Allergy 2002: 57: 4551

Printed in UK. All rights reserved

Copyright # Munksgaard 2002

ALLERGY
ISSN 0105-4538

Rostrum

General considerations for skin test procedures in the diagnosis of

drug hypersensitivity
K. Brockow1, A. Romano2,
M. Blanca3, J. Ring1, W. Pichler4,
P. Demoly5*
1
Klinik und Poliklinik fur Dermatologie und
Allergologie, Muenchen, Germany; 2Department of
Internal Medicine and Geriatrics, UCSC, Allergy Unit,
CI Columbus, Rome and IRCS Oasi Maria SS, Troina,
Italy; 3Research Unit for Allergic Diseases, Carlos Haya
Hospital, Malaga, Spain; 4Clinic for Rheumatology and
Clinical Immunology/Allergology, Inselspital, Bern,
Switzerland; 5Maladies Respiratoires, Hopital Arnaud
de Villeneuve, Montpellier, France

Pascal Demoly
Maladies Respiratoires
INSERM U454
Hopital Arnaud de Villeneuve
CHU de Montpellier
34295 Montpellier cedex 5
France
Accepted for publication 20 August 2001

Diagnostic procedures in allergy diagnosis can be

classified into the patients history, in vivo skin testing,
in vitro laboratory tests and provocation tests (1). In
drug hypersensitivity, a reliable diagnosis is particularly
difficult. The history is often not reliable since different
drugs are often taken simultaneously. Test reagents are
neither standardized for in vitro nor for in vivo (skin)
tests and provocation tests are cumbersome, possibly
harmful for the patient and possibly not sensitive
enough since crucial cofactors might be absent during
the procedure. Finally, the clinical picture of drug

*ENDA: European Network for Drug Allergy, the EAACI interest

group on drug hypersensitivity with the following additional members:
Drs W. Aberer, B. K. Ballmer-Weber, A. Barbaud, A. Bircher, J.
Birnbaum, P. Campi, A. de Weck, M. Drouet, J. Fernandez, T. Fuchs, E.
Gomes, J. L. Gueant, C. Gutgesell, A. Kapp, M. Kowalski, G. Marone,
H. Merk, D. Moneret-Vautrin, C. Pascual-Marcos, B. Przybilla, E.
Rebelo-Gomes, F. Rueff, A. Sabbah, J. Sainte Laudy, M. J. Torres, D.
Vervloet, B. Wedi

hypersensitivity is very heterogeneous, mirroring many

distinct pathophysiological events. When immunologic
mechanisms have been shown, either antibody or cell
mediated, the reactions are referred as drug allergy (20).
Drug allergy is in the vast majority due to IgE-mediated
immediate-type reactions or T-cell mediated delayedtype reactions. In a large number of patients, no allergy
can be proven, which may be either due to the lack of
adequate test reagents or procedures, or may indicate a
non-allergic pathomechanism. Thus, many doctors rely
on history and some reference manuals for drug adverse
event diagnosis, without attempting to prove the
relationship between drug intake and symptoms or to
clarify the underlying pathomechanism of the reaction.
Such an attitude leads to a misunderstanding of the
epidemiology and the pathophysiology of this highly
relevant field.
Skin tests can be used for the evaluation of a drug
hypersensitivity (25). The diagnostic value of skin
tests has not been fully evaluated and the experience in
different centres has rarely been exchanged during the
45

Brockow et al.
last decades. Thus, reliable skin test procedures for the
diagnosis of drug hypersensitivity are generally missing
and test concentrations are unknown or poorly
validated for most drugs.
Skin tests have to be applied according to the
suspected
pathomechanism
of
the
drug
hypersensitivity (25). In immediate b-lactam drug
allergy an IgE-mediated reaction can be demonstrated
by a positive skin prick and/or intradermal test after
20 min (6, 7). On the other hand, non-immediate
reactions to b-lactams manifesting by cutaneous
symptoms occurring more than one hour after last
drug intake, are often T-cell mediated and a positive
patch test and/or a late-reading intradermal test is
found after several hours or days (8). Moreover, skin
tests have the additional capability to give insights
concerning the immunologic pathomechanism.
To harmonize our drug hypersensitivity diagnostic
procedures in Europe, members of ENDA (the core
part of the EAACI interest group on drug hypersensitivity) have first developed a questionnaire based on a
detailed history of the reaction (9). It also includes some
procedures for skin tests, provocation tests and
biological tests. It is available in various languages
and thus utilized in different regions of Europe. Our
next aim is to develop useful test procedures for the
diagnosis of drug hypersensitivity, procedures which
are simple and can be used in centres not specialized in
drug hypersensitivity.
As a first step, we define general principles for skin
testing of drugs, to establish the best skin test
concentrations to be used for already well-studied substances. For other substances and through collaborative
studies, we will be able to provide sensitivity and
specificity data for each drug and drug concentration.

