Can you develop an allergy to alcohol

Alcoholic drinks are capable of triggering a wide range of allergic and allergic-like responses, including rhinitis, itching, facial swelling, headache, cough and asthma ¹, ², ³, ⁴. Limited epidemiological data suggests that many individuals are affected and that sensitivities occur to a variety of drinks, including wine, beer and spirits. In people with alcohol allergy, as little as 1 ml of pure alcohol (equivalent to 10ml of wine or a mouthful of beer) is enough to provoke severe rashes, difficulty breathing, stomach cramps or collapse. Alcohol can also increase the likelihood of severe allergic reactions (anaphylaxis) from other causes like food.

Alcohol is the common term for ethanol or ethyl alcohol, a chemical substance found in beer, wine, and liquor, as well as in some medicines, mouthwashes, household products, and essential oils (scented liquids taken from plants). Alcohol is produced by the fermentation of sugars and starches by yeast.

The main types of alcoholic drinks and their alcohol content are as follows:

• Beers and hard ciders: 3-7 percent alcohol
• Wines, including sake: 9-15 percent alcohol
• Wines fortified with liquors, such as port: 16-20 percent alcohol
• Liquor, or distilled spirits, such as gin, rum, vodka, and whiskey, which are produced by distilling the alcohol from fermented grains, fruits, or vegetables: usually 35-40 percent alcohol (70-80 proof), but can be higher

In surveys of asthmatics, over 40% reported the triggering of allergic or allergic-like symptoms following alcoholic drink consumption and 30-35% reported worsening of their asthma ³. Sensitivity to ethanol itself can play a role in triggering adverse responses, particularly in Asians, which is due mainly to a reduced capacity to metabolize acetaldehyde. People low levels of aldehyde dehydrogenase may accumulate high levels of acetaldehyde after drinking alcohol, as they cannot break it down easily. Acetaldehyde has been blamed for asthmatic reactions to alcohol in up to half of Japanese people with asthma. Acetaldehyde is a toxic chemical and human carcinogen (cancer causing chemical) ⁵. Acetaldehyde produces reactive free radicals and damages DNA. In Caucasians, specific non-alcohol components are the main cause of sensitivities to alcoholic drinks. Allergic sensitivities to specific components of beer, spirits and distilled liquors have been described. Wine is clearly the most commonly reported trigger for adverse responses. Sensitivities to wine appear to be due mainly to pharmacological intolerances to specific components, such as biogenic amines and the sulphite additives. Histamine in wine has been associated with the triggering of a wide spectrum of adverse symptoms, including sneezing, rhinitis, itching, flushing, headache and asthma. The sulphite additives in wine have been associated with triggering asthmatic responses. Clinical studies have confirmed sensitivities to the sulphites in wine in limited numbers of individuals, but the extent to which the sulphites contribute to wine sensitivity overall is not clear. The cause of wine-induced asthmatic responses may be complex and may involve several co-factors.

Alcoholic beverages contain ethanol and other substances

The liver breaks down the alcohol (ethanol) that we drink and converts it to a chemical called acetaldehyde. Acetaldehyde is then transformed to acetic acid (vinegar). Problems occur if alcohol cannot be broken down. As well as ethanol, alcoholic beverages contain a complex mixture of grape, yeast, hop, barley or wheat derived substances, natural food chemicals (such as salicylates) and wood derived substances or preservatives like sodium metabisulfite. Severe allergic reactions have been described in people with allergies to proteins within grapes, yeast, hops, barley and wheat. These people are not sensitive to alcohol itself. Furthermore, fining agents (such as egg or seafood proteins) are sometimes used to remove fine particles. Whether these occur in sufficient amounts to trigger allergic reactions is unknown.

Trying to find the culprit of a possible allergic reaction to beer is a difficult task. There are many reported sources of allergic or allergic-like reactions to beer. These include contents in the beer itself including the alcohol, hops, barley, acetic acid, and other ingredients within the beer ⁶. Prior reports have proposed that ethanol’s metabolic products, acetaldehyde and acetic acid may act as allergens ⁷, ⁸. Testing can be complex, and oftentimes skin tests are not useful and oral challenges need to be performed if the patient wishes to continue consuming beer or other alcoholic beverages. In dealing with patients who have this type of reaction to beer indicates that on many occasions it isn’t possible to identify a specific culprit.

Basically, the most frequent causes of reaction to beer are IgE-mediated reactions to barley/hops or a reaction to the alcohol itself, which is quite often due to acetaldehyde dehydrogenase 2 deficiency. Acetaldehyde dehydrogenase 2 is the enzyme that metabolizes the first metabolic product of alcohol digestion, acetaldehyde. When acetaldehyde accumulates, it produces mast cell degranulation, and therefore its symptoms mimic an allergic response.

Asthmatic reactions may occur due to metabisulfite

Up to a third of people with asthma complain that wine will worsen their asthma and less often with beer or spirits. Beer, wine and champagne contain sodium metabisulfite which has been used as a preservative since Roman times. Some people, particularly those with unstable or poorly controlled asthma, may wheeze when they consume these drinks. In general, there is more preservative in white wine than red wine, and more in cask wine than bottled wine. The amount of metabisulfite also varies from brand to brand. Some low sulfite wines are available, although those with extreme sensitivity may not be able to tolerate them. This is because some grape growers will dust sulfur powder over grapes in the weeks leading up to harvest. Other sources of metabisulfite include vinegar, pickled onions, dried fruit, crustaceans, some restaurant salads and fruit salads. Even when people complain that wine triggers asthma, metabisulfite may not be the only explanation.

Figure 1. Alcohol allergy rash

Histamine and other substances may also cause problems

Histamine can trigger sneezing, runny nose and sometimes wheeze, stomach upset and headache. Although the actual amounts vary between different wines, in general there is more histamine in red than white wines and more in Shiraz than Cabernet. Some challenge studies suggest that antihistamines may reduce the severity of problems after wine, but as the challenges were equivalent to only one glass, these medicines probably won’t prevent a hangover. Others substances in wine may also cause problems to some individuals, but these are not well defined.

Alcohol allergy signs and symptoms

Alcohol sometimes worsens symptoms in people with hives (urticaria) and occasionally alcohol can also trigger hives. As with more serious allergic reactions, the mechanism is unclear. Contact rashes from alcohol are very uncommon.

Common symptoms of an allergic reaction include:

• rhinitis
• nasal congestion
• sneezing spells
• itching (pruritus)
• shortness of breath
• facial swelling
• headache
• hypotension (low blood pressure)
• cough
• asthma
• wheezing, chest tightness, shortness of breath and a cough
• hoarseness
• a raised, itchy, red rash (hives or urticaria)
• swollen lips, tongue, eyes or face
• tummy pain, feeling sick, vomiting or diarrhea.

Flushing is not an allergic reaction

Some people develop severe facial flushing if they drink small amounts of alcohol. This is not an allergic reaction and is most common in those with an Asian background. Other side effects may also occur, including fluttering of the heart (palpitations), feeling hot, headache, tummy discomfort or a drop in blood pressure These may be related to high blood acetaldehyde levels. Not all flushing is due to alcohol. Flushing can occur in skin conditions like rosacea, menopause, low blood sugar levels (hypoglycaemia), or as a response to some antibiotics or medicines used to treat diabetes or high blood fat levels.

Severe allergic reaction (anaphylaxis)

Accidental exposure to alcohol may lead to unexpected reactions. Severe alcohol allergy should be managed in the same way as other severe allergic reactions (anaphylaxis): identify and avoid the cause, wear a medical identification bracelet, and carry adrenaline (epinephrine) as part of an emergency action plan if they are at risk of potentially life threatening allergic reactions in the future.

This affects the whole body and usually develops within minutes of exposure to something you’re allergic to.

Symptoms of severe allergy (anaphylaxis) may include:

• trouble breathing or noisy breathing
• difficulty talking more than a few words and/or hoarse voice
• wheeze
• cough
• swelling and tightness of the throat
• collapse
• light-headedness or dizziness
• diarrhea
• tingling in the hands, feet, lips or scalp
• swelling of tongue
• pale and floppy (in young children)

A severe allergic reaction (anaphylaxis) is a medical emergency. Call your local emergency immediately. Lay the person down. If they have an adrenaline injector and you are able to administer it, do so.

Figure 2. Anaphylaxis Emergency Action Plan

Alcohol allergy test

Allergy skin tests

During allergy skin tests, your skin is exposed to suspected allergy-causing substances (allergens) and is then observed for signs of an allergic reaction.

Allergy tests using alcohol are usually negative, but are sometimes positive to breakdown products of ethanol such as acetaldehyde or acetic acid (vinegar).

Along with your medical history, allergy tests may be able to confirm whether or not a particular substance you touch, breathe or eat is causing symptoms.

Information from allergy tests may help your doctor develop an allergy treatment plan that includes allergen avoidance, medications or allergy shots (immunotherapy).

Before you leave your doctor’s office, you’ll know the results of a skin prick test or an intradermal test. A patch test may take several days or more to produce results.

A positive skin test means that you may be allergic to a particular substance. Bigger wheals usually indicate a greater degree of sensitivity. A negative skin test means that you probably aren’t allergic to a particular allergen.

Keep in mind, skin tests aren’t always accurate. They sometimes indicate an allergy when there isn’t one (false positive), or skin testing may not trigger a reaction when you’re exposed to something that you are allergic to (false negative). You may react differently to the same test performed on different occasions. Or you may react positively to a substance during a test but not react to it in everyday life.

Your allergy treatment plan may include medications, immunotherapy, changes to your work or home environment, or dietary changes. Ask your doctor to explain anything about your diagnosis or treatment that you don’t understand. With test results that identify your allergens and a treatment plan to help you take control, you’ll be able to reduce or eliminate allergy signs and symptoms.

Skin tests are generally safe for adults and children of all ages, including infants. In certain circumstances, though, skin tests aren’t recommended.

Your doctor may advise against skin testing if you:

• Have ever had a severe allergic reaction. You may be so sensitive to certain substances that even the tiny amounts used in skin tests could trigger a life-threatening reaction (anaphylaxis).
• Take medications that could interfere with test results. These include antihistamines, many antidepressants and some heartburn medications. Your doctor may determine that it’s better for you to continue taking these medications than to temporarily discontinue them in preparation for a skin test.
• Have certain skin conditions. If severe eczema or psoriasis affects large areas of skin on your arms and back — the usual testing sites — there may not be enough clear, uninvolved skin to do an effective test. Other skin conditions, such as dermatographism, can cause unreliable test results.

Blood tests (in vitro immunoglobulin E antibody tests) can be useful for those who shouldn’t undergo skin tests. Blood tests aren’t done as often as skin tests because they can be less sensitive than skin tests and are more expensive.

In general, allergy skin tests are most reliable for diagnosing allergies to airborne substances, such as pollen, pet dander and dust mites. Skin testing may help diagnose food allergies. But because food allergies can be complex, you may need additional tests or procedures.

Allergy skin test preparation

Before recommending a skin test, your doctor will ask you detailed questions about your medical history, your signs and symptoms, and your usual way of treating them. Your answers can help your doctor determine if allergies run in your family and if an allergic reaction is most likely causing your symptoms. Your doctor may also perform a physical examination to search for additional clues about the cause of your signs and symptoms.

Medications can interfere with allergy skin test results

Before scheduling a skin test, bring your doctor a list of all of your prescription and over-the-counter medications. Some medications can suppress allergic reactions, preventing the skin testing from giving accurate results. Other medications may increase your risk of developing a severe allergic reaction during a test.

Because medications clear out of your system at different rates, your doctor may ask that you stop taking certain medications for up to 10 days.

Medications that can interfere with skin tests include:

• Prescription antihistamines, such as levocetirizine (Xyzal) and desloratadine (Clarinex).
• Over-the-counter antihistamines, such as loratadine (Claritin, Alavert), diphenhydramine (Benadryl, others), chlorpheniramine (Chlor-Trimeton), cetirizine (Zyrtec, others) and fexofenadine (Allegra).
• Tricyclic antidepressants, such as nortriptyline (Pamelor) and desipramine (Norpramin).
• Certain heartburn medications, such as cimetidine (Tagamet) and ranitidine (Zantac).
• The asthma medication omalizumab (Xolair). This medication can disrupt test results for six months or longer even after you quit using it (most medications affect results for days to weeks).

How allergy skin test is done

Skin testing is usually done at a doctor’s office. A nurse generally administers the test, and a doctor interprets the results. Typically, this test takes about 20 to 40 minutes. Some tests detect immediate allergic reactions, which develop within minutes of exposure to an allergen. Other tests detect delayed allergic reactions, which develop over a period of several days.

Skin prick test

A skin prick test, also called a puncture or scratch test, checks for immediate allergic reactions to as many as 40 different substances at once. This test is usually done to identify allergies to pollen, mold, pet dander, dust mites and foods. In adults, the test is usually done on the forearm. Children may be tested on the upper back.

Allergy skin tests aren’t painful. This type of testing uses needles (lancets) that barely penetrate the skin’s surface. You won’t bleed or feel more than mild, momentary discomfort.

After cleaning the test site with alcohol, the nurse draws small marks on your skin and applies a drop of allergen extract next to each mark. He or she then uses a lancet to prick the extracts into the skin’s surface. A new lancet is used for each allergen.

To see if your skin is reacting normally, two additional substances are scratched into your skin’s surface:

• Histamine. In most people, this substance causes a skin response. If you don’t react to histamine, your allergy skin test may not reveal an allergy even if you have one.
• Glycerin or saline. In most people, these substances don’t cause any reaction. If you do react to glycerin or saline, you may have sensitive skin. Test results will need to be interpreted cautiously to avoid a false allergy diagnosis.

