Predicting severe and early-onset reactions with the tahini-lip dose challenge

Tahini, a sesame seed paste, is often used in skin prick tests (SPTs) and oral food challenges (OFCs) to diagnose sesame allergy, although OFCs are limited owing to resource demands and the inherent risk of allergic reactions.

To evaluate the diagnostic utility of the tahini-lip dose challenge (LDC) as a preliminary step before OFC by comparing its performance with conventional tests and exploring its efficacy across patient subgroups.

This retrospective study reviewed patients with suspected sesame allergy who underwent tahini-LDC before OFC.

Overall, 95 children (median age: 2.4 years; IQR: 1.3-4.9) underwent tahini-LDC before OFC. Of these, 49 (51.6%) had positive LDC test results, including 1 patient who experienced anaphylaxis during LDC. Among patients who showed positive for LDC, only 2 (4.2%) had negative OFC outcomes. Conversely, among the 46 patients who showed LDC-negative, 16 (34.8%) had positive OFC outcomes. The LDC revealed higher specificity than did SPT and specific IgE but lower sensitivity. Combining LDC with standard sesame or tahini SPT did not change sensitivity, specificity, or positive likelihood ratio, whereas combining LDC with optimal SPTs yielded a positive likelihood ratio of up to 23.4 and a specificity of 96.9%, highlighting a strong diagnostic utility. Tahini-LDC positivity was associated with younger age and higher SPT values. In children with sesame allergy, the tahini-LDC positive subgroup experienced more frequent systemic reactions and reactions at earlier stages of the OFC, and required adrenaline more often than did the negative subgroup.

The inclusion of tahini-LDC may help improve diagnostic accuracy in the evaluation of sesame allergy, particularly in identifying patients at high/low risk. Although LDC can not replace OFC, further research is warranted to refine its protocols and expand its application across diverse populations and age groups.