What is the role of skin testing in the workup of asthma?

Answer

Skin testing is one of the most useful ways of determining specific allergen sensitivity. Such tests for allergen-specific IgE are necessary if the clinician is to provide informed advice to patients about allergen avoidance techniques; they are also necessary for planning allergen immunotherapy regimens.

Skin tests have the advantage of being immediately available and visible to patients, which may reinforce to patients the need for environmental control and, possibly, immunotherapy.

Skin testing is recommended for antigens to which the patient is exposed rather than testing with a standard panel. Skin test findings have a fairly high false-positive rate but a very good negative predictive value. Thus, a positive test result does not mean that a patient is currently being exposed to an allergen or that he or she will react to it in a natural exposure. A negative test result generally rules out the possibility that an allergen is having an impact on the patient’s asthma.^[18] It is important to determine if a positive test result is clinically relevant (history of symptoms with exposure/timing).

Antihistamine medications and tricyclic antidepressants (TCAs) interfere with allergy skin testing; short courses of oral glucocorticoids at moderate doses do not.

Testing should not be performed during an asthma exacerbation, and the testing site should be equipped for the treatment of rare, life-threatening reactions.

Skin testing is performed with controls (eg, histamine and saline) to avoid false-positive (dermatographism) or false-negative results. Identification of allergen triggers can assist in formulating an environmental control strategy, titration of therapy (ie, seasonal exacerbation), or an immunotherapy regimen.

Did this answer your question?

Yes No

Additional feedback? (Optional)

Thank you for your feedback!

Expert panel-3. NHLBI NIH; AUG 2007. 440. [Full Text].
Scirica CV, Celedón JC. Genetics of asthma: potential implications for reducing asthma disparities. Chest. 2007 Nov. 132(5 Suppl):770S-781S. [Medline].
Nurmagambetov T, Kuwahara R, Garbe P. The Economic Burden of Asthma in the United States, 2008-2013. Ann Am Thorac Soc. 2018 Mar. 15 (3):348-356. [Medline].
Yaghoubi M, Adibi A, Safari A, FitzGerald JM, Sadatsafavi M, Canadian Respiratory Research Network. The Projected Economic and Health Burden of Uncontrolled Asthma in the United States. Am J Respir Crit Care Med. 2019 Jun 5. [Medline].
Marcus P. Incorporating anti-IgE (omalizumab) therapy into pulmonary medicine practice: practice management implications. Chest. 2006 Feb. 129(2):466-74. [Medline].
Zhang Z, Lai HJ, Roberg KA, Gangnon RE, Evans MD, Anderson EL, et al. Early childhood weight status in relation to asthma development in high-risk children. J Allergy Clin Immunol. 2010 Dec. 126(6):1157-62. [Medline].
Ege MJ, Mayer M, Normand AC, Genuneit J, Cookson WO, Braun-Fahrländer C, et al. Exposure to environmental microorganisms and childhood asthma. N Engl J Med. 2011 Feb 24. 364(8):701-9. [Medline].
Stein MM, Hrusch CL, Gozdz J, Igartua C, Pivniouk V, Murray SE, et al. Innate Immunity and Asthma Risk in Amish and Hutterite Farm Children. N Engl J Med. 2016 Aug 4. 375 (5):411-421. [Medline].
Braman SS. The global burden of asthma. Chest. 2006 Jul. 130(1 Suppl):4S-12S. [Medline].
Eder W, Ege MJ, von Mutius E. The asthma epidemic. N Engl J Med. 2006 Nov 23. 355(21):2226-35. [Medline].
American Lung Association Epidemiology and Statistics Unit Research and Health Education Division. Trends in Asthma Morbidity and Mortality. American Lung Association. Available at https://www.lung.org/assets/documents/research/asthma-trend-report.pdf. September 2012;
Hofmaier S. Allergic airway diseases in childhood: an update. Pediatr Allergy Immunol. 2014 Dec 3. [Medline].
Sasaki M, Yoshida K, Adachi Y, Furukawa M, Itazawa T, Odajima H, et al. Factors associated with asthma control in children: findings from a national web-based survey. Pediatr Allergy Immunol. 2014 Dec 2. [Medline].
Tilles SA. Differential diagnosis of adult asthma. Med Clin North Am. 2006 Jan. 90(1):61-76. [Medline].
Miller MR, Quanjer PH, Swanney MP, Ruppel G, Enright PL. Interpreting lung function data using 80% predicted and fixed thresholds misclassifies more than 20% of patients. Chest. 2011 Jan. 139(1):52-9. [Medline].
Hansen JE. Lower limit of normal is better than 70% or 80%. Chest. 2011 Jan. 139(1):6-8. [Medline].
Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005 Nov. 26(5):948-68. [Medline].
Bernstein IL, Li JT, Bernstein DI, Hamilton R, Spector SL, Tan R, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008 Mar. 100(3 Suppl 3):S1-148. [Medline].
Kowalski ML, Cieslak M, Pérez-Novo CA, Makowska JS, Bachert C. Clinical and immunological determinants of severe/refractory asthma (SRA): association with Staphylococcal superantigen-specific IgE antibodies. Allergy. 2011 Jan. 66(1):32-8. [Medline].
Imaoka H, Gauvreau GM, Watson RM, et al. Sputum inflammatory cells and allergen-induced airway responses in allergic asthmatic subjects. Allergy. 2011 Aug. 66(8):1075-80. [Medline].
Szefler SJ, Mitchell H, Sorkness CA, Gergen PJ, O'Connor GT, Morgan WJ, et al. Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised controlled trial. Lancet. 2008 Sep 20. 372(9643):1065-72. [Medline]. [Full Text].
Juniper EF, Kline PA, Vanzieleghem MA, Ramsdale EH, O'Byrne PM, Hargreave FE. Effect of long-term treatment with an inhaled corticosteroid (budesonide) on airway hyperresponsiveness and clinical asthma in nonsteroid-dependent asthmatics. Am Rev Respir Dis. 1990 Oct. 142(4):832-6. [Medline].
Long-term effects of budesonide or nedocromil in children with asthma. The Childhood Asthma Management Program Research Group. N Engl J Med. 2000 Oct 12. 343(15):1054-63. [Medline].
Pauwels RA, Löfdahl CG, Postma DS, Tattersfield AE, O'Byrne P, Barnes PJ, et al. Effect of inhaled formoterol and budesonide on exacerbations of asthma. Formoterol and Corticosteroids Establishing Therapy (FACET) International Study Group. N Engl J Med. 1997 Nov 13. 337(20):1405-11. [Medline].
Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000 Aug 3. 343(5):332-6. [Medline].
Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest. 2006 Jan. 129(1):15-26. [Medline].
Rabe KF, Pizzichini E, Ställberg B, Romero S, Balanzat AM, Atienza T, et al. Budesonide/formoterol in a single inhaler for maintenance and relief in mild-to-moderate asthma: a randomized, double-blind trial. Chest. 2006 Feb. 129(2):246-56. [Medline].
Pavord ID, Jeffery PK, Qiu Y, Zhu J, Parker D, Carlsheimer A, et al. Airway inflammation in patients with asthma with high-fixed or low-fixed plus as-needed budesonide/formoterol. J Allergy Clin Immunol. 2009 May. 123(5):1083-9, 1089.e1-7. [Medline].
Hanania NA, Alpan O, Hamilos DL, et al. Omalizumab in severe allergic asthma inadequately controlled with standard therapy: a randomized trial. Ann Intern Med. 2011 May 3. 154(9):573-82. [Medline].
Levenson M. Long-acting beta-agonists and adverse asthma events meta-analysis. Statistical briefing package for Joint Meeting of the Pulmonary-Allergy Drugs Advisory Committee, Drug Safety and Risk Management Advisory Committee and Pediatric Advisory Committee. December 10-11, 2008. Available at http://www.fda.gov/ohrms/dockets/ac/08/briefing/2008-4398b1-01-FDA.pdf. Accessed: January 13, 2009.
US Food and Drug Administration. FDA Announces New Safety Controls for Long-Acting Beta Agonists, Medications Used to Treat Asthma. FDA Web site. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm200931.htm. Accessed: March 11, 2010.
Long-Acting Beta agonists (LABAs) and Inhaled Corticosteroids (ICS): Drug Safety Communication - Boxed Warning About Asthma-Related Death Removed. US Food and Drug Administration. Available at https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm590001.htm. December 20, 2017; Accessed: December 22, 2017.
Baur X, Sigsgaard T, Aasen TB, Burge PS, Heederik D, Henneberger P, et al. Guidelines for the management of work-related asthma. Eur Respir J. 2012 Mar. 39(3):529-545. [Medline].
Sheikh A, Hurwitz B, Shehata Y. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev. 2007 Jan 24. CD001563. [Medline].
Vinhas R, Cortes L, Cardoso I, et al. Pollen proteases compromise the airway epithelial barrier through degradation of transmembrane adhesion proteins and lung bioactive peptides. Allergy. 2011 Aug. 66(8):1088-98. [Medline].
Nelson HS. Allergen immunotherapy: where is it now?. J Allergy Clin Immunol. 2007 Apr. 119(4):769-79. [Medline].
Abramson MJ, Puy RM, Weiner JM. Allergen immunotherapy for asthma. Cochrane Database Syst Rev. 2003. CD001186.
Brüggenjürgen B, Reinhold T, Brehler R, Laake E, Wiese G, Machate U, et al. Cost-effectiveness of specific subcutaneous immunotherapy in patients with allergic rhinitis and allergic asthma. Ann Allergy Asthma Immunol. 2008 Sep. 101(3):316-24. [Medline].
Wilson DR, Torres LI, Durham SR. Sublingual immunotherapy for allergic rhinitis. Cochrane Database Syst Rev. 2003. CD002893. [Medline].
Maloney J, Bernstein DI, Nelson H, Creticos P, Hébert J, Noonan M, et al. Efficacy and safety of grass sublingual immunotherapy tablet, MK-7243: a large randomized controlled trial. Ann Allergy Asthma Immunol. 2014 Feb. 112 (2):146-153.e2. [Medline].
Creticos PS, Esch RE, Couroux P, Gentile D, D'Angelo P, Whitlow B, et al. Randomized, double-blind, placebo-controlled trial of standardized ragweed sublingual-liquid immunotherapy for allergic rhinoconjunctivitis. J Allergy Clin Immunol. 2014 Mar. 133 (3):751-8. [Medline].
Creticos PS, Maloney J, Bernstein DI, Casale T, Kaur A, Fisher R, et al. Randomized controlled trial of a ragweed allergy immunotherapy tablet in North American and European adults. J Allergy Clin Immunol. 2013 May. 131 (5):1342-9.e6. [Medline].
Nolte H, Bernstein DI, Nelson HS, Kleine-Tebbe J, Sussman GL, Seitzberg D, et al. Efficacy of house dust mite sublingual immunotherapy tablet in North American adolescents and adults in a randomized, placebo-controlled trial. J Allergy Clin Immunol. 2016 Dec. 138 (6):1631-1638. [Medline].
Karpel J, Massanari M, Geba GP, Kianifard F, Inhaber N, Zeldin RK. Effectiveness of omalizumab in reducing corticosteroid burden in patients with moderate to severe persistent allergic asthma. Ann Allergy Asthma Immunol. 2010 Dec. 105(6):465-70. [Medline].
Rodrigo GJ, Neffen H, Castro-Rodriguez JA. Efficacy and safety of subcutaneous omalizumab vs placebo as add-on therapy to corticosteroids for children and adults with asthma: a systematic review. Chest. 2011 Jan. 139(1):28-35. [Medline].
ClinicalTrials.gov. A Study of Xolair to Evaluate Effectiveness and Long-Term Safety in Patients With Moderate to Severe Asthma. ClinicalTrials.gov. Available at http://clinicaltrials.gov/ct2/show/NCT00252135. Accessed: February 26, 2010.
Mastronarde JG, Anthonisen NR, Castro M, Holbrook JT, Leone FT, Teague WG, et al. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med. 2009 Apr 9. 360(15):1487-99. [Medline]. [Full Text].
Sander N, Fusco-Walkert SJ, Harder JM, Chipps BE. Dose counting and the use of pressurized metered-dose inhalers: running on empty. Ann Allergy Asthma Immunol. 2006 Jul. 97(1):34-8. [Medline].
Aaron SD, Fergusson D, Dent R, Chen Y, Vandemheen KL, Dales RE. Effect of weight reduction on respiratory function and airway reactivity in obese women. Chest. 2004 Jun. 125(6):2046-52. [Medline].
Hallstrand TS, Bates PW, Schoene RB. Aerobic conditioning in mild asthma decreases the hyperpnea of exercise and improves exercise and ventilatory capacity. Chest. 2000 Nov. 118(5):1460-9. [Medline].
Fisher EB, Strunk RC, Highstein GR, Kelley-Sykes R, Tarr KL, Trinkaus K, et al. A randomized controlled evaluation of the effect of community health workers on hospitalization for asthma: the asthma coach. Arch Pediatr Adolesc Med. 2009 Mar. 163(3):225-32. [Medline].
Woessner KM, Simon RA, Stevenson DD. Monosodium glutamate sensitivity in asthma. J Allergy Clin Immunol. 1999 Aug. 104(2 Pt 1):305-10. [Medline].
Bunyavanich S, Schadt EE. Systems biology of asthma and allergic diseases: A multiscale approach. J Allergy Clin Immunol. 2014 Nov 21. [Medline].
Calderón MA, Linneberg A, Kleine-Tebbe J, De Blay F, Hernandez Fernandez de Rojas D, Virchow JC, et al. Respiratory allergy caused by house dust mites: What do we really know?. J Allergy Clin Immunol. 2014 Nov 22. [Medline].
Buist AS, Vollmer WM, Wilson SR, Frazier EA, Hayward AD. A randomized clinical trial of peak flow versus symptom monitoring in older adults with asthma. Am J Respir Crit Care Med. 2006 Nov 15. 174(10):1077-87. [Medline]. [Full Text].
Woolcock A, Lundback B, Ringdal N, Jacques LA. Comparison of addition of salmeterol to inhaled steroids with doubling of the dose of inhaled steroids. Am J Respir Crit Care Med. 1996 May. 153(5):1481-8. [Medline].
Currie GP, Lee DK, Srivastava P. Long-acting bronchodilator or leukotriene modifier as add-on therapy to inhaled corticosteroids in persistent asthma?. Chest. 2005 Oct. 128(4):2954-62. [Medline].

