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Milk Allergy

Milk is one of the most common foods to cause allergic reactions.  Almost 3% of children younger than 3 years of age are allergic to milk.  Notwithstanding, a vast majority of children spontaneously outgrow their milk sensitivities.

CAUSES:

In children with milk allergy, the immune system falsely identifies the protein in the milk as potentially dangerous, and as a result, mounts a defensive attack.  The “pre-formed” milk specific antibodies (i.e., immunoglobulin E or IgE) react with the protein in the milk (i.e., antigen), causing release of chemical substances (e.g., histamine, leukotrienes, prostaglandins) into the tissues.  These chemical substances are what causes the symptoms of allergic reactions.

Cow’s milk is the most common cause of milk allergy although milk from sheep and goats can also cause allergic reactions in certain sensitized children.  Children are more likely to have a milk allergy if there is a history of a food allergy in other family members.

SIGNS and SYMPTOMS:

Children usually begin manifesting symptoms of milk allergy within a few minutes after consuming milk products.  In some children, however, symptoms can sometimes be delayed for a few hours.

  • Skin itching, hives, and/or swelling of soft tissues
  • Redness, itching, and/or tearing of the eyes
  • Fullness/tightness in the throat, difficulty in breathing and/or swallowing
  • Nasal congestion, itching, sneezing, and/or clear runny nose
  • Abdominal pain, cramping, vomiting, and/or diarrhea
  • Irritability, restlessness, and/or dizziness
  • Drop in blood pressure, and/or loss of consciousness

The severity of symptoms can vary from mild to severe life-threatening anaphylactic reactions, depending on the severity of the allergy.

DIAGNOSIS:

  • Comprehensive history taking of the milk reaction with focus on the time of exposure to milk, onset time of symptoms, and progression of symptoms.
  • Family history of food allergies
  • Skin prick testing with a commercially available milk protein antigen with negative and positive controls.  If the wheal diameter of the milk protein is more than 3 mm. than that of the negative control, the test is considered positive, signifying the presence of IgE antibodies to milk.
  • A blood test can also be utilized to detect and measure the quantities of milk specific IgE antibodies and should be obtained for more severe milk reactions.
  • Oral challenge with incremental exposure to milk beginning with a tiny amount and slowly increasing the amount at regular intervals while closely monitoring for signs and symptoms of a reaction.  These oral challenges should be undertaken only when trained professionals are readily available to identify and treat possible untoward reactions as soon as they occur.

TREATMENT:

  • Total avoidance of milk and dairy products
  • Read labels and identify the ingredients of packaged foods
  • In cases of accidental exposures, antihistamines can be given orally or by injection if the symptoms are limited to hives and/or itching of the skin.
  • If the symptoms are rapidly progressing and/or in case respiratory, gastro intestinal, and/or cardiac symptoms, epinephrine should be injected into the muscle on an urgent basis.  Patients should be prescribed a self-injectable epinephrine device (i.e., EpiPen, Auvi-Q, Adrenaclick) and told to go immediately to the closest emergency room if that device is used.
  • Oral immunotherapy is a process of desensitization to milk, which reduces the risk of severe reactions after inadvertent exposure to milk products. This process entails ingestion of small quantities of milk protein in a controlled setting to monitor for reactions.  The amount of milk protein will be gradually increased under close medical supervision.
  • Xolair (i.e., omalizumab) injections can be given either every 2 or 4 weeks in order to prevent a severe milk allergy, as well as any other food allergy.

 

Note:  “Lactose intolerance” is sometimes confused with milk allergy.  Intolerance in this case signifies a difficulty in processing and digesting the sugar in the milk (i.e., lactose) as the enzyme that is needed to break it down (i.e., lactase) is lacking in sufficient quantities.  This process does not involve the immune system and the symptoms are usually limited to the gastrointestinal tract. The typical symptoms may include abdominal bloating, abdominal pain, diarrhea, nausea, and/or vomiting.  These children will be able to tolerate lactose-free milk and dairy products.

PREVENTION:

  • Milk allergy itself may not be preventable, due to a genetic predisposition and susceptibility.
  • Diligent avoidance of milk and dairy products such as cream, cheese, butter, ice cream, and yogurt may prevent severe reactions.
  • Having a self-injectable epinephrine (e.g., EpiPen, Auvi-Q, Adrenaclick) device readily available at all times can reduce the risks of life-threatening anaphylactic reactions.

Close monitoring by a board certified allergist, like the ones at Black & Kletz Allergy, as well as testing for milk allergy at regular intervals, may identify the children who outgrow their milk allergy.  At this point, milk and dairy products may possibly be gradually reintroduced into their diets.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing milk and other food allergies in both adults and children for over 50 years.  We have 3 office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The allergists are able to test for milk allergy and most foods which can be done by either blood tests or allergy skin tests.  We offer onsite parking at each one of our locations 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.  If you feel you may have a milk allergy, other food allergy and/or a food intolerance, please call us today to schedule an appointment. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy are eager to help you find out if you are allergic to milk or other foods.  This will allow you live in less fear as you will be able to avoid the offending food as well as have a detailed plan on what to do if you would accidentally ingest the given food.

Update on Generalized Itching (Pruritus)

Update on Generalized Itching (Pruritus)Generalized itching (i.e., generalized pruritus) is a condition which can be quite annoying.  It is when an individual has diffuse itching of the body usually without an associated rash.  Approximately 20-25% of the general population experiences generalized pruritus at least one time in their life.  The itching may be intermittent or it may be chronic in nature.  “Acute” itching is when the itching has been present for less than 6 weeks.  “Chronic” itching is defined by having it for 6 or more weeks.  The itching may last for years in certain individuals.  The severity of the itching may vary from very mild to very severe where it can interfere with one’s quality of life.  If the itching becomes chronic, it is important to see a board certified allergist, like the ones at Black & Kletz Allergy, so that a cause of the itching can hopefully be identified.  Note that generalized itching may also be associated with hives (i.e., urticaria) and/or swelling (i.e., angioedema).

There are many causes of generalized itching.  Allergies are a very common cause of itching.  Allergies to oral and topical medications, foods, cosmetics, fragrances, metals, shampoos, nail polish, latex, poison ivy, poison oak, and poison sumac are just some of the common allergies that may cause itching.  Contact dermatitis and eczema, (i.e., atopic dermatitis) are 2 other allergic conditions that may cause itching.   Although allergies may be the cause of a lot of individual’s itching, it by no means the only reason for the pruritus.  There are a variety of underlying conditions that may cause a person to have itching even though it may not be the most common symptom of the disease.  Some of the underlying conditions that can cause itching may include diabetes mellitus, hepatitis B, hepatitis C, kidney disease, thyroid disease, malignancy, iron deficiency anemia, dyshidrotic eczema, HIV, folliculitis, ringworm, seborrheic dermatitis, neurodermatitis, shingles, xerosis (i.e., dry skin), psoriasis, bed bugs, parasitic infections, pregnancy, as well as many others.  It is important that a cause be identified so that either the allergen is avoided or the management can be focused on the underlying condition responsible for the itching.

The diagnosis of generalized itching begins with a comprehensive history and physical examination.  By performing a comprehensive history, the allergist is trying to ascertain the cause of the itching.  It is common for a patient to forget or not bring up pertinent information that can help the allergist figure out the cause, so it is important for the allergist to ask a variety of questions in order to try to establish a cause or trigger of the pruritus.  Asking questions such as, “Have been on any recent antibiotics or new medications?” or “Do you take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)?” are good questions because many patients will not volunteer this information because they do not feel that it is important enough to mention to the physician.  In reality, antibiotics, new medications, aspirin, and NSAIDs use are very common reasons for generalized itching.  If no obvious allergen can be identified and the itching has lasted 6 weeks or more, looking for an underlying condition is the next step.  This is usually done by blood tests.

The treatment of generalized itching is directed at avoiding the offending agent.  If for example a new medication appears to be causing the itching, the medication should be stopped or changed to another appropriate medication.  If it is a certain cosmetic or a specific food, then obviously the cosmetic or food should be avoided.  In addition, using oral H1 blockers (i.e., antihistamines) is the most common treatment.  Sometimes, adding an H2 blocker and/or a leukotriene antagonist to the Hi blocker is needed.  Rarely, oral corticosteroids are needed for severe cases.  Topical creams/ointments have been used with limited success.  In most cases, medications may only be needed for 1 or 2 weeks, but can be necessary is some individuals for several years.  If the itching persists for more than 6 weeks and bloodwork is obtained in order to rule out underlying conditions, then treating the underlying condition may in fact get rid of the itching.

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

New Treatment for Anaphylaxis

neffy anaphylaxis treatmentAnaphylaxis is an acute, severe, and life-threatening allergic reaction.  The most common triggers for anaphylaxis include allergenic foods, medications, and insect stings.  Symptoms usually begin within a few minutes of exposure of the triggering agents.  Initially, the symptoms characteristically involve the skin which typically causes itching and hives followed by swelling of the soft tissues.  Unless treated, the reaction may rapidly progress and may involve other organ systems (e.g., respiratory, gastrointestinal, cardiovascular) resulting in symptoms such as shortness of breath, wheezing, coughing, nausea, vomiting, abdominal pain, dizziness, drop in blood pressure, and/or loss of consciousness.

The only effective treatment for anaphylaxis is epinephrine.  If given early in the process, it can stop the reaction from progressing and can be life-saving.  As anaphylactic reactions can occur after accidental exposures anywhere and at any time, it is recommended to have epinephrine readily available at all times for those at risk for anaphylaxis.

Until now, the only form of epinephrine available was an injectable form.  The epinephrine is injected into a muscle either with a syringe and a needle or with an autoinjector device.  There are a few autoinjectors available in different shapes and sizes and dome of the brand names include EpiPen, Auvi-Q, and Adrenaclick.  Autoinjectors are preloaded with different doses of epinephrine suitable for adults and children.  One problem with autoinjectors is that some patients and parents of children at risk for anaphylaxis are not comfortable in using them because they are squeamish about needles.  As a result, a hesitancy in the use of epinephrine can lead to a delay in administering the needed treatment in a life-threatening situation which can be detrimental.

On August 9, 2024, the Food and Drug Administration FDA) approved a new form of epinephrine that is delivered into the nostrils by way of a nasal spray device.  It is called Neffy and it uses the same delivery device used to administer other medications into the nasal cavity such as Narcan, a drug useful in reversing the effects of opiates.

Neffy delivers 2 mg. of epinephrine into the nasal cavity. (Epipen is available in 0.3mg. and 0.15mg. dosage strengths).  In clinical trials, Neffy resulted in comparable blood levels of epinephrine to injectable forms, with a shorter onset of action.  It also showed that it can increase the blood pressure and heart rate rapidly, which are indicators for the reversal of the reaction.

This nasal epinephrine formulation is approved for adults and children weighing 30 kg. (66 lbs.) and above.  Neffy is a single dose nasal spray administered into one nostril.  It is available as a 2-pack, which is similar to injectable forms.  It is recommended to administer the second dose on Neffy from a different device into the same nostril if the anaphylactic symptoms persist 5 minutes after the initial dose.

It is hoped that the nasal spray would remove some barriers for early usage of epinephrine (i.e.  the fear of injections) and thus would meet an unmet need.  The manufacturer says that most commercially insured patients will pay approximately $25 as copay for a 2-pack, while also offering assistance for patients who are not insured.  The medication has a shelf-life of about 30 months and is stable at wide temperature ranges.

Neffy was also studied in patients with nasal congestion due to allergies and infections and it was shown to be well absorbed from the nasal cavity without losing its efficacy.  Note however that Neffy was not studied in patients with nasal polyps and in patients after nasal surgeries, so its efficacy in these patients is currently unknown.

The side effects observed in clinical trial participants included throat irritation, tingling sensation in the nose, runny nose, nasal congestion, headaches, jitteriness, and dizziness. Neffy should also be used with caution in patients with a history of allergic sensitivity to sulfites.

Neffy is expected to be available in the pharmacies in October 2024.

The board certified allergists at Black & Kletz Allergy see both adult and pediatric patients and have over 5 decades of experience in the field of allergy, asthma, and immunology.  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 look forward to providing you with the newest cutting edge allergy care in a welcoming and relaxed environment.

 

Ragweed Allergy Update

As the Summer marches on and we are now in the month of August, many allergy sufferers are about to get ready for another foe, namely ragweed. Usually about August 15th of every year, ragweed pollen begins to blanket the Washington, DC, Northern Virginia, and Maryland metropolitan area like clockwork. The dissemination of ragweed pollen generally comes to an end in our region in late October during the first frost. With the rising temperatures and rising carbon dioxide (CO₂) levels, the ragweed season is now longer than it has been historically and it now may begin as early as early August. Ragweed is a flowering plant and considered a weed. Ragweed is widespread in the U.S., particularly in the Midwestern and Eastern and regions of the U.S. Though many weeds (e.g., cocklebur, mugwort/sagebrush, pigweed, Russian thistle) pollinate in the Fall, ragweed is the most common and predominant allergen in our geographical area. The only state without ragweed is Alaska.  It is typically found in fields, on the side of roads, in vacant lots, and near riverbanks. There are at least 17 species of ragweed in North America. Even though each ragweed plant lives only 1 season, it can produce approximately 1 billion pollen grains, plenty enough to cause havoc amongst allergy sufferers. Increased humidity in conjunction with warm weather and wind enhances the release of ragweed pollen. The ragweed pollen, like other pollens, is transported by the wind and can travel hundreds of miles due to its light weight. The wind causes the ragweed to become airborne for days which provides an easy way for individuals to become sensitized to the ragweed pollen. The ragweed pollen count is typically lowest in the early morning and it tends to reach its highest in the midday.

When a previously sensitized individual has been is exposed to ragweed again in the air, the ragweed proteins trigger specialized cells in the immune system to release increased levels of histamine and other chemical mediators which are responsible for numerous allergic symptoms which is known by the names allergic rhinitis (i.e., hay fever) and/or allergic conjunctivitis (i.e., eye allergies). Some of these symptoms may include runny nose, sneezing, nasal congestion, post-nasal drip, itchy nose, sinus congestion, headaches, itchy throat, fatigue, snoring, itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. In asthmatics, coughing, chest tightness, wheezing, and/or shortness of breath may also occur.

In some ragweed-sensitive individuals, consuming certain fresh fruits or vegetables [e.g., bananas, melons (watermelon, cantaloupe, honeydew), cucumber, zucchini, artichokes, sunflower seeds, white potato, chamomile tea, dandelion] may cause itching and tingling of mouth, tongue, and throat. This condition is called “oral allergy syndrome” or “pollen-food allergy syndrome” and is a result of the cross-reacting proteins in the pollen and fresh fruits or vegetables. The syndrome is caused by allergens in foods that are derived from plants. Thus, only foods that come from plants can cause the syndrome.  Ironically, when the fruit or vegetable is canned or cooked, the protein is denatured and destroyed which usually prevents the allergic reaction from happening. Most of the time, individuals can tolerate canned and/or cooked fruits or vegetables.

Avoidance is the key to combatting ragweed, if at all possible. Some avoidance measures may include the following:

  • Keeping the windows and doors at home as well as the windows in automobiles closed and use air-conditioning.
  • Decreasing outdoor activities, especially in the early morning hours when the pollen counts tend to be at their highest.
  • Showering to remove ragweed pollen from the skin and hair after coming indoors.
  • Washing clothes upon returning from outdoors.
  • Nasal irrigation can wash the ragweed pollen from the nasal passages.
  • Washing the fur and coats of one’s pets after being outside.

If it is impossible to avoid ragweed using the avoidance measures listed above or one still develops those annoying allergy symptoms, there are some medications available in order to prevent or minimize the symptoms of ragweed allergy. They include oral antihistamines, oral decongestants, leukotriene antagonists, nasal antihistamines, nasal decongestants, nasal anticholinergics, nasal corticosteroids, ocular antihistamines, ocular decongestants, ocular anti-inflammatory agents, and/or ocular mast cell stabilizers. For those patients who have asthma, the treatment may include short-acting beta 2 agonists, long-acting beta 2 agonists, inhaled corticosteroids, leukotriene antagonists, monoclonal antibody injections, and/or oral corticosteroids in more severe cases. In addition to the medications listed above, allergy shots (i.e., allergy immunotherapy, allergy injections, allergy desensitization, allergy hyposensitization) are a very effective tool in the treatment of allergic rhinitis, allergic conjunctivitis, and asthma. They have been given to patients in the U.S. for more than 100 years. Allergy shots work in 80-85% of patients who undergo them. They are typically given for 3-5 years. Allergy immunotherapy will offer the most effective long-term relief of symptoms and can reduce or eliminate the need for medications.

The board certified allergists at Black & Kletz Allergy have 3 office 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 allergy specialists at Black & Kletz Allergy diagnose and treat both pediatric and adult patients. For an appointment, please call one of our offices or 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 helping patients with hay fever, asthma, sinus disease, hives, eczema, insect sting allergies, food allergies, medication allergies, and immunological disorders for more than 5 decades. If you suffer from allergies, it is our mission to improve your quality of life by reducing or preventing your unwelcome and irritating allergy symptoms.

Poison Ivy, Poison Oak, and Poison Sumac Summary

Contact dermatitis is an inflammation of the skin triggered by a physical exposure to an allergen. These allergens are usually either chemicals or plants. There are 3 plants, (i.e., poison Ivy, poison oak and poison sumac) which account for a vast majority of plant-based allergens. The active allergen is the sap oil (i.e., urushiol) in the roots, stem, and the leaves of the plants.

About half the adult population in the United States develops contact dermatitis after exposure to these plants. Approximately 10 to 50 million people in the U.S. suffer from this condition every year. Certain professions who work outdoors, such as construction workers, farmers, landscapers, and firefighters are at a higher risk to develop plant-induced contact dermatitis than other professions where workers are primarily based indoors. Individuals who have active lifestyles outdoors or who have a hobby or passion that involves the outdoors are also more prone to developing poison Ivy, poison oak and/or poison sumac.

On exposure to one of these plants, the sap oil urushiol penetrates the skin and cause inflammation. The uruahiol can also spread to different parts of the body by direct contact. Pets and other animals can also transfer the allergen from the plants to the human skin. In addition, contact with plant-exposed clothing or garden tools can also result in contact dermatitis.

