Management and Immunotherapy for Fungal Allergy: Clinical Practice and Unmet Needs.

Fungal allergy is an increasingly recognized health issue, affecting a notable proportion of the general population and a large majority of asthmatics, with sensitization rates rising globally. It contributes to a spectrum of respiratory diseases such as allergic rhinitis, allergic asthma, allergic fungal rhinosinusitis, and allergic bronchopulmonary aspergillosis, often associated with severe symptoms and poor disease control. Current management of fungal allergy relies on environmental control, pharmacotherapy, and allergen immunotherapy (AIT). However, AIT for fungal allergy remains limited by the lack of standardized, high-quality fungal extracts and low-certainty clinical evidence, despite promising results in small-sample trials, particularly for Alternaria alternata and Cladosporium herbarum. Recent advances in biologics targeting type 2 inflammation show promise for severe fungal-driven diseases. Key challenges include molecular allergy diagnosis, extract standardization, optimizing AIT strategies through novel formulations, and conducting large-scale randomized trials. Future progress hinges on collaborative efforts to develop precise diagnostics, improve therapeutic consistency, and validate combination approaches such as AIT with biologics. This review synthesizes current knowledge on the epidemiology, immunopathogenesis, and treatment of fungal allergy, highlighting the urgent needs and further clinical research to improve patient outcomes.