Erythema Multiforme

July 8, 2025 | Black & Kletz Allergy

Erythema Multiforme is a type of a rash on the skin, usually triggered by an infection or an adverse effect of a medication.  The condition gets its name from the appearance of reddish skin lesions of various forms seen at the same time. Erythema multiforme affects less than 1% of the population.  It is most common in young adults (aged 20 - 40 years) with a modest predominance in males.  Some people are genetically predisposed to develop erythema multiforme. Causes:

• Infections - Herpes simplex virus (most common), mycoplasma, cytomegalovirus, Epstein-Barr virus, influenza virus, coronavirus, etc.
• Medications - Antibiotics (e.g., sulfonamides, tetracyclines, erythromycin), aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen), anti-seizure medications, and vaccines.
• Systemic disorders - Inflammatory bowel disease, hepatitis, lymphoma, leukemia, and solid organ tumors.

Diagnosis:

• After exposure to the trigger, there is usually a prodromal period when the individual may experience mild fever, cold like symptoms, sore throat, headache, fatigue, and/or achiness.
• A few days later, the typical skin lesions will erupt.  These lesions may be in the form of red papules (i.e., small raised bumps), vesicles (i.e., blisters filled with clear fluid), ulcers (i.e., skin sores), etc.
• Characteristic lesions are ‘bulls-eye’ target lesions with a central dusky area, surrounded by a pale edematous area and a peripheral reddish ring, demarcating it from the surrounding normal skin.
• Atypical lesions are raised with poorly defined borders and/or fewer zones of color variation.
• Several lesions in different developmental stages may be seen at the same time.
• The skin lesions are usually symmetrical, begin at the periphery and spread centrally.  The skin lesions usually have a predilection to extensor surfaces (i.e., outer side of the limbs)
• Skin lesions may be very itchy, painful, and/or swollen.
• Confirmation of the diagnosis may require a skin biopsy.
• Tests for infections, especially herpes simplex virus, are needed.

Types:

1. Erythema multiforme minor - Mild form of the illness that only affects the skin and causes a rash.
2. Erythema multiforme major - Most severe form of the condition which may be life-threatening because it causes large areas of the skin to blister and peel.  This type affects the mucus membranes in the mouth, eyes, and genitals.  Individuals usually have systemic symptoms such as fevers and/or joint pain.

Erythema multiforme is not contagious.  The lesions, blisters, or rash on the skin cannot spread from person to person.  The viruses and other agents that caused the infection, however, can spread from one person to another. Treatment:

• Most cases of erythema multiforme are mild and self-limiting and usually resolve spontaneously after a few days or weeks.
• Antihistamines and topical corticosteroid medications are helpful in relieving the itching and discomfort associated with more severe skin lesions.
• Antiseptic and local anesthetic mouthwashes may help relieve the pain and irritation associated with mucus membrane lesions inside the mouth.
• Antihistamine or anti-inflammatory eye drops can treat redness, burning, and/or excessive tearing of the eyes.
• Proper care of skin lesions such as avoidance of scratching will help prevent the spread of infections.
• Most severe cases may need a course of systemic corticosteroids such as oral prednisone.
• Recurrent cases are usually treated with 6 months or more of continuous oral antiviral medications such as acyclovir.

Prevention:

• General hand and respiratory hygiene is important in order to reduce the risk of contracting viral and bacterial infections.
• Avoiding medications that had previously caused adverse reactions in the past.

Prurigo Nodularis

June 27, 2025 | Black & Kletz Allergy

Prurigo nodularis is a chronic inflammatory skin disease where an extremely itchy rash in the form of firm bumps called nodules appears most commonly on the arms, legs, upper back, and/or abdomen.  The rash is usually symmetrically distributed on both sides of the body.  The itchiness, burning, and stinging sensation associated with prurigo nodularis is so severe that it often interferes with sleep and one’s psychological well-being. The exact cause of prurigo nodularis is unknown, but altered function of the immune system and nerves in the skin is believed to be associated with heightened sensations of itchiness (i.e., pruritus) that leads to frequent scratching.  Frequent scratching and picking of the skin are also thought to contribute to further lesion formation and thickening seen in the disease. Prurigo nodularis can occur at any age but is more common in the elderly. When it occurs in younger patients, it is more likely to be associated with inflammatory skin diseases, usually eczema (i.e., atopic dermatitis).  Prurogo nodularis is also more likely to manifest in patients with other underlying medical conditions that affect multiple body systems, such as cancer, diabetes, chronic kidney disease, and HIV infection.  Prurigo nodularis is not hereditary or contagious. The rash and itching can be episodic or continuous, lasting for several months in some individuals.  It is typically worsened by sweat, heat, synthetic clothing, and/or stress.  The rash can range in severity from just a few to several hundred lesions.  The lesions can range in size from 0.2 inches to 0.8 inches wide and can appear as firm, dome-shaped papules, nodules, or plaques.  Lesions can be flesh-colored, pink, red, brown, or black in color. Diagnosis:

• The characteristic appearance and distribution of the lesions, the chronicity, and association with other systemic disorders provide clues to the diagnosis of prurigo nodularis.
• The confirmation of the diagnosis is established by biopsy of the skin lesions and examination of them under a microscope.  It usually reveals thickening of different areas of the outermost layer of the skin (i.e., epidermis) with distinct changes (i.e., hyperkeratosis) to the skin protein keratin.  The layer below the epidermis, referred to as the dermis, shows an increase in several inflammatory white blood cell types.
• Blood tests including a complete blood cell count (CBC), a comprehensive metabolic panel (CMP) that includes liver and kidney function tests, and a thyroid hormone panel may be beneficial for diagnosing an underlying systemic disease that may be contributing to the prurigo nodularis.

• Behavioral treatments for prurigo nodularis include ways to prevent scratching and dryness, such as keeping fingernails short, wearing long sleeves, wearing gloves, bandaging lesions, cleaning skin with gentle cleansers, keeping skin moisturized with non-irritating lotions, and avoiding warm environments to reduce sweating. Recommended anti-itch lotions include calamine, menthol, and camphor lotions.
• Moisturizers such as petroleum jelly, fragrance-free and ceramide-rich creams or ointments, and fragrance-free oatmeal or hyaluronic acid creams.
• Second generation oral antihistamines such as Zyrtec, Xyzal, Allegra, Claritin, or Clarinex taken on a regular basis.  Many patients need 2 to 3 times the regular daily dose to get adequate relief from the severe itching and/or burning sensation that can be present in some individuals.
• Some patients respond better to first generation sedating antihistamines such as Palgic, Periactin, Atarax, or Benadryl.
• Topical medications such as corticosteroids (e.g., triamcinolone, fluocinonide, betamethasone, mometasone, clobetasol, fluticasone, desoxymetasone), calcineurin inhibitors (e.g., pimecrolimus, tacrolimus), capsaicin (the spicy ingredient in chili peppers), and vitamin D.
• Phototherapy:  Exposing affected areas of the skin to specific wavelengths of ultraviolet (UV) light may help reduce the itchiness and inflammation of the skin.
• In 2022, dupilumab (i.e., Dupixent), an interleukin-4 receptor alpha antagonist, was approved by the U.S. Food and Drug Administration (FDA) to treat adults with prurigo nodularis.  It is a subcutaneous (SQ) injection which can be self-administered under the skin every 2 weeks.
• In 2024, nemolizumab (i.e., Nemluvio), an interleukin-31 receptor antagonist, was approved by the FDA to treat adults with prurigo nodularis.  It is a subcutaneous (SQ) injection administered every 4 weeks.
• Immunosuppressants such as cyclosporin, azathioprine, and methotrexate are reserved for the most resistant cases of prurigo nodularis because they affect more body systems and can have more serious side effects.

Summer Outdoor Allergies

June 16, 2025 | Black & Kletz Allergy

Histamine Intolerance

May 28, 2025 | Black & Kletz Allergy

Histamine is a biogenic amine (i.e., an organic compound made up of carbon and nitrogen bonds) with several biological effects across different types of cells, mediated through the activation of histamine receptors.  Histamine is normally present within mast cells and other similar cell types such as basophils.  Mast cells are cells of the connective tissue that contain many granules rich in histamine and other chemicals.  Histamine is also present in various types of food, such as cheese, fermented foods, wine, spinach, some types of fish and meats. During an allergic reaction, the mast cells are triggered to release their “granules” which contain histamine and other active substances (e.g., leukotrienes, prostaglandins) into the bloodstream. It is these substances that are responsible for causing allergic symptoms which vary depending on the organ and the sensitivity of the allergic individual. H1 (histamine 1) receptors are predominantly present in the skin and mucous membranes.  When these receptors are activated by histamine, they result in allergic symptoms such as itching (i.e., pruritus), rashes, flushing, hives (i.e., urticaria), and/or soft tissue swellings (i.e., angioedema).  Stimulation of the H1 receptors in the mucous membranes by histamine causes allergic symptoms such as sneezing spells, nasal congestion, runny nose, post-nasal drip, itchy throat, sinus congestion, headaches, itchy eyes, watery eyes, and/or redness of the eyes. Allergies and excessive histamine release also play a role in asthma symptoms such as chest tightness, coughing,  wheezing, and/or shortness of breath.  In addition to stimulating H1 receptors, histamine also stimulates H2 receptors in the stomach and thus plays a role in acid production and digestion.  Excessive levels of histamine can lead to the overproduction of stomach acid and as a result, in can cause heartburn and other gastroesophageal reflux disease (GERD) symptoms. Histamine intolerance occurs when the body’s capacity to eliminate histamine is exceeded by the rate of histamine accumulation.  In healthy individuals, the enzyme called intestinal diamine oxidase (DAO) helps eliminate histamine that was consumed from food.  When the activity of DAO is inhibited by certain factors, the body’s ability to manage histamine is significantly affected.  Genetic mutations causing the decreased expression of the DAO enzyme and some medications are 2 factors that can reduce the effectiveness of DAO.  As a result of these factors (i.e., genetic mutations, medications), an accumulation of histamine may occur which cause symptoms that can mimic true allergic reactions.  Some examples of drugs that have been found to affect DAO’s activity include verapamil, clavulanic acid, and isoniazid, among others.  Certain mineral and vitamin deficiencies (e.g., vitamin C, copper) are also known to decrease DAO activity.  Alcohol, on the other hand, has been found to increase the release of endogenous histamine, affecting the rate of its degradation. Symptoms:  The symptoms of histamine intolerance are varied and may involve different systems of the body.

• Skin:  pruritus, flushing, urticaria, dermatitis, and/or swelling.
• Gastrointestinal: abdominal bloating, abdominal discomfort, gas, diarrhea and/or constipation
• Respiratory:  runny nose, nasal congestion, post-nasal drip, itchy throat, sneezing, sinus congestion, chest tightness, coughing, wheezing, and/or shortness of breath
• Cardiovascular:  cardiac rhythm disturbances and/or blood pressure variations
• Neurological:  headaches

Diagnosis: There are no standardized tests to confirm the diagnosis of histamine intolerance.  The normal levels of DAO in the serum (i.e., blood) and the diagnostic levels for histamine intolerance have not been established. High DAO levels may exclude histamine intolerance, whereas low levels are quite common and not diagnostic of histamine intolerance. At this time, in the absence of clear diagnostic guidelines, the diagnosis rests primarily on clinical manifestations and therapeutic trials. Treatment:

1. Restrict foods that contain high levels of histamine (e.g., seafood, fermented soybean products, aged cheese, avocado, chocolate, nuts, milk, legumes, certain fruits such as bananas).  Instead, substitute histamine-rich foods with foods that are low in histamine (e.g., water, fresh juices, herbal teas, bread, rice, eggs, honey).
2. Keep a food and symptom diary for 4 to 6 weeks and eliminate the suspected foods for 4 to 6 weeks and gradually reintroduce them while closely monitoring the symptoms.
3. Empirical trials with antihistamine drugs, though there are no randomized trials to prove the value of this treatment in addressing histamine intolerance.
4. Mast cell stabilizer medications such as cromolyn and ketotifen may be helpful in selective cases.
5. The approach of supplementation with over-the-counter DAO enzyme in order to reduce excessive levels of histamine in the serum is controversial and there are no standardized guidelines available regarding the dosage.
6. Supplementing with minerals and vitamins such as copper, zinc, vitamin C, and/or vitamin B6 in the case of a known deficiency, malnutrition, or restrictive diet, may be beneficial, if approved by one’s physician.

Note:  The American Academy of Allergy, Asthma and Immunology does not currently recognize histamine intolerance as a condition.  Before implementing any of the above “treatments,” one’s symptoms should be discussed with one’s allergist or primary care physician.  The treatment recommendations listed above should only be adhered to if one’s doctor agrees with them in that specific individual’s situation. If you suffer from symptoms of histamine intolerance or any other food or environmental allergies, please call us in order to schedule an appointment with one of our board-certified allergy doctors at Black & Kletz Allergy.  You may also click Request an Appointment and we will respond within 24 hours by the next business day.  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 pediatric and adult patients.  The allergy specialists at Black & Kletz Allergy have been helping the residents and visitors of the Washington, DC, Northern Virginia, Maryland metropolitan area for more than 50 years and are pleased to help you improve the quality of your life by alleviating those unwanted and annoying allergy and asthma symptoms.

