Apple Allergy Frequency, Symptoms, and Foods to Avoid

Apple allergies can occur, especially in people who are allergic to birch tree pollen. Up to 8% of children and 3% of adults may experience food allergies, including reactions to apples. The main allergens in apples are the proteins Mal D1 to Mal D4, with Mal D1 being the most common trigger among them.

Symptoms of an apple allergy often include itching and tingling in the mouth and throat, which is part of a condition called oral allergy syndrome (OAS). These reactions usually happen after eating raw apples, while gastrointestinal symptoms are rare. The severity of these symptoms can vary based on the type of apple and its ripeness.

Types of Apple Allergy

There are two types of allergic reactions people can have to apples: true apple allergy and oral allergy syndrome (OAS).

True apple allergy occurs when the immune system overreacts to apple proteins Mal D1, Mal D2, Mal D3, or Mal D4, leading to systemic (whole-body) symptoms that can be severe or life-threatening.

In contrast, oral allergy syndrome typically results in mild mouth and throat symptoms like tingling or itching after eating apples. It is often triggered by proteins in the apple that resemble those in pollen, particularly birch pollen.

OAS is common, affecting about 1 in 3 people with seasonal allergies. Unlike a true allergy, OAS is more a case of “mistaken identity.” In OAS, the immune system "reads" the apple proteins as if they are tree pollen proteins, and reacts to them as if they were.

People with OAS often have worse allergy symptoms during the seasons when their bodies are already overwhelmed by airborne pollens. If you can usually tolerate raw apples and then suddenly have a reaction to them, it might be because pollen counts are high.

Frequency

Apples are not considered one of the "big 9" major food allergens. However, they are one of the most common fruit allergies, and can still cause severe allergic reactions.

Apples are the most common food allergy in Korea and Japan and the third most common in China. They are also a major allergy in Central-Northern Europe. However, most people with apple allergy symptoms actually have OAS due to cross-reactivity with birch pollen.

Birch-apple syndrome, as it is commonly called, is so common that up to 94% of people with birch pollen allergy also develop apple allergies.

Symptoms of Apple Allergy

Apple allergy symptoms vary, depending on if you're having a true allergic reaction to apples or if you are experiencing OAS. Symptoms of OAS are usually mild and only felt in the mouth, lips, or tongue.

Oral allergy syndrome symptoms typically include:

• Itchy, irritated mouth, tongue, or throat
• Red and slightly swollen lips, tongue, or throat

OAS symptoms tend to be more surprising than irritating. Usually, they only last a few seconds or minutes—however long it takes for the enzymes in the saliva to break the proteins down.

True apple allergy symptoms affect more than the mouth. The symptoms of an apple allergy range from mild irritation or itchiness to a whole-body, potentially life-threatening allergic reaction.

People with a true apple or a peach allergy are more likely to have pronounced allergy symptoms, such as:

• Nausea or stomach upset
• Abdominal cramps
• Diarrhea
• Rash
• Hives

In severe cases, anaphylaxis—a potentially life-threatening allergic reaction—can occur in people with true apple allergies. Anaphylaxis is a medical emergency that requires urgent care.

Symptoms of anaphylaxis may include:

• Swelling of the face, tongue, or throat
• Wheezing
• Shortness of breath
• Vomiting
• Rapid heartbeat
• Trouble swallowing
• Slurred speech

If left untreated, anaphylaxis can lead to a lack of oxygen, shock, coma, and even death. Do not hesitate to call 911 at the first sign of anaphylaxis.

Foods to Avoid

The most important way to avoid apple allergy symptoms is to avoid apples and other foods that could trigger symptoms.

If you have a true apple allergy, you will need to avoid apples in all forms. Remember, too, that you may also have reactions to some other foods and may need to avoid them as well.

These may include:

• Peach
• Pear
• Cherry
• Apricots
• Plum
• Strawberry
• Nectarine
• Banana
• Melons
• Celery
• Carrots
  
• Hazelnuts
• Almonds
• Walnuts
• Soybeans

People with Oral Allergy Syndrome (OAS) should also avoid eating raw apples, as this form often triggers symptoms.

That said, some individuals can tolerate cooked apples, like those in apple pie, since heating changes the proteins that cause the reaction. Cooked, baked, boiled, or dried apples are generally safe because the proteins break down enough to prevent a reaction.

Peeling or heating apples may also help some people avoid symptoms, as the proteins causing the reaction are usually concentrated in the flesh just under the skin. However, it's wise to avoid all apple forms during high pollen seasons when your immune system is more sensitive.

When to See a Healthcare Provider

If you think you’re having an allergic reaction to apples, talk to your provider. If the symptoms are just in your mouth, it’s likely you have OAS, but you’ll need to see a provider to find out for sure. 

You may need to see an allergist to learn how to manage your allergy symptoms effectively and learn when and how to use an Epi-Pen if needed. 

If you ever have symptoms of anaphylaxis, call 911 or get emergency medical care immediately.

Summary

If you think you are having an allergic reaction after eating apples, you likely have oral allergy syndrome (OAS), especially if the symptoms are mild, don’t last long, and only affect your mouth. This reaction is not like a true apple allergy and is more similar to a pollen allergy.

You should see a provider if you have symptoms after eating apples and you don’t know what's causing them.

Whether you have a true allergy or OAS, you can learn to manage your symptoms by preparing foods in a certain way, avoiding foods that trigger a reaction, and taking medication to treat your allergy symptoms and prevent serious allergic reactions.