The use of recombinant allergens for molecular allergy diagnosis currently revolutionizes diagnosis of IgE-associated allergy. A recently published guide to molecular allergy diagnosis highlights the many advantages of molecular diagnosis . One interesting aspect revealed recently by molecular diagnosis is that sensitization to certain allergen molecules and/or a combination of allergens is more common for certain allergic manifestations than for others. For example, it was found that house dust mite allergens such as Der p 11 [34▪] and Der p 18 , which are associated with mite bodies are more frequently recognized by IgE antibodies from patients with atopic dermatitis, whereas allergens associated with fecal particles such as Der p 1, Der p 2, Der p 5, Der p 23 are more frequently recognized by patients with respiratory allergy [36,37]. This finding may be explained by the fact that there could be different routes of sensitization in atopic dermatitis and respiratory allergy but also by a more polyclonal response in patients with atopic dermatitis which includes otherwise more rarely recognized allergens. Allergic dogs which mainly show atopic dermatitis as the most relevant allergic manifestation also mount IgE-reactivity preferentially to house dust mite body-derived allergens  but not to allergens which are associated with airborne feces. This would indicate that the body-derived allergen indeed may sensitize via the skin.
In the course of the EU-funded research project MeDALL, IgE reactivities towards a large number of micro-arrayed allergen molecules have been determined in several European birth cohorts using the MeDALL allergen chip . This has enabled to determine the evolution of IgE reactivities towards a large number of allergen molecules from early childhood to adolescence [43–46]. Results obtained by multiallergen testing indicate that different allergic phenotypes are associated with monosensitization and oligosensitization versus polysensitization to a large number of allergen molecules . Data obtained in the MeDALL project seem to confirm that patients with atopic dermatitis are often polysensitized towards a large number of different allergen molecules and thus exhibit extremely complex IgE sensitization profiles . Multiallergen tests, mainly chip tests based on micro-arrayed allergen molecules utilizing the ImmunoCAP-ISAC technology have been used for the analysis of IgE reactivity profiles in cohorts of children with atopic dermatitis and adult patients with atopic dermatitis [20▪,34▪,48,49]. The results of these studies provided insights in sensitization profiles associated with different severity of atopic dermatitis. Importantly, a recently published study demonstrates that based on the in depth analysis of IgE-reactivity profiles in children suffering from severe forms of atopic dermatitis, it was possible to improve the management and treatment individually [50▪▪]. The key findings leading to a personalized treatment for each of the children, which in one case was a highly refined diet and in the other case AIT for the treatment of house dust mite allergy, were obtained by chip diagnosis identifying the disease-causing allergens. IgE reactivities to clinically irrelevant cross-reactive carbohydrate antigens which in allergen extract-based tests pretended almost infinite allergic sensitization could be discriminated from clinically relevant sensitizations as indicated in Fig. 3. The latter cases may be considered as paradigmatic examples of how the analysis of complex IgE-reactivity profiles by molecular diagnosis can improve disease management following the principle of precision and personalized medicine approaches in allergy [51–53].
A recent clinical study showed that epicutaneous application of recombinant IgE-reactive birch pollen allergen Bet v 1 and non-IgE-reactive, T cells epitope-containing Bet v 1 fragments induced eczematous skin inflammation [11▪▪]. In this study and in an earlier study , it was found that certain patients showed skin reactions mainly to the IgE-reactive allergen but not to the non-IgE-reactive T cells epitope-containing fragments, whereas others reacted strongly to the non-IgE-reactive Bet v 1 derivatives. The results of these studies may be important for two reasons. First, they may explain why certain patients with atopic dermatitis respond very well to IgE-targeting therapeutic strategies whereas others benefit less from IgE-targeted therapy but from T cells-targeting strategies. Second, the studies indicate that it may be possible to use IgE-reactive allergens and non-IgE-reactive T cells epitope-containing allergen derivatives for atopy patch testing to identify patients who respond either to IgE-targeting or T cells-targeting strategies. If one considers that most of the clinically relevant allergens are available as pure IgE-reactive recombinant molecules and that non-IgE-reactive peptides containing the allergen-specific T cells epitopes can be easily produced by recombinant expression and/or by synthetic peptide chemistry, diagnostic tools for the selection of IgE-targeting or T cells-targeting strategies are available.
However, it has been shown that targeting IgE antibodies by injecting with antihuman IgE such as omalizumab, or by extracorporeal depletion of IgE antibodies [60–62,63▪] or a combination of IgE depletion and injected anti-IgE  may be effective in atopic dermatitis. However, again not all patients with atopic dermatitis seem to respond to the IgE-targeting therapies  and one wonders if clinical treatment results could be improved by using diagnostic tests capable of dissecting patients for responsiveness to IgE-targeting or T cells-targeting strategies. In fact, there are different anti-IgE antibodies in clinical trials  and new, very well characterized single-use devices for the selective depletion of IgE antibodies by immunoapheresis have become available [66▪]. Recombinant and synthetic allergen derivatives should be considered as useful future diagnostic tools for selecting patients for suitable therapies.
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