Q:

6/17/2014
If a skin test was performed and you have a good positive control of about 4x20 and a negative control 0f 2x5 and there is 50% glcerine in both controls does this patient have a sensitivity to glycerin and what is the teaching for the patient if this is the case. Is there literature for avoidance or what? The end result is that the negative control was NOT contaminated with the positive and the results are what it is. Both are positive. I will repeat at a later time but if this is a glycerin sensitivity what do you recommend as far as what is told to the patient.

A:

Thank you for your inquiry.

I will try and answer your question, but I am a little confused by it. You mentioned that your positive control contains glycerin, but usually a positive control is histamine and does not contain glycerin. I do not know what you used as a positive control. However, as you can see from the references and article copied below, glycerin can clearly cause an irritant reaction. Therefore to interpret any skin test you perform, if you are using glycerinated products for your negative control, you must also use glycerinated products for your skin testing. And the determination of whether a skin test is positive or negative requires a comparison between the skin test with allergen and the negative control. The erythema of the skin test to allergen must be at least 3 mm in size, and some experts feel as much as 5 mm greater, than the positive control.

In sum, you can use a negative control containing glycerin as long as your allergy extract contains glycerin. You interpret the result of the skin test to allergen based upon the size of the skin test to the negative control and, as mentioned, glycerin can produce irritant reactions that can mimic positive skin tests. On the other hand, your positive control usually consists of histamine which does not contain glycerin, and I am a little confused as to what you used for the positive control, but it is done not to interpret whether or not the allergy skin test is significantly positive, but rather to see if the patient is reactive per se to any testing.

Thank you again for your inquiry and we hope this response is helpful to you.

The Importance of Glycerin-Containing Negative Control Tests in Allergy Research Studies that Use Intradermal Skin Tests
David S. Hurst, Md, et al
Abstract
Objective: We sought to assess skin whealing with glycerin-containing control injections for intradermal skin tests.
Design: Observational.
Methods: Wheal sizes were measured at 0, 10, and 15 minutes after intradermal injection of 0.01 and 0.02 mL of phenolated normal saline and 0.5% and 5% concentrations of glycerin in the same quantity of phenolated saline.
Results: Intradermal injection of 0.01 mL of phenolated saline produced an average 4.9-mm wheal, which expanded to 5.2 mm at 10 minutes and to 6.0 mm at 15 minutes. Intradermal injection of 0.02 mL of phenolated saline produced a 6.4-mm wheal, which expanded to 7.0 mm at 10 minutes and 8.0 mm at 15 minutes. The addition of glycerin produced proportionally larger wheals.
Conclusions: Because glycerin increases whealing beyond that with phenolated saline, skin tests containing glycerin must be compared with glycerin-containing negative controls. Intradermal skin tests that fail to compare findings in this manner contain an inherent methodologic flaw and are uninterpretable.

A major issue in allergy testing is deciding whether the observed skin response is truly indicative of the patient having a clinically relevant, IgE-mediated reaction.1 Skin test results are influenced by many variables, including patient skin response, specific technique, and tester consistency. Wheal measurement, comparisons with positive and negative control solutions, and interpretation are of equal importance. The development of in vitro methods for allergy diagnosis has helped to independently verify the accuracy of skin tests. In some cases, poor standardization of antigen sources and testing techniques has been shown to lead to discrepancies between skin tests and in vitro IgE antibody results of more than 100-fold.2 It is also possible for skin tests to be falsely negative, as has been shown by comparing IgE blood tests with both skin tests and challenge tests.3 Conversely, skin tests may be falsely positive because of nonspecific irritants, such as glycerin, present in allergen solutions.4,5

Recommendations for immunotherapy must be based on clinical appropriateness as related to valid testing of proposed therapeutic agents. Recent reports by Nelson et al6 and Wood et al7 have suggested that skin prick tests (SPTs), even when negative, are sufficiently sensitive to diagnose clinical atopy without the need for further intradermal skin tests (IDTs). Both authors describe performance of a single IDT with injection of 0.02 mL of antigen solution. The basic tenant of their methodology is that all wheals resulting from an IDT measuring 6 mm or greater, accompanied by erythema, are to be recorded as positive. Nelson et al took measurements at 15 minutes, and Wood et al took measurements at an unspecified time. We were concerned that their methodology for IDTs created many false-positive results. This led to the condemnation of IDTs by these authors, stating that “a positive intradermal skin test response to Timothy grass in the presence of a negative skin prick test response to Timothy grass did not indicate the presence of clinically significant sensitivity to Timothy grass.”6 We found the conclusion based on their particular IDT method to be suspect for 2 reasons: (1) it categorically assumes that an injection of 0.02 would produce a wheal of less than 6 mm and (2) it ignores the effects of small concentrations of the preservative glycerin, used in most all allergy test solutions, on whealing. Either assumption would lead to frequent false-positive skin test interpretations and discredit 60 years of intradermal testing. We therefore sought to evaluate control tests appropriate for use with the methodologies published in the general allergy literature to determine whether a 6-mm wheal with erythema should appropriately be interpreted as a positive or as a negative test.

Skin Testing for Inhalant Allergy 2003: Current StrategiesOtolaryngol Head Neck Surg October 2003 vol. 129 no. 4 suppl S33-S49.
A prick/puncture test with a response of at least 3-mm diameter (with equivalent erythema) more than diluent control done at the same time is required as proof of the presence of cutaneous allergen specific

Allergy diagnostic testing: an updated practice parameter (2008)

Allergy Diagnosis
Pascal Demoly, Francesco Gaeta, Jean Bousquet, and Antonino Romano
In the USA, for example, for skin-prick tests: neg = 0 reaction, 1 + = 1 mm wheal above saline control; 2 + = 1–3 mm wheal above saline control; 3 + (the first point we consider a positive reaction) = 3–5 mm wheal above saline control plus an accompanying flare; 4 + = > 5 mm wheal above saline control, plus an accompanying flare.

Sincerely,
Phil Lieberman, M.D.

The clarification below is added to the response because it should be noted that the mention of a glycerin-free histamine positive control refers only to the intradermal preparation and not to the epicutaneous preparation which can contain glycerin.
 
ADDENDUM:
I wanted to add this as an addendum to clarify an issue. When I mentioned to you that the positive control does not contain glycerin, I was speaking about the intradermal histamine positive control. The prick or scratch test positive control does contain histamine, and I wanted to clarify that issue for you.
 
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology