Allergol Immunopat hol (Madr).

2009;37(3):155-64

Allergologia et
immunopathologia
INTERNATIONAL JOURNAL OF ASTHMA, ALLERGY AND CLINICAL IMMUNOLOGY
OFFICIAL JOURNAL OF THE SPANISH SOCIETY OF PEDIATRIC ALLERGY AND CLINICAL IMMUNOLOGY

Allergologia et January-February 2009. Vol. 37 - N.º 1

EDITORIAL
The monitoring of bronchial inflammation by bioimpedance

ORIGINAL ARTICLES

immunopathologia
Bioimpedance monitoring of airway inflammation in
asthmatic allergic children
Differential Th1/Th2 balance in peripheral blood
lymphocytes from patients suffering from flea bite-induced
papular urticaria
Prevalence of asthma and other allergic diseases in children
born after in vitro fertilisation
Immunophenotypic profile of T cells in common variable
immunodeficiency: is there an association with different
clinical findings?
Potential association between allergic diseases and
pertussis infection in schoolchildren: Results of two
cross-sectional studies seven years apart

POINT OF VIEW

www.elsevier.es/ ai
Montelukast versus inhaled corticosteroids as monotherapy
for prevention of asthma: which one is best?

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1

REVIEW

Skin prick tests and allergy diagnosis

João Antunes*, Luís Borrego, Ana Romeira and Paula Pinto

Serviço de Imunoalergologia, Hospit al Dona Est ef ânia, Lisbon, Port ugal

KEYWORDS Abstract
Skin; Skin t est ing remains an essent ial diagnost ic t ool in modern allergy pract ice.
Prick t est ; A signifi cant variabilit y has been report ed regarding t echnical procedures, int erpret at ion of
Diagnosis; r esul t s and document at i on. Thi s r evi ew has t he ai m of consol i dat i ng met hodol ogi cal
Allergen ext ract ; recommendat ions t hrough a crit ical analysis on past and recent dat a. This will allow a bet t er
Technique underst anding on skin prick t est (SPT) hist ory; t echnique; (cont ra-) indicat ions; int erpret at ion
of result s; diagnost ic pit falls; adverse react ions; and variabilit y fact ors.

© 2008 SEICAP. Published by Elsevier España, S.L. All right s reserved.

Skin has an import ant physiological role in t he int ernal bal-
ance homeost asis and const it ut es a crucial barrier against
ext ernal aggressions, wit h well-known immunological prop-
ert ies. 1 It has been used by allergist s for decades as an eas-
ily assessed laborat ory of t he immunological st at us of t he
individual.
The fi rst skin t est ing t echnique was developed by Charles
H. Blackley in 1865, a Manchest er homeopat hic physician
wit h allergic rhinit is. He abraded a quart er-inch area of his
skin wit h a lancet and t hen applied grass pollen grains. 2 The
so-called scrat ch t est was lat er adopt ed by Schloss for t he
diagnosis of food allergy in children. 3 Epicut aneous t est s can
be divided int o scrat ch t est s and prick/ punct ure t est s. The
fi rst met hod, proposed by Blackley2, implied a linear scrat ch
wit hout drawing blood and could eit her be performed fi rst ,
wit h t he ext ract t hen dropped on t he abraded skin, or be
made t hrough a drop of ext ract . 4 Alt hough it was used ex-
t ensively in t he past , t his t echnique became progressively
obsolet e due t o pat ient discomf ort , poor reproducibilit y,
possible residual lesions and newer and innocuous proce-
dures. 4 Theref ore, scrat ch t est is ment ioned here f or his-
t orical purposes only. It was Sir Thomas Lewis who, in 1924,
fi rst applied skin prick t est s (SPT). 5 Nevert heless, t heir gen-
eralised use in clinical pract ice only became a realit y about
30 years ago, as a result of t echnique modifi cat ions proposed
by Pepys. 6 For t he purpose of t his review and for easier com-
prehension, skin t est ing will be referred int erchangeably as
SPT, what ever device is used for it s applicat ion.
In 1966, Ishizaka’s work on immunoglobulin E (IgE) and im-
mediat e hypersensit ivit y react ions7 est ablished t he scient ifi c
corpus t o what was done t ill t hen on a st rict ly empiric basis.
As writ t en by Dr Walzer in 1974, “ t he fact t hat skin t est ing
has not t urned out t o be a simple and complet ely reliable
t echnique does not det ract f rom t he f act t hat , when it is
int elligent ly and skilfully performed, it remains t he most ef-
fect ive diagnost ic procedure in reaginic allergic disorders” . 8
The reliabilit y of skin t est ing and proper document at ion of
t est result s are essent ial in allergy pract ice. A recent survey
t o all physician members and f ellows of t he American Col-
lege of Allergy, Ast hma and Immunology pract icing in t he

*Corresponding aut hor.

E-mail: j diasant unes@hot mail.com (J. Ant unes).

