SKIN PRICK TEST
FOR THE DIAGNOSIS OF
ALLERGIC DISEASE
Three types of skin testing used in allergy diagnosis
Skin prick testing (SPT)
The primary mode of skin testing for immediate
IgE-mediated allergy (type 1)
Intradermal testing (IDT)
Relevant to both immediate IgE-mediated allergy
and delayed-type hypersensitivity
Patch testing
Applicable to the diagnosis of contact
hypersensitivity and other forms of delayed-type
hypersensitivity (type 4)
Skin prick testing provides information about the presence
of specific IgE to protein and peptide antigens
(allergens).
Small amounts of allergen are introduced into the
epidermis and non-vascular superficial dermis and
interact with specific IgE bound to cutaneous mast cells.
Histamine and other mediators are released, leading to a
visible wheal-and-flare reaction peaking after about 15
minutes.
Allergic rhinoconjunctivitis
Asthma
Atopic dermatitis
Food reactions such as those
manifested by anaphylaxis,
immediate acute urticaria, or acute
flare of eczema
Suspected latex allergy
Conditions in which specific IgE is
considered likely to play a pathogenic
role (eg. selected cases of chronic
urticaria if the history suggests an
exogenous allergic cause)
Rarer disorders such as allergic
bronchopulmonary aspergillosis,
eosinophilic oesophagitis or eosinophilic
gastroenteritis
Indication
Indication
ofof
SPT
SPT
Allergy testing has been shown to increase the
accuracy of diagnosis when added to history and
clinical examination
It may lead to allergen avoidance strategies,
improved use of medications, and for some
patients, desensitisation treatment
(immunotherapy).
The strongest indications for skin prick testing
are where there is good evidence for the
effectiveness of allergen avoidance or
immunotherapy
Patient selection in skin prick testing
Patient age
Contraindications
Drugs that interfere with the skin prick test response
PATIENT AGE
No strict age limits but skin reactions are often diminished in
the very young and the elderly interpretation more
difficult in both cases
Infants often show larger flares and smaller
wheals
Systemic allergic reactions may rarely occur in
response to skin testing in infants (as in patients of
any age)
Contraindications
Diffuse dermatological conditions
Severe dermatographism
Poor subject cooperation
Subject unable to cease
antihistamines/other interfering
drugs
Positive and negative controls
The
Thenegative
negativecontrol
controlisisthe
thesame
samesolution
solutionas
asthe
theallergens
allergensare
aremade
made
up
upin,
in,eg.
eg.saline
salinebuffer/50%
buffer/50%glycerol,
glycerol,without
withoutany
anyallergen.
allergen.ItItisisalso
also
available
availablecommercially
commercially
The
Thepositive
positivecontrol
controlcan
canbe
beaasolution
solutionofofhistamine
histamine(usually
(usuallyhistamine
histamine
phosphate
phosphate10mg/ml)
10mg/ml)(directly
(directlyinduces
inducescutaneous
cutaneouswheal
whealand
andflare
flare
response)
response)ororcodeine
codeine(usually
(usually9%
9%solution)
solution)(degranulates
(degranulatescutaneous
cutaneous
mast
mastcells,
cells,indirectly
indirectlycausing
causingwheal
whealand
andflare).
flare).Availability
Availabilityofofpositive
positive
control
controlsolutions
solutionsisisproblematic
problematic
Positive and negative controls
Wheals of >3mm to the negative control indicate severe
dermatographism and would require rejection of the test
ItIt isis recommended
recommended that
that aa wheal
wheal ofof 4mm
4mm toto the
the positive
positive
control
control isis acceptable
acceptable (or
(or 4mm
4mm greater
greater than
than the
the negative
negative
control)
control) and
and ifif itit isis <4mm
<4mm the
the test
test should
should be
be considered
considered
uninterpretable
uninterpretable
Devices used for skin testing
Sharp lancets are used to prick through the drop into the
epidermis and superficial dermis.
Some devices consist of a point on a flat stopper, so that the
device can be jabbed onto the patients skin entering the
epidermis and upper dermis, without penetrating too deeply.
A sharp pointed device such as a prick lancet can be used with
an oblique prick and lift technique, without inserting the needle
too deeply.
The prick should not be deep enough to draw blood, although in
the elderly with thin skin this may be unavoidable.
Requirements for skin prick testing procedure
Recording
sheets
Tissues for
wiping
solutions
Ruler for
measuring
reactions
Marker pen for the
skin
Gloves (latex
and latex-free)
Allergen
extracts
Positive and
negative control
solutions
Sterile lancets for
skin pricking
Sharps container for
disposal of lancets
Method
Time of reading results
The reaction to the histamine positive control is at its maximum size
at approximately 10 minutes whereas the allergen reaction reaches
its maximum at around 15 minutes.
In practice the histamine wheal is usually still showing at 15 minutes
and this is recommended as the optimal time for reading skin test
results.
Occasionally allergen responses continue to enlarge up to about 20
minutes.
Overall, the histamine result should be read at 10-15 minutes after
the skin prick, and the allergens at 15-20 minutes.
.
INTERPRETATION
OF SKIN PRICK TEST RESULTS
Meaning of positive and negative tests
Skin prick test results need to be interpreted in the context of the
patients history, clinical signs, and allergen exposures.
In the presence of a history of an allergic condition with a positive
skin prick test and known exposure to the allergen, particularly
when the pattern of symptom exacerbation relates to variations in
allergen exposure, it is reasonable to conclude that the allergen is
relevant to the symptoms, and the positive test is significant.
A wheal of 3mm or greater is taken to indicate the presence of
specific IgE to the allergen tested
Meaning of positive and negative tests
It is evident that in general, larger skin test reactions predict a
higher likelihood of a positive response to a challenge, but do not
predict severity of symptoms.
These studies have indicated that for many allergens, a wheal size
(lower cutoff) set at a larger size than 3mm would correlate better
with clinical allergen reactivity.
For example, a wheal size of >6mm may provide more specificity
for the diagnosis of clinical dust mite allergy than the 3mm wheal.