Symptoms:

The symptoms of poison ivy, poison oak, and/or poison sumac typically begins with a reddish and itchy rash that develops over the exposed area of the skin approximately 1 to 2 days after the exposure. Note that the rash may take up to 2 weeks in some individuals to develop after the first exposure, however, as mentioned above, it typically begins within the first day or two. The rash is usually intensely itchy and may cause a burning sensation in some individuals. In severe cases, fluid-filled blisters may develop and they are usually arranged in linear streaks, a pattern that can be explained by the contact with a branch of leaves touching the skin. The symptoms usually increase in intensity over the next week and the whole episode gradually resolves after 2 to 3 weeks.

Management:

The whole body should be washed with soap and water as soon as possible after exposure to these plants. The oily urushiol should be removed from everywhere before it has a chance to get absorbed. Clothing and other items that were exposed to the plants should be thoroughly washed as well. It is also prudent to bathe any pet that was exposed.

Treatment:

  • Wet compresses may help to reduce inflammation and pain.
  • Soothing agents such as calamine lotion, zinc oxide, and/or oatmeal baths can reduce irritation and discomfort.
  • Topical corticosteroid creams/ointments will help control inflammation and can reduce blistering and itching.
  • If more than 20% of the body surface area is involved and/or in case of a severe rash over the face, hands, genitals, etc., systemic corticosteroids (e.g. oral prednisone) may be helpful.
  • Antihistamines can offer some marginal relief from itching. First generation antihistamines are usually more effective but should not be used when one needs to be fully alert and awake as they may cause drowsiness and fatigue.
  • Occasionally, antibiotics are necessary to treat secondary infections that can occur.

Prevention:

  • Identifying and avoiding exposure to poison ivy, poison oak, and/or poison sumac is the only definitive way in preventing plant-induced contact dermatitis.
  • Wearing long sleeves, long pants, boots, and gloves before gardening and other outdoor activities can reduce direct exposure to the plant oils.
  • Barrier skin creams such as Ivy Block or IvyX applied over the skin before possible exposure may offer some additional protection.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating poison ivy, poison oak, and poison sumac for more than 50 years.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC metro area with 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 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.  Please call us today to make an appointment at the office of your choice.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergists at Black & Kletz Allergy pride themselves in delivering the highest quality allergy care in the Washington, DC metropolitan area in conjunction with providing excellent customer service in a welcoming and friendly environment.

Allergies to Mosquito Bites

Now that it is Summer, mosquitoes are becoming more prevalent in the Washington, DC, Northern Virginia, and Maryland region. Mosquitoes are flying insects that tend to be more widespread where there is standing water. They are more active early in the morning and early in the evening. Female mosquitoes typically lay their eggs in stagnant water. Only the female mosquito bites and feeds on human blood, as they need this blood in order to produce their eggs. Male mosquitoes, on the other hand, feed on water and nectar.  Mosquitoes are considered pests and they are a nuisance to almost everyone who comes in contact with these annoying insects. When a person is bitten, the mosquito injects its saliva into the skin which contains proteins that prevent the human blood from clotting. This allows the blood to be transferred to the mosquito’s mouth without clotting. For the most part, mosquitoes bite people and animals without any symptoms or only very mild local symptoms. For many others however, a mosquito bite can cause a great deal of misery, mostly consisting of irritation, itching, redness, and/or swelling at the site of the bite. In very sensitive individuals, the swelling and redness can become quite large. Occasionally this redness and swelling is accompanied by bruising and/or blisters.

The typical localized itching, swelling, and/or redness of the skin that results from the bite is not directly due to the bite itself, but rather caused by the body’s immune response to the proteins in the mosquito’s saliva. In extremely rare occurrences, an individual with a true mosquito allergy, which by itself is rare, may develop a classic systemic allergic reaction (i.e., anaphylaxis) whereby the bite can trigger a life-threatening allergic reaction. An “allergic reaction” to a mosquito bite is when there is a severe immune reaction against the salivary proteins of the mosquito. As emphasized above, this is very uncommon but these mosquito-allergic individuals may experience generalized itchiness (i.e., pruritus), hives (urticaria), wheezing, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, throat closing sensation, lightheadedness, dizziness, fainting, increased heart rate, and/or drop in blood pressure. A self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) should be prescribed for any person with a true mosquito allergy who have exhibited systemic symptoms in the past. It is important to note that if one uses a self-injectable epinephrine device, they should go immediately to the closest emergency room. Individuals with anaphylaxis or systemic reactions from a mosquito bite should also be referred to a board certified allergist like the ones at Black & Kletz Allergy.

