Category Archives: UNCATEGORIZED

The Diagnosis and Treatment of Hives

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

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

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

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

Allergies Associated with Acid Reflux Medications

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

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

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

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

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

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

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

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

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

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

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

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

Air Pollution and Allergies

Air PollutionAir pollution is a major problem in many parts of the world particularly in major cities in the U.S. including Washington, DC. Air pollution occurs when excessive amounts of gases and/or particles reach harmful levels. It can occur both outdoors as well as indoors. When it is indoors in the workplace, it is often referred to as “sick building syndrome.” Sick building causes are frequently due to failings in the air conditioning, heating, and/or ventilation systems. Other reasons have been attributed to pollutants produced by volatile organic compounds (VOC’s), molds, outgassing of some types of building materials, ozone, lack of adequate filtration or fresh air, and/or chemicals used within a building.

Outdoor air pollution is caused by a multitude of gases, chemicals, and particulates. Carbon dioxide is a known gas which is usually a result of burning fossil fuels such as gasoline, natural gas, and coal. The carbon dioxide in the air causes heat to be trapped in the earth’s atmosphere which is known as the “greenhouse effect.” Many scientists feel that this greenhouse effect can lead to global warming. Another greenhouse gas is methane, which may come from gas emitted by livestock, landfills, and the natural gas industry. Chlorofluorocarbons (CFC’s) are another type of greenhouse gas. They were used in aerosol propellants and refrigerants until the 1980’s when they were banned because of they contributed to the breaking down of the Earth’s ozone layer. Other causes of outdoor pollution include sulfur dioxide and particulates. It should be noted that sulfur dioxide is a component of smog and is the primary cause of acid rain. Smog is a visible form of air pollution and is composed of sulfur oxides (e.g., sulfur dioxide), ozone, nitrogen oxides, smoke and other particulates. Smog is usually thought of to be a summer phenomenon. During the summer when the temperatures are warmer and there is more sunlight present, a photochemical reaction of sunlight, nitrogen oxides, and volatile organic compounds (VOC’s) occurs which produces ground-level ozone that is visible. It looks like smoke and in fact, the word “smog” is a combination of the two words “smoke” and “fog.”

Similar to how allergy sufferers monitor the pollen count, individuals interested in monitoring air pollution can follow the air quality index (AQI). The higher the AQI number, the greater the level of air pollution, and thus the greater the health concern. The AQI ranges from 0 to 500 whereby levels between 151 and 500 are “unhealthy.” An AQI number between 0 and 100 is considered to be acceptable by the Environmental Protection Agency (EPA). An AQI value between 101 and 150 may be unhealthy for sensitive (e.g., allergy sufferers, asthmatics, people with other lung diseases and/or heart disease, the elderly, children) individuals. An AQI value of over 300 is hazardous to one’s health. The EPA has assigned a color with each designated specific range of the AQI. The level of health concern, AQI values and colors (e.g., green, yellow, orange, red, purple, maroon), and their meaning are as follows:

Air Quality Index
(AQI) Values
Levels of Health Concern Colors
When the AQI is in this range: ..air quality conditions are: …as symbolized by this color:
0 to 50 Good Green
51 to 100 Moderate Yellow
101 to 150 Unhealthy for Sensitive Groups Orange
151 to 200 Unhealthy Red
201 to 300 Very Unhealthy Purple
301 to 500 Hazardous Maroon

Note: Values above 500 are considered Beyond the AQI. Follow recommendations for the Hazardous category. Additional information on reducing exposure to extremely high levels of particle pollution is available here.

Individuals with allergies and asthma are generally more susceptible to the side effects of air pollution. In many cases the particulates, gases, and chemicals can trigger asthma and/or incite nasal and eyes symptoms consistent with allergic rhinitis and allergic conjunctivitis. Others are affected by air pollution as a direct irritant-type nonallergic reaction. The most common symptoms caused by air pollution may include irritated eyes, burning of the eyes, red eyes, watery eyes, runny nose, burning of the nose, sore throat, fatigue, headaches, coughing chest tightness, chest pain, and/or shortness of breath.

There are some preventive measures as well as recommended treatments that should be undertaken when the AQI values rise. In consultation with one of our board certified allergists at Black & Kletz Allergy, we discuss these issues as well as others in order to prevent untoward and unnecessary reactions to all types of pollution.

The allergists at Black & Kletz Allergy have been diagnosing and treating allergies, asthma, sinus conditions, and immunological disorders for more than 50 years. We have been a proponent of a clean environment for a long time and Dr. Kletz has done volunteer work for the American Lung Association. 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 the delivery of the highest quality allergy care in the Washington, DC metropolitan area. In addition, we strive to provide excellent customer service in a friendly and affable environment.

Reactions to Food Additives

More and more natural and artificial chemicals are being added to our food as preservatives, flavor enhancers, and coloring agents.  The U.S. Food and Drug Administration (FDA) lists close to 4,000 substances as food additives.

Despite widespread use of these chemicals in food, adverse reactions are fortunately uncommon.  Most cases are described in the literature as single case reports or reports of a small cluster of patients.


Sulfites:  These chemicals in the gaseous form can cause lung irritation and may trigger asthma in sensitive asthmatics.  They are commonly found in liquid form in processed cold drinks and fruit juice concentrates in order to extend their shelf lives.  Sulfites are also added to most wines and sprayed onto cut foods in order to keep them fresh and prevent discoloration or browning. They are used to preserve smoked and processed meats, dried fruit (e.g., apricots), and salads.  In its solid form, sulfites can cause hives when ingested.

Benzoic acid (i.e., benzoate) and Parabens:  Benzoates and parabens have antibacterial and anti-fungal properties in order to help with the prevention of food spoilage.  These agents are added to pharmaceutical and food products such as drinks (e.g., sugar-free cola). They occur naturally in prunes, cinnamon, tea, and berries.  These substances may cause urticaria (i.e., hives), asthma and angioedema (i.e., swelling) in sensitive individuals.

Antioxidants:  Synthetic phenolic antioxidants [e.g., BHA (butylated hydroxyanisole) and BHT (butylated hydroxytoluene)] are typically added to processed foods such as dry cereals and potato flakes in order to prevent the fats and oils in these foods from turning rancid when exposed to air.  Unfortunately these antioxidants may trigger asthma, rhinitis, and urticarial in some sensitive individuals.

Flavor Enhancers:

Aspartame (e.g., NutraSweet, Equal), a low-calorie sweetener, can occasionally trigger itchy hives and swelling of the body.  It is also important to note that individuals with genetic condition phenylketonuria should avoid aspartame. Aspartame breaks down into an essential amino acid called phenyalanine which is toxic to individuals with phenylketonuria since these patients are unable to metabolize phenyalanine.


Azo dyes [e.g., tartrazine (i.e., yellow dye #5)] and Non-azo dyes (e.g., erythrocine) can trigger hives, asthma, and generalized allergic reactions.

Nitrates and Nitrites give meat a pink color to look more attractive.  These food colorings are typically found in bacon, salami, and frankfurters.

Monosodium Glutamate (MSG) may trigger the “Chinese Restaurant Syndrome” which causes individuals to experience headaches as well as burning and/or tightening of the chest, neck, and face.  MSG may be found in soups, pot noodles, and instant drinks, among other foods.

Naturally Occurring Substances:

Vasoactive amines: Natural histamine, serotonin, and tyramine occur in some ripe cheeses, fish, cured sausage, red wine, chocolate, and pickled vegetables and may induce cramping, flushing, headache, and palpitations in a dose-related manner.  Of note, there is a condition known as “scombroid poisoning” which occurs in individuals who eat spoiled fish. In this condition, there are abnormally high quantities of histamine in the fish due to improper storage or processing.  The typical fish affected may include tuna, mackerel, herring, sardine, anchovy, marlin, and bluefish. The symptoms may include flushing, headache, generalized itching, blurred vision, abdominal cramps, and/or diarrhea. Scombroid poisoning is often wrongly diagnosed as a fish allergy since similar symptoms may be associated with a true fish allergy.  One key factor to look for is to see if other individuals eating the same piece of fish exhibited symptoms. If so, it is more likely to be scombroid poisoning due to eating spoiled fish as opposed to a fish allergy.

Caffeine found in foods, medication, tea, coffee, and carbonated beverages induces dose-dependent agitation, palpitations, nausea, and/or tremors.

Salicylates (i.e., aspirin-like naturally occurring chemicals) may induce urticaria, asthma, and/or nasal polyp growth.  They are found in curry powder, paprika, oranges, apricots, ginger, honey, berries, fruit skins, tea, and almonds.  Salicylate sensitive individuals also tend to have adverse reactions to benzoates and tartrazine.


The precise mechanism how food additives cause reactions is not well understood in many instances.  The IgE antibody, which plays a crucial role in immediate-type (i.e., Type I) allergic reactions to food, is usually not involved in adverse reactions caused by food additives.

Skin prick tests and allergy blood tests are not helpful in identifying the food additive culprit in most cases.  Careful observation and maintaining food and symptom diaries are sometimes useful in narrowing down the offending additive. Oral challenges under close monitoring in controlled environments may be needed to arrive at a specific diagnosis.


Avoidance of the suspected food additive is the only certain way of preventing adverse effects.  One should be vigilant about reading food labels and asking restaurants about ingredients and cooking methods.

If there is a history of anaphylaxis, carrying an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) is extremely helpful in emergency treatment.  It is important to emphasize that if a self-injectable epinephrine device is used, one should go immediately to the closest emergency room.

The board certified allergists at Black & Kletz Allergy have been diagnosing food additive sensitivitis, food allergies, and food intolerances routinely for many years on both adults and children.  Black &Kletz Allergy has 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA which all offer on-site parking.  The Washington, DC and McLean, VA locations are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Please call us to make an appointment or you can click Request an Appointment and we will reply within 24 hours by the next business day.  The allergists of Black & Kletz Allergy are eager to help you with your allergy, asthma, sinus, and immunology needs.  We are dedicated to providing excellent care and service to you as we have been doing in the Washington, DC metro area for more than 5 decades.

Fatigue Can Be Due to Allergies?

In the hectic days we live in, many individuals feel fatigued or exhausted.  Fatigue is a very common symptom that can be either chronic or intermittent. Many people seek help by seeing a physician in order to find out the cause of their fatigue, as there are many potential causes.  Despite the numerous causes of fatigue, underlying allergies is a fairly common reason for fatigue in many individuals.

Usually patients with allergic rhinitis (i.e., hay fever) and allergic conjunctivitis exhibit many of the classic symptoms of allergies which may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy ears, clogged ears, itchy eyes, watery eyes, redness of the eyes, puffy eyes, sinus pressure, and/or sinus headaches.  The typical symptoms in individuals with asthma may include wheezing, chest tightness, shortness of breath, and/or coughing.  It should also be noted that food allergies can cause fatigue in certain individuals in addition to the more typical abdominal symptoms (e.g., abdominal pain, diarrhea), skin symptoms (e.g., hives, itching, swelling), lung symptoms (e.g., wheezing, shortness of breath, coughing), and of course anaphylaxis.  Even though the symptoms listed above are the “more typical” symptoms associated with allergies, asthma, and food allergies one should realize that fatigue is not an uncommon symptom that occurs in allergic individuals. There are in fact people that only complain of fatigue and do not have any of the more typical symptoms of allergies.  You may be asking: How do you know if your fatigue is due to allergies?  It should be noted that there are a whole host of conditions and/or reasons that can cause fatigue.  Likewise, it is important to rule out these “other” causes of fatigue before declaring one’s fatigue is due to allergies.

What are some common causes of fatigue besides allergies?  Here are some of the more common reasons/conditions that may cause fatigue, but keep in mind that there are numerous other conditions or reasons that may cause fatigue that are not listed below:

  • Thyroid disorders (e.g., hypothyroidism)
  • Anemia
  • Sleep apnea
  • Heart disease
  • Lack of sleep
  • Infection (e.g., hepatitis, mononucleosis, urinary tract infection)
  • Diabetes mellitus
  • Autoimmune disorders (e.g., systemic lupus erythematosus, Sjögren’s syndrome)
  • Fibromyalgia
  • Anxiety/Depression
  • Dehydration
  • Chronic obstructive pulmonary disease (COPD)
  • Medication side effects

Fatigue Can Be Due to Allergies?Assuming that there are no other reasons for one’s fatigue, seeing a board certified allergist in the Washington, DC, Northern Virginia, and Maryland metropolitan area is important in order to rule out allergies as a cause.  In fact, even if you have another condition that can cause fatigue, it is still possible that some or all of your fatigue may be coming from allergies.  The board certified allergists at Black & Kletz Allergy are experts in the field and can find out if you have allergies via blood and/or skin testing.  It is first important for the allergist to perform a comprehensive history and physical examination.  Allergy testing is done in order to identify if, what, and how allergic one is to specific allergens. Once an allergy is identified, preventive measures are discussed in order to minimize one’s exposure to the offending allergens.  In addition, the use of allergy medications are usually beneficial in alleviating those unwanted allergy symptoms which also includes fatigue. Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy hyposensitization) may be utilized to treat the underlying allergies as they are very efficacious and are beneficial in 80-85% of individuals who take them.  Most individuals are on allergy shot for 3-5 years.

The allergists at Black & Kletz Allergy see both pediatric and adult patients and have over 50 years 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 have been servicing the greater Washington, DC metropolitan area for over 5 decades and we look forward to providing you with the highest state-of-the-art allergy care in a friendly and comfortable environment.

Nasal Congestion – Do You Have Sinusitis?

If you are like a lot of individuals in the Washington, DC, Northern Virginia, and Maryland metropolitan area, then you may suffer from allergies. There is an old adage that says that if you move to the Washington, DC area and you do not have allergies, you eventually will! This is not true of course, however, many individuals in the area (whether or not they grew up or moved to the Washington, DC area) do in fact have allergies, particularly allergic rhinitis (i.e., hay fever).

The classic symptoms of allergic rhinitis as well as non-allergic rhinitis may include any or all of the following: nasal congestion, runny nose, post-nasal drip, itchy nose, sneezing, itchy throat, itchy eyes, watery eyes, red eyes, puffy eyes, snoring, fatigue, sinus congestion, headaches, and dark circles under the eyes. Allergies commonly trigger asthma as well. Affected individuals may experience chest tightness, wheezing, coughing, and/or shortness of breath.

It should also be noted that allergies increase the risk of sinus disease, sinus infections, and nasal polyps. Sinus infections can be categorized into 3 distinct types: acute, chronic, and recurrent. It is important for the allergist to be able to distinguish between the three, as the treatment is different for each type.
Acute sinusitis: This type of sinus infection is the most common of the three types and often presents with nasal congestion, sinus pressure and/or pain which can radiate to the teeth, discolored nasal discharge, and a post-nasal drip. Occasionally, a fever may be present in some individuals with acute sinusitis. The diagnosis is usually made by a detailed history and a physical examination. Treatment may necessitate the use of antibiotics, nasal corticosteroids, saline irrigation of the nose, and/or decongestants. Rarely, it may be beneficial to use oral corticosteroids is severe cases.

Chronic sinusitis: The common manifestations of a chronic sinus infection generally include nasal congestion, facial pressure/pain, headache, discolored nasal discharge, post-nasal drip, cough, loss of taste and smell, and/or malaise. The diagnosis requires a comprehensive history of onset and progression of specific symptoms, a detailed physical examination, and imaging studies such as CT scans and/or sinus X-rays. The management of chronic sinusitis usually entails a prolonged course (e.g., 30 days) of antibiotics in addition to nasal corticosteroids, saline irrigation of the nose, and/or decongestants. It may be necessary to give another prolonged course of antibiotics in recalcitrant cases. Surgical intervention may also be necessary if medical therapy is unsuccessful. It is important to note that some individuals may only present with chronic nasal congestion as their only symptom.

Recurrent sinusitis: This type of sinus condition is merely repetitive acute sinus infections. Individuals that get repeated episodes of acute sinusitis may have an immune disorder or a weakened immune system. It is thus important to see a board certified allergist/immunologist like the ones at Black & Kletz Allergy. Blood tests to assess a patient’s immune system are often ordered in individuals who suffer from recurrent sinusitis in order to rule out or diagnose an immune defect. Patients who are found to have an immunodeficiency are then treated with appropriate therapy depending upon their specific immune defect. In addition, the sinus infection is treated with antibiotics, topical nasal corticosteroids, saline irrigation of the nose, and/or decongestants.

The prevention of sinusitis includes identification of specific allergen sensitivities by allergy testing by a board certified allergist. Allergy testing may be done by skin testing or blood testing depending upon the circumstance and age of the patient. The aggressive treatment of allergic seasonal and/or perennial rhinitis (i.e., hay fever) promotes proper sinus drainage and improves upper airway function.

Therapies used to treat allergic rhinitis may include antihistamines, nasal corticosteroids, nasal antihistamines, saline irrigation of the nose, decongestants, leukotriene antagonists, and/or allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization). Allergy shots are effective in 80-85% of patients who take them. They have been used in the U.S. for more than 100 years and are used in both children and adults.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating sinusitis for more than 50 years. We treat both adult and pediatric 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. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from allergies and/or sinus-related symptoms, we are here to help alleviate or hopefully end these undesirable symptoms that have been so troublesome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

Chronic Cough

Coughing is a protective “reflex” given to us by nature as part of our body’s vital defense mechanisms.  It forcibly expels harmful bacteria, viruses, foreign objects, and excessive mucus from the respiratory tract protecting our lungs from irritation, inflammation, and infections.


There are 4 stages in a cough reflex:

  1. An initial deep inspiration filling the lungs with air.
  2. Closure of epiglottis [the flap over the opening of the windpipe (i.e., trachea)].
  3. Forcible contraction of the muscles of the chest and abdomen which pushes up the diaphragm causing compression of the lungs.
  4. As the pressure builds up, the epiglottis is forced open allowing the air to rush out at a high speed producing a whooping noise.

Coughing can be a voluntary act, conscious action, or more commonly an involuntary uncontrollable process.  The reflex is initiated by stimulation of the nerve fibers in the respiratory tract by various substances such as smoke, cold air, allergens, microbes, and tumors, as well as from irritation by normal secretions such as mucus and/or stomach acid.

All of us cough from time to time.  It is very common during colds (i.e., upper respiratory infections), which are usually viral in nature.  Coughing also is common during acute bronchitis and pneumonia (i.e., lower respiratory infections involving mainly the lungs).  It should be noted that following infections, a cough may linger for a few weeks before it subsides.

A cough that lasts for months (and sometimes years) is described as “chronic” and is one of the most common reasons why healthcare providers are consulted.  A cough may interrupt sleep resulting in daytime somnolence and affect school and work performance. Vigorous coughing may also cause physical effects such as urinary incontinence and rib fractures.


  1. Smoking:  Most cigarette smokers eventually develop a “smoker’s cough”. Irritation by noxious chemicals is the predominant cause.  Smoke also plays a significant role in causing chronic bronchitis, emphysema, and lung cancer.
  2. Post-nasal Drip:  In addition to aiding in the perception of smell, the nose also protects the lungs by filtering, warming, and humidifying the air entering the lower respiratory tract.  It accomplishes this by secreting warm, moist, and sticky mucus. When the nose is irritated by chemicals, allergens, microbial organisms, etc., it secretes excessive mucus which is usually thin and watery.  When these copious secretions run down the back of the throat, they irritate the nerves in that area, cause a tickling sensation which may trigger a cough reflex. A post-nasal drip can often be controlled by avoiding exposure to known triggers and stimuli.  Medications such as antihistamines, decongestants, and nasal sprays may help relieve the cough caused by a postnasal drip. Home remedies such as steam inhalation and saline nasal irrigation also may play a role in treatment.
  3. Asthma:  Chest tightness, wheezing, and shortness of breath usually accompany cough in individuals with asthma.  However, in a variant of this condition, a cough may be the only presenting manifestation.  This is called cough variant asthma. The diagnosis is established by pulmonary function testing (sometimes after inhalation of a chemical (e.g., methacholine) that can trigger symptoms which can then be relieved by a medication that opens up the airways).  Occasionally, a therapeutic trial of anti-inflammatory inhaled medications (i.e., inhaled corticosteroids) on a regular basis for a few weeks is helpful in arriving at the diagnosis.
  4. Gastroesophageal Reflux Disease (GERD):  When stomach acid travels up the food pipe (i.e., esophagus), it usually causes heartburn, belching, sore throat, and/or hoarseness.  However, in one third of patients it manifests only as a chronic cough without the other symptoms. Confirmation of the diagnosis is established by placing a probe in the esophagus and monitoring the pH for acidity for 24 hours.  A simpler approach is to empirically treat the individual with lifestyle modifications (e.g., avoiding alcohol, spicy foods, citrus fruits, bulky meals, and carbonated beverages). If the symptoms persist, medications to neutralize the acid and/or reduce acid secretion may be utilized.
  5. Chronic Bronchitis:  Prolonged inflammation of the tissues in the lungs from chemical irritants and pollutants can cause a chronic cough.  Imaging studies are sometimes needed to rule out anatomical and structural abnormalities. Some patients may need long term anti-inflammatory inhaled medications (e.g., inhaled corticosteroids) to control a chronic cough.
  6. ACE inhibitors:  These medications [e.g., lisinopril (Prinivil), enalapril (Vasotec), benazepril (Lotensin), quinapril (Accupril), ramipril (Altace)] are often used to treat high blood pressure and/or heart failure.  Up to 20% of people receiving these medications may develop a cough after a few weeks, which is a known side effect of these types of medications. They may need to discontinue these medications and begin taking an alternative medication in order to get relief from their cough.
  7. Heart Disease:  Congestive heart failure can cause either a dry cough or a productive cough associated with a frothy, thin, white sputum.  Leg swelling (i.e., edema), fatigue, and exercise intolerance are other common symptoms of congestive heart failure.
  8. Aspiration:  When food finds its way into windpipe (i.e., trachea) instead of food pipe (i.e., esophagus), it triggers a recurrent cough.  This is more common in patients with strokes and other chronic neurological disorders.
  9. Lung Cancer:  It is a rare cause of chronic cough in non-smokers, and more common in smokers.
  10.  Stress:  “Psychogenic” coughing increases at times of stress and usually disappears or diminishes during sleep.
  11.  Chronic sinusitis:  It is fairly common for individuals with a chronic sinus infection (i.e., chronic sinusitis) to experience a chronic cough.  In some cases, it is the only symptom of their sinus condition.  In others, it may be accompanied by symptoms such as nasal congestion, decreased ability to smell and/or taste, post-nasal drip, discolored nasal discharge, sinus pressure, and/or sinus headaches.

