Peanut Allergy Diagnosis

Publication Date: July 17, 2020
Last Updated: March 14, 2022


We suggest in favor of diagnostic (skin prick or serum sIgE) testing for peanut allergy in patients with a 1) physician-judged high pre-test probability of peanut allergy or 2) prior to an oral food challenge for patients with moderate pre-test probability of peanut allergy, with whom shared decision-making has been employed to arrive at the final decision.

We suggest against diagnostic testing in patients with a low or very low pre-test probability of peanut allergy.

We suggest in favor of Ara h2 diagnostic testing in a patient presenting for evaluation of suspected peanut allergy for which a single diagnostic test is to be used, since Ara h2 would provide the best diagnostic accuracy as determined by the more optimal positive/negative likelihood ratio.

We suggest against component testing in addition to either skin prick test or sIgE to whole peanut to increase diagnostic accuracy.

We suggest against the clinician using the results of a SPT, sIgE to whole peanut extract, or sIgE to peanut components to determine the severity of a previous reaction and/or allergy phenotype or to predict the severity of a future reaction.
Technical remarks: It is critical to consider diagnostic test performance in the context of the pre-test probability of peanut allergy. The clinician should recognize the circumstances where one or more of the peanut diagnostic tests may not translate to a clinically meaningful improved post-test odds of peanut allergy. Except in cases of high pre-test probability, it is likely that an oral food challenge will be needed to establish the diagnosis of peanut allergy, regardless of the results of the selected diagnosis test(s).
Certain tests may be more appropriate than others in particular situations. We suggest that the choice of SPT, sIgE, or Ara h 2 sIgE is not critical in circumstances where there is high pre-test probability of peanut allergy.
While testing of patients with low pre-test probability is not generally recommended, if the decision is made to test in these circumstances, from a test precision standpoint, use of Ara h 2 rather than SPT or sIgE can help decrease misclassification of patients as peanut allergic, leading to less harm through falsely positive diagnosis. When testing individuals with low pre-test probability, it is recommended that an oral food challenge still be performed to validate the clinical significance of the detection of sensitization, given that the low pre-test probability in the setting of detectable sensitization translates to only moderate post-test odds of a diagnosis.

Recommendation Grading




Peanut Allergy Diagnosis

Authoring Organizations

Publication Month/Year

July 17, 2020

Last Updated Month/Year

August 16, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center, School

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Diagnosis

Diseases/Conditions (MeSH)

D021183 - Peanut Hypersensitivity, D000074924 - Nut and Peanut Hypersensitivity, D000486 - Allergy and Immunology


peanut allergy, nut allergy, serologic IgE testing, allergy testing, allergic reaction

Source Citation

Greenhawt M, Shaker M, Wang J, Oppenheimer JJ, Sicherer S, Keet C, Swaggart K, Rank M, Portnoy JM, Bernstein J, Chu DK, Dinakar C, Golden D, Horner C, Lang DM, Lang ES, Khan DA, Lieberman J, Stukus D, Wallace D, Peanut Allergy Diagnosis- a 2020 Practice Parameter Update, Systematic Review, and GRADE Analysis, Journal of Allergy and Clinical Immunology (2020), doi: