Exercise & allergy


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.

Cholinergic Urticaria (sweating hives)

Cholinergic urticaria is a common condition of young adults, affecting up to 15 per cent of adolescents and up to 7 per cent of people with chronic urticaria. It manifests as an itchy, blotchy red rash (with or without superimposed 1-3 mm lumps). It is triggered by sweating, emotional stress, elevation of core body temperature (e.g. saunas) or by hot or alcoholic beverages. These all activate sweat glands via nerve endings from the “cholinergic sympathetic nervous system”.

Symptoms usually develop during or just after exercise stops and normally resolve within an hour. Occasional people get wheezing/tight chest like asthma. Increases in blood histamine levels have been described, consistent with mast cell degranulation being involved in the cause of symptoms. But symptoms are also triggered by other causes of sweating. eg. hot days, stress, or consuming spicy food or alcohol.

If sufferers fail to respond to preventative high dose antihistamines, management is generally difficult. Elimination diets are only occasionally helpful. Attempts to "desensitize" a person to increasing amounts of exertion rarely meet with success. Weak male hormones have been used in case reports (eg. Danazol), although the side-effect profile is unacceptable to all but the most severely affected.


Exercise-Induced Urticaria (hives) and Anaphylaxis

First described by Sheffer and Austen in 1980, exercise-induced anaphylaxis typically affects young adults. Manifestations include itch (92 %), hives (83 %), body swelling/angioedema (78 %), wheeze/asthma symptoms(59 %), sweating (43 %), fainting (32 %), stomach upset (30 %) or blocked and runny nose (rare).

Some have milder or unusual symptoms such as isolated exercise-related hives, abdominal pain or cardiovascular collapse. Unlike cholinergic urticaria, however, the itchy hives are usually quite large and are not triggered by heat or sweating alone.

Some experience symptoms with exercise alone; most will only do so if allergenic foods are consumed in the previous 4-6 hours. Foods implicated in this syndrome include wheat (responsible for around 50% of cases) and other cereals, celery, seafood, nuts, fruit and some vegetables. The severity of symptoms is generally influenced by the amount of food ingested, the vigor of exercise and the time between the two. Thus severe symptoms are usually due to food eaten only a few hours earlier.

Symptoms usually occur during exercise. Less commonly, symptoms are triggered when the allergenic food is eaten just after exercise. Co-factors that enhance the likelihood or severity of an allergic reaction include exercise, alcohol, spicy food, pain killers or a high environmental temperature that day.

When wheat is the cause, 75% re allergic to wheat/spelt/triticale/semolina only; the rest will need to avoid all gluten containing cereals such as barley and rye as well. While many publications recommend just avoiding wheat in the 4-6 hours before exercise, my own followup studies have shown that 50% will start to react to wheat without exercise. Furthermore, exercise does not have to be hard. It can be running for a bus or walking back to the car after a restaurant meal on a warm night. Thus if wheat is the cause, I recommend complete avoidance. In formation on dietary sources of wheat can be found at the ASCIA website. https://www.allergy.org.au/patients/food-allergy/ascia-dietary-avoidance-for-food-allergy/wheat

Those at risk of anaphylaxis should wear an identifying MedicAlert bracelet, which will increase the likelihood that adrenaline will be administered in an emergency. They should avoid medication that may worsen the severity of anaphylaxis or complicate its treatment. Beta blockers are best avoided as they inhibit the body’s own protective mechanisms.

Those in whom episodes are unpredictable, who are allergic to foods that are extremely difficult to avoid or when the cause cannot be identified should carry injectable adrenaline and be trained in its use. Patients in whom exercise is a co-factor are best advised to premedicate with antihistamines, to exercise in the morning before eating, to carry injectable adrenaline, to not exercise alone and carry a mobile telephone to summon help. And they should document further episodes in case another non-suspected trigger is the cause.

Miliaria (heat rash)

Small 1-2 mm pimple like rashes with surrounding redness occur with heat and sweating. It can occur in adults living in hot humid climates or in very young children. It is triggered by blockage if the sweat glands. Individual lumps last 1-2 days at a time, do not move around and do not respond to antihistamines. Instead, cooling of the skin, cool compresses and Calamine lotion can help. Sometimes antibiotic are needed if secondary Staph infection occurs. It needs to be distinguished from cholinergic urticaria/sweating hives.

Exercise Rhinitis (hay fever like symptoms with exercise)

The nasal cavity is has lots of nerve endings. Sympathetic nerves control blood vessel contraction and expansion by supplying blood vessels including veins. Change sin nerve activity during the day can result in changing clearness of alternate nostrils every few hours (known as the "nasal cycle"). Stimulation of sympathetic nerves results in contraction of blood vessels and thus a shrinkage in the soft tissue lining of the nose and thus results in a clearer nose to breathe through.Various reflexes ensure that the upper nostril is relatively clear when lying down.Parasympathetic nerves, on the other hand, trigger an opposite effect to make the soft tissue lining of the nose swell and increase nasal mucous production. In most people, exercise results in a short-lived clearer nose due to sympathetic nerve stimulation.

