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Yet Another Mystery Rash

These mysterious rashes that patients want help with are a real diagnostic challenge. Usually the visit begins with “I’ve been to dermatologists about this and all I get are steroids. Once I’m done taking them the rash comes right back.”

In previous health tips, we reported on a young man who developed a very real sensitivity to latex that began after he walked along a Hawaii beach in flip-flops, sand scratching the soles of his feet. A few weeks later, I wrote about a woman whose puzzling rash was a rare manifestation of PMS. Now here’s another…

Phyllis, an intelligent woman in her forties, rarely bothers with doctors because she doesn’t need us: she exercises regularly, her diet is very healthful (“strictly Whole Foods, organic, all natural”), and she keeps stress under good control. In other words, the last person you’d expect to arrive in your office covered with an extremely itchy rash.

I could even see dozens of tiny marks, called excoriations, where she’d been scratching herself in her sleep. Except for her rash, Phyllis felt, as she always did, “just fine.”

Her dermatologist had diagnosed her rash as neurodermatitis, a sort of catch-all phrase used when the doc’s not quite sure what’s going on. He suggested she work on stress issues and prescribed steroid lotions. At our clinic Phyllis first saw my associate Dr. Kelley, who suggested she make sure all her detergents and cosmetics were chemical-free, start taking St. John’s wort to help with stress, and return for a skin biopsy in order to find out exactly what was going on.

Skin biopsy holds a clue
Two weeks later, the rash was absolutely no better but her skin biopsy yielded an important piece of information. Phyllis’ rash was clearly due to an allergy. There was something entering her body that her immune system didn’t like one bit, her immune system was creating antibodies to get rid of it, and in the process these antibodies were triggering the rash.

“Let’s go through your day, mouthful by mouthful,” I began.

Phyllis immediately protested that everything she ate was natural, no chemicals, squeaky clean.

I reminded her that the word “natural” doesn’t have any real meaning on a product label (it’s just marketing), and thus it doesn’t let us off the hook. In addition, strawberries are natural, as are shellfish, and, come to think of it, so are bee stings and penicillin. People get bad rashes from all four.

“OK, I start with lots of fruit in the morning, whole grain bread, and Earth Balance spread. I really love Earth Balance. Have you ever tried it? It’s simply delicious. I could live on it. It’s almost addicting.”

At the “almost addicting,” I felt a chill run down my back. I explained to Phyllis that people who work with food sensitivities know that, for unclear reasons, the body starts to crave the food it’s most sensitive to. We see this regularly with patients literally hooked on diet colas, 10 to 12 cans a day, who burst into tears when we tell them their symptoms may be due to a reaction to the chemical swill they’re guzzling day in and day out and they’ll have to stop, cold turkey.

“Oh,” said Phyllis, “But Earth Balance is completely natural.”

I went to their website to check. Then to the ingredients list.

Admittedly it looked pretty harmless and clearly the Earth Balance people had gone out of their way to be careful as far as ingredients went. Everything was non-GMO, though there was that useless word “natural” again, as in “natural oil blend.” There was also “pure” salt (whatever that means). The label overall looked pretty good, but I didn’t know what “annatto” was. I’d never seen the word. Nor had Phyllis.

I clicked to the source of all knowledge in the universe, aka Wikipedia, and quickly learned that annatto (also known as roucou and achiote) is a subtropical seed used primarily for coloring cheese and solid oils, like Earth Balance. Apparently a lot of these products would look pretty much like squares of lard or tubs of Crisco without their annatto coloring.

Scrolling down the Wiki article, my eyes widened when I got to “Precautions.”

“Ah, here we go,” I said aloud, and read the precautions to Phyllis, “In one study in 1978, among 61 consecutive patients with chronic hives…that’s what you have, Phyllis…56 of them had their hives orally provoked by ingesting annatto after an elimination diet.”

That means after deliberately eliminating annatto for a few days and then eating some, virtually all developed a rash. In addition, even when given the tiny amount generally used to color products, 26% of them still reacted to it. Clearly, in the right person this stuff is a potent trigger for allergies, higher, in fact, than the artificial colors tartrazine, Sunset Yellow FCF, and Food Red 17.

