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Atopy patch test

Article  in  Indian Journal of Dermatology Venereology and Leprology · May 2019

DOI: 10.4103/ijdvl.IJDVL_397_17

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Atopy patch test

Varsha Vaidyanathan, Aarti Sarda, Abhishek De1, Sandipan Dhar2

Introduction Definition
Atopic dermatitis is a chronic, relapsing, intensely pruritic, Atopy patch test is an epicutaneously applied patch test
inflammatory skin condition with a significant socioeconomic procedure with allergens known to evoke IgE‑mediated
importance and a negative impact on quality of life.1 Usually, reactions with the test sites evaluated for a delayed
there is an early onset but it can start at any age.2 The worldwide hypersensitivity type eczematous reaction after 48–72 hours.7
prevalence of childhood atopic eczema varies between 3%
and 20.5% while in India it is between 2.4% and 6%.3 History
The pioneers of the atopy patch test were Rostenberg
Although the diagnosis of atopic dermatitis is mainly clinical and Sulzberger who in 1937 used aeroallergens in patch
as per the criteria of Hanifin and Rajka,4 it is best understood testing.8 However, it was not until 1982 that the patch test
as a chronic inflammatory condition with both IgE and was performed specifically in atopic dermatitis patients by
non‑IgE‑mediated immune dysregulation.5 The skin shows Mitchell.9 Ring coined the term “atopy patch test” in 1989.10
a poor barrier function, likely due to a filaggrin mutation, At present, the most widely followed protocol is that of the
allowing the entry of allergens; hypersensitivity to these European Task Force on Atopic Dermatitis.11
allergens worsens atopic dermatitis.6 Conversely, avoidance
of these allergens leads to an improvement. Both food and Indications
aeroallergens are considered to have a role, and they can • Patients in whom an aeroallergen or food allergen is
be evaluated based on the history of exposure along with suspected but there is no positive specific IgE or a
laboratory tests. positive skin prick test
• Severe and/or persistent atopic dermatitis where
Two types of hypersensitivity reactions are involved in atopic trigger factors are unknown
dermatitis: • Multiple IgE sensitizations without proven clinical
• Immediate type I IgE‑mediated – diagnosed with skin relevance in patients with eczema.
prick tests and measurement of serum‑specific IgE
• Delayed type IV T cell‑mediated – The patch test is a Contraindications
standard method to assess delayed hypersensitivity to • Acute flares of eczema, especially on the area to be
contact allergens, a modification of which – the atopy tested
patch test – is used in atopic dermatitis. • Pregnancy and lactation
• Immunodeficiencies
Differences between atopy patch test and patch test are shown • Ongoing immunosuppressive therapies
in Table 1. • Autoimmune diseases.

Dermatology, Wizderm Skin and Hair Clinic, Kolkata, 1Department of Materials

Dermatology, Calcutta National Medical College, 2Department of Pediatric Internationally, a few commercial kits are
Dermatology, Institute of Child Health, Kolkata, West Bengal, India
available – ALK‑Abello, Diallertest and Stallergenes. Different
allergens used include prick test solutions on filter paper,
Correspondence: Dr. Varsha Vaidyanathan,
C1/211, Janakpuri, New Delhi ‑ 110 058, India. purified allergens in hydrogel or in petrolatum and native food.
E‑mail: drvarshavaidyanathan@gmail.com

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10.4103/ijdvl.IJDVL_397_17
How to cite this article: Vaidyanathan V, Sarda A, De A, Dhar S.
PMID: Atopy patch test. Indian J Dermatol Venereol Leprol 2019;85:338-41.
***
Received: July, 2017. Accepted: January, 2018.

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Vaidyanathan, et al. Atopy patch test

