Nurses in Allergy Committee

Standard Operating Procedure

Adult Skin Prick Testing

The following standard operating procedure outlines how to perform a skin prick test to a
reagent or fresh food and is applicable to all health care professionals undertaking this
role.

Skin prick testing (SPT) is a method used to determine the presence of specific IgE. SPT
should only be interpreted in conjunction with a clinical history as a positive SPT alone is
not diagnostic of clinical disease (1,2). Depending on the allergen, approximately half of
positive tests occur in patients who are not allergic to that allergen. SPT should be
performed by an appropriately trained and competent healthcare worker who is also
trained in recognition and treatment of anaphylaxis (3).

Exclusions
SPT reactions are inhibited by antihistamines and may be potentially inhibited by tricyclic
antidepressants, topical corticosteroids and UV light treatment. Therefore where possible
inhibitory medication should be stopped or alternative testing methods considered (1,2).
Short acting anti-histamines should be stopped for 72 hours prior to testing

Cautions
Caution should be taken when considering SPT in pregnancy, for patients with unstable
asthma or those taking beta blockers and/or ACE inhibitors(1,2).

Equipment
 Selected allergens and positive and negative control solutions (stored at +2-
+8oC). Check expiry date and date opened (some manufacturers state that skin
test solutions should be used within 6 months of opening.) (4)
 And/or fresh foods to be used for testing
 Skin prick test recording sheet
 Pen
 Individual sterile skin prick testing lancets
 Sharps bin
 Tissues
 Skin test measure
 Timer / clock / watch
 Emergency equipment should be available to treat anaphylaxis, including
adrenaline 1:1000 (5)

Preparation
Verbal consent for the procedure should be obtained. The procedure should be
undertaken in accordance with local infection control policy using appropriate hand

Kathryn Powrie 2015 BSACI nurses in allergy committee revised version October 2021 (v8)
 Nurses in Allergy Committee
Standard Operating Procedure

hygiene measures. Select appropriate test site free from eczema / dermatitis, the
preferred site is the forearm but the back may also be used.

PROCEDURE (1,2,3,6) RATIONALE

Ensure test site is free from body Body lotion / moisturiser can
lotion and moisturisers cause allergen drops to run,
causing cross contamination.

Test site should be hygienically

clean but does not need to be not
be cleaned with alcohol or
antiseptic

Ensure patient is in a comfortable To ensure patient is relaxed

position sitting or, if needle and able to remain still during
phobic, lying down. the test.

Rest arm on a level surface, using

pillow if necessary.

Mark the test sites approximately To ensure any reactions do

2.5cm apart, using first letter of not overlap so that accurate
allergen being tested. Avoid the measurements can be made.
skin creases (elbow and wrist)

Begin with the negative control To provide consistency, to

and end with the positive control prevent cross contamination
from the histamine control
and for patient comfort
because the histamine
control reaction time is the
quickest.

Place one drop of each selected To ensure accurate

allergen solution* next to relevant identification of the allergen
marked site. when results are read

*for prick to prick testing see

additional guidance below.

Using gentle pressure, push the To ensure that the allergen

lancet through allergen solution penetrates the outer surface
and into the surface layer of the of the skin.
skin at a 90O angle. To reduce risk of causing
bleeding.
To ensure a standardised
test

Kathryn Powrie 2015 BSACI nurses in allergy committee revised version October 2021 (v8)
 Nurses in Allergy Committee
Standard Operating Procedure

Discard lancet into sharps bin To ensure safe disposal of

sharps

Repeat the procedure for each To prevent cross

allergen and the controls using a contamination of the
new lancet each time allergens

Remove surplus allergen by To remove excess allergen

blotting test sites with a single solution and prevent cross
tissue or individual tissue pieces contamination of test sites.
ensuring that there is no cross
contamination between test sites.

Advise patients not to scratch the To allow for accurate reading

test sites whilst waiting for the of results.
results to develop

Advise patients to report promptly To ensure prompt treatment

any systemic adverse reaction of any adverse reaction

Results should be read 10-15 To ensure accurate

minutes after the test. Measure assessment of the reaction is
the wheal diameter in mm. For recorded.
asymmetric wheals measure the
longest extent of the wheal in mm
and the extent 90o to the first
measurement (eg 3x3mm).

An imprint of the result can also

be made by drawing round the
wheal in pen and taking a print
using skin tape which can then be
stuck onto the results sheet.
The flare may also be recorded.

Any pseudopodia should be noted

but not included in the
measurement of the wheal

A wheal diameter of 3mm larger

than the negative control is a
positive reaction

A wheal response to the negative Document the response to

control indicates dermographism the negative control.
Interpretation of other
positive results must allow for
subtraction of the negative
control. The need for further,
alternative testing should be

Kathryn Powrie 2015 BSACI nurses in allergy committee revised version October 2021 (v8)
 Nurses in Allergy Committee
Standard Operating Procedure

considered by the clinician

who has requested the test.

Absence of a wheal at the positive Document that the positive

control suggests that a topical or control has not reacted.
oral medication with antihistaminic Either repeat the skin tests
properties may have been taken. off anti-histamines /other
Repeat the positive control and if medication or the requesting
still negative record as an invalid clinician can consider specific
test. IgE serology.

Advise the patient that the wheals To inform the patient

will fade, usually within an hour.

Oral anti-histamines or a cold To enhance patient comfort

compress may be given to relieve and relieve severe itch
severe itch in line with a
prescription.
Record the outcome of the test Ensure accurate
including; documentation.
 date of test
 patient name, date of birth
and hospital number
 skin prick (SPT) or prick to
prick (PPT) method
 wheal size in mm
 any recent antihistamine
medication with date/time
of last dose.
 name, designation and
signature of person
performing the SPT

*Prick-to-prick testing with fresh foods

The food used for testing fruit and vegetables should be fresh and not tinned or cooked
as these processes can alter allergenicity.
For fruit / vegetables push lancet into a fleshy and juicy/moist site of the food (through
skin if normally eaten) and place a small amount of the food substance onto the skin.
Then introduce the lancet into the surface layer of the skin at a 90O angle through the
food.
For other foods place a small amount onto the skin, where practical, or crush/grind and
make a paste using sterile saline and place this on skin before pricking through it with
the lancet.

Kathryn Powrie 2015 BSACI nurses in allergy committee revised version October 2021 (v8)
 Nurses in Allergy Committee
Standard Operating Procedure

Interpreting the Skin Prick/ Prick to Prick Test

Ensure that the results are discussed with the patient by an appropriate clinician and,
when applicable, allergen avoidance advice is given. It is important to be aware of the
distinction between sensitisation (a positive test without clinical allergy) and allergy.

References:

1 The skin prick test – European Standards (2013) Clinical and Translational
Allergy 3:3
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565910/ (accessed 20/01/21)

2 Bousquet et al (2012) Practical guide to skin prick tests in allergy to

aeroallergens Allergy 67: 18-24
http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2011.02728.x/pdf
(accessed 16/01/21)

3 Fitzsimons R et al (2014) BSACI Allergy Nurse Competency Document

http://www.bsaci.org/professionals/nurses-specialising-in-allergies [accessed
20/01/21]

4 Summary of product characteristics Soluprick Timothy Grass ALK Abello

http://www.alk-
abello.com/UK/products/soluprickSQ/Lists/Soluprick%20SQ/Timothy%20Grass%20SmPC
.pdf (accessed 20/01/21)

5 UK Resuscitation Council (2021) Emergency Treatment of Anaphylaxis-

Guidelines for Healthcare providers

https://www.resus.org.uk/library/additional-guidance/guidance-
anaphylaxis/emergency-treatment
(accessed 27/05/21)

6 BSACI nurses in Allergy (2019) Paediatric Skin Prick Testing SOP BSACI
https://www.bsaci.org/wp-content/uploads/2019/12/paedSPTnew.pdf (accessed
20/01/21)
Kathryn Powrie 2015 BSACI nurses in allergy committee revised version October 2021 (v8)
 Nurses in Allergy Committee
Standard Operating Procedure

Kathryn Powrie 2015 BSACI nurses in allergy committee revised version October 2021 (v8)