 2 groups mentioned above.

Since the signs and symptoms of the 3 conditions (i.e., allergic rhinitis, nonallergic rhinitis, common cold) may be very similar and overlap, it is important for the allergist to distinguish them in order to manage them more effectively.

The classic symptoms of hay fever or allergic rhinitis may include sneezing, itchy nose, runny nose, nasal congestion, post-nasal drip, itchy throat, itchy eyes, watery eyes, redness of the eyes, and/or puffy eyes. Some individuals will also experience sinus congestion, sinus headaches, snoring, and/or fatigue. Fever and/or chills is not usually present despite the name “hay fever.”

The typical symptoms of nonallergic rhinitis is similar to that of allergic rhinitis although the itchiness is usually not present. Thus, the symptoms are typically sneezing, runny nose, post-nasal drip, and/or nasal congestion. Some patients may also complain of sinus headaches and/or sinus congestion. Ocular symptoms may include watery eyes and/or redness of the eyes.

The common cold is caused by an infection with a virus. The symptoms of a “cold” are similar to those of nonallergic rhinitis although, in addition, fever, chills, and/or muscle aches may also be present. Eye symptoms and itchiness is generally not a feature of the common cold. The length of time of the discomfort is usually far less than that of patients with either allergic rhinitis or nonallergic rhinitis, since viruses are usually self-limited and the average length of time of a “cold” is generally less than 7 days. The symptoms of allergic rhinitis or nonallergic rhinitis in the Spring may last the entire pollen season which may be up to 4-5 months in duration. Of course, many individuals may be allergic to other allergens such as weeds, dust mites, and/or pet dander which can complicate the matter and cause the person to experience symptoms at other times of the year or have perennial symptoms.

The treatment of the 3 conditions is different and it is thus important to know which malady is present in an individual. The management of allergic rhinitis may include antihistamines, decongestants, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, leukotriene antagonists, ocular antihistamines, ocular mast cell stabilizers, ocular nonsteroidal anti-inflammatory agents (NSAIDs), and/or ocular corticosteroids. Allergy immunotherapy (i.e., allergy shots, allergy desensitization, allergy hyposensitization) is very efficacious in the treatment of allergic rhinitis as it helps in 80-85% of individuals who take it. Allergy shots, on the other hand, are not prescribed in patients with nonallergic rhinitis or the common cold.

The treatment of nonallergic rhinits is similar to the management of allergic rhinitis however, nasal corticosteroids are the primary method of treating this condition. It is unnecessary to use leukotriene antagonists and less important to use oral, nasal, and ocular antihistamines. As mentioned above, allergy immunotherapy is not used to treat nonallergic rhinitis.

The management of the common cold is based on treating the symptoms only as viruses are self-limiting and the symptoms of the common cold will generally disappear within 7 days of the onset of the cold. The treatment is similar to that of nonallergic rhinitis with the exception of the use of eye drops since patients with the common cold do not generally exhibit ocular symptoms. In addition, the use of acetaminophen (i.e., Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen) may be desired in order to help alleviate associated fevers, chills, and/or muscle aches.

The board certified allergists at Black and Kletz Allergy have over 50 years of experience in diagnosing and treating allergic rhinitis, nonallergic rhinitis, and the common cold. We treat both adult and pediatric patients. Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To make an appointment, please call any one of our offices directly or you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergists at Black & Kletz Allergy have been servicing the greater Washington, DC metropolitan area for more than 5 decades and we look forward to providing you with the best state-of-the-art allergy care in a pleasant and hospitable environment.

Pancake Syndrome (Oral Mite Anaphylaxis)

Dust mites are one of the most common triggers of allergic conditions such as in the conditions of hay fever (i.e., allergic rhinitis), allergic asthma, atopic dermatitis (i.e., eczema), and/or food allergies. Dust mites are microscopic insects that live in house dust and on human skin scales. The allergens are excreted in their droppings which then become aerosolized. When sensitized individuals are exposed to these substances in the air, they develop bothersome allergy symptoms such as nasal congestion, runny nose, sneezing, post-nasal drip, itchy nose, itchy eyes, watery eyes, redness of the eyes, fatigue, sinus pressure, sinus headaches, chest tightness, coughing, wheezing and/or shortness of breath.