Exercise rhinitis is associated with runny nose and nasal blockage related to nerve activity imbalance and release of inflammatory chemicals in the nose, perhaps triggered by drying of the nose. Symptoms can be reduced by trying to limit heat and moisture loss from the nose by wearing of masks or balaclavas, particularly when exercising in cool dry air, as has been used with some success to limit the severity of exercise-induced asthma. Unfortunately, antihistamines generally have a disappointing effect on symptoms even when taken before exercise. Sometimes Atrovent nasal spray (no script needed in Australia) can help if taken before exercise.Cold-induced runny nose / congestion ("skiers nose") is a related condition and may respons to the same treatment. Those with preexistent hay fever or non-allergic rhinitis may have their symptoms influenced by exercise; sometimes worse, sometimes better. 

Exercise-Induced Asthma

Exercise-induced asthma (EIA) is common. Whilst the mechanism is uncertain, the best evidence is that exercise-related higher breathing rates cause evaporative water loss from the airways, resulting in increased salt concentration in the fluid of the lower airways (hyperosmolarity) and release of chemical mediators that cause spasm of the airways. Under controlled asthma can increase the likelihood of symptoms.

Methods of inhibiting EIA include a submaximal exercise warm-up period or the wearing of a mask (or scarf or balaclava) to minimize heat and moisture loss. Short acting bronchodilators/asthma reliever puffers such as salbutamol (Ventolin, Asmol) or terbutaline (Bricanyl) may protect for 2 to 3 hours.  Nedocromil (Tilade) and cromoglycate (Intal) prevent early and late exercise induced wheezing if taken before exercise. Leucotriene blockers (Singulair/montelukast generic) and long-term inhaled steroid puffers are also effective for long term prevention.

Exercise associated stomach upset

Occasional individuals (especially with high intensity exercise) can experience stomach upset with nausea, abdominal pain and sometimes diarrhoea and even bleeding from the bowel. Symptoms are through to be due to problems with blood flow to the gut during exercise or stomach emptying and gut motility during exercise.


Millward DT, Tanner LG, Brown MA. Treatment options for the management of exercise-induced asthma and bronchoconstriction. Phys Sportsmed. 2010 Dec;38(4):74-80.

Brannan JD, Turton JA. The inflammatory basis of exercise-induced bronchoconstriction. Phys Sportsmed. 2010 Dec;38(4):67-73.

Robson-Ansley P, Toit GD. Pathophysiology, diagnosis and management of exercise-induced anaphylaxis. Curr Opin Allergy Clin Immunol. 2010 Aug;10(4):312-7.

Morita E, Matsuo H, Chinuki Y, Takahashi H, Dahlström J, Tanaka A. Food-dependent exercise-induced anaphylaxis -importance of omega-5 gliadin and HMW-glutenin as causative antigens for wheat-dependent exercise-induced anaphylaxis-. Allergol Int. 2009 Dec;58(4):493-8.

Mullins RJ. Anaphylaxis: risk factors for recurrence. Clin Exp Allergy. 2003 Aug;33(8):1033-40. doi: 10.1046/j.1365-2222.2003.01671.x.

Horikawa T, Fukunaga A, Nishigori C. New concepts of hive formation in cholinergic urticaria. Curr Allergy Asthma Rep. 2009 Jul;9(4):273-9.

Giannetti MP. Exercise-Induced Anaphylaxis: Literature Review and Recent Updates. Curr Allergy Asthma Rep. 2018 Oct 26;18(12):72. doi: 0.1007/s11882-018-0830-6.

Scherf KA, Brockow K, Biedermann T, Koehler P, Wieser H. Wheat-dependent exercise-induced anaphylaxis. Clin Exp Allergy. 2016 Jan;46(1):10-20. doi: 10.1111/cea.12640.

Asaumi T, Ebisawa M. How to manage food dependent exercise induced anaphylaxis (FDEIA). Curr Opin Allergy Clin Immunol. 2018 Jun;18(3):243-247. doi: 10.1097/ACI.0000000000000442.

de Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal complaints during exercise: prevalence, etiology, and nutritional recommendations. Sports Med. 2014 May;44 Suppl 1(Suppl 1):S79-85. doi: 10.1007/s40279-014-0153-2.

Costa RJS, Snipe RMJ, Kitic CM, Gibson PR. Systematic review: exercise- induced gastrointestinal syndrome-implications for health and intestinal disease. Aliment Pharmacol Ther. 2017 Aug;46(3):246-265. doi: 10.1111/apt.14157.

Last reviewed 5 June 2020

Exercise is not always good for one's health. It can trigger asthma, rhinitis, urticaria and sometimes even anaphylaxis!