Food allergy, anaphylaxis, dermatology, and drug allergy
The atopy patch test in the diagnostic workup of suspected food-related symptoms in children

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Background

There is an increasing need to develop test instruments that make oral food challenges superfluous.

Objective

We sought to study the utility of atopy patch tests (APTs) in the diagnostic workup of food allergy.

Methods

We investigated 437 children (median age, 13 months; 90% with atopic dermatitis) referred for evaluation of suspected food allergy. Specific serum IgE (sIgE) measurements, skin prick tests (SPTs), APTs, and controlled oral food challenges were performed.

Results

We analyzed 873 oral challenges with cow's milk, hen's egg, wheat, and/or soy. One thousand seven hundred single APTs were performed. As a single parameter, the APTs showed the best specificity compared with sIgE measurements, SPTs, or both. Combining the APT with either the SPT or sIgE measurement resulted in improved sensitivity and specificity. Decision points for sIgE measurement and for the SPT showed lower values when combined with a positive APT result. Correctly bypassing an oral food challenge with combined testing, including APTs, only between 0.5% and 7% (99% predicted probability) and between 6% and 14% (using 95% predicted probability) of children would fulfill the criteria for avoiding an oral food challenge.

Conclusion

Although the predictive capacity of the APT is improved when combined with sIgE measurement or the SPT, oral food challenges become superfluous in only 0.5% to 14% of study patients. In addition, the APT is time consuming and demands a highly experienced test evaluator.

Clinical implications

For daily clinical practice, the APT adds only a small predictive value to the standard SPT and sIgE measurement in the diagnostic workup of suspected food-related symptoms in our study population.

Section snippets

Study population

We studied 437 children consecutively referred to our department for evaluation of suspected food allergy. Suspicion was defined as either the feeling of the parents that food could contribute to clinical symptoms of the child or that an IgE test result was positive in a child with moderate or severe eczema. Patients with a clear history of a severe allergic reaction to an isolated food were not included. Patients' ages ranged from 3 months to 14 years (median, 13 months), and the majority were

Clinical outcome

We analyzed a total of 873 controlled oral challenges with CM, HE, wheat, soy, and placebo in 437 children. Three hundred ninety (73%) of 532 verum challenge results and 10 (3%) of 341 placebo challenge results were assessed as positive. One hundred twenty-eight (66%) of 193 egg challenge results, 168 (49%) 341 of those with CM, 57 (36%) 159 of those with wheat, and 37 (26%) 180 of those with soy were assessed as positive. Of the 390 positive food challenge results, 262 (67%) were assessed as

Single test parameters

Considering the APT as a single test, our data show that specificity of the APT was higher than that for sIgE measurement or the SPT for all 4 allergens (Table I). In contrast, sensitivity was lower. This confirms previous investigations of the APT.38, 42 Between the 2 IgE-testing parameters, the SPT was superior to the determination of specific IgE regarding specificity, whereas sensitivity was lower for all 4 foodstuffs. Regarding the predictive parameters of specificity, sensitivity,

References (55)

  • E. Isolauri et al.

    Combined skin prick testing enhances identification of food allergy in infants with atopic dermatitis

    J Allergy Clin Immunol

    (1996)
  • O. Keskin et al.

    Evaluation of the utility of atopy patch testing, skin prick testing, and total and specific IgE assays in the diagnosis of cow's milk allergy

    Ann Allergy Asthma Immunol

    (2005)
  • M. Osterballe et al.

    The diagnostic accuracy of the atopy patch test in diagnosing hypersensitivity to cow's milk and hen's egg in unselected children with and without atopic dermatitis

    J Am Acad Dermatol

    (2004)
  • C. Roehr et al.

    Atopy patch test together with level of specific IgE reduces the need for oral food challenges in children with atopic dermatitis

    J Allergy Clin Immunol

    (2001)
  • J.L. Seymour et al.

    Clinical effects of diaper types on the skin of normal infants and infants with atopic dermatitis

    J Am Acad Dermatol

    (1987)
  • E.G. Langeveld-Wildschut et al.

    Evaluation of the atopy patch test and the cutaneous late-phase reaction as relevant models for the study of allergic inflammation in patients with atopic eczema

    J Allergy Clin Immunol

    (1996)
  • D.A. Hughes et al.

    Food allergy: a problem on the increase

    Biologist (London)

    (2001)
  • P. Eigenmann et al.

    Interpreting skin prick tests in the evaluation of food allergy in children

    Pediatr Allergy Immunol

    (1998)
  • B. Niggemann et al.

    Outcome of double-blind, placebo-controlled food challenge tests in 107 children with atopic dermatitis

    Clin Exp Allergy

    (1999)
  • A. Mehl et al.

    Anaphylactic reactions in children—a questionnaire-based survey in Germany

    Allergy

    (2005)
  • H.A. Sampson et al.

    Fatal and near-fatal anaphylactic reactions to food in children and adolescents

    N Engl J Med

    (1992)
  • S. Reibel et al.

    Which safety measures need to be undertaken in oral food challenges in children?

    Allergy

    (2000)
  • S.A. Bock et al.

    Double-blind, placebo-controlled food challenge (DBPCFC) as an official procedure: a manual

    J Allergy Clin Immunol

    (1988)
  • P.A. Eigenmann

    Breaking frontiers for better early allergy diagnosis

    Allergy

    (2004)
  • B. Niggemann et al.

    Proposals for standardization of oral food challenge tests in infants and children

    Pediatr Allergy Immunol

    (1994)
  • S.H. Sicherer

    Food allergy: when and how to perform oral food challenges

    Pediatr Allergy Immunol

    (1999)
  • T. Boyano Martinez et al.

    Validity of specific IgE antibodies in children with egg allergy

    Clin Exp Allergy

    (2001)
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    Disclosure of potential conflict of interest: K. Beyer has received grant support from the Danonc Institute FAAN, and the European Union. The rest of the authors have declared that they have no conflict of interest.

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