The development of a true allergic reaction from mosquitoes usually progresses as follows:

  • Individuals who have never been exposed to a particular species of mosquito do not usually develop reactions to the initial bites from such mosquitoes.
  • Subsequent bites result in delayed local skin reactions.
  • After recurrent mosquito bites, immediate wheals (i.e., hives) may develop.
  • With additional exposure, the delayed local reactions diminish and eventually disappear, although the immediate reactions persist.
  • Individuals who are repeatedly exposed to mosquito bites from the same species of mosquito eventually also lose their immediate reactions. They become tolerant to the mosquito bite. This is in essence what happens when an allergy patient receives allergy shots to environmental allergens. The allergy injections cause the individual who may be allergic to dust mites, molds, pollens, or pets become less bothered by these allergens since they develop antibodies to the allergens.

In addition to local and systemic reactions to mosquitoes, one must be concerned about the mosquito-borne diseases that may result from a simple mosquito bite. Some of the diseases that are known to be transmitted by mosquitoes include malaria, West Nile virus, dengue fever, encephalitis, chikungunya, yellow fever, Eastern equine encephalitis filariasis (i.e., elephantiasis), St. Louis encephalitis, Japanese encephalitis, Western equine encephalitis, Zika virus-related illnesses, Venezuelan equine encephalitis, Ross River fever, Rift Valley fever, and La Crosse encephalitis.

Avoiding exposure to mosquitoes is the best solution to prevent mosquito bites. Even if you stay indoors, it is recommended that one install screens in the windows and doors in order to help prevent mosquito exposure. Unfortunately, it is not always easy to avoid them if you plan to leave the house. If you venture outdoors, stay clear of free-standing water as mosquitoes tend to congregate and breed there. Avoid going outside from dusk until dawn, if possible, as mosquito bites occur more often during this time. Wear permethrin-treated clothing as well as light-colored long-sleeved clothing and hats. Use a bed net if sleeping outdoors. Use citronella-scented candles when at outdoor events. Use insect repellent that preferably contains a 10-25% concentration of DEET (N,N-diethyl-3-methyl-benzamide or N,N- diethyl-meta-toluamide). Alternatively, one can use insect repellents containing either picaridin or oil of lemon eucalyptus.

The treatment of run-of-the mill local reactions from mosquito bites vary depending on the severity of the reaction. Applying a cold pack or ice to the affected area is sometimes helpful. Using various creams (e.g., calamine lotion, anti-itch creams, topical antihistamines, corticosteroid creams) topically often give some relief. Oral antihistamines may offer additional relief in certain individuals. As mentioned above, anyone who has had a systemic reaction to mosquito bites should be prescribed a self-injectable epinephrine device and referred to a board certified allergist.

The board certified allergy specialists at Black & Kletz Allergy see patients of all ages and have over 50 years of experience in the field of allergy, asthma, and immunology. Mosquito bites as well as other insect bites (e.g., bees, wasps, yellow jackets, hornets, spiders) are common occurrences 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. Our 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 allergists at Black & Kletz Allergy are happy to answer any questions or concerns you may have about any allergic, asthmatic, or immunologic issue.

Grass Allergy Update

Grass pollen allergy is a very common environmental allergy. Grass pollinates in at different time of the year depending on where in the U.S. one is located. In the Northeastern and Mid-Atlantic regions of the U.S., grass pollinates from the Spring through the Summer. In the Washington, DC, Northern Virginia, and Maryland metropolitan area specifically, grass predominantly pollinates begins in April and generally lasts until the end of August, however, the peak pollination tends to be from May through the end of June. It should be noted that in some parts of the U.S. (e.g., the Southern U.S.), grass pollinates all-year long. It is a perennial allergen. Approximately 10-30% of the U.S. population is allergic to grass pollen. There are many species of grasses in the U.S. and many of them cross-react with each other, meaning that if you are allergic to one species of grass, you are likely to be allergic and bothered by other species of grasses.

There are many types of grasses and they are categorized by what family and subfamily of grasses they encompass. In the grass family Poaceae, there are several subfamilies that contain highly allergenic grasses. Pooideae is the largest subfamily of the grass family Poaceae. The common grasses associated with this subfamily include Orchard, Timothy, Kentucky blue, Sweet vernal, Red top, Meadow fescue, and June grasses. The common cereal grasses (e.g., rye, barley, oat, wheat) are also members of the grass family Poaceae. Panicoideae is a subfamily of Poaceae too and is comprised of many grasses with the most notable allergenic grasses being Bahia and Johnson grasses. Chloridoideae is also a subfamily of Poaceae and the most allergenic grass from this subfamily is Bermuda grass. Bermuda grass, however, tends to grow and pollinate primarily in the Southern U.S. where there are warmer temperatures.

The classic symptoms that an allergic individual who has allergic rhinitis (i.e., hay fever) to grass pollen may experience are the same symptoms that one would experience with any other pollen, dust mite, mold, or pet allergy. The characteristic symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, snoring, hoarseness, sinus headaches, sinus congestion, itchy ears, clogged ears, itchy eyes, watery eyes, redness of the eyes, puffy eyes, chest tightness, wheezing, coughing, and/or shortness of breath. In allergic individuals who are very allergic, contact with grass may cause hives and itchy skin. It should be noted that in extreme cases, it has been reported that very sensitive grass-allergic individuals can develop anaphylaxis upon scraping their skin with grass. This unusual anaphylactic reaction tends to occur while playing certain sports that are played on grass such as soccer, football, and baseball.

In addition to the above allergic rhinitis symptoms, some individuals with grass pollen allergies may experience itching of the mouth, throat, tongue, and/or lips due to a reaction to a protein in certain fresh fruits, vegetables, and/or nuts. The protein in the fresh fruits, vegetables, and/or nuts looks very similar to the allergenic protein found in grass pollen. The most common fruits and vegetables that cause these symptoms in grass-allergic individuals include melons (e.g., cantaloupe, honeydew, watermelon), tomatoes, and potatoes. These individual’s immune systems “see” the protein in these foods as the same protein found in grass pollen even though they are not actually the same proteins. As a result, the grass-allergic patient reacts to the food proteins because it is so similar to the grass pollen protein. This condition is called oral allergy syndrome or pollen food allergy syndrome. Note that if the food is cooked (i.e., heated), the protein of the food is denatured (i.e., broken down), and as a result, the individual can tolerate the food without having the mouth, throat, tongue, and/or lips symptoms. It is also interesting to note that oral allergy syndrome also occurs in individuals with tree pollen and ragweed pollen allergies.

The diagnosis of grass pollen allergy begins with a board certified allergist like the ones at Black & Kletz Allergy performing a comprehensive history and physical examination from the patient. Allergy skin testing or blood testing is usually done in order to identify specific allergens as the cause of the allergy symptoms. Pulmonary function tests may also be performed if one’s symptoms are indicative of asthma or the patient has a history of asthma.

The treatment of grass allergies begins with prevention and avoidance. The patient should try to avoid contact with grass by minimizing yardwork and lawn mowing, if possible. Removing one’s clothing and shoes when coming indoors after being outside may be helpful. Taking a shower after being outdoors for a prolonged period of time is also recommended. Wiping down or washing the fur of one’s pets after they are outside is also suggested.

Medications are usually the next step in the treatment of grass pollen allergy. Oral medications may include antihistamines, decongestants, and leukotriene antagonists. Nasal medications may include corticosteroids, antihistamines, and anticholinergics. Ocular medications may include antihistamines, decongestants, and mast cell stabilizers. Ocular corticosteroids are only used for severe ocular allergy symptoms due to the potential for long-term side effects. Oral corticosteroids may also be utilized but again reserved for recalcitrant and difficult to treat allergy symptoms. As with ocular corticosteroids, oral corticosteroids can also cause long-term side effects and are used judiciously.

Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) is often used to treat pollen allergies as well as dust mite, mold, and pet allergies. They are effective in 80-85% of the patients who take allergy shots. The average length of time on allergy immunotherapy is typically 3-5 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 children and adults with grass 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 allergy and asthma needs of the Washington, DC metro area community for more than 5 decades and we strive to offer high quality allergy and asthma care in an empathetic and professional atmosphere.

Conjunctivitis

In order to understand conjunctivitis, one must first understand a little about the anatomy of the eye as well as a little physiology of the way eyes become lubricated. The conjunctiva is the thin transparent membrane that lines the inside of the eyelids (i.e., palpebral area) and the front of the eyeballs (i.e., bulbar area). The lacrimal glands, which are located in the outer corners of the eyes, secrete tears which lubricate the eyes. These tears then drain into the nose via tear ducts from the inner corners of the eyes. Inflammation of the conjunctival membrane is called conjunctivitis. There are several conditions which cause inflammation of the conjunctiva which are as follows:

Viral infections – Viral infections are the most common cause of conjunctivitis. Several types of viruses can cause infections of the eye. Most viral infections are highly contagious and spread by contact with the infected individual’s eye secretions. The most common viruses that cause “cold-like” symptoms are primarily responsible for the majority of conjunctival infections. It should be noted that eye infections and upper respiratory infections often co-exist.

The symptoms of viral conjunctivitis may include redness (i.e., “pink eye”), watery discharge, feeling of grittiness, and/or a burning sensation in the eye. Occasionally the discharge becomes mucus-like and the eyelids can stick together with dried and crusted secretions primarily in the mornings. The symptoms usually begin in one eye and then may spread to the other eye after approximately 1 to 2 days.

