Reactions to alcohol


IMPORTANT The information provided is of a general nature and should not be used as a substitute for professional advice. If you think you may suffer from an allergic or other disease that requires attention, you should discuss it with your family doctor. The content of the information articles and all illustrations on this website remains the intellectual property of Dr Raymond Mullins and cannot be reproduced without written permission.

Allergic reactions to alcoholic beverages are uncommon, but have been described. By contrast, non-allergic adverse reactions to alcohol such as flushing, irritant reactions, toxic reactions and psychological effects are more common.

Alcohol is a natural product
Alcohol (ethanol) is a normal by-product of human and animal cell chemistry/metabolism. Cell processes result in normal physiological levels of 0.01 to 0.03 mg of alcohol/100 ml of blood. By contrast, a blood alcohol limit for driving of 0.05 per cent is equivalent to 50 mg of alcohol/100 ml of blood.

Alcohol is broken down in the liver
Alcohol (ethanol) is broken down by liver enzymes within minutes. Conversion of ethanol to acetaldehyde requires the enzyme alcohol dehydrogenase. Acetaldehyde is then transformed to acetic acid ("vinegar") by the enzyme aldehyde dehydrogenase. If individuals can't break down alcohol easily, problems may occur if alcohol is consumed.

Flushing is not an allergic reaction
Some patients will experience intense facial flushing after having even small amounts of alcohol. These symptoms are most common in those with an oriental / Asian background. Other side-effects of fluttering of the heart (palpitations, tachycardia), sensation of heat, headache, tummy discomfort or a drop in blood pressure (hypotension) are related to high blood acetaldehyde levels. Individuals with these problems appear to be partially deficient in aldehyde dehydrogenase, resulting in high levels of accumulated acetaldehyde.

Other conditions may also trigger flushing
Not all flushing is due to alcohol. Flushing can occur in skin conditions such as rosacea, the menopause, low blood sugar levels (hypoglycaemia), and sometimes as a response to some antibiotics or medicines used to treat diabetes or high blood fat levels or due to naturally occurring substances such as amines in wood matured or brewed beverages.

Alcoholic beverages contain ethanol and other substances
The liver breaks down the alcohol (ethanol) 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 (eg. salicylates), wood and fruit-derived substances (eg. Histamine, tyramine in chianti), added enzymes (like papain) and preservatives (like sulphites). Severe allergic reactions have been described in people with allergies to proteins within grapes, yeast, hops, barley and wheat. These patients are not sensitive to alcohol itself. Furthermore, "fining agents" (like egg protein, milk proteins, parvalbumin and seafood proteins and "isinglass" which is a fish swim-bladder product) are sometimes used to remove fine particles. Whether these occur in sufficient amounts to trigger allergic reactions is unknown.

Asthma can be triggered by sulphites (sulfites)
Up to a third of people with asthma complain that wine will worsen their asthma, less often with beer or spirits. Beer, wine and champagne contain sulphites (additive 220-226), 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 metabisulphite also varies from brand to brand. Some "low sulphite" wines are available, although those with extreme sensitivity may not be able to tolerate them. This is because some grape growers will dust sulphur powder over grapes in the weeks leading up to harvest. Other sources of sulphites include vinegar, pickled onions, dried fruit, or when dusted onto crustaceans and some restaurant salads or fruit salads. Sometimes grapes are transported with bags of sulphites to keep them fresh. Even when people complain that wine triggers asthma, sulphites may not be the only explanation. See link about the type of foods containing these preservatives:

Not all sulphurs are created equal

Sulphite preservatives in food, sulphonamide antibiotics and sulphur molecules in some medicines have no relationship with each other. So a person reacting to sulphite preservatives in wine are not, for example, at higher risk of having an allergic reaction to a sulphonamide antibiotic.

Low /no sulfite wines
As a rule, sulfites are found at higher levels in the cask wine than bottled wine, and are at much higher concentrations in white wine than red wine, when natural tannins help preserve the beverage. Some winemakers in Australia produce wines and state that they do not add sulfites into the wine. There are various technical reasons related to winemaking why very low levels of sulfites might still be present, even when not added to the wine itself. The author has not personally verified the claims of being preservative free. Those interested should make inquiries of the winemaker. The following Australian winemakers produce low / no sulfite wines. This listing is for information purposes only, is not exhaustive, should not be interpreted as a recommendation, should be verified with the manufacturer whether they still produce low sulfite beverages and no payment of any kind has been received by the author for this listing.

  1. BulletHapps (Margaret River, Western Australia) Tel 08-8562 2598

  2. BulletBotobolar (Mudgee, New South Wales) Tel 02-6373 3840

  3. BulletMacaw's Creek (Riverton, South Australia) Tel 08-8847 2237

  4. BulletHardy's "No added preservative wines" tel 1800 088 711

  5. BulletOrganic Wines Australia listings

  6. BulletWines by KT Pazza Riesling and red

  7. BulletPaxton wines

  8. BulletYangarra wines

  9. BulletThere are also many others that can be found by searching online.

Low / no sulfite beers
Some brewers produce beer and state that they do not add sulfites. There are various technical reasons why very low levels of sulfites might still be present, even when not added to the product itself. The author has not personally verified the claims of being preservative free. Those interested should make inquiries of the brewery. The following brewers claim to produce low / no sulfite beers. This listing is for information purposes only, is not exhaustive, should not be interpreted as a recommendation, and no payment of any kind has been received by the author for this listing.

  1. BulletCoopers (Australia) Tel 08 8440 180

  2. BulletHolsten Premium Beer (from UK) Tel 02- 02 9722 1200

  3. BulletSelect Organics Listing

Asthma can also be due to enzyme deficiency
Patients with aldehyde dehydrogenase deficiency accumulate high levels of acetaldehyde after consuming alcohol and most commonly triggers nausea and flushing. Acetaldehyde has been blamed for asthmatic reactions to alcohol in up to half of Japanese asthma patients. Sometimes histamine within alcoholic beverages has been blamed for allergic reactions.

Histamine and other substances may also cause problems
Histamine can trigger sneezing, runny nose and sometimes wheeze, stomach upset and headache. There is more histamine in red than white wines, although the amounts will vary from wine to wine. Some small studies have shown that antihistamines can help reduce the severity of symptoms, but as the amount of wine challenge was equivalent to only one glass, probably won't prevent hangovers! Others substances within wine may also cause problems to some unlucky individuals, but these are not well defined.

Serious allergic reactions to beer or wine may occur
Anaphylaxis has been described in patients with severe allergic reactions to proteins within grapes, yeast, hops, barley and wheat. These patients are not sensitive to alcohol itself.

Anaphylaxis to alcohol is rare
Allergic reactions to alcohol itself are rare, but described in a few dozen published case reports. 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, a condition known as anaphylaxis. Given that the body constantly produces small amounts of alcohol itself, the reason that such reactions occur is poorly understood. Allergy tests using alcohol are usually negative, but sometimes positive to breakdown products of ethanol such as acetaldehyde or acetic acid ("vinegar"). Provocation tests with alcohol are usually positive, but only sometimes when acetaldehyde or acetic acid are used. Finally, alcohol can sometimes act as a "co-factor", increasing the likelihood of anaphylaxis from other causes.

Sources of alcohol are not always obvious
When one thinks of alcohol sensitivity, beverages come immediately to mind. There are however, potentially a number of other less obvious sources. These include as alcoholic soft drinks, mixes, spiked drinks, food marinades or tomato puree. Over-ripe fruit can ferment, resulting in enough alcohol production to trigger a reaction. Some medicines like cough syrups also contain alcohol, as do some medicines given by injection.

Management of alcohol allergy
Accidental exposure may lead to unexpected reactions. Patients with alcohol allergy should be managed in the same way as others with serious allergic reactions: identify and avoid the cause, wear a Medic Alert bracelet, and carry adrenaline (epinephrine) as part of an emergency action plan if they are at risk of dangerous allergic reactions in the future.

Milder reactions to alcohol may also occur
Alcohol can worsen symptoms in patients with hives / urticaria. Occasionally, alcohol can also trigger hives directly. As with more serious allergic reactions, the mechanism is unclear. Less common reactions include localized contact hives and contact dermatitis.

Not all adverse reactions to alcohol are due to allergy
Other effects of alcohol toxicity are well known, including its effect on the liver, stomach, brain and mental functioning in large amounts. Even though alcohol has a relaxant effect on the brain, some individuals will experience paradoxical agitation and anxiety. Such symptoms are due to the drug-like activity of alcohol. They do not represent "allergy" anymore than a "hangover" does.

Ayres, J. G. and D. Allsopp. Fungal growth on wine corks--a potential source of exposure to susceptible individuals. Clin Exp Allergy 1994; 24(12): 1179-80.
Boehncke W-H, Gall H. Ethanol metabolite acetic acid as causative agent for type-I hypersensitivity-like reactions to alcoholic beverages. Clin Exp Allergy 1996; 26: 1089-91.
Bonadonna, P., M. Crivellaro, et al. Beer-induced anaphylaxis due to barley sensitization: two case reports." J Investig Allergol Clin Immunol 1999; 9(4): 268-70.
Clayton, D. E. and W. Busse. Anaphylaxis to wine. Clin Allergy 1980; 10(3): 341-3.
Curioni A et al. Urticaria from beer: an immediate hypersensitivity reaction due to a 10kDa protein derived from barley. Clin Exp Allergy 1999; 29: 407-13.
Dahl, R., J. M. Henriksen, et al.Red wine asthma: a controlled challenge study. J Allergy Clin Immunol 1986; 78(6): 1126-9.
Dalton-Bunnow, M. F. Review of sulfite sensitivity. Am J Hosp Pharm 1985; 42(10): 2220-6.
Ehlers, I., U. C. Hipler, et al. "Ethanol as a cause of hypersensitivity reactions to alcoholic beverages." Clin Exp Allergy 2002; 32(8): 1231-5.
Elphinstone PE et al. Alcohol-induced urticaria. J Royal Soc Med 1985; 78: 340-1.
Fernandez-Anaya, S., J. F. Crespo, et al.Beer anaphylaxis. J Allergy Clin Immunol 1999; 103(5 Pt 1): 959-60.
Figueredo, E., S. Quirce, et al. Beer-induced anaphylaxis: identification of allergens. Allergy 1999; 54(6): 630-4.
Garcia-Casado, G., J. F. Crespo, et al. Isolation and characterization of barley lipid transfer protein and protein Z as beer allergens. J Allergy Clin Immunol 2001; 108(4): 647-9.
Garcia-Robaina, J. C., F. de la Torre-Morin, et al. Anaphylaxis induced by exercise and wine. Allergy 2001; 56(4): 357-8.
Gershwin, M. E., C. Ough, et al. Grand rounds: adverse reactions to wine. J Allergy Clin Immunol 1985; 75(3): 411-20.
Gotz, M. Pseudo-allergies are due to histamine intolerance. Wien Med Wochenschr 1996; 146(15): 426-30.
Halpern, G. M., M. E. Gershwin, et al. The effect of white wine upon pulmonary function of asthmatic subjects. Ann Allergy 1985; 55(5): 686-90.
Harada S et al. Aldehyde dehydrogenase deficiency as cause of facial flushing reaction to alcohol in Japanese. Lancet 1981; 982.
Imai, K., T. Tokuno, et al. A case of food-dependent anaphylaxis induced by alcohol Arerugi 1992; 41(9): 1419-22.
Kelso, J. M., M. U. Keating, et al. Anaphylactoid reaction to ethanol. Ann Allergy 1990 64(5): 452-4.
Kleinhans, D. Sensitivity of asthma patients to sulfur compounds in food, wine and injection solutions. Dtsch Med Wochenschr 1990; 107(37): 1409-11.
Kochumian, A. A., R. R. Bedzhieva, et al. 3 cases of death in bronchial asthma patients after consuming alcoholic beverages. Ter Arkh 1987; 59(1): 110-1.
Mallon, D. F. and C. H. Katelaris. Ethanol-induced anaphylaxis following ingestion of overripe rock melon, Cucumis melo. Ann Allergy Asthma Immunol 1997; 78(3): 285-6.
Ormerod AD, Holt PJA. Acute urticaria due to alcohol. Br J Dermatol 1983; 108: 723-4.
Pastorello EA et al. Identification of grape and wine allergens as an Endochitinase 4, a lipid-transfer protein, and a Thaumatin. J Allergy Clin Immunol 2003; 111: 350-9.
PrzybillaB, Ring J. Anaphylaxis to ethanol and sensitization to acetic acid. Lancet 1983; 483.
Reed TE et al. Alcohol and acetaldehyde metabolism in Caucasians, Chinese and Amerinds. CMA Journal 1976; 115: 851-5.
Sticherling, M. and J. Brasch. Alcohol: intolerance syndromes, urticarial and anaphylactoid reactions. Clin Dermatol 1999; 17(4): 417-22.
Ting, S. Anaphylactoid reaction to ethanol. Ann Allergy 1992; 69(5): 463.
Tsevat, J., G. N. Gross, et al. Fatal asthma after ingestion of sulfite-containing wine. Ann Intern Med 1987; 107(2): 263.
Vally, H., A. Carr, et al. Wine-induced asthma: a placebo-controlled assessment of its pathogenesis. J Allergy Clin Immunol 1999; 103(1 Pt 1): 41-6.
Vally, H., N. de Klerk, et al. Alcoholic drinks: important triggers for asthma. J Allergy Clin Immunol 2000; 105(3): 462-7.
Vally, H. and P. J. Thompson (2001). "Role of sulfite additives in wine induced asthma: single dose and cumulative dose studies." Thorax 56(10): 763-9.
Wantke, F., M. Gotz, et al. The red wine provocation test: intolerance to histamine as a model for food intolerance. Allergy Proc 1994; 15(1): 27-32.
Wantke, F., W. Hemmer, et al. Histamine in wine. Bronchoconstriction after a double-blind placebo-controlled red wine provocation test. Int Arch Allergy Immunol 1996; 110(4): 397-400.
Wright, W., Y. G. Zhang, et al. Effect of inhaled preservatives on asthmatic subjects. I. Sodium metabisulfite. Am Rev Respir Dis 1990; 141(6): 1400-4.
Wuthrich, B. and T. Huwyler. Asthma due to disulfites. Schweiz Med Wochenschr 1989; 119(35): 1177-84.
Zellweger, J. P. Asthma and rhinitis induced by the ingestion of pure ethanol and by the inhalation of alcohol vapors]." Schweiz Med Wochenschr 1982; 112(6): 212-4.

Vally H, Thompson PJ. Alcoholic drinks and asthma (Review). Clin Exp Allergy 2002; 32: 186-91.

Añíbarro B, Seoane FJ. Ethanol-induced urticaria caused by sensitization to

acetic acid. Ann Allergy Asthma Immunol. 2018 Mar;120(3):337-338. doi:


Versluis A, van Os-Medendorp H, Kruizinga AG, Blom WM, Houben GF, Knulst AC.

Cofactors in allergic reactions to food: physical exercise and alcohol are the

most important. Immun Inflamm Dis. 2016 Sep 15;4(4):392-400.

Eriksson CJ. The role of acetaldehyde in the actions of alcohol (update 2000).

Alcohol Clin Exp Res. 2001 May;25(5 Suppl ISBRA):15S-32S.

Last reviewed 12 July 2020