Current Controversies and Future Prospects for Peanut Allergy Prevention, Diagnosis and Therapies

Peanut allergy has increased substantially in the past few decades, both in developed and developing countries. Peanut allergy has become a major public health concern, affecting up to 1 in 50 children, with repercussions for school and airline policies. Recent research findings have shown that, contrary to the long-standing teaching of "delayed" introduction of allergens, early introduction of peanut protein is of benefit as an allergy prevention strategy, especially in high-risk cases. Ideal dose, frequency and duration of "proactive" peanut therapy for maximum protection remain to be determined in order for it to become acceptable and practical on a large scale. Logistics around widespread screening of high-risk patients remain complex. The correct diagnosis of peanut allergy is crucial and diagnostic tests have been fine-tuned in the past 2 decades in order to help differentiate true allergy from false-positive sensitization through cross-reactivity. Component-resolved diagnostics have become routinely available, and the use of basophil activation tests has increased, although standardization and availability remain issues. Future tests, including epitope testing and histamine-release assays, promise to be even more specific in ruling out false positives and reducing the need for incremental food challenges. Stringent peanut avoidance and prompt treatment of reactions remain the cornerstone of treatment. The concept of exposing the allergic body to small amounts of peanut protein in a cautious, orderly, escalating fashion in the form of desensitization has been widely applied in the past 10-15 years, mainly in the research domain, but of late spilling over into every-day practice. However, desensitization does not equate to a cure, and has significant safety concerns and practical ramifications; probably requiring lifelong-controlled peanut ingestion for ongoing protection. Further strategies to enhance the safety and efficacy of immunotherapy are under exploration, many with a non-specific immune-modifying effect. Despite recent advances in peanut allergy, we still need to go back to basics with accurate diagnosis, nutritional counselling, well-organized allergy action plans and accessible emergency kits.