Reply to Comment on ‘Food Allergy Test‐Guided Dietary Advice for Children With Atopic Dermatitis: A Consensus Study’

We thank Dr. Gupta for taking the time to read and submit the points raised in their letter [1], to which we are pleased to respond. As Dr. Gupta acknowledges, we clearly state “It is not an endorsement of the use of SPT [skin prick tests] in all cases of infantile AD [atopic dermatitis], but rather an effort to clarify how to interpret results when such testing is done, including inappropriately.” [2]. We also cite a survey that shows how healthcare professionals' use of skin prick testing in children with eczema varies across general practice, pediatrics, allergy and dermatology [3]. We acknowledge that not including peanut, tree nuts, and other foods is a limitation. However, the prevalence of allergy to peanut and tree nuts in infants is similar to the foods we included [4]. As we explain, we focused on cow's milk, hen's egg, wheat, and soya because they are commonly excluded by parents of infants with eczema, and hence they are being evaluated in a trial of skin prick test-guided dietary advice (TIGER, ISRCTN52892540) [2]. In the paper we agree that “Given the complexity of FA [food allergy] in children, it can be argued that decision-making cannot be protocolized. Taking an allergy-focused history requires time and care, especially with severe AD of early onset, certain symptom complexes (e.g., co-occurrence of skin and gut symptoms), when multiple foods are implicated, or prior FA diagnosis.” [2]. An allergy-focused history should be taken prior to any testing but it is not always adequately done in practice for a variety of reasons and does not always give all the answers, that is, selective testing in this situation can be helpful. Interpretation of “intermediate” SPTs can be challenging (as reflected in the lack of consensus with wheal sizes of 3–5 mm), and we recognize that clinicians will want to integrate the clinical context to avoid unnecessary restriction by considering “… AD disease severity, known FAs, wheal size and positive predictive value of SPTs.” [2]. We acknowledge that the use of blood specific IgE or SPTs to guide dietary advice for eczema symptoms or control is controversial and not without risks, as reiterated by Dr. Gupta. Despite this, dietary modification by parents, without healthcare input, is common [5] and as stated above, some healthcare professionals still use these tests for this purpose. The flowchart can guide decision-making in scenarios where the allergy diagnosis is uncertain. Time-limited dietary exclusion and reintroduction or Oral Food Challenge are recommended, which reduces the risks of extended periods of dietary restriction that may be unnecessary. We agree with Dr. Gupta's concluding comments that our “flowchart is not a substitute for individualized care” and until trials like TIGER offer definitive answers, “clinicians should continue to prioritize detailed history-taking and shared decision-making”. We believe that our work represents an important step toward addressing these challenging clinical questions around food allergy and eczema. M.J.R. is funded by an NIHR Research Professorship (NIHR303123) and is chief investigator on the TIGER (Trial of IgE food allergy tests for Eczema Relief) study (NIHR133464). J.W. has sat on clinical advisory panels to Allergy UK and Anaphylaxis UK. G.S. acts as Trustee to Allergy UK, contributed to an educational video on atopic dermatitis with Sanofi and is Principal Investigator for NARF study. R.M. is on the advisory panel of CoMISS supported by Nestle Health Science, has provided consultancy to Else Nutrition, and received honoraria for lectures from Nutricia/Danone, Abbott, and Reckitt Benckiser. I.S. has received honoraria for lectures from ThermoFisher, Royal College of GPs, TouchiME. S.J.B. has received research funding (but no personal financial benefits) from the Wellcome Trust (220875/Z/20/Z), UKRI, Medical Research Council, Rosetrees Trust, Stoneygates Trust, British Skin Foundation, Charles Wolfson Charitable Trust, anonymous donations from people with eczema, Unilever, Pfizer, Abbvie, Sosei-Heptares, Janssen, European Lead Factory (multiple industry partners) and the BIOMAP consortium (EC-IMI project ref No 821511). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.