Transepidermal Water Loss Monitoring Helps Reduce Anaphylaxis During Peanut Allergy Food Challenges: JAMA
USA: Researchers have found in a randomized clinical trial that using transepidermal water loss (TEWL) as a stopping criterion during oral food challenges (OFC) in children with peanut allergy significantly reduced anaphylaxis rates. The findings suggest that TEWL-guided OFC may improve safety and accessibility, with larger multicenter studies needed to confirm these results.
A randomized clinical trial published in JAMA Network Open by George E. Freigeh and colleagues from the University of Michigan provides promising evidence that TEWL measurement—a marker of skin barrier function—can play a valuable role in enhancing the safety of peanut oral food challenges among young children.
Food allergy remains a common chronic condition in childhood, yet diagnostic tools remain limited. This study explored whether real-time monitoring of TEWL could help detect early physiological changes during peanut exposure and reduce the occurrence and severity of anaphylactic reactions.
The trial included 40 children between 6 months and 5 years old, each with a confirmed history of peanut allergy based on clinical reaction and positive skin prick or serum IgE testing. All participants underwent peanut oral food challenges at a specialized allergy clinic between May 2023 and August 2024. Children were randomly assigned to either a control group using standard OFC stopping rules or an intervention group where physicians were allowed to stop the challenge earlier if TEWL rose by 1 g/m²/h, along with one objective allergic symptom.
The primary outcome was the rate of anaphylaxis, assessed using several established scoring systems, including the Consortium for Food Allergy Research (CoFAR), Brighton Collaboration, Food Allergy and Anaphylaxis Network (FAAN), and World Allergy Organization (WAO) criteria.
The study led to the following notable findings:
- The intervention group experienced fewer severe allergic reactions compared with the control group.
- Based on CoFAR criteria, anaphylaxis occurred in 63% of reactors in the TEWL-guided group versus 100% in the control group.
- According to the WAO criteria, only 13% of children in the intervention group developed anaphylaxis compared with 57% in the control group.
- No significant differences were noted when assessing anaphylaxis using Brighton or FAAN criteria, although the overall trend favored TEWL use.
- Median CoFAR scores were lower in the TEWL-guided group, indicating reduced reaction severity.
- Fewer children in the intervention group required epinephrine (50%) compared with those in the control group (86%), suggesting a clear clinical benefit.
Despite these encouraging results, the authors noted important limitations. The trial was conducted at a single center, involved a relatively small sample size, and included only peanut challenges in very young children. Differences in peanut skin prick test wheal sizes between groups and limitations of the TEWL device—such as being corded and not optimized for clinical use—also affect broader applicability. The researchers are developing improved technology for future investigations.
"Overall, the pilot study demonstrates that TEWL rises dynamically during food reactions and has potential as an early warning measure to prevent severe allergic responses during OFCs. Larger multicenter trials will be essential to validate these findings and support the development of TEWL-based tools to make food allergy testing safer for children," the authors concluded.
Reference:
Freigeh GE, O’Shea KM, Troost JP, Kaul B, Franco LM, Schuler CF. Transepidermal Water Loss in Oral Food Challenges in Children With Peanut Allergy: A Randomized Clinical Trial. JAMA Netw Open. 2025;8(11):e2543371. doi:10.1001/jamanetworkopen.2025.43371
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