Precision medicine in eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a common, chronic, immune-mediated disease of the esophagus, affecting approximately 1 of 700 individuals in the United States. Despite its rising prevalence, clinical management remains largely empiric and invasive: diagnosis and monitoring rely on endoscopy with biopsies, and treatment selection is guided by population-level response rates, patient preference, and access rather than individualized disease biology. Patients often experience diagnostic delays, repeated procedures, and cycles of trial-and-error therapy before achieving remission, whereas prolonged inflammation increases the risk of fibrostenotic complications. Recent advances in epidemiology, genetics, molecular profiling, and immunology increasingly support EoE as a heterogeneous disease with distinct biologic drivers. Emerging tools-including polygenic risk scores, molecular endotyping frameworks, and minimally invasive biomarkers-may improve risk stratification, reduce reliance on endoscopy, and better align therapy with the underlying mechanisms. In this review, we describe the current EoE patient journey and evaluate opportunities to integrate precision medicine strategies across the disease continuum, from risk identification and diagnosis to treatment selection, food trigger identification, and noninvasive monitoring. We also discuss future directions aimed at defining antigen-specific immune pathways and how these insights may enable next-generation diagnostics, targeted therapies, and disease modification in EoE.