case report patch test

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INTRODUCTION

Atopic Dermatitis (AD) is a chronically relapsing skin disease that occurs

most commonly during early infancy and childhood It is fre!uently associated

"ith a#normalities in skin #arrier function$ allergen sensiti%ation$ and recurrent

skin infections& Atopy is defined as an inherited tendency to produce

immunoglo#ulin ' (Ig') anti#odies in response to minute amounts of common

enironmental proteins such as pollen$ house dust mites$ and food allergens &$

Dermatitis deries from the *reek +derma$, "hich means skin$ and +itis$, "hich

means inflammation

Atopic Dermatitis (AD) affects a#out one-fifth of all indiiduals during their

lifetime$ #ut the prealence of the disease aries greatly throughout the "orld In

seeral industrialised countries$ the prealence increased su#stantially #et"een

&./0 and 000 so much that many refer to as the +allergic epidemic, 1o"eer$

current indications point to ec%ema symptoms haing leelled off or een haing

decreased in some countries "ith a formerly ery high prealence$ such as the

United 2ingdom and Ne" 3ealand

This indicates that the allergic diseaseepidemic is not increasing continually "orld"ide Neertheless$ AD remains a

serious health concern$ and in many countries$ particularly in the deeloping

"orld$ the disease is still ery much on the rise

The appearance of the indiidual skin lesion in AD does not differ from

other ec%emas such as contact ec%ema In it4s acute form$ ec%ema is characterised

#y a liely red infiltrate "ith oedema$ esicles$ oo%ing$ and crusting5

lichenification$ e6coriations$ papules$ and nodules dominate the su#acute and

chronic form Accordingly$ the diagnostic approach #uilds upon other

characteristics such as the distri#ution of the ec%ema as "ell as associated features

of the patient&$

The most "idely used diagnostic criteria for AD "ere deeloped #y 1anifin

and Ra7ka in &.80 and "ere later reised #y the American Academy of

Dermatology This set of criteria is primarily useful in clinical practice5 another

set of diagnostic !uestions "idely used in epidemiological research "as

1



deeloped #y the U2 9orking :arty in &..; The seerity of ec%ema can #e

graded according to seeral scoring systems such as <coring Atopic Dermatitis

(<CORAD) and 'c%ema Area and <eerity Inde6 ('A<I)=$;

Rapidly deeloping symptoms (type-& reactions) caused #y allergens in

allergic diseases can #e easily diagnosed "ith detailed anamnesis$ skin tests

and>or specific Ig' leel measurements 1o"eer$ diagnostic approaches are

rather comple6 in late onset reactions$ such as AD& Immediate-type

hypersensitiity is usually diagnosed #y skin prick tests (<:Ts) or #y

measurement of serum-specific Ig' The disadantage of <:T is the need for thediscontinuation of topical steroid and antihistamine treatment$ "hich can lead to a

"orsening of the pree6isting AD In addition$ the re!uirement of intact skin

cannot al"ays #e fulfilled5 this is especially true in childhood$ "hen AD lesions

are commonly locali%ed on the olar side of the forearms "here <:T is usually

performed In contrast$ specific Ig' measurement has no such limitations=$/

Delayed$ allergen-specific T-cell reactions also play an important role in the

pathogenesis of AD$ #ut since it is not possi#le to detect these reactions using tests

of immediate-type hypersensitiity$ a different kind of test needs to #e used in

their diagnosis The patch test is a standard method used for testing of delayed-

type hypersensitiity reactions to contact allergens? The atopy patch test (A:T)

poses its modification$ "hich is performed "ith allergens also kno"n to elicit

immediate-type hypersensitiity reactions@$8$. In the diagnosis of food allergy$

A:T can increase the diagnostic #enefit of <:T and>or specific Ig' measurement$

een if it is often necessary to erify results #y a dou#le-#lind$ place#o-controlledfood challenge <ensitiity and specificity of A:T aries depending on the type of

food allergen@$8 In this paper$ it has #een reported a case of atopic dermatitis in

adult that has #een treated "ith moisturi%er$ topical corticosteroid$ sistemic

antihistamin and "ere done skin prick test and atopy patch test to identified

triggering factors

2



CA<' R':ORT

A &. years old girl came to dermatoenereology outpatient clinic at dr

<aiful An"ar *eneral 1ospital on <eptem#er &?th 0&/$ "ith chief complaint red

patches on #oth of her arms and legs and also itchy mostly at night since = "eeks

#efore admission and got "orse in the last = days irstly$ it appeared like small

red pimples and felt itch on her #oth arms and started to spread on her #oth legs

