Mean Wheal Research Articles

A clinical pathway for the diagnosis of sesame allergy in children

BackgroundSesame allergy (SA) is a common cause of life-threatening, persistent food allergy, not only in the Middle East and Asia, but increasingly worldwide. Commercially available tests such as extracts for skin testing or specific IgE for sesame or its components in serum, have very limited predictive values. Therefore the diagnosis is dependent on the performance of oral food challenges (OFC), frequently avoided in children, due to time and resource constraints, as well as the risk of anaphylaxis. In the current study we aimed to develop a simple, readily available, clinical tool, able to predict sesame OFC outcomes in children. MethodsChildren with a history of SA were evaluated in the outpatient allergy clinic. All children underwent natural sesame OFC, with an additional baked-sesame challenge offered to children with SA. Clinical data were compared between the sesame tolerant (ST) and SA groups. Machine-learning tools were applied, to create a simple, clinically driven, decision tree analysis (DTA), predicting the outcome of sesame OFCs and the diagnosis of SA. ResultsOne hundred four children, mean age 47.2 months, 58% boys were included, with a high prevalence of additional food allergies, atopic dermatitis, asthma, and rhinitis. Following OFC, 56 (54%) were diagnosed as ST and 48 (46%) SA. Among SA children, 85% were able to consume baked-sesame in equal or higher protein amounts compared to natural sesame paste. Compared to ST, SA children had a tendency towards a higher incidence of allergic rhinitis (5% Vs 17%, p = 0.062), multiple food allergies (3.6% vs 12.5%, p = 0.09) and requiring medical treatment after the initial SA reaction (27% vs 41%, p = 0.022). As a group, skin tests with both commercial and natural tahini paste differed significantly between ST and SA (mean wheal in mm, for extract 4.2 vs 13.4, p < 0.001 and for natural sesame paste 6.7 vs 24.4, p < 0.001), However, the PPV of any individual test was only between 60%–85%. Our exploratory, clinical DTA, predicted OFC outcomes and the presence or absence of Sesame Allergy, with ≥96% positive (PPV) and negative (NPV) predictive values. ConclusionOFCs remain the gold standard for the diagnosis of Sesame Allergy and are indicated to define ST/SA status even in highly atopic patients with previous immediate allergic reactions to sesame. A decision-tree analysis based on clinical parameters easily available in every allergy clinic, can predict the outcome of sesame OFC in the vast majority of children, increasing the safety and availability of such diagnostic procedures.

Early Atopic Sensitization to House-Dust Mite in Children with Recurrent Wheeze-A Cross-Sectional Study.

To determine sensitization to house-dust mite (HDM) antigen in under-five children with recurrent wheeze, compare it with nonwheezers, and assess atopic comorbidities in them. A cross-sectional study was done in the Pediatric department of a teaching hospital in North India, in 190 children aged 1-5 y. Out of these, 127 had recurrent wheeze (RW), and 63 had no wheeze (NW). Sensitivity was done by skin prick test (SPT) for two dust mites antigens: Dermatophagoide farinae and Dermatophagoide pteronyssinus antigens. In addition, atopic comorbidities like atopic dermatitis and allergic rhinitis were assessed. Mean age of the study population was 34.52 ± 20.50 mo. SPT positivity for either of the dust mites was 97 (76.4%) in RW and 13 (20.6%) in NW which was significant (p < 0.001, aOR = 12.27). HDM species sensitization for D. pteronyssinus was 55.1% vs. 15.9% (p < 0.001 aOR = 7.81) and D. farinae was 39.4% vs. 9.5% (p < 0.001, aOR = 5.45) in groups, respectively. Mean wheal size in RW Group was also significantly higher than NW group for D. pteronyssinus (2.39 ± 1.44 vs. 0.52 ± 1.19mm, median (IQR) 3 (1-3), p < 0.001), D. farinae (1.80 ± 1.39 vs. 0.32 ± 1.00mm, median (IQR) 2 (0-3), p < 0.001). Allergic rhinitis was present in 55 (43.3%) vs. 7 (11.1%) (p < 0.001), atopic dermatitis in 28 (22%) vs. 2 (3.2%) (p = 0.001) in group 1 and 2, respectively. All children with allergic rhinitis had HDM sensitization in both groups. This study showed early sensitization to HDM in children with recurrent wheeze. Atopic comorbidities were also present in them.

Low Potency of Indian Dust Mite Allergen Skin Prick Test Extracts Compared to FDA-Approved Extracts: A Double-Blinded Randomized Control Trial.

BackgroundSkin prick testing is the most important diagnostic tool to detect immunoglobulin E-mediated allergic diseases. With increase in the number of allergy tests performed in India, it is imperative to know the potency of indigenous extracts in comparison with U.S. Food and Drug Administration (USFDA)-approved extracts.MethodsA randomized comparison trial of Indian manufactured and USFDA-approved extracts of Dermatophagoides pteronyssinus (DP) and Dermatophagoides farinae (DF) was done at Christian Medical College & Hospital, Vellore, India from April 2014 to June 2015, to compare the skin test reactivity of indigenous allergen extracts of dust mites against validated allergen. Study enrollment included 197 patients with allergic disorders that showed sensitivity to dust mite during routine allergy skin testing. Study participants were tested with varying dilutions of DP and DF indigenous extracts along with USFDA-approved allergens in a blinded fashion. Results were recorded, and statistical significance was calculated using the Friedman rank sum test.ResultsUsing the Friedman rank sum test with a Tukey adjustment for multiple comparisons, we found that the extracts in each dilution were significantly different (P < .0001). The full strength indigenous extracts, B-DF (DF allergen standard extract from Bioproducts and Diagnostics, India) and C-DF (DF allergen extract from Creative Diagnostics, India) extracts, had mean wheal sizes of 7.69 (standard deviation [SD] 9.91) and 31.01(SD 51.04), respectively. The full strength S-DF (DF allergen extract from Jubilant Hollister Stier, Spokane, WA, USA) had a mean wheal size of 109.97 (SD 162.73), which was significantly higher (P < .0001) than both the indigenous extracts. For each of the dilutions, the S-DF mean wheal size was significantly greater than that of the corresponding B-DF and C-DF wheal sizes. The full strength indigenous C-DP (DP allergen extract from Creative Diagnostics, India) had mean wheal size of 39.37 (SD 51.74). The full strength standard S-DP (DP allergen extract from Jubilant Hollister Stier, Spokane, WA, USA) extract had a mean wheal size of 167.66 (SD 270.80), which was significantly higher (P < .0001) than the indigenous C-DP extract. Similar differences were seen across all dilutions.ConclusionThe indigenous extracts have significantly lower potency compared to USFDA-approved extracts; hence, there is an urgent need for policy makers to institute stringent criteria for standardization of antigens in India.

CETIRIZINE SUPPRESSION TO SKIN PRICK TEST RESULTS IN ATOPIC ALLERGY PATIENTS

This study was done to determine the suppression index of Cetirizine to the skin prick test results to obtain a correction constant or factor that can be used to assess the results of the skin prick test in patients who cannot stop the use of antihistamines (Cetirizine). This pre and post test study design clinical trial involved 22 atopic allergy patients who seek medical treatment at the Allergy and Immunology Outpatient Clinic Dr. Soetomo Hospital. Skin prick tests were done twice (SPT1 and SPT2) using house dust mite allergen extract to all study subjecs. The first (SPT1) were done after washout of all antihistamine for 1 week prior the test. All study subjects were then given Cetirizine 10 mg once daily for 5 days and on day 6 we performed the second test (SPT2). Cetirizine suppresion index and correction factor were calculated by comparing the wheal area of SPT1 and SPT2. All 22 study subjects (6 males and 16 females) were sensitized to house dust mite allergen. Mean serum total IgE levels were 176.42 + 352.5 IU/dL. Mean wheal area generated by the positive control (histamine 1 mg/mL) in SPT1 was 7.53 + 7.31 mm2, and in SPT2 was 1.08 + 1.46 mm2. Mean wheal area generated by house dust mite allergen in SPT1 was 43.57 + 36 mm2, and in SPT2 was 10.28 + 8.47 mm2. Cetirizine suppression index for positive controls (histamine 10 mg/mL) was 94.63 + 7.90% (p=0.000), while the Cetirizine suppression index for house dust mite allergen is 72.31 + 13.96% (p=0.000). There was no significant influence of serum total IgE levels to Cetirizine suppression index (p=0.381). The correction constant based on the calculation was 1.9. In conclusion, Cetirizine suppression index to the mean wheals area generated by house dust mite allergen was 72.31% and the correction constant was 1.9. In allergic patients who cannot stop their antihistamine drugs, Cetirizine 10 mg once daily can be used as a replacement and they still be able to undergo skin prick tests. The actual wheal diameter (or area) of the skin prick test results can be calculated by multiplying the measured wheal diameter (or area) under the Cetirizine administration with the correction constant.

Inhibitory effect of Phlai capsules on skin test responses among allergic rhinitis patients: a randomized, three-way crossover study

BackgroundZingiber cassumunar Roxb., commonly known as Phlai in Thai, has been used as a traditional medicine in Thailand for the treatment of various diseases, including inflammation and chronic airway disease. ObjectiveThe purpose of this study was to assess the antihistaminic effect of Phlai on skin testing. Design, Setting, Participants and InterventionThis was a randomized, open-label, three-way crossover study. Twenty allergic rhinitis (AR) patients were enrolled. In randomized sequence, patients received a single dose of Phlai capsules (100 or 200 mg) or loratadine (10 mg) with a washout period of 1 week between each treatment. Main Outcome MeasuresSkin prick testing for histamine and common aeroallergen (house dust mite) were performed before treatment and after 1, 2, 3, 4, 6, 8, 12 and 24 hours of treatment. The main treatment outcomes were the mean wheal and flare responses to the skin prick test after treatment. ResultsBoth 100 mg and 200 mg Phlai doses suppressed wheal and flare responses to house dust mite allergen, but only 200 mg of Phlai capsules significantly suppressed wheal and flare responses to histamine. Repeated measures analysis of variance showed that loratadine caused more wheal and flare suppression than Phlai capsules in responses to the histamine skin prick test. However, there were no significant differences among the effects of 100 mg Phlai capsules, 200 mg Phlai capsules and loratadine in suppression of wheal and flare induced by the mite skin prick test. Both doses of Phlai were well-tolerated with no adverse events. ConclusionBoth 100 mg (compound D 4 mg) and 200 mg (compound D 8 mg) Phlai capsules, when taken as a single therapeutic dose, inhibited skin reactivity to histamine and mite skin prick tests in AR patients. Trial RegistrationThai clinical trial registry (TCTR20160510001).

Comparison between skin prick test and serum immunoglobulin E by CAP system to inhalant allergens

BackgroundSkin prick tests (SPTs) and measurements of serum specific immunoglobulin E (sIgE) antibodies are the most commonly used diagnostic tools for confirming sensitization. However, disagreement between the tests has been observed. ObjectiveTo compare SPT and the CAP system for diagnosis of sensitization to common inhalant allergens. MethodsSubjects included 2,635 patients 10 to 90 years old who underwent analyses by SPT and CAP at the Dong-A University Hospital (Busan, Korea) from June 2011 through May 2016. The 2 test results were compared for 17 inhalant allergens. ResultsAgreement between the SPT and sIgE level was 75.3%. Overall agreement was moderate (κ = 0.59), with strong agreement for house dust mites and birch (κ > 0.7) and weak agreement for Tyrophagus putrescentiae and dog (κ < 0.3). When CAP was compared with SPT as the reference, the sensitivity was 75.8% and the specificity was 75.2%. Mean wheal size by SPT showed a positive correlation with sIgE levels (r = 0.59), which decreased with age. ConclusionThere was a discrepancy between SPT and CAP for diagnosing allergic sensitization among inhalant allergens. The allergic sensitization and correlation between the tests decreased with age. Cautious interpretation of the clinical relevance of allergen sensitization based on SPT and CAP results is required, especially in older patients.

Autologous serum and plasma skin test to predict 2-year outcome in chronic spontaneous urticaria.

BackgroundAutologous serum skin test (ASST) and autologous plasma skin test (APST) are simple methods to diagnose autoimmune chronic urticaria. However, the association data of ASST or APST with disease severity and long-term outcome are still unclear.ObjectiveThe results of ASST and APST might be used to predict urticaria symptom severity and long-term outcomes among chronic spontaneous urticaria (CSU) patients.MethodsWe evaluated the prevalence of reactive ASST and APST in 128 CSU patients. The patients were characterized by 4 groups: negative, ASST positive, APST positive, and both ASST and APST positive. We observed remission rate among the CSU patients during 2 years.ResultsForty-four of 128 CSU patients (34%) had negative autologous skin test. The CSU patients with positive ASST, positive APST, and both positive ASST and APST were 47 (37%), 6 (5%), and 31 (24%), respectively. No significant difference was found between the groups according to urticaria severity score (USS) and dermatology life quality index (DLQI). Mean wheal diameter of ASST showed positive correlation with DLQI. Also, mean wheal diameter of APST showed positive correlation with USS and DLQI. Both the positive ASST and APST groups had a high proportion of 4-fold dose of H1-antihistamine than the positive ASST (p = 0.03) and negative groups (p = 0.0009). The rate of remission over 2 years in the negative, positive ASST, positive APST, and both positive ASST and APST groups were 81.1%, 62.3%, 60%, and 46.1%, respectively. The urticaria remission rate in patients in the negative group was significantly higher compared with both positive ASST and APST groups (odds ratio, 5.0; 95% confidence interval, 1.61–15.44; p = 0.006).ConclusionASST and APST results could predict remission rates among patients with CSU. Our results suggested investigating ASST and APST among CSU patients before starting treatment.

Performance and Pain Tolerability of Current Diagnostic Allergy Skin Prick Test Devices

Allergen skin prick testing remains an essential tool for diagnosing atopic disease and guiding treatment. Sensitivity needs to be defined for newly introduced devices. Our aim was to compare the performance of 10 current allergy skin prick test devices. Single- and multiheaded skin test devices (n = 10) were applied by a single operator in a prospective randomized manner. Histamine (1 and 6 mg/mL) and control diluent were introduced at 6 randomized locations onto the upper and lower arms of healthy subjects. Wheal and flare reactions were measured independently by 2 masked technicians. Twenty-four subjects provided consent, and 768 skin tests were placed. Mean wheal diameter among devices differed from 3.0 mm (ComforTen; Hollister-Stier, Spokane, Wash) to 6.8 mm (UniTest PC; Lincoln Diagnostics, Decatur, Ill) using 1 mg/mL histamine (P < .001) and 4.8 mm (GREER Pick; Greer, Lenoir, NC) to 8.4 mm (Duotip-Test II; Lincoln Diagnostics, Decatur, Ill; and Sharp-Test; Panatrex, Placentia, Calif) using 6 mg/mL histamine (P < .001). The false-negative rates ranged from 0% to 45% with 1 mg/mL histamine. The analytical specificity was 100% for all devices tested. All devices were well tolerated, with average pain score of less than 4 on a 10-point visual analog scale. Pain scores were higher among women, but this did not reach statistical significance. The Multi-Test PC and the UniTest PC had the lowest pain scores compared with the other devices. All 10 skin prick test devices displayed good analytical sensitivity and specificity; however, 3 mm cannot arbitrarily be used as a positive threshold. The use of histamine at 1 mg/mL is unacceptable for certain devices but may be preferable for the most sensitive devices. On average, there was no pain score difference between multiheaded and single-head devices.

Occupational allergic multiorgan disease induced by wheat flour

Bakers are repeatedly exposed to wheat flour (WF) and may develop sensitization and occupational rhinoconjunctivitis and/or asthma to WF allergens.1 Several wheat proteins have been identified as causative allergens of occupational respiratory allergy in bakery workers.1 Testing of IgE reactivity in patients with different clinical profiles of wheat allergy (food allergy, wheat-dependent exercise-induced anaphylaxis, and baker's asthma) to salt-soluble and salt-insoluble protein fractions from WF revealed a high degree of heterogeneity in the recognized allergens. However, mainly salt-soluble proteins (albumins, globulins) seem to be associated with baker's asthma, and prolamins (gliadins, glutenins) with wheat-dependent exercise-induced anaphylaxis, whereas both protein fractions reacted to IgE from food-allergic patients.1 Notwithstanding, gliadins have also been incriminated as causative allergens in baker's asthma.2 We report on a 31-year-old woman who had been exposed to WF practically since birth because her family owned a bakery housed in the same home where they lived. She moved from this house when she was 25 years, but she continued working every day in the family bakery. In the last 8 years she had suffered from work-related nasal and ocular symptoms such as itching, watery eyes, sneezing, nasal stuffiness, and rhinorrhea. These symptoms markedly improved when away from work and worsened at work. In the last 5 years, she had also experienced dysphagia with frequent choking, especially when ingesting meats or cephalopods, which had partially improved with omeprazole therapy. Two years before referral to our clinic, she began to have dry cough and breathlessness, which she also attributed to her work environment. Upper and lower respiratory tract symptoms increased when sifting the WF and making the dough. The patient did not experience gastrointestinal symptoms with ingestion of cereal products. Skin prick test results were positive to grass (mean wheal, 6 mm), cypress (5 mm) and Russian thistle pollen (4 mm), WF (4 mm), and peach lipid transfer protein (6 mm) and were negative to rice flour, corn flour, profilin, mites, molds, and animal dander. Skin prick test with a homemade WF extract (10% wt/vol) was strongly positive (15 mm). Serologic tests yielded the following results: eosinophil cationic protein, 47 ?g/L; total serum IgE, 74 kU/L; specific IgE (ImmunoCAP; ThermoFisher, Uppsala, Sweden) to WF, 7.4 kU/L; barley flour, 1.24 kU/L; and corn, gluten, alpha-amylase, peach, and apple, less than 0.35 kU/L. Specific IgE binding to microarrayed purified WF allergens (WDAI-0.19, WDAI-0.53, WTAI-CM1, WTAI-CM2, WTAI-CM3, WTAI-CM16, WTAI-CM17, Tri a 14, profilin, ?-5-gliadin, Tri a Bd 36 and Tri a TLP, and gliadin and glutamine fractions) was assessed as described elsewhere.3 The patient's serum specifically recognized ?-5-gliadin and the gliadin fraction, and no IgE reactivity was observed to other wheat allergens. Spirometry revealed a forced vital capacity of 3.88 L (88%), an FEV1 of 3.04 L (87%), and FEV1/forced vital capacity of 83%. A methacholine inhalation test was performed following an abbreviated protocol,4 and the results were expressed as PD20 in cumulative dose (mg) of methacholine. Methacholine inhalation challenge test result was positive (0.24 mg cumulative dose) when she was working, and after a 3-month period away from work and with no visits to the bakery house, it gave a negative result. A chest x-ray was normal. Specific inhalation challenge test was carried out in the hospital laboratory by tipping WF from one tray to another for 15 minutes. Spirometry was performed at baseline and at 2, 5, 10, 15, 20, 30, 45, and 60 minutes after the challenge with WF. Peak expiratory flow was measured at baseline and then hourly over 24 hours (respecting sleeping time). A 12% fall in FEV1 was observed at 20 minutes and a 26% drop in peak expiratory flow at 9 hours after exposure to WF,

