Intracutaneous Tests Research Articles

Insulin allergy can be successfully managed by a systematic approach

BackgroundType I insulin allergy can be a challenging condition, and there is no international consensus on how to establish the diagnosis. Measurement of specific IgE and skin testing have been cornerstones in the diagnostic work-up. However, these tests have limitations, mainly lack of correlation between test results and clinical findings. At the Allergy Centre, Odense University Hospital, patients with suspected insulin allergy have been evaluated since 2003. The aim of this study was to establish a systematic approach to diagnose and treat patients with insulin allergy.MethodsThe study was conducted retrospectively by retrieving data from the Allergy Centre database on patients with suspected insulin allergy evaluated from 2003 to 2017. The examination comprised a comprehensive medical history, specific IgE against insulin and intracutaneous tests (ICT) with different insulins.ResultsA total of 144 patients were examined on suspicion of insulin allergy of which 110 had negative specific IgE in serum. Of the remaining 34 patients, 33 had ICT performed; 2 had negative ICTs, while 31 had one or more positive ICT. All 34 patients had mild symptoms, and 4 could obtain symptom relief with antihistamines or local steroids, 9 could be managed with oral antidiabetics, and 7 were switched to other insulins. The final 14 patients were offered an insulin pump because of reactions to many different insulins, many positive ICTs, unmanageable diabetes, young age and compliance, or convenience.ConclusionInsulin allergy can be managed by a systematic approach, and symptom relief is obtainable in most patients.

Efficacy and tolerability of a house dust mite allergoid in allergic bronchial asthma: a randomized dose-ranging trial.

This multicenter randomized placebo-controlled double-blind clinical trial investigated which maintenance dose shows the optimal benefit-risk ratio for subcutaneous immunotherapy with a Dermatophagoides pteronyssinus allergoid preparation. To evaluate four maintenance doses of the allergoid preparation versus placebo. The late-phase reaction of the intracutaneous test was chosen as efficacy parameter and minimal dose of fluticasone required for asthma control. A total of 146 adults with bronchial asthma were randomized. After subcutaneous immunotherapy, reductions in swelling size were greatest with 10,000therapeutic units (TU). The 18,000TU group showed the highest percentage of patients with fluticasone dose reduced to 0μg/day. The optimal dose of allergoid for the investigation in a confirmatory trial with inhaled corticosteroid reduction is 18,000TU.

Evaluation of the medical devices benchmark materials in the controlled human patch testing and in the RhE in vitro skin irritation protocol

Several irritants were used in the in vitro irritation medical device round robin. The objective of this study was to verify their irritation potential using the human patch test (HPT), an in vitro assay, and in vivo data. The irritants were lactic acid (LA), heptanoic acid (HA), sodium dodecyl sulfate (SDS), Genapol® X-80 (GP), and Y-4 polymer. Dilute saline and sesame seed oil (SSO) solutions of each were evaluated using a 4 and 18 h HPT and the EpiDerm™ SIT-MD RhE assay; results were then compared to existing rabbit skin irritation test data. Results from the 4 h HPT were negative in most cases except for GP and SDS, while the 18 h HPT also identified some LA, HA, and GP samples as irritants. EpiDerm™ SIT-MD correctly identified all irritants except GP in SSO due to limited solubility. Data from cutaneous rabbit irritation tests were negative, while all intracutaneous results were strongly or weakly positive except for the most dilute GP solutions. These findings indicate that EpiDerm™ SIT-MD results correlate with those from the rabbit intracutaneous test and confirm that RhE assays are suitable replacements for animals in evaluating the tissue irritation potential of medical devices.

Aeroallergen spectrum for patients with allergic rhinitis in Chongqing

Objective:To determine the distribution characteristics of inhaled allergens and its influencing factors among allergic rhinitis (AR) patients in Chongqing. Method:Intracutaneous test was carried out in 2 474 AR patients. All the cases were divided into six groups according to age, 6-13 years old, >13-18 years old, >18-29 years old, >29-39 years old, >39-49 years old, >49 years old and four groups on the basis of season (spring, summer, autumn, winter). The correlations between the positive rates and gender, age, season were analyzed. Result:The most common allergens were dermatophagoides farin (71.26%), dermatophagoides pteronyssinus (73.61%) and polyvalent insect (60.79%). There was no significant correlation between most allergens and gender(P>0.05). Statistical analysis was conducted among different age groups, it showed that the positive rates of overwhelming majority allergens were highest in the group of 13-18 years old and higher in 6-13 years old group, and then gradually declined with age with a striking difference in each groups (P<0.05). Similar analysis was carried out among the groups in four seasons. It revealed that the prevalence rates of most allergens were higher in summer and autumn than that in spring and winter (P<0.05). Conclusion:Dermatophagoides and polyvalent insect are the most prevalent inhalant allergens in AR disease in Chongqing. Most AR patients had multiple allergens. The prevalence rates of most allergens were significantly different with age and season.

Proof of concept testing of a positive reference material for in vivo and in vitro skin irritation testing.

In vivo and in vitro irritation testing is important for evaluating the biological safety of medical devices. Here, the performance of positive reference materials for skin irritation testing was evaluated. Four reference standards, referred to as Y-series materials, were analyzed: a polyvinyl chloride (PVC) sheet spiked with 0 (Y-1), 1.0 (Y-2), 1.5 (Y-3), or 10 (Y-4) parts of Genapol X-080 per 100 parts of PVC by weight. Y-1, Y-2, and Y-3 did not induce skin irritation responses in an in vitro reconstructed human epidermis (RhE) tissue model, as measured by tissue viability or interleukin-1α release, or in an in vivo intracutaneous response test using rabbits. In contrast, Y-4 extracts prepared with saline or sesame oil at 37°C and 50°C clearly elicited positive irritation responses, including reduced viability (< 50%) and significantly higher interleukin-1α release compared with the solvent alone group, in the RhE tissue model and an intracutaneous response test, where substantial necrosis was observed by histopathology. The positive skin irritation responses induced in vitro under various extraction conditions, as well as those elicited in vivo, indicate that Y-4 is an effective extractable positive control material for in vivo and in vitro skin irritation tests of medical devices. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2807-2814, 2018.

Is a positive intracutaneous test induced by penicillin mediated by histamine? A cutaneous microdialysis study in penicillin-allergic patients

BackgroundDiagnostic workup of penicillin allergy comprises skin testing with penicillins, and patients are deemed allergic if skin test is positive. However, the literature suggests that skin test-positive patients may be challenge-negative, indicating that the skin test may be falsely positive.ObjectiveTo investigate real-time histamine release from a positive intracutaneous test induced by penicillin in patients with positive and negative challenges to penicillin.MethodsSkin microdialysis was performed in 21 penicillin-allergic patients with positive skin test, 13 non-allergic volunteers serving as negative controls, and 7 grass pollen-allergic patients serving as positive controls. Histamine was measured by microdialysis after skin test with penicillin/grass/NaCl. Penicillin challenge was subsequently performed in 12 of the patients.ResultsOnly 10/21 patients (47.6%) were skin test positive at microdialysis. During microdialysis 13 single intracutaneous tests were positive and histamine was detected in 4/13 occurring in four challenge positive patients. Thirteen/21 patients (61.9%) were deemed allergic to penicillin; eight had positive skin test. Two patients with positive skin test were challenge negative. In grass pollen allergic patients, 7/7 had a positive intracutaneous test to grass and all released histamine in the wheals. All 13 negative controls had negative intracutaneous test to penicillin and no histamine release.ConclusionHistamine was only detected in the minority of positive intracutaneous tests with penicillin in penicillin-allergic patients. Other mediators may be involved.

