Eosinophilic Esophagitis: What People With Eczema Need to Know

Researchers are learning more about eczema every day. The good news is that many new studies lead to new treatment options; the more challenging side of new research is that we discover conditions that co-occur with eczema. One such associated condition is called eosinophilic esophagitis (or EoE) and it’s especially troubling for children who live with atopic dermatitis.

What is EoE and how common is it?

Eosinophilic esophagitis (pronounced e-o-sin-o-FILL-ik uh-sof-uh-JIE-tis) is a disease that leads to inflammation and narrowing of the esophagus, causing food to get stuck or difficulty swallowing.¹ The challenge for someone living with eczema, or for parents of young eczema warriors, is that the early symptoms of EoE can deceptively resemble a milder, more common condition – acid reflux. 

Dr. Neal Jain is an Arizona-based pediatrician who specializes in allergies, asthma and immunology. “If a child with severe eczema or allergies is also having gastrointestinal symptoms such as loss of appetite, vomiting, acid reflux, or weight loss,” said Dr. Jain, “they should see an allergist and a gastroenterologist to determine if they have EoE.” 

According to the journal Immunology and Allergy Clinics of North America, EoE is a relatively “new” condition that was first identified in the 1990s and has dramatically increased in prevalence in the last several decades. Dr. Jain added that the symptoms of EoE are easily mistaken for gastroesophageal reflux disease (also known as GERD). 

“We estimate that eosinophilic esophagitis occurs in about 1 out of every 1,000 – 2,000 people,” Dr. Jain said. “But it’s likely far more common than recent reports.” 

Dr. Abha Kaistha, pediatric gastroenterologist at the NYU Grossman School of Medicine, echoed Dr. Jain’s observation about the increased frequency of EoE in children, noting that “as many as 20-55% of children with EoE also have atopic dermatitis.” Dr. Kaistha also pointed out that research data corroborate her observations that children with severe eczema, food allergies and respiratory allergies are at significantly higher risk for EoE.² Dr. Jain advised any adult with these symptoms, or someone who has trouble swallowing food, to “seek out a diagnosis with an endoscopy and see an allergist as well.”

What causes EoE?

The exact cause of EoE is not fully understood, but studies suggest that an interaction of allergies, immune system and a genetic predisposition are at work in this disease. Dr. Kanwaljit Brar, a pediatric allergy specialist at NYU Grossman School of Medicine, said the most common dietary allergies triggering EoE are cow’s milk and wheat, as well as eggs and soy. Peanuts, tree nuts, fish and shellfish are not as commonly related to EoE but can sometimes be involved. Dr. Jain added that pollen and animal dander along with chemicals, plastics, and pesticides that make their way into our foods can trigger EoE. 

Other risk factors include: being white and/or male; living in a cold, dry climate; the seasons (with EoE more likely to flare in fall or spring); and family history. Abnormalities in the types of bacteria living in and on our bodies (dysbiosis) may be a factor, too. Also, researchers are investigating if EoE in people with eczema (especially children) could be related to the atopic march: the development of atopic conditions, often in sequence from eczema, to food allergies, to allergic rhinitis and asthma.

How to spot the symptoms of EoE

There is some debate about whether cases of EoE are increasing or being diagnosed more often.

The most common symptoms of EoE are:

• coughing while eating
• trouble swallowing
• needing frequents sips of water with meals
• using lots of dipping sauces to lubricate food
• avoiding certain food textures
• “picky” eating
• slow eating
• choking on meat or bread
• chest pain, abdominal pain, heartburn
• vomiting or regurgitation of undigested food
• failure to thrive (malnutrition, weight loss, or stunted growth in children).

How is EoE treated?

Dr. Jain explained that while an allergist can test for food and environmental allergens, these tests are not always accurate at predicting which foods may be contributing to EoE. Similarly, EoE is not easy to diagnose with just an allergy test. 

In the event of a diagnosis of EoE, Dr. Jain described three possible treatments for EoE:

1. Proton pump inhibitors taken at high doses to reduce acid in the esophagus and stomach and which may have anti-inflammatory properties, as well.
2. Steroid medications that are swallowed to coat the throat. These include fluticasone, ciclesonide, or budesonide. They are used “off-label” and work like topical steroids for eczema to reduce inflammation on the mucosal surface of the esophagus and help restore esophageal barrier function. 
3. Dietary avoidance measures, such as avoiding foods known to potentially trigger EoE. Or, in some cases, an elemental diet (a prescribed liquid meal replacement program) may be recommended to “calm” the GI system and bring down inflammation. 

Other treatment options may also be on the horizon. For instance, there are reports, said Jain, of patients being treated for allergic rhinitis with allergy shots and having their EoE improve. Similarly, some patients receiving dupilumab for severe eczema or asthma say their EoE also improved. More research in these areas is needed. 

If all this gives you a lump in your throat, don’t worry. Although EoE can have serious impacts if left untreated, most people with EoE do well with proper care and can manage their symptoms for good quality of life.

References

1. The Mayo Clinic Staff. “Diseases & Conditions: Eosinophilic Esophagitis.” MayoClinic.org. https://www.mayoclinic.org/diseases-conditions/eosinophilic-esophagitis/symptoms-causes/syc-20372197; Accessed 4/29/22.
2. Benninger MS, Strohl M, Holy CE, Hanick AL, Bryson PC. Prevalence of atopic disease in patients with eosinophilic esophagitis. Int Forum Allergy Rhinol. 2017 Aug;7(8):757-762. doi: 10.1002/alr.21968. Epub 2017 Jun 14. PMID: 28614630.