Allergies to Pollen

May 23, 2025 | Black & Kletz Allergy

Individuals with pollen allergies may be affected throughout the year, depending on where they live or travel.  In the Washington, DC, Northern Virginia, and Maryland metropolitan area, pollen allergies are bothersome to allergic individuals generally from late February through the first frost, which is usually at the end of October.  In this region, trees are the first to pollinate, generally releasing tree pollen from the end of February through the end of May.  The pollen peaks in April and is recognized by everyone when their cars appear “yellow” in color.  The yellowish color of the cars is due to the yellow-colored tree pollen falling on and sticking to all of the motor vehicles that dominate the Washington, DC metro area.  Grass pollen is released after tree pollen, usually beginning in early May and continuing until the end of the Summer.  Lastly, ragweed begins to pollinate in mid-August and it lasts until the first frost, which as mentioned above, ends in late October. It is interesting to note that a short time after the trees begin to pollinate, the cherry trees begin to flower.  People both familiar and unfamiliar with allergies often misassociate the two events and wrongly conclude that the cherry trees are causing their allergies because of the timing of the two events.  Notwithstanding, the media tends to get it wrong, as they tend to associate the two occurrences, which further confuses the issue.  The truth is that the flowering cherry trees are not causing the hay fever (i.e., allergic rhinitis) and/or the eye allergies (allergic conjunctivitis) symptoms that the allergy sufferers are feeling, but rather it is the non-flowering trees that are the culprit.  In general, flowering trees and bushes do not generally cause allergy symptoms.  Individuals who have allergy symptoms from tree pollen need to inhale the pollen in order to develop the usual symptoms of allergic rhinitis.  The pollen of flowering trees and bushes is heavy compared with non-flowering trees and is not wind-dispersed as a result.  The pollen of non-flowering trees and bushes, on the other hand, is light in weight and thus easily dispersed by the wind.  As a result, the pollen from the non-flowering trees (“ugly trees”) and bushes (“ugly bushes”) are the pollen that individuals become sensitized to and thus allergic to due to the fact that they are breathing in this pollen causing the immune system to be affected.  In certain individuals, the immune system decides that it doesn’t like the tree pollen allergens and mounts a defensive response.  This allergic reaction involves the production on inflammatory mediators and chemicals.  These chemicals (e.g., histamine, leukotrienes, prostaglandins), which are released into the bloodstream, cause the annoying symptoms that allergic individuals dread every pollen season. The classic symptoms experienced by most people afflicted with allergic rhinitis or hay fever may include sneezing, itchy nose, itchy throat, nasal congestion, runny nose, post-nasal drip, itchy eyes, watery eyes, redness of the eyes, itchy ears, clogged ears, sinus pressure, fatigue, headaches, snoring, coughing, chest tightness, wheezing, and/or shortness of breath. The diagnosis of pollen allergies begins with a comprehensive history and physical examination.  In the history, it is important for the allergist to ascertain if the patient experiences hay fever symptoms or worsening hay fever symptoms in the months where pollination takes place, mostly in the Spring and/or Fall.  The next step is usually allergy skin testing (or blood testing) to environmental allergens in order to see if the individual is allergic and to what extent. Avoidance measures are usually the first things recommended to a person with pollen allergies, assuming that individual wants or is able to avoid pollen.  Many things can be done, but it is up to the patient to follow the recommendations by the allergist.  Some of these preventive measures are as follows: 1.     Turn on air conditioning. 2.     Change air filters often (i.e., monthly). 3.     Wash pets after they go outdoors. 4.     Avoid mowing lawns and yard work or wear a filtered mask. 5.     Shower, wash hair, and change clothing after coming back indoors. 6.     Drive a car that has an air filter. 7.     Re-circulate air in car so it doesn’t come in from the outdoors. 8.     Keep sunroofs and windows closed in your vehicle. The treatment of patients who have pollen allergies depends on the duration and the severity of symptoms.  Oral antihistamines are usually the first line of defense.  In individuals who need more intensive treatment, oral decongestants, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, nasal mast cell stabilizers, nasal decongestants, and oral leukotriene antagonists may be utilized.  In patients exhibiting ocular symptoms, eye drops containing antihistamines, leukotriene antagonists, and/or mast cell stabilizers are available.  Asthmatic patients may also be treated with inhaled bronchodilators, inhaled corticosteroids, inhaled anticholinergics, and biologicals.  Allergy injections (i.e., allergy shots, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are very efficacious as they help in 80-85% of individuals with allergic rhinitis, allergic conjunctivitis, and/or asthma.  The average patient is on allergy injections for 3-5 years. Pollen season is upon us and the Spring pollen is blanketing the landscape in the Washington, DC metropolitan area.  The board certified allergy doctors at Black & Kletz Allergy have 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  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.  Our allergists at Black & Kletz Allergy have been helping patients with hay fever, eye allergies, asthma, sinus disease, generalized itching (pruritus), hives (i.e., urticaria), eczema (i.e., atopic dermatitis), anaphylaxis, medication allergies, food allergies, insect sting allergies, and immunological disorders for more than 5 decades.  If you suffer from allergies, it is our goal to improve your quality of life by decreasing or stopping your undesirable allergy symptoms.

Is Primatene Mist Good for Asthma?

April 15, 2025 | Black & Kletz Allergy

There are a few over-the-counter (OTC) medications that some patients with asthma and other respiratory conditions occasionally use. One of them is an inhaler called Primatene Mist. Primatene Mist contains epinephrine (i.e., adrenaline) in an inhalable form. Though it is the same drug that is in an EpiPen, Auvi-Q, Adrenaclick, and other self-injectable epinephrine devices as well as the nasal spray, Neffy, used to treat acute allergic emergencies such as anaphylaxis, Primatene Mist does not help in those situations and should not be used. Although Primatene Mist became available in 1967, the FDA took it off the market in 2011, as it contained propellants called chlorofluorocarbons (CFC’s) which are harmful to the environment as they deplete ozone from the atmosphere. However, Primatene mist was recently reintroduced into the market with a newer propellant called hydrofluoroalkanes (HFA’s), which are environment friendly. Primatene Mist temporarily opens up the airways in the lungs thus offering a very short-term relief from shortness of breath and/or wheezing. It is approved only for individuals with an established prior diagnosis of asthma. It is used for the temporary relief of mild symptoms of intermittent asthma in patients aged 12 years or older and should not be used as a replacement for prescription asthma medications. Primatene Mist can do more harm than good if used for a chronic cough, for instance, without a known cause. The risks of Primatene Mist usage include masking of the symptoms without addressing the underlying cause. The symptoms of chest tightness, wheezing, cough, and/or shortness of breath should lead to the proper evaluation in order to establish the reason behind the symptoms. In cases of asthma, the underlying cause could be long-standing inflammation of the lungs. Proper evaluation and management should include the assessment of the lung function in addition to trying to control the causative factors. Uncontrolled inflammation can result in damage to the lung tissues and a reduction in lung capacity over time, which can be irreversible. Several deaths are reported each year in the USA due to uncontrolled asthma. Deaths also occur in cases of mild asthma with acute exacerbations. Primatene Mist is also associated with undesirable side effects such as palpitations, increase in blood pressure, nervousness, etc. In the elderly and in individuals with certain conditions such as heart problems, Primatene Mist may be harmful as epinephrine may worsen their underlying conditions. There is also concern for misuse or abuse. Primatene Mist may make the individual feel better temporarily when in fact the underlying reason for the exacerbation of the asthma goes unchecked, leading to a worse outcome overall because the individual did not seek the proper care. Albuterol, a prescribed alternative medication, is typically used for the quick relief of asthma symptoms. It is a bronchodilator which acts by relaxing the muscles around the airways so that they can open up better making it easier to breath. Primatene Mist is less potent and has a much shorter duration of action than albuterol, and thus not preferred. Primatene Mist is not recommended for severe asthma or as a long-term treatment. It should not be used in children under the age of 12 years old. There is a defined role for albuterol in relieving symptoms while also controls the underlying cause(s) with anti-inflammatory medications. In fact, there is an albuterol inhaler that has a corticosteroid added to it in order to give the medication an anti-inflammatory benefit when treating the symptoms of asthma. This medication is called AirSupra and it contains both albuterol and the corticosteroid called budesonide. It should also be noted that the national and international guidelines by organizations such as the National Institutes of Health (NIH) and the Global Initiative for Asthma (GINA) do not recommend using Primatene Mist. The board certified allergists at Black & Kletz Allergy are always available for our patients to ask any questions that they may have regarding asthma or allergies. We have been treating adult and pediatric patients with asthma for more than 50 years. In addition, we diagnose and treat individuals with allergic rhinitis (i.e., hay fever), allergic skin conditions such as urticaria (i.e., hives) and atopic dermatitis (i.e., eczema), eosinophilic disorders, insect sting allergies, medication allergies, and immune disorders. 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. All of our offices offer on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. If you would like to be evaluated today for asthma or any other allergic or immunologic problem, please call us today. You may also click Request an Appointment instead and we will respond to your request within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy pride themselves in providing the highest quality asthma and allergy care in the Washington, DC metro area.

