Why Can't Some Contact Dermatitis Be Diagnosed by Blood Test, EVER?

I often see patients for allergies who desire allergy testing due to mysterious hive-like rash on the skin, and given many are fearful of needles, they opt for a blood test like RAST or immunoCAP to diagnose what they are allergic to. Some would even argue that skin prick testing would not be diagnostic.

Though such blood tests have become remarkably accurate (skin prick is still the most accurate way to diagnose what a person is allergic to), there are profound and significant limitations.

In order to understand why, first a little biology lesson.

In "classic" allergy (Type 1 hypersensitivity), there are antibodies called IgE floating around in the blood. When such antibodies come into contact with what a person is allergic to, it causes mast cells to explode releasing bioactive chemicals that triggers the classic signs of allergy including runny nose, sneezing, and hives.

The timing of exposure to reaction is very short... within minutes.

In this scenario, the allergy blood testing is appropriate... because such testing measures the amount of IgE antibodies floating around in the blood.

Unfortunately, not all contact dermatitis is due to this biologic response.

There is another type of allergic reaction that can cause skin manifestations that is NOT mediated by IgE antibodies at all!

Known as Type 4 Hypersensitivity, special cells called macrophages initiate the "allergic" reaction when it detects an allergic substance.

This type of reaction occurs hours to days AFTER exposure.

Obtaining a blood test for allergies will NOT diagnose this type of allergic reaction because the test measures the level of IgE which is not involved in this type of reaction!

The ONLY way to test for Type 4 Hypersensitivity is skin patch testing, typically performed by dermatologists.

Patch testing is performed on skin where the dermatitis is not apparent (typically upper back). The allergens are mixed with a non-allergic material (base) to a suitable concentration which is then placed in direct contact with the skin within small aluminium discs. Adhesive tape is used to fix them in place. The patches are left in place for 48 hours. The patches should not be exposed to sunlight or other sources of ultraviolet (UV) light. After 48 hours the patches are removed and an initial reading is taken one hour later. The final reading is taken a further 48 hours later. Additional readings beyond 48 hours increase the chance of a positive test patch by 34 per cent. The patient should refrain from washing until the last reading is taken.

Some chemicals produce an allergic reaction only when exposed to light (usually ultraviolet type A). If this scenario is suspected, patch testing is performed, one while exposed to UVA light and the other hidden in darkness. A positive light-reaction is made if the patch exposed to UVA light causes a skin reaction whereas the one hidden in darkness looks fine.

What are some common chemicals/substances that cause Type 4 skin reactions?

• Balsam of Peru: an aromatic mixture made from resins and essential oils. It is found in the haemorrhoid preparation Anusol, some perfumes and certain spices. 
• Caine mix: local anaesthetics found in preparations for sore throats, sunburn remedies, haemorrhoid preparations, Wasp-eze. Used by dentists and doctors for minor surgical procedures. 
• Carba mix: rubber 'accelerators' (chemicals used to speed up the polymerisation process in the manufacture of rubber). It is found in rubber gloves, shoes, bandages and elastic. Of those allergice to carba, 85 per cent are also allergic to thiuram. 
• Chlorocresol: a substituted phenol preservative that kills bacteria. It is widely used in medications and some cosmetics. It cross-reacts with Dettol, which you should also avoid if you have a chlorocresol allergy. 
• Chromate: a metal used for plating other metals to prevent rusting and in the manufacture of stainless steel. It is also found in cement and tanned leather. 
• Cobalt: found in jewellery, dental implants, artificial joints, jet engines. Most patients are also allergic to nickel, and some are also allergic to chromate. 
• Colophony: present in adhesives, plasters, paper, printing inks, medicated creams, glue tackifiers (stamps, labels), and cosmetics. 
• Epoxy resin: plastics, used mainly as adhesives in the industrial setting but also by DIY enthusiasts. Found in two-component glues, such as Araldite. 
• Formaldehyde: preservative frequently used in household products and in industry. Often found in cosmetics and shampoo. 
• Fragrance mix: used in patch testing, this collection of eight individual fragrances detects about 75 per cent of patients allergic to perfume. If you have perfume allergy, you will not be allergic to all fragrances, but you cannot tell from the label which fragranced cosmetics are safe. Avoid all cosmetics listing 'parfum' as an ingredient on the label. Also found in air fresheners, washing powders and candles. 
• Lanolin: produced by sheep to protect the fleece from the results of weathering. It is widely used in cosmetics, medical creams and bandages. 
• Latex: most commonly found in gloves used by healthcare professionals.
• Mercapto mix/thiazoles: a rubber accelerator found in rubber shoes, insoles, gloves and elastic. It is also a component of balloons and bandages. 
• MBT (mercaptobenzothiazole): another rubber accelerator. Neomycin: an antibiotic commonly used in ear and eye drops and creams to treat infected skin problems. Cross-reacts with other antibiotics. 
• Nickel: 10 per cent of women and at least 1 per cent of men are affected by nickel allergy. Nickel is released from metals such as alloys or electroplated items. Found in jewellery, keys, coins, zips and buckles, pacemakers and batteries. 
• Parabens: preservatives found in cosmetics and topical medical products to inhibit the growth of fungi and prevent slow deterioration. They are commonly used in cosmetics, household products, glue, shoe polish, shampoos and conditioners, sunscreens and medical creams. 
• PPD (paraphenylenediamine): a permanent hair dye that is very frequently used in hair salons and at home. Dyed hair cannot cause an allergy but the dye may do during application. Also found in skin paints, such as 'henna' tattoos, and occasionally in fur and leather dyes. Primin: a substance produced by the plant Primula obconica, a common houseplant. 
• PTBPF resin (para-tertiary-butylphenol-formaldehyde): a synthetic polymer used as an adhesive. It is often combined with leather or rubber to make shoes, handbags, watchstraps, hats and belts. 
• Thiuram (tetramethylthiuram disulphide or TMTD): another rubber accelerator that is also found in pesticides. People who are carba allergic often react to thiuram. Patients who react to the drug disulfiram (Antabuse), used for alcohol dependence, may also be allergic to thiuram. 
• Toluene sulphonamide formaldehyde resin (TSF resin): the commonest polymer in nail polish and a frequent allergen.

