Allergic to the Fine Print: Food Allergy to Additives, Rare but Real

Dyes, Sulfites, and Other Food Additives
Food additives have been used for thousands of years, while recently there are more natural and artificial substances than ever before. Almost 4,000 food additives can be found on the U.S. Food and Drug administration (FDA) website. This poses an interesting question: Are dyes, sulfites and other food additives responsible for allergic reactions?

Despite the widespread use of these additives, reactions are rare. There are few studies that show adverse reactions to additives. Most reports are of single patients or small clusters of patients. Sulfites are one of the most commonly used preservatives as they reduce spoilage, act as antioxidants, and prevent fruit and vegetable browning. Asthma exacerbations, anaphylaxis, and urticaria have all been reported from reactions to sulfites, and the FDA requires labeling on any food or beverage with greater than 10 parts per million of these preservatives. Dyes have also been reported to cause adverse reactions. Carmine, which is commonly used for red food coloring and Saffron, used for yellow food coloring, have been reported to cause anaphylaxis in a few case reports. Annatto, which is used for yellow food coloring has also been reported to cause anaphylaxis, as well as urticaria and angioedema in a few cases.

How do I know if I had a reaction to a food additive?
If you have allergic reactions to many unrelated foods, or only with commercially prepared food, food additives may be suspected.

What should I do if I suspect I had a reaction to a food additive?
Careful reading of food labels is necessary to discover common additives. Discussion with your physician is advised to rule out major food allergens. Discuss your symptoms, how often they occur and when they occur, with your physician. It may be beneficial to create a food diary.

Should I be skin tested?
Skin tests are of no diagnostic value in allergic reactions to food additives. Oral challenges are more effective in determining these kinds of allergies. During an oral challenge you will eat the food additive in question in the safety of an allergist's office and be observed for the signs and symptoms of an allergic reaction. If you develop symptoms of an allergic reaction, the allergist will treat you immediately. If you do not react, an allergy to the additive in question will be ruled out.

How should I manage a suspected adverse reaction to a food additive?
Avoidance of the suspected food additive is necessary, as well as avoiding possibly related additives. Be vigilant about reading food labels and asking restaurants about ingredients and cooking methods. If there is a history of anaphylaxis, always carry an epinephrine auto-injector.

Resources:
Wilson B, Bahna S. “Adverse reactions to food additives.” Annals of Allergy, Asthma and Immunology. Volume 95, issue 6, Pages 499-507. December 2005.

Bernstein IL, Li JT, Berstein DI, et al. “Allergy Diagnostic Testing: An Updated Practice Parameter.” Annals of Allergy, Asthma and Immunology. Volume 100, issue 3, Supplement 3 Pages S1-S148. March 2008

This article has been reviewed by Andrew Moore, MD, FAAAAI

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