Q:

5/12/2013
For significance of total serum IgE before modified skin prick test in cases of allergic rhinitis. In patients of AR with normal serum IgE should we do modified skin prick test or not?

A:

Thank you for your inquiry.

I am not aware of any significant effect of total IgE on the type of skin test one would perform. Below, for your interest, are abstracts of some articles which will help you put this issue into perspective.

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

Ann Allergy. 1989 May;62(5):432-5.
Total serum IgE, allergy skin testing, and the radioallergosorbent test for the diagnosis of allergy in asthmatic children.
Tang RB, Wu KK.
Source
Department of Pediatrics, Veterans General Hospital, Taipei, Taiwan, Republic of China.
Abstract
Correlations of total serum IgE, skin test reactivity, and specific IgE antibodies to selected antigens were evaluated in asthmatic children. There was a significant difference in mean IgE level of each positive RAST score group compared with that of the RAST-negative score for dog epithelium, Candida, ragweed, and Bermuda grass allergen. The correlation coefficient between the total IgE and the RAST to D. farinae was 0.39 (P less than .05). There was no significant correlation between the total IgE and the RAST to D. pteronyssinus, Candida, dog epithelium, ragweed, Eucalyptus pollen, and Bermuda grass (P greater than .05). This indicates a low total serum IgE concentration does not exclude the possibility of significant elevation of specific IgE to a common allergen. Concordance for results of intradermal skin testing and RAST was high for most allergens. Lower efficiency for dog allergen and Candida suggests greater sensitivity of allergy skin testing for these allergens.

J Allergy Clin Immunol. 2003 Feb;111(2 Suppl):S687-701.
23. Clinical laboratory assessment of IgE-dependent hypersensitivity.
Hamilton RG, Adkinson NF Jr.
Source
Allergy and Clinical Immunology Division, Department of Medicine, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Room 1A20, Baltimore, MD 21224, USA.
Abstract
This chapter reviews clinical and laboratory analyses that aid in the diagnosis and management of human allergic (IgE-dependent) diseases. The diagnostic algorithm for immediate-type hypersensitivity begins with a thorough clinical history and physical examination. Once signs and symptoms compatible with an allergic disorder have been identified, a skin test and/or blood test for allergen-specific IgE antibodies may serve as primary confirmation to strengthen the diagnosis. Puncture and intradermal skin testing provide a biologically relevant immediate-type hypersensitivity response in the skin, with resultant wheal and flare reactions within 15 minutes of allergen application. Bleeding, dermatographism, and antihistamines may confound the quality of the skin test. Allergen-specific IgE antibody may also be detected in the blood using a radioallergosorbent test (RAST). Nonisotopic "second-generation" RAST-type assays have evolved to provide more quantitative, sensitive, precise IgE antibody results. In vivo provocation tests may serve as secondary confirmatory tests when the clinical history is discordant with a primary IgE antibody test result. The multiallergen screen is a qualitative RAST-type assay that detects specific IgE antibody to approximately 15 allergens that evoke a large majority of aeroallergen or food-related allergic disorders. Other useful serological assays performed in the diagnostic allergy laboratory include total serum IgE, Hymenoptera venom-specific IgG antibody, IgG precipitins for organic dusts, mast cell tryptases, and the venom RAST inhibition test. Above all, in vivo or laboratory confirmatory test results that are inconsistent with the clinical history should be repeated as for any laboratory assessment.

J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S284-96. doi: 10.1016/j.jaci.2009.09.055.
Clinical laboratory assessment of immediate-type hypersensitivity.
Hamilton RG.
Source
Allergy and Clinical Immunology Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md, USA.
Abstract
Clinical laboratory analyses aid in the diagnosis and management of human allergic (IgE-dependent) diseases. Diagnosis of immediate-type hypersensitivity begins with a thorough clinical history and physical examination. Once symptoms compatible with an allergic disorder have been identified, a skin test, blood test, or both for allergen-specific IgE antibodies provide confirmation of sensitization, which strengthens the diagnosis. Skin testing provides a biologically relevant immediate-type hypersensitivity response with resultant wheal-and-flare reactions within 15 minutes of allergen application. Allergen-specific IgE antibody in serum is quantified by using 3 laboratory-based autoanalyzers (ImmunoCAP, Immulite, and HYTEC-288) and novel microarray and lateral-flow immunoassays. Technologic advances in serologic allergen-specific IgE measurements have involved increased automation, with enhanced reproducibility, greater quantification, lower analytic sensitivity, and component-supplemented extract-based allergen use. In vivo provocation tests involving inhalation, ingestion, or injection of allergens serve to clarify discordant history and skin- or blood-based measures of sensitization. Other diagnostic allergy laboratory analyses include total and free serum IgE measurement, precipitating IgG antibodies specific for organic dusts, mast cell tryptase, and indicator allergen analyses to assess indoor environments to promote patient-targeted allergen avoidance programs. A critique is provided on the predictive utility of serologic measures of specific IgE for food allergy and asthma. Reasons for the lack of clinical utility for food-specific IgG/IgG4 measurements in allergy diagnosis are examined. When the specific IgE measures are inconsistent with the clinical history, they should be confirmed by means of repeat and alternative method analysis. Ultimately, the patient's clinical history remains the principal arbiter that determines the final diagnosis of allergic disease.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology