and Clinical application

focus in Skin Prick Test (SPT)

Skin test

Ketut Suryana

Medical Faculty of Warmadewa University Denpasar

Introduction
The diagnosis of Allergic diseases :
A comprehensive history Physical examination

Laboratory and other diagnostic testing :

Laboratory (eos. count, feces ex, IgE) Roentgen Skin test

Skin test :
The direct introduction of an antigen into the skin of a patient A simple, rapid and efficient technique for determining IgE antibodies to specific antigens

Methods of skin testing :

Patch test Scratch test Prick test Intradermal test

Patch Tests
Have been used for 100 years to diagnose contact allergies.

Allergen are applied to the intact skin, under an occlusive dressing

The reaction ranging from minutes to days To determine allergen (protein & glycoprotein antigen) as large as 30.000 D Typically detect delayed allergic reactions due to late phases of type I hypersensitivity reaction or type IV cell mediated

Allergy patch test

Morris A. Current Allergy & Clinical Immunology 2005; 18 (3):140-42

Scratch Test
The oldest form of skin testing By cutting / scratch superficial epidermal about 2 mm Now only historic interest

Intradermal Tests (Intracutaneous) This technique was used in 1911 by Robert Cooke for allergy skin tests (reported in 1914) There is no fundamental difference between intradermal and prick tests Relatively more sensitive than prick tests but the systemic risk / anaphylatic risk of intradermal more frequent than prick tests (epicutaneous)

Prick test / Skin Prick Tests (SPT)

(Epicutaneous tests)

First described by Lewis and Grant in 1926,

were popularized in the 1970s by Pepys

Most frequent performed as a diagnostic procedures

Should be performed before intradermal tests

 Diagnostic approach for the immediate hypersensitivity reaction.

Determining IgE antibodies to specific antigens

Food allergy :

Positive predictive value < 50%

Negative predictive value > 95% Interpretation base on Wheal and Flare / WF reaction.

Immunopathogenesis Immediated hypersensitivity reaction (Type I of Gell and Coombs classifications)

Indications for SPT An allergic patient / suspected allergy

When SPT should be done :

SPT should be undertaken during periods

of free symptoms To prevent worsening of the clinical status

Preparations of SPT : Washout of any medication include ;

antihistamines AH-1 (a 3-days washout),

AH-2 (one day washout)

antidepressants, codeine, long-term oral steroid (a 1-week washout)

A 1- week course of daily glucocorticosteroids

was reported to have no effect on immediate skin tests. High dose allergy immunotherapy results in a reduction in skin test reaction.

Emergency Kit

Procedure of SPT SPT was performed on volar region of antebrachium Cleanse the skin with 70 % ethyl alcohol and

allow it to dry by evaporation Aseptically place a drop of a standardized allergen (2 cm apart, to prevent coalescence of positive results) The vaccinostyl / a sterile needle no. 26 should not be inserted so deep (1mm) at about a 45 angle into the superficial skin About 15-20 minutes, observe the test sites for erythema and wheal formation (WF reaction)

Diagnosis of ALLERGY : Skin prick test

Reliable, sensitive
and reproducible

Pricking device

Immediate results
(15-20 min)

Cheap Painless

Drop of allergen extracts for diagnostic use

Local reactions

Grading and interpretation :

based on the diameter WF Although many grading systems, consistency and familiarity with the system are most important.

Negative +1 +2 +3

= no WF formation / diameter < 3 mm = WF formation with diameter 3 mm = WF formation with diameter 4-6 mm = WF formation with diameter > 6 mm

Reading the results 15 20 min

Wheal

erythema

Skin reaction

Measuring the diameter of the wheal

Guidelines for correct interpretation include the following :

Skin test positive skin tests correlate highly when the

suspected manifestation of food allergy is : Acute urticaria Angioedema anaphylaxis

Skin test

for food allergy :

Positive predictive value < 50% Negative predictive value > 95%

Skin test

immediate hypersensitivity reaction to drugs is limited because

metabolites of drug in question,

not the drug itself are usually responsible, except : Penicillin Drugs in serum soluble

A negative control :
A test using diluent solution (coca solution)

A positive control :
A test using 0.1% histamine solution

Control test could be evaluate :

Technique non specific

Allergen
false negative / false positive

False negative :
Technique test Low allergen Preparation not optimal (discontinue of the drugs)

False positive : Technique test

Deviation from physiologic pH /

osmolaritas of the allergen Presence of LMW, irritants

Clinical application

Asthma Gastro-intestinal Sign & symptoms Rhinitis Exem / itching

Positive

History oft allergy

Negative

Skin test / RAST Positive Negative Positive

Skin test / RAST Negative

Review the anamnesis Clinical history Anamnesis / clinical history was not confirm Continue skin test / RAST Provocative tes For target organ Diagnostic approach by allergen avoidances

Consider to

Referal

Diagnosis allergy was confirmed Consider Allergen avoidance Immunotherapyi

Repeat the prior procedure

Diagnosis allergy was excluded No spcific theraphy for allergy

Algorytm diagnostic approach