Although uncommon, some individuals who are sensitive to mites can also develop severe allergic symptoms immediately after eating foods prepared with wheat flour contaminated with various species of mites. This syndrome is designated as oral mite anaphylaxis (OMA) or “pancake syndrome.” It is called pancake syndrome because the most common food to cause such a severe allergic reaction are pancakes.

This condition is more commonly reported from tropical and subtropical regions, probably because in those regions there are environmental conditions favorable for mite reproduction, especially higher temperatures and relative humidities, for longer periods of time. The majority of subjects are adolescents and young adults, although oral mite anaphylaxis can occur in children. In most cases, there is a previous history of atopy where individuals have a history of allergic rhinitis, asthma, atopic dermatitis, and/or food allergies. The allergic individual tends to develop symptoms between 10 minutes and 4 hours after eating the mite-infested food.

The types of mites identified in the pancake syndrome are generally either dust mites or storage mites. The most common dust mites are Dermatophagoides farinae and Dermatophagoides pteronyssinus. The most common storage mites include Blomia tropicalis, Blomia freeman, and Suidasia pontifica, Aleuroglyphus ovatus, Thyreophagus entomophagus, Lepidoglyphus destructor, and Tyrophagus putrescentiae.

The typical symptoms of the pancake syndrome may include shortness of breath, laryngeal and/or facial angioedema (swelling of the vocal cords and/or face which may result in a blocked airway), wheezing, coughing, runny nose, difficulty swallowing, urticaria (i.e., hives), abdominal cramping, and/or redness of the eyes. The clinical presentation may be very severe, such as anaphylaxis, which can lead to hospitalization in the intensive care unit due to laryngeal edema and acute respiratory failure.

Implicated foods usually contain wheat flour, and may include foods such as pancakes, bread, pasta, and pizza. As mentioned previously, pancakes are the most frequently involved food. It is important to note that the allergens causing oral mite anaphylaxis are resistant to heat. Thus, the reactions to the mite-contaminated foods can be induced by well-cooked foods. This is different than what is seen in oral allergy syndrome (i.e., pollen food allergy syndrome). In oral allergy syndrome, well-cooked foods denature the allergen, so individuals can eat well-cooked fresh fruits and/or vegetables without symptoms. In oral mite anaphylaxis, individuals will still develop symptoms even if the mite-infested food is well-cooked. Of note, allergy skin tests with mite-contaminated wheat flour, both before and after it is cooked, will also be positive.

In addition to oral mite anaphylaxis being more common in dust mite sensitive individuals with allergic rhinitis, asthma, atopic dermatitis and/or food allergies, it is also more commonly seen in patients with aspirin and/or NSAID (i.e., nonsteroidal ant-inflammatory drug) hypersensitivity. These patients generally develop hives and/or swelling when they consume aspirin or NSAIDs. Genetic factors are thought to be responsible for this association.

There is also a variant of oral mite anaphylaxis which only occurs after eating mite-infested food followed shortly thereafter by exercise. If the person does not exercise, no symptoms occur. If the person only eats the mite-contaminated food, no symptoms occur. It is the consumption of the mite-contaminated food followed by exercise within a relatively short period of time that will cause the allergic symptoms we have been referring to throughout this blog. This variant of the pancake syndrome has been named dust mite ingestion-associated exercise-induced anaphylaxis.

Risk Factors for Oral Mite Anaphylaxis:
1. Mite allergy
2. History of atopic disease (i.e., allergic rhinitis, asthma, atopic dermatitis)
3. Aspirin/NSAIDs hypersensitivity (i.e., hives/swelling from aspirin/NSAIDs)
4. Consumption of foods prepared with mite-contaminated wheat flour
5. Consumption of more than 1 mg. of mite allergen (>500 mites/gram of flour)

Diagnosis of Oral Mite Anaphylaxis:
1. Previous history of rhinitis, asthma, atopic dermatitis, and/or food allergies
2. Allergic symptoms occur after eating foods prepared with wheat flour
3. Positive skin test with the suspected flour
4. Negative skin tests to wheat and to uncontaminated flour
5. Mite allergens present in flour
6. Identification of mites via a microscope in suspected flour
7. Ability to eat uncontaminated flour without symptoms
8. Aspirin/NSAIDs hypersensitivity in some patients
9. Exercise-induced anaphylaxis with mite-contaminated food in some patients

Prevention:
It is known that mites can grow in closed packages of wheat flour at room temperature. It is also known that exposure to low temperatures inhibits mite proliferation. In order to try to prevent oral mite anaphylaxis, is recommended to store flour in sealed containers in the refrigerator.

The board certified allergy specialists at Black & Kletz Allergy have been treating mite allergies in children and adults in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than half a century. Black & Kletz Allergy provides on-site parking at all of their convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA locations are Metro accessible and there is a complementary shuttle that runs between our McLean office and the Spring Hill metro station on the silver line. Please call any of our offices to schedule an appointment for your allergy, asthma, or immunology needs. Alternatively, please click Request an Appointment and we will respond within 24 hours on the next business day. We strive to provide our patients with the highest quality and most up-to-date allergy diagnostic tests and treatments in a pleasant, caring, and professional environment.

Hay Fever in the Spring

Later this month, Spring is officially here. Along with the warmer weather and longer days comes the pollination of trees and grasses. For some allergy sufferers, the presence of tree and grass pollens can be a miserable sight as these pollens may cause an array of allergy and asthma symptoms that are very annoying.

The allergic reaction to the pollen in the Spring is known as hay fever. The technical term however is called allergic rhinitis. The classic symptoms of hay fever (allergic rhinitis) may include nasal congestion, sneezing, runny nose, post-nasal drip, itchy nose, sinus congestion, itchy throat, sinus headaches, snoring, and/or fatigue. Individuals with allergic rhinitis are also more prone to sinus infections (i.e., sinusitis). It is caused by the inflammation of the inside of the nose. There are other allergens that may also cause allergic rhinitis and some of them may include dust mites, other pollens (e.g., weeds), molds, animal dander/urine/saliva (i.e., cat, dog, hamster), and/or cockroach. Allergic rhinitis can be classified into 2 groups: seasonal allergic rhinitis and perennial allergic rhinitis. Seasonal allergic rhinitis is a condition where an allergic patient experiences symptoms of allergic rhinitis during a particular season. It is usually attributable to a pollen allergy as pollen levels generally fluctuate depending on the season. It should be noted however that molds are also a common allergen that will cause allergic rhinitis. Although any season is possible, the most common season(s) are either Spring or Fall or a combination of both Spring and Fall. Tree pollen in the Washington, DC, Northern Virginia, and Maryland metropolitan area usually begins to pollinate in mid-February and continues until late-May. Grasses typically pollinate in the DC area from early May through the end of July. Perennial allergic rhinitis is a condition where an allergy patient can suffer throughout the year. It is typically dust mites, molds, pets, and/or cockroaches that are the cause of the perennial nature of this disease.

In addition to nasal symptoms, many individuals also suffer or only suffer from eye symptoms due to the tree or grass pollens. Molds may also play a role in some individuals. These patients are also said to have hay fever, but in this case, the technical term is called allergic conjunctivitis. The classic symptoms of allergic conjunctivitis may include itchy eyes, watery eyes, puffy eyes, burning eyes, and/or redness of the eyes. It is caused by inflammation of the thin layer of tissue (i.e., membrane) that covers the inside of the eyelids and eyeball. This thin membrane is called the conjunctiva. Some other allergens that may cause allergic conjunctivitis may include dust mites, molds, other pollens (e.g., weeds), cockroach, animal dander/urine/saliva (i.e., cat, dog, hamster), cosmetics, perfumes, eye drops, and/or dermatologic medications.

Asthma is an inflammatory condition of the airways of the lungs. In addition to inflammation, asthma is also associated with narrowing of the airways and increased mucus secretion into the airways. Asthma can be caused or triggered by numerous factors such as allergens (e.g., pollens, molds, dust mites, cockroach, pets), irritants, viruses [e.g., respiratory syncytial virus (RSV), rhinovirus], exercise, cold air, food additives (e.g., sulfites), gastroesophageal reflux disease (GERD), certain medications (e.g., beta-blockers, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or aspirin. In the Spring, the pollens as well as molds can trigger asthma in sensitized individuals.