Daptomycin-induced Eosinophilic Pneumonia and a Review of the Published Literature

A 53-year-old man was admitted to the hospital with a diagnosis of cellulitis and osteomyelitis. Twenty-four days after the initiation of daptomycin and sulbactam/ampicillin, he developed a fever and pulmonary infiltration. Bronchoalveolar lavage revealed a high number of eosinophils, while an intracutaneous test revealed positivity for daptomycin. The patient improved after discontinuing antimicrobial therapy. The plasma daptomycin minimum concentration (Cmin) was elevated (27.4 μg/mL), but plasma protein binding of daptomycin was low (87.8%). Although the pathophysiology of eosinophilic pneumonia remains unclear, antigenic stimulation due to daptomycin accumulation in the alveoli may have caused continuous immune activation.

Cleaning and Sterilization of Used Cardiac Implantable Electronic Devices With Process Validation

This study sought to develop a validated, reproducible sterilization protocol, which could be used in the reprocessing of cardiac implantable electronic devices (CIEDs).Access to cardiac CIED therapy in high-income and in low- and middle-income countries varies greatly. CIED reuse may reduce this disparity.A cleaning and sterilization protocol was developed that includes washing CIEDs in an enzymatic detergent, screw cap and set screw replacement, brushing, inspection, and sterilization in ethylene oxide. Validation testing was performed to assure compliance with accepted standards.With cleaning, the total mean bioburden for each of 3 batches of 10 randomly chosen devices was reduced from 754 to 10.1 colony-forming units. After sterilization with ethylene oxide, with 3 half-cycle and 3 full-cycle processes, none of the 90 biological indicator testers exhibited growth after 7 days. Through cleaning and sterilization, protein and hemoglobin concentrations were reduced from 99.2 to 1.42 μg/cm2 and from 21.4 to 1.03 μg/cm2, respectively. Mean total organic carbon residual was 1.44 parts per million (range 0.36 to 2.9 parts per million). Endotoxin concentration was not detectable at the threshold of <0.03 endotoxin units/ml or <3.0 endotoxin units/device. Cytotoxicity and intracutaneous reactivity tests met the standards set by the Association for Advancement of Medical Instrumentation and the International Organization for Standardization.CIEDs can be cleaned and sterilized according to a standardized protocol achieving a 12-log reduction of inoculated product, resulting in sterility assurance level of 10-6.

Fruit sensitization in patients with allergy to latex

In the last years, latex has frequently been found to be involved in immediate hypersensitivity reactions. The first case mentioned with recurrent urticaria and laryngoedema was reported by Stern (1) in 1927. Since then, latex has also been implicated in generalized urticaria, rhinoconjunctivitis, asthma and anaphylaxis. Associated sensitization to several fruits is frequently seen in latex-allergic patients with the symptoms described above. This study was performed in seven patients (six females and one male) with hypersensitivity to latex and concomitant fruit sensitization. Six of them were healthcare personnel. The age of the patients ranged from 25-39 years, with a mean of 30 years. Prick tests and intracutaneous tests with latex (10% w/v in PBS), banana, chestnut, avocado, kiwi and melon were carried out. A specific histamine release test (HRT) was performed according to the fluorometric assay. Antigen-specific IgE was also performed. Latex CAP inhibition with banana and SDS-PAGE immunoblotting were carried out in one patient. Although in latex-allergic patients multiple sensitization to fruits may be observed, banana and avocado are those most frequently involved, followed by chestnut and melon. This is likely to be due to the presence of common antigens in these fruits and latex, as demonstrated in our study only for banana and avocado. We consider that further investigation is needed on the possible sensitization to latex in sanitary personnel reporting symptoms after fruit ingestion.

