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2. Photosensitivity test (Chapter 13)

Various photosensitivity tests are conducted by examining the
reaction to irradiation. Ultraviolet radiation is divided into ultra-
violet A (UVA) (operative wavelength of 320 to 400 nm), ultra-
violet B (UVB) (operative wavelength of 290 to 320 nm) and
ultraviolet C (UVC) (operative wavelength of 100 to 290 nm).
5
UVA, UVB and visible light are most frequently used.

1) Photo test
The degree of photosensitivity and suitable operative wave-
length can be measured and determined by the amount of radia-
tion that causes cutaneous reactions such as pigmentation and
erythema. By testing the operative wavelength on patients, it is
possible to know which particular radiation exposure should be
eliminated.
The most widely conducted photo test is exposure to UVB
irradiation in the minimal dose that causes erythema in 24 hours
(minimal erythema dose; MED). The average dose for ethnic
Fig. 5.5 Photo test to measure minimal ery-
Japanese is 60 to 100 mJ/cm2 (Fig. 5.5). When the MED is low, thema dose (MED).
involvement of a photosensitive disease is suspected. Erythema appeared at the site of 60 mJ/cm2 irra-
Diseases of photosensitivity to UVA are rare, occurring for diation; the MED for this patient is 60 mJ/cm2.
example in some cases of chronic actinic dermatitis. Pigmenta-
tion (suntan) is caused by UVA exposure; it is called the minimal
response dose (MRD), in contrast to the MED. The normal MRD
for ethnic Japanese is 5 to 15 J/cm2. The result is determined 48
hours after irradiation.
Chronic actinic dermatitis and some cases of porphyria
cutanea tarda are diseases in which there is sensitivity to visual
light. There is no standard technique for measuring MRD for
photosensitive diseases; they are generally observed in the cuta-
neous reaction induced by exposure to slide projector light for 15
to 20 minutes.
A photo-provocation test of exposure to 2 to 3 MED for 3 con-
secutive days may be performed in the case of photosensitive dis-
eases to observe the reaction.

2) Photo-patch test
The photo-patch test is conducted to examine the influence of
rays when a chemical substance is placed on the skin. Twenty-
four to 48 hours after a material that is suspected of causing pho-
tosensitive disease is pasted on the skin, the site is exposed to UV
rays. If reddening or swelling occurs within 24 hours, the test is
considered to be positive for such disease.

3) Photo-drug test
The influence of radiation in the presence of a chemical sub-
stance can also be examined by photo-drug test. A drug that is
 66 5 Diagnosis of Skin Diseases

suspected of causing a photosensitive disease is taken orally

instead of topically. The photodrug test is generally used for
diagnosis of drug-induced hypersensitive diseases.

3. Allergy test
5 The tests for allergic reactions to a specific antigen are largely
divided into those for type I allergy (immediate) and those for
type IV allergy (delayed). A scratch test and an intracutaneous
reactivity test are conducted for type I allergy; a patch test and an
intracutaneous reactivity test are conducted for type IV allergy.
ELISA and Western blot test are performed to detect the anti-
body in autoimmune blistering diseases.

1) Patch test
The patch test, for detection of the antigen of contact dermati-
tis, is conducted by applying the antigen to normal skin to
g
observe the reaction.
j
The antigen that is suspected of causing
p q
a b c d e f h i k l m n o r
allergy is mixed in a vehicle of a topical agent such as white
petrolatum and spread on an adhesive plaster or put in a Finn-
chamber (a plaster to which an aluminum plate is affixed). The
plaster is adhered to a site of normal skin (usually the back or the
upper inner arm). After 48 hours, the patch is removed, and the
test result is determined in about 20 minutes when stimulation
caused by the plaster has subsided. If reddening, edema, papule
or erosion is produced, the test is considered to be positive for
allergy (Fig. 5.6, Table 5.1). The site may be observed after 72
hours and 96 hours for more reliable results. A series of diluted
a b c d e f g h i j p q
test substanceskis usedl for themtest. Inn casesoin which the result isr
Fig. 5.6 Patch test. positive only when the test substance is diluted to a certain level
a: The antigens are spread on adhesive plasters
that are then stuck to the back of the patient. b: In
48 hours, various allergic reactions (edematous
erythema and papules (arrows)) are seen if the
Table 5.1 Readings and interpretation of patch test reactions.
patient is allergic to the antigen.
Japanese criterion ICDRG criteron
− Negative − Negative
Faint erythema Doubtful reaction; faint
± ＋？ erythema only

Erythema Weak positive reaction;

＋ ＋ palpable erythema,
infiltration, possibly papules
Edematous erythema Strong positive reaction;
erythema, infiltration,
papules, vesicles
Infiltrative erythema, papules, Extreme positive reaction;
vesicles intense erythema and
infiltration and coalescing
vesicles
Fig. 5.7 Prick lancet. Coalescing vesicles Irritant reaction of different
IR types
NT Not tested
ICDRG: International Contact Dermatitis Research Group
 3. Allergy test 67

or higher, it is considered the primary irritant (Chapter 7). Table 5.2 Readings of scratch test reactions.
Wheal diameter Erythema diameter
Reading
(mm) (mm)
2) Scratch test Negative (-) ＜5 ＜15
The scratch test is a simple test to detect an immediate allergen Positive (+) ≧5 ≧15
(type I allergy). The flexor surface of the forearm is scratched
with a needle or a needle-like tool without drawing blood, and
Table 5.3 Readings of intradermal test reac- 5
tions (in 15 minutes).
one drop of antigen solution is applied to the forearm (Fig. 5.7).
Wheal diameter Erythema diameter
If the patient is allergic to the allergen, reddening or swelling is Reading
(mm) (mm)
produced on the spot. The diameter of the reddening or swelling Negative (-) ＜7 ＜15
along the minor axis is measured 15 to 20 minutes after applica-
+)
Doubtful (- ＜9 ＜20
tion for identification of the allergy (Table 5.2).
Positive (+) ＜15 ＜40
A scratch test may cause shock in patients with a history of
anaphylactic shock. Therefore, the antigen solution should be Strongly ≧15 ≧40
positive ( )
tested first on normal skin to see whether urticaria is produced in
30 minutes (open test). If the result of the open test is positive, it
is unnecessary to perform a scratch test or an intracutaneous reac-
tivity test.