The diagnosis and treatment of allergic rhinitis, allergic conjunctivitis, and/or asthma are routinely performed by the board certified allergists at Black & Kletz Allergy at any one of our 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area. After a comprehensive history and physical examination, allergy testing may be performed by either skin testing or blood testing. If one has asthma or has symptoms of asthma (i.e., wheezing, coughing, chest tightness, or shortness of breath), a pulmonary function test may be performed as well. Depending on the results, a variety of medications may be prescribed which may include antihistamines, decongestants, nasal sprays, leukotriene antagonists, eye drops, and/or asthma inhalers. Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) may be recommended as it is a very effective tool to combat allergic rhinitis, allergic conjunctivitis, and/or asthma. It is efficacious in 80-85% of patients who go on allergy shots. Allergy injections have been given in the U.S. for more than 100 years and are used in both children and adults.

If you would like to schedule an appointment with one of our board certified allergy doctors, please call one of our offices. The offices of Black & Kletz Allergy are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer 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. In lieu of calling one of our offices, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy have been diagnosing and treating allergic rhinitis, allergic conjunctivitis, and asthma for more than 50 years in the Washington, DC area and we pride ourselves in providing state-of-the-art allergy, asthma, and immunology care in a relaxed and professional environment.

Oral Allergy Syndrome

Oral allergy syndrome (also known as pollen food allergy syndrome) affects approximately one third of people with seasonal allergic rhinitis (i.e., hay fever).

The symptoms of seasonal allergic rhinitis may include nasal congestion, runny nose, itchy nose, sneezing, itchy eyes, watery eyes, and/or red eyes during tree, grass and/or weed pollinating seasons. In our geographical area, the trees and grasses pollinate mostly in Spring and early Summer and the weeds, especially ragweed, pollinate in the Fall. It is common for these individuals to experience the symptoms during those seasons. The underlying mechanism of oral allergy syndrome is a genetically determined “sensitization” of the immune system to various pollens and subsequent “reactions” when exposed to these pollens. The immune system considers these pollens as “foreign” and thus reacts against them resulting in the annoying symptoms of hay fever.

A number of individuals with pollen allergies will experience a situation where they will develop itching of the lips, gums, tongue, palate and/or throat after eating raw fresh fruits and/or vegetables. This condition is termed pollen food allergy syndrome or oral allergy syndrome. This occurs because of the similarity of the protein antigens in the pollen and the protein antigens of the fresh fruits and/or vegetables. The immune system which is previously sensitized to pollen will also react to the similarly structured proteins in the fruits and/or vegetables. This phenomenon is termed cross-reactivity. Thus when an individual who has a pollen allergy eats certain raw fresh fruits and/or vegetables, the person’s immune system “thinks” that they are being exposed to pollen proteins when in fact they are being exposed to fruit/vegetable proteins that have a very similar structure to the pollen proteins. The body in turn reacts to the fruit/vegetable proteins in a similar fashion as a typical allergic reaction but is usually more localized to where the food makes direct contact, such as the lips, gums, tongue, palate, and/or throat.

This condition tends to be more prominent and bothersome in the Spring months when we are exposed to higher levels of pollen. Specific tree pollen sensitivity cross-reacts with specific fruit/vegetable proteins due to the closeness in the amino acid sequences. For example, patients with birch pollen sensitivity tend to react more commonly with fresh raw pitted fruits (e.g., peaches, apricots, plums), apples, and/or carrots. Birch pollen allergy can also cross-react with peanuts and/or tree nuts.

Individuals with allergies to grasses may have a reaction to peaches, celery, tomatoes, melons (e.g., cantaloupe, watermelon, honeydew), and oranges. Ragweed pollen sensitivity in the Fall usually cross-reacts with melons, bananas, zucchini, and/or cucumbers.

The symptoms usually begin within a few minutes after eating the raw fresh fruits and/or vegetables and generally subside within a few hours. The symptoms of oral allergy syndrome typically include itching of the lips, mouth, and/or throat as mentioned above. The symptoms are usually mild, but in rare cases, can cause throat swelling and/or difficulty in swallowing. Such severe reactions are more likely to happen with peanuts and/or tree nuts. It is important to note that some people with itchy lips, mouth and/or throat after eating a raw fresh specific fruit and/or vegetable may in fact have a true food allergy to a specific fruit and/or vegetable and not have oral allergy syndrome. These truly food-allergic individuals generally will have the same or similar symptoms even when eating the fruit/vegetable cooked, unlike patients with oral allergy syndrome who can generally tolerate the cooked fruit/vegetable without symptoms.

The diagnosis is established mostly by a history of oral pruritus (i.e., itching) and irritation in patients who have previously tested positive to pollen and are symptomatic during the respective pollen seasons.

The treatment of oral allergy syndrome involves avoiding the offending raw fresh fruits/vegetables. Peeling the skin before eating and/or cooking (i.e., baking, microwaving) before eating may decrease the severity of the symptoms, as heat denatures the protein and reduces its allergenic potential.

Below is a chart from the American Academy of Allergy, Asthma & Immunology of different types of pollens and the corresponding foods that may cause oral allergy syndrome:

SPRING               SUMMER                LATE SUMMER – FALL               FALL

Pitted Fruit
Apple                         X
Apricot                      X
Cherry                       X
Peach                         X                               X
Pear                            X
Plum                          X

Melons
Cantaloupe                                                                                                 X
Honeydew                                                                                                   X
Watermelon                                                X                                             X

Other
Banana                                                                                                         X
Kiwi                            X
Orange                                                         X
Tomato                                                        X

Vegetables
Bell pepper                                                                                                                                           X
Broccoli                                                                                                                                                 X
Cabbage                                                                                                                                                X
Carrot                         X
Cauliflower                                                                                                                                           X
Celery                          X
Chard                                                                                                                                                     X
Cucumber                                                                                                    X
Garlic                                                                                                                                                     X
Onion                                                                                                                                                     X
Parsley                        X                                                                                                                        X
White potato                                                X                                           X
Zucchini                                                                                                      X

Spices
Aniseed                                                                                                                                                  X
Caraway                                                                                                                                                 X
Coriander                                                                                                                                              X
Fennel                                                                                                                                                    X
Black pepper                                                                                                                                         X

Legumes*
Peanut                       X
Soybean                    X

Nuts*
Almond                     X
Hazelnut                   X

*Mouth or throat itching from peanut, soybean, almonds, and hazelnuts may also be an initial
manifestation of a more serious food allergy with the potential for anaphylaxis. See an
allergist/immunologist if such symptoms are noted.

© 2019 American Academy of Allergy, Asthma & Immunology.

 

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating oral allergy syndrome and food allergies for more than 50 years. We treat both pediatric and adult patients. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. To schedule an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from an itchy mouth or throat after eating fruits and/or vegetables or you have other food allergy symptoms, we are here to help diagnose and treat your food allergy. The allergists at Black & Kletz Allergy are happy to help you with any allergic condition that you may have as we are dedicated to providing you with the highest quality allergy care in a relaxed, caring, and professional environment.

Bug Bite and Sting Allergies and Reactions

Bug bites are certainly very common. Almost everyone has been bitten by a bug in their lifetime and almost everyone has had at least a minor local reaction to the bug bite. In some instances, an individual may have a more severe reaction that is not an allergic reaction but it can mimic an allergic reaction. In other cases, however, an individual may actually have a true allergic reaction. In order to differentiate between an allergic reaction and a non-allergic reaction, a consultation with a board certified allergist may be necessary.

There are 4 basic types of reactions that may occur from a bug bite. They are classified as follows:

  • Local irritant reaction
  • Allergic reaction
  • Toxic reaction
  • Serum sickness reaction

The first two reactions are by far the most common. Overwhelmingly, a local irritant reaction is the most common of the four reactions. The symptoms of a local irritant reaction may include local redness, pain, itching, and/or swelling. It is generally self-limited and usually resolves on its own without treatment. If treatment is desired, one can use over-the-counter (OTC) antihistamines or OTC topical corticosteroids to treat this type of reaction.

