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However, even this relatively small percentage translates into a large absolute number, as this part of the world accounts for approximately 25% of the global population. There is a huge unmet need for allergy specialists in India and Sri Lanka. Penicillin allergy management is further compromised by unavailability of skin test reagents, lack of formal training in drug allergy, pre\u2010emptive, non\u2010standardised and unregulated skin testing by untrained operators and a weak health service framework. This has an adverse impact on antimicrobial stewardship, particularly in the management of rheumatic fever, rheumatic heart disease, bacterial endocarditis, syphilis and other sexually transmitted infections. This narrative review highlights the burden of PALs in India and Sri Lanka, as well as gaps in the published literature. 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