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Eye Allergies (Allergic Conjunctivitis)

Now that it is March and the Spring has begun, many individuals will experience irritated eyes.  The typical eye symptoms that allergic individuals may notice include itchy eyes, watery eyes, puffy or swollen eyelids, thick sticky discharge, eyelids sticking together especially in the mornings when awakening.  In most cases, tree and/or grass pollen allergy is the cause, however allergies to other allergens such as molds, pets, dust mites, and/or cockroaches may be the allergic cause.

Most individuals with allergic conjunctivitis have associated allergic rhinitis (i.e., hay fever)where they have other symptoms which may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, sinus headaches, sinus pressure, and/or snoring.  Asthmatic individuals may experience increased asthma symptoms in the Spring if they are sensitive to outdoor allergens such as tree pollen, grass pollen, and/or molds.  It is not unusual for some individuals to experience increased asthma, allergic rhinitis, and allergic conjunctivitis symptoms together.

The diagnosis of allergic conjunctivitis begins with a comprehensive history and physical examination by a board certified allergist.  Allergy skin testing or blood testing is usually performed in order to identify if and what the offending allergens are that are causing the allergic eye symptoms.

When evaluating an individual with the symptoms of eye allergies, it is important for the physician to rule out other causes of red eyes or “pink eye.”  Viral, bacterial, and/or parasitic infections of the eye(s) can cause similar symptoms but are treated differently. Chemical irritation or a foreign body can also cause the eyes to become red.  Anterior uveitis, which can be associated with an autoimmune disorder or a sexually transmitted disease, may also cause redness of the eyes. In addition, there is usually “photophobia” which is the pain in the eyes when in a bright environment.  A subconjunctival hemorrhage or bleed may also occur when the capillaries break near the “whites” of the eyes. Some causes of subconjunctival hemorrhages may include trauma, coughing, straining, sneezing elevated blood pressure, diabetes, and/or certain blood thinning medications [e.g.., aspirin, Coumadin (warfarin), Plavix (clopidogrel), Eliquis (apixaban), Pradaxa (dabigatran), Xarelto (rivaroxaban), Brilinta (ticagrelor), Effient (prasugrel), Aggrenox (aspirin plus dipyridamole)].  They can also just occur spontaneously without an apparent cause.

The treatment of allergic conjunctivitis may include the use of various eye drops, oral antihistamines, nasal corticosteroids, leukotriene antagonists, and/or allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization).  Of course, avoiding the offending allergen is the first and primary focus with any allergy, but in most cases, especially if allergic to the pollen in the Spring, it is almost impossible to avoid.  That being said, there are still some avoidance measures that can be practiced in order to limit one’s exposure to pollen. Some of them are as follows:

  1.  Close the windows of your home and automobiles.
  2.  Change your clothes and shower after spending a long time outdoors or after yard work.
  3.  Follow the local pollen count on our website by clicking Today’s Pollen Count.
  4.  Go outdoors after it rains as the pollen count is “washed away” temporarily after the rain.
  5.  Wash the fur of your pet after it comes indoors from the outside.
  6.  Leave your shoes outdoors after being outdoors.
  7.  Begin using nasal sprays and/or antihistamines early in the pollen season.
  8.  Consider allergy shots, as mentioned above, if more severe or persistent symptoms to pollens and/or molds, as they generally are effective in 80-85% of individuals with allergic conjunctivitis and/or allergic rhinitis.

The board-certified allergy doctors at Black & Kletz Allergy are specialists in diagnosing and treating both adults and children with allergic conjunctivitis as well as many other allergic disorders.  Some of these include allergic rhinitis, asthma, sinus disease, eczema (i.e., atopic dermatitis), hives (i.e. urticaria), generalized itching (i.e., pruritus), contact dermatitis (e.g., poison ivy, poison oak, poison sumac), swelling episodes (i.e., angioedema), anaphylaxis, insect sting allergies, food allergies, medication allergies, eosinophilic disorders (e.g., eosinophilic esophagitis), and immunological disorders.  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), and Manassas, VA.  All of our locations offer on-site parking and our Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.

If you suffer from allergies or any of the conditions listed in the above paragraph, please call us in order to schedule an appointment with one of our board-certified allergists.  You may also click Request an Appointment and we will respond within 24 hours by the next business day.  The allergists at Black & Kletz have been helping the residents and visitors of the Washington, DC metropolitan area for more than 50 years and are pleased to help you improve the quality of your life by alleviating those unwanted and annoying allergies and asthma symptoms.

Allergies in the Spring

March is the month that many trees begin pollinating in the Washington, DC metropolitan area. As temperatures begin to climb, we will start seeing a light yellowish coating on our automobiles. For many allergy sufferers, this represents the onset of misery for many individuals who are sensitized to tree pollen.

Birch, oak, cedar, elm, ash, cottonwood, hickory, and maple are the predominant trees producing pollen in our area.  It is the reproductive season for the trees and the pollen grains are released into the atmosphere to fertilize the ovules of other trees.  Pollen is produced and dispersed by the wind throughout the day, but their counts are highest in the morning hours.

Over the past several years, many researchers have noted a progressive increase in the tree pollen counts across the country.  Though it is somewhat controversial, many scientists believe that climate change is contributing to this trend at least in part.  Carbon dioxide is the principal gas needed for the growth and development of trees, (along with nutrients, water, and sunlight), and increasing levels of carbon dioxide are being documented every year.  Changes in the climate may impact pollen seasons of trees, grasses, and weeds by both increasing the amount of pollen produced as well as by extending the duration of the pollen season.

Pollen grains are not toxic or harmful when inhaled, unless the person’s immune system mistakes them as potentially dangerous and mounts a defensive attack on them.  This process, called allergic sensitization and reactivity, results in the release of certain chemicals such as histamine, which are mediators of the bothersome symptoms of allergic rhinitis (i.e., hay fever) and allergic conjunctivitis.

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

Spring allergies are diagnosed by board certified allergists by first taking a comprehensive history and physical examination.  Allergy testing is often done by either skin testing or occasionally by blood testing in order to identify the offending allergen.  Once identified, preventive measures are recommended in order to reduce exposure to the allergen(s).

Measures to reduce exposure to pollen and to minimize symptoms include the following:

  1. Follow the local pollen counts on the homepage on our website by clicking Today’s Pollen Count and avoid outdoor activities on high pollen days, especially in early morning hours.
  2. Run errands shortly after it rains, as the water keeps the pollen closer to the ground and keeps it from blowing around.
  3. After being outdoors, change clothes and wash the ones that were worn outside.
  4. Leave shoes outside so you do not bring the pollen into the home.
  5. Wipe down the fur of the pet or wash the pet before the animal comes indoors.
  6. Shower before going to bed in order to wash the pollen off one’s hair and skin.
  7. Close the windows in homes and automobiles and run the air conditioning if needed.
  8. Begin taking antihistamines and nasal sprays early in the season.  They are more effective if begun before the onset of severe symptoms and if taken daily throughout the season.  There are a variety of other types of prescription medications that may be utilized by the allergist in order to mitigate unwanted allergy and/or asthma symptoms in sensitive individuals.
  9. In cases of persistent or severe symptoms, consider allergy desensitization (i.e. allergy shots, allergy immunotherapy, allergy injections, allergy hyposensitization) to the pollen, which can provide a long-term benefit and reduce the need for medications.  They are effective in 80-85% of patients.

Does local honey help?

There is no scientific evidence to substantiate the claim that consuming local honey will help either to desensitize to pollen or to reduce symptoms.

The board certified allergy doctors at Black & Kletz Allergy has 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.  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.  The allergists of Black & Kletz Allergy diagnose and treat both pediatric and adult patients.  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 allergies, it is our mission to improve your quality of life by reducing or preventing your unwanted and aggravating allergy symptoms.

Allergies to Moisturizers

Excessive dryness of the skin is a feature of many chronic dermatological disorders and contributes greatly to itchy skin.  Regular application of a moisturizer is critically important in the prevention and treatment of atopic dermatitis (i.e., eczema) or eczematous-like conditions such as contact dermatitis.

There are hundreds of different moisturizing products available over the counter. A recent article published in the JAMA Dermatology journal offers some guidance on how to choose the right product for most individuals

A total of 174 unique best-selling moisturizer products were identified in the cohort study.  The median price per ounce was $0.59 with a wide range varying between $0.10 and $9.51 per ounce.  This represents a tremendous range of 9,400%.  The most popular type of moisturizers were lotions (59%), followed by creams (13%), oils (12%), butters (8%), and ointments (2%).