An allergic reaction to a bug bite is not very common, however they do occur. Symptoms can mimic a local irritant reaction but the reaction may be more severe. Additional symptoms may include blistering of the skin, generalized itching of the skin, throat closing sensation, hives (i.e., urticaria), warm feeling, increased heart rate, drop in blood pressure, lightheadedness, dizziness, fainting, wheezing, and/or shortness of breath. It is more common to have true allergic reactions to the venom of stinging insects such as honey bees, yellow jackets, hornets, wasps, and fire ants. The treatment of an allergic reaction to a bug bite is aimed at treating and controlling the symptoms. OTC antihistamines and/or OTC topical corticosteroids are generally adequate enough in to treat this condition. Occasionally, prescription medications such as more potent antihistamines, histamine2-blockers (e.g., Pepcid, Tagamet), leukotriene antagonists (e.g., Singulair), and/or oral corticosteroids may be necessary in order to treat the allergic reaction. Rarely, the use of asthma inhalers (e.g., albuterol) may be necessary in individuals who develop symptoms of asthma which may include shortness of breath, chest tightness, coughing, and/or wheezing. An individual who has had a systemic allergic reaction to a stinging insect (e.g., honey bees, yellow jackets, hornets, wasps, fire ants) should be skin tested by a board certified allergist. If that individual reacts to the venom skin testing, it is strongly recommended that this person go on a course of venom immunotherapy (i.e., allergy shots for stinging insects) as they are very efficacious in preventing anaphylaxis. It is very important that such an individual carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) in case they are stung, as insect sting allergies can be fatal. If the epinephrine device is used, it is imperative that the patient go immediately to the closest emergency room. It also should be known that honey bees leave their stingers in their victims and if stung by a honey bee, never pull out the stinger. Instead, one should scrape off the stinger. Pulling out a stinger may cause the pinching of the venom sac, which may in turn cause the venom sac to introduce more venom into the affected person.

A toxic reaction to bug bites or stings occurs when a bug introduces various substances into an individual such as a toxin or venom. Assuming there is not an allergic reaction to the venom, as mentioned above, the venom may act as a poison and cause direct harm to the tissues of the individual. Toxic reactions can occur from one sting or bite from a highly toxic insect or spider, or from multiple stings or bites from insects or spiders not normally considered poisonous. The symptoms of a toxic reaction may include nausea, vomiting, fever, fainting, lightheadedness, pain or redness or swelling at the site of the sting or bite, headache, muscle spasms, seizures, and/or shock. It is even potentially fatal. The treatment of a toxic reaction to bug bites or stings is primarily based on supportive care. Antihistamines and corticosteroids may be used. In addition, standard wound care precautions and treatment should be utilized as it is not uncommon for the site of the bite or sting to become infected. Antibiotics should be used when needed.

The fourth type of reaction that can occur due to a bug bite or sting is serum sickness. Serum sickness can occur as a result of a reaction towards the venom of either insect stings or spider bites. The symptoms generally manifest hours to days after the sting or bite. The classic symptoms may include fever, joint pain, itching, rash or hives, and/or fatigue. Other symptoms may include swollen lymph nodes, enlarged spleen, drop in blood pressure, and/or shock. In addition to venom, medications (e.g., penicillins, cephalosporins, allopurinol), blood products (e.g., transfusions), and antitoxins (e.g., antivenom) have been known to rarely cause serum sickness. The treatment of serum sickness usually entails antihistamines, corticosteroid creams, and/or nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen). In severe cases, oral corticosteroids are often utilized.

If you or someone you know have experienced an insect sting or bug bite and had more than a minor reaction, the board certified allergists at Black & Kletz Allergy are here to help. We diagnose and treat both adults and children in all facets of allergy, asthma, and immunology. We often see patients for consultations about insect stings and bug bites. Our allergists will perform venom testing on those individuals who meet the requirement for testing. In addition, a specific plan for future stings and/or bites will be discussed with the patient in order to reduce the individual’s fear and confusion regarding reactions to the bite and/or sting. 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. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment as we have done for over 50 years.