Clinical and laboratorial aspects of hens egg allergy in childhood

Results It was evaluated 159 children, with 58.5% male. The mean age at diagnosis was 1 year and 11 months old. Among the patients followed 25.1% achieved oral tolerance, and this was achieved after 1 year and 10 months of diagnosis. The clinical manifestations evaluated were: atopic eczema (27.0%), urticaria (24.5%), atopic eczema associated with urticaria (13.2%), anaphylaxis (8.8%), gastrointestinal tract manifestations (8.8%), respiratory tract manifestations (8.8 %), urticaria and angioedema (7.5%) and angioedema (1.8%). The following laboratory aspects evaluated were: Eosinophilia was present in 30.1% of patients. The mean total IgE was 1108.8 IU/ml. The specific IgE to hen s egg was 9.3 IU/ml and to the allergenic component ovomucoide was 1.9 IU/ml. The mean wheal to hen s egg in prick test was 4.8mm.

Diagnosis of food allergy: History, examination and in vivo and in vitro tests

One cannot depend on one single test to diagnose food allergy. A detailed history is an essential initial step in cases of suspected food allergy. Aspects of the history should be gathered separately for each food being considered, as a patient may experience different types of reactions with various foods, each of which requires individual diagnostic and management strategies. History alone is not diagnostic and additional measures of sensitisation or food challenges are often required. In suspected immunoglobulin E (IgE)-mediated allergy, skin-prick tests (SPTs) and/or measurement of serum specific IgE antibodies (ImmunoCAP) to suspected foods is used to prove sensitisation. Sensitisation does not, however, confirm clinical food allergy as these tests indicate an immunological response to the specific allergen, but the diagnosis requires a clear correlation between the test result and clinical reaction (by positive history or food challenge). The magnitude of the test result (SPT mean wheal size or ImmunoCAP level in kU/L) correlates with the likelihood of clinical allergy, but not the severity of a reaction. Choice of the allergens tested should be guided by the history, but limited to the lowest necessary number to avoid false-positive results. Tests for sensitisation to foods should not be performed when the history indicates that such foods are tolerated. Ninety-five per cent positive predictive values (where a clinical reaction can be predicted in 95% of cases) have been described for immediate reactions, but may be population specific. There are no validated tests to confirm non-IgE- or mixed IgE- and non-IgE-mediated food allergies. Diagnosis of this group of allergies depends on elimination of the suspected food, clearance of symptoms, and recurrence of symptoms on re-introduction of the food.

A Randomized, Double-Blind, Placebo-Controlled Pilot Study of Sublingual versus Oral Immunotherapy for the Treatment of Peanut Allergy

To compare safety and efficacy of oral versus sublingual immunotherapy (OIT and SLIT) for the treatment of peanut allergy. After a baseline double-blind placebo-controlled food challenge (DBPCFC, maximum 1gm peanut protein), subjects were randomized to active SLIT/placebo OIT or active OIT/placebo SLIT. After initial escalation, SLIT/OIT doses were increased biweekly/weekly to 3696μg/day SLIT and 2000mg/day OIT. A 10gm DBPCFC was completed after 6 months of maintenance. 21 subjects, 7-13yrs (median 11.1; male 52%) were enrolled. Baseline characteristics included median total IgE 667kUa/L (range 170-1557), peanut IgE 169kUa/L (35.1-814), peanut IgG4 1.12mgA/L (0.19-5.89), 5-log peanut endpoint skin titration (PEST) mean wheal 5.5mm (1.3-8.9), and DBPCFC threshold 21mg (1-146). Three subjects withdrew (1 systemic reaction, 1 GI symptoms, 1 unrelated to study). There were significant increases at maintenance in total IgE (median 844, range 201-3938; p<0.001), peanut IgE (344, 47.4-1960; p<0.001), and peanut IgG4 (5.79, 0.47-47.2; p<0.001). Of the 9 subjects completing the 6 month DBPCFC, median challenge threshold increased to 246mg (21-4996; p<0.05) and PEST mean wheal decreased to 1.8mm (range 0.7-7.2; p<0.05). Significant increases in total and peanut IgE remained (p<0.05). Symptoms elicited by the 4772 home doses included: 15.4% oropharyngeal, 10.2% GI, 3.8% lower respiratory, 2.4% skin, and 0.9% upper respiratory. Treatment included antihistamines (43.2% of doses), beta2-agonists (1.3%), and epinephrine (1 dose). Preliminary results demonstrate peanut SLIT and OIT are effective in changing challenge threshold, serologic markers, and skin reactivity with infrequent systemic symptoms. SLIT versus OIT will further be compared after unblinding following the 12 month DBPCFC.

Comparison of reservoir effect of topical corticosteroids in an experimental animal model by histamine-induced wheal suppression test

Introduction:Topical corticosteroids used in various dermatological diseases are available in different potencies and different formulations. The reservoir effect of different potency corticosteroids in the stratum corneum will help the clinicians to choose an appropriate topical steroid to maximize their efficacy and safety as therapeutic agents.Aims:This study was designed to compare the duration of reservoir of different potency topical corticosteroids experimentally in rabbits using histamine-induced wheal suppression test.Materials and Methods:The study was carried out in albino rabbits (as their skin is similar to humans) using four different concentrations of topical steroids, namely mometasone furoate ointment (0.1%), fluticasone propionate ointment (0.005%), betamethasone valerate cream (0.1%), and hydrocortisone butyrate cream (0.1%). These were applied on the back of rabbit on one side and the vehicle was applied on the other. One hour later, histamine-induced wheal suppression test was performed on both sides and wheal area was measured at 10 min for 7 days. Statistical analysis was done by ANOVA followed by post hoc test.Results:Maximum wheal suppression was seen on day 1 (P<0.001) in all four groups, both at test and at control sites. Interday comparison of mean wheal size by topical steroids showed that the reservoir of mometasone furoate ointment (0.1%) persisted till day 4 in the stratum corneum of the skin. In case of fluticasone propionate ointment (0.005%) and betamethasone valerate cream (0.1%), the reservoir persisted till day 2 and for hydrocortisone butyrate cream (0.1%), the reservoir was present only on day 1.Conclusions:It is concluded that the duration of reservoir depends on the potency of topical steroids. Higher the potency more is the duration of reservoir in stratum corneum and vice versa.

Sensitization to indoor allergens and frequency of asthma exacerbations in children

Background The rapid increase in asthma incidence has implicated the importance of environmental influences over genetic influences. Sensitization to perennial indoor allergens has been associated with increased asthma symptoms.Objective To examine the correlation between sensitization to indoor allergens and frequency of asthma exacerbations in children.Methods A cross-sectional study was carried out on asthmatic children aged 6 to 12 years in the Department of Child Health, Udayana University Medical School /Sanglah Hospital, Denpasar. Degree of sensitization was assessed by mean wheal diameter (positive defined as 3 mm greater than negative control) for seven common indoor allergens. Frequency of asthma exacerbation for three consecutive months prior to data collection was retrospectively reviewed.Results Positive skin test results for one or more allergens were found in 84 of 89 (94%) asthmatic children. Higher frequency of asthma exacerbations weakly correlated with the number of allergens with positive sensitization (r=0.284; P=0.007). Mean wheal diameter of each allergen did not correlate to the frequency of asthma exacerbations. In addition, the frequency of asthma exacerbations was independent for parental and sibling atopic history, preceding respiratory infections, use of asthma controllers and passive environmental tobacco smoke exposure.Conclusions Sensitization to common indoor allergens correlates weakly with frequency of asthma exacerbations.

Influence of acupuncture on type I hypersensitivity itch and the wheal and flare response in adults with atopic eczema – a blinded, randomized, placebo‐controlled, crossover trial

Itch is a major symptom of allergic skin disease. Acupuncture has been shown to exhibit a significant effect on histamine-induced itch in healthy volunteers. We investigated the effect of acupuncture on type I hypersensitivity itch and skin reaction in a double-blind, randomized, placebo-controlled, crossover trial. An allergen stimulus (house dust mite or grass pollen skin prick) was applied to 30 patients with atopic eczema before (direct effect) and after (preventive effect) two experimental approaches or control observation: acupuncture at points Quchi and Xuehai [verum acupuncture (VA), dominant side], 'placebo-point' acupuncture (PA, dominant side), no acupuncture (NA). Itch intensity was recorded on a visual analogue scale. After 10 min, wheal and flare size and skin perfusion (via LASER-Doppler) were measured at the stimulus site, and the validated Eppendorf Itch Questionnaire (EIQ) was answered. Mean itch intensity was significantly lower in VA (35.7 +/- 6.4) compared to NA (45.9 +/- 7.8) and PA (40.4 +/- 5.8) regarding the direct effect; and significantly lower in VA (34.3 +/- 7.1) and PA (37.8 +/- 5.6) compared to NA (44.6 +/- 6.2) regarding the preventive effect. In the preventive approach, mean wheal and flare size were significantly smaller in VA (0.38 +/- 0.12 cm(2)/8.1 +/- 2.0 cm(2)) compared to PA (0.54 +/- 0.13 cm(2)/13.5 +/- 2.8 cm(2)) and NA (0.73 +/- 0.28 cm(2)/15.1 +/- 4.1 cm(2)), and mean perfusion in VA (72.4 +/- 10.7) compared to NA (84.1 +/- 10.7). Mean EIQ ratings were significantly lower in VA compared to NA and PA in the treatment approach; and significantly lower in VA and PA compared to NA in the preventive approach. Acupuncture at the correct points showed a significant reduction in type I hypersensitivity itch in patients with atopic eczema. With time the preventive point-specific effect diminished with regard to subjective itch sensation, whereas it increased in suppressing skin-prick reactions.

Mean Wheal Size and Concentration at Positive as Risk Factors for Systemic Reaction with Imported Fire Ant Whole Body Extract Immunotherapy

RATIONALE: To determine if initial skin test mean wheal size (MWS) or concentration at which test was positive are predictive of increased risk for future systemic reactions with imported fire ant (IFA) whole body extract (WBE) immunotherapy which could allow physicians to modify immunotherapy treatment schedules to limit risk and for more accurate risk management communication to patients when discussing IFA immunotherapy.

Study of reservoir effect of clobetasol propionate cream in an experimental animal model using histamine-induced wheal suppression test

Background:Topical corticosteroids used in various dermatological diseases several times a day led to an increase risk of side effects. By demonstrating a significant reservoir of corticosteroids in the stratum corneum, one can maximize their efficacy and safety as therapeutic agents.Aim:The study was designed to demonstrate a reservoir of topically applied corticosteroid clobetasol propionate cream experimentally in rabbits using histamine-induced wheal suppression test.Materials and Methods:The work was carried out on albino rabbits, as rabbit skin is akin to human skin, using a topical steroid. The topical steroid clobetasol propionate 0.05% cream was applied on the back of rabbit, and after 1-h occlusion histamine-induced wheal suppression test was performed and wheal area measured at 10 min till day 7. Statistical analysis was done by ANOVA followed by “Post Hoc” test.Results:Maximum wheal suppression was seen on day 1 (P < 0.001). Interday comparison of mean wheal size showed no significant difference (P > 0.05) on day 2, 3, and 4 as compared to day 1. Day 5-7 show highly significant difference (P < 0.001) as compared to day 1, thereby suggesting that the reservoir effect of topical clobetasol propionate 0.05% cream persisted till day 4.Conclusions:This work demonstrated that histamine-induced wheal by the topical steroid clobetasol propionate 0.05% cream was suppressed till day 4, indicating that the reservoir of topical corticosteroid persisted till day 4.