0301-0546/ $ - see front mat t er © 2008 SEICAP. Published by Elsevier España, S.L. All right s reserved.
156
Unit ed St at es det ect ed a signifi cant degree of variabilit y re-
garding skin t est devices, ext ract concent rat ions, int erpre-
t at ion and document at ion of result s and qualit y assurance
procedures. 9
This het erogeneit y observed in clinical pract ice j ust ifi es
t he int erest and relevance of t he present review work. It is
our aim t o consolidat e import ant t echnical recommenda-
t ions, providing a new insight on t he subj ect .
Skin prick tests
General considerations and indications
It is imperat ive t hat t he clinician be fully aware of t he clini-
cal indicat ions, correct t echnique, and int erpret at ion crit e-
ria, as well as t he risks and limit at ions of SPT. Skin t est ing
should always be an adj unct t o hist ory and physical exami-
nat ion and not a subst it ut e for medical evaluat ion.
SPT confi rm t he diagnosis of immediat e hypersensit ivit y
react ions. 4,10
On skin level, t he IgE-mediat ed immune response is de-
pendent on bot h chemical and neurogenic mediat ors. 11, 12
Af t er int racut aneous inj ect ion, al l ergens cross-l ink pre-
f ormed IgE bound t o t he high-af fi nit y recept or FcERI mast
cells and a complex signal t ransduct ion cascade is act ivat ed.
This event ually culminat es in mast -cell degranulat ion begin-
ning in seconds, wit h release of a variet y of preformed in-
f l ammat ory medi at ors. Among t hese are hi st ami ne — a
short -lived vasoact ive amine t hat causes an immediat e in-
crease in local blood f low and vessel permeabilit y — and
enzymes such as mast -cell chymase, t rypt ase and serine es-
t erases. 11 A wheal and fl are react ion develops wit hin min-
ut es aft er superfi cial inj ect ion of ant igen int o t he epidermis
and last s for up t o 30 minut es. On act ivat ion, mast cells also
synt hesize and release chemokines, lipid mediat ors such as
prost aglandins, leukot rienes and plat elet -act ivat ing-fact or,
and addit ional cyt okines such as int erleukins 4 and 13 which
perpet uat e t he Th2 response. 11 These changes can some-
t imes be followed by a lat e-phase react ion (LPR), which is
ext remely rare and almost exclusive t o pat ient s sensit ised
t o moulds, grass and pariet aria pollens. 13
In a posit ive react ion, hist amine can be det ect ed only at
t he cent re of t he wheal, not in t he periphery. It is suggest ed
t heref ore t hat af t er allergen challenge, t he mediat ors re-
leased by t he challenged mast cell induce an axon refl ex by
direct st imulat ion of c-fi bres. This induces t he release of
neurogenic pept ides and mast cel l mediat ors f rom “ t he
next ” mast cell, becoming t he maj or players in t he immedi-
at e wheal and fl are react ion. 12
Skin t est ing can be used t o select evict ion measures and/
or specifi c immunot herapy. 14
To opt imally defi ne t est performance, a met hod should be
reproducible and validat ed by comparison wit h gold st and-
ard met hods. Direct challenge t est s under supervision of a
physician are appropriat e ways t o confi rm or refut e t he va-
lidit y of SPT. It provides obj ect ive evidence for sensit ivit y,
specif icit y, predict ive values and likelihood rat ios. When
compared t o gold st andard procedures, i.e. organ challenges
such as nasal bronchoprovocat ion challenge or oral provoca-
t ion challenge, SPT have demonst rat ed good result s. 15-18 The
simplicit y, rapidit y of performance, low cost and high sensi-
Ant unes J et al
t ivit y make skin t est ing preferable t o in vit ro t est ing for de-
t ermining t he presence of specifi c IgE ant ibodies (sIgE). It is
import ant t o not e t he higher sensit ivit y of SPT when com-
pared t o sIgE dosing. Nevert heless, every posit ive result
must be correlat ed wit h hist ory and physical fi ndings since a
posit ive skin react ion does not necessarily imply t he diagno-
sis of allergy. 19
Int erpret at ion of skin t est s is highly dependent on t he
const it ut ive allergenicit y, pot ency and st abilit y of t he aller-
gen ext ract . For t his reason, SPT sensit ivit y t ends t o be
higher among aeroallergens, in part icular pollens, house
dust mit e, fungi and cert ain epidermals. 10
In clinical pract ice, skin t est ing has been ext ensively used
for assessing sensit isat ion t o inhalant allergens. SPT is useful
t o confi rm or exclude a suspect ed diagnosis of allergic rhi-
nit is, allergic conj unct ivit is or ast hma t riggered by aller-
gens10, 20, 21 and t o demonst rat e sensi t i sat i on t o i nhal ant
occupat ional allergens. 22,23
Previous observat ions suggest t hat skin t est posit ivit y at
an early age is associat ed wit h subsequent development of
rhinit is and wheeze. 24-26 The role of allergic sensit isat ion as a
cause of eczema is less clear. 27
Skin t est ing in f ood allergy is common pract ice as well,
alt hough less reliable for commercial ext ract s of fruit s and
veget ables, as explained below. 28 The clinical ut ilit y of SPT
in pat ient s wit h f ood allergy suspicion, especially inf ant s
and children, has been evaluat ed in various st udies using
oral food challenges and sIgE.
Most previous st udies on food allergy obt ained a concord-
ance rat e bet ween SPT wit h commercial ext ract s and oral
challenges from 60 %t o 85 %28-32, specifi cit y being generally
lower, in t he range of 40 %t o 80 %. 28 A negat ive result is use-
f ul t o exclude t ype I react ions t o f ood allergens (negat ive
predict ive accuracy > 95 %) 32 but a posit ive result may or
may not be associat ed wit h t rue clinical react ions. The over-
all concordance bet ween a posit ive SPT and posit ive oral
challenge differs bet ween aut hors, but consensus exist s re-
garding clear superiorit y of f resh f ood when compared t o
commercial ext ract s, as shown by Ort olani et al. 33, Rosen et
al. 30, and Norgaard et al. 34 Wit h fresh food, sensit ivit y usu-
ally exceeds 90 %and can even reach 100 %. 34 This is part icu-
l arl y import ant when a st rong suspicion of f ood al l ergy
subsist s af t er negat ive result s wit h commercial ext ract s.
Fresh food t est ing makes use of a different procedure, t he
prick-prick t echnique.
Under caref ully defi ned circumst ances, SPT can also be
used as a primary approach t o drug and hymenopt era ven-
om. In such cases however, int radermal t est s are usually
required f or a correct diagnosis. For most chemicals asso-
ciat ed wit h occupat ional allergy it is not indicat ed, wit h
t he except i on of agent s known t o be i mpl i cat ed i n IgE
react ions, such as plat inum salt s, acid anhydrides, poly-
isocyanat es, sulphonechloramide and succinylcholine ana-
logues. 35-37
Technique
The goal for t he allergist is t o perform skin t est ing wit h de-
vices which minimise bot h false posit ive and false negat ive
result s while reducing pat ient discomfort . SPT should be a
non-t raumat ic procedure (blood-free) and several sharp in-
st rument s such as a hypodermic needle, solid bore needle,
Skin prick t est s and allergy diagnosis
lancet wit h or wit hout bifurcat ed t ip, and mult iple-head de-
vices, may be used. 38
Hist orically, in t he met hod fi rst int roduced by Pepys, t he
needle or blood lancet t ip was insert ed at an angle of 60.º t o
70.º t o t he skin surface, gent ly lift ing t he superfi cial epider-
mal layers t o creat e a small break in t he skin. 6
In 1979 a new met hod —punct ure t est —was proposed by
Øst erballe & Weeke, using a lancet wit h 1 mm t ip and shoul-
ders t o prevent f urt her penet rat ion. 39 Lancet s should be
pr essed wi t h equal st r engt h at 90º t o t he ski n sur f ace
t hrough a drop of ext ract or cont rol solut ions. 4 This t ech-
nique appears t o be more precise t han t he original SPT
met hod proposed by Pepys. 40,41
Mult iheaded devices are designed t o fi rst be dipped int o
t he ext ract bot t les, t hen applied t o t he skin in one st ep.
They appear t o be more painful t han single devices but it is
not ewort hy t hat wit h a minimal increase in pain, as many as
eight t imes more t est s are applied, rendering mult iheaded
devices part icularly useful in paediat ric ages. 38
Lancet s should be st erilised, a fresh lancet for each prick,
wit h normalised measures and each lancet should be used
only once for each ext ract , in order t o avoid unint ent ional
pricks, blood borne infect ions and allergen cont aminat ion.
Met al lancet s wit h 1mm penet rat ion limit are considered
equally ef fi cient and less painf ul t han ot her synt het ic de-
vices wit h 1.4 or 1.6 mm penet rat ion limit s. 39 The penet ra-
t ion limit is t herefore a det erminant fact or when considering
t est effi cacy and pat ient comfort , rendering met al lancet s
pref erabl e when compared t o ot her synt het ic devices. 13
Nevert hel ess, an obj ect ive comparison has not shown a
clear-cut advant age f or any single or mult it est device and
opt imal result s can be obt ained by choosing a single prick/
punct ure device, and properly t raining it s use. 38,40,42
Ant isept ic solut ions are recommended before SPT and skin
should be t ot ally dry before procedure. 43
Recommendat ions have been made regarding t he appro-
priat e placement of allergen ext ract s. The recommended
dist ance f or skin prick t est ing has varied bet ween 2 and
5 cm44 and t est sit es should be marked wit h an appropriat e
code. 4 It is possible, however, for a posit ive react ion t o en-