Reliability of histamine release test in dust mite allergy: Influence of the degree of sensitization

The histamine release test has been proven to be a very useful method for in vitro diagnosis of IgE-mediated allergy to inhalant and food allergens, as well as for the immunotherapy follow-up of the allergic patient. The aim of the present study was to assess the influence of the degree of sensitization in allergic patients sensitive to Dermatophagoides pteronyssinus on their dose-response curves in histamine release tests. To achieve this aim, we studied 109 D. pteronyssinus allergic patients and 25 healthy control subjects. Intracutaneous skin test, D. pteronyssinus-specific and total IgE quantitations, and histamine release tests were carried out in all the patients. In the case of the histamine release test, five D. pteronyssinus extract concentrations were used (2822.5, 282.25, 28.22, 2.82 and 0.28 UBE/ml), and two patterns of histamine release in sensitive patients were found: one with maximal histamine release at the highest antigen concentration (group I) and the other with maximal release attained at lower concentrations (group II). A sensitization score was designed, after the results from specific IgE and intracutaneous skin tests. There were significant differences (p < 0.05) in antigen-specific and total IgE levels, and in papule diameters and sensitization scores, between the control group and groups I and II. Both groups showed significantly higher (p < 0.05) histamine releases than the control group in response to anti-IgE antibodies. When stimulating the cells with anti-IgE antibodies, histamine release in group II was higher than in group I, although this difference was not significant. Finally, the best correlation between sensitization score and antigen-specific histamine release was found at the 2.82 UBE/ml concentration (r = 0.84, p < 0.001).

Preclinical safety and efficacy evaluation of ‘BioCaS’ bioactive calcium sulfate bone cement

A new bioactive calcium sulfate-based formulation (named ‘BioCaS’) has been developed for bone filler applications. This is a self-setting injectable cement where the preset form comprises bassanite obtained from the uniform submicron-sized precursor crystals of gypsum, modified with hydrogen orthophosphate ions. The results of the safety and efficacy evaluation of BioCaS cement, done as per the International Standards and guidelines, are presented in this paper. The study plan consisted of in vitro screening tests of cytotoxicity and haemolysis and in vivo biocompatibility evaluation, including an acute systemic toxicity test (in mice), an intracutaneous reactivity test (in rabbits), a pyrogen test (in rabbits) and a maximization sensitization test (in guinea pigs). The efficacy of the material in healing bone defects was investigated by implanting it in artificially created defects in rabbit femora, with clinically established hydroxyapatite porous ceramic as the control, followed by histological analysis at 12, 26 and 52 weeks. Set BioCaS cement consisted of hydrogen orthophosphate incorporating low-dimensional gypsum crystal lattices, the bioactivity of which has been identified by immersion in simulated body fluid. BioCaS was proved to be non-cytotoxic and non-haemolytic in the screening tests. In the live/dead assay, human osteoblast-like human osteosarcoma cells adhered well and spread on the surface of the material, attaining typical morphology and affirming the bone cell compatibility of the material. In the biocompatibility evaluation there were no acute systemic effects and the material proved non-pyrogenic. There was no intracutaneous erythemic or oedematous reactivity and no hypersensitivity observed in the Magnusson–Kligman method. The material satisfied the biocompatibility requirements. Bone implantation study revealed BioCaS to be osteoconductive and its efficacy of healing the experimental bone defects in rabbit femora is on a par with that of hydroxyapatite ceramic. The material resorbed at a pace matching that of new bone formation. This property of osteotransductivity will help the defect to heal and gain strength faster.

Local Anaesthetic Effect of Methanolic Leaves Extract of Lannea schimperi (Hoschst. Ex Rich) Eng.

Local anaesthetics provide relief from pain when applied locally to nerve tissue by blocking conduction of sensory nerve impulse from the receptor to the brain cortex. This study aimed at evaluating local anaesthetic activity of the methanolic leaves extract of Lannea schimperi. Six groups of five animals were used; groups I-IV were used for intracutaneous wheal test in guinea pigs for infiltration anaesthesia, while group V and VI were used for guinea pig corneal reflex method of surface anaesthesia. The result indicated a significant ( 0.05) dose dependent local anaesthetic activity of the methanolic leaves extract of Lannea schimperi with faster onset and longer duration of action at 24 mg/ml than at 12 mg/ml of the extract. Additions of 5 μg of adrenaline into the 24 mg/ml preparation also prolonged the duration of local anaesthetic activity of the extract. The extract at 24 mg/ml significantly (0.05) inhibited corneal reflex, lidocaine was used as a standard drug in positive control group, while normal saline was used as negative control in all the treated groups. The patent data therefore revealed that the methanolic leaves extract Lannea schimperi possess local anaesthetic principles that may require further scientific elucidation.

