Chronic urticaria (CU) and angioedema represent common morbid conditions, affecting millions worldwide and imposing substantial personal, societal, and economic costs 1. While the biological underpinnings of many forms of mast cell mediated urticaria/angioedema and bradykinin-mediated angioedema are increasingly well characterised, the lived experience and care of patients with these conditions remains strikingly unequal across regions. Access to timely diagnosis, specialist care, and effective therapies varies widely between high-income countries and much of Asia, Africa, and other low- and middle-income regions 2. The inaugural EAACI East Meets West (and the Middle) Allergy School in Hong Kong (27–29 August 2025) provided a rare and powerful forum to discuss the state-of-care across the world and how to tackle disparities. By convening clinicians and scientists from Europe, Asia, Australasia, and Africa, the School created an opportunity not only to compare regional disease burdens and practices but to interrogate why—despite shared disease biology—care and consequently outcomes differ across the globe. Day 1 of the school produced robust discussion centred around West and East perspectives on chronic urticaria and recurrent angioedema including hereditary forms, highlighting both remarkable scientific progress and growing data from global networks and diverse populations, as well as uncomfortable inequities that persist in real-world care. International collaborative efforts have demonstrated that the core clinical features of chronic urticaria are broadly consistent across populations. Data from the Chronic Urticaria Registry (CURE) show similar disease phenotypes, triggers, comorbidity profiles, and natural history across regions—East, West and in the middle, reinforcing the concept that CU is a global disease with shared fundamental mechanisms 3. On the other hand, there are remarkable differences in the prevalence of hereditary angioedema (HAE) reported from different parts of the world. The low prevalence reported in several parts of Asia suggests that HAE is grossly underdiagnosed in these countries 2, 4. Diagnostic delays, morbidity, and mortality remain disproportionately higher in low- and middle-income countries (LMIC), driven largely by limited awareness, inadequate access to diagnostics, and scarcity of specialist services 4. Delayed diagnosis of HAE continues to translate into preventable deaths in parts of Asia and Africa 4. Despite the shared fundamental mechanisms, presented data outlined differences in dominant disease phenotypes, for example, cholinergic urticaria in Japan, with distinct clinical patterns and treatment responses compared with Western populations 5. Similarly, African cohorts demonstrate a striking overrepresentation of bradykinin-mediated angioedema related to angiotensin-converting enzyme inhibitors, reflecting both prescribing patterns and likely unique biology and genetic susceptibility 6. These observations point to population-specific biology that remains inadequately explored, and the need to continue to improve representation of diverse populations in growing international patient registries such as CURE and Chronic Angioedema registry (CARE) and clinical trials. Crucially, studying underrepresented populations is not an act of equity alone—it is a scientific imperative. Diverse genetic backgrounds, environmental exposures, and comorbidity profiles offer unparalleled opportunities for discovery, with the potential to uncover novel mechanisms, biomarkers, and therapeutic targets that benefit patients globally. A major focus of chronic urticaria and angioedema scientific efforts and collaborations in the last decade has been the development of several novel and effective treatments for urticaria and HAE. Targeted biologics and small molecule drugs have transformed the management of chronic spontaneous urticaria, shifting treatment goals from partial symptom relief to complete disease control and normalisation of quality of life 7. In HAE, the availability of effective on-demand and long-term prophylactic therapies has redefined what is possible, moving the field from crisis management to complete control, with potentially even functional cure through gene editing on the horizon 8, 9. Much of the subsequent discussion highlighted that these advances are not equitably realised across the world. Clinical trial participation remains heavily skewed toward Europe and North America, with persistent underrepresentation of patients from Asia, Africa, and other regions that together comprise the majority of the global population 10. This imbalance perpetuates a vicious cycle of inequity. No diagnoses, limited research infrastructure and trial access lead to sparse local data, which in turn undermines regulatory approval, reimbursement, and investment. Thus, ultimately denying patients access to guideline-recommended therapies (Figure 1). Beyond therapeutics, broader systemic gaps remain. Initiatives such as the MENTALIST project—a global physician perspective to identify unmet needs in hereditary angioedema—were discussed and have catalogued persistent deficiencies in education, mental health support, multidisciplinary care, and patient-reported outcome integration in angioedema care, further compounding inequities even where medications are nominally available 2. Despite these challenges, the presenters and panellists highlighted slow but steady momentum toward change. Global collaboration in urticaria and angioedema has accelerated, driven by pragmatic, context-sensitive innovation. The expansion of UCARE and ACARE (Urticaria and angioedema centres of references and excellence) networks has demonstrably improved diagnostic accuracy, clinician education, and patient access to reliable information, education and improved access to treatment in multiple regions. Regional patient advocacy groups, supported by international organisations such as Hereditary Angioedema International (HAEi), have emerged as powerful catalysts, driving awareness, influencing policy, and reframing expectations around acceptable disease control 2. Innovative diagnostic strategies in countries like India and China are also closing gaps. Simplified approaches to HAE diagnosis—such as leveraging elevated C1-inhibitor antigen levels as a surrogate for functional deficiency in type II HAE—offer feasible solutions where specialised assays are unavailable 11. Cascade family screening programmes have proven highly effective in identifying previously undiagnosed patients in remote areas, reducing diagnostic delay and preventing morbidity and mortality 4. Importantly, these initiatives are not isolated successes but components of a broader “flywheel” effect: awareness drives diagnosis, diagnosis enables advocacy, advocacy attracts resources, and resources fuel research and access. Although potentially slow to begin, when sustained, this cycle gathers momentum and has the power to transform care landscapes even in resource-constrained settings. Funding remains a central obstacle for turning the flywheel with greater momentum. In regions where disease awareness is low and diagnosis infrequent, attracting traditional research funding or pharmaceutical investment is inherently challenging, perpetuating inequity. Our discussions in Hong Kong made clear that no single stakeholder can solve this alone. Clinicians, scientists, patient advocates, industry partners, and policymakers must recognize their shared interest in inclusive, globally relevant research and care. The ambition of normal quality of life for all patients, West and East (and middle) with urticaria and angioedema is achievable—but only through sustained global collaboration. By embracing diversity as a scientific asset rather than a logistical challenge, and by committing to equity as a core principle of innovation, the global community can ensure that advances in urticaria and angioedema benefit all patients, everywhere. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Peter et al. (Wed,) studied this question.