Selection of patients for skin testing

A list of common clinical symptoms, for which skin

testing is recommended is listed in .Table 1. For the
practising allergist, skin testing with SPT, IDT and/or
patch test is especially recommended in adverse drug
reactions to beta-lactam antibiotics (mainly penicillins,
cephalosporins). SPT and IDT are often positive to
myorelaxants, insulin, protamine, heparin, streptokinase and chymopapain. It is also recommended to
perform patch tests and IDT in delayed local or
exanthematic adverse reactions to other antibiotics,
carbamazepine, practolol, pyrazonolines and tetrazepam. Skin tests and provocation tests to local
anesthetics should be performed; however, in this case
the purpose is to exclude a reaction to a preparation
under test conditions, rather than to confirm drug
hypersensitivity.
Symptoms and signs generally indicating drug
allergy, as opposed to non-immunologic adverse
46

reaction, are the presence of a sensitization period,

reaction to low dosages of the drug, and typical
symptomatology such as urticaria and anaphylaxis
immediately after administration of a drug (Table 1).
However, in adverse reactions to drugs, this general
scheme is often unreliable, as sensitization may not be
apparent and some reactions may mimic symptoms of
allergy. Thus, centres with a special interest on drug
allergies are encouraged to test patients with other
drugs to gain and publish experience on the value of
skin testing under different conditions.
There are other diseases where immunological
reactions to drugs could be involved, but skin testing
has generally not been found helpful. For example,
renal or hepatic manifestations may occur as a part of a
generalized allergic reaction (e.g., in Drug Reaction
with Eosinophilia and Systematic Symptoms). However, the value of skin tests in hematological (anemia,
thrombocytopenia, leukopenia), renal (e.g., glomerulonephritis) or hepatic manifestations (e.g., hepatitis) has
not been proven. Also skin testing is not considered
to be helpful in autoimmune diseases like systemic
lupus erythematosis, bullous pemphigoid, pemphigus
vulgaris, and interstitial lung disease.
An algorithm for the use of skin tests is given in .Fig. 1.
In immediate, possibly drug-related symptoms of
urticaria/angioedema, rhinitis, conjunctivitis, bronchospasm or other anaphylactic symptoms, skin prick tests
and intradermal tests are recommended. However, it has
to be considered that systemic reactions during skin
testing might occur (see Testing of patients at higher risk;
below).
In non-immediate, possibly drug-related reactions of
contact dermatitis, photo-contact dermatitis, exanthematous drug eruptions, urticaria/angioedema, purpura
pigmentosa progressiva, leucocytoclastic vasculitis, fixed
drug eruptions (testing in previously involved areas and in
unaffected skin), StevensJohnson Syndrome, erythema
multiforme, and toxic epidermal necrolysis, patch tests
and/or late readings of the intradermal tests after 24, 48
and 72 h are recommended (25, 8, 1012). Also in nonimmediate drug hypersensitivity, systemic reactions
following skin testing are known (13). In severe situations
especially, skin testing has to be performed with caution
(see specific chapter, Testing of patients at higher risk). A
recurrence or elicitation of a toxic epidermal necrolysis
due to skin testing has not been described in the literature.

Skin test methods

Standardized skin test methods considered in this

document are the skin prick test (SPT), the intradermal
test (IDT), the patch test and the photopatch test.
Scratch tests are used in some centres, but will not be
further considered in this paper.

Skin tests for drug hypersensitivity

Table 1 Common clinical indications for skin testing in the diagnosis of drug
hypersensitivity
Patch tests can be used
as first line of investigation

Skin prick tests and

intradermal tests

Acute generalized
exanthematous pustulosis
Contact dermatitis
Erythema multiforme
Exanthematous drug
eruption
Fixed drug eruption
Photoallergic reactions
Purpura/Leucocytoclastic
Vasculitis
StevensJohnson Syndrome
Toxic epidermal necrolysis

