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

April 20, 2020
Black & Kletz Allergy

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

April 11, 2020
Black & Kletz Allergy

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.

What Can Be Done for Hives?

March 20, 2020
Black & Kletz Allergy

Hives (i.e., urticaria) are a fairly common occurrence which is usually very annoying to the individual who suffers from them. They are often called “welts” by the general public and “wheals” by allergists. Hives are itchy, red blotches on the skin that are usually raised. Some affected individuals may experience a burning sensation while others notice a stinging sensation. Hives, in some instances, may be flat and not raised. The size of an individual hive may range from very small to rather large. They can also coalesce with other hives to create giant “plaques” of hives. Hives can be various shapes and are usually not symmetrical. They often look like mosquito bites but without the actual bite. They can occur anywhere externally on the body (e.g., face, neck, extremities, back, abdomen) or be located internally (e.g., throat, intestines). When they are internal, symptoms such as swelling of the throat, abdominal pain, or diarrhea may ensue. When hives occur on the lips, tongue, eyes, or ears, it is not uncommon for the individual to notice only swelling of these body parts. This swelling is termed angioedema. Angioedema is essentially a hive that is in the deeper tissue layers. As a result, the lesion appears as a swelling, opposed to a hive. Either way, both are bothersome to the person who is afflicted with either or both of them.

Hives are basically grouped into two main categories, although there are actually more than two. The first category is referred to as acute urticaria. Acute urticaria is a condition where the hives occur for 6 weeks or less. If hives linger on and persist for more than 6 weeks, they are called chronic urticaria. Some cases of hives may last for months and even years in a small percentage of patients. Approximately 25% of the general population in the U.S. develop hives at some point in their lives. Each episode of hives generally last less than 24 hours in duration but may last for days or weeks in certain circumstances.

The diagnosis of hives begins with a comprehensive history and physical examination by a board certified allergist such as the allergists at Black & Kletz Allergy. The workup for hives will vary depending on what was discovered in the history and physical examination in conjunction with how long the hives have been present. For many individuals, a medication allergy is to blame. For others, a food may be the culprit. For those who present with chronic urticarial (i.e., hives that have persisted for more than 6 weeks), bloodwork is generally needed in order to rule out a multitude of diseases and conditions that are known to cause hives. Despite all of the bloodwork done on a patient with chronic urticaria, approximately 95% of these individuals will have normal test results. If the workup is completely negative, the term idiopathic chronic urticaria is used as a diagnosis. This basically is a fancy way of saying that no identifiable cause was discovered to cause the hives of that individual. Some of the conditions that are known to be associated with chronic urticaria include thyroid disorders, autoimmune disorders (e.g., systemic lupus erythematosus, Sjögren’s syndrome, rheumatoid arthritis), hepatitis B, other infections, cancers, complement disorders, and physical elements (e.g., heat, cold, pressure, exercise, vibration), to name a few.

The treatment of hives can range from avoidance to using medications. Antihistamines are usually the first line of defense of most cases of hives. Beta-2 agonists such as Pepcid (famotidine) are often utilized to enhance the effect of the antihistamine when an antihistamine alone is not enough to prevent hives. Leukotriene antagonists [e.g. Singulair (montelukast)] are often added to the regimen is difficult-to-treat hives. In recalcitrant disease, oral corticosteroids may be used to bring the hives under control for a short time since the use of long-term steroids is not ideal because of the risks and many side effects that may develop. Xolair (omalizumab) injections are used for idiopathic chronic urticaria in patients where other therapy is unsuccessful. Xolair injections Xolair are very effective in the management of chronic hives.

New Treatments for Chronic Cough

Why do we cough? Coughing is a natural defense mechanism to expel excessive mucus, microbes, and irritant substances from our airways which acts to protect our lungs from the potential damage caused by them. Coughing, however, can also be a bothersome symptom and is one of the most common reasons why patients consult their doctors.
The sound of a cough is produced after forcible expiration (i.e., breathing out) against a closed glottis (i.e., voice box) as the air flows out when the glottis suddenly opens. A cough is defined as “acute” when it persists for less than 3 weeks, subacute when the duration is between 3 and 8 weeks, and chronic if it continues to be present for longer than 8 weeks.