Effect of acupuncture on allergen-induced itch in patients with atopic eczema

Background Itch is a complex and unpleasant sensory experience that induces the urge to scratch and is a major symptom of allergic skin disease. Acupuncture has been shown to exhibit a significant positive effect on histamine-induced itch in healthy volunteers. Objective We investigated the effect of acupuncture on allergen-induced itch, and wheal and flare response in a double-blind, randomized, placebo-controlled, crossover trial. Methods A skin prick test (house dust mite or grass pollen) was applied to 30 patients with atopic eczema before (direct effect) and after (preventive effect) two experimental approaches of conditioning or control observation: acupuncture at points Quchi and Xuehai (A1, dominant side), “placebo point” acupuncture (A2, dominant side), no acupuncture (NA). Itch intensity was recorded on a visual analogue scale. After 10 min, wheal and flare size, as well as temperature, were measured at the stimulus site and the validated Eppendorf Itch Questionnaire (EIQ) was completed by the patient. Results Mean itch intensity was significantly lower in A1 (35.7±6.4) compared to NA (45.9±7.8) and A2 (40.4±5.8) with regard to the direct effect; and significantly lower in A1 (34.3±7.1) and A2 (37.8±5.6) compared to NA (44.6±6.2) with regard to the preventive effect. Mean wheal and flare size was significantly smaller in A1 (0.38±0.12 cm 2 /8.1±2.0 cm 2 ) compared to A2 (0.54±0.13 cm 2 /13.5±2.8 cm 2 ) and NA (0.78±0.28 cm 2 /15.1±4.1 cm 2 ) in the preventive approach. Skin temperature showed no significant difference between groups. Mean EIQ ratings were significantly lower in A1 compared to NA and A2 in the treatment approach; and significantly lower in A1 and A2 compared to NA in the preventive approach. Conclusions Acupuncture at the correct points reduced allergen-induced itch intensity and prevented wheal and erythema formation compared to placebo procedures in patients with atopic eczema.

Mean Wheal Size from Peanut Prick Skin Test and IgE Levels in Peanut Allergic Patients Receiving Oral Peanut Immunotherapy

Oral immunotherapy (OIT) for peanut allergy is in clinical pilot studies. The relationship between prick skin test results and serum specific peanut IgE levels could be important clinical markers for tolerance.

Allergy Skin Test Responses During Experimental Infection With Respiratory Syncytial Virus

Skoner DP, Gentile DA, Angelini B, Doyle WJ. Ann Allergy Asthma Immunol. 2006;96:834–839 PURPOSE OF THE STUDY. To determine if a viral upper respiratory infection affects allergy skin-test responsiveness. STUDY POPULATION. Sixteen adults experimentally exposed to respiratory syncytial virus (RSV). METHODS. Subjects without concurrent upper or lower airway disease were cloistered and inoculated with 106 plaque-forming units of RSV type B. Daily physical examination and symptom scores were recorded. Nasal lavages were performed and stored at −70°C for RSV-antigen assay and culture. Blood samples were obtained for immunoglobulin E (IgE) measurement on days 0, 2, 4, 6, 8, 10, and 21. Skin-prick testing was performed for 17 locally relevant aeroallergens and controls on days 0, 3, 6, and 21. RESULTS. Eight patients had ≥1 positive skin-test result at baseline and were considered atopic. Eleven (5 atopic, 6 nonatopic) had evidence of postinoculation RSV infection. Atopic patients had a higher IgE level at baseline as compared with nonatopic subjects (123 ± 80 vs 45 ± 36 IU/mL; P &amp;lt; .01). There was no change in total IgE level in those in the nonatopic group, but the atopic subjects had a nonsignificant increase in IgE level on days 8 and 10 (146 ± 112 IU/mL). Of the 8 nonatopic patients, only 3 had negative skin-test results to all antigens on all 3 postinoculation test days. The mean number of positive wheal responses to allergens for all patients was 1.7 ± 2.3, 4.4 ± 3.8, 3.6 ± 3.5, and 3.9 ± 3.6 at baseline and days 3, 6, and 21, respectively (P &amp;lt; .01 versus baseline for all pairings). For patients with positive skin-test results at baseline, mean wheal and flare area provoked by those allergens increased after RSV exposure. The increased number of positive responses to skin testing was noted for both seasonal and perennial aeroallergens. CONCLUSIONS. The results may have some implication in explaining complications of RSV infection such as otitis media, asthma exacerbation, and subsequent development of asthma. REVIEWER COMMENTS. There has long been a chicken-and-egg question when it comes to RSV infection in childhood and subsequent development of asthma. That is, does RSV predispose to later recurrent wheezing illnesses, or does the predisposition to wheeze lead to worse outcomes with RSV infection? Are children with an atopic predisposition more likely to have a severe RSV infection, or are those with severe infection more likely to develop atopy? This small study did not answer the question, but it provides a hint that RSV infection itself might affect immunologic responsiveness to aeroallergens, at least in the short-term. The study results cannot be extrapolated to make any long-term conclusions. Furthermore, the study was undertaken in healthy adults. It would be unethical to intentionally infect infants and toddlers with RSV at an age when they might be most susceptible to the risks of environmental influences on the development of atopy and to the risks of the infection itself.