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

If a patient tests positive for an insect sting allergy, expert David Golden, MD, from Johns Hopkins University, recommends testing tryptase levels in the blood to assess for any underlying mast cell condition.

HCPLive spoke with Golden at the 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.

Underlying Mast Cell Disorders

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.

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.