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Red Cheeks- Is it a food allergy?

Frey’s syndrome – a masquerader of food allergy?

We have seen many children who were evaluated for food allergy and/or who were brought by parents to be evaluated for food allergy because of redness to the cheeks that is observed after eating.

What I haven’t heard about is a syndrome called ‘Frey’s Syndrome’. 

In the January edition of Postgraduate Medicine there is a case report, pictures, and a review of this syndrome which frequently precipitates an allergy evaluation. The problem is not due to allergy. It is an allergy-pretender.

Frey’s syndrome is also called the auriculotemporal nerve syndrome.  It involves redness over the cheeks after eating or drinking. The cause is abnormal nerve regeneration which can happen with forceps delivery or after parotid-gland surgery.  The actual incidence of the syndrome is unknown and it is by this report rare in children. Sucking on a lemon brings out the facial flushing. The use of starch/iodine brings sweating which is seen more in the adult.

The facial flushing with eating, gustatory flushing, may mimic food allergy and lead to unnecessary testing and the consequence of restrictive diets.

The clinical course is benign in children. The authors point out that it is important to recognize it so unnecessary evaluations are avoided.

The treatment is explanation and reassurance.

If you can see the paper, there  pictures of this flushing. The reaction looks distinctly delineated. It follows the distribution of the nerve.  The young lady would experience the flushing after eating sweets, citrus fruit, grapes, tomato sauce, fruit-flavored ice cream, and spicy foods. She had no history of any trauma to the area of the auriculotemporal nerve. There were no other symptoms besides this flushing. There was no personal history of allergy. Her teachers thought that this was a food allergy issue. In the clinic, the flush was seen one minute after eating a citrus-flavored sweet.

 I had not heard of Frey’s syndrome before, but I have seen a good number of red-cheeked children who had no other signs/symptoms of a food allergy. In this case, the types of food that elicited the problem, the timing of the flush in relation to eating, and the specific distribution help with the diagnosis of Frey’s syndrome.

We will start stocking sweet citrus-flavored candies for test purposes only. I am soliciting suggestions. So far I think Skiddles may work. If you can think of a candy that is has more of the citrus bite, let me know.

My thanks to the authors N Hussain, M Dhanarass, and W Whithouse for this article (Postgraduate Medicine Journal January 2010 Vol 86 N0 1011 page 62.)

Fred Leickly

February 1, 2010 · fleickly · 10 Comments
Tags:  · Posted in: Food Allergies, Interesting Stories

10 Responses

  1. Eva - February 3, 2010

    Lemonheads!

  2. C - March 4, 2010

    I’m not a doctor, however, I’ve been dealing with what I now know is Frey’s syndrome for my entire 30 years.

    I would urge caution with using a candy such as Skittles for testing because there are ingredients in them which can trigger an allergic reaction.

    The packets of powdered lemon or lime (Pure Lemon, Pure Lime) have never failed to give me a red streak and don’t have the added food colouring and high fructose corn syrup so common in the cheap candies.

  3. fleickly - March 4, 2010

    That is a good point. Sometimes the additives cause reactions.
    Thanks for bringing this up and thanks also for the suggestions for substitute products to try. Your thirty year experience certainly supports the potential chronic nature of the syndrome.
    FEL

  4. Gretchen Moore - March 29, 2010

    Hello, I have two children ages almost 2 & almost 3. Both of them get a red cheek after eating certain foods, one’s right cheek, the other’s left. They were both born with Pierre-Robin sequence. Both have had jaw distractions at birth. My question is if you have seen this in other patients who have had jaw distractions. I didn’t know if this could be damage to the nerve during the placement of the distractors or if it is something they were just born with. We are at Riley several times a year for check-ups

  5. Gretchen Moore - March 29, 2010

    also, apples bring out the redness everytime without fail. They have not been diagnosed with Frey’s sydrome but we have been told it is not a food allergy. The redness occurs within seconds of eating apples.

  6. fleickly - March 30, 2010

    I have not made the diagnosis of Frey’s Syndrome- but I have had a number of children with histories consistent with that diagnosis. The posting was more of an ‘FYI’ and to reassure as well as possibly prevent an extensive allergy evaluation in pursuit of a problem that clearly is not allergy and is benign.
    It would seem that if the auriculartemporal nerve is damaged, this Frey’s Syndrome may ensue.
    Perhaps your surgeon could help with answering the question as to whether or not that nerve is affected in the PR sequence or in procedures used in palliation.
    Very interesting question. Thanks for the question.
    FEL

  7. fleickly - March 30, 2010

    Thanks yet again Ms. Moore for your question. According to the article, the diagnostic test is lemon. Raw apple requires a significant amount of crunching and may depend on the variety of apple- Granny Smith (most sour) vs. a Delicious variety (more sweet). Out of curiosity, does the redness occur with applesauce or apple pie? Raw vs. heated fruit- raw fruit tends to be more problematic. Heating causes significant changes in the proteins.
    FEL

  8. Gretchen Moore - March 30, 2010

    yes, it does it with applesauce, apple pie, it even did it with pureed store bought baby food that had apples in it. thanks for the info

  9. s. fung - September 28, 2010

    I get a sweaty flush on my cheeks after eating tart apples or some pears. When the fruit is cooked it doesn’t happen. It can even happen when breathing steam from cooking raw apples.

  10. fleickly - October 4, 2010

    That is the usual story- the protien in the food is heat-labile. Heating causes changes in how the protein looks and the IgE antibodies no longer recognize it. This is especially true of the fruits. It has been a problem with testing to fruits. Often the fresh/raw fruit has to be brought to the clinic for appropriate testing.
    Thanks for the comment,
    FEL