The symptoms usually become progressively worse for 2 to 3 days and then begin to gradually decrease in intensity over the next 4 to 5 days. It may take 1 to 2 weeks for total resolution of the symptoms to occur.

The treatment of viral conjunctivitis may include the application of an eye drop containing an antihistamine and/or decongestant which is typically used 2 to 3 times a day for no more than 3 to 4 days at a time. Oral antihistamines and analgesics may also be helpful if respiratory symptoms are also associated. Warm or cool compresses can help to relieve any accompanying discomfort. Despite any relief these medicines may bring, these measures do not reduce the duration of the illness, as there is no specific curative treatment for the virus which is the causative agent in viral conjunctivitis.

Bacterial infections – Bacterial infections causing conjunctivitis are also highly contagious spreading by contact with conjunctival secretions and transmitted through objects (i.e., fomites). Usually, several members of a family or several children in a school are infected at the same time. Bacterial conjunctivitis is more common in children than in adults.

The most common symptoms of bacterial conjunctivitis include redness and a thick discharge from one eye, although both eyes can become infected. The discharge may be white, yellow, or green, and it usually continues to drain throughout the day. The affected eye often is “closed shut” in the mornings.

The treatment of bacterial conjunctivitis may include the application of an antibiotic eye drop or antibiotic ointment several times a day. It is also important to maintain good hand and eye hygiene so that it will not spread to the other eye or to other individuals. Ointments are preferable in children and should be applied in the space between the lower eyelid and the eyeball.

The ocular symptoms usually improve on their own even without treatment, but topical antibiotics can reduce the duration of the illness in some individuals. Vision may be blurred for up to 30 minutes after the application of the ointment as the ointment is thick. Contact lens wearers should avoid using their lenses for a few days.

Allergic conjunctivitis – Allergic conjunctivitis caused by the contact of aeroallergens in the environment with the eyes. The symptoms may include severe itching, redness, watery eyes, and in severe cases, blurring of vision and swelling of the eyelids. These symptoms are made worse by rubbing the eyes, however, allergic conjunctivitis is not contagious.

Allergic conjunctivitis can be “seasonal” (i.e., caused by tree and grass pollens in the Spring and/or weed pollens in the Fall) or “perennial” (i.e., caused by indoor allergens such as dust mites, mold spores and/or animal allergens). The symptoms may also be acute or chronic. Allergic conjunctivitis may also be associated with other atopic conditions such as hay fever (i.e., allergic rhinitis) and/or eczema (i.e., atopic dermatitis).

The treatment of allergic conjunctivitis may include the application of an eye drop containing an antihistamine and/or vasoconstrictor which is usually instilled 2 to 3 times a day for relief of the itching and redness. It should be noted that these drops should not be used for more than 3 to 4 days at a time. Eye drops that have both antihistaminic as well as mast cell stabilizing properties [e.g., Zaditor (ketotifen) Patanol (olopatadine)] may be used for a longer course of treatment, if needed. Very severe symptoms not responding to these agents may require treatment with a corticosteroid eye drop for a few days.

Oral antihistamines [e.g., Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine), Xyzal (levocetirizine)] can help relieve other associated symptoms such as itching and excessive sneezing. Lubricant eye drops are also useful in moisturizing the eyes while simultaneously reducing discomfort due to dry eyes.

Avoiding exposure to the pollen in the Spring and Fall, as well as employing environmental controls in order to minimize exposure to indoor allergens (e.g., dust mites, molds, animals) will help reduce the severity of both allergic conjunctivitis and allergic rhinitis symptoms. It should be pointed out that most patients will experience long-term benefit with allergen desensitization (i.e., allergy shots, allergy injections, allergy hyposensitization) treatments by building up a tolerance to the common allergens. Allergy shots are effective in 80-85% of the patients that take them. The average length of time that an individual is on allergy injections is 3 to 5 years.

Other causes of conjunctivitis may include adverse reactions to medications and preservatives, as well as a foreign body in the eye.

Preventive measures recommended in order to reduce the spread of conjunctivitis include avoidance of sharing handkerchiefs, tissues, towels, pillows, and sheets with uninfected people, as well as using frequent and proper hand-washing techniques and/or using alcohol-based hand rubs.

The board certified allergists at Black & Kletz Allergy have 3 locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. 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 allergy doctors of Black & Kletz Allergy diagnose and treat both adult and pediatric 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 allergic conjunctivitis, hay fever, asthma, sinus disease, eczema, hives, insect sting allergies, immunological disorders, medication allergies, and food allergies for more than 5 decades. If you suffer from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.