9th Singapore Allergy & Rhinology Conference Skin Prick Testing

3 – 5 May 2018 A/Prof Matthew Ryan

Allergy Skin Testing

Matthew W. Ryan, MD
Associate Professor
Department of Otolaryngology
University of Texas Southwestern Medical Center
Dallas, Texas, USA

We perform allergy testing only when

we think it will provide useful clinical
information
 The mainstay of diagnosis of allergic
disease is the history.

 Testing is performed to:

 1) confirm the diagnosis
 2) identify clinically significant allergens
 3) determine the degree of sensitivity

Positive Allergy Skin Tests Are Common

in ‘Normal’ People
 3rd USA National Health and Nutrition Survey
 N = 10,508
 Ages = 6-59 year
 Prick test for 10 allergens, with controls
 53.9% had 1 or more positive test

THEREFORE: Allergy test results must be

correlated with patient symptom pattern to
determine the clinically relevant allergens!
Arbes S et al. J Allergy Clin Immunol 2005;116:337-83.

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

Positive skin tests in the US

population

Arbes S et al. J Allergy Clin Immunol 2005;116:377-83.

Allergy skin tests have the same

limitations as other medical tests
 A positive result does not mean that an allergic
disease is present

 Some ‘allergy symptoms’ may not be due to allergy

 Negative allergy tests don’t definitively exclude

allergy

 Test results must be interpreted in the context of the

patient’s history

What does the size of a skin test

reaction mean ?

Pediatr Allergy Immunol 2013: 24: 195–209.

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

Selection of Allergens to Test

 dust mites
 common molds
 pets
 insects
 major allergenic pollens
 other prevalent airborne allergens in your
area and patient population

How many tests should we use?

In a US based survey study, the most

common number of aeroallergens
tested ranged from 11 to 20

Ryan MW et al. Int Forum Allergy Rhinol. 2014;4:789=-795

Why Test the Skin?

 Skin tests have been the primary diagnostic tool
in allergy since their introduction in 1865 by
Blackley

 The intracutaneous (intradermal) test described

by Mantoux in 1908 was also applied to allergy

 Lewis and Grant described the prick test in

1924

Demoly P, Piette V, Bousquet J. in Middleton’s

Allergy, 6th Ed.

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

Why Test the Skin?

 Mast cells reside in the subepithelial layer of the
skin
 Allergen + Sensitized mast cell = Allergic
reaction which leads to release of chemical
mediators
 Classic wheal (edema) and flare (erythema) is
easily seen on the skin
 Skin testing is an indirect measure of cutaneous
mast cell reactivity due to presence of IgE

Skin Tests Rely on the Effects of

Histamine

 Increased vascular permeability

 Vasodilation

 Irritation

The Skin Whealing Response to Allergen

 After a delay of up to 5 minutes, the skin begins to swell due to

increased vascular permeability and transudation of plasma proteins
into the tissues, with a corresponding influx of water.
 This swelling, (the "wheal" response), is proportional to the amount
of mast cell degranulation, and is therefore a specific indicator of
IgE mediated release of histamine and other mediators.
 Mediators also trigger sensory nerves in the skin, causing itching
and erythema.
 This immediate response is maximal at about 10-20 minutes, and
lasts for up to an hour.

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

A Variety of Factors Affect Skin Whealing

 Before proceeding with skin testing, it is

necessary to determine that the skin:

 responds normally to histamine

 does not exhibit whealing responses to
non-antigenic stimuli

Controls

 Positive control: Glycerinated Histamine

 Histamine phosphate (1mg/mL histamine base)
 Histamine dichloride (6mg/mL histamine base)

 Negative control: Diluent

 50% glycerine in normal saline

Why do we need Controls?

Factors that inhibit the whealing response

 Medications
False
 Antihistamines Negative
 Tricyclic antidepressants Result

Factors that enhance the whealing response

 Glycerine sensitivity
False
 Skin conditions Positive
Result
 Dermatographism
 Eczema
 Urticaria

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

The most important skin tests for

allergy : prick and intradermal testing

Demoly P, Piette V, Bousquet J. in Middleton’s

Allergy, 6th Ed.

Technique of Prick Testing

 Use stock allergen (concentrate) from
manufacturer
 Antigen is either placed on skin or “dipped”
 Skin is then “pricked” with sharp device
 Read at peak size (15-20 mins)
 Measure wheal diameter (flare diameter)
 Positive and negative controls must be used

Skin Prick Applicator Devices

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

Prick Testing
Interpretation:
 Wheal diameter > 3mm (larger than negative
control) is considered significant
 Erythema (flare) and itching are part of a positive
response

Multi-Prick devices make skin testing

faster, simpler, and more reliable

 Device delivers a reproducible amount of antigen to a

precise depth in the epidermis or superficial dermis
 Several allergens can be placed on the skin simultaneously

The Intradermal Test

 Injection of DILUTED allergen into
the dermal layer of skin
 100-fold to 1000-fold dilution

 Technique:
 .01-.05mL of allergen dilution injected
intradermally to create a 4 mm wheal:

A wheal that grows to 7mm

diameter or larger after 10
minutes is considered positive

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

Intradermal Dilutional Testing (IDT)

Intradermal Dilutional Testing is a way to

‘Quantitate’ sensitivity to allergens
 Consecutive dilutions of antigenic
concentrates are applied in a sequential
manner

 Quantitates the degree of sensitivity based

upon reaction size

 Determines a safe initial starting dose for

subcutaneous immunotherapy

Antigen dilutions used in intradermal testing by US

ENT Allergists:
Antigen extracts used in US ENT allergy practices
are diluted by a factor of 5:

Concentrate 1:20 w/v 10,000 AU/mL

#1 Dilution 1:100 w/v 2,000 AU/mL
#2 Dilution 1:500 w/v 400 AU/mL
#3 Dilution 1:2,500 w/v 80 AU/mL
#4 Dilution 1:12,500 w/v 15 AU/mL
#5 Dilution 1:62,500 w/v 3 AU/mL
#6 Dilution 1:312,500 w/v 0.7 AU/mL

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9th Singapore Allergy & Rhinology Conference Skin Prick Testing
3 – 5 May 2018 A/Prof Matthew Ryan

Intradermal Tests (ID)

10
Mins

Summary
 Skin testing remains the most common form of
clinical allergy testing

 Test results must be interpreted in the context of

the patients history

 In most instances prick testing is sufficient for

diagnosis. Intradermal testing can provide
additional data in certain circumstances

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