Update on Tree Nut and Seed Allergies: Prevalence, Clinical Characteristics, Diagnosis, and Management

Tree nut (TN) and seed allergies have become increasingly recognized as important global health concerns, paralleling rising consumption driven by dietary trends. These allergies are often severe, typically develop in childhood, and may persist throughout life. Recent population-based studies show rising prevalence, particularly for TNs and sesame, with substantial regional variability. Clinical outcomes are strongly influenced by the underlying sensitization profile: storage proteins and lipid transfer proteins are associated with systemic reactions and anaphylaxis, whereas sensitization to pathogenesis-related group 10 and profilins usually results in milder manifestations including pollen-food syndrome. Co-sensitization among TNs and seeds occurs frequently; however, clinical co-allergy is observed to a lesser degree, with the highest overlap reported between cashew-pistachio and walnut-pecan. Advances in diagnosis, including component-resolved diagnostics and the basophil activation test, improve discrimination between clinical allergy and asymptomatic sensitization or mild localized reactions, and help minimize the need for oral food challenges. Acute management aligns with standard principles for immunoglobulin E-mediated food allergy, with prompt intramuscular epinephrine being the first-line treatment for anaphylaxis. Long-term management emphasizes accurate allergen identification, pragmatic dietary recommendation that supports inclusion of tolerated nuts, and preparedness with epinephrine for accidental exposure. Emerging data support the use of oral immunotherapy for selected TNs and sesame, with promising desensitization rates. Regulatory progress in allergen labeling and targeted education in high-risk settings, such as schools, restaurants, and air travel, are essential for prevention. Further studies are required to clarify natural history, to optimize immunotherapy, and to refine management for better supporting affected individuals across the lifespan.