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Allergy Skin Tests

Allergy Skin Tests

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Published by: Anindya Putri Kusumajati on Sep 01, 2013
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07/22/2014

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Allergy skin tests, Techniques, and interpretation
 Introduction
The clinical evaluation of a patient with a suspected allergic disease begins with adetailed history, physical exam and ancillary tests (such as PFT, Xray etc.) intended todefine and characterize the patients disease state.Allergy testing helps define triggers of allergic disease. These tests are intended to detectType 1 ( IgE mediated hypersensitivity) sensitization. Allergy tests, strictly speaking, arenot tests for the diagnosis of allergic disease; they simply report the presence of detectable amounts of allergen specific IgE that might in part be responsible for triggering disease symptoms. Specific IgE can be found in patients with allergic diseaseas well as in about 15% of asymptomatic normal individuals.Allergy testing employs carefully prepared extracts of pollens, fungi, animal products,food, latex etc. Extracts are complex mixtures of allergenic proteins and other substances.Each extract may contain several allergens. For successful testing of a patient, an extractmust contain all relevant major and minor allergens.
Skin testing 
Several skin test methods are available. These include patch testing, or the directintroduction of antigen into the skin epicutaneously or intracutaneously.The epicutaneous methods in general use are prick testing and puncture testing.
 Patch testing 
Patch test has been used for 100 yrs to diagnose contact allergies.Allergens are applied to the intact skin, under an occlusive dressing. In most cases 1 or 2days of exposure is used.Studies have shown that protein and glycoprotein antigens as large as 30,000 Daltons can penetrate intact skin.Patch test typically detect delayed allergic reactions due to either the late phase of type 1immediate hypersensitivity reactions or to type 4 cell mediated hypersensitivity.Advantages include1.Only method to confirm that a specific contact is causing sensitization2.solid antigens such as fabrics can be tested3.not painfuldisadvantages include1.less reproducible – typical sensitivity ranges from 60 to 70% andspecificity 70 to 80%2.difficult to differentiate irritative reactions from true allergic reactions3.Generally safe but may cause flares of atopic dermatitis and locally severeskin reactions
 
 Prick testing 
First described by Lewis and Grant in 1926, and popularized in the 1970’s by Pepys.In this method a drop of extract is placed on the skin. A sharp needle – 25 gauge isintroduced into the skin at an angle, through the antigen droplet and the most superficiallayers of the skin ( about 1 mm deep ) are lifted up with no downward pressure on theskin, introducing a minute amount of extract. Must not induce any bleeding.This is the technique of choice for dermatographic patients.A variety of testing devices is available.Because of the possibility of false positive reactions when tests are placed closelytogether, prick test should be separated by about 2 cm. Fresh prick devices should beused for each antigen to prevent cross contamination.The greater the experience level of the testing personnel, the lower the test variability, so personnel training and monitoring is vital.Blotting away antigen instead of leaving the droplet alone does not influence the testresult.
 Puncture testing 
Here a drop of extract is placed on the skin and the testing device is placed perpendicular to the skin. The device is placed on the skin with enough downward pressure to form asmall indentation in the skin.Because puncture methods to some extent involve downward pressure on the skin, theyare less appropriate for dermatographic individuals.However they are thought to be easier to learn and use. Some devices can be dipped inthe extract before skin application.
 Intracutaneous skin testing 
Mantoux is credited with inventing intradermal or intracutaneous skin testing in 1908.His technique was used in 1911 by Robert Cooke for allergy skin test.Testing is performed with a disposable tuberculin syringe and a small-gauge needle. Asmall amount ( about 0.02 ml - range 0.01 to 0.05ml) of dilute extract is injected into thesuperficial layers of the skin to produce a 2 to 3 mm diameter superficial bleb in the skin.The syringe is placed at a 45 degree angle to the skin. Penetration into the sub epidermalcapillary bed of the skin should be avoided.Many of the clinicians who employ intradermal test for inhalant allergy testing use a 50to 100 fold dilution of the stock extract when an epicutaneous test with the stock extractis negative or equivocal, yet clinical suspicion of allergic sensitization is high.
 
Although this approach does increase the clinical sensitivity for skin testing, it does sowith a loss of clinical specificity. Other disadvantages include – it is more difficult andtime consuming, more painful for the patient and irritant reactions occur commonly.
Safety of intradermal tests
There is no fundamental difference in safety between intradermal and epicutaneous teststhat is not explainable by the amount of absorbed antigen. Fatalities from intradermalskin testing have been reported, both due to use of potent allergens and due to injectionof excessive amounts of allergen.As a consequence many allergist recommend screening prick test prior to doingintradermal test. As a general rule the starting dose of intradermal extract solutions in patients with preceding negative prick test should range between 100 to 1000 folddilutions of the extract used for prick/puncture test.Particular care should be taken in patients treated with B blocking agents, ACEI, or monoamine oxidase inhibitors, which may increase the risk of systemic reactions.Although systemic reactions have been observed no fatalities have been reported inepicutaneous skin testing.
Skin End Point Titration
This is a quantitative modification of intradermal testing that tests multiple antigendilutions to establish the minimum amount of antigen required to produce a positive skintest. An end point is determined by sequential intradermal injection of constant volumesof successively stronger antigen dilutions until eventually a skin wheal forms that isclearly more reactive than the negative control. This first positive wheal is thenconfirmed by injecting one additional, more highly concentrated antigen dilution anddetermining that the stronger dilution produces a wheal that is even larger than the firstreactive wheal.It has been found experimentally that skin wheals in the 4 mm to 15mm size range liewithin the linear portion of the dose response curve, where wheal size and antigen dosecan be correlated.Currently skin end point titration is used for 1.determining stability of allergenic extracts2.evaluation of sensitivity to standardized allergenic extracts3.to determine relative potency of allergenic extracts4.yield a safe starting dose for immunotherapy – generally treatment can beinitiated at doses of about 5 to 20 times greater than the SET doseDisadvantages of SET includes increase testing time and complexity making it toodifficult for general clinical use.

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