Cough Medications

  1. Dextromethorphan is a commonly used, partially effective cough suppressant.  Prescription medications containing codeine and its derivatives are more effective but have more undesirable side effects and may be habit-forming.
  2. Guaifenesin is the most commonly used expectorant which may be useful in thinning out viscous secretions which ultimately help the mucus drain more easily.

Warning Signs:  One should consult his or her physician as soon as possible if one experiences any of the following symptoms:  bloody sputum, fever, weight loss, night sweats, breathlessness, excessive fatigue, and/or chest pain.

The board certified allergy doctors at Black & Kletz Allergy have a great deal of experience in diagnosing and treating both adults and children with a chronic cough.  It is important to find the underlying reason for a cough in order to treat it appropriately.  At Black & Kletz Allergy, we search for a cause beginning with a comprehensive history and physical examination.  Breathing tests, X-rays, blood tests, and/or allergy skin tests may be performed depending upon each individual’s history and physical, as it is tailored to each person’s own situation.

The allergists at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Our 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 one of our offices or alternatively, 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 care in a welcoming and professional environment.

Non-Allergic Rhinitis

Non-Allergic RhinitisSymptoms such as nasal congestion, clear runny nose, and itchy throat are most commonly due to sensitivity to common “allergens” in the environment (e.g., pollens, dust mites, mold spores, animals).  Our immune system mistakes them as potentially harmful and thus mounts a defensive attack on these substances when it encounters them.  During this process, there is a release of chemical substances (e.g., histamine, prostaglandins, leukotrienes) into the tissues inside the nose and eyes and these chemicals are responsible for the symptoms of allergies.

The symptoms may be relieved with medications that block the actions of these chemicals which can be utilized to make allergic individuals more comfortable.  The symptoms may also be prevented either by avoiding the exposure to the allergens, by environmental controls, or by getting desensitized to the allergens by allergy immunotherapy (allergy shots, allergy injections, allergy desensitization, allergy hyposensitization).  Sensitizing allergens can vary from person to person and allergy tests obtained by skin or blood testing are needed to identify the offending allergen in order to consider specific environmental controls and/or desensitizing treatments.

What if one has all the symptoms suggestive of “allergies” but all the tests are negative?  You may have a condition called vasomotor rhinitis or more appropriately called non-allergic rhinitis.