hance false-posit ive skin react ions at an adj acent sit e, even
over t he range of 5 cm. 43-45
SPT are usual l y perf ormed on t he vol ar surf ace of t he
forearm, at least 5 cm above t he wrist and 3 cm below an-
t ecubit al f ossae, 4 t he least and most react ive areas of t he
upper limb, respect ively. The t est s can also be done on t he
upper arm or t he back, wit h special at t ent ion t o avoid reac-
t ivit y dif f erences bet ween locat ions. 43 It should be t aken
int o account t hat not only is t he back 20 % more react ive
t han t he forearm but specifi c locat ions on t he back vary in
react ivit y as well. 46. 47 Theref ore, a minimum of 2 cm dis-
t ance bet ween each SPT should be adopt ed.
For an accurat e int erpret at ion of wheal and fl are reac-
t ions t o allergens, bot h posit ive and negat ive t est s should
be used. A negat ive cont rol solut ion is required t o evaluat e
unspecifi c react ions relat ed t o prick t est ing t rauma (dermo-
graphism). 4,48,49 A saline solut ion, phenol at 0.5 %or glycerine
at 50 %are recommended. 10
For posit ive cont rol, hist amine dihydrochloride 10 mg/ ml
(54.3 mmol/ 1), equivalent t o 6.14 mg/ ml of hist amine base,
or codeine phosphat e at 9 % can be recommended. 49 Some
aut hors advocat e t he use of hist amine at 1 mg/ ml 50; how-
157
ever, in a st udy by Morais de Almeida et al., t he concent ra-
t ion of 1 mg/ ml consist ent ly present ed negat ive result s in
more t han 10 % of t he pat ient s. 13 Theref ore, hist amine at
1 mg/ ml should be defi nit ely abandoned.
The prick-prick t est requires a different procedure, prick-
ing t he food fi rst , and t hen t he skin, using t he same needle;
or pricking t he skin t hrough f ood in a single manoeuvre. 51
Foods wi t h a hard consi st ency, such as peanut , can be
ground, dilut ed in buf f ered saline at 1/ 3 weight / volume
(w/ v), or 500 mg of food t o 1.5 ml of saline. 52
Dreborg recommends at least t wo parallel t est s performed
wit h t he same mat erial in every pat ient wit h t he except ion of
infant s, in order t o assure precision, as single negat ive t est s
(5 %) will be obt ained in sensit ised pat ient s even wit h skilled
t echnicians. 4 In duplicat e t est s, t he diamet er should not vary
more t han 1 mm. 53-56 Several publicat ions have provided in-
novat ive met hods t o assure skin t est validit y. A suggest ed pro-
t ocol for qualit y assurance t est ing and profi ciency t est ing for
SPT can be found in lit erat ure. 10 In Europe, a coeffi cient vari-
at ion of less t han 20 %aft er hist amine cont rol t est has been
suggest ed57, whereas a recent Childhood Ast hma Management
St udy considered a variat ion inferior t o 30 %. 58
Reading and interpretation
The size of t he papule is of paramount import ance in SPT.
However, bot h eryt hema and wheal should be measured for
proper int erpret at ion. 10
Øst erballe and Weeke39 demonst rat ed t hat t he wheal size
wit h hist amine peaks earlier (9-12 min) t han wit h allergens
(13-16 min). In a recent st udy, using laser Doppler fl ow im-
aging and scanning of drawn wheal sizes, t he maximum his-
t amine wheal size was reached at 20 minut es. 59 We t herefore
propose a consensus reading t ime for bot h posit ive cont rol
and allergen react ions at 20 minut es post -prick.
A valuable opt ion concerning appropriat e document at ion
of skin t est result s consist s in out lining t he wheal and fl are
react ion wit h a f elt -t ip pen and t ransf erring result s wit h
t ransparent t ape t o a blank sheet of paper. 4,13
Various indices have been used for int erpret at ion of skin
react ions. The papule’s area is t he most accurat e49, 59 and
can be eval uat ed by pl ani met r y, ei t her di r ect l y wi t h
image-processing programs or f rom a t raced copy. 13, 60 The
int erpret at ion of t he skin prick t est is subj ect t o int er-ob-
server variat ion. To overcome t his issue, comput erised pro-
cedures have been proposed, allowing a more precise area
evaluat ion. 60, 61 Ot her met hods such as laser Doppler t ech-
nique62 and ult rasound63 have been t est ed wit h success.
The size of t he react ion can also be assessed using:
• minimal diamet er;
• mean wheal diamet er, calculat ed as t he sum of t he larg-
est diamet er and it s largest ort hogonal diamet er divided
by 2; or
• skin index, defi ned as t he rat io of allergen wheal diamet er
divided by t he hist amine wheal size.
The SPT result should be considered posit ive if:
• minimal wheal diamet er is great er t han 3 mm or;
• mean diamet er is 3 mm or larger; and/ or
• skin index superior t o 0.6.
158
Of t he crit eria explained above, mean wheal diamet er is
t he most commonly used.
The skin react ion is considered posit ive if t he wheal’s area
is 7 mm2 or higher, which corresponds approximat ely t o a