Media Gallery

of 0

Author

John J Oppenheimer, MD Clinical Professor, Department of Medicine, Rutgers New Jersey Medical School; Director of Clinical Research, Pulmonary and Allergy Associates, PA

John J Oppenheimer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, New Jersey Allergy, Asthma and Immunology society

Disclosure: Received research grant from: quintiles, PRA, ICON, Novartis: Adjudication<br/>Received consulting fee from AZ for consulting; Received consulting fee from Glaxo, Myelin, Meda for consulting; Received grant/research funds from Glaxo for independent contractor; Received consulting fee from Merck for consulting; Received honoraria from Annals of Allergy Asthma Immunology for none; Partner received honoraria from ABAI for none. for: Atlantic Health System.

Coauthor(s)

Mauli Desai, MD Associate Professor of Medicine, Division of Allergy and Clinical Immunology, Icahn School of Medicine at Mount Sinai

Mauli Desai, MD is a member of the following medical societies: American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, New Jersey Allergy, Asthma and Immunology society, New York Allergy & Asthma Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen C Dreskin, MD, PhD Professor of Medicine, Departments of Internal Medicine, Director of Allergy, Asthma, and Immunology Practice, University of Colorado Health Sciences Center

Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, Joint Council of Allergy, Asthma and Immunology, American Association of Immunologists

Disclosure: Received consulting fee from Genentech for consulting; Received grant support from NIH for research; Received consulting fee from Clinical Immunization and Safety Assessment (CISA) Network (administered by Vanderbilt University) for consulting; Received consulting fee from o Member, Medical Expert Panel, Division of Vaccine Injury Compensation (DVIC), Department of Health and Human Services. for med legal reviews; Received consulting fee from o Member, Medical Expert Panel, Vaccine Review, Pfize.

Chief Editor

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; Medical Director, Institute for Asthma and Allergy

Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, Association of American Physicians

Disclosure: Nothing to disclose.

Additional Contributors

William F Kelly, III, MD Associate Professor of Medicine, Uniformed Services University of the Health Sciences; Staff Physician, Division of Pulmonary/Critical Care Medicine, Department of Medicine, Walter Reed National Military Medical Center

William F Kelly, III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Chest Physicians

Disclosure: Nothing to disclose.

Gregory J Argyros, Col, MD Chief, Graduate Medical and Dental Education, J7/Joint Task Force, National Capital Region Medical; Professor of Medicine, Uniformed Services University of the Health Sciences

Gregory J Argyros, Col, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society

Disclosure: Nothing to disclose.

Brian M Cohee, MD Fellow in Pulmonary and Critical Care Medicine, Walter Reed National Military Medical Center

Brian M Cohee, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Thoracic Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

What is the role of skin testing in the workup of asthma?

Answer

Related Questions:

References

Tables

Contributor Information and Disclosures