The symptoms of non-allergic rhinitis may include:

  • Nasal congestion
  • Runny nose
  • Sneezing
  • Mucus (i.e., phlegm) in the throat (e.g. post-nasal drip)
  • Cough

These symptoms can be long term or may last only a short period of time.  They can come and go all year-round.  Itching of the nose, eyes, and/or throat are not present in non-allergic rhinitis as they are more likely to be features of allergic rhinitis (i.e., hay fever).

The exact cause of non-allergic rhinitis is not known.  The effect is widening of the blood vessels inside the nostrils and leakage of fluids into the tissues resulting in excessive mucus and swelling of the mucus membrane linings and nasal turbinates.

The common triggers of non-allergic rhinitis are:

  • Environmental or occupational irritants: Dust, smoke, pollutants, strong odors, perfumes, colognes, potpourri, chemical sprays, fumes, etc.
  • Weather changes: Fluctuations in temperature and humidity.
  • Food: Hot and spicy foods, certain alcoholic beverages.
  • Infections: Viral infections such as the common cold or influenza (i.e., the flu)
  • Medications: Aspirin, Ibuprofen, certain blood pressure medications (e.g., beta-blockers ACE inhibitors), sedatives, antidepressants, and oral contraceptives.
  • Rhinitis medicamentosa: Prolonged and/or overuse of over-the-counter decongestant nasal sprays (e.g., Afrin, Neosynephrine) can cause rebound congestion and habituation.
  • Hormonal changes: Pregnancy, menstruation, and hypothyroidism.
  • Stress: Emotional or physical stress.
  • Other triggers: Sleeping posture, sleep apnea, acid reflux, etc.


  • Nasal polyps: These are soft, benign growths that develop on the lining of the nose or sinuses due to chronic inflammation.  Small polyps may not cause problems, but larger ones may block the airflow through the nose, making it difficult to breathe.  They also increase the likelihood of recurrent sinus infections.
  • Sinusitis: Prolonged nasal congestion due to non-allergic rhinitis may increase the chances of developing sinusitis, an infection or inflammation of the membranes that line the sinuses.
  • Middle ear infections: Increased fluid and nasal congestion may lead to middle ear infections.
  • Interrupted daily activities: Non-allergic rhinitis may affect focus and concentration and in turn impact learning at school and/or productivity at work.

The diagnosis is established when one presents with the classic symptoms of rhinitis and when the skin tests and/or blood tests fail to identify specific environmental sensitivities.  Common infections of the nose and sinuses also need to be ruled out by examination and imaging tests. There are no confirmatory tests for non-allergic rhinitis and it is usually an exclusion diagnosis.


Avoidance of the common triggers is the first step in the management of non-allergic rhinitis.  When avoidance is not possible or when it does not work, the following actions may be helpful.

  • An over-the-counter nasal saline spray or homemade salt water solution to flush the nose of irritants and help thin the mucus and soothe the membranes inside the nose.
  • Corticosteroid nasal sprays (e.g., fluticasone, triamcinolone, budesonide) may help reduce the congestion due to their anti-inflammatory effect by shrinking the swelling and reducing excessive mucus production.
  • Antihistamine nasal sprays (e.g., azelastine, olopatadine) are more helpful than oral antihistamines in relieving the symptoms of non-allergic rhinitis.
  • Anticholinergic nasal sprays (e.g., ipratropium bromide) can help to dry up the excessive nasal secretions and relieve runny nose and post nasal drip.
  • Oral decongestants (e.g., pseudoephedrine, phenylephrine) can help relieve nasal stuffiness by shrinking the blood vessels and reducing mucus buildup. Side effects of these medications however may include elevated blood pressure, rapid pulse, restlessness, sleep disturbances, palpitations, and/or tremors.


A recent small study showed that eating oily fish (e.g., herring, mackerel, salmon) at least once a week may reduce the risk of rhinitis.  However more studies are needed to confirm this finding.

The board certified allergists 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 allergy specialists at Black & Kletz Allergy are extremely knowledgeable regarding non-allergic rhinitis as well as allergic rhinitis.  We diagnose and treat both pediatric and adult patients.  In addition, we treat patients with food, medication, insect sting, and skin allergies, asthma, eosinophilic esophagitis, sinus disease, and immunological disorders.  To schedule an appointment, please call any of our offices or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years and we look forward to providing you with comprehensive state-of the-art allergy care in a friendly and professional environment.