Contact dermatitis is the condition that results in chronic inflammation of the skin, triggered by exposure to a chemical allergen or irritant. The study found that some moisturizers contain common chemical allergens, potentially worsening the very condition it is designed to treat!

The North American Contact Dermatitis Group (i.e., NACDG) publishes a list of most of the chemical allergens that play a role in the causation of contact dermatitis.  The three most common allergens in moisturizers were fragrance mix, paraben mix, and tocopherol (i.e., DL-a-tocopherol).  Most of the moisturizers contained more than one allergen.  In fact, 43% of the moisturizers contained three to four allergens while 13% contained five or more allergens.

Even products with a claim of “fragrance free,” 45% of the moisturizers had at least one fragrance cross-reactor or botanical ingredient.  When an individual is allergic to one fragrance, the risk of having a reaction to other fragrances is much higher because of the chemical similarity between ingredients.

Lotions were statistically less expensive per ounce than butters, creams, and oils. Products without any ingredients in the North American Contact Dermatitis Group’s list of allergens were not statistically more expensive per ounce than products with one or more allergens.

The most common potential allergens of the 174 best-selling moisturizer products are as follows:

  1. Fragrance mix
  2. Paraben mix
  3. Tocopherol (i.e., DL-a-tocopherol)
  4. Phenoxyethanol
  5. Formaldehyde releasers
  6. Propylene glycol
  7. Benzyl alcohol
  8. Iodopropynyl butylcarbamate
  9. Cocamide diethaholamine
  10. Methylisothiazolinone
  11. Compositae mix
  12. Lanolin
  13. Lavandula angustifolia oil
  14. Ethyl acrylate
  15. Benzophenone-3
  16. D-Limonene
  17. Melaleuca alternifolia

The study also found that the three most affordable moisturizers that were free of ingredients listed by the North American Contact Dermatitis Group included Ivory raw unrefined shea butter; Vaseline original petroleum jelly, and Smellgood African shea butter.

In addition to a comprehensive history and physical examination, diagnostic patch testing is often performed in order to identify the allergen(s) that may be causing any skin manifestations such as redness, dryness, itching, burning, peeling, scaling, and/or blistering.  Identifying the allergen is very important, since treatment is aimed at avoiding contact with the offending allergen found in a moisturizer.  Patch testing can also identify other chemicals and metals typically found in an array of products and used in various industries.  These products may include cosmetics, hair dyes and other dyes, shampoos, rubber products, fragrances and perfumes, caine medications (e.g., benzocaine, tetracaine, dibucaine), industrial chemicals, topical antibiotics, topical anti-fungals, soaps, metals, jewelry, adhesives, sealants, paints, pine oil cleaners, dermatological creams, bandages, flavoring agents, glues, leather goods, shoes, pesticides, creams, lotions, ointments, oils, sunscreens, coolants, plastics, building materials, vaccines, corticosteroids, and textiles.

The board certified allergists at Black & Kletz Allergy see patients of all ages and have over 50 years’ experience in the field of allergy, asthma, and immunology.  Skin disorders such as eczema, contact dermatitis, poison ivy, poison oak, poison sumac, hives (i.e., urticaria), generalized itching (i.e., pruritus) are common skin ailments that we routinely diagnose and treat.  Black & Kletz Allergy has 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA and all locations have on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To make an appointment, please call us or alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy are happy to answer any questions or concerns you may have about any allergic, asthmatic, or immunologic issue.

Self-Injectable Epinephrine Devices

Woman injecting emergency medicine into her leg

Self-injectable epinephrine devices or epinephrine autoinjectors have been in the news quite a lot recently due to their high cost.  In recent months, generic versions have become available which are much less costly.  Epinephrine (i.e., adrenaline) is a medication that is used to treat individuals who have systemic allergic reactions (i.e., anaphylaxis) among other disorders such as cardiac arrest, asthma, and superficial bleeding.  Regarding asthma, epinephrine is occasionally used in emergency rooms to treat acute severe exacerbations of asthma.

Epinephrine is a naturally occurring hormone that is made in both the adrenal glands and certain nerve cells.  Epinephrine causes increased cardiac output, increased blood flow to the muscles resulting in increased muscle contraction, increased heart rate, dilation of the pupils of the eyes, smooth muscle relaxation causing dilation of the bronchial tubes, increased respiratory rate, and increased glucose production.

