David Golden, MD

When to Test and How to Treat Insect Sting Allergies, with David Golden, MD

2025 American Academy of Allergy, Asthma, & Immunology (AAAAI) 

annual meeting in San Diego from February 28 – March 3, 

 sat down with David Golden, MD, from Johns Hopkins to discuss when to test for 

Generally, Golden recommends only testing patients for insect sting allergies if they have an anaphylactic reaction, not simply uncomfortable swelling. Of course, Golden considers how an insect sting impairs quality of life, giving the 

 frequently getting stung by bees, and how they may need epinephrine to improve their overall wellbeing. In this case, Golden recommends the beekeeper be tested for an insect sting allergy.

Golden also recommends testing for insect sting allergies in individuals with 

. However, people may not know they have a mast cell condition, and it is often discovered when they have an allergic reaction.

“We worry a lot about those people because we know that they're like a gun ready to go off. Their mast cells are primed and ready to go, and that's potentially dangerous,” Golden said. “If we knew someone had mast cell condition and they had a sting reaction, we would be…pushing the idea that they need to be tested.”

Unlike mast cell conditions, having other allergic conditions—such as asthma or severe allergies to something non-insect related—is not something that can increase the likelihood of a more severe insect sting allergy. Golden does not recommend testing for an insect allergy simply because the patient has asthma or severe allergies.

Golden said there are no emerging treatments for managing insect sting allergies. However, patients can undergo venom immunotherapy.

“One of the biggest problems is that outside of the field of allergy, nobody knows about it,” Golden said. “It's amazing to me that, and I'll be willing to bet that 90 to 95% of healthcare practitioners don't know that venom immunotherapy exists.”

Many patients with insect sting allergies do not tell their doctor about their previous reaction since they do not believe a reaction like that will happen in the future. And for those who do tell their doctor, many practitioners will give them an epinephrine injector and say there is no need for them to visit an allergist. However, 80% of patients with an epinephrine injector do not use it when they experience anaphylaxis.

“Let's face it, people don't like needles, but we can get around that now by prescribing an epinephrine nasal spray that we not only hope people will actually use, but they'll use early,” Golden said.

He said people often delay the use of an epinephrine injector, saying something along the lines of, “Oh, well, I'll just wait and see if I get worse.”

“That's a terrible idea because if you wait too long, it doesn't even work,” Golden said. “So having a [nasal] spray, we hope [that] will mean people will use it as soon as they notice that they're having a reaction, and that's going to prevent a lot of severe reactions in hospital visits. So that is new, and it's an exciting addition to our ability to help protect people and treat reactions.”

A relevant disclosure for Golden includes Genentech USA, Inc.

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

Dribin TE, Waserman S, Turner PJ. Who Needs Epinephrine? Anaphylaxis, Autoinjectors, and Parachutes. J Allergy Clin Immunol Pract. 2023 Apr;11(4):1036-1046. doi: 10.1016/j.jaip.2023.02.002. Epub 2023 Feb 14. PMID: 36796511; PMCID: PMC10259181.

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At AAAAI, Golden discussed when to test for insect sting allergies, the role of venom immunotherapy, and the potential impact of epinephrine nasal spray.


Treating Insect Sting Allergies in Various Populations, with David Golden, MD

, expert David Golden, MD, from Johns Hopkins University, recommends testing tryptase levels in the blood to assess for any underlying mast cell condition.

2025 American Academy of Allergy, Asthma, & Immunology (AAAAI)

 annual meeting in San Diego to discuss his session, “Dilemmas in Insect Allergies.” During the meeting, Golden shared 

when to test—or to not test—patients for insect sting allergies

, considering underlying mast cell conditions and the patient’s age.

“It turns out that more than any kind of allergy, mast cell disorders seem to be very intimately related to insect seeing allergy mast cells,” Golden said.

Mast cell conditions, such as mastocytosis or hereditary alpha tryptasemia, will not necessarily cause patients to get a reaction from an insect sting. However, these mast cell disorders can worsen the severity of insect sting reactions.

“It's really important for us to know in our insect allergy patients whether they do or don't have an underlying mast cell condition,” Golden said. “In our guidelines for anaphylaxis in general, we now recommend that the doctor should test for the tryptase level in the blood in every person who has severe anaphylaxis or keeps having repeated episodes of anaphylaxis and an insect sting allergy. If they have anaphylaxis to a sting, we always want to check their trip days, and we especially hone in on people who have certain patterns.”

Golden said it is very suspicious if a patient experiences hypotension and dizziness following an insect site—but not breaking into hives. Many people who react to an insect sting get itching or hives, but they do not get hypotension.

“Most people actually get itching or hives,” Golden said. “If you don't and you also have the low blood pressure part of the anaphylaxis, then that's suspicious for mastocytosis.”

Evaluating for Insect Sting Allergy in Children vs Adults

As for age, Golden said a distinction no longer exists between the recommendations for evaluating insect sting allergy in children and adults.

Having skin reactions, such as hives or face swelling, but no trouble with breathing or throat swelling, dizziness, or unconsciousness, is not considered anaphylaxis. Research has shown children with skin reactions rarely get more severe reactions in the future. Allergists were previously concerned that skin reactions in adults would worsen and become anaphylactic.

“It turns out that that's actually not the case, so we changed the recommendations, and… now treat children and adults the same way,” Golden said.

At AAAAI 2025, David Golden, MD, discussed when to test for insect sting allergies, the role of mast cell disorders, and updated guidelines for all ages.

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

meeting in San Diego from February 28 – March 3, David Golden, MD, from Johns Hopkins University, presented on when to test for 

“The important thing for doctors and patients to know is that a positive test is not a diagnosis,” Golden told 

 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.”

HCPLive spoke with Golden at AAAAI on the pitfalls of diagnosing all patients with insect stings for insect sting allergies.

David Golden, MD

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