Atopy patch test

Author: Aamenah Al-Ani, Medical Student, University of Auckland, New Zealand.  DermNet New Zealand Editor-in-Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. February 2018. 


What is an atopy patch test?

The classical tests for immediate Type 1 hypersensitivity (allergy) are specific IgE antibody levels, such as the radioallergosorbent test (RAST), and skin prick tests. Although often performed in patients with asthma and hay fever, these tests are not applicable to atopic dermatitis, which is not caused by a Type 1 reaction. However, the same allergens may also cause Type IV or delayed hypersensitivity reactions.

An atopy patch test is an epicutaneous patch test with the type 1 allergens known to elicit IgE-mediated hypersensitivity reactions. Eczematous skin lesions, if any, are evaluated after 24–72 hours. Atopy patch tests can be used as a diagnostic tool in patients with atopic dermatitis triggered by aeroallergens or by food allergy [1,2].

  • Patients with atopic dermatitis often have elevated total IgE and/or allergen-specific IgE directed against aeroallergens, such as house dust mite, and against food allergens.
  • These allergens can produce eczema flares in some patients with atopic dermatitis but not in all sensitised individuals [1].

Positive atopy patch tests are associated with allergen-specific T-lymphocyte responses.

  • Eczematous skin lesions in a positive atopy patch test may be due to IgE-associated activation of allergen-specific T-lymphocytes in the skin.
  • IgE facilitates allergen presentation to these T-lymphocytes by binding to receptors on Langerhans cells in the epidermis [1, 2].
Patch tests applied to skin of upper back

What are the indications for atopy patch tests?

The indications for atopy patch tests in a patient with atopic dermatitis include:  

  • Suspicion of aeroallergen/food allergy symptoms when predictive specific IgE levels and skin prick tests are negative
  • Severe and/or persistent atopic dermatitis with unknown trigger factors
  • Multiple IgE sensitisations of unknown clinical relevance [1].

What technique is used for atopy patch tests?

The atopy patch test technique is similar to usual patch tests used for the diagnosis of contact allergic dermatitis (which is a Type IV hypersensitivity reaction).

Allergens are applied directly onto clinically uninvolved and untreated skin of the back. They remain in place for 48 hours. Tape stripping should be avoided [1].

Which allergens are tested?

The most common allergens tested in atopy patch tests are:

  • House dust mite extract
  • Grass and birch pollen
  • Cat dander
  • Cow’s milk
  • Hen’s egg
  • Wheat
  • Soy products [1,2]

The European Task Force on Atopic Dermatitis (ETFAD) study in six European countries showed that the allergen that most often elicited a positive atopy patch test reaction was house dust mite extract, followed by pollen allergens [1].

Various vehicles have been used to carry the allergen: petrolatum, hydrogel and no vehicle. Allergens in petrolatum generally elicit more positive atopy patch test reactions than allergens in a hydrophilic vehicle [1].

Grading

Evaluation of the sites is conducted after 48 and 72 hours. The ETFAD grading system may be used.

  • Negative (–)
  • Erythema, questionable (?)
  • Erythema with infiltration (+)
  • Erythema with few papules (++)
  • Erythema with many or spreading papules (+++)
  • Erythema with vesicles (++++)

What is the diagnostic accuracy of atopy patch tests?

There is no “gold standard” for atopy patch tests. Positive results may correlate with a history of allergen-specific flares of dermatitis.

When compared with classic tests of IgE-mediated hypersensitivity:

  • The atopy patch test has a higher specificity but a lower sensitivity.
  • The classic tests may have some value as screening tests for IgE hypersensitivity; the atopy patch test may add specificity.

The atopy patch test does not replace the classic methods of diagnosis of IgE-mediated allergy [1].

Predictors of positive atopy patch test reactions include:

  • Increased specific serum IgE
  • Positive skin prick tests
  • Flares of dermatitis associated with exposure to specific allergens
  • Increased total IgE
  • Long duration of eczema
  • Rhinoconjunctivitis [1].

 

Related Information

References

  1. Darsow U, Ring J. Atopy Patch Testing with Aeroallergens and Food Proteins. In: Johansen J, Frosch P, JP (eds). Contact Dermatitis. Springer, Berlin, Heidelberg. 2011: 465-74.
  2. Turjanmaa K, Darsow U, Niggeman B, Rance F, Vanto T, Werfel T. EAACI/GA2LEN position paper: present status of the atopy patch test. Allergy. 2006 Dec; 61 (12): 1377-84. DOI: 10.1111/j.1398-9995.2006.01136.x. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17073865 (accessed 09 October 2017)
  3. Mansouri M, Rafiee E, Darougar S, Mesdaghi M, Chavoshzadeh Z. Is the AtopyPatch Test Reliable in the Evaluation of Food Allergy-Related Atopic Dermatitis? Int Arch Allergy Immunol. 2018 Jan 13. doi: 10.1159/000485126. [Epub ahead of print] PubMed PMID: 29332097. PubMed.

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