<he said that it happened after she ate meat#alls and tongkol fish = "eeks ago

<he keep scratching it all day long #ut the itch got "orsen at night <he appliedinerson on the itch part of her #ody #ut not regularly and sho"ed no

improement

rom the history of the past illness$ she had the same symptoms like this

since she "as a child (the patient forgot "hen e6cactly) <ometimes got #etter #y

it self #ut sometimes she has to go to general practitioners (*:) to get some

medication The *: said that she had allergies <he usually use inersonB and

olie oil for her o"n medication #ut not regularly The redness patch sometimes

dissapear #ut sometimes not According to the patient$ the itch #egan to appeared

eerytime she eats meat#all and tongkol fish$ that is "hy she tried to aoid it <he

also felt itch and had runny nose or snee%ing eerytime she helps her mother to

clean the house or "hen the "eather is cold ut if she has runny nose or snee%ing

in the morning$ it "ill #ecome seldom or gone if she "ears "arm cloth or "hen

it4s already noon <he used to had "heals "hen she "as a child and appeared

"hen the "eather is cold ut she neer e6perienced it again since she "as in 7unior high school <he had "hite and dry patches on her face "hen she "as a

child$ sometimes she had it no" #ut not as often as "hen she "as a child

(tratak4en) <ometimes she had itch on #oth of her eyes and only fe" times on her

nipples <he "as the third and the last child

3



rom family history of atopy$ her mother has the same ec%ema on #oth of

her arms and legs <he usually felt it "hen the "eather is cold 1er first #rother

has the same ec%ema 1er second sister has asthma ut all of her si#ling already

married and lie "ith their o"n family

In patient daily enironment$ the patient use cotton mattres #ut not cleaned

eery month$ only change the sheeth eery "eeks <he use dettolB soap for

eeryday usage 1er skin is ery dry #ut she uses hand and #ody lotion t"ice

daily <he sleeps on a #ed #unk 1er father hae pets like some chickens and

#irds There are a lot of "ild cats "andering arround her house and sometimessleeps on her doormat or on her kitchen <he "orks as a administration on an

electricity housing supplier "arehouse in alang <he "orks from 8 am until /

pm eeryday e6cept on <unday

rom dermatological e6amination$ on her face sho"ed no perior#ital

darkening (igure &A) On her trunk$ upper right arm$ upper and lo"er left arm$

upper and lo"er legs$ sho"ed multiple hyperpigmented patches "ith ill defined

#order$ irregular shape$ aried in si%es (igure &$ D$ $ *$ 1$ I) On her right

lo"er arms sho"ed multiple erythematous papules "ith ill defined #order$ round

shape$ si%e E -=mm (igure &') On her dorsal feet sho"ed multipleϕ

hyperpigmented pla!ue "ith "ell defined #order$ "ell defined$ aried in si%es$

some coered "ith "hite-yello"ish rough scale (igure &F)

4



igure & A There "ere no perior#ital darkening$ face palor$ Dannie organ fold nor pityriasis

al#a

igure & On her trunk and her #ack <ho"ed multiple hyperpigmented patches "ith ill defined #order$ irregular shape$ aried in si%es (green arro") C No lession

5

1A

1B 1C



igure & orm her left upper and lo"er arm D <ho"ed multiple hyperpigmented patches "ith illdefined #order$ irregular shape$ aried in si%es (green arro") ' <ho"ed erythematous papules$

multiple$ round shape$"ith ill defined #order$ si%e E -=mm (green arro")ϕ

igure & On her left upper and lo"er arm <ho"ed multiple hyperpigmented patches "ithirregular shape$ aried in si%es$ ill defined #order (green arro") * <ho"ed multiple

hyperpigmented patches "ith irregular shape$ aried in si%es$ ill defined #order (green arro")

6

1E1D

1 1G



igure & On her #oth upper and lo"er legs 1 <ho"ed multiple hyperpigmented papules "ith illdifined #order$ round shape$ aried in si%es I <ho"ed multiple hyperpigmented macules "ith ill

defined #order$ irregular shape$ and aried in si%es

igure & On her dorsal feet F <ho"ed multiple hyperpigmented pla!ue "ith defined #order$aried in si%es$ some coered "ith "hite-yello"ish rough scale

7

1H 1I

1J



igure & On her hands 2 G H <ho"ed no lession

rom general e6amination$ the patient "as compos mentis and looks "ell

her #lood pressure "as &0>80 mm1*$ pulse rate 806>mnt$ respiratory rate

06>mnt$ and her a6ilar temperature =@$= C 1er Ig' serum leel "as eleated

(&&. IU>mH)

The patient "as diagnosed as AD$ made clinicaly #ased on history taking

and physical e6amination rom 1anifin and Ra7ka criteria$ on ma7or sign "ere

found pruritus$ typical morphology and distri#ution$ tendency to"ard chronic or

chronically relapsing dermatitis$ personal or family history of atopic disease J

asthma$ allergic rhinitis$ AD On minor sign "as found drynes on her skin$

eleated serum immunoglo#ulin '$ early age onset$ tendency to"ard non spesific

hand or foot dermatitis$ history of nipple ec%ema$ recurrent con7unctiitis$

pityriasis al#a and food intolerance 1er <CORAD "as /$. and include

moderate AD

Ta#le & <CORAD or score for AD

Spread (K) (K) (K) (K) (K) (K) Total

ront ace 0 Upper

torso 0

Arm right

and left 0

*ene

Talia

0

Heg right n

left &8

Ho"er torso

ack 1ead 0 Upper

torso 0

Arm right

and left .

Heg right n

left &8

Ho"er torso

;.>/

Intensity ---------- -------- --------- ---------- ---------- -------------

'rythe

ma &

'dema 0 Oo%ing 0 '6coria

tion &

Hichenificat

ion &

Lerosis

@/>

Subjective

sign

---------- -------- --------- ---------- --------- -------------

:ruritus

@

Insomnia @

8

11



Total score /$.

The patient "as gien moisturi%er cream$ deso6ymethasone ointment

t"ice daily$ loratadine &0 mg once daily$ also education a#out the disease$ ho" to

maintain the moisture of the skin$ and ho" to aoid the triggers so the patient can

make the e6acer#ation less happen The patient came #ack after &; days for the

follo" up and sho"ed "ith a good result 1er <CORAD score "as ; categori%ed

as mild AD

igure A G ollo" up after &; days There "ere no lession

9

22

2D2C



igure C G D ollo" up after &; days On the trunk and #ack sho"ed multiple hyperpigmented

patches "ith irregular shape$ aried in si%es$ ill defined #order

igure ' and ollo" up after &; days On the #oth legs sho"ed multiple hyperpigmented patches "ith irregular shape$ aried in si%es$ ill defined #order

igure * ollo" up after &; days The lession #efore "as gone Dryness (M)

The patient "as educated to identify the triggering factor of her disease #y

doing skin prick test and atopy patch test irstly$ she "as e6plained a#out the

procedure$ the function of the test$ and also the side effect that might could

happend during or after the test :atient "as told not to drink any drugs that can

decrease the prutitus such as loratadin$ cold or flue medication that sold on oer

10

22

2



the counter store$ and the patient didn4t take any oral corticosteroid Also there

"asn4t any flare during the test$ or else the test can4t #e done ecause the patient

"as under & years old and didn4t accompanied #y her mother$ then she "as told

to come#ack later again "ith her mother for hospital policy on signing informed

concent On Decem#er &;th 0&/$ she came to do the skin prick test irst "e

make sure that the ollar area "ere free from any lession$ the patient didn4t hae

any flares and did all the instruction #efore After that the mother4s patient signed

an informed concent for skin prick test

irstly "e do the dermographism in the patient and if the result "asnegatie then "e can do the skin prick test (igure =) Then "e do the aseptic on

the upper right arm near the ollar area using alchohol and dra" & for histamin

dihydrocloride (&mg>mH) as a positie control$ for coca as a negatie control

9e put a drop of histamin using the cap of the steril lancet and use the steril lancet

to prick the droplet & mm into the skin "ithout any #leeding 9e do the same "ith

coca as a negatie control After &/ minutes there "ill #e reaction on num#er &

"hich as a positie control it "ill appeared as a "heal$ in this case the "heal

diameters "as ;$80 mm (MMM) and the negatie control didn4t appear at allϕ

(igure ;A and ;)

igure = Dermographism (green circle) ;A Num#er & "as histamin dihydrochloride (&mg>mH)

(green arro") and num#er "as coca (red arro") ; After &/ minutes appeared "heal onnum#er &"ith ;$80mm (red arro")ϕ

11

443



After that$ "e continued "ith other allergen e6tracts such as dog4s hair

(num#er ;)$ chicken feather (num#er /)$ house dust (num#er ?)$ ra" cotton

(kapuk) (num#er @)$ yeast (ragi) (num#er 8)$ mullet fish (ikan #andeng) (num#er

.)$ pindang fish (num#er &0)$ cra# (num#er &&)$ "heat flour (num#er &)$ co"4s

meat (num#er &=)$ chocolate (num#er &;)$ co# fish (ikan tongkol) (num#er &/)$

pinapple (num#er &?)$ #anana (num#er &@)$ peanuts (num#er &8)$ co"4s milk

(num#er &.)$ chicken4s meat (num#er 0)$ shrimp (num#er &)$ orange (num#er

)$ chicken egg "hites (num#er =)$ chicken egg yolk (num#er ;)$ duck egg

"hite (num#er /)$ duck egg yolk (num#er ?)$ goat4s meat (num#er @)$ tempe

(num#er 8)$ and papaya (num#er .) 9ith the same techni!ue "e use all

alergens on the patient4s right and left fore arm After &/ minutes the reaction can

#e seen and interperated rom all alergens only house dust mite (num#er ?) "as

positie "ith diameter ;$?/ mm (MM) On cra# allergen e6tract (num#er &&) alsoϕ

appeared "heal "ith diameters $ mm #ut not consider as a positie reactionϕ

12



13



igure ;C dra"n on ollar area for preperation of allergen e6tract prick test D G ' A drop

different allergen "as gien and pricked on eery num#er <ho"ed "heal on num#er ? ( ;$?/ϕ

mm)(red arro" and red circle) and && ( $ mm) after &/ minutes * <ho"ed no "healϕ

After skin prick test "as done$ the patient came #ack on Decem#er &?th 0&/

to do the atopy patch test irstly "e make sure that the #ack area "ere free from

any lession$ the patient didn4t hae any flares and did all the instruction #efore

The patient "ere e6plained once again a#out the function of the test$ the

procedures$ and the side effect that could happen during or after the test After that

the patient agreed and signed an informed concent for atopy patch test 9e do the

asepsis on the #ack of the patient using alchohol s"a# y using the prick skin

allergens "e applied it on the finn cham#er "ith si%e 8 mm "ith a filter paper in

it$ then aplied it on the patient #ack using "hite tape 9e identified eery alergens

and "rite it on the "hite tape "ith num#ers la#el according to the num#ers that

"ritten on the skin prick test allergens (igure /A G /)

14

44

444



igure /A <ho"ed the #ack of the patient "ere clear from any lession / The finn cham#ers"ere apllied on the #ack "ith the "hite tape after applying prick test allergens and then la#elled #y

the se!uence num#er of prick allergens

After la#elled #y the the se!unce num#er of prick allergens$ "e apllied

another "hite tape to ensure that the finn cham#ers "ere sttached firmly to the

patient #ack (igure /C) 9e educated the patient to did not do actiities that are

too heay that could make her s"eats too much 9e also told the patient not to

drink any medication$ not to applied anything that can make the tape came off$

and if she felt itch it means that the allergens are giing reaction #ut if it she felt

#urning sensation or pain sensation then she can take off the "hite tape The

reading of the A:T reactions are read after ;8$ and @ hours

igure /C The atopy patch test "ere applied "ith another "hite tape to ensure the finn cham#er attached firmly

15

5B5A

5



After ;8 hours "e took off the "hite tape and all of the fin cham#ers to see

the reaction The reading started &/ minutes after "e took off the atopy patch On

the left part "ere seen no reaction on the control "hich is coca (num#er ) and

erythematous papules on histamin allergen (num#er &) "ith interpretation MM

Also seen erythematous papules on num#er ; (dog4s hair)$ num#er ? (house dust)$

num#er &0 (pindang fish)$ and num#er & ("heat flour) (figure /D and /')

igure /D G ' :ositie MM on num#er &$ ;$ ?$ &0$ & <ho"ed fe" erithematous papules (redarro")

On the right side of the #ack seen fe" erithematous papules on num#er &8

(peanuts)$ &. (co"4s milk)$ & (shrimp)$ (orange)$ @ (goat4s meat)$ and 8

(tempe) "ith interpretation "ere MM (igure / and /*)

16

5 5E



igure / G * :ositie MM on num#er &8$ &.$ &$ $ @$8 <ho"ed fe" erithematous papules(red arro")

After @ hours$ the reading only seen on num#er &$ ;$ ?$ $8 "ith some

erithematous papules and the interpretation "as MMM Num#er and @ sho"ed

less papules and erythema$ the interpretation "as M (igure /1 and /I)

igure /1 G /I <ho"ed many spreading erythematous papules on num#er &$ ;$ ?$ and 8$interpretation MMM and num#er @ interpretation M (red arro")

17

5

5

5I5



The patient "as educated a#out the positie findings on prick test and

atopy patch test <he also told to aoid the trigering factors that already kno"n

from the tests such as dog4s hair$ house dust$ and tempe

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Ta#le Result of <:T and A:T

No Allergens A:T ;8 hr A:T @ hr <:T

& 1istamin &mg>mH MM MMM MMM(;$80mm)

Coca (control) - - -

; dog4s hair $/ mg>ml MM MMM -

/ chicken feather $/ mg>ml - - -

? house dust / mg>ml MM MMM MM(;$?/mm)

