# Pollen Food Allergy Syndrome in Southern European Adults: Patterns and Insights
## 5 Treatment of PFAS  
The symptoms of PFAS are usually confined to the oral cavity and are not life-threatening unlike other types of food allergy. Avoidance of the raw form of the culprit food is recommended, particularly for the patients with a history of systemic reaction [77]. Furthermore, given the typically mild nature of most PFAS reactions, tailored suggestions can be offered through shared decision making with the patient.  
Reactions are often self-limiting, and the use of antihistamines is an effective treatment [78]. However, the severity of reactions after ingestion of plant foods may vary. For individuals with PFAS, consuming peeled and deseeded fruits and vegetables is often sufficient to prevent a reaction [78,79]. Nevertheless, certain plant foods associated with PFAS--such as nuts, soy milk, and smoothies or fresh juices--may trigger systemic reactions, especially if consumed rapidly or in large quantities [77]. For patients with a history of anaphylaxis, training in the management of systemic reactions and the use of an emergency kit, including epinephrine, are essential.  
A recently published international Delphi consensus provides practical guidance for clinicians managing PFAS patients [77]. The consensus aimed to establish standardized recommendations for PFAS management. The international panel of experts emphasizedthe importance of counseling patients on the nature of PFAS, recognizing the rare risk of severe systemic reactions, and avoiding only the specific raw food that triggers symptoms rather than all cross-reactive foods. In accordance with an EAACI Position paper, authors also concluded that the role of allergen immunotherapy in PFAS remains unclear and should not be considered a primary treatment [13].  
In patients with polinosis and PFAS, the use of pollen extracts for sublingual and subcutaneous immunotherapy appears effective for treating allergic rhinitis, but its efficacy in treating PFAS is not established [13,78]. Alternatively, studies on food desensitization, particularly for apple, show promising results [80,81]. In cases of apple-related PFAS, tolerance can be induced through a slow gradual increase in its consumption, with a favorable safety profile. However, maintaining tolerance depends on the continued consumption of apples, and relapse has been observed after discontinuation [80].  
An alternative treatment of PFAS using local nasal immunotherapy with a Birch pollen-galactomannan conjugate (BP-GMC) ointment has been introduced [82]. The results demonstrated that the BP-GMC was well tolerated, with no significant adverse effects, and, at the end of the study, patients were able to consume up to 64 g of apples without symptoms, suggesting a potential therapeutic benefit.  
Omalizumab is a biologic globally used for the treatment of asthma and chronic urticia. It has been used to reduce reactions following incidental exposure in food-allergic individuals and has also been administered in a few cases of PFAS. Although its efficacy is time-limited, it may be useful in cases of children where antihistamines fail to alleviate symptoms [83].