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Tuberculosis Skin
Test (PPD Skin Test)
Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: William C. Shiel Jr., MD, FACP,
FACR
Medically Reviewed on 9/11/2019

'
Facts

Tests For Tuberculosis

Procedure

How to Read

Results

Side E!ects/Risks

Tuberculosis Skin Test (PPD Skin

Test) Center

WHAT DOES A POSITIVE TB

1. ›
TEST LOOK LIKE

2. COUGHING FROM ALLERGIES ›

3. HOME CHLAMYDIA TEST ›

4. HOW TO READ A PPD TEST ›

5. TB SKIN TEST REACTION ›

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Tuberculosis skin test

facts

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Purified Protein Derivative (PPD) Procedure for

Detecting Tuberculosis by McGraw Hill

The tuberculosis skin test is

another name for the tuberculin
test or PPD test.

The PPD test determines if

someone has developed an
immune response to the bacterium
that causes tuberculosis (TB).

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Blood tests for TB are also

available, and health care
professionals may use them in
place of the PPD skin test. The skin
test is the preferred test in children
under 5 years of age.

The standard recommended

tuberculin test is the Mantoux test,
which is administered by injecting
a 0.1 mL of liquid containing 5 TU
(tuberculin units) PPD (purified
protein derivative) into the top
layers of skin of the forearm.

Doctors should read skin tests 48-

72 hours after the injection.

The basis of the reading of the skin

test is the presence or absence
and the amount of induration
(localized swelling).

A negative test does not always

mean that a person is free of
tuberculosis.

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A person who received a BCG

vaccine (administered in some
countries but not the U.S.) against
tuberculosis may also have a
positive skin reaction to the TB
test.

What is the tuberculosis

skin test?

The tuberculosis skin test

determines if someone has
developed an immune response to
the bacterium that causes
tuberculosis (TB). This response
can occur if someone currently has
TB, if they were exposed to it in the
past, or if they received the BCG
vaccine against TB (which is not
administered in the U.S.). Estimates
indicate that one-third of the
world's population has latent TB,
and around 1.3 million people
worldwide die of TB each year. The
tuberculin test or PPD (purified
protein derivative) test are other
names for the tuberculosis skin
test.

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The tuberculin skin test is based on

the fact that infection with M.
tuberculosis bacterium produces a
delayed-type hypersensitivity skin
reaction to certain components of
the bacterium. Medical
professionals extract the
components of the organism from
TB cultures and are the core
elements of the classic tuberculin
PPD (also known as purified protein
derivative). This PPD material is
used for skin testing for
tuberculosis. Reaction in the skin to
tuberculin PPD begins when
specialized immune cells, called T
cells, sensitized by prior infection,
are attracted by the immune
system to the skin site where they
release chemical messengers
called lymphokines. These
lymphokines induce induration (a
hard, raised area with clearly
defined margins at and around the
injection site) through local
vasodilation (expansion of the
diameter of blood vessels) leading
to fluid deposition known as
edema, fibrin deposition, and
attraction of other types of
inflammatory cells to the area.

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An incubation period of two to 12

weeks is usually necessary after
exposure to the TB bacteria in
order for the PPD test to be
positive. Anyone can have a TB
test, and physicians can perform
the test on infants, pregnant
women, or HIV-infected people
with no danger. It is only
contraindicated in people who
have had a severe reaction to a
previous tuberculin skin test.

How do medical
professionals administer
the tuberculosis skin
test?

The standard recommended

tuberculin test, known as the
Mantoux test, is administered by
injecting a 0.1 mL of a liquid
containing 5 TU (tuberculin units) of
PPD into the top layers of skin
(intradermally, immediately under
the surface of the skin) of the
forearm. Health care providers
should use a skin area that is free of
abnormalities and away from veins.
Typically, medical professionals
make the injection using a 27-
gauge needle and a tuberculin
syringe. Inject the tuberculin PPD
just beneath the surface of the skin.
A discrete, pale elevation of the
skin (a wheal) 6 mm-10 mm in
diameter should be produced
when the injection is done
correctly. This wheal or "bleb" is
generally quickly absorbed. If it
becomes apparent that the first test
was improperly administered,
another test can be given at once,
selecting a site several centimeters
away from the original injection.