Pollen Food Allergy Syndrome Revisited

April 10, 2025 | Black & Kletz Allergy

Tree Pollen Allergies Update in the Washington, DC Area

March 25, 2025 | Black & Kletz Allergy

Spring is here!  This means that quite a few Washingtonians will be pretty miserable as they will be suffering from hay fever (i.e., allergic rhinitis).  In the early Spring, tree pollen is mostly to blame for the annoying symptoms that cause hay fever.  Other than tree pollen, molds are also a common environmental allergen that plays havoc with allergy sufferers.  It should be noted that tree pollen can exacerbate asthma as well as cause allergic eye symptoms (i.e., allergic conjunctivitis). In the Washington, DC, Northern Virginia, and Maryland metropolitan area, trees typically begin to pollinate at the end of February, peak in mid- to late-April and continue to pollinate through late May and occasionally through early June.  The first trees to pollinate in the Washington, DC metro area cedar, birch, maple, poplar, elm, and alder.  Later in the Spring season, the principal tree that causes difficulties for people with tree pollen allergies is the oak tree.  In addition to oak tree, however, other tress that pollinate during the same time as oak trees include hickory, walnut, and pine trees. Tree pollen, as well as other pollens (e.g., grasses, weeds), pollinates by releasing its pollen into the air.  In general, most non-flowering trees have pollen that is light in weight.  When the pollen in released into the air, it is carried by the wind and the pollen grains land on other trees.  It is this cross-pollination that allows trees to reproduce.  Although it is good for the trees, it is not so good for allergy patients.  If outdoors when tree pollination takes place, a tree-sensitive individual will breathe in the pollen-infested air which will cause that person to exhibit allergic rhinitis symptoms. The symptoms of tree pollen allergy may include sneezing, runny nose, nasal congestion, post-nasal drip (which may cause a sore throat or cough), itchy throat, itchy nose, itchy eyes, watery eyes, red eyes, puffy eyes, sinus pressure and/or pain, snoring, chest tightness, wheezing, cough, and/or shortness of breath.  Tree pollen as well as other environmental allergens (e.g., grasses, weeds, molds, dust mites, pets, cockroaches) may also exacerbate asthma in patients with this condition. An interesting fact regarding flowers or flowering trees is that they generally do not cause hay fever symptoms because the pollen is too heavy, and as a result, the pollen is not wind-disbursed.  If they are too heavy to be transported in the air to other flowering trees, then one generally does not become sensitized to the pollen because they are not breathing in this heavier pollen.  It is thought that the flowers are an adaptation over millions of years in order to attract bees.  By design, bees have taken over for cross-pollinating flowering trees by landing on the flowers and then flying to other flowering trees.  When the bee lands on the flower, tree pollen gets stuck to their abdomen.  When they fly to another flowering tree, the pollen on its abdomen rubs off on the flowers allowing cross-pollination of that species of tree. The diagnosis of tree pollen allergy begins with a comprehensive history and physical examination.  Allergy skin testing or blood testing (in select individuals) is usually performed in order to identify a tree allergy. Once a diagnosis of tree pollen allergy is confirmed, avoidance of tree pollen and prophylactic measures should be tried, if at all possible.  If one goes outside, take a shower, wash one’s hair, and change one’s clothing when returning home in order to lessen pollen exposure.  It is wise to turn on the air conditioner and change air filters regularly (approximately once a month).  In addition, close one’s windows and sunroof and re-circulate the air in the car in order to avoid outside air from entering the vehicle.  At home, avoid mowing one’s lawn and yard work.  If these tasks must be done, where a filtration mask to lessen exposure to tree pollen.  Also avoid close contact with a pet that goes outside since they carry tree pollen on their coats.  If they go outdoors, wash the per regularly.  Check pollen counts every day and click Today’s Pollen Count on our website to see the daily pollen count.  Stay inside whenever possible during the Spring, especially when the tree pollen count is high.  If you must go outside, try to avoid exercising outdoors in the early mornings because pollen tends to be released more during that time frame.  Avoid wearing contact lenses which may trap the tree pollen in one’s eyes.  It is important to know that rain washes tree pollen from the air causing the pollen counts to be lower on wet cooler days. The treatment of tree pollen allergy, other than trying to avoid exposure, usually begins with taking allergy medications.  There are also a multitude of medications available that may help diminish allergy symptoms.  Some of these medications may include antihistamines, decongestants, leukotriene inhibitors, nasal corticosteroids, nasal antihistamines, nasal mast cell stabilizers, nasal anticholinergics, ocular antihistamines, and/or ocular mast cell stabilizers.  Allergy shots (i.e., allergy immunotherapy, allergy desensitization, allergy hyposensitization) are a very efficacious treatment modality in patients with all types of environmental allergies, including tree pollen allergies.  They work in 80-85% of patients that take them.  It is also helpful in the treatment of allergic conjunctivitis as well as asthma. The board certified allergy specialists at Black & Kletz Allergy have been treating individuals with tree pollen allergies for over 50 years.  If you suffer from any of the symptoms above in the Spring, please call our office for an allergy consultation in order for us to determine if you have tree or other allergies that may cause any of the symptoms above.  We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area with office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Black & Kletz Allergy specializes in treatment of both adult and pediatric patients.  Alternatively, to schedule an appointment, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy pride themselves in providing superior allergy and asthma care in a specialized and caring environment.

