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Cat, Dog, and Other Pet Allergies

German Shepherd Dog and cat together Twenty percent of the U.S population have cat allergies and 10% of the population have dog allergies. In the U.S., the most common pet are dogs, which are followed by cats as the second most common pet. Approximately 70% of homes having at least one pet. This is a higher percentage of homes with pets than in the past as more and more families are acquiring pets. In addition to cats and dogs, some other common pets include birds (e.g., parakeets, parrots), fish, rabbits, rodents (e.g., guinea pigs, hamsters, gerbils, chinchillas, rats, mice) reptiles (e.g., snakes, lizards, turtles, geckos), hermit crabs, ferrets, horses, and spiders. Horses normally do not live in people’s homes, but they may be rather allergenic. In recent years, there is a fad of owning miniature horses which in some cases do live in their owner’s house. This is probably not a good idea in general, but for those who are allergic to horses, it is especially unwise.

Allergies to pets are in fact really an allergy to the specific proteins that are produced by a particular pet. In dogs, the major protein responsible for allergies to dogs is called “Can f 1.” This protein produced by dogs is most commonly found in the dog’s dander, saliva, and urine. In cats, the major proteins associated with allergies are known as “Fel d 1” and “Fel d 4.” These two proteins are responsible for most of the suffering in individuals with cat allergies. Similarly, most of the proteins that cause allergies in cats are concentrated in the sebaceous glands in the skin (i.e., dander), the saliva, and the urine. Unlike dogs, cat dander tends to “stick” to things such as walls, carpeting, clothing, bedding, etc. and is commonly transported from the home to home or home to work environments. If the Fel d 1 protein is measured on a cat owner’s clothing, bedding, or upholstered furniture at work, it is likely that the protein will be found. In addition, it may take months for these proteins to dissipate and become undetectable, despite a thorough cleaning of the home, due the stick-to-itiveness of cat dander. Note that since the protein is also found in urine, cat litter boxes are a rich source of these proteins and allergic individuals should avoid exposure to litter boxes. In dogs, fortunately the protein Can f 1 is not as “sticky” as the cat proteins, but still can adhere to walls, clothing, carpeting, bedding, etc. Interestingly, there is an increased incidence of horse allergy in some individuals that have cat and/or dog allergies due to a common protein that is shared between all three animals. In rodents, in addition to the allergenic protein being present in the urine, dander, and saliva, certain rodents such as mice contain allergenic proteins in their mouse droppings.

In addition to pet allergies, there are additional potential medical hazards to consider when owning certain pets. Mice and rats carry many diseases such as the bubonic plague, Hantavirus pulmonary syndrome (HPS), leptospirosis, tularemia, rat bite fever (RBF), lymphocytic choriomeningitis, salmonellosis, and Lassa fever. Exposure to birds can cause infections and diseases such as psittacosis, salmonellosis, allergic alveolitis, campylobacteriosis, avian flu, avian tuberculosis, Newcastle disease, cryptosporidiosis, and giardiasis. Reptiles can irritate one’s skin. Snakes can cause life-threatening allergic reactions from the venom that is introduced from a snake bite.

As a general rule, if an individual is allergic to a specific pet, it is advisable not to own that pet. Even though this seems pretty obvious, a majority of individuals still choose to either acquire a pet or keep an existing pet that they own despite that the pet causes unwanted allergy symptoms. This is understandable, although not advisable, since a pet becomes a member of the family and often causes great happiness.

One myth to debunk is that there are “hypoallergenic” cats and dogs to get if one is allergic to such a pet. While some pet-allergic individuals feel that they have reduced allergic symptoms around short-haired cats and/or dogs that do not shed (e.g., poodles), most scientific studies do not support this phenomena.

Obviously, the best way to combat pet allergies is to completely avoid them as mentioned above. If this is not an option, one can take some measures to reduce their exposure to the allergens that cause pet allergies. Brushing your cat or dog frequently and bathing your cat or dog often will help reduce the levels of cat and proteins. It is also advisable to prevent the pet from entering your bedroom.

The symptoms of pet allergies are similar to any other type of environmental allergy. The symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy eyes, watery eyes, redness of the eyes, puffy eyes, headaches, sinus congestion, itchy skin (i.e., pruritus), hives (i.e., urticaria), wheezing, chest tightness, coughing, and/or shortness of breath.

The treatment of pet allergies begins with avoidance of the offending pet as previously mentioned. Medications used for the management of pet allergies may include antihistamines, decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, and/or asthma inhalers. Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are very effective in treating pet allergies as they are also very efficacious in the management of dust mite, mold, and pollen allergies. They work in 80-85% of patients with allergies and have been used in the U.S. for more than 100 years.

The board certified allergists at Black & Kletz Allergy have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and treat both adults and children with pet allergies. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Black & Kletz Allergy offers on-site parking at each of their 3 office locations and the Washington, DC and McLean, VA offices are also Metro accessible. There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To make an appointment, please call our office or you can click Request an Appointment and we will respond within 24 hours on the next business day. Black & Kletz Allergy has been serving the asthma and allergy needs of the DC metro area community for more than 50 years and we strive to offer high quality allergy and asthma care in a compassionate professional environment.

Is It the Common Cold or Allergies

As we are in the Fall season and approaching Winter, many individuals may experience a clear runny nose, post-nasal drip, sneezing, sore throat, nasal congestion, sinus pressure, headache, coughing, and/or fatigue. The question to many becomes, “Do I have a common cold or do I have Fall/Winter allergies? It is a common question to an even more common complaint. How does someone know if they are having allergies rather than the common cold? Well, if someone does not have a history of allergic rhinitis (i.e., hay fever) and they develop the above-mentioned symptoms, they probably are not experiencing allergies, unless these symptoms persist for several weeks or more. If the symptoms persist, one should consult a board certified allergist like the ones at Black & Kletz Allergy. The allergy specialist can help identify if one has allergies vs. are the symptoms a result of a lingering cold or a secondary bacterial infection (e.g., sinus infection, upper respiratory infection, pneumonia)?

The common cold is caused by a variety of viruses (e.g., rhinovirus, human coronavirus, influenza viruses, parainfluenza virus, human respiratory syncytial virus (i.e., RSV), enteroviruses other than rhinovirus, and adenoviruses). There are over 200 viruses associated with the common cold, although rhinovirus accounts for most of them. In addition, approximately 25% of colds are caused by unknown factors, which are presumed to be due to unidentifiable viruses.

Of particular importance to infants and young children is the human respiratory syncytial virus which can be fairly severe in these age groups and cause life-threatening illness in approximately 1-2% of infants and young children who get the virus. RSV may also cause serious symptoms in individuals whose immune systems are compromised, as well as in individuals with chronic heart or lung disease. Most of the time, RSV has a mild self-limited course in children and adults resulting in a cold-like illness. In fact, almost all children get RSV by the age of 2. It is only this 1-2% of infants and young children, some individuals whose immune systems are compromised, and some people with chronic heart or lung disease who go on to develop more serious symptoms which may include pneumonia (i.e., infection of the lungs), and/or bronchiolitis [i.e., inflammation of the bronchioles (small breathing tubes in the lungs]. Infants and young children with this more severe course often require intravenous antibiotics and fluids, oxygen, and sometimes need to be placed on a ventilator for a short period of time in order to help them through the respiratory distress that can accompany this virus. In addition, infants and young children that develop complications from RSV may be more likely to develop asthma in the future.

While discussing the common cold, there is a common myth to debunk regarding the development of the common cold and environmental factors. It is a myth that being out in the cold weather will cause a cold. The traditional theory is that a cold can be “caught” by the prolonged exposure to cold weather, which is probably how the disease got its name. It is much more likely that in the Fall and Winter months, when it happens to be cold outside, some of the viruses that cause the common cold occur more frequently during this time period. If these viruses are more prevalent during this time period, it stands to reason that we are exposed to more of these viruses at this time and therefore are more likely to “catch” a cold in these colder months. One other factor to consider is that once a few individuals develop colds, since it is easily transmissible, more and more people who are in close contact will then develop colds. This process becomes exponentially larger and before you know it, “almost everybody” has a cold.

What about someone who does have a history of allergies? If they develop the classic symptoms of a cold in the Fall or Winter as mentioned in the first paragraph, is it their allergies or a common cold? The same basic formula applies to them. If the symptoms are present for a week or two, one is to assume it is a common cold. However, if the symptoms last several weeks or more, then one is to assume that their allergies are playing a role. The allergens that typically cause allergic rhinitis symptoms in the Fall and Winter include dust mites, molds, pets, cockroaches, and other animals such as rodents. Allergy testing can be done via skin or blood testing. If an environmental allergy is identified, it is important to try to prevent exposure to the allergens. If that does not relieve the symptoms, then there are host of medications that can be utilized in order to help mitigate one’s allergy symptoms.

If you are suffering from a prolonged “cold” and/or are not sure if your symptoms may be due to allergies and you would like to be seen at one of Black & Kletz Allergy’s 3 convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), or Manassas, VA, please call us to make an appointment. Alternatively, you can click Request an Appointment and we will get back to you within 24 hours by the next business day. We offer parking at each office location and we are Metro accessible at our Washington, DC and McLean, VA locations. We also offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Black & Kletz Allergy provides a friendly and caring environment for you to get the top quality allergy, asthma, and immunology treatment that we have been providing the community for more than 50 years.

Mast Cell Disorders

master cell image A mast cell is a component of the immune system that is involved in the allergic response. Mast cells contain histamine and other chemical mediators. These chemicals are released into the bloodstream and then into the surrounding tissues during an allergic reaction.

In a disorder called “mastocytosis,” individuals harbor excessive numbers of mast cells in the bone marrow and other organs. It is important to note that this condition may occur both in children and adults. Individuals with mastocytosis frequently experience generalized itching, flushing, skin rashes, abdominal cramps, nausea, vomiting, diarrhea, shortness of breath, dizziness, and/or passing out (i.e., syncope).

Children are more likely to have symptoms limited to the skin whereas the majority of adults have systemic symptoms which usually involve multiple organ systems. These symptoms are similar to that of anaphylaxis. In addition, these individuals are more sensitive to various triggers such as temperature changes, certain medications, spicy foods, alcohol, bee stings, etc. Occasionally they suffer anaphylaxis spontaneously without exposure to any obvious trigger(s).

The first step in the diagnosis of this condition is a comprehensive history taking note of the specific symptoms, as well as their onset, progression, and severity. Physical examination sometimes reveals freckle-like skin lesions called “urticaria pigmentosa” which typically appear over one’s thighs, abdomen, etc. These spot-like skin lesions can lead to hives (i.e., urticaria) upon stroking the skin (also known as Darier’s sign), as well as after exposure to temperature changes (e.g., taking hot showers). This occurs as a result of the compression of mast cells.

The most helpful diagnostic laboratory test is a serum tryptase level, which is usually elevated in systemic mastocytosis. Urine examination also can be useful in detecting higher levels of metabolites of various chemical mediators of allergic reactions. Confirmation of the diagnosis usually requires a skin biopsy, bone-marrow examination, evaluation of organ functions, and occasionally genetic studies.

The usual course of treatment of this condition is avoidance of exposure to the known triggers of mast cell activation in order to prevent acute symptoms. There are several medications that are utilized in order to treat this condition. Antihistamines block the effects of histamine, which is one of the most common mediators of allergic reactions. As a result, antihistamines [e.g., Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine)] are the most commonly used medications to treat mast cell disorders. A medication called cromolyn is helpful to alleviate the gastrointestinal symptoms (i.e., abdominal cramping, nausea, vomiting) that may occur with mast cell disorders including. Aspirin, ketotifen and leukotriene modifiers [e.g., Singulair (montelukast), Accolate (zafirlukast), Zyflo (zileuton)] are also sometimes employed in the treatment of mast cell disease.

It is important to note that individuals with mast cell disorders are also at risk for fractures due to osteopenia and/or osteoporosis, and bone health needs special attention. More aggressive forms of systemic mastocytosis may require interferon, immune modulators, and/or chemotherapeutic agents.

All patients with established mast cell disorders need to have ready access to epinephrine auto-injectors (e.g., EpiPen, Auvi-Q, Adrenaclick) at all times to be used at the onset of symptoms suggestive of anaphylaxis. Once used, it is important for the individual to go to the closest emergency room. It is also important for patients with mast cell disorders to make surgeons and anesthesiologists aware of their mast cell disorder in case a surgical procedure is needed, as surgery can also be a trigger systemic symptoms.

The board certified allergists at Black & Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area and are very experienced in the diagnosis and treatment of mast cell disorders. Black & Kletz Allergy treat both adults and children and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible. There is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please call our office to make an appointment or 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 Washington, DC metropolitan area for more than 50 years and we pride ourselves in providing excellent allergy and asthma care in a professional and pleasant setting.

Dust Allergies

Dust is a very common allergen which can cause havoc among sensitized individuals. Most people are not aware that the cause of dust allergies are dust mites. Dust mites are microscopic animals belonging to the class Arachnida. Arachnids are arthropods which are invertebrate animals that have an exoskeleton (i.e., external skeleton), a segmented body, along with paired jointed appendages. In addition to mites, some other examples of arachnids include spiders, ticks, and scorpions. Dust mites, which are also known as house dust mites, are between 0.2 to 0.3 mm. in length and are translucent, making them almost invisible to the naked eye.

Dust mites survive by eating the dead skin of humans and pets as it flakes off their bodies. They also eat some varieties of mold. They live throughout the world except at high altitudes (i.e., above 5,000 feet). Dust mites are generally found in bedding (e.g., pillows, mattresses, box springs, blankets), upholstered furniture, carpeting, drapes, and curtains. They tend to thrive in humid conditions where the relative humidity is above 50%. The allergenic components of dust mites are the exoskeleton and their fecal deposits. Since the exoskeleton and fecal deposits are relatively heavy in nature, they are not suspended for long in the air. Thus, they are generally found on the floor and other surfaces. The dust that you see in the air is not usually composed of dust mite allergens unless the floor or surface is disturbed. If this occurs, the dust mite allergens only remain in the air for a couple of hours or less. The two major species of dust mites that are highly allergenic and tend to affect sensitized individuals in the U.S. are Dermatophagoides farinae (i.e., American house dust mite) and Dermatophagoides pteronyssinus (i.e., European house dust mite).

Individuals who are allergic to dust mites may exhibit signs and symptoms of allergic rhinitis (i.e., hay fever), allergic conjunctivitis, and/or asthma. These symptoms may include sneezing, runny nose, nasal congestion, postnasal drip, itchy nose, itchy eyes, watery eyes, redness of the eyes, puffy eyes, sore throat, snoring, fatigue, sinus headaches, wheezing, coughing, chest tightness, and/or shortness of breath.

The diagnosis of dust mite allergy requires a thorough history and physical examination by a board certified allergist like the ones at Black & Kletz Allergy. Testing to dust mites can be done via skin or blood testing. The severity of the dust mite allergy can also be assessed. Once diagnosed, the allergist will recommend several preventative measures that should be implemented by the allergy sufferer.

Some of these preventative measures may include:

1.) Covering the pillows, mattress, and box spring with allergy-proof encasings

2.) Washing the bedroom sheets in hot water (greater than or equal to 130 °F)

3.) Vacuuming carpeting at least once a week

4.) Keeping the relative humidity less than or equal to 45%

5.) Reducing or eliminating stuffed animals and other dust-gathering toys

6.) Replace bedroom wall-to-wall carpeting to hardwood or vinyl flooring

7.) Use a HEPA filter in the HVAC system and replace the filter every 3 months

The treatment of dust mite allergies may include the use of oral antihistamines, decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergic medications, allergy eye drops, inhaled corticosteroids, inhaled bronchodilators, allergy immunotherapy (i.e., allergy shots, allergy injections, allergy hyposensitization), and/or biologicals (e.g., for the treatment of moderate to severe asthma).

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

Trick-or-Treat Allergies on Halloween

Every year, several children are taken to emergency departments on Halloween day for the management of severe allergic reactions. What is meant to be a fun-filled activity can turn out to be a harrowing experience for some families. A few general precautions made by families can prevent most allergic emergencies in children and are as follows:

Many families understand how to read labels on foods and avoid those that contain ingredients that their children are sensitized to. However, most “fun-sized” candies handed out while trick-or-treating either do not have any labeling at all or they may contain different ingredients than regular sized packages.
Preventing children with food allergies to trick-or-treat without adult supervision as well as avoiding candies without proper labeling can prevent a life-threatening reaction. It is a good practice for severely allergic individuals to carry epinephrine self-injectable devices (e.g., EpiPen, Auvi-Q, Adrenaclick) while trick or treating.
Children with food allergies should be taught to politely refuse homemade foods such as cookies and cupcakes that may be unsafe for them.
Ragweed and mold spores are the most common environmental aeroallergens in the Fall in many geographical areas in late October. In addition, exposure to cats and dogs are not uncommon while trick or treating. Exposure to these allergens may trigger allergic rhinitis (i.e., hay fever) and/or severe respiratory allergic reactions. The use of allergy and/or asthma medications before heading out may be protective. Showering, washing one’s hair, and changing into fresh new clothes after trick or treating will reduce airborne allergen exposure.
Cold air is a known irritant and prolonged exposure to cold air may aggravate asthma in susceptible children. Frequent indoor breaks and covering the nose and mouth while outdoors can minimize this risk. Children with a history of asthma should also take their rescue inhalers [e.g., albuterol (Proventil, ProAir, Ventolin), levalbuterol (Xopenex)] with them while trick-or-treating.
Haunted houses with smoke machines may pose a danger to children and adults with severe asthma. Exposure to smoke of any kind can cause an acute asthma exacerbation. Preparation and avoidance are necessary in order to prevent severe asthma attacks.
Halloween costumes containing strong chemicals may be irritating to children with sensitive skin and as a result a flare-up of their eczema (i.e., atopic dermatitis) may occur. Latex-containing masks as part of the costume may be especially deleterious to children with a history of latex allergy. Children with a sensitivity to metals such as nickel may be exposed to nickel buttons and buckles in costumes which may lead to itching and skin rashes

To help insure that a food allergic child can participate in Halloween and have as much fun as the next child, although nothing is guaranteed, there is a program run by the Food Allergy Research and Education (FARE) organization called the “Teal Pumpkin Project”. This FARE-sponsored international program has been in place since 2014. It began in Tennessee by the mother of a severely food allergic child. The Teal Pumpkin Project’s purpose is to raise awareness of the severity of food allergies and show support to families who have food allergic children. This is done by painting a pumpkin the color teal and then placing it on one’s front porch to signify that “non-food” treats are available at that location on Halloween night. The color teal is used because it represents food allergy awareness. Typically, “non-food” treats may include toys, crayons, stickers, rings, bracelets, necklaces, glow sticks, hair accessories, coins, finger puppets, balls, bookmarks, spider rings, vampire fangs, whistles, etc.

It important to point out that the Teal Pumpkin Project is not exclusionary and it still promotes the option of distributing normal trick-or-treat candy to children without food allergies. It recommends that the “non-food” items be kept in a different bowl than the traditional candy bowl. FARE provides a “Teal Pumpkin Project Participation Map” on its website so that participating houses can be easily assessed by the parents of food allergic children.

Being cognizant of the hidden dangers of trick-or-treating and proactive in preventing allergen exposures can greatly reduce parents’ anxiety as well as help children fully enjoy the Halloween experience. The board certified allergists at Black & Kletz Allergy have had over 5 decades of experience in diagnosing and managing food and environmental allergies, asthma, and eczema in the Washington, DC, Northern Virginia, and Maryland metropolitan area. Both food and environmental allergies can be diagnosed by a thorough history and physical examination along with prick skin testing and/or blood testing. We would be happy to see you in one of our 3 convenient locations with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. There is on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible. There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To schedule an appointment, please call our office or alternatively, you may click Request an Appointment and we will respond within 24 hours on the next business day. Black & Kletz Allergy is proud to provide quality allergy, asthma, and immunology care in a relaxed compassionate environment.

New Treatment for Peanut Allergy

There is some exciting news for children and their families with a history of peanut allergies. On September 13, 2019, the Allergenic Products Advisory Committee of the Food and Drug Administration (FDA) voted to recommend approval of a new oral immunotherapy product for children with peanut allergy.

Peanut is one of the most common foods that can be allergenic in children. It is also responsible for more severe and occasionally life-threatening reactions in highly sensitive children and adults. Adding to the concerns, in the U.S., peanut allergy in children has increased 21% since 2010, and nearly 2.5% of U.S. children may have an allergy to peanuts.

The current standard of care for the treatment of food allergies is the avoidance of the allergen (e.g., peanut) in conjunction with the treatment of anaphylaxis with self-injectable epinephrine devices (e.g., EpiPen, Auvi-Q, and/or Adrenaclick). It should be noted that parents of children with severe sensitivity to peanut live with constant fear of a life-threatening reaction triggered by an accidental exposure to peanut products.

Oral immunotherapy (OIT) refers to feeding an allergic individual an increasing amount of an allergen with the goal of increasing the threshold that triggers a reaction. The procedure entails feeding the allergenic food to the child, beginning with an extremely small dose and gradually increasing the dose at regular intervals while closely monitoring for adverse reactions. This must be done by in a hospital or in an allergist’s office where the allergist and staff are prepared to treat an adverse reaction without delay. The “escalation” of doses, as mentioned above, is typically performed in an allergist’s office, which is equipped to monitor and treat potential reactions whereas maintenance doses can be given at home.

“Desensitization” refers to the improvement in food challenge outcomes after therapy and relies on ongoing exposure to the allergen. If successfully accomplished, desensitization has the potential to substantially reduce the risk of a severe reaction following accidental exposure to the allergen and would hopefully minimize the anxiety of parents. This form of treatment also requires regular exposure to the food indefinitely in order to maintain the “desensitized” or “tolerant” state. OIT with peanut is unlikely to induce “sustained unresponsiveness” which refers to the retention of the protective benefit achieved through therapy. This sustained unresponsiveness is not reliant on the ongoing exposure to peanut.

The possible side effects of OIT include symptoms limited to the gastrointestinal tract such as itching of the mouth and/or lips, abdominal cramping, and diarrhea. Rarely more severe systemic reactions such as generalized hives (i.e., urticaria), swelling of tongue and/or throat (i.e., angioedema), difficulty in swallowing, shortness of breath, wheezing, and drop in blood pressure may occur.

The FDA has not yet approved the new treatment but they are likely to approve it soon based on the recommendations of its Allergenic Products Advisory Committee. “Palforzia” will be the brand name of the new drug, which is a powder containing 12 peanut proteins (Ara h 1, Ara h 2, Ara h 3, etc.) thought to be the principal allergens in peanuts. The letters of the terminology, Ara h, correspond to the genus and species of the peanut plant, Arachis hypogaea, and the number (1, 2, 3, etc.) distinguishes each discrete protein component. In peanut allergy, 5 proteins are associated with clinical reactions of varying severity: Ara h 1, Ara h 2, Ara h 3, Ara h 8, and Ara h 9. Ara h1, Ara h 2, Ara h 3, and Ara h 9 are associated with severe symptoms whereas Ara h 8 is associated with much milder or no symptoms to peanut. This protein component of peanut is also linked to oral allergy syndrome, also known as pollen-food allergy syndrome. This syndrome is caused by cross-reacting allergens found in both pollen and raw fruits, vegetables, and/or some tree nuts. The immune system recognizes the pollen and similar proteins in the food and directs an allergic response to it. People affected by oral allergy syndrome can usually eat the same fruits or vegetables in a cooked form because the proteins are denatured during the heating process, and the immune system no longer recognizes the food. Palforzia will come packaged in pull-apart capsules or sachets, to be mixed into age-appropriate foods such as applesauce or pudding.

The manufacturer is seeking FDA approval for Palforzia for use only in children between 4 and 17 years of age. In the clinical trials, the starting dose was 0.5 mg. of the product, gradually increasing to a maintenance dose of 600 mg. requiring about 8 biweekly visits to allergist’s office.
The new treatment will also likely carry a “black box” warning about possible anaphylaxis and a requirement to carry a self-injectable epinephrine device at all times.

It is likely that patients will need to continue therapy indefinitely, particularly in light of a recent study published online in Lancet on September 13, 2019. The study found that, in patients treated to a point where they could eat peanuts without incident, withdrawal of treatment led to waning tolerance over time. This implies that treatment may be life-long.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating food allergies for over 50 years. This new medication to treat peanut allergy is exciting and very promising. If this new medication is a success, we feel that there will be other drugs containing other food allergens such as fish, shellfish, milk, egg, wheat, and soy. This is of course pure speculation at this time, but it would make sense to develop other food-related OIT protocols, if Palforzia is successful.

The allergy doctors at Black & Kletz Allergy treat both adult and pediatric patients. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. The Washington, DC and McLean, VA offices are Metro accessible and the McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line. You may also click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been a fixture in the greater Washington, DC, Northern Virginia, and Maryland metropolitan community for over 5 decades for our outstanding services for the diagnosis and treatment of allergic, asthmatic, and immunological conditions.

The Diagnosis and Treatment of Hives

Hives (i.e., urticaria) is a type of skin rash that usually presents with red, raised, and itchy bumps, usually similar in appearance to mosquito bites. Other colloquial terms for hives include welts or wheals. They may occur anywhere on the body and appear in various shapes and sizes. They usually blanch with pressure. In some instances, they may look like small red dots or even be flush with the skin. The borders of each hive may be sharply demarcated or they may blend in with the surrounding skin. If the hives are deep enough in the skin layer, the result may be swelling of that area commonly referred to as angioedema.

Hives are quite common as they affect 20% to 25% of the population at some point in their lives. Hives generally, as a rule, are intermittent and usually last less than 24 hours in duration. They may occur very frequently (i.e., multiple times per day) or they may occur very rarely (i.e., one isolated episode). If an episode of hives resolves within 6 weeks, it is known as “acute urticaria.” If the episode lasts more than 6 weeks in duration, it is known as “chronic urticaria.”
You may be asking yourself, what are the causes of hives, since they are so common. Many times, the cause is fairly obvious in such cases where the hives develop shortly after eating a certain food, or immediately after a bee sting. They may occur during the course of or shortly after completing a course of antibiotics. Other medications may be the causative agent in others affected with hives. Aspirin and nonsteroidal anti-inflammatory drugs (NSAID’s) are the most common classes of medications that cause hives besides antibiotics. Some of the most commonly prescribed NSAID’s include ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn, Anaprox), salsalate (Disalcid), indomethacin (Indocin), etodolac (Lodine), diclofenac (Voltaren, Arthrotec, Cataflam), ketorolac (Toradol), piroxicam (Feldene), meloxicam (Mobic), Oxaprozin (Daypro), nabumetone (Relafen), tolmetin (Tolectin), fenoprofen (Asaid), sulindac (Clinoril), and celecoxib (Celebrex). It is important to note that any medication or food can cause hives in any individual, despite the fact that they may have ingested the food or medication in the past without reactions. An assortment of other conditions such as infections (viral, bacterial, fungal, or parasitic), inflammatory conditions, autoimmune disorders (when the immune system fights an individual’s own tissues and organs instead of defending them against outside intruders), and rarely even cancers can play a role in causing hives. If the hives persist longer than 24 hours and/or they leave residual marks on the skin, it may indicate inflammation of the small blood vessels, a condition known as “vasculitis.” Other factors that may cause or exacerbate hives may include exercise, cold, heat, vibration, pressure, sun exposure, and/or water, to name a few.

If you suffer from hives, it is important to see a board certified allergist such as the allergists at Black & Kletz Allergy. Our allergy specialists see numerous cases of hives and/or swelling episodes each week. We have over 5 decades of experience in the Washington, DC, Northern Virginia, and Maryland metropolitan area in diagnosing and treating hives. We see patients of all ages ranging from newborns to the elderly. At your first consultation with our allergists, a comprehensive history and physical examination will be performed. Depending upon your history and examination, diagnostic tests may include bloodwork, allergy skin testing, urinalysis, X-rays, and/or a skin biopsy.
Since histamine is the principal chemical that is responsible for the development of hives, most of the cases are responsive to medications that block the action of histamine on the skin. In some individuals, avoidance of a particular food or medication is all that is needed. For others, there are a variety of treatment options, some of which include antihistamines, leukotriene antagonists, histamine-2 blockers, corticosteroids, immune modulators, and “biologicals” [e.g., omalizumab (Xolair) injections] or various combinations of the aforementioned medications.

Black &Kletz Allergy has 3 convenient locations in the Washington, DC metro area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA which all offer on-site parking. The Washington, DC and McLean, VA locations are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please call us to make an appointment or you can click Request an Appointment and we will reply within 24 hours by the next business day. The allergy specialists of Black & Kletz Allergy are eager to help you with your hives, swelling episodes, allergic rhinitis (i.e., hay fever), asthma, sinus conditions, and immunology needs. We are dedicated to providing excellent care to you as we have been doing in the Washington, DC metro area for more than 50 years.

Allergies Associated with Acid Reflux Medications

Proton pump inhibitors (PPIs) are a group of medications commonly used to treat symptoms caused by excessive stomach acid. The most common PPIs available in the U.S. are Nexium (i.e., esomeprazole), Protonix (i.e., pantoprazole), Prilosec (i.e., omeprazole), Prevacid (i.e., lansoprazole), Aciphex (i.e., rabeprazole), and Dexilant (i.e., dexlansoprazole). These medications act by reducing the amount of acid secretion produced by the parietal cells in the lining of the stomach. In addition to lifestyle and dietary modifications, they are usually the first line medications prescribed to treat common conditions such as gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), erosive esophagitis, Zollinger-Ellison syndrome, and peptic ulcers (duodenal or stomach ulcers). GERD is commonly referred to as “heartburn” by the general public. These PPIs are also used in combination with corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or some antibiotics to protect the stomach.

These medications are considered relatively safe and some are also available over the counter. Even though they are available over the counter, there are side effects, particularly if used long-term. Some of the more common side effects may include headaches, rashes, fever, abdominal pain, nausea, vomiting, diarrhea, constipation, lightheadedness, and change in or unpleasant taste. Long-term use has been linked to osteoporosis (i.e., thinning of the bones) which may lead to bone fractures. Other more severe side effects may include acute interstitial nephritis (i.e., kidney failure), lupus, pneumonia, low magnesium levels, muscle spasms, heart palpitations, and clostridium difficile-associated diarrhea, to name a few.

In addition to the side effects of PPIs, there have been a few recent publications that have reported their association with possible allergic reactions.

In an article published in The Journal of Allergy and Clinical Immunology: In Practice, the authors reported serious allergic reactions in five patients receiving PPIs. These patients developed allergic reactions within 30 to 60 minutes of taking the medications orally. One patient developed a more rapid reaction after receiving the drug intravenously.

All patients were subsequently evaluated for sensitivity to PPIs using skin prick testing and intradermal skin testing techniques. All patients showed positive reactions indicating an immediate allergic sensitivity that was mediated by the IgE antibody.

When patients develop life-threatening anaphylactic reactions, foods and insect stings are usually thought to be the causative agents as medications other than penicillins cause anaphylaxis very rarely. However, this report highlights the need for a high index of suspicion for medications such as PPIs being the culprits in causes of anaphylaxis.

A more recent publication in the journal Nature Communications, the authors reported an increase in allergic symptoms in patients receiving PPIs on a regular basis. The data revealed that people taking PPIs for any reason had a two-to-three times higher chance of receiving prescriptions for medications used to treat allergies at a later date.

Stomach acid is needed for proper digestion of ingested food. It contains various enzymes which help break down the complex proteins in the food before they are further processed. It also protects the digestive system from infections caused by bacteria and other harmful substances.

Reducing the acid production by PPIs can impede the proper digestion of proteins. PPIs also alter the microbiome of the stomach. Consequently harmful proteins and other substances can get absorbed into the bloodstream unchallenged. This has the potential to weaken the natural defense mechanisms and can either cause or aggravate allergic sensitization to certain foods and environmental triggers.

The authors of this publication caution people not to use acid suppressor medications any longer than absolutely necessary.

The board certified allergists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan region and have been providing allergy and asthma care to this area for more than 5 decades. Our offices 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. In addition, our McLean, VA office location offers a complementary shuttle that runs between this office and the Spring Hill metro station on the silver line. For an appointment, please call one of our offices. Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from allergies or asthma, it is our mission to help alleviate your unwanted symptoms, so that you can enjoy a better quality of life.

Black & Kletz Allergy is dedicated to providing the highest quality allergy and asthma care in a compassionate, relaxed, and professional environment.