title: Measurement and interpretation of skin prick test results.
abstract: BACKGROUND
  There are several methods to read skin prick test results in type-I allergy testing. A commonly used method is to characterize the wheal size by its 'average diameter'. A more accurate method is to scan the area of the wheal to calculate the actual size. In both methods, skin prick test (SPT) results can be corrected for histamine-sensitivity of the skin by dividing the results of the allergic reaction by the histamine control. The objectives of this study are to compare different techniques of quantifying SPT results, to determine a cut-off value for a positive SPT for histamine equivalent prick -index (HEP) area, and to study the accuracy of predicting cashew nut reactions in double-blind placebo-controlled food challenge (DBPCFC) tests with the different SPT methods.
  
  
  METHODS
  Data of 172 children with cashew nut sensitisation were used for the analysis. All patients underwent a DBPCFC with cashew nut. Per patient, the average diameter and scanned area of the wheal size were recorded. In addition, the same data for the histamine-induced wheal were collected for each patient. The accuracy in predicting the outcome of the DBPCFC using four different SPT readings (i.e. average diameter, area, HEP-index diameter, HEP-index area) were compared in a Receiver-Operating Characteristic (ROC) plot.
  
  
  RESULTS
  Characterizing the wheal size by the average diameter method is inaccurate compared to scanning method. A wheal average diameter of 3 mm is generally considered as a positive SPT cut-off value and an equivalent HEP-index area cut-off value of 0.4 was calculated. The four SPT methods yielded a comparable area under the curve (AUC) of 0.84, 0.85, 0.83 and 0.83, respectively. The four methods showed comparable accuracy in predicting cashew nut reactions in a DBPCFC.
  
  
  CONCLUSIONS
  The 'scanned area method' is theoretically more accurate in determining the wheal area than the 'average diameter method' and is recommended in academic research. A HEP-index area of 0.4 is determined as cut-off value for a positive SPT. However, in clinical practice, the 'average diameter method' is also useful, because this method provides similar accuracy in predicting cashew nut allergic reactions in the DBPCFC.
  
  
  BACKGROUND
  Trial number NTR3572.
authors.affiliation: Department of Internal Medicine, Section of Allergology, Erasmus MC, Burg. St. Jacobsplein 51, 3015CA Rotterdam, The Netherlands.
authors.forename: J P M
authors.initials: JP
authors.lastname: van der Valk
authors.affiliation: Department of Internal Medicine, Section of Allergology, Erasmus MC, Burg. St. Jacobsplein 51, 3015CA Rotterdam, The Netherlands.
authors.forename: R
authors.initials: R
authors.lastname: Gerth van Wijk
authors.affiliation: ICT Services, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Hoorn
authors.affiliation: Department of Internal Medicine, Section of Allergology, Erasmus MC, Burg. St. Jacobsplein 51, 3015CA Rotterdam, The Netherlands.
authors.forename: L
authors.initials: L
authors.lastname: Groenendijk
authors.affiliation: Department of Internal Medicine, Section of Allergology, Erasmus MC, Burg. St. Jacobsplein 51, 3015CA Rotterdam, The Netherlands.
authors.forename: I M
authors.initials: IM
authors.lastname: Groenendijk
authors.affiliation: Department of Internal Medicine, Section of Allergology, Erasmus MC, Burg. St. Jacobsplein 51, 3015CA Rotterdam, The Netherlands.
authors.forename: N W
authors.initials: NW
authors.lastname: de Jong
keywords: Allergy; Cut-off value; Histamine equivalent index; Mean wheal diameter; Skin prick test