Approximately 12% of U.S. population experiences a chronic cough at some point in their lives. It is more common in women than in men and generally peaks between the 5th and 6th decades of life. A chronic cough can be very bothersome which may negatively impact one’s quality of life. A severe cough may lead to vomiting, broken ribs, bleeding, incontinence, sleep disturbance, social distress, and/or depression.

Common causes of a chronic cough:

Asthma
Medications such as ACE (angiotensin converting enzyme) inhibitors and some diabetes mellitus medications
Upper airway cough syndrome (e.g., post-nasal drip)
GERD (i.e., gastroesophageal reflux disease) – Also known as acid reflux.
Environmental irritants
Tobacco use
Eosinophilic bronchitis
Tumors

Initial evaluation begins with obtaining a comprehensive history, which includes:

Duration of the condition
Characteristics of the cough
Triggers for the cough (e.g., environmental, dietary)
Medications taken (e.g., over-the-counter, herbal, prescriptions)

“Red flags” in the history suggesting a serious illness may include:

Coughing up blood (i.e., hemoptysis)
Chronic smoking with a new cough
Difficulty in breathing
Persistent hoarseness
Difficulty in swallowing
Vomiting
Fever
Weight less
Swollen hands and/or feet
Abnormal examination
Abnormal chest X-ray

Treatments:

Upper airway cough syndrome: Post-nasal drip is usually a result of inflammation of the nose and throat either from allergens or irritants. This condition frequently responds to either antihistamines or nasal sprays or the combination of both antihistamines and nasal sprays.
Asthma: Cough may be the only symptom of asthma (e.g., cough variant asthma) and can be controlled with inhaled corticosteroids and/or oral leukotriene modifiers (e.g., Singulair, Accolate, Zyflo)
Non-asthmatic eosinophilic bronchitis: A trial of oral corticosteroids such as prednisone for 1 to 2 weeks is usually helpful in relieving the cough.
GERD: Approximately 10% of the population report frequent “heartburn” from acid reflux. Lifestyle modifications and medications to reduce acid secretion (e.g., Prilosec, Nexium, Prevacid) for 4 to 8 weeks will usually result in a substantial improvement of the cough.
Speech evaluation and speech therapy may be useful in certain situations.

If the cough does not respond to the above treatments at the correct dosage for a sufficiently long duration, it is termed a chronic refractory cough.
New medications which target the neurological pathways and block the cough reflex are actively being investigated and are as follows:

Sodium channel blockers: Similar to local anesthetics such as lidocaine.
Neurokin-1 (NK-1) receptor antagonists (e.g., Orvepitant, Aprepitant)
Purinergic receptor antagonists: Gefapixant is the name of one of the most promising drugs currently in development which exhibited significant efficacy in controlling a refractory cough. It is undergoing phase 3 clinical trials at this time. It is given by mouth twice a day. Side effects reported so far include taste disturbances.

The board certified allergists at Black & Kletz Allergy have been treating coughs in adults and children in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years. 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 one 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.

Spring Allergies

Historically, March is the month that many trees begin pollinating in the Washington, DC metropolitan area. This year, trees have begun to pollinate in February, as the temperatures in the metro area have been higher than normal for a typical Winter. We will begin to see tree pollen marked by a yellowish coating on our automobiles soon. For many allergic individuals, this represents a tumultuous time for those who are sensitized to tree pollen. Birch, cedar, ash, oak, elm, cottonwood, hickory, and maple are the predominant trees producing pollen in our area during the Spring. This time of the year is the reproductive season for the trees. As a result, the tree pollen grains are released into the atmosphere in order to fertilize the ovules of other trees. This process is called pollination. Pollen is produced and then dispersed by the wind throughout the day, however, the tree pollen counts are highest during the morning hours.

Pollen grains are not harmful or noxious when inhaled, unless an individual’s immune system mistakes the pollen as potentially hazardous and subsequently mounts a defensive attack on them. This process is called allergic sensitization and results in the release of certain chemical mediators such as histamine and leukotrienes, which are mediators of the annoying symptoms of allergic rhinitis (i.e., hay fever) and allergic conjunctivitis (i.e., eye allergies).

