Pollen Food Allergy Syndrome—Two Decades Apart: A Follow-up AAAAI Survey

Background: Pollen food allergy syndrome (PFAS), also called oral allergy syndrome, results from cross-reactivity between pollen allergens and plant-derived foods. Although typically mild, PFAS can occasionally cause systemic reactions. A 2003 US survey characterized its epidemiology and management; this study repeated the survey in 2023 to assess changes. Objective: To evaluate changes in prevalence, clinical patterns, diagnostic practices, and management of PFAS among US allergists over 2 decades. Methods: A 16-question survey (7 original and 9 new) was electronically distributed to 737 randomly selected American Academy of Allergy, Asthma & Immunology members in October 2023, and results were compared with 2003 survey responses. Results: Sixty-seven allergists (9%) responded. The reported prevalence of PFAS increased in children (median 5%-10%, P =. 01) and adults (8%-20%, P <. 001). The proportion of allergists with patients experiencing systemic PFAS rose from 20% to 67%, though the median percentage of affected patients declined (5%-1%). Grass pollen emerged as a key sensitizer, alongside birch and ragweed. Nut-induced PFAS was increasingly recognized, cited as a frequent trigger of systemic symptoms and a reason for epinephrine autoinjector (EAI) prescription. Overall, EAI prescribing declined, with 0% of allergists “always” prescribing in 2023 versus 30% in 2003. Diagnostic practices showed increased but limited use of component-resolved diagnostics, whereas dietary advice remained variable, especially for nut PFAS. Conclusion: Allergists report a higher estimated prevalence of PFAS, greater recognition of nut-induced and systemic PFAS, and evolving diagnostic and management practices. Findings underscore the need for updated guidelines on PFAS diagnosis and management.