*4.3. Oral Food Challenge*

If the diagnosis of peach allergy is in doubt, OFC is required as it represents the gold standard for the diagnosis of any food allergy. Some OFC protocols are intended to test peach peel and pulp separately [33], others to test them both, and some to assess exercise-induced anaphylaxis [76]. Furthermore, clinicians may consider allergy testing and, ultimately, OFC to plant foods containing nsLTPs or GRP with known potential crossreactivity with peach if oral tolerance to these foods is in doubt, and according to the patient's preference (Figure 1).

reactivity with peach if oral tolerance to these foods is in doubt, and according to the

**Figure 1.** Diagnostic algorithm for peach allergy. Adapted from [40]. **Figure 1.** Diagnostic algorithm for peach allergy. Adapted from [40].

### **5. Prevention and Management 5. Prevention and Management**

patient's preference (Figure 1).

### *5.1. Primary and Secondary Prevention 5.1. Primary and Secondary Prevention*

To date, no study has shown a possible effective strategy for the primary prevention of peach allergy. Neither polyunsaturated fatty acid supplementation during pregnancy nor the use of probiotics and fish oil supplementation in infancy were effective at preventing the appearance of food allergies [77]. The early introduction of food during diversification could be a possible primary prevention strategy [78]. Even though current data show moderate evidence that the early introduction of peanut and egg reduces the To date, no study has shown a possible effective strategy for the primary prevention of peach allergy. Neither polyunsaturated fatty acid supplementation during pregnancy nor the use of probiotics and fish oil supplementation in infancy were effective at preventing the appearance of food allergies [77]. The early introduction of food during diversification could be a possible primary prevention strategy [78]. Even though current data show moderate evidence that the early introduction of peanut and egg reduces the risk of food allergy, there is no sufficient scientific information on other major food allergens [79].

risk of food allergy, there is no sufficient scientific information on other major food allergens [79]. In peach-allergic patients, as with other food allergies, prescribing preventive antihistamines was not shown to be effective at preventing possible allergic reactions; furthermore, this strategy may delay the timely and appropriate use of adrenaline to treat anaphylaxis [40]. The use of mast-cell stabilizers to prevent allergic reactions showed different clinical results, making it not advisable, so far, as a prophylactic strategy for food allergies in general and, therefore, for peach allergy as well [40]. The use of monoclonal antibodies, such as omalizumab and dupilumab, has been suggested instead in the In peach-allergic patients, as with other food allergies, prescribing preventive antihistamines was not shown to be effective at preventing possible allergic reactions; furthermore, this strategy may delay the timely and appropriate use of adrenaline to treat anaphylaxis [40]. The use of mast-cell stabilizers to prevent allergic reactions showed different clinical results, making it not advisable, so far, as a prophylactic strategy for food allergies in general and, therefore, for peach allergy as well [40]. The use of monoclonal antibodies, such as omalizumab and dupilumab, has been suggested instead in the treatment of food allergies, mostly as adjuvant therapy for immunotherapy rather than as a possible preventive strategy against the development of clinical symptoms in allergic patients [80].

treatment of food allergies, mostly as adjuvant therapy for immunotherapy rather than as

### a possible preventive strategy against the development of clinical symptoms in allergic *5.2. Management of Peach Allergy*

patients [80]. Once the diagnosis of peach allergy is made, peach should be eliminated from the patient's diet. Foods possibly cross-reacting with peach allergens should also be investigated by, firstly, assessing whether the patient is exposed to these foods without presenting symptoms and, if this is found not to be the case, by performing skin tests and/or specific IgE dosing. This strategy should mainly be considered for food cross-reacting via Pru p 3 (LTP) or Pru p 7 (peamaclein), given the higher risk of severe reaction associated with sensitization to these allergens.

Management strategies should include both the management of acute accidental reactions and long-term avoidance strategies.

A written emergency action plan for acute reactions should always be provided to all patients with peach allergy. In addition, two adrenaline auto-injectors (AAI) should be prescribed to patients with a history of anaphylaxis to peach.

In order to properly avoid peach, patients should also be educated on how to recognize the presence of peach in commercial products (such as fruit juices). Unfortunately, current labeling practices and legislation do not include the obligation to include the presence of this food, nor to highlight it on the label [81], which could result in the threat of accidental exposure. Other important aspects of educational programs for peach allergy include understanding and recognizing the early signs/symptoms of a possible allergic reaction, avoiding possible triggers or cofactors able to elicit the allergic reaction (e.g., asthma exacerbations, infections, exercise, alcohol, tiredness, use of NSAIDs, and menstruation), and knowing when and how to administer proper treatment, especially if an adrenaline auto-injector has been prescribed [34,40,78].
