Dermatology vs. Allergy: Defining Specialty Roles in CSU Management

Dr. Chovatiya raises what he calls the controversial question: how should dermatologists handle the role of allergy and immunology in CSU, given that many patients and referring providers still think of it as an allergy specialty's disease? He directs the question to Dr. Hawkes, who frames the discussion not as a competition but as a matter of expanding patient access.

Dr. Hawkes draws a parallel to atopic dermatitis, where allergists historically managed many cases but prescribing of type 2 pathway inhibitors has shifted overwhelmingly to dermatology—now accounting for approximately 85% of those prescriptions. He argues that neither specialty has a monopoly on doing the right thing: some allergists are doing well, and some are stuck in the same "dishwasher cycle" of trying different antihistamines without escalating to advanced therapies. The same is true of some dermatologists. The goal, he argues, is for both specialties to advance therapy appropriately and collectively increase patient access.

He acknowledges that patients often arrive requesting a referral to an allergist, believing their condition must have an allergic cause. His response: they're welcome to see an allergist, but if allergy testing reveals sensitivity to grass or dogs and their CSU is still uncontrolled, treatment will look exactly the same. Someone—allergist or dermatologist—needs to escalate therapy. He advocates for a shared commitment to guideline-based care across both specialties, noting that dermatologists in particular need to accelerate their adoption of advanced CSU therapies now that options exist that are highly familiar to them. With the arrival of newer oral and injectable options that dermatologists already use in other conditions, there is no longer a clinical reason to defer these patients.

In the next episode, "Evaluating a Severe CSU Case: Angioedema, Emergency Visits, and Uncontrolled Disease," the panel introduces Case 2—a more severe patient with daily CSU, recurrent angioedema, throat tightness, and prior emergency department visits.