So much for “natural”
“It’s the annatto,” I said. “Your Earth Balance craving will have to go. And from now on, you’ll need to check ingredients, even on these so-called natural foods.” Phyllis was relieved the solution was straightforward, but sad to say goodbye to her morning toast spread. I asked her, “By the way, when did you discover Earth Balance?”

“I think last Spring sometime, maybe April.”

“And the rash began…?”

“A month later, but obviously I never made the connection.” She paused. “I really, I mean really, like the stuff. You won’t believe this, but every time I ate it, I actually felt tingly all over my body, like a healthy glow. It felt…good.”

This spurt of new information made me smile. “Tingly? Phyllis, you were having an allergic reaction. Your tingly morphed into your rash!”

For her morning toast, I suggested Phyllis start using a little grass-fed butter like Kerrygold. Trader Joe’s has a grass-fed butter too and Organic Valley calls theirs pasture butter. Spendy, yes–though less expensive than steroid creams–but the yellow in this spread comes with all kinds of healthful nutrients from grass-grazing cows.

Would she enjoy it as much as Earth Balance, Phyllis wondered.  I wasn’t worried, and sent Phyllis on her way with a “Just as long as it doesn’t make you tingly…”

Be well,

David Edelberg, MD

  1. Marguerite Hill says:

    Very interesting!

  2. Diane Engelhardt says:

    I love reading your articles even tho they don’t pertain to me…no rashes here!

  3. Nancy Olivi says:

    Wow you are amazing! Now tackle granuloma annulare. Not sure of spelling. I’ve had it for 20 yrs. Now I’m wondering if it is a reaction to something I’ve eaten. I think something bit me while I was gardening.Another skin rash with no sense or treatment. However it did go away with Chemo but came back.Been everywhere tried everything. It is just there with no itching or other problems.

  4. Eugenia says:

    Another type of “mystery rash” that pops up and not always recognized is dermatitis hepataformis associated with celiac and gluten sensitivity….not always recognized by people..
    Thanks Dr. E for your interesting posts!

  5. Mary says:

    LOL! Cute article, gotta try this Earth Balance.

    Actually, a lot of puertorrican cooking uses annato (called achiote). Its a common coloring, adds a deep henna-like color. The flavor is kind of negligible, it’s mostly used for color.

  6. Don Wharton says:

    Good job Dr. Edelberg, or should I say Detective Edelberg. Thanks for sharing.
    Sounds like Earth Balance has a little tilt to it

    Have a good day,
    Don W.

  7. Kristina Gaunt says:

    What a fantastic article! Thanks for sharing! The article grabbed my attention because my mom has the exact same hives situation. I am wondering if it is the same with her I will check it out for sure.

  8. linda wolf says:

    why can’t all docs be like you?

  9. Kate Wigley says:

    You’re a genius! If only all docs were like you Dr E!

  10. Dr E says:

    For your granuloma annulare: try (1) two tablespoonfuls of apple cider vinegar in water every morning, and (2) totally eliminating all gluten from your diet.

  11. Thomas Goetz says:

    Dr. E. Love your posts. From our response to Nancy with the ingestion of 2 Tbs of Apple cider vinegar in glass of water. I am drinking 2-3 8 oz glasses of Water with 2 tsps.Bragg’s ACV and 2 tsps. Agave nectar to aid in the control of my dermatitis. Are there any studies that I can read to support my continuation of this Tx for my skin problems. Rosacea and plaque dermatitis?

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Far and away, the commonest phone call/e mail I receive asks about COVID-19 diagnosis.
Just print this out, tape it on your refrigerator door, and stay calm.


• Runny nose
• Sneezing
• Red, swollen eyes
• Itchy eyes and nose
• Tickly throat
• No fever

• Runny nose
• Sneezing
• Sore throat
• Mild muscle aches
• Mild dry cough
• Rarely a low fever

• Painful sore throat
• Hurts to swallow
• Swollen glands in neck
• Fever

FLU (Standard seasonal flu)
• Fever
• Dry cough (no mucus)
• Sudden onset over few hours
• Headache
• Sore throat
• Fatigue, sometimes quite severe
• Muscle aches, sometimes quite severe
• Rarely, diarrhea

• Shortness of breath
• Fever (usually above 100 degrees)
• Dry cough (no mucus)
• Slow onset (2-14 days)
• Mild muscle aches
• Mild fatigue
• Mild sneezing

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