P.2.a.009 - Visuospatial planning in unmedicated major depressive and bipolar disorder: distinct and common neural correlates

This study analyzed in vivo antiviral cellular immune reactions in the Shope rabbit papilloma – carcinoma model. Antigens studied in experimentally infected domestic rabbits were cottontail rabbit papillomavirus particles produced with the athymic (nu/nu) mouse xenograft system and bacterial fusion proteins containing the major or minor capsid protein. Recall reactions to antigens were tested by classic intracutaneous tests. Positive reactions had a biphasic course. Histopathology of skin test biopsy specimens showed infiltrating polymorphonuclear cells during the early stages. Later they were replaced by predominantly perivascular infiltrates composed of mononuclear cells. Time course of swelling and infiltrates resembled a delayed-type hypersensitivity reaction. Ten of 11 regressor rabbits (p = 0.00006) and 10 of 20 progressors (p = 0.009) had positive skin tests with intact and/or denaturated virus particles and individual capsid proteins also could elicit specific skin reactions. Skin reactivity to the cottontail rabbit papillomavirus particles was also greater (p = 0.042) in regressor rabbits (8 of 11) when compared to progressors (7 of 20). Recall reactions remained detectable at post-regression times, ranging from several months up to more than 2 years. We conclude that specific skin reactions against the cottontail rabbit papillomavirus in infected domestic rabbits exist, and are strongly positive to intact particles of this papillomavirus in animals (regressors) clinically free of disease.

Follow-Up of Venom Immunotherapy on Flow Cytometry and Definition of a Protective Index

Background: A major problem of venom-specific immunotherapy (VIT) is the absence of reliable parameters for deciding treatment discontinuation. Aim of the Study: Intracutaneous tests (ICTs), the basophil activation test (BAT), specific IgEs (sIgEs) and blocking factor (BF) activity were measured during VIT. We made an evaluation by means of a protective index (PI) including ICT, BAT and BF values. Material and Methods: A population of 45 patients who had experienced a systemic reaction after an insect sting were tested before VIT (T0), at 1 week (T1w), at 10 weeks (T10w) and at 21 weeks (T21w), and, for a subgroup of 17 patients, at 3-5 years (T3-5y). Basophil activation (expressed in % CD63 and in the area under the curve) and BF activity were measured by flow cytometry using the CCR3/CD63 protocol. Results: The first 21 weeks of follow-up showed no significant variation in the ICT, sIgE and BAT measurements, except for BAT, by eliminating weak negative anti-IgE responses. In these conditions, the decrease in basophil activation was significant at T10w (p = 0.009) and T21w (p = 0.009). Increased BF activity was also significant at T10w (p = 0.008) and T21w (p = 0.002). The PI threshold calculated from the mean ± 3 standard errors (SE) was 64.8 (14.7 ± 16.7, n = 25) at T0. PI increase was significant at T3-5y (3,430 ± 6,282; p < 0.001). Conclusion: VIT induced a significant decrease in ICT values and basophil activation, along with an increase in serum BF activity, significant after 10 weeks of VIT. Evaluated in a larger population, the PI could represent a new tool for the clinico-biological follow-up of VIT efficacy.

Allergenicity and safety of recombinant human C1 esterase inhibitor in patients with allergy to rabbit or cow's milk