mean diamet er of 3 mm. 9,40,57,64,65
The degree of eryt hema (fl are) is considered t o be a non-
specifi c react ion of t he skin t o t he t rauma of t he punct ure. 66
Nevert heless, some aut hors consider a posit ive react ion if
t he mean fl are diamet er is over 10 mm. 49
The result s obt ained can only be correct ly assessed and
t aken int o account wit h valid posit ive and negat ive cont rol
react ions. Thus, hist amine’s papule mean diamet er should
be great er t han 3 mm and negat ive cont rol should not ex-
ceed 3 mm wit h eryt hema diamet er inferior t o 10 mm. De-
vices t hat syst emat ically produce negat ive cont rol wheals
over 3 mm should be avoided. 67 St uckey et al. f ound t hat
pat ient s wit h more posit ive sensit isat ions and higher t ot al
IgE have larger hist amine papules. 68
Qualitative scoring (0 to 4+; 0 or +) is no longer recommend-
ed because of marked variabilit y bet ween observers. 69,70
Wheal size has assumed great er diagnost ic signifi cance
due t o t he posit ive correlat ion wit h clinical sympt oms se-
verit y. 71-74 Invest igat ing graduat ed t est responses and es-
t abl i shi ng pr obabi l i t y deci si on poi nt s mi ght i mpr ove
diagnost ic accuracy and predict posit ive react ions during
organ challenge. 75 In a previous st udy, especially regarding
f ood allergy, Sporik74 defi ned specifi c wheal diamet ers as
‘ 100 %diagnost ic’ . In his work, cut -off values were propos-
ed for cow’s milk (≥ 8 mm), hen’s egg (≥ 7 mm) and peanut
(≥ 8 mm), suggest ing t hat children exceeding t hese limit s
are al l ergic t o t his specifi c f ood. These recent advances
might obviat e t he need for oral challenge in t he fut ure. 74-76
These cut -of f point s vary f or dif f erent al l ergens, being
more accurat e for cow’s milk and hen’s egg t han for soy or
wheat . Addi t i onal l y, di f f erent popul at i ons may exhi bi t
signifi cant variabilit y. Even t hough t here is a correlat ion
bet ween SPT result or sIgE and likelihood of a clinical reac-
t ion, sensit isat ion level does not always correlat e wit h al-
lergic manifest at ions. 77-79
One st udy point s t o bet ween 7.5 %and 19 %asympt omat ic
sensit isat ions among Finnish schoolchildren. 80 Skin t est reac-
t ivit y t o inhalant allergens is reduced in asympt omat ic sen-
sit isat ions when compared wit h sympt omat ic pat ient s. 81
Asympt omat ic sensit isat ion is generally considered a pre-
morbid st at e of allergic disease, and has been proven t o be
a risk fact or for t he development of allergic rhinit is in chil-
dren and young adult s. 82, 83 Bodt ger et al. , in a 3-years f ol-
low-up st udy, showed t hat adult s wit h asympt omat ic skin
sensit isat ion t o birch pollen have an increased risk (about
60 %) of developing hay fever. 82
Several st udies have demonst rat ed t hat posit ive SPT in in-
fancy, especially t o hen’s egg, predict s subsequent presence
of eczema in childhood. 83-86 Thus, sensit isat ion in asympt o-
mat ic children can precede and predict t he development of
eczema. 87
Limitations
In t he past , t he manufact ure of skin t est solut ions imposed
import ant t echnical limit at ions. The recent availabilit y of
st andar di sed commer ci al ext r act s const i t ut es a maj or
achievement in allergy t est ing. Allergen ext ract s are com-
Ant unes J et al
plex mixt ures derived from nat ural source mat erials and as
such are prone t o nat ural variat ion, requiring proper st and-
ardisat ion t o ensure consist ency and reproducibilit y. Some
physicians report non-negligible variabilit y bet ween ext ract s
f rom dif f erent manuf act urers, easily at t est ed in our daily
pract ice. 88, 89 Qualit y of allergen ext ract s is dependent on
several paramet ers such as raw mat erial qualit y, proper t est
ext r act i ons, adequat e pr ocessi ng and r emoval of l ow
molecular weight component s by dialysis or fi lt rat ion. 90 St a-
bilit y, pot ency and allergen concent rat ion are also det er-
mining.
The most int ernat ionally recognised way t o express aller-
gen ext ract st rengt h is micrograms of maj or allergen be-
cause t his appears t o correlat e well wit h overall biological
pot ency of t he ext ract . 91 In-house ref erences shoul d be
charact erized wit h respect t o dry weight , allergen complex-
it y, maj or allergen cont ent and IgE binding capacit y. Biologi-
cal act ivit y shoul d ideal l y be assessed in vivo, wit h skin
t est ing. 90-92 However, t he met hods used dif f er f rom manu-
f act urer t o manuf act urer, making product s f rom dif f erent
companies impossible t o compare. 93
Non-relat ed allergen mixt ures may account for loss of bio-
logical pot ency as a consequence of excessive dilut ion or
enzymat ic det eriorat ion of t he epit opes. Time and higher
t emperat ures can also accelerat e t he decay process. To as-
sure st abilit y, allergens are usually preserved wit h 50 %glyc-
erine and st ored under cold (4 ºC). 94,95
Recombinant allergens of f er f ut ure int erest ing perspec-
t ives as in vivo diagnost ic t ool s. These genet ical l y engi-
neered molecules appear t o be highly specif ic, saf e and
biologically act ive. Their sensit ivit y, however, appears t o be
lower when compared t o nat ural allergen ext ract s. 89,96
Which allergens t o t est is a common doubt in daily prac-
t ice. A recent survey performed in t he Unit ed St at es showed
t hat most allergist s do not rely on hist ory when choosing
which allergens t o use t o perform skin t est ing. 9
When considering inhalant allergy, several crit eria should
be t hought -out before choosing skin t est ing reagent s, such
as bot anical and aerobiological surveys. Flowering season,
t ypes and levels of pollens and spores along t he year and
peak days of pollinat ion should be considered. Annual pollen
sampl i ng dat a i n var i ous count r i es ar e now avai l abl e
on-line. 97, 98 Air composit ion and concurrent allergy symp-
t oms during recurrent seasons const it ut e t he best indicat ors
in t he select ion of appropriat e out door aeroallergens f or
skin t est ing. 10
The infl uence of pollen load is more evident in sIgE chang-
es t han on SPT react ions or clinical sympt oms. 99
Regarding f ood allergy, SPT can be perf ormed bot h wit h
commercial allergen ext ract s and fresh foods. Fresh food is
oft en used as it more accurat ely refl ect s t he pat ient ’s life.
In a French st udy it was demonst rat ed t hat fresh foods were
more reliable in food allergy diagnosis t han commercial ex-
t ract s. 100 Commercial ext ract s of fruit s and veget ables (e.g.,
apples, oranges, bananas, pot at oes, carrot s, and celery),
are likely t o lose biological propert ies wit h t ime, reinforcing
t he role of prick-prick met hod wit h fresh food. 100 This t ech-
nique is also valuable when t here are differences in t he al-
l ergenicit y of dif f erent cul t ivar st rains (e. g. , appl es) or
when no commercial ext ract s are available. 101
Alt hough prick-t o-prick t est s are widely used, it is impor-
t ant t o not ice t hat t hey are not st andardised, of t en give
Skin prick t est s and allergy diagnosis
false-posit ive result s, and st ill bear t he risk of syst emic re-
act ions, as discussed in lat er sect ions.
Inst ead of fresh food, freezing aliquot s may facilit at e skin
prick t est ing in part icular cases. Freezing cow’s milk and
hen’s egg at —20 ºC has been t est ed and it does not alt er t he
allergenic propert ies of each component . 102 However, t hese
result s cannot be t ransferred aut omat ically t o ot her foods
wit hout furt her t est ing.
Furt hermore, commercial ext ract s may produce false-neg-
at ive result s since st orage, cooking or digest ive process may
induce immunological alt erat ions in relevant allergens, ren-
dering a part icular f ood more allergenic t han achieved by
commercial ext ract s. 10
The presence of act ive cut aneous lesions, as commonly
observed in pat ient s wit h act ive at opic dermat it is, impair
t he proper SPT reading, and const it ut e a cont ra-indicat ion
t o skin t est procedures. 4,48,103 Nevert heless, SPT can be per-
formed in eczemat ous infant s since no lesions exist on t est -
ing area. This can be usef ul as inf ant s wit h eczema in t he
fi rst 2 years of lif e wit h concomit ant allergic sensit isat ion
have a great er risk of childhood ast hma and allergic rhinit is
t han infant s wit h non-at opic eczema. 104
Pat ient s wit h dermographism should be excluded as it is
dif fi cult t o dist inguish bet ween a t rue or f alse posit ive re-
sult , invalidat ing any conclusions. 4
In such circumst ances involving ext ensive skin disease; or
in pat ient s under skin t est suppressive t herapy (f or exam-
ple, ant ihist amines) t hat cannot be discont inued; uncoop-
erat ive pat ient s; or when t he hist ory suggest s an unusually
high risk of anaphylaxis from skin t est ing, sIgE immunoassays
may be preferable t o skin t est ing.
False-posit ive react ions can be due t o skin t rauma, most ly
in pat ient s wit h dermographism4, as explained above, but
also t o cont aminat ed allergen ext ract s (occurring during ex-
t ract preparat ion or simply for not changing lancet s during
SPT)105 or cross-react ivit y phenomena. 106 Cross-react ivit y de-
pends on t he t ype of allergens involved, in part icular t heir
st ruct ural and sequent ial similarit y. 106 Pan-allergens respon-
sible for cross-react ivit y in veget ables are pat hogen-relat ed
prot eins (PRP) and profi llins. 107 For invert ebrat es, t ropomy-
