Eosinophilic esophagitis I Natural history I Esophageal remodeling I Food impaction I Indications for treatment I Corticosteroids I Immunosuppressants I Biologic therapy I Unmet needs Opinion statement Eosinophilic esophagitis (EoE) is an immune-mediated, chronic inflammatory disease of the esophagus. If left untreated, eosinophilic inflammation induces esophageal remodeling with fibrosis and stricture formation, and patients are permanently at risk of experiencing food impactions. Therefore, it is widely accepted that active EoE should be treated. An ideal EoE therapy should achieve two therapeutic goals: first, to resolve symptoms and, second, to control inflammation. Avoidance of food allergens by the means of food elimination diets as well as anti-inflammatory drugs has the ability to achieve both of these goals. Among the pharmacologic options, only corticosteroids have documented efficacy, whereas alternatives have shown rather disappointing results or are still under evaluation. Swallowed topical corticosteroids (TCS) are at least as efficient as systemically administered corticosteroids (SCS) and have fewer side effects. As such, TCS are widely used as a first-line drug in the treatment of EoE, even though this compound is not approved for this indication by regulatory authorities. Unfortunately, the therapeutic goals cannot be achieved in approximately 30 % of EoE patients, despite appropriate treatment with corticosteroids. For this Bdifficult-to-treat^patient category, therapeutic alternatives are urgently needed. Key points 1. Clinically and histologically active eosinophilic esophagitis must be treated, even when patients effectively cope with their symptoms. 2. Swallowed topical corticosteroids have proven efficacy, a good safety profile and are currently used as a first-line pharmacologic treatment of eosinophilic esophagitis. 3. Eosinophilic esophagitis is a chronic disease; as such, a long-term follow-up and therapeutic strategy is needed.