Recombinant human C1 inhibitor (rhC1INH) for on-demand treatment of hereditary angioedema is purified from milk of transgenic rabbits. It contains low amounts (<0.002%) of host-related impurities, which could trigger hypersensitivity reactions in patients with rabbit allergy (RA) and/or cow's milk allergy (CMA). This study is an assessment of allergenicity and safety of rhC1INH in patients with RA and/or CMA. Patients with CMA and/or RA underwent skin prick test (SPT), intracutaneous test (ICT), and, when results for both were negative, subcutaneous (SC) challenge with up to 2100U (14mL) rhC1INH. The negative predictive value of the skin test protocol was calculated, defined as the ratio of patients without systemic symptoms of hypersensitivity following SC challenge, over the number of patients having tested negative for both the SPT and the ICT. Adverse events after exposure to rhC1INH were recorded. Twenty-six patients with RA and/or CMA were enrolled. Twenty-four had negative SPT and ICT results for rhC1INH, whereas 2 had negative SPT result but positive ICT result to rhC1INH (only the highest concentration). Twenty-two patients with negative SPT and ICT results underwent SC challenge. None developed allergic symptoms. Local treatment-emergent adverse events occurred in 7 patients (32%) after SC challenge. In 5 these were considered drug related. All were mild. None of the patients with negative SPT and ICT results for rhC1INH had allergic symptoms during rhC1INH challenge. The negative predictive value of the combination of SPT and ICT for the outcome of the SC challenge was 100% (95% CI, 84.6%-100%). SC administration of rhC1INH was well tolerated.

Immediate Wheal Reactivity to Autologous Sweat in Atopic Dermatitis Is Associated with Clinical Severity, Serum Total and Specific IgE and Sweat Tryptase Activity

Background: Sweating can worsen atopic dermatitis (AD). The purpose of this work was to study the associations between reactivity to autologous sweat and the clinical severity of AD as well as investigate the possible wheal-inducing factors of sweat. Methods: Intracutaneous skin tests with autologous sweat were performed on 50 AD patients and 24 control subjects. In skin biopsies, tryptase and PAR-2 were enzyme and immunohistochemically stained. The associations between skin test reactivity and sweat histamine concentration, tryptase or chymase activity levels, tryptase or PAR-2 expression and AD clinical severity or IgE levels were investigated. Results: The wheal reactions in the intracutaneous tests with autologous sweat were positive, weakly positive and negative in 38, 34 and 28% of the AD patients, respectively, and in 4, 46 and 50% of the healthy controls, respectively (p = 0.008). In AD, the wheal reaction was associated significantly with clinical severity, serum total and specific IgE levels and sweat tryptase activity, but not with sweat histamine and chymase. In nonlesional AD skin, the percentage of PAR-2+ mast cells (MCs) or the number of tryptase+ MCs did not differ significantly between the intracutaneous test reactivity groups. Conclusion: Reactivity to autologous sweat correlates with the clinical severity of AD, and tryptase may be one of the factors involved in the sweat-induced wheal.

The comparison of laboratory tests Quantiferon, Tubinferon and Diaskintest in children with tuberculosis infection.

The study was carried out to compare results of three tests on the basis of antigens CFP-10 and ESAT-6: laboratory tests QuantiFERON (QFT) and Tubinferon (TIF) and intra-cutaneous test with allergen tuberculous recombinant - Diaskintest (DST). Tubinferon is a Russian analog of test QuantiFERON and is based on quantitative analysis of interferon-gamma after incubation of samples of whole blood in the presence of antigens of Mycobacterium tuberculosis (MBT) - tuberculin and recombinant antigens ESAT-6 and САЗ-10. The results QFT, TIF and DST are examined on 63 patients aged from 7 months to 15 years at parallel setup. According complex examination 63 children were divided at three groups: group I - 29 children infected with MBT and without disease; group II - 8 children non-infected with MBT; group III - 26 children with active forms of tuberculosis. It is established that at high rate of coincidence of results of all three tests (68.3%) in particular situations they can react differently, providing thereby additional information. The results of tests QFT and TIF coincide in 74.6% of all cases. The tests in vitro (QFT, TFT) occurred more sensitive under immuno-pathologic conditions in comparison with DST test. The TFT test demonstrated higher sensitivity under infection with MBT (58.6%) as compared with DST (34.5%) and QFT (34.5%) but lesser than in children with tuberculosis: TFT - 61.5%, QFT - 92.3%, DST - 80.8%. The conclusion is made that all three tests provide positive result more often under tuberculosis infection than in case of infected with MBT. The Tubinferon test is recommended to application and especially for children infected with MBT prior development of disease.

