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Factors Affecting Skin Tests

Area of the Body


Reactivity to both allergen and histamine varies according to the part of the body. The mid and lower back
are more reactive than the forearm. The back as a whole is more reactive than the forearm. The
antecubital fossa is the most reactive part of the arm, whereas the wrist is the least reactive. The ulnar
side of the arm is more reactive than the radial.
Age
Skin reactions vary according to age. Infants react predominantly with large erythematous flare and a
small wheal. Using prick test, a significant wheal is detectable after 3 months of age in most infants tested
with either histamine or allergen extracts. (3)
The mean wheal size is significantly smaller than later in
life. (4)
It is therefore possible to perform skin tests to diagnose allergic disorders in infancy, but the size of
the wheal is often smaller and the criteria of positivity should always compare the size of the wheal
induced by allergen extracts with that elicited by positive control solutions.
Skin test wheals increase in size from infancy to adulthood and then decline after the age of 50. (5)
The
reactivity to histamine is parallel to that of allergens.
Sex
There is no sex difference in skin test reactivity. Women have the weakest histamine whealing capacity
during the first day of the menstrual cycle, but this is clinically insignificant.
Race
The whealing capacity to histamine is significantly greater in healthy non-atopic Blacks with darkly
pigmented skin than it is in Whites with light skin pigmentation. (6)
Flare measurement is also different. My
experience is that this seems to be the case in Polynesians as well.
Circadian Rhythm
Circadian variation of histamine, bradykinin or allergen whealing capacities have been shown. There are
clinically insignificant peaks in the late evening and a decreased reactivity in the morning.
Seasonal Variation
Seasonal variations related to specific IGE antibody synthesis have been demonstrated in pollen allergy.
Skin sensitivity is increased after the pollen season and then declines until the next season. This is
significant in patients with low sensitivity.
A recent study in AAA&I (April 2001) concluded, "Although skin reactivity may be slightly greater to tree
pollen during the pollen season, the timing of skin testing is not a critical determinant in patients with
pollen allergy"
Pathological Condition
Eczema is known to decrease the skin reactivity to histamine. Peripheral nerve abnormality, like diabetic
neuropathy shows a decreased reaction to skin test. Also, in the case of previous systemic anaphylactic
reaction, a delay of at least 1 week is preferable before skin testing.
Drugs/Medications
Antihistamines:
The H1-antagonists, which block the capillary effect of histamine, inhibit the wheal-and-flare reaction to
histamine allergen and mast cell secretagogue. The duration of this inhibitory effect is related to the half-
life of the drug and its metabolites. The duration of the inhibitory activity varies from 3 to 10 days for
cetrizine, loratadine and terfenadine to up to 60 days for astemizole. (7) This fact is probably the
commonest cause of a false-negative test and again stressing the importance of doing positive controls.
In practice, apart from astemizole, 72 hours off antihistamines seems an adequate length of time to wait
before skin testing.
Corticosteroids:
Short-term (< 1 week) administration at therapeutic doses in asthmatics does not modify skin prick test.
Conversely, long-term steroid treatment does not alter histamine-induced vascular reactivity in skin but
affects skin mast cell responses (8 modifies skin texture, therefore making the interpretation of immediate
skin tests difficult. It is recommended that low-dose oral corticosteroids (< 15mg of prednisone per day)
should not be discontinued, whereas high-dose should be reduced, if possible, before performing skin
tests. Application of topical corticosteroids for a period of 1 week reduces both the immediate and late-
phase skin reaction induced by allergens. (9)

antihistamin:

H1-antagonis, yang memblokir efek kapiler histamin, menghambat reaksi wheal-dan-suar untuk alergen histamin dan secretagogue sel mast. Durasi

efek penghambatan ini terkait dengan paruh obat dan metabolitnya. Durasi aktivitas penghambatan bervariasi dari 3 sampai 10 hari untuk cetirizine,

loratadine dan terfenadin untuk hingga 60 hari untuk astemizol. (7) Fakta ini mungkin adalah penyebab paling umum dari tes negatif palsu dan lagi

menekankan pentingnya melakukan kontrol positif. Dalam prakteknya, selain astemizol, 72 jam off antihistamin tampaknya panjang yang cukup waktu

untuk menunggu sebelum tes kulit.

kortikosteroid:

jangka pendek (<1 minggu) administrasi pada dosis terapi pada penderita asma tidak memodifikasi uji tusuk kulit. Sebaliknya, pengobatan steroid

jangka panjang tidak mengubah histamin-induced vaskular reaktivitas di kulit, tetapi mempengaruhi respon sel mast kulit (8 memodifikasi tekstur kulit,

sehingga membuat interpretasi tes kulit langsung sulit. Disarankan bahwa dosis rendah kortikosteroid oral (< 15mg prednison per hari) sebaiknya tidak

dihentikan, sedangkan dosis tinggi harus dikurangi, jika mungkin, sebelum tes kulit melakukan. Penerapan kortikosteroid topikal untuk jangka waktu 1

minggu mengurangi kedua reaksi langsung dan kulit akhir-fase yang disebabkan oleh alergen . (9)

Intradermal Skin Tests


These are more sensitive than SPT, but they are also much more dangerous. There have been several
reports of anaphylaxis following intradermal tests. They are usually indicated for diagnosing some drugs
and venom allergy. Intradermal skin testing is not recommended for the evaluation of food allergy.
Scratch tests are no longer recommended.
Provocation Challenge Testing
The skin tests and RAST test are indirect assays of an allergic state. A positive result only indicates that
the individual is sensitized to that allergen, it does not give any information of clinical reactivity. Many
patients will still have a positive skin prick test result even after they have clinically outgrown their allergy.
Direct challenge, either by inhalation or ingesting antigens, may be of great diagnostic use. In addition to
antigen challenge, the general hyper-responsive state of the airway associated with asthma may be
evaluated by exercise or by inhalation of chemicals to which asthmatics are more sensitive than non-
asthmatics.
Nonspecific Tests
Exercise
Physical exercise is a major precipitant of bronchial asthma. The diagnosis of asthma can probably be
made after 6 to 8 minutes of exercise and pre- and post-pulmonary function testing. In patients with
exercise-induced asthma (EIM) 6 to 8 minutes exercise is generally followed by a 20% or greater fall in the
FEVI.
Bronchial Challenges
Asthma is characterised by enhanced bronchial hyper-reactivity. This hyper-reactivity can be manifested
clinically by the asthmatic adverse response to cold air, cigarette smoke, fumes, weather changes, and
other stimuli that have little or no effect on a non-asthmatic patient. In the doctors office setting, airway
hyper-reactivity can be demonstrated by the patients response in a bronchial challenge such as the
inhalation of a methacholine solution at a concentration of less than 25 mg/ml is indicative of a positive
response.
Diagnosa Hipertropy Adenoid
Diagnosis ditegakkan berdasarkan:
1. Tanda dan gejala klinik.
2. Pemeriksaan rinoskopi anterior dengan melihat tertahannya gerakan velum palatum mole
pada waktu fonasi.
3. Pemeriksaan rinoskopi posterior (pada anak biasanya sulit).
4. Pemeriksaan nasoendoskopi dapat membantu untuk melihat ukuran adenoid secara langsung.
5. Pemeriksaan radiologi dengan membuat foto polos lateral dapat melihat pembesaran adenoid

Prosedur Pemeriksaan Radiologi:


1. Posisi Pasien : Pemeriksaan dilakukan pada pasien dengan posisi berdiri tegak pada film
sejauh 180 cm.
2. Pengukuran adenoid (A) : A adalah titik konveks maksimal sepanjang tepi inferior bayangan
adenoid. Garis B adalah garis yang ditarik lurus dari tepi anterior basisoksiput. Jarak A
diukur dari titik A ke perpotongannya pada garis B.
3. Pengukuran ruang nasofaring : Ruang nasofaring dikukur sebagai jarak antara titik C, sudut
posterior-superior dari palatum durum dan D (sudut anterior-inferior sincondrosis
sfenobasioksipital.
4. Jika sinkondrosis tidak jelas, maka titik D ditentukan sebagai titik yang melewati tepi
posterior-inferior pterigoidea lateralis dan lantai tulang nasofaring.
5. Rasio adenoid nasofaring diperoleh dengan membagi ukuran adenoid dengan ukuran ruang
nasofaring, yaitu Rasios AN = A/N.
Dengan kriteria sebagai berikut :
Rasio Adenoid Nasofaring 0 0,52 : tidak ada pembesaran.
Rasio Adenoid Nasofaring 0,52 0,72 : pembesaran sedang non obstruksi.
Rasio Adenoid Nasofaring > 0,72 : pembesaran dengan obstruksi.

6. CT-Scan merupakan modilitas yang lebih sensitif daripada foto polos untuk identifikasi
patologi jaringan lunak, tapi kekurangannya karena biaya yang mahal.1,3

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