Over the past decade, several scientists have noticed a steady increase in the tree pollen counts across the country. Many scientific researchers believe, although controversial, that climate change is contributing in part to this trend of increasing pollen counts. Carbon dioxide is the primary gas needed for the growth and development of trees, (along with sunlight, water, and nutrients), and increasing levels of carbon dioxide are being documented every year. These changes in the climate may impact the pollen season of not only trees, but in addition, may affect the pollination of both grasses and weeds. Climate change may cause an increase in the amount of pollen produced as well as cause an extension of the duration of the pollen seasons.

What are the symptoms of Spring allergies?
The most common symptoms of Spring allergies may include sneezing, clear runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy eyes, watery eyes, red eyes, puffy eyes, cough, itchy ears, clogged ears, sinus headaches, sinus congestion, sinus pressure, snoring, and/or fatigue. In asthmatics, the pollen can also trigger chest tightness, coughing, wheezing, and/or shortness of breath.

How are Spring allergies diagnosed?
Spring allergies are diagnosed by board certified allergists such as the allergy specialists at Black & Kletz Allergy who first take a comprehensive history and perform a detailed physical examination. Allergy testing is often done either by skin testing or occasionally via blood testing in order to identify the offending allergen. Once the allergens are known, preventive measures are recommended in order to reduce exposure to the allergens.
Some preventive measures to reduce exposure to pollen and to minimize symptoms may include the following:

Track the local pollen counts on the homepage on our website, www.bkallergy.com by clicking Today’s Pollen Count and avoid outdoor activities on days where the pollen count is high, especially in early morning hours.
Go outdoors shortly after it rains, as the water keeps the pollen from blowing from place to place.
Change and clothes after wearing them worn outside.
Leave shoes outdoors in order to help prevent bringing pollen into the home.
Wipe down a pet’s fur and/or wash the pet before he/she comes indoors.
Shower off the pollen from skin and hair before going to bed.
Close the windows in automobiles and at home to keep the pollen out.
Run the air conditioner in automobiles and at home.

How are Spring allergies treated?
Begin using antihistamines and nasal corticosteroid sprays early in the season. They are more effective if begun before the onset of symptoms and if taken daily throughout the season. Other common types of prescription medications may include decongestants, leukotriene antagonists, nasal antihistamines, nasal anticholinergic agents, eye drops, inhaled corticosteroids, and inhaled beta-agonists. In cases of persistent or severe symptoms, consider allergy desensitization (i.e. allergy shots, allergy immunotherapy, allergy injections, allergy hyposensitization) to the pollen, which usually provides a long-term benefit and reduces the need for medications. They are effective in 80-85% of patients. They are generally taken for 3-5 years.

The board certified allergists at Black & Kletz Allergy have 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Our 3 office locations have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. Our McLean office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line. The allergy specialists at Black & Kletz Allergy diagnose and treat both adult and pediatric patients. To schedule an appointment, please call our office directly or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy have been serving patients with hay fever, asthma, sinus disease, hives, eczema, insect sting allergies, food allergies, medication allergies, and immunological disorders for more than 50 years. If you are bothered from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.

Unusual and Uncommon Allergies

Most everyone is aware of the classic and common allergies that many individuals suffer from routinely. Allergies to dust mites, molds, pollens, pets, and/or cockroaches usually manifest themselves as symptoms of allergic rhinitis (i.e., hay fever), allergic conjunctivitis (i.e., eye allergies), and/or asthma. Food allergies are not uncommon and it commonly known that the most common food allergens are milk, egg, soy, wheat, peanuts, tree nuts, fish, and shellfish. When people think of allergies of the skin, they often think of atopic dermatitis (i.e., eczema), allergic contact dermatitis (i.e., poison ivy, poison oak, poison sumac, cosmetic allergy), and hives (i.e., urticaria). All of these allergies are relatively common but there are a number of allergies that are uncommon and/or unusual that are very interesting. It is some of these more unusual and uncommon allergies that we will explore in the following paragraphs.

