BJD
C O M ME N T A R Y
Patch test technique
DOI: 10.1111/j.1365-2133.2010.10135.x
ORIGINAL ARTICLE, p 116
Jadassohn’s description of the patch test in 1896 involved the
application of a mercury-containing ointment, to which a
patient had previously reacted, to an area of skin on the left
arm, covered by a 5 cm2 piece of tape for 24 h, reproducing
in miniature the original reaction.1
Subsequent modifications of the method were often empiri-
cal and were concerned with improving usability such as the
type of tape and removing colophony from the adhesive. In
the initial description, the allergen was applied to the skin and
the dose nonstandardized. Later, filter discs were attached to
the tape to which the allergen was applied and various cham-
bers developed.
The procedure is time consuming for both patient and cli-
nician. To improve outcomes for the patient and avoid false
negatives the sensitivity and specificity of the procedure
should be as high as possible. Preprepared allergens are com-
mercially available in an easy-to-use format providing a con-
sistent dose; however, the allergens available are limited.
While a ‘standard’ series has been developed that empirically
detects the most frequent contact allergens, this is better
termed a ‘baseline’ series as it correctly implies that other
allergens should be applied dependent on the patient’s presen-
tation and exposures, including the patient’s own samples.
This may increase the yield of relevant positive reactions by
~20%. Sensitivity is further improved by occluding the aller-
gen for 48 h and by having multiple reading times. A single
reading at day 4 has been identified as yielding the most posi-
tives if a single reading point is used. An additional reading at
day 7 detects a further 10% of positive reactions above com-
bined readings at days 2 and 4. Expertise in the reading and
interpretation of the test is essential to avoid misinterpreting
reactions and subsequently giving irrelevant advice. Guidelines
have been developed that detail the evolving evidence base.2
The work of the team from Singapore and Malmö published
in this issue3 highlights a further topic that has generated
4 BJD  2011 British Association of Dermatologists 2011 164, pp4
British Journal of Dermatology
debate: a belief that allergens may be safely kept beyond their
expiry date and prepared before application without affecting
the results of the test. The team’s work clearly shows that
unless stored in a refrigerator and prepared fresh prior to ap-
plication some volatile allergens could be predicted to give a
false-negative reaction. Indeed, for some highly reactive aller-
gens such as isocyanates storage in a freezer may be required4
to avoid degradation of the allergen preparation.
In addition to patient-related factors, such as immunosup-
pression,2 this study emphasizes that factors related to the
allergen, storage and preparation of the test are essential to
take into account when trying to maximize the usefulness of
the investigation.
Department of Dermatology, Leeds General Infirmary, M. WILKINSON
Leeds LS1 3EX, U.K.
E-mail: mark.wilkinson@leedsth.nhs.uk
Funding sources
None.
Conflicts of interest
None declared.
References
1 Lachapelle JM. Giant Steps in Patch Testing: A Historical Memoir. Phoenix,
AZ: SmartPractice, 2010.
2 Bourke J, Coulson I, English J. Guidelines for the management of
contact dermatitis: an update. Br J Dermatol 2009; 160:946–54.
3 Goon ATJ, Bruze M, Zimerson E et al. Variation in allergen content
over time of acrylates ⁄ methacrylates in patch test preparations. Br J
Dermatol 2011; 164:116–24.
4 Frick-Engfeldt M, Zimerson E, Karlsson D et al. Is it possible to
improve the patch-test diagnostics for isocyanates? A stability study
of petrolatum preparations of diphenylmethane-4,4’-diisocyanate
and polymeric diphenylmethane diisocyanate. Contact Dermatitis 2007;
56:27–34.
 2011 The Author