Interstitial lung abnormalities: to treat or not to treat? The hamlet dilemma

Interstitial lung abnormalities (ILAs) are increasingly recognized as incidental findings on chest computed tomography and may represent an early stage in the spectrum of interstitial lung disease (ILD). However, their clinical significance and optimal management remain debated. While some ILAs may progress to pulmonary fibrosis and functional impairment, many remain stable, and the criteria for initiating diagnostic evaluation, determining monitoring intensity, and starting therapeutic interventions are not clearly established. Current guidelines emphasize risk stratification and longitudinal surveillance, yet significant uncertainties persist regarding which individuals may benefit from early treatment rather than conservative follow-up. This narrative review synthesizes the existing evidence on ILA epidemiology, natural history, and proposed management approaches. We analyse data supporting both early intervention-particularly when ILAs evolve into clinically meaningful ILD-and watchful waiting strategies to avoid overtreatment in asymptomatic and stable cases. The review highlights persistent knowledge gaps, including the lack of consensus on defining progression, determining optimal follow-up intervals, and identifying clear indications for pharmacologic therapy. Overall, ILAs represent a heterogeneous and still poorly defined entity. By critically examining current evidence and ongoing debates, this review aims to guide clinicians in navigating the "to treat or not to treat" dilemma and to outline key priorities for future research.