Uncommon Food Allergies:

Oral Allergy Syndrome (Pollen Fruit Syndrome; Pollen/Food-Associated Syndrome): An allergic reaction in the mouth usually causing itching that occurs in certain allergic individuals that have certain pollen allergies. Classic examples include birch tree allergies and reactions to raw apples, kiwi, apricots, cherries, peaches, plums, pears, avocados, celery, and/or carrots. Ragweed allergies and reactions to melons, cucumbers, zucchini and bananas. In this disorder, the raw fruit or vegetable looks similar structurally to the pollen and the body “thinks” that the food is the pollen and an allergic reaction (e.g., itchy mouth) occurs. Interestingly, if the food is cooked and or processed, the individual can usually tolerate the food without any symptoms.

Mammalian Meat Allergy: Some individuals that are bitten by a Lone Star tick may develop a meat allergy due to the development of an antibody to a carbohydrate called galactose-alpha-1,3-galactose (i.e., alpha-gal). This carbohydrate is found on all mammalian meat (e.g., beef, pork, lamb, venison, whale). When an individual with the alpha-gal antibody eats any mammalian meat, the meat triggers the release of the chemical called histamine. It is the histamine that causes the allergic symptoms which usually appear 4-8 hours after the consumption of the meat. Symptoms may include generalized itching (i.e., pruritus), hives, and/or swelling (i.e., angioedema).

Chamomile Tea: Chamomile is related to ragweed and some ragweed-sensitive individuals may also react to chamomile tea and chamomile lotions. Symptoms can range from allergic rhinitis symptoms to anaphylactic shock, although it is rare to have such a violent reaction.

Gelatin Allergy: Some individuals are allergic to gelatin; however, this allergy is rare. Gelatin is a protein formed when connective tissue from animals is boiled. Some individuals are allergic to this protein and when exposed, they can have an allergic reaction that may also be quite severe. Gelatin may be found in chewy candies, frosted cereals, and in some vaccinations such as the flu shot.

Wine: Certain individuals are hypersensitive to sulfating agents used in processing certain foods, beverages, and drugs. Sulfur dioxide and several forms of inorganic sulfites that release sulfur dioxide when used as food ingredients are known collectively as sulfating agents. The preservative sulfite is used in the production of wine and other foods. Some individuals, especially asthmatics, are sensitive to sulfites and should avoid certain foods that may contain sulfites such as sauces, gravies, soups, wine vinegar, processed meats, dried/frozen/canned fruits and vegetables, and occasionally salad bars.

Hot Dogs and Deli Meats: Hot dogs and various deli meats are highly processed foods that contain many additives. An allergic reaction after eating these meats could be due to any of these added ingredients. It is believed however that nitrate and nitrite additives are generally the cause in most instances.

Water: Yes, individuals can be allergic to water. It is quite rare, however, there are some individuals who have a condition called aquagenic urticaria. If one has this malady, the contact with water will cause itching and hives. There is no optimum treatment for this disorder at the present time

Uncommon Non-Food Allergies:

Latex Allergy: Latex or natural rubber allergies can range from a mild irritation of the skin to a severe anaphylactic reaction. Common latex products include latex gloves, condoms, dental dams, adhesive bandages, balloons, waistbands, tires, and pacifiers, to name a few. It is interesting to note that there are similar proteins in natural rubber latex and certain foods (e.g., avocados, chestnuts, papaya, bananas, kiwis), so cross-reactivity can occur.

Sex: There are individuals that have a disorder called seminal fluid hypersensitivity whereby they are allergic to the seminal fluid of a particular person. It is generally an allergy to a specific man’s seminal fluid and not necessarily to all men. The symptoms can range from just a minor irritation on the skin, to hives, to anaphylaxis. Symptoms can be avoided with the use of condoms. Many times, in vitro fertilization is needed in order for the couple to conceive without risk to the allergic individual.

Sunlight: A small percentage of the population have a sensitivity to sunlight where they may develop hives, itchy skin, rash, nausea, and/or headache. Solar urticaria is a condition where hives form upon exposure to sunlight.

Exercise: Exercise may trigger a generalized itching, hives, swelling, asthma, and/or anaphylaxis, depending on the person. These conditions are called, exercise-induced pruritus, exercise-induced urticaria, exercise-induced angioedema, exercise-induced asthma, and exercise-induced anaphylaxis respectively. In some instances, an individual must exercise in the cold air for symptoms to occur. In others, a specific food must be eaten a few hours before exercise in order for there to be an allergic reaction. This is called food-dependent-exercise-induced urticaria. An example of this is a person who can eat celery without problems and they can exercise without problems. However, if they eat celery within 2 hours before exercise, they will develop hives. Patients with these conditions should never exercise alone and if they exercise, should always stop exercising at the first sign or symptom of their allergy.

Cold: Cold can be a trigger for some individuals to develop generalized itching, hives, swelling, asthma, and/or anaphylaxis. The names of the corresponding conditions are cold-induced pruritus, cold-induced urticaria, cold-induced angioedema, cold-induced asthma, and cold-induced anaphylaxis respectively. Similar to exercise above, these patients should avoid the cold, if possible.

Money: Individual with nickel allergy may develop allergic contact dermatitis from handling coins. Metal allergy is not that uncommon, but having reactions to holding coins is fairly uncommon. Obviously, the condition is more prevalent in individuals who handle money more often such as bank tellers and cashiers.

Scratches: Some individuals have a disorder called dermatographism where a simple scratch or pressure on the skin will cause the affected area to develop hives in a linear pattern to match the scratch. The name dermatographism means “skin writing” so it is possible to write a word on the individuals’ skin just by writing the word using a fingernail on the skin. Approximately 5 minutes later, the word is visible in a reddish and raised fashion.

There are more uncommon allergies than mentioned above, but the ones listed above give some indication of the diversity of unusual allergies. Individuals can be allergic to almost anything. It is a combination of the patient’s awareness of their symptoms and situation in conjunction with the allergist’s knowledge that is needed in order to diagnose and then prevent and/or treat such unusual allergies.

The board certified allergists at Black & Kletz Allergy have 3 office locations in the Washington, Northern Virginia, and Maryland metropolitan area. The allergy doctors at Black & Kletz Allergy treat both pediatric and adult patients. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. The McLean office has a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy have been helping patients with hay fever, asthma, sinus disease, eczema, hives, insect sting allergies, immunological disorders, medication allergies, and food allergies for more than 50 years. If you suffer from any allergy, whether unusual or not, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.

Keratoconjunctivitis and Eye Allergies

Keratoconjunctivitis is term used to describe inflammation of the cornea and conjunctiva. Keratitis specifically is the inflammation of the cornea (i.e., the transparent dome that covers the pupil and the iris of the eye). Conjunctivitis, on the other hand, is the inflammation of the conjunctiva [i.e., the thin membrane covering the sclera (i.e., the white of the eye) as well as the lining of the inner part of the eyelids]. It is more commonly referred to as “pink eye.” Keratoconjunctivitis is one of the most common causes of red and irritated eyes as millions of individuals visit doctors for this condition every year.

Most of the cases of keratoconjunctivitis and conjunctivitis are due to allergies. Conjunctivitis due to allergies is referred to as allergic conjunctivitis. Infections are another common cause of keratoconjunctivitis and conjunctivitis with viruses accounting for most of the infections across all age groups. Of note, conjunctivitis caused by bacteria is more common in children. Other infectious agents may include a parasite or a fungus. It should also be noted that an injury to the eye can inflame the cornea or conjunctiva without a secondary infection.

Types of Keratoconjunctivitis:

Keratoconjunctivitis sicca is also commonly known as dry eye syndrome. Dry eye occurs when either the eye does not produce enough tears or when the tears evaporate too quickly. It can also occur when there is an imbalance in the tear mixture. Tears are comprised of water, fatty oils, and mucus. Individuals need the correct mixture of all three of these ingredients in order to properly nourish one’s eyes. Some of the more common causes may include allergies, contact lens use, pregnancy, meibomian gland (i.e., glands in eyelids that excrete oil into the tears) dysfunction, and certain medications such as (e.g., antihistamines, some blood pressure medications, hormone replacement therapy, antidepressants).

Epidemic keratoconjunctivitis (EKC) is an eye infection caused by a specific virus called the human adenovirus. It is also known as “adenoviral keratoconjunctivitis” or just “viral keratoconjunctivitis.”

The incubation period of EKC is long and it is very contagious. It tends to spread quite easily especially when individuals are in close quarters (e.g., dormitories, hospitals, schools, arenas, movie theaters).

