SKIN PRICK TEST & MODIFIED

QUANTITATIVE TEST
 Skin testing in allergy
• Skin prick test testing (SPT)
 The primary mode of skin testing for immediate IgE-
mediated allergy.
• Intradermal testing (IDT)
 Relevant to both immediate IgE-mediated allergy and
delayed-type hypersensitivity
• Patch testing
 relevant to contact hypersensitivity and some other forms
of delayedtype hypersensitivity

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 SKIN PRICK TEST
Indication:

- Rhinitis/rhinoconjunctivitis/rhinosinusitis/allergic conjunctivitis;
- Asthma;
- Atopic dermatitis;
- Food reactions;
- Suspected latex allergy;
- Conditions in which specific IgE is considered likely to play a pathogenic
role
- Rarer disorders such as allergic bronchopulmonary aspergillosis,
eosinophilic oesophagitis or eosinophilic gastroenteritis.

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 SKIN PRICK TEST
Not routinely indicated:
- Nonspecific rash without allergic/atopic characteristics;
- Chronic urticaria in the absence of allergic features on history;
- Food intolerance without allergic features (e.g. irritable bowel syndrome);
- Assessment of the effectiveness of allergen immunotherapy;
- Chronic fatigue without allergic features;
- Migraine headaches/behavioural disorders;
- Reactions to respiratory irritants (smoke, fumes, perfumes etc.); and
- Screening for allergy in the absence of symptoms (e.g. family history of
allergy).

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 SKIN PRICK TEST
Patient selection: Relative
- Patient age  no strict age contraindications/precautinos:
limits but often diminished in - Persistent severe/unstable
the very young and elderly asthma
- Contraindication - Pregnancy
1. Diffuse dermatological - Babies and infants
conditions - Patient on beta blockers
2. Severe dermatographism
3. Poor subject cooperation
4. Subject unable to cease
antihistamines/other
interfering drugs

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 SKIN PRICK TEST
Interfered drugs: skin prick testing
- Beta-blockers  risk of systemic
- Anti depressants anaphylaxis is increased
such as doxepin, other tricyclics, - ACE inhibitors  interfere with the
tetracyclics normal compensatory mechanism
- Oral corticosteroids in anaphylaxxis ad beta-blockers
interfere with the effect of
 Not significantly diminish the skin
adrenaline
test reaction even after prolonged
use
 Prolonged topical corticosteroid 
reduce skin reactivity

Drugs that may be contraindicated in

ASCIA, 2016
 SKIN PRICK TEST
Patient factors leading to Condition can reduce skin
variability in skin test results reactivity:
- Dermatographism  cause - Chronic renal failure
nonspecific wheal-and-flare  - CVA
skin pricking alone - Cancer
- Negative control  sow wheal - Spinal cord injury
and renders the allergens
- Diabetic neuropathy
- Mild dermatographism does
- Recent anaphylaxis
not preclude skin testing
- Advanced chronological age

ASCIA, 2016
 SKIN PRICK TEST
Devices used for skin testing

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 SKIN PRICK TEST

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 SKIN PRICK TEST
Requirements for skin prick testing • Marker pen for the skin;
procedure: • Ruler for measuring reactions;
• Allergen extracts; • Tissues for wiping solutions;
• Positive and negative control • Recording sheets; and
solutions; • Gloves (optional).
• Sterile lancets for skin pricking;
• Sharps container for disposal of
lancets;

Site of application
Reaction to allergen:
- Volar surface of the
• Back > arm
forearm or outer upper
arm • Lower back > upper back
- The back • Upper forearm > wrist

Generally it is advisable to site tests more than 5cm from the wrist and 3cm
from the antecubital fossa
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 SKIN PRICK TEST
Method
- Clean the skin site wit alcohol prior to skin prick testing 
may contraindicated in cases of extreme dry skin and eczema
- Positions  marked by numbers on the skin to identify the
allergen
- Pricks should be made  adjacent to the numbers to avoid
confusino between allergens
- Skin prick tests sould be at least 2cm apart avoid overlapping
reactions and false-positive results

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 SKIN PRICK TEST
Drop then prick
- Drop of allergen will be applied from the dropper bottle onto the skin
prior to pricking the skin
- Drop on the tip of the dropper can be touched on the skin to transfer the
liquid but the actual tip of the dropper should not touch the skin
- In patient with eczema who use mouisturisers te drop may flatten or run
more easily on the skin
- Many practitioners leave the drops on the skin until the test is ready to
read but this is probably not necessary; the test solution can be blotted
from the skin after pricking without compromising the eventual result.