osin is t he most implicat ed prot ein. For vert ebrat es, several
allergens are implicat ed: parvalbumin (f ish), livet in and
ovot ranferrin (egg and birds) and casein (milk). 108
Ext ensive cross-react ivit y has been described among aer-
oallergen-sensit ised pat ient s. 10,109 House dust mit es, epider-
mals, but most of all, pollens have been widely st udied.
Theref ore, t est ing wit h mult iple locally prevalent pollens
may be required t o avoid signifi cant omissions. Cross-aller-
genicit y among maj or classes of airborne fungi has not been
well delineat ed so far. 10
Wit h regard t o food allergy, we shall briefl y ment ion t he
most int erest ing and relevant syndromes as it can be useful
t o bet t er underst and skin t est result s. Pat ient s wit h: 1) birch
apple; 2) art emisia-celery-carrot -spices; 3) grass-peach;
4) plant ago-melon; 5) lat ex-f ruit s; 6) dust mit es-seaf ood;
7) bird-egg; 8) pig-cat ; 9) shellfi sh; 10) peanut , soybean and
ot her l egumes; 11) t ree nut s; 12) r osaceous f ruit s; and
13) cereal grains can be expect ed t o show cross-react ivit y
wit h SPT.
Concerning false-negat ive result s, special at t ent ion should
be given t o pat ient ’s age, concomit ant drugs and diseases
such as HIV inf ect ion or chronic renal insuf fi ciency, which
159
may inhibit skin react ivit y. 10 Even when all qualit y parame-
t ers are considered, pat ient s wit h evident allergic sympt oms
can st ill have negat ive SPT. It is import ant t o consider t hat
non-IgE mechanisms, impossible t o be assessed by SPT, can
be implicat ed in pat ient ’s complaint s. Powe et al. 110 demon-
st rat ed t hat infl ammat ion in non-allergic rhinit is may be a
consequence of localised IgE-mediat ed react ions, not involv-
ing syst emic Th2 responses or at opy. Therefore, local IgE pro-
duct ion in non-allergic pat ient s could explain t he presence
of sympt oms in SPT negat ive pat ient s (localised mucosal al-
lergic disease in t he absence of at opy —“ ent opy” ). 110
Adverse reactions
In t he last t hirt y years, t he occurrence of syst emic react ions
wit h SPT for inhalant ext ract s has decreased dramat ically. 111
Recent surveys indicat e an overall risk inferior t o 0.02 %for
anaphylact ic react ions t o SPT, whereas IDT are more likely
t o induce syst emic react ions. 111 Most of t he syst emic reac-
t ions incit ed by SPT were relat ed t o fresh food (prick-prick
t est s wit h kiwi, fi sh, fresh pine nut and milk) 112-114, lat ex (SPT
wit h nat ural rubber lat ex and commercial ext ract s) 115,116 and
drugs (penicillin, amoxicillin). 111 In a 12-year survey of fat al
react ions (1990-2001), one fat alit y was confi rmed aft er SPT
wit h mult iple f ood allergens (90 f ood prick t est s were ap-
plied at one t ime in a pat ient wit h moderat ely persist ent
ast hma). 117
A ret rospect ive review of medical records concerning SPT
wit h f oods corroborat es t he low rat e of generalised reac-
t ions, as previously st at ed, and point s out t hat all react ions
in inf ant s (n = 6) occurred under 6 mont hs of age and only
wit h fresh food specimens. 118
Special at t ent ion should be given t o young children and
pregnant women. Skin t est duplicat ion should be avoided in
children wit h suspect ed food allergy (fresh food or commer-
cial ext ract s), especially when suffering from ext ensive ec-
zema. 111 As f or pr egnant women, al t hough SPT i s not
cont raindicat ed, it is prudent t o post pone such procedures
and/ or propose sIgE assays inst ead. 111
Variability factors
Mult iple f act ors have been f ound t o infl uence SPT result s.
These variabilit y fact ors include t echnical issues, biological
det erminant s and ot her ext ernal f act ors such as previous
medicat ion or infect ions (Table I).
Skin react ivit y is known t o vary according t o age: children,
part icularly under t he age of 2 years, are less react ive t han
adult s. 119 The prevalence of posit ive skin t est result s in-
creases unt il t he 2nd decade, wit h a slow decline above t he
age of 60 years. 120 In children wit h manifest allergy, howev-
er, skin has similar react ivit y from 1 year of age unt il puber-
t y. 4 Nevert heless, SPT t est s can be used in infant s as young
as 1 mont h, wit h a high degree of reliabilit y, usually wit h
more eryt hema t han wheal react ion. 119
Test result s also depend on anat omic locat ion since skin
react ivit y differs from region t o region. In decreasing order,
t he degrees of react ivit y are as follows: mid and upper back
> lower back > upper arm > elbow > forearm (ulnar > radi-
al) > wrist . 47
Besides age and anat omic locat ion, ot her biological and
physiological f act ors may also infl uence skin t est result s,
160 Ant unes J et al

