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Navigating Allergies and Food Sensitivities

Salicylate Intolerance

The percent of people with salicylate sensitivity or intolerance is estimated to be approximately 2.5%.1

Salicylates are naturally occurring hormones found in most food plants including fruits, vegetables, and many nuts, seeds, herbs, spices, mint, and oils. The purpose of the salicylate in fruits and vegetables is to protect the plant from being eaten by insects.  It usually exists in concentrated amounts in the fruit or vegetable’s skin and below the skin.  As the fruit or vegetable ripens, the salicylate level usually decreases.

Uses of Salicylate and its Derivatives

Understanding Salicylate Intolerance
The medicinal use of salicylate dates to the 5th century BC when it was extracted from willow bark to ease aches and pains and reduce fevers.  In modern medicine, salicylic acid and its derivatives are used as the basis for aspirin, liniments to soothe joint and muscle pain, to relieve the pain of mouth ulcers, and as a key ingredient in many skin-care products for the treatment of dermatitis, acne, psoriasis, calluses, corns, keratosis pilaris, and warts. 2,3,4,5,6

Bismuth subsalicylate, a salt of bismuth and salicylic acid, is the active ingredient in stomach relief aids such as Pepto-Bismol®.

Although toxic in large quantities, small amounts of salicylic acid are used as a food preservative and as a bactericidal and antiseptic 7. For some people with salicylate sensitivity even these small doses can be harmful.

The Most Common Symptoms of Salicylate Sensitivity are: 8, 9, 10

  • Itchy skin, hives or rashes, (urticaria)
  • Stomach pain, cramps or diarrhea
  • Vomiting
  • Asthma and other breathing difficulties
  • Recurrent Nasal Polyps
  • Persistent cough
  • Headaches
  • Swelling of hands, feet, eyelids, face and/or lips
  • Bed wetting or urgency to pass water
  • Changes in skin color/skin discoloration
  • Fatigue
  • Sore, itchy, puffy or burning eyes
  • Hyperactivity
  • Memory loss and poor concentration
  • Depression
  • Heartburn
  • Body aches
  • Blood in stool
  • Anaphylaxis in severe cases (e.g., allergy to aspirin)
Frequency of Salicylate Intolerance Symptoms 11,12,13,14,15
Symptom Frequency
Polyps with asthma 20% – 30%
Nasal polyps 5% – 30%
Bronchial asthma 10%
Rhinitis 5% – 10%
Chronic intestinal inflammation 2% – 7%
Urticaria/Quincke edema (Hives and Swelling) 5% – 10%

Salicylate Research Efforts

Salicylate sensitivity or intolerance has been known for approximately 100 years, but only recently has the prevalence and severity of this condition become widely recognized.

In 1965, Dr. B.F. Feingold a pediatrician and allergist, considered a pioneer in the fields of allergy and immunology, was referred an adult patient whose severe hives had not responded to typical treatments 16. Dr. Feingold placed her on a low-salicylate diet with no synthetic coloring or flavoring. In addition to causing her hives to disappear, the same patients’ personality disorders were documented to have improved by her psychiatrist. This began Dr. Feingold’s efforts to develop a diet for people – especially children – with behavioral problems as well as allergy, and eventually found the diet often worked for children with behavioral problems even without allergy symptoms. See Autism, ADHD and Diet for more information regarding the “Feingold Diet.” 17,18,19

In 1985, Anne Swain, Stephen Dutton, and Stewart Truswell of the Human Nutrition Unit of the University of Sydney, Australia were investigating a “Mysterious Disease X” when they noticed the symptoms were similar to those of patients who suffered side effects of aspirin, which contains a salicylate derivative as its active ingredient. With this hypothesis in mind, and building on a series of studies that indicated the potential allergy-reducing benefits of reducing salicylate exposure, they tested 333 foods to identify those that contained measurable amounts of salicylate. 20

In 1991, using even more sophisticated testing methods (gas chromatography and mass spectrometry), Michael J. Scotter, Dominic P.T. Roberts, Lesley AWilson, Frances A.C. Howard, June Davis, and Nicholas Mansell conducted an additional study further identifying the salicylic acid and acetyl salicylic acid content of foods. 21

The results of these testing efforts are reflected in the below table that indicates foods that may contain salicylates.

Foods that May Contain Salicylates 20,21,22

Foods That Contain Salicylates Salicylate-Containing Ingredients Products That May Contain Salicylates Foods That May be Allowed
Fruits: apples, (except peeled golden delicious and peeled red delicious apples), apricot, avocados, blackberries, blueberries, cantaloupes, cherries, cranberries, chicory, dates, figs, grapes, grapefruit, guavas, kiwi fruit, loganberries, melon, nectarines, olives, oranges, peaches, pineapple, plums, prunes, radish, raisins, raspberries, strawberries, and tomato.Vegetables: alfalfa sprouts, asparagus (fresh), bean sprouts, bell peppers (all colors), broad beans, broccoli, corn, cucumbers, eggplant, endive, mushrooms, olives, okra, parsnip, peppers (all kinds), pimento, pumpkin, radishes, spinach, squash, sweet potato, and zucchini, watercress, and water chestnut.

Starch: Corn (Maize)

Dairy: Cheese (with yellow coloring including annatto), fruited yogurt.

Oils: Coconut oil, olive oil.

Flavorings: herbs, spices, – All herbs and spices contain large quantities of salicylates. Examples include: Bay Leaf, Cumin, Curry, Cilantro, Cinnamon, Dill, Mustard, Paprika, Pepper, Thyme, Turmeric.

Condiments: tomato pastes and sauces, Ketchup, Mustard, Worcestershire sauce, Vinegar (all but white distilled), Soy Sauce, Jams, Jellies, and Honey.

Sweeteners: Honey

Beverages: coffee, tea, (regular and herbal) wine, beer, orange juice, apple cider, juices, rum, and sherry. Note: Caffeine is very high in salicylates

Nuts: almonds, brazil nuts, cashews, coconut, peanuts, pistachios, pine nuts, and water chestnuts.

Many candies, such as peppermints, licorice, mint-and cinnamon fruit flavored or artificial flavored gum, and breath mints.

Seeds: sesame, sunflower seeds,

Cooking Oil – olive oil, coconut oil, peanut oil, sesame oil, sunflower oil

Yeast

Ice cream, gelatin

AspirinAlka-Seltzer

Acetylsalicylic acid

Artificial food coloring and flavoring

Benzoates

Beta-hydroxy acid

Cinnamon

Magnesium salicylate

Menthol

Mint

Salicylic acid

Peppermint

Pepto-Bismol

Phenylethyl salicylate

Sodium salicylate

Any mint, anise, wintergreen, spearmint,

Fragrances and perfumesShampoos and conditioners

Herbal remedies

Cosmetics such as lipsticks, lotions, and skin cleansers

Mouthwash and mint- and cinnamon tooth paste

Shaving cream

Sunscreens or lotions

Moisturizers

Teething Gel

Face/Acne Creams

Fruits: apples (golden and red delicious peeled), apricot nectar, banana, figs (fresh and canned), light seedless grapes (canned), lemon, mango, peach nectar, pears (peeled), persimmon, pineapple juice, red plums (peeled), pomegranate, rhubarbVegetables: asparagus (canned), bamboo shoots, brussels sprouts, cabbage, carrots, celery, cauliflower, lentils, lettuce (iceberg), green peas, split peas, chickpeas, onions, potato (white peeled), spinach (frozen), tomato (fresh), turnip

Starch: Barley, Oat, Rice, Rye, Wheat, Potato Flours or Starches

Dairy: Cheese (white without annatto and with allowed ingredients), cream (pure, not low- fat),milk, plain yogurt with allowed ingredients.

Oils: Butter (pure, no color), canola oil, margarine with allowed ingredients

Flavorings: coriander (fresh), garlic (fresh), onion (fresh), and parsley (fresh), may all be tolerated in small quantities. Salt, chocolate (pure), cocoa powder (pure), vanilla (pure).

Condiments: vinegar (white distilled only)

Sweeteners: molasses, sugar, syrup.

Beverages: water, milk, chocolate milk with allowed ingredients, gin, lemonade, vodka, whiskey.

Cooking oil: canola oil

Ice cream with allowed ingredients

Patient Testing and Diagnosis

There are no laboratory or skin testing methods for testing salicylate sensitivity. A provocative challenge is one method of obtaining a reliable diagnosis.

A provocative challenge, or food challenge, is when the patient is given increasing doses of the food to which sensitivity is suspected, under direct supervision of a physician as potential adverse reactions may occur. A challenge is considered positive at the first apparent sign of a reaction.

When testing for salicylate sensitivity, increasing doses of aspirin are delivered under medical supervision, until either symptoms appear or the likelihood of symptoms appearing is ruled out.

Treatment

Completely eliminating salicylate from one’s diet and environment is virtually impossible. The range of foods that have no salicylate content is very limited, and consequently salicylate-free diets are very restricted.

Nonetheless, a salicylate-reduced diet is possible, but to ensure the patient receives the required nutrients it is recommended that a Doctor and Registered Dietitian be consulted to help compile a proper diet for each patient, as each patients’ needs, additional health concerns, and levels of sensitivities are unique.

Under the supervision of a physician, salicylate inactivation or desensitization is a possible biological approach. Desensitization involves daily consumption of small doses of acetylsalicylic acid (e.g., aspirin) without symptoms recurring and slowly increasing the dosage. The first dose is usually 5 mg. The single doses are then increased up to 100 to 300 mg, which must then be taken once daily on a long-term basis. Depending on the procedure and the patient’s tolerance, this can last from a few days to two weeks. In about 80% of cases, improvements in nasal respiration, sense of smell and freedom from recurrent polyps are retained for two to three years. 23,24,25,26

Salicylate Sensitivity or Intolerance – Links

SalicylateSensitivity.com
Food Intolerance Network – Salicylates
The Feingold Association of the United States – Salicylate & Aspirin Sensitivity

Citations

1Zopf et al. The Differential Diagnosis of Food Intolerance. Dtsch Arztebl Int. 2009 May; 106(21): 359–370.

2Fryers G. in New Perspectives on aspirin therapy,1982 Aspirin Foundation Symposium, New Orleans, April 21-3 1982.

3Pierpoint WS. The natural history of salicylic acid, plant product and mammalian medicine. Interdisciplinary Science Reviews 1997;22:45-52.

4Stone E. An account of the success of the bark of the willow in the cure of agues. Philos.Trans. 1763;53:195-200.

5Friend D. aspirin: the unique drug. Arch.Surg. 1974;108:765-9.

6Steele, K.; Shirodaria, P.; O’Hare, M.; Merrett, J.D.; Irwin, W.G.; Simpson, D.I.H.; Pfister, H. (1988). “Monochloroacetic acid and 60% salicylic acid as a treatment for simple plantar warts: effectiveness and mode of action”. British Journal of Dermatology 118 (4): 537–43. doi:10.1111/j.1365-2133.1988.tb02464.x. PMID 3377974.

7Definition of Salicylic acid”. MedicineNet.com.

8http://www.sswahs.nsw.gov.au/rpa/allergy/research/salicylatesinfoods.pdf

9http://www.webmd.com/allergies/guide/salicylate-allergy

10Scotter MJ, Roberts DPT., Wilson LA, Howard FAC, Davis J, Mansell Chromatography – mass spectrometry. Food Chemistry, Vol 105, 1, 2007

11Hanns-Wolf Baenkler. Dtsch Arztebl Int v.105(8); Feb 2008

12>Szczeklik A, Stevenson DD. Aspirin-induced asthma: advances in pathogenesis, diagnosis and management. J Allergy Clin Immunol. 2003;111:913–920. [PubMed]

13>Farooque S, Lee T. Mechanisms of aspirin-sensitive respiratory disease – as two component Model. Int Arch Allergy Immunol. 2007;142:59–63. [PubMed]

14Schiavino D, Nucera E, Milani A, Del Ninno M, Buenomo A, Sun J, Patriarca G. The aspirin disease. Thorax. 2000;55:66–69.

15Velten FW, Bayerl C, Baenkler HW, Schaefer D. Functional eicosanoid test and typing (FET) in acetylsalicylic acid intolerant patients with urticaria. J Physiol Pharmacol. 2006;57:35–46. [PubMed]

16Allan Magaziner, Linda Bonvie, Anthony Zolezzi (2003). Chemical-Free Kids: How to Safeguard Your Child’s Diet and Environment (pp.62). Kensington Books. ISBN 0-7582-0369-1.

17Feingold, B.F. (1985). Why Your Child is Hyperactive (pp.1-2). Random House. ISBN 0-394-73426-2.

18>http://www.feingold.org/Research/PDFstudies/Feingold-AAP.pdf

19John Emsley and Peter Fell, 1999 “Was it something you ate?” Oxford University Press

20http://www.sswahs.nsw.gov.au/rpa/allergy/research/salicylatesinfoods.pdf

21Scotter MJ, Roberts DPT., Wilson LA, Howard FAC, Davis J, Mansell Chromatography – mass spectrometry. Food Chemistry, Vol 105, 1, 2007

22What is Salicylic acid and in which foods does it occur?. Food-Info.net. Retrieved on 2012-06-03.

23Szczeklik A, Stevenson DD. Aspirin-induced asthma: advances in pathogenesis, diagnosis and management. J Allergy Clin Immunol. 2003;111:913–920. [PubMed]

24Gosepath J, Schäfer D, Mann WJ. Analgetika-Intoleranz: Langzeitergebnisse bis zu 3 Jahren bei adaptativer Desaktivierung mit einer täglichen Erhaltungsdosis von 100 mg Aspirin. Laryngo-Rhino-Otol. 2002;81:732–738.

25Pfaar O, Klimek L. Aspirin desensitization in aspirin intolerance: update on current standards and recents improvements. Curr Opin Allergy Clin Immunol. 2006;6:161–166. [PubMed]

26Schapowal A, Schmitz-Schumann M. Provokationstests bei aspirinsensitivem Asthma und aspirinsensitiver Rhinosinusits. Allergologie. 1992;15:158–164.