Cezmi Akdis | Professor of Primary Health Care, University of Bristol, UK
Citation: EMJ Allergy Immunol. 2026; https://doi.org/10.33590/emjallergyimmunol/36HH78E4
Primary care manages the majority of eczema and suspected food allergy cases, yet diagnostic uncertainty remains high. Where do you see the biggest mismatch between current evidence and everyday clinical practice?
The problems are several-fold:
- Eczema and food allergy are common
- Eczema is a risk factor for food allergy
- Eczema commonly presents around the time that food is being introduced for the first time (complementary feeding or ‘weaning’)
- Normal infant behaviour can be mistaken as a symptom of food allergy (e.g., reflux, variation in stool colour)
- There is plenty of misinformation out there for parents to get confused by
The above is accompanied by often limited dermatology/allergy training for healthcare practitioners, variation in specialists’ use of food allergy tests in eczema, and a limited evidence base. No wonder family doctors and families can feel confused.
With growing use of IgE and allergy testing in children with eczema, how do we balance identifying true food allergy with the risk of overdiagnosis and unnecessary dietary restriction?
I am not aware of any evidence that more skin prick or blood-specific IgE tests are being done in children with eczema, but, with the rise of ‘direct to consumer’ tests, it would not surprise me. When they are being done, the question is why?
If it is to confirm suspected food allergy or follow-up on a diagnosed immediate (IgE-mediated) food allergy, that is appropriate.
If they are being done as a panel of foods, in the absence of any symptoms to suggest a food allergy, ‘just in case it might be causing the eczema’, this is inappropriate. As IgE tests have a high false-positive rate, excluding foods from the child’s diet on the basis of these can cause harm.
The more difficult middle ground is where one or more foods might be causing delayed (hours/days after ingestion, so-called non-IgE) eczema symptoms. While most guidelines agree to reserve tests for children with severe/more difficult-to-treat eczema, the evidence base is unclear. Oykhman et al.1 undertook a systematic review of studies in 2022 comparing dietary elimination versus no dietary elimination for the treatment of eczema. They identified 10 RCTs, four of which excluded foods based on food allergy tests and/or oral food challenge. There was low-certainty evidence that dietary elimination slightly improved eczema severity, pruritus, and sleep disturbance. However, there was no evidence of any differences based on elimination strategy (empiric versus guided by testing) or food-specific sensitisation. There were also insufficient data on any associated harms. The TIGER study2 of skin prick test-guided dietary exclusions in children <2 years with eczema, which is due to report later this year, will hopefully provide more clarity.
Your work has highlighted variation and underuse of topical therapies in eczema. What are the most common treatment pitfalls you see in primary care, and how can clinicians address them in everyday practice?
Around one in 10 consultations in primary care include a skin problem. Yet, as highlighted above, training of family physicians and allied front-line health professionals is often limited. This, coupled with time-limited consultations where the skin problem is often the second or third problem, does not provide the best context for an optimal encounter.
The first thing to do is to find out what the patient or carer understands about eczema, how it is affecting them, what they have tried before, and what they are looking for. This might identify, for example, concerns about an underlying food allergy, sleepless nights due to scratching, inadequate or no anti-inflammatory skin treatments, and hopes of a cure.
Next is to address any misunderstandings and agree on a treatment plan based on the core messages of getting control of the eczema, usually with an appropriate strength topical corticosteroid (TCS), followed by keeping control with emollient(s). The most common harm with respect to TCS is from underuse, rather than overuse. In the absence of symptoms suggestive of food allergy, the focus should be on treating the skin, because, if you can improve the eczema, parental concerns about underlying causes usually reduce.
Keep regimens as simple as possible (one TCS and one emollient ideally) but support the message of ‘two treatments used well’ with written information, through websites such as Eczema Care Online,3 or with a personalised action plan (e.g., Eczema Written Action Plan).4
You’ve led multiple pragmatic trials in primary care. How has this approach changed the kind of evidence we generate in allergy and dermatology, and what advantages does it offer over traditional trial designs?
Evaluations of treatments that have only been tested in selected populations (e.g., recruited through hospital clinics) or under ideal or highly controlled circumstances (efficacy studies) may perform very differently in the ‘real world’. Pragmatic trials seek to establish their effectiveness under more everyday circumstances. For example, collecting data on what is used and how often rather than actively enforcing emollient type and frequency of application. This way, when clinicians read the results of the study, they can have more confidence that the findings apply to their setting.
Your research incorporates online tools and patient involvement. How do you see digital and patient-driven models reshaping long-term management of chronic skin and allergy conditions?
The desire to support shared decision-making and self-management is not new, and anything that has the potential to help patients understand and look after themselves better warrants exploration. For example, Eczema Care Online3 is evidence-based and designed to support behaviours that have been shown to improve eczema symptoms. However, not everyone is able or wants to access information online or through an app, and digital interventions in whatever format cannot meet all needs. Often patients and carers need in-person contact with a trusted healthcare professional, to feel heard and/or for practical demonstration of treatments. Therefore, offering the two alongside one another, flexibly, and according to the needs of the family is probably the way forward.
In the context of early-life eczema and food allergy, how close are we to effective prevention strategies, and what should clinicians realistically be doing now in routine practice?
Since the publication of landmark studies, such as LEAP in 2015 and EAT in 2016, there has been a turnaround in advice from delaying introduction of allergens such as peanut and egg into infants’ diets, to encouraging their introduction alongside other foods to prevent food allergy. Unnecessarily excluding foods from the diets of infants with eczema risks missing the ‘window of introduction’ or losing oral tolerance, thereby increasing the risk of food allergy.
Sadly, despite much hope, measures to ‘enhance’ the defective skin barrier through early emollient use has not been shown to prevent eczema. Earlier, more aggressive treatment of eczema does not appear to have any longer-term benefits and must be balanced with potential harms from treatments such as TCS on growth.
Looking ahead, what do you think will have the greatest impact on outcomes in common allergic disease: better diagnostics, improved self-management, system-level changes in primary care, or something else entirely?
As the saying goes: ‘Prediction is very difficult, especially about the future’. It is sometimes the unexpected or currently unknown that turns out to provide the most benefit.
It will probably be a combination of these things (and others), but public health and primary care are likely to be central to discovery and delivery. We recently completed a Jame Lind Alliance exercise, which asked patients, carers, and their clinicians what their research priorities were for childhood food allergy.5 Comparing submissions against systematic reviews of existing evidence identified that some areas were relatively well researched, whereas others had received hardly any attention. The top 10 spanned a range of priorities, from prevention to early diagnosis and treatments. One thing is for certain: allergy deserves the same recognition as other conditions and commensurate research funding to answer these important questions.
References
- Oykhman P et al. Dietary elimination for the treatment of atopic dermatitis: a systematic review and meta-analysis. J Allergy Clin Immunol Pract. 2022;10(10):2657-e8.
- University of Bristol. Trial of food allergy (IgE) tests for eczema relief (TIGER). Available at: https://tiger.blogs.bristol.ac.uk/. Last accessed: 13 May 2026.
- Eczema Care Online. Welcome to Eczema Care Online. Available at: https://eczemacareonline.org.uk/en?language_set=1. Last accessed: 13 May 2026.
- University of Bristol. Eczema Written Action Plan (EWAP). Available at: https://www.bristol.ac.uk/primaryhealthcare/researchthemes/apache/ewap/. Last accessed: 13 May 2026.
- University of Bristol. Food allergy in children priority setting partnership. Available at: https://foodallergyinchildrenpsp.blogs.bristol.ac.uk/. Last accessed: 13 May 2026.