Table I. False result s in skin prick t est s

False negat ive result s False posit ive result s

Biological fact ors
Ext ernal fact ors
Technical fact ors
SPT diagnost ic limit at ions
Sensit isat ion, sex, race, age and anat omic locat ion Dermographism
Drugs, UV radiat ion and ot her diseases Cross-react ivit y
Ext ract qualit y/ concent rat ion and incorrect Trauma and non-blood-free procedure,
t echnique ext ract qualit y (impure mixt ures)
Non-allergic hypersensit ivit y and non-IgE
mediat ed react ions

such as hist ologic qualit ies of t he skin (vascularit y, number models have been used t o evaluat e t he degree and durat ion
of hist amine recept ors, mast cells, and dermal t hickness). 29 of drug suppression on skin react ivit y, making direct com-
In one st udy, UV-B exposure was found t o reduce skin reac- parisons unreliable (Table II).
t i on by as much as 48 %. 121 Concer ni ng r aci al f act or s, The hist amine-induced wheal and fl are model helps t o
dark-skinned pat ient s seem t o have larger wheal-and-fl are ident if y t he obj ect ive ef f ect iveness of AH in humans, as
react ions, but some aut hors f ound Caucasians t o be more well as t heir dif f erences in t he onset and durat ion of ac-
react ive t han non-Caucasians. 10,46 t ion. Several st udies have employed t his model t o compare
Circadian rhyt hm has no infl uence on skin react ivit y10, 122 AH and assess t hei r pharmacoki net i c propert i es. When
but some dat a show maximum wheal size during t he night . 46 compared t o ot her 2nd generat ion AH, such as desl orat a-
Dif f erent st udies ident ifi ed a relevant increase in wheal- dine, levocet irizine appears t o be more ef f ect ive in inhib-
and-f l are react ion in pat ient s wit h al l ergic ast hma and it ing wheal and fl are response. 126,127 Ebast ine, fexofenadine,
rhinit is af t er pollen season. 123 On t he cont rary, t he reduc- cet irizine and mizolast ine rank next and have similar skin
t ion in skin react ivit y in sensit ised subj ect s is a common ef f ect s. Superior ef fi cacy of ebast ine (20 mg) was f ound in
fi nding af t er specifi c immunot herapy, eit her sublingual or comparison t o cet irizine (10 mg) or lorat adine (10 mg) on
subcut aneous. 124,125 t he overall skin wheal response af t er single and mult iple
Concurrent drugs, in part icular ant ihist amines (AH), t ricy- doses, 127 wit h a longer-act ing ef f ect t han f exof enadine as
clic ant idepressant s and t opical cort icost eroids may affect well. 128
t he validit y of skin t est ing. 10 Dif f erent phamacodynamic The general principle concerning fi rst - and second-gener-
at ion AH is t o st op medicat ion 2 t o 3 days before SPT, wit h
t he except ion of cet irizine, hydroxyzine (5 days) 129, clemas-
Table II. List of drugs wit h skin inhibit ory effect t ine (5 days) 130, lorat adine (7 days) 131 and perhaps ot hers not
yet st udied. For t his reason, and as it seems easier for t he
Drugs and skin react ivit y pat ient t o remember, we suggest a one-week drug-free in-
t erval before skin t est ing.
Drug Dose Wheal inibit ory Many pat ient s who require SPT cannot deal wit h prurit us
effect (days) wit hout t aking AH. In a recent work by Danart i et al 132 t opi-
Ant i-H1 1st generat ion cal AH can be used in such circumst ances. Because of t heir
short durat ion of act ion (< 180 minut es), t hese drugs can be
Clemast ine 1 mg 2×/ d 5-10
used in pat ient s who need ant ihist amines but are scheduled
Hydroxyzine 25 mg 4×/ d 5-8
t o undergo skin prick t est ing aft er a few hours, wit hout in-
Promet hazine 25 mg 4×/ d 3-5 fl uencing t he pat ient ’s skin response. 132
Ant i-H1 2nd generat ion Doxepin, a t ricyclic ant idepressant , and ant i-H2 drugs can
Fexofenadine 60 mg 2×/ d 2 also cause f alse-negat ive result s f or as long as 6 days133 or
Lorat adine 10 mg 1×/ d 7 24h134, respect ively.
Cet irizine 10 mg 1×/ d 3 Syst emic cort icost eroids do not inhibit skin react ivit y
Tricyclic ant idepressant s when used for short t erm t herapy (i.e. 30 mg prednisone a
Desipramine 25 mg 1×/ d 2 day for 1 week). 135 When used for longer periods, confl ict ing
result s have been obt ained, recommending a more crit ical
Doxepine 25 mg 1×/ d 6
anal ysi s. 10 Topi cal st eroi ds shoul d be di scont i nued 2 t o
Cyst einyl leucot riene
3 weeks before t est ing as prolonged use (over 3 weeks) can
ant agonist s
suppress wheal react ion in t he applicat ion sit es. 136
Mont elukast 10 mg 1×/ d 0 Bronchodilat ors, epinephrine and t heophylline do not sig-
Zafi rlukast 20 mg 1×/ d 0 nifi cant ly suppress skin react ivit y. 137 In t he case of cyst einyl
Local anest het ic leukot rienes ant agonist s (e.g. mont elukast and zafi rlukast )138
EMLA cream 5 mg 0 (but supresses or EMLA cream139, no signifi cant ef f ect on wheal-and-fl are
eryt hema) react ion has been described eit her. Concerning int ranasal
Ant i-H2 t opical AH (e.g. azelast ine) result s are somehow cont radic-
Ranit idine 150 mg 1 dose <1 t ory and discont inuance is recommended for a 48h minimum
period. 10,140
Skin prick t est s and allergy diagnosis
Papule size depends as well on allergen concent rat ion and
number of allergens t est ed f or which t he pat ient is sensi-
t ised. Some aut hors have st udied t hese variables and calcu-
lat ed, as an example, t hat t he wheal diamet er increases
1:5 t imes (area 2:5 t imes) if t he allergen concent rat ion in-
creases 10 t imes. 53,54 In polysensit ised individuals, simult a-
neous pri ck t est i ng wi t h mul t i pl e al l ergens can i nduce
addit ive hist amine release f rom cut aneous mast cells. In
vivo and in vit ro st udies suggest an addit ive effect of mult i-
ple prot eins (allergens mixt ure) on hist amine release from
cut aneous mast cells, causing mean wheal diamet ers larger
t han obt ained wit h single allergens. 141
Future directions
Skin t est ing remains an essent ial diagnost ic t ool in modern
allergy pract ice. Allergen ext ract s have experienced great
progress in recent years but a long way remains ahead. Many
allergens have yet t o be charact erized. The qualit y of ex-
t ract s st ill needs furt her advances, wit h crit erious allergen
select ion and biologic pot ency assessment . The capacit y t o
different iat e bet ween clinically irrelevant and relevant sen-
sit isat ions const it ut es an import ant mot ivat ion t o fut ure in-
vest igat ions. The defi nit ion and use of recombinant allergens
promises t o lead t o an improvement in t his area, eliminat ing
diagnost ic errors due t o cross-react ivit y phenomena.
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