Anaphylaxis
Bronchospasm
Conjunctivitis
Rhinitis
Urticaria/angioedema

Skin prick tests and intradermal tests

(1) Procedure. A SPT is done by pricking the skin

percutaneously with a prick needle through an
allergen solution (14). It is the safest and easiest test,
but only moderately sensitive, for immediate drug
reactions. An intradermal test is accomplished by
injecting 0.020.05 ml of an allergen intradermally,
raising a small bleb measuring 3 mm in diameter. The
IDT is more sensitive than the SPT, but also carries a
higher risk for inducing an irritative, falsely positive
reaction and might even lead to an anaphylactic
reaction in IgE-dependent reactions.
Certain drugs have to be discontinued prior to skin
testing .(Table 2). The patient should be free of
infectious diseases, fever or inflammatory reactions at
the time of testing, unless the skin test is urgently
needed. The intake of b-adrenergic blocking agents
should be discontinued (usually for 48 h,) according to
their half-life of elimination, if the drug to be tested had
induced an anaphylactic reaction, as these drugs may
interfere with treatment of a possible systemic reaction
elicited by the skin test.
SPT should be performed on the volar aspect of the
forearm. If this is negative after 1520 min, an
intradermal test can be performed on the volar forearm,
although other regions can be tested (however, there is
no comparison for drug allergens). The pain of
intradermal tests may limit their use in young children.

Figure 1. Algorithm for the use of skin tests in the diagnosis of

drug hypersensitivities. The only in vitro test thoroughly validated
is the RAST to penicillin determinants. Results of in vitro tests have
to be regarded in concert with the history and results of skin tests.

Normally these tests are well tolerated, but in highly

IgE sensitized patients generalized symptoms (urticaria
and anaphylaxis) might appear.
(2) Documentation and scoring. Readings should be
taken after 1520 min if immediate reactions are
analyzed, and after 24 and 72 h for evaluation of
non-immediate (late) reactions. In selected cases,
additional readings (e.g., after 96 h) are sometimes
recommended, as time intervals between testing and
positive test reactions may vary.
Immediate reactions are documented by measuring
the mean diameter of the wheal (and erythema) of the
test preparations and the negative control directly after
the injection and after 1520 min. Different qualitative
scoring systems are available and used in different
centres (14). In order to compare the results, a
morphological score should be applied as well, enabling
a later comparison of different scoring systems. The
preferred documentation manner is by outlining the size
of the injected area and of the reaction at 1520 min on
a translucent cellophane tape. As a criterion for

Table 2 Drug-free interval demanded for drugs decreasing reactivity of skin tests (adapted from (14))
Medication

Route

H1-antihistamines Imipramines, phenothiazines

b-adrenergic drugs
Glucocorticosteroids***
Long-term
Short-term, high dose
Short-term, < 50 mg pred*
Topical corticosteroids

Oral, intravenous
Oral, intravenous
Oral, intravenous
Oral, intravenous
Oral, intravenous
Oral, intravenous
Topical****

Immediate reaction

Non-immediate reaction

Free interval

+
+
t
t
t
t
t

+
+

5d
5d
**
3 weeks
1 week
3d
> 2 weeks

*Prednisolone equivalent; ** no clinical relevance; *** withdrawal may not be possible; **** at the site of testing only.

47

Brockow et al.
positivity, which has been employed in the diagnosis of
penicillin allergy and may be used tentatively for other
drugs, reactions are considered positive when the size of
the initial wheal increases by 3 mm or greater in
diameter after 1520 min and is associated with a flare
(15). The mean diameter is recorded by measuring the
largest and the smallest diameters at right angles to each
other. Both diameters are recorded, summed and
divided by 2. The area can be determined by other
methods: weighing of the cellophane, planimetry and
computerized scanning.
Late reactions, such as delayed or late-phase reactions, should always be examined. They are documented by the diameter of erythema, papulation/infiltrate
and morphological description, such as erythematous
swelling, erythematous infiltrate, erythema only,
eczema with papulation and/or vesicles. Any infiltrated
erythema is considered to represent a positive reaction.
For later comparison and research purposes, photodocumentation and, if possible, histology may be
recommended.
Patch tests and photopatch tests