@ ra" cotton / mg>ml - - -

8 east & mg>ml - - -

. mullet fish (#andeng) mg>ml - - -

&0 pindang fish mg>ml MM - -

&& Cra# mg>ml - - -

& "heat flour & mg>ml MM - -

&= co"4s meat mg>ml - - -

&; chocolate & mg>ml - - -

&/ co# fish (tongkol) mg>ml - - -

&? :inapple & mg>ml - - -

&@ anana & mg>ml - - -&8 :eanuts & mg>ml - - -

&. Co"4s milk & mg>ml - - -

0 chicken4s meat mg>ml - - -

& shrimp mg>ml - - -

Orange - M -

= chicken egg "hites & mg>ml - - -

; chicken egg yolk & mg>ml - - -

/ duck egg "hite & mg>ml - - -

? duck egg yolk & mg>ml - - -

@ goat4s meat mg>ml - M -

8 tempe & mg>ml - MMM -

. :apaya & mg>ml - - -

DI<CU<<ION

The appearance of the indiidual skin lesion in AD does not differ from

other ec%emas such as contact ec%ema In its acute form$ ec%ema is characteri%ed

#y a liely red infiltrate "ith oedema$ esicles$ oo%ing$ and crusting5

lichenification$ e6coriations$ papules$ and nodules dominate the su#acute and

chronic form Accordingly$ the diagnostic approach #uilds upon other

characteristics such as the distri#ution of the ec%ema as "ell as associated features

of the patient The typical patient "ith AD is a person "ith an early onset of itchy

ec%ema localised at typical sites such as the fle6ures of the el#o"s and knees in an

atopic patient or in a person "ith a familial predisposition to atopic disease The

most "idely used diagnostic criteria for atopic dermatitis "ere deeloped #y

1anifin and Ra7ka in &.80 and "ere later reised #y the American Academy of

Dermatology (igure ?)&$

19



igure ? 1anifin Ra7ka criteria for AD

In this case the patient "as diagnosed as AD$ made clinicaly #ased on

history taking and physical e6amination rom 1anifin and Ra7ka criteria$ on

ma7or sign "ere found pruritus$ typical morphology and distri#ution$ tendency

to"ard chronic or chronically relapsing dermatitis$ personal or family history of

atopic disease J asthma$ allergic rhinitis$ AD On minor sign "as found dryness on

her skin$ eleated serum immunoglo#ulin '$ early age onset$ tendency to"ard non

specific hand or foot dermatitis$ history of nipple ec%ema$ recurrent con7unctiitis$

pityriasis al#a and food intolerance

Ha#oratory testing is not needed in the routine ealuation and treatment of

uncomplicated AD <erum Ig' leels are eleated in appro6imately @080K of

AD patients& This is associated "ith sensiti%ation against inhalant and food

allergens and>or concomitant allergic rhinitis and asthma In contrast$ 0=0K of

AD patients hae normal serum Ig' leels This su#type of AD has a lack of Ig'

sensiti%ation against inhalant or food allergens 1o"eer$ some of these patients

may possess Ig' sensiti%ation against micro#ial antigens such as S. aureus to6ins$

and Candida albicans or Malassezia sympodialis can #e detected As "ell$ some

of these patients sho" positie reactions using the atopy patch test despite

negatie immediate skin tests& 9e measure the patient Ig' leel #y #lood test and

sho"ed high Ig' leel "hich is &&. UI>ml

20



Atopic Dermatitis (AD) is not cura#le$ and many patients "ill e6perience a

chronic course of the disease Accordingly$ the treatment of AD aims to minimi%e

the num#er of e6acer#ations of the disease$ so-called flares$ second$ reduce the

duration and degree of the flare$ if flare occurs The first aim relates primarily to

preention5 the second aim relates to treatment :reention is #est attained #y

trying to reduce the dryness of the skin$ primarily ia daily use of skin

moisturi%ing creams or emollients along "ith aoidance of specific and unspecific

irritants such as allergens and noncotton clothing 9hen dryness is reduced$ the

desire to scratch "ill lessen and the risk of skin infection "ill decrease Aoiding

long$ hot #aths further preents skin dryness$#ut "hen a #ath is taken$ an

emollient should #e applied directly after it to secure a moist epidermis and

augment the skin #arrier function&$

Reducing the flare is "arranted "hen actual ec%ema occurs or "hen mild

intermittent ec%ema "orsens anagement of an ec%ema e6acer#ation re!uires

medical treatment often in the form of corticosteroid creams Topical

corticosteroids are the mainstay of the treatment for moderate to seere AD$ #oth

in children and adults ost patients #enefit from treatment "ith mild to moderate

corticosteroid preparations$ "hereas only a small su#set those "ith seere disease

needs potent preparations5 ery strong preparations are rarely needed ild and

moderate corticosteroid creams are resered for children$ "hile adults can #e

treated "ith stronger preparations In this case "e gae emolient to the patient$

due to dryness of her skin and #ecause the outcome of these patients <CORAD

are moderate leel$ then "e gie a moderate potency corticosteroid preparations

Oral antihistamines are recommended for itching #ut hae no effect on the

actiity of the ec%ema Non-sedating antihistamines should #e used$ #ut "hen

night-time itching interferes "ith sleep$ sedating antihistamines are

recommended In this case "e use loratadin due to the the patient4s heay

actiity

<coring Atopic Dermatitis (<CORAD) is a clinical tool used to assess the

e6tent and seerity of ec%ema Dermatologists may use this tool #efore and after

21



treatment to determine "hether the treatment has #een effectie The scoring

include = measuring irst is area to determine e6tent$ the sites affected #y ec%ema

are shaded on a dra"ing of a #ody The rule of . is used to calculate the affected

area (A) as a percentage of the "hole #ody <econd is intensity$ A representatie

area of ec%ema is selected In this area$ the intensity of each of the follo"ing signs

is assessed as none (0)$ mild (&)$ moderate () or seere (=)

• Redness

• <"elling

• Oo%ing > crusting

• <cratch marks

• <kin thickening (lichenification)

• Dryness (this is assessed in an area "here there is no inflammation)

The intensity scores are added together to gie PP (ma6imum &8) And the third is

su#7ectie symptoms ie$ itch and sleeplessness$ are each scored #y the patient or

relatie using a isual analogue scale "here 0 is no itch (or no sleeplessness) and

&0 is the "orst imagina#le itch (or sleeplessness) These scores are added to gie

PCP (ma6imum 0)= In this case "e measure the <CORAD "ith result /$. and

categori%ed as moderate atopic dermatitis

The prick test is usually the most conenient test method for detecting

immunoglo#ulin ' (Ig')-mediated allergy/ <eeral re!uirements are adocated to

reach an ideal prick test <ome of them are controling the efect of medication

Antihistamines of the so-called third generation$ e6tensiely used no"adays$

a#olish the immediate reactiity of the skin usually for &= days This concerns

cetiri%ine$ loratadine$ fe6ofenadine$ e#astine$ mi%olastine$ and the ne"comers

desloratadine and leocetiri%ine :rick testing can #e performed = days after

stopping treatment Honger "ash-out periods are needed "ith ketotifen (&/ days)

and astemi%ole (; "eeks) Oral methylprednisolone more than 8 mg daily and

22



e!uialent doses of other corticosteroids may also "eaken the immediate

reactiity of the skin Other drugs such as non-steroidal anti-inflammatory drugs

as "ell as topical application of corticosteroids do not affect prick test results

significantly/ In this case "e educated the patient to aoid ussage of antihistamin

drugs$ cold or flue medication that sold on oer the counter store$ and the patient

didn4t take any oral corticosteroid

Harge num#ers of commercial prick test allergens are aaila#le5 self-made

allergens can also #e used Drops of allergen solutions are applied to the olar

aspect of the forearm or to the upper part of the #ack The fle6ures of the el#o"smust #e aoided$ #ecause this may gie rise to not easily reada#le reactions$ either

positie or negatie Other skin sites are not conenient as "ell An important

point concerns the distance #et"een the indiidual prick tests These are applied

ideally =/ cm apart to aoid oerlapping of reactions at reading If such a

distance is not respected$ difficulties in correct reading are o#ious and no definite

conclusions can #e dra"n This mistake in technology happens too often$ een

among "ell-trained clinicians 9hen drops of allergen solutions are applied to the

skin$ they are pierced "ith a special lancet Aller#iopoint is a stainless steel lancet

(lengthJ && mm5 penetration angle ;/Q5 presenting itself as a #lister of ten sterile

disposa#le lancets) :uncture is made #y gentle pressure5 some authors$ "hen

puncturing$ e6ert a slight rotation moement to ensure #etter penetration of the

allergen No #leeding may occur/

23



igure @ :rick testing (a) :rick test lancets5 (#) :ositie prick test to late6J positie and negatiecontrols?

:rick testing of allergens needs the concomitant use of controls$ positie and

negatie 1istamine chlorhydrate solution (&-&0 mg>ml) to measure direct

reactiity to histamine <aline and>or the ehicle of the allergens is used as a

negatie control/ In this case "e use histamin & mg>ml as a positie control and

coca as a negatie control

After &/ min$ the allergen and control droplets are "iped off "ith soft

paper tissue Conentional time reading is &/0 min$ as "e are ealuating an

immunological immediatetype & reaction Reading prick test reactions needs

careful ealuation and interpretation$ taking into account seeral parameters of

prime importance The negatie control ought to #e negatie5 if positie$ it raises

!uestions a#out the reading of allergen prick tests Its main interest is therefore to

detect false-positie reactions/ In this case the coca4s reading "as negatie and

the histamin4s reading "as positie (MMM)

Reading and interprating prick test should #e measure carefully These are

some parameters that should #e notice on reading prick testJ

24



9heal and flare reactions to positie controls$ "hich appear around the piercing

usually in minutes$ are measured in terms of diameters and surface areas

Allergen prick test results are usually e6pressed as the mean of the longest

diameter of the "heal and the largest diameter perpendicular to it

Reactions greater than = mm and at least half of that produced #y histamine are

regarded as positie Reactions smaller than those produced #y histamine may not

#e clinically significant

If the patient has dermographism (factitious urticaria)$ skin piercing produces

usually small (& mm) "heals$ "hich may make the interpretation of the results

ery difficult/

There is a clear-cut difference in terms of readings #et"een patch testing

and prick testing :atch testing is a codified procedure that does not imply any

control$ "hereas prick testing is inaria#ly su#mitted to controls either positie or

negatie in order to achiee correct interpretation of the results The final goal in

prick testing is to assess (either past or current) the releance The practical means

to conclude +likely$, +possi#le$, +dou#tful$, or +not traced, releance/ In this

case the result "as positie MM on house dust #ecouse the diameter "as more than

= mm or at least more than half of the positie control (;$80mm) "hich is

;$?/mm

Atopic patch test (A:T) can #e used as a diagnostic tool in characteri%ing

patients "ith allergen triggered AD@$8$. <hankar 2$ Chakraarthi studied a#out

A:T using prick test allergens in aluminium patch test cham#ers8 The antigens

are loaded in aluminium patch test cham#ers "ith filter paper using the dropper

proided #y the manufacturer A drop from the dropper "as appro6imately &>&?

ml The test site "as upper #ack The antigens used "ere dust mitesJ D. farinae,

D. pteronyssinus$ pollens of Cynodon dactylon and Parthenium hysterophorus$

foods like rice$ "heat$ milk$ egg and dog and cat epithelia8 The reading "as taken

after ;8 and @ hours and interpretation and *rading of A:T reaction "as done

according to the guidelines #y 'uropean task force on AD consensus (igure

25



8)@$8$. After ;8 hours$ "ere seen erythematous papules on num#er ; (dog4s hair)$

num#er ? (house dust)$ num#er &0 (pindang fish)$ and num#er & ("heat flour)

And also after @ hours$ the reading only seen on num#er &$ ;$ ?$ $8 "ith some

erithematous papules and the interpretation "as MMM Num#er and @ the

interpretation "as M

igure 8 *rading A:T reactions@

inn Cham#er is a round aluminum patch test deice "hich proides good

occlusion #ecause of the cham#er design The 8 mm inner diameter proides a /0

mm area and a#out 0 SH olume The outer diameter is && mm and the distance

#et"een the cham#ers is 0 mm Apart from standard 8 mm (inner diameter) inn

Cham#ersB$ large & mm (inner diameter) inn Cham#ers can #e purchased (00

strips of one cham#er) These are of special interest "hen using the A:T or

li!uid allergens$ place a filter paper disk in the cham#er$ and apply one drop of

li!uid$ 7ust sufficient to soak the disk :etrolatum patches can #e made up a fe"

hours in adance5 li!uid patches should #e made up at the last minute ? In this case

"e use finn cham#er 8 mm si%e due to lack of the si%e & mm 9e also use filter

paper disk to apply the allergens and immediately applied to the #ack area

Dust mites are considered to #e the most important triggering agent for AD

In a study conducted in Croaotia #y 2ul7anac et al, on Dermatophagoides

pteronyssinus "ith A:T and concluded that A:T may detect the trigger factor in

AD patients@ According to Tur7amaa et al$ and "erfel et all$ among the allergens

26



found to #e releant in atopic ec%ema$ food allergens (mostly in children) and

aeroallergens are the most important&0$&& 'nironmental su#stances like

aeroallergens produce flares in some patients "ith atopic ec%ema oreoer

aeroallergen aoidance$ especially "ith regard to house dust mites$ can result in

marked improement of skin lesions An epicutaneous patch test$ A:T$ "ith type &

allergens kno"n to elicit Ig'-mediated reactions$ and the ealuation of

ec%ematous skin lesions after ;@ h can #e used as a diagnostic tool in

characteri%ing patients "ith aeroallergen and food-triggered A' Atopy patch

testing (A:T) has #een inestigated as a potential tool to identify foods "hich

may cause late-type symptoms such as e6acer#ation of AD&

Another study done #y irosla Necas$ a#out A:T using aeroallergen

prick testing$ using histamin &0mg>ml as a positie control and salone solution as

a negatie control The allergens "ere applied to the patients4 #acks during the

remission of atopic dermatitis The first reading "as made after ;8 hours and the

second after @ hours The ealuation of the reactions "as made according to the

'TAD group recommendations$ sho"ed the most common allergen "ere house

dust mite allergens (&8K)$ follo"ed #y grass and plant pollen (&0;K) and dog

allergens (8K)&= rom this case$ positie result on hause dust found on #oth test$

<:T and A:T eside that$ it has positie result on dog4s hair allergen and tempe

(MMM) and "eak reasult on orange (M)

27



<UAR

9e reported a case of a &. years old girl "ith atopic dermatitis "ho

presented #y chief complaint red patches on #oth of her arms and legs since =

"eeks ago and got "orse in the last = days rom history taking and clinical

appearence fit to hanifin and ra7ka criteria for atopic dermatitis <CORAD "as

used as seerity score "ith the alue of /$. The therapy "as gien$ emolient$

deso6ymethasone ointment t"ice daily$ loratadine &0 mg once daily$ also

education a#out the disease The patient is also done skin prick test and atopy

patch test to identify the triggering factors of her disease The result of the <:T"as house dust mite (MM) and also for the A:T are positie on dog4s hair$ house

dust$ and tempe :atient then aducated a#out the result and to aoid the triggerring

factors

28



R''R'NC'<

& Heung $ 'ichenfield H$G ogunie"ic% AD (Atopic 'c%ema) In J

it%patrick4s Dermatology In *eneral edicine$ 8th edition$ edited #y

*oldsmith HA$ 2at% <I$ *ilchrest A$ :aller A<$ Heffel DF$ and 9olff 2$

0&5 p &?/-&8

Thomsen < ADJ Natural 1istory$ Diagnosis$ and Treatment ISRN llergy$

0&;$ article ID =/;/0 pJ &-@

3. Hiska $ *utoa $ :an%ner :$ rodska : The Clinical Releance of

arious 1ypersensitiity Tests in :atients "ith AD as Assessed #y Their

1istory$ <CORAD Changes$ and Num#er of Days "ith Need of Anti-

Inflammatory Treatment Pediatric llergy, Immunology, nd Pulmonology0&/5 8 ()J pJ8@-.&

; 1anifin F$ Thurston $ Omoto $ Cherill R$et all$ The ec%ema area and

seerity inde6 ('A<I)J assessment of relia#ility in AD$ !"perimental

Dermatology$ 00& ol &0$ no &$ pp &&&8

/ Hachapelle F$ ai#ach I1 The etodology Of Open (Non-:rick) Testing$

:rick Testing$ And It4s ariants In J :atch Testing And :rick Testing$ A

:ractical *uide$ nd edition$ edited #y Hachapelle F$ ai#ach I1$ 00.5

pJ&;&-/&

? Hachapelle F$ ai#ach I1 :atch Testing etodology In J :atch Testing

And :rick Testing$ A :ractical *uide$ nd edition$ edited #y Hachapelle F$

ai#ach I1$ 00.5 pJ==-?@

@ Darso" U$ Ring F The Atopy :atch Test In AD InJ :atch Testing And :rick

Testing$ A :ractical *uide$ nd edition$ edited #y Hachapelle F$ ai#ach

I1$ 00.5 pJ &&-?

8 <hankar 2$ Chakraarthi Atopic :atch testing Indian # Dermatol

$enereol %eprol $ 0085 pJ;?@-@0

. Cudo"ska $ 2ac%marski Atopy :atch Test In The Diagnosis Of ood

Allergy In Children 9ith Atopic 'c%ema Dermatitis <yndrome Roczni&i

&ademii Medyczne' ( )ialymsto&u.00/5pJ ?&- ?@

&0 Tur7anmaa 2$ Darso" U$ Niggemann= $ Ranc 2$ anto/ T$ 9erfel? T

:resent status of the atopy patch test Allergy 00?J ?&J &=@@&=8;

&& 9erfel T$ allmer-9e#er $ 'igenmann :A$ Niggemann $ Ranc $

Tur7anmaa $ 9orm 'c%ematous reactions to food in atopic ec%ema

Allergy 00@J ?J @=@8

& ToniV RF$ Hipo%eniV F Role and <ignificance of Atopy :atch Test cta

Dermatao*enerol Croat +-5&8(&)J=8-//

13. Necas Atopy :atch Testing "ith air#orne allergens cta

Dermato*enerologica 0&=5J=.-;

Documents

case report patch test