About 15 minutes after the skin pricks, the nurse observes your skin for signs of allergic reactions. If you are allergic to one of the substances tested, you’ll develop a raised, red, itchy bump (wheal) that may look like a mosquito bite. A nurse will then measure the bump’s size.

After the nurse records the results, he or she will clean your skin with alcohol to remove the marks.

Skin injection test

You may need a test that uses a needle to inject a small amount of allergen extract just into the skin on your arm (intradermal test). The injection site is examined after about 15 minutes for signs of an allergic reaction. Your doctor may recommend this test to check for an allergy to insect venom or penicillin.

Patch test

Patch testing is generally done to see whether a particular substance is causing allergic skin irritation (contact dermatitis). Patch tests can detect delayed allergic reactions, which can take several days to develop.

Patch tests don’t use needles. Instead, allergens are applied to patches, which are then placed on your skin. During a patch test, your skin may be exposed to 20 to 30 extracts of substances that can cause contact dermatitis. These can include latex, medications, fragrances, preservatives, hair dyes, metals and resins.

You wear the patches on your arm or back for 48 hours. During this time, you should avoid bathing and activities that cause heavy sweating. The patches are removed when you return to your doctor’s office. Irritated skin at the patch site may indicate an allergy.

Allergy skin test risks

The most common side effect of skin testing is slightly swollen, red, itchy bumps (wheals). These wheals may be most noticeable during the test. In some people, though, an area of swelling, redness and itching may develop a few hours after the test and persist for as long as a couple of days.

Rarely, allergy skin tests can produce a severe, immediate allergic reaction, so it’s important to have skin tests performed at an office where appropriate emergency equipment and medications are available.

Elimination diet

If you have a suspected food allergy, you may be advised to avoid eating a particular food to see if your symptoms improve.

After a few weeks, you may then be asked to eat the food again to check if you have another reaction.

Don’t attempt to do this yourself without discussing it with a qualified healthcare professional.

Challenge testing

In a few cases, a test called a food challenge may also be used to diagnose a food allergy.

During the test, you’re given the food you think you’re allergic to in gradually increasing amounts, to see how you react under close supervision.

This test is riskier than other forms of testing, as it could cause a severe reaction, but is the most accurate way to diagnose food allergies. And challenge testing is always carried out in a clinic where a severe reaction can be treated if it does develop.

Alcohol allergy rash treatment

The treatment for an allergy depends on what you’re allergic to. In many cases, your allergist will be able to offer advice and treatment.

Immunotherapy (desensitization)

Immunotherapy may be an option for a small number of people with certain severe and persistent allergies who are unable to control their symptoms using medical measures (see medications below) or desire to continue alcohol consumption.

The treatment involves being given occasional small doses of the allergen – either as an injection, or as drops or tablets under the tongue – over the course of several years.

The injection can only be performed in a specialist clinic under the supervision of a doctor, as there is a small risk of a severe reaction. The drops or tablets can usually be taken at home.

The aim of treatment is to help your body get used to the allergen so it doesn’t react to it so severely. This won’t necessarily cure your allergy, but it will make it milder and mean you can take less medication.

Treating severe allergic reactions (anaphylaxis)

Some people with severe allergies may experience life-threatening reactions, known as anaphylaxis or anaphylactic shock.

If you’re at risk of this, you’ll be given special injectors containing a medicine called adrenaline to use in an emergency.

If you develop symptoms of anaphylaxis, such as difficulty breathing, you should inject yourself in the outer thigh before seeking emergency medical help.

Allergy medications

Medications for mild allergies are available from pharmacies without a prescription, but always ask your pharmacist or GP for advice before starting any new medicine, as they’re not suitable for everyone.

Antihistamines

Antihistamines are the main medicines for allergies. They can be used:

• as and when you notice the symptoms of an allergic reaction
• to prevent allergic reactions – for example, you may take them in the morning if you have hay fever and you know the pollen count is high that day

Antihistamines can be taken as tablets, capsules, creams, liquids, eye drops or nasal sprays, depending on which part of your body is affected by your allergy.

Decongestants

Decongestants can be used as a short-term treatment for a blocked nose caused by an allergic reaction.

They can be taken as tablets, capsules, nasal sprays or liquids. Don’t use them for more than a week at a time, as using them for long periods can make your symptoms worse.

Steroids

Steroid medications can help reduce inflammation caused by an allergic reaction. They’re available as:

• nasal sprays and eye drops for an inflamed nose and eyes
• creams for eczema and contact dermatitis
• inhalers for asthma
• tablets for hives (urticaria)

Sprays, drops and weak steroid creams are available without a prescription. Stronger creams, inhalers and tablets are available on prescription from your doctor.

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