Apple
Allergy Facts, Symptoms, and Treatment

Apple

One of the most widely cultivated tree fruits, apples are available in thousands of varieties and are a source of carbohydrates, vitamins A and C, and dietary fiber. The vast majority of apples are produced in China, but throughout the world the fruit is eaten fresh and used to create foods such as vinegar, juice, jelly, apple butter, pie stock, applesauce, wine, and brandy.1 While apple allergy is caused by proteins in the fruit, the level of allergens in an apple is influenced by the apple variety, storage conditions, and degree of maturity.2 In a 2014 European study assessing fruit sensitization rates, apple ranked as the second most frequent inducer of sensitization (after peach) with a rate of 6.5 percent.3 While an average apple weighs 200 to 250 grams, as little as 5 grams of apple can generate a reaction.2

Where are apples found?

Apple trees are native to the temperate zones of both hemispheres, and apples are primarily eaten fresh as a whole fruit.1,2 However, in addition to being used to create items such as vinegar, juice, jelly, apple butter, pie stock, applesauce, wine, and brandy, apples are often ingredients in items such as breakfast cereals, candy bars, yogurt, deserts, cakes, pies, and pastries.1,2 Apples are also used in some hygiene products such as soap, shampoo, and shower gel; as a fruit extract in some biological cosmetics; and in pectin, which is employed as a gelling agent.2,3

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Are there other allergens I could be sensitized to?*

Some people with apple allergy may also experience symptoms when eating other seemingly unrelated foods. This is called cross-reactivity and occurs when your body's immune system identifies the proteins, or components, in different substances as being structurally similar or biologically related, thus triggering a response. The most common cross-reactivities with apple include cherries, peaches, hazelnuts, peanuts, carrots, pears, raspberries, strawberries, and mulberries.3

If you experience an itchy mouth or throat after eating apples or other related fresh fruits or raw vegetables, you may suffer from Oral Allergy Syndrome (OAS), sometimes called Pollen Food Allergy Syndrome (PFAS). This condition is caused by your immune system's reaction to similar proteins, or components, found in plant foods and tree pollens.6 It is quite common, with up to 25 percent of children with allergic rhinitis (i.e., hay fever) also suffering from OAS when eating fruits or vegetables.7 Common pollen allergies that could cause OAS when eating apple include tree pollens such as birch, alder, and hazel.3

Do I need to avoid all forms of apple?

An apple consists of different types of proteins that all have different characteristics that may be associated with varying risk of causing severe allergic reactions. Some people with apple allergy may be able to eat apple if it is extensively heated (cooked), as high temperatures break down the causative proteins. Other proteins are mostly located in the peel, and apple may be tolerated if peeled. For other patients, apple may need to be avoided in all forms, it could potentially cause a severe event, also called anaphylaxis. Your specific risk profile depends on which proteins you are allergic to.3

Knowing the proteins, or components, within each allergen that are triggering your symptoms can help guide your management plan. With that in mind, and based on your symptom history, your healthcare provider may suggest something called a specific IgE component test, which can help reveal other pollens and foods you may react to.3

Already have your specific IgE component test results?

Your component test results will include the name of the components (a series of letters and numbers and/or name). Your healthcare provider will likely review the results with you, but here you'll find an at-a-glance breakdown you can use as a reference. Simply match the component names to the list below to see what they mean in terms of symptom management.3

rMal d 1

  • Usually associated with mild symptoms, such as OAS, but sometimes also severe reactions.
  • Present in all pollens and plant foods, associated with cross-reactions, typically to birch and grass pollen.
  • Sensitive to heat and digestion, and cooked foods are often tolerated.

rMal d 3

  • Usually associated with severe reactions as well as OAS.
  • High concentration in the peel. Peeled apple may be tolerated.
  • Stable to heat and digestion, cooked apples can also cause symptoms.

MUXF3 (CCD)

  • Positive specific IgE for apple in combination with MUXF3 CCD (Cross-Reactive Carbohydrate Determinant) being the only positive component test indicates that the cause of symptoms may be something other than apple.

Test results should be interpreted by your healthcare provider in the context of your clinical history. Final diagnosis and decision on further management is made by your healthcare provider.

*These products may not be approved for clinical use in your country. Please work with your healthcare provider to understand availability.

How do I manage my allergy?

Because there is no cure for food allergies, your healthcare provider may recommend a plan that includes the following.8-11

  • Read ingredient labels and "may contain" advisory panels on food and nonfood products carefully, and avoid all foods and products containing any form of the allergen. Note that these lists and panels may not appear on the same side of a product's packaging and that manufacturers frequently change ingredients. If you're unable to obtain a list of ingredients, it's safest to avoid that item.
  • Avoid cross-contamination when cooking by using two sets of cooking and eating utensils, with one exclusively for the allergic individual. Wash all dishes and utensils in hot soapy water between uses.
  • Craft an action plan with a list of steps for you and others to take should you accidentally ingest the allergen. Print out a copy of the plan and carry it with you.
  • Talk with restaurant chefs about your allergy and order food that's simply prepared and void of any form of the allergen. Avoid desserts, as they often contain or have come into contact with food allergens.
  • Plan ahead for traveling to ensure your food allergy will be managed and any emergency medication is always available.
  • Wear a medical ID bracelet identifying the allergen to which you're allergic.
  • Carry any recommended or emergency medication with you at all times.
  • Teach children with food allergies which foods to avoid. Work with caregivers and school staff to eliminate or reduce exposure to the allergen and to ensure they understand when and how to use medication to treat symptoms.

Your healthcare provider may direct you to take one of the following medications:

  • Epinephrine auto-injector when there are signs of an acute severe event, aka anaphylaxis (see below). Ensure your family members know how to administer it in case of an emergency.
  • Antihistamines as a supplement may be useful in relieving mild symptoms (e.g., itch); however, they do not halt the progression of an allergic reaction.
  • Bronchodilator (albuterol) as a supplemental therapy for respiratory symptoms, especially in those with a history of bronchospasm or asthma.

If you're with someone who's having an allergic reaction and shows signs of shock, act fast. Look for pale, cool, and clammy skin; a weak, rapid pulse; trouble breathing; confusion; and loss of consciousness. Do the following immediately:

  • Call local emergency services.
  • Ensure the affected individual is lying down with legs elevated.
  • Administer epinephrine immediately for any obvious signs of anaphylaxis.
  • Check the affected individual's pulse and breathing and administer CPR or other first-aid measures if necessary.

Looking for more allergy info and management tips?

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Apple Allergen Facts, Symptoms, and Treatment

Common Symptoms

Apple allergy can range from mild to severe and may vary over time, resulting in mild symptoms during one episode and severe symptoms in another. Although food allergy symptoms can start a few minutes to several hours after ingestion, most begin within two hours.3,4 Symptoms may involve the skin, gastrointestinal tract, cardiovascular system, and respiratory tract, and may include one or more of the following:4,5

  • Abdominal pain, diarrhea, nausea, vomiting, stomach cramps
  • Hives (allergic urticaria), itching, eczema
  • Wheezing, nasal congestion, shortness of breath, repetitive cough
  • Shock, circulatory collapse
  • Tight, hoarse throat, trouble swallowing
  • Pale or blue skin coloring
  • Dizziness, lightheadedness, fainting, weak pulse
  • Anaphylaxis, a potentially life-treatening event

Symptoms may also include the following, which are associated with Oral Allergy Syndrome (OAS), aka Pollen Food Allergy Syndrome (PFAS):6

  • Itchy mouth and hives on the mouth
  • Scratchy throat
  • Swelling of the lips, mouth, tongue, and throat
  • Itchy ears

How do I know if I'm allergic?*

Together with your symptom history, skin-prick testing or specific IgE blood testing can help determine if you are allergic to a particular allergen. If you are diagnosed with an allergy, your healthcare provider will work with you to create a management plan.

*These products may not be approved for clinical use in your country. Please work with your healthcare provider to understand availability.

Is there a risk for a severe event?

Because food allergic reactions are unpredictable and symptoms range from local to systemic, it is recommended that an epinephrine prescription be considered for any patient with an IgE-mediated food allergy.8

  1. Encyclopedia Britannica [Internet]. Chicago: Encyclopedia Britannica Inc.; 2019 Nov 26. Available from: https://www.britannica.com/print/article/30599.
  2. The University of Manchester [Internet]. Manchester, UK: The University of Manchester; 2006 Oct 18. Available from: http://research.bmh.manchester.ac.uk/informall/allergenic-food/index.aspx?FoodId=2#:~:text=Most%20apple%20allergic%20patients%20notice,the%20%E2%80%9Coral%20allergy%20syndrome%E2%80%9D.
  3. EAACI, et al. Molecular allergology user's guide. Zurich, Switzerland: European Academy of Allergy and Clinical Immunology; 2016. 199-212 p. Available from: http://www.eaaci.org/documents/Molecular_Allergology-web.pdf.
  4. American College of Allergy, Asthma & Immunology [Internet]. Arlington Heights, IL: American College of Allergy, Asthma & Immunology; 2014. Available from: https://acaai.org/allergies/types/food-allergy.
  5. Mayo Clinic [Internet]. Rochester, MN: Mayo Foundation for Medical Education and Research; 2019 Nov 2. Available from: https://www.mayoclinic.org/diseases-conditions/food-allergy/symptoms-causes/syc-20355095.
  6. American College of Allergy, Asthma & Immunology [Internet]. Arlington Heights, IL: American College of Allergy, Asthma & Immunology; 2014. Available from: https://acaai.org/allergies/types/food-allergies/types-food-allergy/oral-allergy-syndrome.
  7. Roberts, Graham & Xatzipsalti, M & Borrego, Luis & Custovic, Adnan & Halken, Susanne & Hellings, Peter & Papadopoulos, Nikolaos & Rotiroti, G & Scadding, Glenis & Timmermans, Frans & Valovirta, Erkka. (2013). Paediatric rhinitis: Position paper of the European Academy of Allergy and Clinical Immunology. Allergy. 68. 10.1111/all.12235.
  8. Wright BL, Walkner M, Vickery BP, Gupta RS. Clinical Management of Food Allergy. Pediatr Clin North Am. 2015 Dec;62(6):1409-24. doi: 10.1016/j.pcl.2015.07.012. Epub 2015 Sep 7. PMID: 26456440; PMCID: PMC4960977
  9. American College of Allergy, Asthma & Immunology [Internet]. Arlington Heights, IL: American College of Allergy, Asthma & Immunology; 2014. Available from: https://acaai.org/allergies/types-allergies/food-allergy/food-allergy-avoidance.
  10. Harvard Health Publishing [Internet]. Boston, MA: Harvard Medical School; 2020. Available from: https://www.health.harvard.edu/healthbeat/6-tips-for-managing-food-allergies.
  11. Mayo Clinic [Internet]. Rochester, MN: Mayo Foundation for Medical Education and Research; 2019 Sep 14. Available from: https://www.mayoclinic.org/diseases-conditions/anaphylaxis/symptoms-causes/syc-20351468.
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