Modern allergy diagnostic procedures and their clinical application

Due to the increasing incidence of allergies, the importance of allergy diagnostic procedures is growing. In addition to a patient's history and prick, intracutaneous and patch testing, serological testing is an important diagnostic procedure. In recent years, tremendous advances have been made in the area of in vitro allergy tests. In particular, it is possible to predict severity and risk management of food allergies with component-based IgE diagnostic procedures. Even new allergy syndromes have been elucidated at the molecular level.

Biocompatibility of a titanium dioxide-coating method for denture base acrylic resin.

Ease of denture cleaning is of paramount importance in geriatric patients and those with limited dexterity. We have previously investigated methods of coating dentures with titanium dioxide (TiO2 ) and reported the effects (self-cleaning and antibacterial) of such treatments in invitro studies. This study was to verify the biocompatibility of a TiO2 -coated acrylic resin produced by the new coating method with spray-coating technique. Specimens were prepared from denture base acrylic resin and polished up to grit #1000. The TiO2 -coating agent was sprayed onto the specimens using an airbrush gun. Specimens were then divided into 'polymethyl methacrylate (PMMA)', 'primer-coated PMMA' and 'TiO2 -coated PMMA' groups to be evaluated for biological safety using a hamster oral mucosa irritation test, a guinea pig skin sensitisation test and a rabbit intracutaneous test. The biological reaction was scored. Reaction scores were considerably <1.0, the acceptable limit set by the ISO, in all three tests. Indeed, in most samples, there was no deleterious effect at all. These results tested on animals demonstrate that denture base resin coated with TiO2 by this method does not cause irritation or sensitisation of the oral mucosa, skin or intracutaneous tissue and is therefore good biocompatibility for use in close proximity to oral mucosa and skin.

Authorised allergen products for intracutaneous testing may no longer be available in Germany: Allergy textbooks have to be re-written.

Background:Beside the skin prick test, the intracutaneous test represents the most important skin test method for detecting type-1 allergies. With the incorporation of European directives into national law, test allergens used for allergy diagnosis are deemed medicinal products within the meaning of the German Medicinal Products Act (Arzneimittelgesetz) and therefore require marketing authorisation for distribution in Germany. The high costs of acquiring and maintaining these authorisations have lead to no new finished intracutaneous test products being authorized in Germany for more than 20 years. Instead, most manufacturers have voluntarily withdrawn their existing marketing authorisations for intracutaneous test extracts. The last manufacturer to offer approved finished allergen products for intracutaneous tests recently announced that it would now cease production and distribution of these solutions.Methods:Research on the current European and German legislation; selective literature search in Medline, including national and international guidelines and Cochrane meta-analyses; licensing information on the Paul-Ehrlich-Institute homepage (www.pei.de) as well as in the Bundesanzeiger (Federal Gazette).Results:According to information on www.pei.de, marketing authorisations still existed as of 31.01.2015 for intracutaneous test solutions of six grass/cereal/herbal pollens, seven tree pollens, ten food allergens, twelve moulds and yeasts as well as two fungal mixtures, five house dust and storage mites and five animal epithelia/danders, all held by only one company in Germany. These marketing authorisations were granted between 16th March 1987 and 17th January 1992; more recent marketing authorisations do not exist.Conclusions:European legislation and the associated increase in production and licensing costs have already lead to numerous suppliers withdrawing their marketing authorisation for diagnostic test allergens — marketing authorisations for 443 diagnostic allergens were voluntarily withdrawn by manufacturers in 2013 alone. If the announced restrictions on the allergen portfolio go ahead, considerable problems in the management of allergy patients in Germany due to the discontinuation of the intracutaneous test are likely to be encountered. Moreover, the fact that a diagnostic procedure that has been established for decades seems set to disappear quite simply because all the requisite substances vanish from the market in one fell swoop may well be without parallel in modern medicine.The situation for skin prick test allergens is less dramatic, although, here again, the available range is becoming increasingly limited.