Skin testing has limited usefulness to plan dietary therapy in adult eosinophilic esophagitis

Published Online: August 6, 2012

Eosinophilic esophagitis (EoE) is an increasingly recognized, food-allergy associated, inflammatory esophageal disorder. Several dietary interventions have been extensively evaluated in children, including elimination diet based on skin testing, which has shown a high degree of effectiveness. Whether this strategy can be generalizated to adults as a non-pharmacological maintenance therapy has been assessed solely in small series so far.

In a letter to the Editor in The Journal of Allergy and Clinical Immunology (JACI), Molina-Infante et al describe the largest prospective series to date in adult EoE addressing this issue using three different skin tests (skin prick test, prick-prick test, and atopy patch test). Food allergy was evaluated in 22 consecutive adult EoE patients by multimodality skin testing to 26 different foods including milk, egg, grains, peanuts, legumes, meats, vegetables, seafood, fish, and fruits. Two patients were found not to be sensitized to any food and five patients rejected the diet owing to its complexity. Finally, an individualized six-week diet was designed in the remaining 15 patients by removing every food with at least a positive result in any of the three skin tests evaluated.

In this report from Spain, five out of 15 patients (33%) achieved remission of the disease upon elimination diet based on skin testing. The most common food allergies identified were to legumes, barley, rye, tomato, fruits, nuts, potato, corn, seafood, and egg. While atopy patch test was negative in most patients (77%), prick-prick test interestingly showed a higher rate of detecting food sensitisation (73%) compared to skin prick test (55%).

The results of the study show the limited usefulness of skin testing for detecting offending foods in adult EoE and do not support the development of dietary therapy based exclusively on skin testing. Currently, empirical six-food elimination diet (avoiding milk, soy, wheat, egg, peanuts/tree nuts and, shellfish/fish with further reintroduction of each one) seems the best dietary approach for adult EoE, in light of recently reported results.

The Journal of Allergy and Clinical Immunology (JACI) is the official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.

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