Table 1: Differences between atopy patch test and patch Table 2: List of some allergens available for use in atopy
testing patch test in India
APT Patch test Mites
To detect aeroallergens or food allergens To detect cutaneous allergens Dermatophagoides farina and pteronyssinus (house dust mite)
Used in atopic patients Any patient with a suspected Blomia spp.
contact allergy Fungi
Skin prick test allergens are separately Patch test kits with Aspergillus spp.
loaded onto patch test chambers and standardised series available Fusarium solani
then used for testing for direct testing
Rhizopus nigricans
APT: Atopy patch test
Candida albicans
Penicillium spp.
In India, patch test solutions are aqueous allergens (supplied
Pollen
by Creative Drug Industries, Navi Mumbai) which are loaded
Cynodon dactylon (durva grass)
in aluminum patch test chambers with filter paper using the
Parthenium hysterophorus (congress grass)
dropper provided by the manufacturer (Systopic Laboratories,
Xanthium strumarium (chota dhatura)
New Delhi).12 Some of the antigens used in India are listed
Mangifera indica (mango tree)
in Table 2. Others include corn, potato, peanut, soy, chicken,
Ricinus communis (castor‑oil plant)
beef, pork, fish, cockroach antigens and tree pollen.13 Isotonic
Cocos nucifera (coconut tree)
saline solution or petrolatum can be used as the negative
Dusts
control. Best results are obtained with purified allergens with
Wheat dust
a known protein content. Allergen strengths are expressed in
Cotton dust
protein nitrogen units for aeroallergens and 1% weight by
Saw dust
volume for food allergens. Protein nitrogen unit between 5
Rice dust
and 7 is ideal. Allergen concentration needs to be higher for
Spider web dust
atopy patch test than skin prick test.7
Epithelia
Dog epithelia
Technique
Sheep wool
Certain precautions need to be taken before performing atopy
Pigeon feather
patch test:14
Cat dander
• Area should be nonlesional
Food
• Avoid topical steroids for 5 days
Rice
• No ultraviolet radiation for 4 weeks
Moong dal
• Avoid oral antihistamines for at least a week
Toor dal
• Oral steroids and immunosuppressants are stopped
Wheat
depending on the dose and duration (generally
Tomato
4 weeks)
Milk
• No pretreatment of the area, e.g.  tape stripping or
Egg (white) and egg (yolk)
acetone painting.
Garlic
Salmon
Using a dropper, the allergen extracts are placed on a filter
Peanut
paper loaded individually into 12‑mm aluminum test cups.
Potato
These are then placed on the skin of the back using an adhesive
Brinjal
tape. Patient is asked to avoid activities such as vigorous
exercise and sweating that may lead to the dislodgement of
cups. The test chambers are removed after 48 hours when the dust mites were found to be the most common cause for
first reading is done. Final reading is at 72 hours.15,16 atopy patch test positivity followed by grass pollen, birch
pollen and cat dander in various studies from Germany,17
Reading the Czech Republic,12 Croatia18 and Thailand.19 Interestingly,
Readings are based on the European Task Force on Atopic in India, parthenium accounted for nearly half of the atopy
Dermatitis key shown in Table 3. This is roughly similar to patch test positivity (42%), followed by house dust mites
the International Contact Dermatitis Research Group reading and Cynodon.13 In one study, more urban patients than rural
key used for conventional patch testing.11 patients showed positive atopy patch test, and, of them, the
most frequent allergen in the urban group was house dust
Discussion mites and grass pollen for the rural group, possibly indicating
Important aeroallergens that cause atopic flares are house the role of extent of exposure to the allergens.12 A significant
dust mites, tree and grass pollen and animal dander. House association was found between positive atopy patch test

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Vaidyanathan, et al. Atopy patch test

Table 3: European Task Force on Atopic Dermatitis key for involves repeated food administration over a period of few
atopy patch test reading hours and carries the risk of dangerous anaphylaxis in a few
Result Visual inspection
patients.24 Atopy patch tests can be used as a substitute here.
Negative No change in skin
In one study, atopy patch test predicted the results of oral food
challenge in 28 out of 33 cases. There was 100% negative
Questionable (?) Only erythema
predictive value for atopy patch test.25 Another study showed
1+ Erythema and infiltration
that positive predictive value was best for skin prick test (0.91)
2+ Erythema and a few papules
followed by radioallergosorbent test (RAST) (0.82) followed
3+ Erythema with many or spreading papules
by atopy patch test (0.63).26 Atopy patch test can be a useful
4+ Erythema with vesicles
tool to study the pathomechanisms of atopic dermatitis.