The side effects of epinephrine are numerous and may vary.  Some of the side effects may include rapid heart rate, increase in blood pressure, anxiety, dizziness, headache, nausea, vomiting, sweating, trembling or shaking, difficulty breathing, stroke, chest tightness, chest pain, blurred vision, decreased sense of touch, hives, numbness, rashes, jaw pain, arm pain, and/or restlessness.  Most patients experience a rapid or pounding heart rate and a shakiness feeling.  Typically these symptoms generally last less than 30 minutes.

Epinephrine is usually administered intramuscularly (i.e., IM) when given to individuals that require it due to an allergic reaction.  Commercially available preparations come either in vials, bottles, or self-injectable devices.  Patients that are prescribed epinephrine by their physicians are usually given prescriptions for a self-injectable epinephrine device.  There are several brands that exist in the U.S. with the most common brand being an EpiPen.  Other self-injectable device brands include Auvi-Q, and Adrenaclick.  There are generic brands available as of late and they are labeled epinephrine on the autoinjector.  The generic versions are generally much less expensive than the brand name self-injectable devices.

Self-injectable epinephrine devices come in two different strengths of epinephrine.  In adults and children weighing more than 66 lbs., usually the 0.3 mg. strength is prescribed.  In children that weigh between 33 lbs. and 66 lbs., there is a 0.15 mg. strength that is typically prescribed.  In the case of EpiPens, there is a regular EpiPen which contains 0.3 mg. of epinephrine and there is an EpiPen Jr. which contains 0.15 mg. of epinephrine.  Auvi-Q also comes in two strengths and they are referred to as Auvi-Q 0.3 mg. and Auvi-Q 0.15 mg. depending on the amount of epinephrine they contain.  Adrenaclick is labeled either Adrenaclick 0.3 mg or Adrenaclick 0.15 mg.  Likewise, the generic versions are labeled Epinephrine 0.3 mg and Epinephrine 0.15 mg.

The technique of using a self-injectable epinephrine device may vary depending on the brand.  In general, the devices contain a fixed dose of epinephrine and a spring-loaded needle that exits the tip or edge of the device and penetrates the individual’s skin, to deliver the epinephrine via an intramuscular injection.  EpiPens, Adrenaclicks, and the generic epinephrine autoinjectors all look like long magic markers and when used should be administered by forcefully pressing the tip of the autoinjector to the outer thigh and holding the device in place for at least 3 seconds.  Auvi-Q’s are smaller in size and are more of a rectangular-shaped device that can be put into a pocket.  The Auvi-Q device also has a retractable needle as well as automated voice instructions to assist the user(s) on how to correctly use the autoinjector.  It also should be administered by forcefully pressing the edge of the autoinjector to the outer thigh and holding the device in place for the audible countdown heard from the Auvi-Q device.

It is very important that the adult patient or parent/caregiver of the allergic child who has been prescribed a self-injectable epinephrine device understand how and when to use it as well as understand that he/she should go immediately to the closest emergency room after using it as the beneficial effect of the epinephrine may wear off or not be effective.  If the epinephrine effect wears off and the systemic signs or symptoms begin to reoccur in the patient, a second dose of another self-injectable epinephrine device should be given on the way to the emergency room.  It is also important to realize that self-injectable devices have expiration dates marked on them and they should be checked regularly and replaced if they have expired.

It should also be noted that epinephrine self-injectable devices contain the preservative known as sodium metabisulfite.  In the EpiPen package insert, it says “The presence of a sulfite in this product should not deter administration of the drug for treatment of serious allergic or other emergency situations even if the patient is sulfite-sensitive.  Epinephrine is the preferred treatment for serious allergic reactions or other emergency situations even though this product contains sodium metabisulfite, a sulfite that may, in other products, cause allergic-type reactions including anaphylactic symptoms or life-threatening or less severe asthmatic episodes in certain susceptible persons.  The alternatives to using epinephrine in a life-threatening situation may not be satisfactory.”  This implies that if someone is having a serious life-threatening allergic reaction, it may be worth the risk of using the self-injectable epinephrine device rather than do nothing about it, since the anaphylactic reaction is life-threatening on its own.  One should check with their physician and discuss whether or not to use an autoinjector in the case that individual has a sulfite allergy.

The board certified allergists at Black & Kletz Allergy have been treating anaphylaxis and prescribing self-injectable devices for many years.  We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and they are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 offices have on-site parking and 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.  If you or someone you know have an allergic condition that predisposes you to anaphylaxis (i.e., food allergies, insect sting allergies, medication allergies, idiopathic anaphylaxis), please make an appointment so that we may help you.  Alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day.  The allergists at Black & Kletz Allergy have been treating both adults and children in the Washington, DC metropolitan area for allergies, asthma, sinus disease, and immunologic disorders for more than 50 years and would be happy to provide allergy relief for you in a caring and professional atmosphere.

Allergies to the Cold Weather

This is a very relevant subject now as we have had very cold temperatures so far over this last month in the Washington, DC, Northern, VA, and Maryland metropolitan area.  And yes, you read it correctly.  Individuals can be “allergic” to the cold.  There is a condition known as “cold-induced urticarial” in which exposure to the cold will cause hives (i.e., urticaria).  The annoying hives can be triggered by cold weather or cold water.  Being exposed to the cold weather, swimming in cold water, drinking a cold beverage, and/or being in an air conditioned room may all cause certain individuals to develop hives and other symptoms.  In addition to the hives, these other symptoms usually present as swelling (i.e., angioedema), itching (i.e., pruritus), redness of the skin or other rashes, dizziness, fatigue, wheezing, headaches, anxiety, and/or shortness of breath.

It is not uncommon to experience “cold” allergies and in some families, there is a genetic linkage.  Many people are perplexed with the notion that the cold environment can cause such symptoms.  Keep in mind that it is not unusual for anyone to experience minor symptoms when exposed to the cold weather.  These “normal” responses generally consist of a little red flushing of the exposed part of the body (usually the face).  One may also experience a minor burning sensation, especially upon re-warming of the involved skin.  Obviously, individuals that are exposed to very cold temperatures or cold temperatures over a prolonged period of time run the risk of frostbite which can be very serious, as it may result in gangrene and thus loss of limbs and other body parts.

Individuals with Raynaud’s phenomenon or Raynaud’s disease also have cold intolerance.  People with these conditions have cold fingers or toes, skin color changes, and/or numbness/prickly feeling upon re-warming of the skin when they are exposed to the cold.  Although the exact cause is not completely understood, the blood vessels in individuals with Raynaud’s overact to cold temperatures and/or stress.  Often people with Raynaud’s phenomenon will have an accompanying autoimmune disorder such as systemic lupus erythematosus, scleroderma, Sjögren’s syndrome, vasculitis, or rheumatoid arthritis.  Others still have increased symptoms if they smoke, develop carpal tunnel syndrome, acquire a disease of the arteries, partake in repetitive actions such as playing the piano, texting, typing, etc., injure their hands or feet, and/or are exposed to certain medications (e.g., ADHD medications, certain over the counter “cold” medications, migraine medications, certain chemotherapy medications, beta blockers).

Regardless of the condition, the cold can play havoc with one’s body.  Luckily, we do not live in the far north of the U.S. where cold is more of an issue for longer periods of time.  However, since we live in a more temperate climate, allergies to pollens (i.e., allergic rhinitis/hay fever) in the Spring and Fall tend to be worse in the Washington, DC, Northern Virginia, and Maryland metropolitan area.

If you suffer from cold-induced symptoms of any kind, the board certified allergists at Black & Kletz Allergy have the expertise in order to diagnose and treat this condition.  We treat both adult and pediatric patients and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible.  Please either call us for an appointment or you may alternatively 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 treating allergy and asthma patients in the Washington, DC metro area for more than 50 years and we strive to provide state of the art allergy care to its residents and visitors.

Food-Dependent Exercise Induced Anaphylaxis

Food-Dependent Exercise Induced AnaphylaxisExercise-induced anaphylaxis (EIA) is defined as the onset of allergic symptoms during, or immediately after, exercise.  The manifestations may include hives (i.e., urticaria), swelling of the soft tissues (i.e., angioedema), generalized itching (i.e., pruritus), wheezing, shortness of breath, nausea, dizziness, fainting, and/or a drop in blood pressure.  In some individuals, these reactions occur only if exercise is undertaken after eating certain specific foods!  When the food intake and the exercise are independent of each other, there are no symptoms.  This condition is termed “food-dependent exercise Induced anaphylaxis” (i.e., FDEIA).

