Allergies to Moisturizers

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

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

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

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

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

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

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

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

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


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

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

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

Self-Injectable Epinephrine Devices

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

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

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

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

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

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

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

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

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

Allergies to the Cold Weather

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

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

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

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

If you suffer from cold-induced symptoms of any kind, the board certified allergists at Black & Kletz Allergy have the expertise in order to diagnose and treat this condition.  We treat both adult and pediatric patients and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible.  Please either call us for an appointment or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy have been treating allergy and asthma patients in the Washington, DC metro area for more than 50 years and we strive to provide state of the art allergy care to its residents and visitors.

Food-Dependent Exercise Induced Anaphylaxis

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

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

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

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

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


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

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

If a specific food is implicated, there should be:

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

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

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

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


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

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

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

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

Allergies and Christmas, Hanukkah, and Kwanzaa Holidays

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

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

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

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

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

New Targeted Treatments for Asthma

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

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

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

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

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

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

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

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

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

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

The board certified allergy doctors at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  The allergists at Black & Kletz Allergy are extremely knowledgeable about the most current treatment options for patients with asthma and related disorders and can promptly answer any of your questions.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC area for more than 50 years and we look forward to providing you with excellent state of the art allergy and asthma care in a friendly and pleasant environment.

Allergies and Thanksgiving

Allergies and ThanksgivingIt is that time of the year again when families and friends gather together for the highly anticipated Thanksgiving Day holiday.  Most people do not think about how Thanksgiving may affect one’s allergies, however, the holiday is full of potential triggers for many individuals prone to various allergies.

The most obvious allergies in relationship to Thanksgiving would be food allergies.  This relationship stems from the fact that when the average person thinks of Thanksgiving, they immediately associate the holiday with food and gluttony.  There are individuals who are allergic to turkey, the staple food of Thanksgiving, but turkey allergy is not very common.  More commonly, many individuals will experience sleepiness after eating turkey meat.  This phenomenon is explained due to the fact that turkey contains higher levels of the amino acid “L-tryptophan.”  L-tryptophan will enter the bloodstream from the digestive tract and travel to the brain where it gets converted to the chemical “serotonin.”  It is the serotonin that is responsible for causing this sleepiness.  In addition to turkey which helps fill the plates on a Thanksgiving Day dinner, there are lots of other foods that accompany this holiday favorite.  Common food allergens such as wheat, soy, egg, milk, nuts, and peanuts are often found around the table.  Gravy used for turkey and mashed potatoes frequently contains soy, wheat, and/or dairy.  Nuts are commonly found on string beans and in some types of stuffing.  Nuts and peanuts are common in many desserts such as pecan pie and brownies.  Eggs and milk (dairy) are also used in many baked goods.  Although pumpkin allergies are not common, pumpkin pie may contain an array of ingredients that may trigger a food allergy in susceptible individuals.  It is also important to note that among various cultures, many families incorporate many ethnic foods in their celebrations.  These foods may not be traditional but they increase the likelihood of other allergenic foods such as fish, shellfish, etc. to be the causative agent of an impending food allergy.  If someone has a serious food allergy, it is advisable for that person to bring their own food.

In addition to food allergies, one always is exposed to the typical environmental allergens such as dust mites, pets, molds, and to a lesser extent pollens.  By Thanksgiving, the pollen count in most places in the U.S. is low or non-existent, except in the southern states.  It is the molds, dust mites, and pets that tend to bother individuals during the end of November in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  These allergens can cause the typical symptoms of hay fever (I.e., allergic rhinitis and/or allergic conjunctivitis) and/or asthma which may include runny nose, nasal congestion, post-nasal drip, sneezing, itchy nose, itchy throat, sinus headaches, itchy eyes, watery eyes, redness of the eyes, wheezing, coughing, chest tightness, and shortness of breath.  One must keep in mind that many of these symptoms may mimic the symptoms of the common cold or flu (i.e., influenza) which tend to become more prevalent during this time of the year.

Other irritants that can cause allergic-like symptoms at a Thanksgiving Day event may include perfumes, colognes, cigarette smoke, smoke from a fireplace or wood-burning oven, and cleaning fluids.  Unfamiliar soaps may cause contact dermatitis to individuals with eczema (i.e., atopic dermatitis) and sensitive skin.

Thanksgiving is a festive time and loved by almost everyone.  It is a time to congregate with family and friends and an excuse to eat too much!  Given the positives about the Thanksgiving holiday, it is crucial to remember that there can be potentially serious complications from this seemly innocuous occasion.  With this in mind, have a very happy Thanksgiving!

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating allergies, asthma, sinus conditions, and immunological disorders for more than 50 years.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at each location and the Washington, DC and McLean offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  Please call us today to make an appointment at the office of your choice.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy pride themselves in delivering the highest quality allergy care in the Washington, DC metropolitan area in conjunction with providing excellent customer service in a friendly and affable environment.

Allergic to Penicillin?

PenicillinAdverse reactions to medications are very common.  Among the drugs associated with immediate hypersensitivity reactions (i.e., Type I allergy, IgE antibody-mediated allergy), penicillins are the most commonly observed.

Penicillin allergy is reported in approximately 7 to 10% of community populations and up to 20% of hospitalized patients.  What is amazing is that more than 90% of these patients do not actually have true penicillin allergy!

There are three common causes for this high rate of false positive penicillin allergy reports:

  1. Mislabeling of a side effect (e.g., gastrointestinal upset) as an “allergy”
  2. Coincidental event (e.g., headache or rash due to an underlying infection)
  3. Loss of true allergy sensitivity over time with avoidance of penicillins.

Penicillin allergy can be ruled out with the help of a standardized testing procedure which is routinely done in our office at Black & Kletz Allergy.  Skin testing was introduced as a diagnostic intervention for the evaluation and management of patients with a history of penicillin allergy in 1960’s.  This procedure is commonly performed with minimal risk.  Penicillin skin testing can be done safely in properly selected patients with suspected penicillin allergy and can even be performed in pregnant women with Streptococcal infections.

The procedure for testing involves three stages:

  1. Skin prick testing with a small amount of diluted penicillin “antigens” (commercially prepared testing reagents) with negative and positive controls.
  2. If the prick tests are negative after 20 minutes, a tiny quantity of the antigen in injected into the superficial layers of the skin (i.e., intradermal skin test).
  3. If the intradermal skin test in in this second stage is also negative after 20 minutes, the patient will be given 250 mg. of amoxicillin by mouth (i.e., oral challenge) and will be closely monitored for 90 minutes.

If the patient tolerates all three stages without any adverse effects, the patient may receive penicillins if needed, without increased risk of immediate allergic reactions.  The negative predictive value of penicillin allergy testing is more than 99%.

Penicillin allergy testing should be performed in a healthcare setting only by clinicians with the knowledge, training, and experience to select appropriate patients for this procedure, interpret test results, and manage a systemic allergic reaction should it occur.

Unverified penicillin allergy in hospitalized patients is associated with longer hospital stays and increased rates of serious drug-resistant infections.  The alternative antibiotics to penicillin can be associated with higher cost and/or greater risk for untoward side effects.

For this reason, the “Choosing Wisely” program of the American Board of Internal Medicine Foundation recommended in 2014 that clinicians not overuse non-penicillin antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation.  The National Quality Partners’ Antibiotic Stewardship Action Team recommends penicillin allergy skin testing as a component of a comprehensive antibiotic stewardship program.

Penicillin allergy testing is associated with an unrealized potential:  this procedure can accurately identify the approximately 9 of 10 patients who despite reporting a history of penicillin allergy can receive penicillins safely.

On the basis of current evidence, the American Academy of Allergy, Asthma and Immunology (AAAAI) believes that more frequent and routine performance of penicillin allergy testing will result in reduced costs of care, enhanced patient safety, and improved outcomes.

The board certified allergy doctors at Black & Kletz Allergy have been performing penicillin skin testing 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.

Influenza (Flu)

Influenza-virus“Flu” season is almost here and it is time to get prepared for its onslaught.

Influenza is a highly contagious viral infection which is the cause of the “flu.”  It impacts people of all ages.  Though it can occur any time of the year, most cases are reported from October through March, with peaks between December and February of each year.  It affects between 5 to 20% of the U.S. population annually.  It accounts for thousands of lost school and work days.  It can be especially serious in the very young and the elderly.  Each year, more than 200,000 individuals are hospitalized and several thousand people die from the complications of influenza.


Influenza usually presents initially as “cold-like” symptoms with runny nose, nasal congestion, itchy and/ or burning eyes, sore throat, and a dry cough.  Fever (usually 100°F – 102 degrees° F) is usually present and can be associated with chills.  Muscle aches (e.g., body aches) and fatigue are extremely common.  Joint pains, joint stiffness, gastrointestinal manifestations (e.g., diarrhea, nausea, vomiting) may also occur, but are not as common.

The symptoms usually lasts for approximately 7 to 10 days, but the malaise can continue for several weeks. Pneumonia is not an uncommon complication of the influenza virus and can substantially prolong the duration of illness.  Like other viral infections, influenza can also trigger acute flare-ups of asthma and chronic obstructive pulmonary disease (COPD) in susceptible individuals.

The influenza virus spreads from human to human via aerosols created by coughs and/or sneezes of infected individuals.  The incubation period ranges from 18 – 72 hours.  Shedding of the virus continues for 5 – 10 days in most individuals, however the duration of the shedding is longer in young children and immunocompromised persons.


There are rapid diagnostic tests that can directly detect influenza A or B virus-associated antigens or enzymes within 30 minutes by testing material obtained from throat swabs or nasal swabs.  Due to the cost, availability, and sensitivity of these tests, however, most physicians diagnose influenza based on clinical criteria alone.


Most patients with influenza benefit from rest and increased fluid intake and generally recover in a few days, though the fatigue may persist for weeks.  Antiviral medications can reduce the duration and severity of illness.  To be effective, these drugs must be started within 40 hours of the onset of symptoms.  There are two common antiviral medications used in the treatment and prevention of influenza A and B.  The first medication is oseltamivir (i.e., Tamiflu) which is taken orally 75 mg. twice a day for 5 days for individuals over the age of 12.  If using oseltamivir for prophylaxis for individuals 5 years of age and over, the dose is 10 mg. once a day for 10 days, but can be used in adults and adolescents (13 years of age and older) for up to 6 weeks for a community outbreak.  Smaller doses are given to children between the ages of 1 and 12.  The second medication is called zanamivir (Relenza) and is taken by inhalation using a Diskhaler (i.e., a device similar to an asthma inhaler) 10 mg. twice a day for 5 days for individuals 7 years of age and over.  If using zanamivir for prophylaxis for individuals 5 years of age and over, the dose is 10 mg. once a day for 10 days, but can be used in adults and adolescents for up to 28 days for a community outbreak.  Zanamivir should not be used by anyone who has respiratory problems such as asthma or other lung diseases.


Avoiding exposure to infected individuals and maximizing personal hygiene (e.g., frequent hand-washing with soap and water, not touching one’s nose and eyes) are the first line of defense in preventing the spread of the influenza virus.

Each year in U.S., vaccines that contain antigens from the strains most likely to cause infection during the winter flu season are produced.  These vaccines become effective 10 – 14 days after administration. It is recommended that all persons 6 months of age and above receive a routine annual influenza vaccination.

Only injectable vaccines are recommended for use during the 2017 – 2018 season.  The live nasal spray vaccine (e.g., FluMist) is not recommended due to concerns about its effectiveness against the H1N1 strains of the viruses.  A number of inactivated as well as recombinant vaccines are available for this season. Trivalent vaccines are designed to protect against three different influenza viruses (2 influenza A viruses and 1 influenza B virus). Quadrivalent vaccines protect against the same three viruses as the trivalent vaccine plus an additional influenza B virus.

In 2016, only about 50% if children ages 6 months to 17 years of age received the vaccine.  In adults 65 years of age and above, approximately 66% received the vaccine.  In individuals from ages 18 through 64, the percentage of people vaccinated for influenza was less than the two cohorts mentioned above.  Needless to say, there is great room for improvement in vaccinating the population against such a potentially virulent illness.

Special Populations:

Pregnant women can receive any licensed inactivated or recombinant trivalent or quadrivalent vaccine.  It is always advisable to check with your Obstetrician/Gynecologist physician and get his or her approval before receiving a flu vaccination.

Children between 6 months and 8 years of age who have never been vaccinated will require two doses of influenza vaccine administered at least 4 weeks apart.  If a child received two or more doses before July 1, 2017, only one dose of 2017 – 2018 flu vaccine is recommended.

As per the Centers of Disease Control and Prevention (CDC), children and adults with a history of severe allergic reaction to egg (i.e., any symptom other than hives) should receive the influenza vaccine in a medical setting under the supervision of a healthcare provider who is able to recognize and manage severe allergic conditions.  A previous severe allergic reaction to the flu vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine.

The board certified allergy doctors at Black and Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We diagnose and treat both adult and pediatric patients.  The allergists at Black & Kletz Allergy are extremely knowledgeable about vaccinations as we specialize in immunological conditions. In addition, we also specialize in allergies (environmental, foods, insect stings, medications), asthma, sinus problems, eczemageneralized itching (pruritus)hives (urticaria)swelling episodes (angioedema), and eosinophilic disorders (e.g., eosinophilic esophagitis).  Each one of our offices offers on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle service that runs between our McLean, VA office and the Spring Hill metro station on the silver line.

If you would like to make an appointment to see one of our board certified allergists, please call us today.  Alternatively, you may click Request an Appointment and we will respond to your inquiry within 24 hours by the next business day.  Black & Kletz Allergy has been serving the Washington, DC and Northern Virginia metro area for more than 50 years and we look forward to helping you with you allergy, asthma, and immunologic needs.

Allergies and Halloween

Halloween AllergyHalloween is just around the corner and most individuals do not think of allergies when thinking of Halloween.  They more aptly think of costumes, trick-or-treating, candy, bobbing for apples, skeletons and skulls, and Halloween parties.  It is a festive time of the year and both adults and children enjoy the holiday.  Even though adults enjoy the event, it is the children that really become excited!

You may have never pondered about the connection between Halloween and allergies and you would not be alone.  Unfortunately, approximately 8% of all children in the U.S. have some type of food allergy.  These kids and their families are generally the only ones who connect this cheerful holiday with food allergies.  There is a good reason for this as food allergies can be very serious and in some cases fatal.  Almost 40% of children with food allergies have had a severe reaction to a food.  About 30% of children with food allergies have multiple food allergies.  According to Centers for Disease Control and Prevention (CDC), food allergies in children have increased by 50% between the years 1997 and 2011.  Peanut is the most common food allergy in children followed by milk.  The other 6 foods that are in the top 8 most allergic foods, (in addition to peanut and milk mentioned above) include shellfish, tree nuts, soy, wheat, eggs, and fish.  These 8 foods account for 90% of all food allergy reactions.  It is not surprising that Halloween candy often contains 6 of the 8 most common food allergens.  You guessed it, fish and shellfish are generally not a problem in Halloween candy, however, peanuts, tree nuts, milk products, soy, eggs, and/or wheat are found in a multitude of Halloween candy.  It is important to note that in some cases, miniaturized candies often given out during Halloween may contain different ingredients than their full-sized versions.  In addition, many miniaturized candies do not have labels which make it nearly impossible for the parents to deem the candy safe for their child.

What can be done to insure that a “food allergic” child can participate in Halloween and have as much fun as the next child?  Nothing is guaranteed, however, there is a program run by the Food Allergy Research and Education (FARE) organization called the “Teal Pumpkin Project.  This FARE-sponsored international program has been around since 2014.   It began in Tennessee, however, as a local crusade in 2012 by the mother of a severely food allergic child.  She also created a food allergy support group called the Food Allergy Community of East Tennessee (FACET).

The Teal Pumpkin Project’s aim is to raise awareness of the severity of food allergies and show support to families who have a food allergic child.  This is accomplished by painting a pumpkin teal and placing it on one’s front porch to signify that non-food treats are available at that location on Halloween night.  The color teal was used because it represents food allergy awareness.  Typically, non-food treats may include toys, stickers, crayons, glow sticks, hair accessories, rings, bracelets, necklaces, coins, bookmarks, spider rings, vampire fangs, whistles, balls, finger puppets, etc.

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

The board certified allergists at Black & Kletz Allergy support the efforts of FARE’s Teal Pumpkin Project and hope that our patients will continue to expand this endeavor.  We have always had a link, on the upper portion of our website under the blue “Resources” tab, to the Food Allergy Research Education (FARE) organization.   If you or your child suffer from food allergies, food intolerances, or eosinophilic esophagitis, please call us to make an appointment.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas with on-site parking all 3 locations.  Our Washington, DC and McLean, VA locations are Metro accessible and we offer a free shuttle between our McLean, VA office and the Spring Hill metro station on the silver line.  We look forward to helping you with all your allergy, asthma, and immunology needs as we have been doing in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than a half century.