3) Intracutaneous test
(type I allergy test, type IV allergy test)
Type I allergens can be detected by intracutaneous test 1. In
this, 0.02 ml of a solution containing the suspected substance is
injected intradermally, and if an urticarial lesion or pseudopodia-
like projection occurs within 15 to 20 minutes, the test is deter-
mined to be positive (Table 5.3). Since there is a risk of causing
anaphylactic shock in the intracutaneous reactivity test, it is
desirable to perform a scratch test in advance to determine the
severity of the reaction.
Intracutaneous test 2 is conducted to examine the strength of
cellular immunity against an antigen. Forty-eight hours after
intradermal injection of 0.1 ml of the solution containing the sus-
pected substance, if the reddening or swelling along the minor
axis averages 10 mm or more, the result is generally considered
positive to allergy. Common intracutaneous tests are listed in
Table 5.4.

4) Drug-induced lymphocyte stimulation test

(DLST)
The drug-induced lymphocyte stimulation test (DLST) is known
to be useful in identifying drug-induced eruptions associated with
T cells; however, the involvement of a drug cannot be ruled out
even when the results are negative, because of the low sensitivity
of the test. DNA synthesis accompanying a lymphocyte prolifera-
tive reaction can be determined by 3H-thymidine after peripheral
blood lymphocytes are cultured with a drug.
 68 5 Diagnosis of Skin Diseases
Table 5.4 Typical type IV allergy tests.
Tuberculin skin test (PPD skin test)
A tuberculin skin test is used to detect delayed
hypersensitivity to tuberculosis, by injecting
tuberculosis antigen intradermally. 0.1 ml of
tuberculosis antigen (purified protein derivative;
PPD, 0.05 mg/ml) is injected into the inner side
5 of the forearm. The long diameter of the
erythema 48 hours after injection is used for
interpretation: less than 10 mm is negative, and
more than 10 mm as positive. Positive reaction
is sometimes categorized into weak (only
erythema), moderate (erythema and induration),
and strong (erythema with vesicles and necrosis).
Tuberculin skin test is specific to tuberculosis.
However, patients with measles, sarcoidosis,
Hodgkin’s disease, severe tuberculosis, and
serious malignancies may show weak reaction
or false negative.
Trichophytin reaction
An antigen derived from trichophyton
(trichophytin antigen) may be used to test
intradermally for trichophytid and tinea profunda.
Sporotrichin reaction
Sporotrichin antigen is injected intradermally for
diagnosis of sporotrichosis.
Ito’s reaction
Haemophilus ducreyi antigen is used for
diagnosis of chancroid.
Frei reaction
Frei reaction is an intradermal test for
lymphogranuloma venereum.
Lepromin reaction (Mitsuda reaction)
Lepromin reaction (Mitsuda reaction).
Antigen derived from leproma is intradermally
injected for diagnosis and classification of leprosy.
Kveim test
Diagnosis of sarcoidosis used to be done by a
skin test whose antigen is derived from another
patient’s spleen and lymph nodes. Kveim test is
rarely done today.
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5) Drug challenge test
The drug suspected of causing allergy is administered to the
patient to determine whether the eruptions will recur. One one-
hundredth to one tenth of the usual dosage is given orally. In seri-
ous drug eruptions, there is a high risk that a drug challenge test
will cause anaphylactic shock. The drug challenge test is the
most reliable allergy test.
4. Skin function test
Tests for measuring various skin function, such as temperature
control, secretion, and vascular regulation, are as follows.
1) Measurement of skin temperature
and thermography
Thermography, which uses an infrared-camera-equipped emis-
sion pyrometer to express the distribution of skin temperature
two-dimensionally, has become widely used for diagnosing dis-
eases of the blood vessels, and nervous system disorders, inflam-
mations, tumors, and other disorders.
2) Transepidermal water loss (TEWL)
Transepidermal water loss (TEWL) from the skin surface is
measured by electric hygrometer (Fig. 5.8). This test is effective
in determining the clinical condition of keratinization. The
TEWL value usually is elevated in dyskeratoses, such as in
ichthyosis.
3) Skin capillary resistance test
The fragility of skin capillaries can be determined by measur-
ing ecchymosis produced in artificially pressured blood vessels.
In the Rumpel-Leede test, the upper arm is pressed by a blood
pressure manchette to congest the blood vessels. Two minutes
after pressure between the systolic and diastolic pressures is
applied to the patient’s upper arm for 5 minutes to constrict the
blood vessels, hemorrhagic spots occur. When 10 hemorrhagic
spots or more produced, the test is positive for dysfunction of
vascular regulation. It may also be positive if there is abnormality
in the capillaries or platelets, such as Henoch-Schönlein purpura
or thrombopenic purpura.
5. Fungal examination
Potassium hydroxide (KOH) is used for observation and detec-
tion of fungi and mites. Scales or blister contents are swabbed
(Fig. 5.9) and applied to a glass slide onto which 20% KOH solu-
tion is dripped, and a slide cover is placed on top. The slide is
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