Adverse Effects of Dupilumab, Effects of Peanut OIT on the Gut Microbiome and Allergy Training in the United Kingdom

In this month's editorial, the Editors of the journal have selected three fascinating articles that are included in this issue. The first article investigates dupilumab-associated ocular surface disease (DAOSD) in paediatric patients with atopic dermatitis (AD) [1]. Currently, moderate-to-severe AD is treated with biologics like dupilumab, which targets IL-4 and IL-13 pathways. Despite the well-known efficacy of dupilumab, it has been associated with ocular side effects, yet long-term real-world safety data have remained limited.

Therefore, the prospective study by Van der Rijst et al. explores the incidence and risk factors of DAOSD in paediatric AD patients with dupilumab treatment. Children participating in the BioDay Registry were assessed for ocular symptoms every 4–12 weeks in 104 patients aged 3–17 years. DAOSD was initially handled by applying lubricating eye drops, antihistamine eye drops or tacrolimus ointment—where persistent symptoms were additionally treated with ocular anti-inflammatory therapy.

The study revealed that 34.6% of AD patients developed DAOSD, with 30.6% of these cases requiring anti-inflammatory treatment. It was notable that baseline serum IgE levels ≥ 3000 kU/L were independently associated with DAOSD development. Examples of the most common ocular symptoms were pruritus (75%), redness (72.2%) and tearing (58.3%). All patients necessitating anti-inflammatory therapy had shown tarsal conjunctivitis on ophthalmological examination. In addition, 3.8% of patients with DAOSD had chosen dupilumab discontinuation.

These findings suggest new directions into the real-world management of DAOSD in paediatric AD patients. The high incidence of DAOSD highlights the importance of monitoring ocular symptoms during dupilumab treatment, especially in paediatric patients where the symptoms can be challenging to manage. This study also suggests the potential role of serum IgE levels in predicting DAOSD and emphasises the need for collaborative care and study between dermatologists and ophthalmologists to manage these side effects wisely (Figure 1).

The second editor's choice article studies the impact of 1 year of peanut oral immunotherapy (OIT) on the gut microbiota and plasma metabolome in peanut-allergic young children [2]. Peanut allergy is one of the most common food allergies in children, which rarely triggers life-threatening anaphylaxis [3]. While the allergic condition is persistent, only about 21% of children outgrow their allergy to adulthood [4]. Peanut OIT has been recognised as a promising solution to desensitise allergic individuals, allowing tolerance of higher doses of peanut protein and potentially reducing dietary restrictions and improving quality of life [5]. However, its broader effects on the microbiome and metabolic profiles have been understudied.

The study by Badolati et al. observes how peanut OIT modulates microbial biodiversity and metabolic signatures in paediatric patients. Gradually increased peanut doses from 2 mg to 300 mg had been given to 17 children aged 4–15 years over 1-year course. At baseline and post-therapy, changes in the oral and gut microbiome have been examined using 16S rRNA gene sequencing and faecal short-chain acid (SCFA) analysis with buccal and stool specimens.

The authors report a significant increase in α-diversity of the oral microbiome after therapy, which was consistent with previous research in adults [6]. Several metabolites like uridine/pseudouridine and bilirubin were also reported with increased levels after a year of OIT. As bilirubin had been previously found to protect against allergic inflammation through negative regulation of ILC2s [7], this finding suggests directions for future studies regarding OIT, microbiota and metabolome.

Overall, this study emphasises the importance of understanding microbiome-related mechanisms underlying OIT success. As peanut allergy continues to cause concern globally, integrating microbiome research into clinical practice may enhance treatment efficacy and safety, offering hope for improved outcomes in paediatric food allergy treatment.

The third article selected by the editors investigates the state of allergy training within the UK Foundation Programme, highlighting significant gaps in education that could impact patient care and safety [8]. The authors have conducted the study by the British Society for Allergy & Clinical Immunology (BSACI), with a national survey of 1159 foundation doctors. This reveals that allergy education remains an under-prioritised area in medical training, despite the high prevalence of allergic conditions and their potential severity [9].

The survey underscores the reality of medical education, where allergy training is undervalued and insufficiently integrated into curricula. Over 60% of respondents reported receiving 4 h or less of allergy teaching during medical school. Alarmingly, two-thirds received no formal allergy training during their foundation years, and 89% had no exposure to allergy clinics. Although 70% felt confident in the emergency medical management of anaphylaxis, the deficiencies leave many doctors unprepared to manage common scenarios such as drug allergies, which can lead to inappropriate treatments and poorer outcomes.

Therefore, the survey leads to the suggestion for improvement. The survey respondents expressed a strong preference for practical, expert-led teaching focused on key areas like drug allergy management and anaphylaxis protocols. The BSACI advocates for integrating targeted allergy modules into foundation training to address these gaps. By equipping all doctors with core competencies in allergy care, the healthcare system can ensure safer patient outcomes while alleviating pressure on specialist services.

This study highlights an urgent need to re-evaluate how allergy education is prioritised within medical training. As allergic conditions have a high prevalence globally, addressing these gaps is essential to improving patient care and building a more resilient healthcare workforce.

In summary, this editorial underscores three key articles in allergy and immunology research. These studies emphasise the need for better monitoring of biological treatment side effects, a deeper understanding of immunotherapy mechanisms and improved allergy education for medical professionals.

M.H.S. and R.J.B. have equally contributed to this Editorial.

The authors declare no conflicts of interest.