Assessment of Allergy

Allergy testing

Presented by

Sylvie Daigle, RN, BSc

Universit
de Montral

Assessment of Allergy
The

term "Allergy"

Allergic

reaction

Assessment
Skin

of atopy

or immunological testing

What is Allergy?
Also known as
Hypersensitivity
Disease

Definition
The term allergy ( von Pirquet -1906),
can be summarized as the acquired,
specific, altered capacity to react.
From Greek words: allos "change, altered"
+ ergon "reaction, reactivity".
Acquired means prior adequate
antigenic or allergenic exposure.

Allergy has increased

Incidence of allergy has doubled in the
last 20-30 years, why?
Less

exposure to parasitic disease?

Lower

rate of breast-feeding ?

Exposures
Exposure
The

to air pollution?

to allergens in town vs in the country

"hygiene hypothesis"?

Classificationofallergicreaction
byGell&Coombs*
TypeI
Anaphylaxis(IgE)
(immediate)
TypeII
Cytotoxic

Atopicdiseases

TypeIII

Immune complex
(IgG)

Farmerslung

TypeIV

Delayedallergy

Skin reaction to tuberculin

Autoimmune hemolytic
anemia

Firstpublishedin1968:Clinicalaspectsof
immunology

Assessment of Atopy

Clinical essential for asthma management

(in particular if pets at home, in relation to the
pollen seasons, etc.)

Epidemiologic studies

Occupational investigation

Type I Hypersensitivity Detection

Skin

Prick Testing, recommended to assess

atopic status
RAST (ELISA), serum specific antibodies
Intradermal Skin Testing: more sensitive
than prick testing but less specific, with risk of
anaphylactic reaction; also, difficulty of
interpretation (local trauma due to injection)

Skin Prick Test

Widespreaded in the 1970s after its
modification by J. Pepys
Advantages
Mechanisms
Technique
Interpretation
Factors

affecting skin test

Relevant allergens (ubiquitous,

occupational)
House

dust mite
Ragweed, tree pollen
Pets
Cockroaches
Molds
Occupational protein
allergens

Occupational protein allergens

Many occupational agents cause asthma by
sensitization
mostly high-molecular-weight proteins
some low-molecular-weight agents
In the case of high-molecular-weight
allergens , skin prick tests are the preferred
diagnostic correlates of Ig-E sensitization

Advantages

Skin prick testing is cheap, rapid and accurate

High degree of specificity

Safe and painless

Wide range of allergens

Objective evidence of sensitization

Technique and reaction

Introduction of allergen
extract into the dermis

Ig-E-mediated response

Allergen-induced whealand-flare reaction

Technique

Use the inner forearm

Mark the area to be tested (2 cm apart)
Place a drop of each allergen extract on each mark
Prick the skin through the drop
Use a new lancet/needle for each allergen
Negative (saline solution) and positive control
(histamine phosphate, 10 mg/ml) must be
included: to exclude false positive reactions
(dermographism) and false negative reactions
(intake of antihistamines)

Put drops of allergen

extracts on the skin

Prick the skin through

the drop

INTERPRETATION
Read

at their peak (15-20 minutes)

Measure with a millimeter rule
Largest + smallest of wheal and erythema
2
The wheal is principally used (diameter)
What if the negative control is positive?
What if the positive control is negative?
The size of the wheal does not relate to the severity
of symptoms

Common errors in prick testing

Tests

too close together (< 2 cm)

Induction of bleeding, leading possibly to
false-positive results
Insufficient penetration of skin by lancet
leading to false-negative
Spreading of allergen solutions during the
tests.

Causes of false-positive skin prick tests

Irritant reaction
Dermographism
Contamination of an allergen extract
Enhancement from a nearby strong reaction
Causes of false-negative skin prick tests
Extract of diminished potency
Medications modulating allergic reaction
Diseases attenuating the skin response, e.g. eczema
Improper technique (no or weak puncture)

Factors affecting skin test results

Quality

of the allergen extract (standardized)

Area of the body, wrist least reactive
Age, less reactive after 50
Circadian rhythms do not affect the skin reaction
Drugs: short acting antihistamines inhibit the
wheal-and-flare reaction for up to 24 h; longacting antihistamines may affect reaction for up
4-5 days.

CONCLUSIONS
When properly performed, skin tests
represent one of the major tools for
diagnosis of Ig-E-mediated diseases.
Assessment of the atopic status of subjects
is often included in epidemiological studies
of asthma and occupational asthma because atopy
is a risk factor.

Natural history of sensitization, symptoms and diseases in

apprentices exposed to laboratory animals
D Gautrin, H Ghezzo, CInfante-Rivard, J-L Malo. Eur Respir J, 2001.

Predictive value of specific skin reactivity for W-R symptoms

Skin reactivity
W-R symptoms
Skin
Nasal
Ocular
Nasal and/or ocular
Respiratory

before

same time

PPV

21
18
14
17
9

22
17
16
19
4

28%
30%
21%
30%
9%

PPV of W-R RC symptoms for probable OA : 11.4%

references
- Bernstein IL, Chan-Yeung M, Malo JL, Bernstein DI. Asthma in the
Workplace. Francis & Taylor, 2006
- Middletons Allergy: Prinnciples and practice vol. 1,chap 38.
- Pepys, J. Clinical allergy, 1973, pp 491-509.
- Pepys, J. Atopy: a study in definition. Allergy 1994;49: 397-399
- Bernstein DI and al.Characterization of skin prick testing responses
J Allergy Clin Immunol 1994; 49:498-507
Web sites of interest
- www.asthma-workplace.com
- www.asthme.csst.qc.ca/document/Info_Gen/AgenProf/
- www.remcomp.com/asmanet/asmapro/index.htm