Food Protein-Induced Enterocolitis Syndrome (FPIES)

March 20, 2025 | Black & Kletz Allergy

Food protein-induced enterocolitis syndrome (FPIES) is a rare condition that causes gastrointestinal symptoms several hours after consumption of certain foods by an individual who has an intolerance to that food.  The prevalence rate in the United States is approximately 0.5%. The most common types of food allergy in children and adults are mediated by an antibody called IgE. Food allergies may result in adverse reactions which in some cases may be very severe and even life-threatening in some that may occur within minutes of ingestion of the offending food.  The IgE antibodies are specific to the food that causes the reaction.  However, in individuals with FPIES, the intolerance to the food is not caused by IgE antibodies and the symptoms are usually delayed in onset.  It should however be noted that on occasion, FPIES may coexist with IgE mediated classic food allergies. In infants and children with FPIES, the most common foods that trigger gastrointestinal symptoms are milk, soy, oats, rice, and eggs.  For exclusively breastfed infants, FPIES reactions generally only begin when other foods are added to their diet.  For bottle-fed infants, FPIES reactions may begin in the first few months of life.  The most common trigger in adults with FPIES is seafood, particularly shellfish. Symptoms:

• Vomiting, typically occurring 1 - 4 hours after ingestion
• Diarrhea
• Blood and mucus in the stools
• Dehydration
• Fatigue
• Changes in blood pressure and body temperature

Diagnosis:

• In most cases, allergy skin prick and/or allergy blood tests will be negative, as this condition is not mediated by the IgE antibody.
• The diagnosis is most often established based on a comprehensive history and physical examination, after excluding other common conditions.
• Blood tests usually reveal the immune system’s response to stress, such as infections.
• Confirmation of the diagnosis often requires an oral challenge with the suspected food under close monitoring in a controlled environment in an attempt to trigger the symptoms.

Treatment:

• Children can rapidly become dehydrated following vomiting and diarrhea which may lead to a shock-like condition. Immediate rehydration intravenously and/or orally can be lifesaving.
• Zofran (ondansetron), an oral medication that controls nausea and vomiting, is sometimes useful in older children and adults.
• Breastfeeding infants, who begin exhibiting FPIES symptoms when solids are introduced into their diets, may need to continue exclusive breastfeeding for several more months.
• Infants who have reacted to dairy and/or soy-based infant formulas often need to be switched to hypoallergenic or elemental formulas.
• Oral corticosteroids may sometimes be prescribed in order to reduce the immune reaction as a short term measure.
• In older children and adults, eliminating one or more foods based on the clinical history and/or oral challenges may be warranted for prolonged periods.
• Foods are gradually reintroduced into the diet, one at a time, based on the results of oral challenges.

Prognosis:

• Many children outgrow FPIES and will be able to tolerate the foods spontaneously by the age of 3.
• Dairy is usually tolerated much earlier than rice and other cereals. Seafood may take several years to outgrow.
• Some children continue to experience FPIES symptoms into adolescence and into adulthood.
• As the underlying pathology is not yet fully understood, no curative treatments are available at this time.

The board certified allergy doctors at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  The allergists at Black & Kletz Allergy are very knowledgeable regarding FPIES as well as food allergies.  We diagnose and treat both adult and pediatric patients.  In addition, we treat hay fever (i.e. allergic rhinitis), asthma, and patients with medication, skin, and skin allergies.  We also diagnose and treat sinus disease, eosinophilic esophagitis, mast cell disorders, 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 5 decades and we look forward to providing you with all-inclusive state-of the-art allergy care in a welcoming and professional environment.

Update on Angioedema (Swelling Episodes)

February 13, 2025 | Black & Kletz Allergy

Some individuals have episodes of swelling or “angioedema” of various tissues that may occur without any known rhyme or reason.  They may have 1 episode or they may have multiple or recurrent episodes.  Most people with this condition are very surprised and nervous when they notice an area of their body swelling up right in front of their eyes.  The swelling can occur on any part of the body or even internally.  They may occur by themselves or they may be accompanied with hives (i.e., urticaria) and/or generalized itching (i.e., pruritus).  The severity of the swelling can range from very mild to extremely severe.  The swelling occurs because there is seepage of fluid through small blood vessel walls which in turn results in soft tissue swelling. The allergic causes of angioedema are varied and may include the following:

• Allergies to Food – Peanuts (legumes), tree nuts, fish, shellfish, eggs, milk, etc.
• Insect Sting Allergies – Honey bees, wasps, yellow jackets, hornets, fire ants, etc.
• Medication Allergies – Penicillin, sulfa, erythromycin, tetracycline, aspirin, nonsteroidal anti-inflammatory drugs (NDAIDS), vaccines, etc.
• Natural Rubber Latex – Gloves, balloons, condoms, catheters, dental dams, etc.