(1) Procedure. In a patch test the allergen is usually

fixed on the back of the patient for 12 days and the
result is read after 1 day and/or 23 days (16). A
photopatch test is a modification of the patch test
used when photoallergic or phototoxic reactions are
suspected. After one day the patch test is removed
and the skin is irradiated with ultraviolet light, 5 or
10 J/cm2 UVA (12). This test is read after two, three
and four days.
Patch testing should not be done in patients after
prior strong UV-exposure (e.g., after holidays at the
seaside), because the test reactivity is usually diminished. Demanded drug-free intervals for certain drugs
are listed in Table 2. Large doses of topical glucocorticosteroid treatment away from the test site may have
the same effects as low doses of systemic glucocorticosteroid treatment. The patient should be free of
infectious diseases, fever or inflammatory reactions at
the time of testing.
Patch test are done on the upper back on unaffected,
untreated and uncleaned skin (no prior rinsing with
alcohol) using Finn Chambers or an equivalent fixed
with a hypoallergic tape. Immediate reactions to the
drug should be ruled out by the clinical history before
the patch tests are applied.
The patch test should be applied for 2 days until
results comparing 1 and 2 day application is available.
Further patch tests with longer durations of application
might be indicated in special cases.
(2) Documentation and scoring. Readings should be
done at least at two consecutive times: 48 h and 72 h.
It still has to be determined whether applications of
48

patch tests for 24 h and readings after 24 and 72 h

yield the same results. Additional readings, for
example in hospitalized patients, after 96 h or more
might also be needed in some cases. Scoring is done
according to international standards (12, 16).
Sometimes reactions occur earlier or much later (as in
the case of corticosteroids and phenylephrine).
Patients should be instructed to report to the doctor
if they notice a reaction at any time. Scoring is done
according to the European Environmental and Contact
Dermatitis Research Group patch test and photopatch test classifications .(Table 3) (12, 16).

Best time interval between drug hypersensitivity and skin

testing

There is a consensus of opinion that skin tests should be

performed after a time interval which allows resolution
of clinical symptoms, clearance from the circulation of
the incriminated drugs and anti-allergic medications.
However, it is not known whether the reactivity might
be higher (e.g., cellular hyperreactivity) or lower (e.g.,
initial histamine depletion of mast cells or tolerance) if
skin tests are performed directly after the reaction
(within the next few days). It is also not known to what
extent the sensitization to a drug decreases over time.
Thus, many groups carry out tests after some minimal
time interval of, for example, three weeks, but not after
more than three months, if possible.

Testing of patients at higher risk

There are some patients experiencing systemic reactions

after percutaneous and epicutaneous skin testing.
Patients who have been hospitalized because of an
allergic reaction and/or who had a life-threatening drug
hypersensitivity, including anaphylaxis and severe skin
reactions (e.g., toxic epidermal necrolysis, severe bullous
exanthemas, vasculitis, StevensJohnson Syndrome) or
systemic reactions (e.g., hypersensitivity syndrome) are
at risk, even if there is a long time interval between the
drug hypersensitivity and skin testing (17). Case-control
studies gathering such data from different centres are
needed to evaluate precisely the exact risk factors. In
Table 3 Scoring of patch test reactions (modified from (16))
Clinical picture

Score

Conclusion

Faint erythema only

Erythema, infiltration, possibly discrete papules
Erythema, infiltration, papules, vesicles
Intense erythema, infiltration, coalescing vesicles

? or + ?
+
++
+++

IR
NT

Doubtful reaction
Weak positive reaction
Strong positive reaction
Extreme positive reaction
Negative reaction
Different irritant reactions
Not tested

+, + + , + + + are regarded as positive skin test reactions and as a negative

skin test reaction.

Skin tests for drug hypersensitivity

such high risk patients a risk-benefit analysis has to be
done: is the skin test necessary? Are all precautions taken
in case of some reactions occur? The risk-benefit analysis
has to be made by the allergist in regard to the clinical
reaction, the possibilities of treatment for a possible
adverse reactions, the risk for the patient and the
importance of the drug. If ever possible, pregnant
women should not been tested. The drug should initially
be tested with a higher dilution of the test preparations
(e.g., 1/101/100000). Although not validated as well, an
open application can be performed initially in very
severe immediate reaction. The next concentration step
has to be applied only if the higher dilution has yielded a
negative result. In severe, nonimmediate reactions it has
to be considered to extend the time interval between tests
and not to perform intradermal test with the highest
concentration before performing patch tests.