There’s no specific treatment for EKC. Symptoms typically last a few weeks in duration before abating. Adenoviruses may also target the digestive, respiratory, and genitourinary tracts.

Vernal keratoconjunctivitis (VKC) is a recurrent, chronic allergic inflammation of the eyes. It generally results in small, round bumps known as giant papillae underneath the eyelid. VKC generally affects the upper eyelids more than the lower eyelids. The symptoms are much more common in the Spring with the arrival of pollen, particularly tree and/or grass pollen.

The cause is thought to be an allergic disorder, but may also involve genetic and/or immune system disorders. It is more common in tropical environments and is more common in boys than in girls.

Atopic keratoconjunctivitis (AKC) is a chronic inflammatory disease of the eye that usually affects patients with a history of atopic dermatitis (i.e., eczema). Males are affected with AKC more often than females, and it is more likely to involve the lower eyelids more than the upper eyelids.

Symptoms characteristically worsen in the Winters. Without treatment, AKC may lead to serious complications such as:

Ulceration
Keratoconus (i.e., thinning and bulging cornea)
Corneal vascularization (i.e., growth of new blood vessels into the cornea

Herpetic keratoconjunctivitis is an infection caused by the herpes simplex virus, particularly Type 1. Touching one’s eyes after touching a cold sore may transfer the virus to the eyes.

Allergic keratoconjunctivitis refers to any keratoconjunctivitis caused by an allergen. Vernal keratoconjunctivitis and atopic keratoconjunctivitis, for example, are included in this group. The allergies can be seasonal or perennial in nature.

Symptoms of Keratoconjunctivitis:

Symptoms range from mild to severe. The symptoms may vary depending on the cause. Some symptoms associated with keratoconjunctivitis may include:

Redness
Itchiness/Burning
Puffy eyelids
Discharge from the eyes (i.e., watery eyes)
Stickiness of the eyes (i.e., eyes become “glued shut”)
Light sensitivity (i.e., photophobia)
Dryness
“Foreign body” sensation in the eyes
Blurry of vision (usually mild)

Diagnosis of Keratoconjunctivitis:

The diagnosis can be made based on the medical history, symptoms, and visual inspection of the eyes. Depending on the initial findings, a physician may also want to examine:

Visual acuity
Under the eyelids
Ocular pressure
Pupillary reactions
Discharge of the eyes
Corneal sensation

In some cases, one may need to be tested for:

Allergens
Viruses
Autoimmune disorders
Genetic conditions

Treatment of Keratoconjunctivitis:

Treating the symptoms:

One may need a combination of therapies which may include:

Topical antihistamines or mast cell stabilizers
Preservative-free lubricating gels and ointments
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Topical corticosteroids

In cases of severe keratoconjunctivitis sicca, punctal plugs may be inserted to reduce the drainage of the tears into the nose.

Treating the underlying condition(s):

Some viral infections, such as herpes, may require treatment with topical or oral antiviral medications. Any underlying autoimmune or genetic conditions may also need specific treatments.

Black & Kletz Allergy has board certified allergists in 3 convenient locations in the greater Washington, DC, Northern Virginia, and Maryland metropolitan area. The allergists are trained and very familiar with allergic eye disorders such as mentioned above. The allergy specialists at Black & Kletz Allergy diagnose and treat both adults and children. We offer on-site parking in our Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA locations. The Washington, DC and McLean, VA offices are Metro accessible and the McLean office has a free shuttle that runs between the McLean office and the Spring Hill metro station on the silver line. If you are experiencing what appears to be allergy symptoms associated with your eyes, please call us to schedule an appointment. Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been serving the needs of allergy and asthma sufferers in the Washington, DC metro area for more than 5 decades.

Eczema Exacerbations

What are some of the causes?

As we enter into the season of colder days and nights in the Washington, DC metropolitan area, we are exposed to colder and drier air. The cold and dry air in conjunction with lower humidity levels predispose individuals to flare-ups of eczematous skin conditions.

Layers of clothing during outdoor activities and returning to overheated homes can trigger a cycle of sweating, itching, scratching, and irritation. Dry heat from our furnaces will evaporate the normal protective oils of one’s skin which may lead to cracking of the skin.

The smoke emitted by indoor fireplaces and wood burning stoves in combination with exposure to dust and dust mites may cause exacerbations of allergies, eczema, and asthma in individuals predisposed to these conditions. Parched air can dry up the normal moisture in the mucus membranes leading to nose bleeds as well as a burning sensation in the eyes.

The pile of wet leaves in people’s yards create a breeding ground for the molds to grow and their spores may trigger allergic rhinitis (i.e., hay fever), asthma, and eczema (i.e., atopic dermatitis) in sensitized individuals. The wool in one’s sweaters can irritate sensitive skin and cause itching (i.e., pruritus) and rashes.

Other common triggers of eczema may include hot water, smoke, sweat, extreme temperatures, perfumes, colognes, cleaning solutions, scented laundry detergent, scented candles, scented soaps, scented shampoos, scented dryer sheets, fabric softeners, pets, molds, pollens, skin infections, stress, and certain foods in people with known food sensitivities.

What can be done in order to improve the situation?

Thorough and regular moisturizing of the skin with emollients (e.g., creams, ointments, lotions, gels) is the best protection against flare- ups of individuals with eczema. Thick oil-based creams and/or ointments generally help protect the skin from excessive dryness better than water-based lotions. “Soak and seal” methods are efficacious in helping prevent the loss of moisture from the skin.

Direct exposures to sources of dry heat (e.g., radiant warmers) should be avoided. If the HVAC system does not have a central humidifier, an ultrasonic water vaporizer in the bedrooms, especially during nights, will reduce excessive dryness of the mucus membranes and the skin.

Long, hot showers can strip the skin of its natural oils. Shorter, lukewarm showers or baths are skin-friendly. Milder soaps, detergents, and shampoos without fragrances are kinder to the skin.

Woolen and synthetic clothes can irritate the skin and cause itching when they are in direct contact with skin. Natural fabrics such as cotton and cashmere are less likely to cause flare-ups of itching and rashes while in direct contact with skin.

In spite of above measures, if eczema does flare-up, one may need to use medications in order to control eczema. Below are a list of several medications used to treat eczema:

1.) In order to manage eczema, it is very common to use topical anti-inflammatory medications (e.g., topical corticosteroids) for a short period of time.

2.) The itching usually responds well to first generation antihistamine medications.

3.) Second generation antihistamines may also help and have the advantage of being generally non-sedating.

4.) Eucrisa (crisaborole) ointment 2% is a nonsteroidal cream that is quite efficacious in the treatment of eczema and has very few side effects. The most common side effect is a mild burning or stinging sensation of the skin where the ointment is applied. Eucrisa ointment 2% is indicated in the treatment of eczema in children ages 2 years of age and older as well as in adults.

5.) Topical immunosuppresants are commonly used in both children and adults. The two most common medications in this class include Protopic (tacrolimus) ointment and Elidel (pimecrolimus) ointment. They are both fairly effective and are steroid-free. Protopic can be used in children 2 years of age and older as well as in adults. Elidel is approved for children 3 months of age and older as well as for adults.

6.) Rarely, a short course of oral corticosteroids may be necessary during severe exacerbations of eczema, although the use of oral corticosteroids is generally avoided due to the potential side effects that corticosteroids can produce.

7.) If all else fails, there is a class of medications called “biologicals” that may be utilized and has been very effective in the treatment of eczema. Dupixent (dupilumab) is currently the only biological that is FDA-approved to treat moderate-to severe-eczema. It is currently approved for adolescents (12 years of age and above) as well as for adults. Of note, Dupixent also is approved for the treatment of asthma in patients 12 years of age and older, as well as in adults with chronic rhinosinusitis with nasal polyps (CRSwNP).

The board certified allergy specialists at Black & Kletz Allergy have expertise in diagnosing and treating eczema as well as other skin conditions [i.e., hives (urticaria), contact dermatitis, poison ivy]. We are board certified to treat both pediatric and adult patients and have been doing so in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than a half a century. 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 directly 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 skin-related disorder, we are here to help alleviate or hopefully end these unwanted symptoms that have been so bothersome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a friendly and professional environment.