The nonallergic causes of angioedema are also varied and may include the following:

• Autoimmune Disorders – Rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s syndrome, polymyositis, scleroderma, Grave’s disease, Hashimoto’s thyroiditis, etc.
• Certain cancers
• Infections – Hepatitis B, syphilis, etc.

Nonallergic reactions to some medications may cause angioedema and some of these medications may include:

• Angiotensin II Receptor Antagonists - Diovan (valsartan), Cozaar (losartan), Atacand (candesartan), Micardis (telmisartan), Benicar (olmesartan), Avapro (irbesartan), etc.
• Proton Pump Inhibitors - Prevacid (lansoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Prilosec (omeprazole), Aciphex (rabeprazole), Protonix (pantoprazole), etc.
• Angiotensin Converting Enzyme (ACE) Inhibitors - Altace (ramipril), Vasotec (enalapril), Zestril (Lisinopril), Capoten (Captopril), Lotensin (benazepril), Accupril (quinapril), etc.
• Selective Serotonin Reuptake Inhibitors (SSRI’s) - Lexapro (escitalopram), Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), etc.
• Statins - Zocor (simvastatin), Lipitor (atorvastatin), Pravachol (pravastatin), Crestor (rosuvastatin), Lescol (fluvastatin), Mevacor (lovastatin), etc.

There is a genetic cause of angioedema which is in a category all by itself: Hereditary angioedema is a condition that is genetic that will cause swelling episodes.  In this disorder, there is an inherited abnormal gene that causes a deficiency of a normal blood protein called “C1 esterase inhibitor.”  If an individual has this deficiency, they may have repetitive swellings which may last for 1 to 2 days in duration.  Hereditary angioedema usually begins to cause swelling episodes in patients after puberty.  These swelling episodes are not accompanied by hives (i.e., urticaria) whereas with allergic causes of angioedema, hives are quite commonly associated with the swelling episodes.   The episodes of swelling in individuals with hereditary angioedema can be spontaneous or they may be triggered by alcohol, physical or emotional stress, and/or hormonal factors. If no cause of the angioedema can be identified, the individual is said to have idiopathic angioedema.  Idiopathic means that an unknown reason is causing the swelling episodes, however many causes have been ruled out as a cause. The diagnosis of angioedema begins with a comprehensive history and physical examination.  Allergy testing and bloodwork may be necessary depending on the history and physical examination findings.  Allergy skin tests are often performed to rule out food, medication, insect sting, or latex, or allergies.  Blood testing is usually done if the swelling episodes become more chronic in nature, (more than 6 weeks), in order to rule out underlying conditions that may be causing the angioedema. The treatment of angioedema depends on the severity and length of time of the swelling episodes. In mild to moderate acute angioedema, taking an oral antihistamine and/or corticosteroid may be beneficial in curtailing and eliminating the swelling.  Alternatively, intramuscular administration of an injection of epinephrine can be performed along with an intramuscular injection of an antihistamine and/or a corticosteroid. Severe acute angioedema is treated similarly, however, keeping the airway open is the main objective.  In order to maintain an open airway, intramuscular epinephrine is often used, particularly if the angioedema occurs in the throat or respiratory tract.  In such patients, a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, adrenaclick) should be prescribed and used if the throat or respiratory tract is involved.  The patient should also go immediately to the closest emergency room if the self-injectable epinephrine device is used.  The treatment of chronic recurrent angioedema often involves the use of oral antihistamines, leukotriene antagonists, H2-blockers, and/or corticosteroids. Hereditary angioedema management typically involves the use of intravenous C1 inhibitor concentrate, the deficient enzyme causing the condition.  The C1 inhibitor concentrate can also be infused prophylactically about 1 hour before a surgical procedure in order to prevent swellings due to physical trauma.  It should be noted that hereditary angioedema generally does not respond well to antihistamines.  There are also various complement system blockers that can be used via injection to treat acute symptoms.  Newer medications such as Kalbitor (ecallantide) and Firazyr (icatibant) may also be used to treat this genetic condition. The board certified allergy doctors at Black and Kletz Allergy have over 5 decades of experience in diagnosing and treating angioedema.  We treat both adult and pediatric patients.  Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC metropolitan area for many decades and we look forward to providing you with the utmost state-of-the-art allergy care in a friendly and professional environment.