Test preparations, test vehicles and solutions

Specific standardized skin test reagents are commercially available only for penicillins. PenicilloylPolylysine (PPL) and Minor Determinant Mixture
(MDM) (Allergopen, Allergopharma, Steinbeck,
Germany) have been specifically developed for skin
testing of suspected drug allergy to penicillins and
validated procedures do exist. However, when tested
according to the recommendations of the manufacturer these reagents are negative in SPT and IDT, it is
recommended to test also the culprit b-lactam
preparation. For this, as for all other drugs, test
material is normally restricted to drugs commercially
available on the market. Because of better standardization, skin testing should be encouraged in the form
of preparations for parenteral administration. If the
reaction occurred with the oral preparation, this
should be tested also by patch and skin prick tests as
it may contain different constituents. Initial testing
using a suitable dilution can be performed with the
whole culprit medication suspected to have elicited
the drug hypersensitivity reaction (see Test concentrations). In the case of a positive test reaction, it is
possible that either an active ingredient or a drug
additive is responsible for the reaction and both must
be tested separately. It should be attempted to
identify the relevant constituent of the drug preparation that leads to a reaction .
For patch testing, intradermal testing and the skin
prick test, preparations for parenteral (mostly intravenous) route should be diluted in 0.9% NaCl.
Pharmacological data concerning the application of
parenteral preparations in the skin are not known. For
intradermal tests, sterile solutions are obligatory. For
non-hydrosoluble drugs a stock solution can be
prepared in dimethyl-sulfoxide (DMSO) and further

diluted down with 0.9% NaCl. A negative control with

the same concentration of DMSO is needed in these
cases.
For skin prick tests and patch tests of drugs that are
only available as a tablet, not in a soluble form, the
tablets can be smashed in a mortar and diluted with
0.9% NaCl or petrolatum. There is some experience of
this method in certain groups (13). The tablets should
be weighed and the concentration of the active
ingredient should be determined. Test concentrations
should be given in mg drug/ml vehicle and optimal test
concentrations for individual drugs should be calculated for the future.
For patch tests, substances should be diluted in
0.9% NaCl or in petrolatum, depending on the
solubility and toxicity of the preparation (e.g., with
acidic preparations). There are no data in the literature
which compare both vehicles systematically. Thus we
do not know if the reactivity to a drug in a sensitized
individual tested at 5% in petrolatum is equivalent to
the reactivity tested at 50 mg/ml of 0.9% NaCl.

Test concentrations

A skin test reaction to a drug tested in a concentration

that does not cause a reaction in a sufficient number of
controls is indicative of a drug allergy. Sometimes test
concentrations for some drugs can be found in the
literature .(Table 4). If not, one may begin to test the
compound in a similar concentration as a related drug
for which there are data in the literature. Ideally, molar
concentrations of the drug are given, but for practical
purposes concentrations in mg drug/ml vehicle are
more often used.
For other drugs, the optimal test concentration is
unknown and must be determined. The optimal test
concentration is the highest concentration of a particular drug, which does not give any skin reaction
(irritative reactions are not rare) in a group of neverexposed subjects and a group of already-exposed but
non-allergic individuals (see Controls below), but may
be positive in patients with drug allergy. Whether this
concentration relates to the serum or skin concentration
of the drug when one takes a therapeutic dose of this
medication is not known.
In immediate reactions, gradually increasing concentrations are tested in the patient to titrate the
concentration causing a positive test reaction.
Appropriate concentrations for testing with fresh
preparations have not been well studied in large
groups of patients and controls. Thus, the starting
dilution (sometimes as low as 1/100 000) is not clearly
defined for most drugs and also depends on the severity
of the reaction (see below Patients at higher risk).
Initially the skin prick test is done with a low
concentration (usually not lower than 1/100 of the
49

Brockow et al.
Table 4. Patch test concentrations used in the literature and in the practice
Antibiotic

DKG1

De Groot (18)

Barbaud (2)

Others (8, 18)

Penicillin G

5% pet

Pure in powder with sodium citrate*

Romano: 5000 iU/g pet

Bruynzeel: 20% w/w

Other penicillins

5% pet

Pure in powder*

Cephalosporins

5% pet

Romano: 5% pet (20 controls)

Bruynzeel: 20% w/w
Bruynzeel: 20% w/w

Cotrimoxazole
Tetracycline-HCl

Trimethoprim 5% pet
Sulfamethoxazol 5% pet
2% pet

Gentamycin sulfate
Ciprofloxacin, ofloxacin
Erythromycin

20% pet
5% pet
1% pet

Pure
1% pet
10000 iU pet
Pure
1% pet
20% pet or pure
0.5% water
Sulfonamide (not specified):
5% pet
3% pet
5% pet
20% pet
1% pet
5% pet
10% pet

Pristinamycine
Carbamazepine

Pure in powder*
80 mg/ml in water
Doxycycline: 20 mg/ml in water

Norfloxacin: in powder from pill*

Pure in powder*

Pure in powder*
Pure in powder*

1
DKG: German contact allergy group (test concentrations in German practice).
*All these preparations were tested pure and diluted to 30% in water and in petrolatum.
pet=in petrolatum (vaselin); w/w=watery solution.

intravenous preparation). If no reaction occurs, 10-fold

increases in the test concentration are done until a
positive reaction is seen. If no reaction can be elicited by
the skin prick test, intradermal testing starts with a
dilution of 1/100 of the skin prick test concentration
and the concentration is increased in logarithmic steps
(1/10, 1/1) until the final concentration is reached with a
positive test reaction after 20 min The final concentration should be validated (see Controls below). In the
case of beta-lactam antibiotics validated test concentrations, as well as data on sensitivity, specificity, and
comparison with results of in-vitro tests, exist and have
been published (2, 6, 7, 8).
In non-immediate reactions, patch tests can be
performed with the vehicles and concentrations given
in Table 4. However, there is a need for further
validation of the optimal vehicle and test concentrations. Only those test concentrations are listed, for
which sufficient experience seems to exist (Table 4) (2,
8, 18, 19). If more than one test concentration and in
addition a watery test vehicle are listed, the higher
concentrations and the watery solution have to be
validated against eliciting unspecific test reactions in
exposed non-allergic individuals.

Controls

All test methods can produce irritative reactions,

which are not indicative of an allergy, but reflect an
irritant potency of the drug and its preparation. To
study the specificity of the test preparation and
procedure, data should be present for as many
patients as possible who tolerate the drug (already
exposed, non allergic individuals). It is also recom50

mended to test a number of never-exposed controls

(at least 10) to exclude irritation, if this is acceptable
to the ethical committee. The most important outcome is the highest concentration of a drug, which
can be used for skin testing without producing a
positive unspecific (irritative) reaction. From the
clinical experience on contact sensitizing drugs it is
known that there is a remote possibility of sensitizing
individuals. Although orally taken drugs have less
sensitizing potency than contact sensitizing agents, as
most drugs are chemically not reactive, this is a
remote possibility to be considered.

Interpretation of test results

The negative predictive value of skin tests is generally

low. This may be partly due to the fact that physiologic
metabolites rather than the active drug itself is
responsible for the reaction and because many drugs
are haptens, which have to be conjugated with a carrier
protein before becoming an allergen. Thus, a negative
skin test to a drug alone is unreliable for ruling out drug
allergy. In the case of a negative skin test, one should
consider proceeding to more hazardous drug provocation tests after carefully evaluating the risks and the
benefits in the specific patient (.Fig. 1).
On the contrary, even when a proper technique and
proper drug material are employed, a positive skin test
result does normally indicate the diagnosis. The positive
predictive value of a skin test tends to be high, provided
that a sufficient number of controls have been tested
negative with exactly the same methodology (6). As for
positive skin tests with other allergens, the result should
be always interpreted together with the clinical history

Skin tests for drug hypersensitivity

and in-vitro test results when available. When there is a
specific reaction to a skin test, plus a corresponding
clinical history, the patient is advised to avoid thereafter
the relevant drug and related drugs (e.g., aminoglycoside
antibiotics) (Fig. 1) and an allergy pass may be issued.
In centres that are interested in drug allergies, however,
even in the light of a positive skin test, it is prudent to
confirm the diagnosis by use of a provocation test, in
order to gain and publish information about false
positive and false negative skin test reactions, as well as
positive and negative predictive values for specific drugs
and clinical manifestations. Also provocation tests or
desensitization protocols to the culprit drug, or
provocation to alternative drugs, may be attempted in
specific cases when satisfactory substitutes are not
available or in patients with multiple drug intolerance
syndrome.
Ethical considerations and informed consent

The issue of obtaining data concerning the irritative

effects of drugs on skin, tested in unexposed non-allergic

controls as described above, requires approval from
local ethical committees, as well as the validation of
different skin tests by provocation tests. The second
ethical issue to consider regards the collection, storage
and distribution of data in a database of the results of
drug hypersensitivity tests and diagnosis, including skin
tests. It will be one of the future goals of ENDA to
collect data on exposed individuals with good tolerance
of a drug, to bypass the necessity of having new controls
in each different centre.
Skin testing for the detection of drug allergy is
commonly used in different centres. Skin testing of
patients for a possible allergic reaction to a drug
probably does not require authorization by a local
ethical committee, but it does require patient informed
consent. Please contact your local ethical committee
before proceeding in your centre. Of course skin testing
in the context of clinical studies requires the agreement
of the local ethical committee, since sensitization and
adverse systemic reactions may occur.

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