NEW evidence from a randomized clinical trial suggests that using transepidermal water loss (TEWL) monitoring during peanut oral food challenges can reduce anaphylaxis rates and reaction severity in young children. As oral food challenges remain the gold standard for food allergy diagnosis, tools that enhance safety may expand their use in clinical practice.
The study, conducted at a single allergy referral centre, enrolled 40 children aged 6 months to 5 years with confirmed peanut allergy. Participants were randomised to either standard stopping criteria or an intervention guided by TEWL monitoring. In the intervention group, challenges were stopped if TEWL rose by at least 1 g/m²/h along with one objective allergic symptom, allowing for earlier intervention.
Among children who reacted during the oral food challenges, the TEWL-guided protocol markedly lowered anaphylaxis rates. Using the Consortium for Food Allergy Research criteria, anaphylaxis occurred in 63% of reactors in the TEWL group compared with 100% in the control group. When assessed using World Allergy Organization criteria, the difference remained substantial at 13% versus 57%, respectively. Reaction severity scores were significantly lower in the TEWL group as well.
Although not statistically significant, fewer children in the TEWL group required epinephrine (50% vs 86%), suggesting a potential reduction in the intensity of reactions. Mucocutaneous symptoms occurred in all reactors, but respiratory, gastrointestinal, and ocular symptoms were more common in controls, indicating more systemic involvement without TEWL-based early stopping.
Transepidermal Water Loss as an Emerging Allergy Tool
TEWL rises were observed early in challenges, often within the first two doses, supporting the potential of TEWL as an early physiological signal of escalating allergic response. Despite the young age of participants, adherence to continuous TEWL monitoring proved feasible throughout the challenge process.
The authors emphasised the need for larger, multicentre studies to validate these findings and to refine TEWL-based stopping criteria. If confirmed, TEWL monitoring could offer clinicians an objective, real-time tool to enhance oral food challenges safety and reduce anaphylaxis risk.
Reference
Freigeh GE et al. Transepidermal Water Loss in Oral Food Challenges in Children With Peanut Allergy. JAMA Netw Open. 2025;8(11):e2543371.