&

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Bacterial Infections 101:
Types, Symptoms, and
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What is the method of

reading the tuberculosis
skin test?

"Reading" the skin test means

detecting a raised, thickened local
area of skin reaction, referred to as
induration. Induration is the key
item to detect, not redness or
bruising. Read skin tests 48-72
hours after the injection when the
size of the induration is maximal.
Tests read after 72 hours tend to
underestimate the size of the
induration and are not accurate.

How do physicians
interpret skin test
results?

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The basis of the reading of the skin

test is the presence or absence and
the amount of induration (localized
swelling). A physician will measure
the diameter of the induration
transversely (for example,
perpendicular) to the long axis of
the forearm and recorded in
millimeters. The area of induration
(palpable, raised, hardened area)
around the site of injection is the
reaction to tuberculin. It is
important to note that redness is
not measured.

A tuberculin reaction is classified as

positive based on the diameter of
the induration in conjunction with
certain patient-specific risk factors.
In a healthy person whose immune
system is normal, induration
greater than or equal to 15 mm is
considered a positive skin test. If
blisters are present (vesiculation),
the test is also considered positive.

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In some groups of people, the test

is considered positive if induration
less than 15 mm is present. For
example, an area of induration of 10
mm is considered positive in the
following groups:

Recent immigrants from high-

prevalence areas

Residents and employees of high-

risk areas

IV drug abusers

Children under 4 years old

People who work with

mycobacteria in laboratories

An induration of 5 mm is
considered positive for the
following groups:

People with suppressed immune

systems

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HIV-infected people

People with changes seen on

chest X-ray that are consistent with
previous TB

Recent contacts of people with TB

People who have received organ

transplants

On the other hand, a negative test

does not always mean that a
person is free of tuberculosis.
People who have been infected
with TB may not have a positive
skin test (known as a false negative
result) if their immune function is
compromised by chronic medical
conditions, cancer chemotherapy,
or AIDS. Additionally, 10%-25% of
people with newly diagnosed
tuberculosis of the lungs will also
have a negative result, possibly due
to poor immune function, poor
nutrition, accompanying viral
infection, or steroid therapy. Over
50% of patients with widespread,
disseminated TB (spread
throughout the body, known as
miliary TB) will also have a negative
TB test.

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A person who received a BCG

vaccine (administered in some
countries but not the U.S.) against
tuberculosis may also have a
positive skin reaction to the TB test,
although this is not always the
case. This is an example of a false
positive result. The positive
reaction that is due to the vaccine
may persist for years. Those who
were vaccinated after the first year
of life or who had more than one
dose of the vaccine have the
greatest likelihood of having a
persistent positive result than those
who were vaccinated as infants.

People infected with other types of

mycobacteria other than
Mycobacterium tuberculosis may
also have false-positive TB skin
tests.

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Are there side e!ects or

risks from having the
PPD skin test?

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The test typically does not produce

side e!ects. There is a very slight
risk of having a severe reaction to
the test, including swelling and
redness of the arm, particularly in
people who have had tuberculosis
or been infected previously and in
those who have previously had the
BCG vaccine. Allergic reactions are
also rare complications.

Since the test does not use live

bacteria, so there is no chance of
developing tuberculosis from the
test.

Tuberculosis Diagnosis

Because TB may occur as either a

latent or active form, the definitive
diagnosis of active TB depends on
the culture of mycobacteria from
sputum or tissue biopsy. However,
it may take weeks for these slow-
growing bacteria to grow on
specialized media.
Learn more about how physicians diagnose
tuberculosis »

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