Given a patient often has no idea why, how, when a hive reaction occurs, it is important to obtain a good history to see if a reaction is immediate or delayed as it may influence what type of allergy testing may be required.

BUT, the key thing for people to remember is that allergy blood testing and skin prick testing can NOT diagnose all allergies due to intrinsic factors.

Skin patch testing may be the ONLY test to determine what that mysterious hive reaction is due to.

AND, now you know why!

For physicians, skin patch testing supplies can be purchased at www.dormer.com. However, your local dermatologist should be able to perform such patch testing (our office does not).

In our area, Dr. Moshell at Georgetown is the expert in this field.

Phone: 301-951-2400
5530 Wisconsin Ave, Suite 730
Chevy Chase, MD 20815

Another dermatologist in Northern Virginia who performs patch testing is:

Kurt Maggio, MD
7512 Gardner Park Dr
Gainesville, VA 20155
Phone: 703-753-9860

Robert Gurney, MD
11315 Sunset Hills Rd
Reston, VA 20190
Phone: 703-437-7744

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There are FOUR Distinct Types of Allergic Reactions

When people think of allergic reactions, they incorrectly believe there is only one kind... the kind that makes a person's nose run or the rash that appears after eating a food one is allergic to.

Sounds simple, but sadly it is WAY more complex than that.

There are actually 4 distinct types of allergic reactions that occur. All images courtesy of University of Georgia unless otherwise specified.

Type 1
This is the classic type of allergic reaction everyone is familiar with. Generally, it is activated by IgE antibodies in the blood in conjunction with mast cells. This is the type of allergy that is typically tested for by skin prick as well as blood testing (RAST or immunoCAP).

The reaction goes something like this: The allergen (stuff you are allergic to; green starfish in image below) binds IgE (stuff measured in allergy blood tests; Y shape in image) found on mast cells (the cell responsible for allergies). When that happens, the mast cell explodes releasing chemicals that cause all the classic symptoms of allergy.

Type 2
This is the allergic reaction that occurs if you get the wrong blood type during a blood transfusion. Rather than IgE, this reaction is mediated by IgG and does not involve mast cells.

The reaction goes something like this: Antibodies (homing beacons; green Y in image) in the blood attach to certain cells (cells that have a red triangle) which than marks them for destruction. Destructive proteins (called complement) and killer soldier cells than "home in" on these tagged cells and destroy them (like laser-guided missiles).

Courtesy of University of Florida

Type 3
This reaction typically occurs in autoimmune diseases like rheumatoid arthritis but can occur with injections.

The reaction is due to clustering of IgG antibodies (Y shape in image below) and the "allergic" substance (green pellets). This clustering can ultimately create a mega-complex (called immune complex) which can than activate destructive proteins (complement as in Type 2) as well as clog up the small arteries causing surrounding tissue death and/or ischemia.

Type 4
This type of reaction is what mediates latex allergy and other forms of contact dermatitis. It also forms the basis for organ rejection after a transplant as well as the PPD reaction that occurs when testing for tuberculosis.

Rather than antibodies, special cells called macrophages actually directly cause the damage. These cells hunt and "eat" the offending protein or cell with the end result being a "reaction".

Summary
To summarize, take a look at this chart:

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