When to Test for Insect Sting Allergies, with David Golden, MD

At the 2025 American Academy of Allergy, Asthma, & Immunology (AAAAI) meeting in San Diego from February 28 – March 3, David Golden, MD, from Johns Hopkins University, presented on when to test for insect sting allergies—or rather, when not to test.

“The important thing for doctors and patients to know is that a positive test is not a diagnosis,” Golden told HCPLive at AAAAI. “What people don't really know… is that there are many people who have a positive test but don't have the allergy. There are tons of people walking around with positive tests to insect stings, and they get stung and nothing happens. We don't know why… doing a test doesn't prove that someone has or is going to have an allergic reaction, so we have to limit our testing to people who…we feel are at increased risk of having an allergy or reaction.”

He said it is like patients with peanut allergies—some patients who test positive for peanut allergies may still be able to eat peanuts without a reaction. The same applies to a positive insect allergy test.

“If someone came to me and said, ‘Well, I got stung and my foot swelled up— I want to be tested for insect allergy. Should I do it? No, because if I do it, there's a good chance it's going to be positive, and this person is going to be really worried about a life-threatening reaction,” Golden said. “They're going to want to go in consider treatment or carry an epinephrine injector, and I'm going to have to explain to them, which is very hard, a very hard concept to accept and digest, that we don't want to test you because that reaction you're describing is not the kind of reaction that puts you in danger of a severe reaction.”

An unnecessary test could create barriers to opportunities, such as joining the military. For example, if someone visited a doctor as a child for a swollen insect bite and received a positive Yellow Jacket venom allergy test, the military may disqualify them based on that result.

Golden said tests should be reserved for patients with anaphylactic reactions, with the one exception of insect stings being a continuous burden to quality of life. Unlike peanut allergy testing, insect allergy testing does not predict the severity of the reaction.

“There are people who have a very, very strong test and have hardly any reaction or none at all, and there are people with a very, very weak test, barely detectable allergy that have near fatal reactions to stings,” Golden said. “We want to avoid that pitfall of saying, ‘Oh, you have such a strong test. You have a really bad allergy.’ We can't and shouldn't say that.”

A relevant disclosure for Golden includes Genentech USA, Inc.

References

Golden, D, and Adams, K. Dilemmas in Insect Allergy. Presented at AAAAI 2025 in San Diego on March 1.