Symptoms of FDEIA may begin at any stage of exercise and occasionally occur just after exercise.  The offending food is usually ingested within 4 hours preceding exercise, or rarely just after exercise.  The frequency with which symptoms occur varies among patients with FDEIA and can be very unpredictable, even for a given patient.  Early signs and symptoms may include fatigue, diffuse warmth, flushing, and/or generalized itching.  These symptoms usually subside after some time if the person stops exercising.  If the exercise is continued however, it can lead to swelling of the throat, breathing difficulty, drop in blood pressure, and vascular collapse which can potentially be fatal.

Though a wide variety of foods are known to play a role, the most common foods which have been observed to cause this condition are grains (especially wheat) and nuts in Western populations and shellfish in Asians.  Most patients develop symptoms only after eating a specific food, although a few have attacks if any food (usually solids rather than liquids) has been ingested.  Patients have been described where symptoms occurred only if 2 foods were eaten together before exercise.  The processing of the food(s) may also be critical in some cases, such as a patient who developed FDEIA with tofu but could tolerate soy milk.

The exact mechanism of how food plus exercise triggers life-threatening reactions is not clearly known.  A leading theory suggests that physical exertion enhances the absorption of the food from the gut. Ingestion of alcohol can also facilitate this condition, probably by the same mechanism.  Another hypothesis suggests that exercise stimulates the mast cells (which are previously sensitized to specific food proteins) to release chemical mediators responsible for the reaction.  In some instances, taking medications such as aspirin or nonsteroidal anti-inflammatory drugs [(e.g., Motrin, Advil (ibuprofen), Aleve (i.e., naproxen)] can also contribute to the reaction, supporting the hypothesis of mast cell activation.

As mentioned above, wheat is the most commonly reported allergen in FDEIA overall.  Gliadin, a protein component of gluten, is an important allergen in this disorder, as well as in wheat allergy causing anaphylaxis independent of exercise.

DIAGNOSIS:

The following criteria are needed to establish the diagnosis of FDEIA:

  1. Signs and symptoms consistent with anaphylaxis that occurred during (or within 4 hours of) exercise but only when exercise was preceded by food ingestion.
  2. No other diagnosis that explains the clinical presentation.

If a specific food is implicated, there should be:

  1. Evidence of a specific antibody to the implicated food, either by skin tests or by blood tests and
  2. No symptoms on ingestion of that food in the absence of exertion and no symptoms if exercise occurs without ingestion of that food, although there may be rare exceptions (i.e., patients may report isolated incidences when symptoms occurred at rest in the presence of other exacerbating factors, such as illness).

A serum tryptase level should be measured in all patients and should be normal in individuals with FDEIA when the patients are in their usual state of health.  Elevated levels at baseline should prompt an evaluation for a mast cell disorder.

Skin testing or blood testing for environmental allergens is sometimes useful if the patient is more susceptible to attacks during certain pollen seasons or in a patient with concomitant allergic respiratory disease such as asthma.

A positive food plus exercise challenge confirms the diagnosis, but a negative challenge does not reliably exclude the diagnosis because symptoms can be difficult to induce in a laboratory setting and the procedure is not standardized.

TREATMENT:

Avoidance of ingesting the suspected food before exercising is critical.  Identification of aggravating factors such as alcohol, aspirin, and/or nonsteroidal anti-inflammatory drugs and their avoidance is also important.

  1. Always carry an epinephrine self-injectable device (e.g., EpiPen, Auvi-Q, Adrenaclick) and mobile phone in all exercise settings.  If the epinephrine is ever used, always go immediately to the closest emergency room.
  2. Stop exertion immediately if any symptoms occur (never “push through”).
  3. Avoid the causative food for at least 4-6 hours before exercise.
  4. Always exercise with other informed individuals.

In some individuals with this condition, pre-treatment with certain medications such as first generation antihistamines and/or cromolyn may provide some preventive benefit.  It should be noted that this is not a substitute for avoidance of eating the allergic food and then exercising.

The board certified allergists at Black & Kletz Allergy will promptly respond to any questions regarding FDEIA and other allergic or immunologic disorders.  We have been treating this condition for many years and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have been serving the Washington, DC, Northern Virginia, and Maryland metropolitan area for over 50 years and treat both adult and pediatric patients.  All 3 offices at Black & Kletz Allergy offer on-site parking and the Washington, DC and McLean, VA offices are Metroaccessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you are concerned that you may have FDEIA or any other allergy, asthma, sinus, skin, or immunology problem(s), please call us to schedule an appointment.  You may also click Request an Appointment and we will reply within 24 hours by the next business day.  At Black & Kletz Allergy, we strive to improve the quality of life in allergic individuals in a professional and caring setting.

Allergies and Christmas, Hanukkah, and Kwanzaa Holidays

As we approach the festive holiday season, many individuals will be plagued with increased allergy and/or asthma symptoms.  While most of us will not experience allergic symptoms this holiday season, there are a lot of people who have allergies that will be affected by various allergens during the Christmas, Hanukkah, and Kwanzaa holidays.

During the holidays, individuals may be exposed to decorations that are stored in closets or basements for a long period of time.  These decorations regularly attract dust and/or molds which to many will cause allergic rhinitis, allergic conjunctivitis, and/or asthma symptoms.  The typical symptoms that occur may include runny nose, nasal congestion, post-nasal drip, sneezing, itchy nose, itchy eyes, watery eyes, redness of the eyes, sore throat, sinus congestion, sinus headaches, snoring, fatigue, wheezing, coughing, chest tightness, and/or shortness of breath.

Christmas trees may also cause allergy and/or asthma symptoms.  Both natural and artificial trees may be to blame.  Natural Christmas trees are known to harbor many varieties of mold.  A study published in the Annals of Allergy, Asthma, and Immunology found that there were about 50 varieties of mold isolated from some natural Christmas trees.  About 75% of these molds were known to cause allergic rhinitis (i.e., hay fever) symptoms.  In addition, having a real Christmas tree in a home can increase the amount of indoor mold.  Mold counts in a room with a live Christmas tree are higher than the same room once the tree is removed.  Artificial Christmas trees often introduce dust and molds to individuals especially in the case where they have been stored in dusty and/or moldy environments.  Occasionally, the materials used to make the tree is the offending agent as it can cause nasal, sinus, ocular, and pulmonary symptoms.  Usually this is due to an irritant (e.g., chemical) in the materials, and thereby not an actual allergy in the classical sense, however, allergy-like symptoms may ensue.  It is recommended to clean the tree by shaking the tree, hosing it off with water, and/or blowing the dust off using an air compressor regardless if it is natural or artificial in order to minimize the allergens and irritants.

Regardless whether you celebrate Kwanzaa, Hanukkah, Christmas, or merely just get together with family or friends for a non-religious occasion, the winter holiday season can be a problem for some allergic individuals because of food allergies.  The most common food allergies are milk, wheat, soy, eggs, peanuts, tree nuts, fish, and shellfish.  In sensitive individuals, a food allergy can be very severe and life-threatening.  It is very important for the host(s), as well as other people who bring dishes from their homes to be extremely careful when cooking food to know exactly what is in the food so that they can warn the food-allergic individual(s).  More and more, people will prepare dishes without the offending food for the sensitive individual, so he or she can eat without concerns.

The board certified allergists at Black & Kletz Allergy hope that everyone enjoys the upcoming holiday season.  We are here to meet your allergy and asthma needs for the people of the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We treat both adults and pediatricpatients.  We have offices on K Street, N.W. in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  There is on-site parking at each of the 3 offices.  Our Washington, DC and McLean, VA locations are Metro accessible.  Black & Kletz Allergy offers a free shuttle service between our McLean, VA office and the Spring Hill metro station on the silver line.  If you suffer from allergies, asthma, sinus problems, hives, or immunological disorders, please call us to make an appointment.  You may also click Request an Appointment and we will get back to you within 24 hours by the next business day.  Again, we wish you a happy holiday season.

New Targeted Treatments for Asthma

Asthma is a chronic inflammatory disorder of the lungs.  Genetics play a major role in the causation of the disease process.  It is a characteristically variable disease with the severity varying from person to person.  It also varies at different stages in one’s lifetime of an affected individual.  Environmental factors such as exposure to allergens, irritants, and infections are the usual factors that trigger exacerbations of asthma.

Even when symptoms are not present, low-grade inflammation is believed to exist in affected individuals.  In patients who are susceptible to frequent flare-ups of asthma, it has been well established that adequately controlling the ongoing inflammation will substantially reduce the frequency and severity of exacerbations.  Uncontrolled inflammation can also adversely affect the lung function in the long term.

Corticosteroids are global anti-inflammatory agents and have been the mainstay of maintenance therapy for several decades.  They are proven to suppress the inflammatory cascade at multiple points in a dose-dependent fashion.  They are very reliable in preventing flare-ups of asthma as well as preserving lung function.  However, long-term use of corticosteroids (especially in high doses) unfortunately is not without risks.  The potential side effects may include increased susceptibility to infections, thinning of bones, cataracts, glaucoma, increased appetite, weight gain, mood swings, glucose intolerance as well as many other adverse effects.  These side effects can be minimized by using these agents in the lowest effective dosage and for the shortest possible time.

Over the past several years, scientists have focused on developing alternatives to corticosteroids with fewer side effects.  Research has been fruitful in delineating various “pathways” in the causation and progression of inflammation.  Different chemical mediators mediate the process at different stages.  Blocking these mediators by specific drugs has proven to be effective in controlling the resulting inflammatory damage to tissues.

Leukotrienes were one of the earliest identified mediators for which blocking drugs were developed. Zileuton (i.e., Zyflo), zafirlukast (i.e., Accolate) and montelukast (i.e., Singulair) were approved by the U.S. Food & Drug Administration (i.e., FDA) for maintenance treatment of asthma in the late 1990’s.  These are oral medications used daily in patients with persistent asthma.  Zyflo works by inhibiting leukotriene formation whereas both Accolate and Singulair block the action of specific leukotrienes.  Though these drugs do not help everyone, they are very effective in asthmatics in which leukotrienes play a major role in perpetuating inflammation.  These agents do not have the steroid related side effects, however, a very small percentage of people using Singulair were noted to experience emotional disturbances such as depression.  In addition, patients taking Zyflo must have their liver function tests monitored while on the medication.

Immunoglobulin E (i.e., IgE) is the antibody that mediates allergic reactions and contributes to the disease frequency and severity of asthma exacerbations.  Omalizumab (i.e., Xolair) is a monoclonal antibody that depletes IgE in the blood and has been shown to reduce the frequency of symptoms and exacerbations in patients with asthma.  Note that it is also helpful in the treatment of recalcitrant chronic idiopathic urticaria (i.e., hives).  For asthma, it is given as an injection under the skin (i.e., subcutaneously) at a dose of 75 to 375 mg. every 2 or 4 weeks to patients 6 years of age and older.  The dose is calculated based on the serum IgE level and the weight of the patient and is given to patients with moderate to severe persistent asthma.  This medication is however unlikely to be helpful in patients with non-allergic asthma.  In the treatment of chronic idiopathic urticarial, Xolair is given subcutaneously at a dose of 150 or 300 mg. every 4 weeks to patients 12 years of age and older and is not dependent on the serum IgE level or body weight.

Eosinophils, on the other hand, are a type of white blood cell, long known to cause tissue damage when present in excessive numbers.  In a subtype of asthma, these cells play a predominant role in the inflammatory pathway.  Three “biological” medications were recently approved by the FDA for maintenance treatment of “eosinophilic” asthma.  These medications are effective in controlling asthma in patients who have high levels of eosinophils in their peripheral blood, detected in a commonly done test called a CBC (i.e., complete blood count).

Mepolizumab (i.e., Nucala) was approved in November of 2015.  It is a monoclonal antibody that blocks a molecule called IL-5 (i.e., interleukin-5) which is essential for growth and survival of eosinophils.  It is given as a subcutaneous injection at a fixed dose of 100 mg. every 4 weeks in patients 12 years of age and older who have severe persistent asthma.

Reslizumab (i.e., Cinqair) is another monoclonal antibody that received FDA approval in March of 2016. This medication is administered intravenously in a dose of 3mg. per kg. of body weight, every 4 weeks, infused over 20 to 50 minutes for patients with severe persistent asthma aged 18 years and older.

The most recent medication receiving approval for maintenance treatment of severe persistent asthma was benralizumab (i.e., Fasenra).  It was approved in November of 2017 for patients 12 years of age and older with the eosinophilic asthma phenotype.  It is injected subcutaneously in a fixed dose of 30 mg. The frequency of administration is once every 4 weeks for the first 3 doses and then once every 8 weeks thereafter.

The board certified allergy doctors at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  The allergists at Black & Kletz Allergy are extremely knowledgeable about the most current treatment options for patients with asthma and related disorders 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.