results for aeroallergens and an air‑exposed eczema pattern in The test can be performed at a younger age. Atopy patch
a Chinese study.14 Strong atopy patch test positivity to house test has been found to be positive earlier than skin prick test
dust mites is associated with extensive atopic dermatitis in small children with food allergies, especially in case of
suggesting that sensitization to house dust mite allergens cereals.27 Specificity of atopy patch test ranges from 69–
plays a significant role in determining the severity of atopic 92% and sensitivity 42–75%.7 Specificity and sensitivity of
dermatitis. atopy patch test vary for different allergens ranging from a
specificity of 43.5% for milk to 90% for barley and sensitivity
Important food allergens, known to cause not only atopic of 90.2% for milk to 98.7% for barley.28
flares but also gastrointestinal disturbances, include cow’s
milk, egg, wheat proteins, soy, peanuts, seafood and rice. Food However, atopy patch test is not suitable for diagnosing
allergy depends upon the child’s age and the eating traditions immediate food allergies. It is expensive, time‑consuming
of the family and the nation. Milk, soy and egg were the most and cumbersome. It may be difficult to interpret in cases of
common allergens causing positive atopy patch test.19,20 “angry back syndrome” where a strong positive patch test
could cause hyperreactivity to other patch tests. Being prone
The importance here lies in the fact that patients showing to skin irritations, atopic patients may show higher degree
positive atopy patch test to food allergens have relief of false positive reactions. Different results may be obtained
from atopic flares and gastrointestinal complaints on with variations in allergen (whole mite vs mite extract),
eliminating the offending food from the diet.21,22 Food allergen concentration, vehicle, site of testing, skin condition
allergens were found to be less significant compared to at the time of testing and reading time. There can be local
the aeroallergens in an Indian study.13 Atopy patch test flares of eczema, irritation to the adhesive used and urticarial
has also been performed with food additives, implicating reactions to allergens such as egg and soy.
carmine in the evolution of atopic dermatitis in some
patients.23 Conclusion
Atopy patch test is generally not considered in isolation. It
Significance of Atopy Patch Test can be thought of as another arrow in the quiver available
Atopy patch test helps to determine the patients in whom for the diagnosis of atopic dermatitis. It should be used in
atopic flares are related to extrinsic allergen exposure, and addition to a good history, clinical examination and skin
these patients can be counselled to avoid these triggers as prick test and serum‑specific IgE. A combination of all these
far as possible. Although it is not possible to completely tools helps in a better understanding of atopic dermatitis.
eliminate house dust mites, a few changes can help minimize
the exposure such as: Financial support and sponsorship
• Removal of wall‑to‑wall carpets from the house Nil.
• Avoid keeping pets in the house
• Use of dust mite‑proof mattress protectors and Conflicts of interest
pillowcases There are no conflicts of interest.
• Frequently washing bed sheets in hot water
• Installing high‑efficiency media filter in References
airconditioning unit. 1. Weidinger S, Novak N. Atopic dermatitis. Lancet 2016;387:1109‑22.
2. Illi  S, von Mutius  E, Lau  S, Nickel  R, Grüber C, Niggemann  B,
et al. The natural course of atopic dermatitis from birth to age
Narrowing down the allergens to a select few, especially in 7 years and the association with asthma. J Allergy Clin Immunol
the case of food allergens, can avoid unnecessary elimination 2004;113:925‑31.
of large food groups from the diet. 3. Bearley  R, Keil  V, Mutius  EV, Pearce  N. World wide variation in
prevalence of symptoms of asthma, allergic rhinoconjunctivitis and
atopic eczema ISAAC. Lancet 1998;351:1225‑32.
While double‑blind placebo‑controlled food challenge is still 4. Hanifin  JM, Rajka  G. Diagnostic features of atopic eczema. Acta
the gold standard for diagnosing food allergy, the procedure Dermatol Venereol 1980;92:44.e47.

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Vaidyanathan, et al. Atopy patch test

5. Wollenberg A, Bieber T. Atopic dermatitis: From the genes to skin 18. Kuljanac I, Milavec‑Puretić V. Atopy patch test with Dermatophagoides
lesions. Allergy 2000;55:205‑13. pteronyssinus (Dp 1) in atopic dermatitis patients. Coll Antropol
6. Thyssen JP, Kezic S. Causes of epidermal filaggrin reduction and their 2006;30:181‑3.
role in the pathogenesis of atopic dermatitis. J Allergy Clin Immunol 19. Visitsunthorn N, Chatpornvorarux S, Pacharn P, Jirapongsananuruk O.
2014;134:792‑9. Atopy patch test in children with atopic dermatitis. Ann Allergy Asthma
7. Wollenberg A, Vogel S. Patch testing for noncontact dermatitis: The Immunol 2016;117:668‑73.
atopy patch test for food and inhalants. Curr Allergy Asthma Rep 20. Kutlu A, Karabacak E, Aydin E, Ozturk S, Taskapan O, Aydinoz S,
2013;13:539‑44. et al. Relationship between skin prick and atopic patch test reactivity
8. Rostenberg  A, Sulzberger  MB. Some results of patch tests. Arch to aeroallergens and disease severity in children with atopic dermatitis.
Dermatol 1937;35:433‑54. Allergol Immunopathol (Madr) 2013;41:369‑73.
9. Mitchell  EB, Crow  J, Chapman  MD, Jouhal  SS, Pope  FM, 21. Syrigou  E, Angelakopoulou  A, Zande  M, Panagiotou  I, Roma  E,
Platts‑Mills TA, et al. Basophils in allergen‑induced patch test sites in Pitsios C, et al. Allergy‑test‑driven elimination diet is useful in children
atopic dermatitis. Lancet 1982;1:127‑30. with eosinophilic esophagitis, regardless of the severity of symptoms.
10. Ring  J, Kunz  B, Bieber  T, Vieluf D, Przybilla B. The “atopy patch Pediatr Allergy Immunol 2015;26:323‑9.
test” with aeroallergens in atopic eczema. J Allergy Clin Immunol 22. Rokaite R, Labanauskas L, Balciūnaite S, Vaideliene L. Significance
1989;82:195. of dietotherapy on the clinical course of atopic dermatitis.
11. Turjanmaa K, Darsow U, Niggemann B, Rancé F, Vanto T, Werfel T, Medicina (Kaunas) 2009;45:95‑103.
et al. EAACI/GA2LEN position paper: Present status of the atopy 23. Catli G, Bostanci I, Ozmen S, Dibek Misirlioglu E, Duman H, Ertan U,
patch test. Allergy 2006;61:1377‑84. et al. Is patch testing with food additives useful in children with atopic
12. Krupa Shankar  DS, Chakravarthi  M. Atopic patch testing. Indian J eczema? Pediatr Dermatol 2015;32:684‑9.
Dermatol Venereol Leprol 2008;74:467‑70. 24. Jurakić Toncić R, Lipozencić J. Role and significance of atopy patch
13. Nečas M. Atopy patch testing with airborne allergens. Acta test. Acta Dermatovenerol Croat 2010;18:38‑55.
Dermatovenerol Alp Pannonica Adriat 2013;22:39‑42. 25. Fogg  MI, Brown‑Whitehorn TA, Pawlowski  NA, Spergel  JM. Atopy
14. Dou X, Kim J, Ni CY, Shao Y, Zhang J. Atopy patch test with house dust patch test for the diagnosis of food protein‑induced enterocolitis
mite in Chinese patients with atopic dermatitis. J Eur Acad Dermatol syndrome. Pediatr Allergy Immunol 2006;17:351‑5.
Venereol 2016;30:1522‑6. 26. Majamaa  H, Moisio  P, Holm  K, Kautiainen  H, Turjanmaa  K. Cow’s
15. de Bruin‑Weller  MS, Knol  EF, Bruijnzeel‑Koomen  CA. Atopy patch milk allergy: Diagnostic accuracy of skin prick and patch tests and
testing – A diagnostic tool? Allergy 1999;54:784‑91. specific IgE. Allergy 1999;54:346‑51.
16. Rancé F. What is the optimal occlusion time for the atopy patch test 27. Strömberg L. Diagnostic accuracy of the atopy patch test and
in the diagnosis of food allergies in children with atopic dermatitis? the skin‑prick test for the diagnosis of food allergy in young
Pediatr Allergy Immunol 2004;15:93‑6. children with atopic eczema/dermatitis syndrome. Acta Paediatr
17. Darsow U, Vieluf D, Ring J. Evaluating the relevance of aeroallergen 2002;91:1044‑9.
sensitization in atopic eczema with the atopy patch test: A randomized, 28. Spergel  JM, Brown‑Whitehorn  T, Beausoleil  JL, Shuker  M,
double‑blind multicenter study. Atopy Patch Test Study Group. J Am Liacouras CA. Predictive values for skin prick test and atopy patch test
Acad Dermatol 1999;40:187‑93. for eosinophilic esophagitis. J Allergy Clin Immunol 2007;119:509‑11.

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