Graded Exposure to Baked Egg May Improve Tolerance in Patients with Egg Allergy

A recent study on egg allergy management emphasizes the value of adding strategies such as graded exposure to denatured or baked egg to the standard approach of allergen avoidance.1

“This review also underscores the importance of considering broader implications beyond clinical efficacy when evaluating management strategies for egg allergy,” wrote investigators, led by Aoife Gallagher, PhD, from University College Cork in Ireland. “Quality of life considerations, such as the impact of allergen avoidance on social inclusion and dietary diversity, warrant consideration in decision-making processes.”

A 2019 report estimates that egg allergy affects about 2 million adults in the United States.2 Although shellfish, milk, peanut, tree nut, and fin fish trigger more allergic reactions, egg allergy continues to gain prevalence.

Completely avoiding food with eggs can be tricky given the ever-present nature of egg in many unprocessed foods. Patients must read food labels closely to see if egg is a hidden ingredient.

Eggs can be found in baked treats, pasta, breadcrumbs, vegetables in a casserole, fudge, salad dressing, root beer, and many other foods.3 For patients with an egg allergy, it would be a good idea to tell them to avoid anything with the following ingredients: albumin, egg whites, egg yolk, dried egg, egg powder, egg solids, egg substitutes, eggnog, fat substitutes made with egg, globulin, livetin, lysozyme, mayonnaise, meringue, ovalbumin, ovomucin, ovomucoid, ovovitellin, and surimi. A shiny glaze on a baked good may indicate egg presence, and egg whites and eggshells may be used as clarifying agents in coffees.

Since accidental egg exposure can occur even with careful label reading, an alternative to strict avoidance may be necessary. Oral immunotherapy has shown promise in managing egg allergies, but the approach carries a risk of anaphylaxis and demands significant resources and costs.1

Investigators aimed to compare the traditional method of strict avoidance with cost-effective alternatives for managing egg allergy at home, such as a gradual introduction. They conducted a systematic review of 28 studies that either managed IgE-mediated egg allergy through graded exposure to denatured or baked egg (n = 20) or allergen avoidance (n = 6). Two studies explored both graded exposure and avoidance.

The review looked at 8 retrospective non-randomized trials, 7 review articles, 2 debates, 2 guidelines, 2 prospective non-randomized controls, 2 cross-sectional trials, 2 systematic reviews, 2 randomized control trials, and 1 case-control study. Most were conducted in the United States (n = 8), Australia (n = 4), and Canada (n 6), with others from Japan, Ireland, Belgium, Greece, Israel, Poland, and the UK. Studies often had small sample sizes (26 to 243 participants); 3 trials had larger sample sizes of 522, 458, and 881 participants.

Most trials diagnosed an IgE-mediated egg allergy with a combination of a skin prick test, specific immunoglobulin E, oral food challenge, and clinical symptoms. One study only used a skin prick test, another only used an oral food challenge, and 2 only examined specific immunoglobulin.

All but 4 studies emphasized that although allergen avoidance remains the cornerstone of egg allergy management, emerging strategies such as oral immunotherapy or the introduction of baked egg, may also be beneficial. The remaining 4 studies highlighted the feasibility of introducing baked egg, particularly in those with only a mild allergy. This supports the 2021 British Society for Allergy and Clinical Immunology (BSACI) guideline, which notes that although avoidance is still the primary approach, prolonged exclusion may contribute to persistent allergy.

The review found that graded exposure to denatured or baked egg was the most used treatment for children with IgE-mediated egg allergy, though the term encompasses various methods. Some studies used a ladder approach, factoring in dose, timing, temperature, wheat matrix, cultural considerations, taste, and texture. Others used strategies such as stepwise oral food challenges, a dietary advancement therapy, structured graduated exposure protocols, and the introduction of heated or baked egg with or without oral immunotherapy.

Overall, 70% to 92.7% of participants tolerated baked egg, showing its high tolerability. However, 4 trials reported the need for an oral food challenge to confirm baked egg tolerance before introducing it at home.

“It is important to note that graded exposure may not be suitable for all children and should be done under medical supervision,” investigators wrote.

References

1. Gallagher A, Delgado Mainar P, Cronin C, Muñoz C, Calleja JR, Loughnane C, Trujillo J. Managing egg allergy: A systematic review of traditional allergen avoidance methods and emerging graded exposure strategies. Pediatr Allergy Immunol. 2025 Apr;36(4):e70075. doi: 10.1111/pai.70075. PMID: 40167149; PMCID: PMC11960040.

2. Gupta RS, Warren CM, Smith BM, Jiang J, Blumenstock JA, Davis MM, Schleimer RP, Nadeau KC. Prevalence and Severity of Food Allergies Among US Adults. JAMA Netw Open. 2019 Jan 4;2(1):e185630. doi: 10.1001/jamanetworkopen.2018.5630. PMID: 30646188; PMCID: PMC6324316.

3. Egg Allergy Diet for Children. Stanford Medicine. https://www.stanfordchildrens.org/en/topic/default?id=egg-allergy-diet-for-children-90-P01684. Accessed April 25, 2025.