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 SKIN PRICK TEST
Dip then prick
- The allergen extract is placed into small wells in a multi-well
tray.
- The dropper (Duotip, Stallerpoint, Multitest) is dipped into the
allergen extract, withdrawn, and then applied to the skin with
firm pressure
- With the Duotip some advocate twisting the lancet to slightly
shear the two tips into the skin and allow more allergen to
penetrate

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 SKIN PRICK TEST
Time of reading results

- Reaction to the histamine positive control  10 minutes, max 15

minutes
- The histamine wheal  still showing at 15 minutes, recommended as
the optimal time for reading skin test results
- Allergen responses continue to enlarge >20 minutes
- Histamine result  10-15 minutes after skin prick
- Allergens  15-20 minutes
- If left for longer than 20 minutes  allergen response may diminish or
be lost
- If not measures on time due to delay  test may need to be repeated

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 SKIN PRICK TEST
Patient aftercare
- Itching  subsides within 15 minutes or so  topical creams
to reduce itching such as urea creams or ice-pack
- Topical corticosteroid  have been shown not to be useful
- Oral antihistamines
- Warned possibility of a late-phase reaction
- Patient should receive counselling regarding the significance
of the test result from medical practitioner

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 SKIN PRICK TEST
Composition of skin testing extracts
- Contain all allergenically relevant proteins of the labeled substance, free of
cross-contamination with allergenic proteins of the oter substance
- Allergen extracts  complex mixtures and contain a range of allergenic
protein  can be separated by electrophoresis and visualised by
immunoblotting
- Allergenic substances invariably contain hundreds of different proteins,
each with a unique sequence; only a subset of these proteins is potentially
allergenic

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 SKIN PRICK TEST
Allergens extract: - Whole egg
- Histatrol - Cow’s milk
- Glycerinated phenol-saline - Soybean
control - Cocoa bean
- D. pteronyssinus - Peanut
- D. farinae - Crab
- Standardized cat hair - Shrimp
- American cockroach - Tuna
- German cockroach - Chicken meat

RSHS
 Modified quantitative testing
 Recent work by Krouse to develop a blend of IDT and SPT
methods led to modified quantitative testing (MQT).
 This method combines the ease of SPT with the sensitive and
quantitative data of IDT
 Method of testing has been adopted by the American
Academy of Otolaryngic Allergy as a valid form of testing and
was recently validated
 A blend of SPT (skin prick test) and IDT (intradermal test).

Fornadley, J., 2014. Skin testing for inhalant allergy. International Forum of Allergy & Rhinology,
4(S2), pp.S41-S45.
 Modified quantitative testing
SPT  used initially to determine an approximate range of
sensitivity, and a single weaker or more concentrated
intradermal test is used to define the level of sensitivity and
quantify the allergic response

MQT overcomes the lack of sensitivity of SPT and yields

quantitative data to allow for safer calculation of
immunotherapy starting doses

MQT was a safe alternative to IDT for determining starting

immunotherapy dosing for mold antigens
Fornadley, J., 2014. Skin testing for inhalant allergy. International Forum of Allergy & Rhinology,
4(S2), pp.S41-S45.
Fornadley, J., 2014. Skin testing for inhalant allergy. International Forum of Allergy & Rhinology,
4(S2), pp.S41-S45.
 • “blending” of skin-prick testing with single
intradermal tests closely approximates other
prick test–based techniques, but with the
advantage of having semiquantitative data on
each antigen’s sensitivity level to determine
the starting strength for immunotherapy

Fornadley, J., 2014. Skin testing for inhalant allergy. International Forum of Allergy & Rhinology,
4(S2), pp.S41-S45.
 Modified quantitative testing
Technique
- Brought patient into testing room and properly identified
- Patient  questioned concerning the use of any
medications that may adversely affect either the
accuracy or the safety of the test
- Both the volar surface of the forearms and the upper
outer aspects of both arms are used for testing
- The forearms are first cleaned with alcohol, and ink is
used to mark the location and orientation of the testing
punctures that will be placed.

Krouse, J. and Mabry, R., 2003. Skin Testing for Inhalant Allergy 2003: Current Strategies. Otolaryngology–Head and Neck Surgery, 129(4_suppl),
pp.S33-S49.
 Modified quantitative testing
Technique
- The antigens to be tested have been
previously positioned in testing
wells in a discrete pattern so that
they can be identified after they
have been placed on the skin

- The test antigens are then placed

onto the forearm with moderate
pressure and a gentle rocking
motion both from side to side and
from forward to backward

Krouse, J. and Mabry, R., 2003. Skin Testing for Inhalant Allergy 2003: Current Strategies. Otolaryngology–Head and Neck Surgery, 129(4_suppl),
pp.S33-S49.
 Modified quantitative testing
Technique
- As the device is taken off the skin, small droplets of antigen
will remain at the individual testing sites and should not be
wiped clean for at least 5 minutes.
- Patients should be advised to keep their arms relatively
immobile during those 5 minutes to prevent cross-
contamination of antigens.
- For screening purposes, 1 Multi-Test II device of 8 tests may
be placed on each volar forearm.
- For any additional testing, up to 2 panels of 8 tests each, may
be placed on each volar forearm, for a total of 30 antigens and
2 controls
Krouse, J. and Mabry, R., 2003. Skin Testing for Inhalant Allergy 2003: Current Strategies. Otolaryngology–Head and Neck Surgery, 129(4_suppl),
pp.S33-S49.
 Modified quantitative testing
Technique
- In young children there may not be
adequate surface area to allow use of 2
devices on each forearm, and testing may
need to be conducted on either the
anterior thigh or the back.
- After placement of the tests, 20 minutes
are allowed for the wheals to develop at
the site of each test  then measured and
their size recorded
- Positive test  a wheal with a diameter of
3 mm or greater at 20 minutes, consistent
with the guidelines of the European
grading systems

Krouse, J. and Mabry, R., 2003. Skin Testing for Inhalant Allergy 2003: Current Strategies. Otolaryngology–Head and Neck Surgery, 129(4_suppl),
pp.S33-S49.
 Modified quantitative testing
Technique
- If all tests show whealing, as may occur with a
dermatographic patient or with a patient who is overly
sensitive to the trauma of the puncture, a positive wheal is
defined as a wheal with a diameter of 3 mm or greater than
the diameter of the negative control wheal.
- lf positive test responses are then circled on the recording
sheet for ease of identification.
- On the basis of whether the prick test is negative, a single
intradermal test of either a No. 2 dilution (1:500 wt/vol) or a
No. 5 dilution (1: 62,500 wt/vol) is then placed on the upper
outer arm.
Krouse, J. and Mabry, R., 2003. Skin Testing for Inhalant Allergy 2003: Current Strategies. Otolaryngology–Head and Neck Surgery, 129(4_suppl),
pp.S33-S49.
 Modified quantitative testing
- MQT is designed to further refine this initial estimate of
sensitivity through use of intradermal tests with either
stronger or weaker concentrations of antigens
- These intradermal tests can then be used to estimate
dilutions of antigen with an IDT model and therefore to
provide a quantitative basis for the provision of
immunotherapy.

Krouse, J. and Mabry, R., 2003. Skin Testing for Inhalant Allergy 2003: Current Strategies. Otolaryngology–Head and Neck Surgery, 129(4_suppl),
pp.S33-S49.