Adam T. Fox

Carsten Flohr

Helen A. Brough

Martin Penagos

Sian Ludman

World Allergy Organization Journal

PubMed

Ludman, Sian

Penagos, Martin

Brough, Helen A

Flohr, Carsten

Fox, Adam T

King's Research Portal

Postinflammatory hyperpigmentation after skin prick testing

Helen A Brough

Adam T Fox

Crossref

Postinflammatory Hyperpigmentation After Skin Prick Testing

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LETTER TO THE EDITOR
Postinflammatory
Hyperpigmentation After
Skin Prick Testing
To the Editor:
Postinﬂammatory hyperpigmentation (PIH) is an acq-
uired hypermelanosis, which occurs after inﬂammation, trauma,
or therapeutic interventions. PIH presents as irregular darkly
pigmented macules that can persist for months or even years.
PIH occurs more frequently in the darker Fitzpatrick skin types
IV to VI, for instance, found in individuals from Africa,
Asia, and South America.1 Localized PIH has been found to
occur in a few individuals after both patch testing2,3 and
intradermal testing4 for allergy diagnosis. However, to our
knowledge, there are no published reports of PIH after skin
prick tests (SPT).
CASE REPORT
We report the case of a 15-year-old girl of African
descent (Fitzpatrick skin type VI) who presented to our
tertiary allergy clinic. She had a marked allergic reaction to
ﬁsh when she was an infant, and this allergy has persisted.
The patient also experienced seasonal allergic rhinitis in the
tree and grass pollen seasons and mild eczema but no asthma
or contact dermatitis.
The patient underwent SPT on the volar aspect of her
forearm (SPT reagents; Stallergènes S.A., Antony, France)
(1-mm lancets; ALK-Abelló A/S, Hørsholm, Denmark) to
a number of aeroallergens and for ﬁnﬁsh and shellﬁsh at
her initial consultation, eliciting positive wheals with no
lasting effects. She was prescribed self-injectable adre-
naline devices, antihistamines (chlorphenamine, cetirizine),
and intranasal steroids (mometasone furoate). She was also
considered for immunotherapy for her seasonal allergic rhi-
nitis and returned in the month of October for further SPTs
using the same method as before, as part of the workup. She
reacted vigorously to all tree and grass pollens tested
(wheal size ranged from 10–25 mm at 15 minutes of test-
ing), and the skin inﬂammation persisted for several days.
At her follow-up visit, 7 months after the aeroallergen,
SPTs were performed; PIH was present at all sites where
the skin prick testing had been performed (Fig. 1). The
patient reported that the hyperpigmentation started 48 hours
after skin prick testing.
DISCUSSION
SPTs are a common procedure for the diagnosis of
atopic disease, and they are generally considered safe with
very rare local and systemic complications.5 PIH can be
found in the epidermis or dermis. The pathogenesis involves
an upregulation in melanin synthesis by melanocytes trig-
gered by an inﬂammatory process. In addition, melanin trans-
fer from melanocytes to the surrounding keratinocytes is
increased (epidermal PIH). If the basal cell layer is disrupted
as part of this process, then the melanin can also be trapped
by macrophages in the dermis (dermal PIH), causing deep
blue discoloration of the skin.1 Cutaneous late-phase reac-
tions after an allergen challenge peak at 6 to 8 hours and
resolve by 24 to 48 hours. These are common after intrader-
mal tests, but they are rarely reported after SPT.6 Due to the
late onset of the hyperpigmentation in this patient, the possi-
bility of a type IV immune response to the SPT solution base
components (sodium chloride, glycerol, phenol, and mannitol)
requires further investigations (eg, patch tests), which have
been declined by the patient to date. A wide literature search
on August 31, 2011, for PIH associated with SPT found no
previous reports. Although rare, PIH should be recognized as
a potential complication of SPT especially in patients with
darker skin and patients counseled as such.
Sian Ludman, MRCPCH1
Martin Penagos, MD, MSc1
Helen A. Brough, MRCPCH1
Carsten Flohr, MRCPCPH, MSc, PhD1,2
Adam T. