Patch test

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Patch test
Epikutanni-test.jpg
Patch test
Specialty Immunology, dermatology
MeSH D010328

A patch test is a diagnostic method used to determine which specific substances cause allergic inflammation of a patient's skin.

Contents

Patch testing helps identify which substances may be causing a delayed-type allergic reaction in a patient and may identify allergens not identified by blood testing or skin prick testing. It is intended to produce a local allergic reaction on a small area of the patient's back, where the diluted chemicals were planted.

The chemicals included in the patch test kit are the offenders in approximately 85–90 percent of contact allergic eczema and include chemicals present in metals (e.g., nickel), rubber, leather, formaldehyde, lanolin, fragrance, toiletries, hair dyes, medicine, pharmaceutical items, food, drink, preservative, and other additives.

Mechanism

A patch test relies on the principle of a type IV hypersensitivity reaction.

The first step in becoming allergic is sensitization. When skin is exposed to an allergen, the antigen-presenting cells (APCs) – also known as Langerhans cell or Dermal Dendritic Cell – phagocytize the substance, break it down to smaller components and present them on their surface bound major histocompatibility complex type two (MHC-II) molecules. The APC then travels to a lymph node, where it presents the displayed allergen to a CD4+ T-cell, or T-helper cell. The T-cell undergoes clonal expansion and some clones of the newly formed antigen specific sensitized T-cells travel back to the site of antigen exposure. [1] [2]

When the skin is again exposed to the antigen, the memory t-cells in the skin recognize the antigen and produce cytokines (chemical signals), which cause more T-cells to migrate from blood vessels. This starts a complex immune cascade leading to skin inflammation, itching, and the typical rash of contact dermatitis. In general, it takes 2–4 days for a response in patch testing to develop. The patch test is just induction of contact dermatitis in a small area. [3]

Process

Application of the patch tests takes about half an hour, though many times the overall appointment time is longer as the provider will take an extensive history. Tiny quantities of 25 to ~150 materials (allergens) in individual square plastic or round aluminium chambers are applied to the upper back. They are kept in place with special hypoallergenic adhesive tape. The patches stay in place undisturbed for at least 48 hours. Vigorous exercise or stretching may disrupt the test. At the second appointment, usually, 48 hours later, the patches are removed. Sometimes additional patches are applied. The back is marked with an indelible black felt tip pen or another suitable marker to identify the test sites, and a preliminary reading is done. These marks must be visible at the third appointment, usually 24–48 hours later (72–96 hours after application). In some cases, reading at 7 days may be requested, especially if a special metal series is tested.[ citation needed ]

Patch Testing for cosmetic and skincare products can be broken down into a variety of different categories, including the following: [4]

Interpretation of results

The dermatologist or allergist will complete a record form at the second and third appointments (usually 48 and 72/96 hour readings). The result for each test site is recorded. One system used is as follows:

Weak positive 1+ reaction.jpg
Weak positive
Strong positive 2+ reaction.jpg
Strong positive

Irritant reactions include miliaria (sweat rash), follicular pustules, and burn-like reactions. Uncertain reactions refer to a pink area under the test chamber. Weak positives are slightly elevated pink or red plaques, usually with mild vesiculation. Strong positives are 'papulovesicles' and extreme reactions have spreading redness, severe itching, and blisters or ulcers.

Relevance is determined by exposure to the positive allergen, and is rated as definite, probable, possible, past, or unknown. For an allergen to have definite relevance, the product the patient is exposed to must be tested and also be positive in addition to the test allergen. Probable would be used to describe a positive allergen ingredient which is in a product the patient uses (i.e., quaternium-15 listed in a moisturizing cream used on the sites of dermatitis). Interpretation of the results requires considerable experience and training. A positive patch test might not explain the present skin problem, since the test only indicates that the individual became allergic during encounters with that chemical at some point in their life. Relevance, therefore, has to be established by determining the causal relationship between the positive test and eczema. The confirmation of relevance will occur after the patient has avoided exposure to the chemical and after they have noticed that the improvement or clearance of their dermatitis is directly related to this avoidance. This outcome usually occurs within four to six weeks after stopping the exposure to the chemical.

If all patch tests are negative, the allergic reaction is probably not due to an allergic reaction to a contactant. It is possible, however, that the patient was not tested for other chemicals that can produce allergic reactions on rare occasions. If the suspicion is high in spite of negative patch testing, further investigation might be required.

Common allergens

The top allergens from 2005–06 were: nickel sulfate (19.0%), Myroxylon pereirae (Balsam of Peru, 11.9%), fragrance mix I (11.5%), quaternium-15 (10.3%), neomycin (10.0%), bacitracin (9.2%), formaldehyde (9.0%), cobalt chloride (8.4%), methyldibromoglutaronitrile/phenoxyethanol (5.8%), p-phenylenediamine (5.0%), potassium dichromate (4.8%), carba mix (3.9%), thiuram mix (3.9%), diazolidinyl urea (3.7%), and 2-bromo-2-nitropropane-1,3-diol (3.4%). [5]

The most frequent allergen recorded in many research studies around the world is nickel. Nickel allergy is more prevalent in young women and is especially associated with ear piercing or any nickel-containing watch, belt, zipper, or jewelry. Other common allergens are surveyed in North America by the North American Contact Dermatitis Group (NACDG). [5]

Food allergy

Dermatologists may refer a patient with a suspected food allergy for patch testing. [6] Foods identified by blood testing or skin prick testing may or may not overlap with foods identified by patch testing. [6]

Certain food additives and flavorings can cause allergic reactions around and in the mouth, around the anus and vulva as food allergens pass out of the body, or cause a widespread rash on the skin. Allergens such as nickel, Balsam of Peru, parabens, sodium benzoate, or cinnamaldehyde may worsen or cause skin rashes.

Foods that cause urticaria (hives) or anaphylaxis (such as peanuts) cause a type I hypersensitivity reaction whereby the part of the food molecule is directly recognized by cells close to the skin, called mast cells. Mast cells have antibodies on their surface called immunoglobulin E (IgE). These act as receptors, and if they recognize the allergen, they release their contents, causing an immediate allergic reaction. Type I reactions like anaphylaxis are immediate and do not take 2 to 4 days to appear.

In a study of patients with chronic hives who were patch tested, those who were found allergic and avoided all contact with their allergen, including dietary intake, stopped having hives. Those who started eating their allergen again had recurrence of their hives. [7]

See also

Related Research Articles

<span class="mw-page-title-main">Allergy</span> Immune system response to a substance that most people tolerate well

Allergies, also known as allergic diseases, are various conditions caused by hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic dermatitis, allergic asthma, and anaphylaxis. Symptoms may include red eyes, an itchy rash, sneezing, coughing, a runny nose, shortness of breath, or swelling. Note that food intolerances and food poisoning are separate conditions.

<span class="mw-page-title-main">Dermatitis</span> Inflammation of the skin

Dermatitis is inflammation of the skin, typically characterized by itchiness, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become thickened. The area of skin involved can vary from small to covering the entire body. Dermatitis is often called eczema, and the difference between those terms is not standardized.

An allergen is a type of antigen that produces an abnormally vigorous immune response in which the immune system fights off a perceived threat that would otherwise be harmless to the body. Such reactions are called allergies.

<span class="mw-page-title-main">Food allergy</span> Hypersensitivity reaction to a food

A food allergy is an abnormal immune response to food. The symptoms of the allergic reaction may range from mild to severe. They may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. This typically occurs within minutes to several hours of exposure. When the symptoms are severe, it is known as anaphylaxis. A food intolerance and food poisoning are separate conditions, not due to an immune response.

<span class="mw-page-title-main">Contact dermatitis</span> Human disease

Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are not contagious or life-threatening, but can be very uncomfortable.

<span class="mw-page-title-main">Type I hypersensitivity</span> Type of allergic reaction

Type I hypersensitivity, in the Gell and Coombs classification of allergic reactions, is an allergic reaction provoked by re-exposure to a specific type of antigen referred to as an allergen. Type I is distinct from type II, type III and type IV hypersensitivities. The relevance of the Gell and Coombs classification of allergic reactions has been questioned in the modern-day understanding of allergy, and it has limited utility in clinical practice.

<span class="mw-page-title-main">Atopy</span> Predisposition towards allergy

Atopy is the tendency to produce an exaggerated immunoglobulin E (IgE) immune response to otherwise harmless substances in the environment. Allergic diseases are clinical manifestations of such inappropriate, atopic responses.

<span class="mw-page-title-main">Soy allergy</span> Type of food allergy caused by soy

Soy allergy is a type of food allergy. It is a hypersensitivity to ingesting compounds in soy, causing an overreaction of the immune system, typically with physical symptoms, such as gastrointestinal discomfort, respiratory distress, or a skin reaction. Soy is among the eight most common foods inducing allergic reactions in children and adults. It has a prevalence of about 0.3% in the general population.

<span class="mw-page-title-main">Allergic contact dermatitis</span> Medical condition

Allergic contact dermatitis (ACD) is a form of contact dermatitis that is the manifestation of an allergic response caused by contact with a substance; the other type being irritant contact dermatitis (ICD).

<span class="mw-page-title-main">Balsam of Peru</span> Type of tree balsam

Balsam of Peru or Peru balsam, also known and marketed by many other names, is a balsam derived from a tree known as Myroxylon balsamum var. pereirae; it is found in El Salvador, where it is an endemic species.

<span class="mw-page-title-main">Wheat allergy</span> Medical condition

Wheat allergy is an allergy to wheat which typically presents itself as a food allergy, but can also be a contact allergy resulting from occupational exposure. Like all allergies, wheat allergy involves immunoglobulin E and mast cell response. Typically the allergy is limited to the seed storage proteins of wheat. Some reactions are restricted to wheat proteins, while others can react across many varieties of seeds and other plant tissues. Wheat allergy is rare. Prevalence in adults was found to be 0.21% in a 2012 study in Japan.

<span class="mw-page-title-main">Skin allergy test</span> Allergy diagnosis

Skin allergy testing comprises a range of methods for medical diagnosis of allergies that attempts to provoke a small, controlled, allergic response.

MELISA is a blood test that detects type IV hypersensitivity to metals, chemicals, environmental toxins and molds. Type IV hypersensitivity reactions, particularly to nickel, are well established and may affect 20% of the population.

Allergy testing can help confirm or rule out allergies and consequently reduce adverse reactions and limit unnecessary avoidance and medications.

<span class="mw-page-title-main">Iodopropynyl butylcarbamate</span> Chemical compound

Iodopropynyl Butyl Carbamate (IPBC) is a water-soluble preservative used globally in the paints & coatings, wood preservatives, personal care, and cosmetics industries. IPBC is a member of the carbamate family of biocides. IPBC was invented in the 1970s and has a long history of effective use as an antifungal technology.

<span class="mw-page-title-main">Nickel allergy</span> Medical condition

Nickel allergy is any of several allergic conditions provoked by exposure to the chemical element nickel. Nickel allergy often takes the form of nickel allergic contact dermatitis (Ni-ACD), a form of allergic contact dermatitis (ACD). Ni-ACD typically causes a rash that is red and itchy and that may be bumpy or scaly. The main treatment for it is avoiding contact with nickel-releasing metals, such as inexpensive jewelry. Another form of nickel allergy is a systemic form: systemic nickel allergy syndrome (SNAS) can mimic some of the symptoms of irritable bowel syndrome (IBS) and also has a dermatologic component.

<span class="mw-page-title-main">Allergies in children</span> Medical condition

Allergies in children, an incidence which has increased over the last fifty years, are overreactions of the immune system often caused by foreign substances or genetics that may present themselves in different ways. There are multiple forms of testing, prevention, management, and treatment available if an allergy is present in a child. In some cases, it is possible for children to outgrow their allergies.

<span class="mw-page-title-main">Fish allergy</span> Type of food allergy caused by fish

Fish allergy is an immune hypersensitivity to proteins found in fish. Symptoms can be either rapid or gradual in onset. The latter can take hours to days to appear. The former may include anaphylaxis, a potentially life-threatening condition which requires treatment with epinephrine. Other presentations may include atopic dermatitis or inflammation of the esophagus. Fish is one of the eight common food allergens which are responsible for 90% of allergic reactions to foods: cow's milk, eggs, wheat, shellfish, peanuts, tree nuts, fish, and soy beans.

<span class="mw-page-title-main">Shellfish allergy</span> Type of food allergy caused by shellfish

Shellfish allergy is among the most common food allergies. "Shellfish" is a colloquial and fisheries term for aquatic invertebrates used as food, including various species of molluscs such as clams, mussels, oysters and scallops, crustaceans such as shrimp, lobsters and crabs, and cephalopods such as squid and octopus. Shellfish allergy is an immune hypersensitivity to proteins found in shellfish. Symptoms can be either rapid or gradual in onset. The latter can take hours to days to appear. The former may include anaphylaxis, a potentially life-threatening condition which requires treatment with epinephrine. Other presentations may include atopic dermatitis or inflammation of the esophagus. Shellfish is one of the eight common food allergens, responsible for 90% of allergic reactions to foods: cow's milk, eggs, wheat, shellfish, peanuts, tree nuts, fish, and soy beans.

<span class="mw-page-title-main">Metal allergy</span> Medical condition

Metal allergies inflame the skin after it has been in contact with metal. They are a form of allergic contact dermatitis. They are becoming more common, as of 2021, except in areas with regulatory countermeasures.

References

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  2. Lee YJ, Jameson SC, Hogquist KA (2011). "Alternative memory in the CD8 T cell lineage". Trends in Immunology. 32 (2): 50–56. doi:10.1016/j.it.2010.12.004. PMC   3039080 . PMID   21288770.
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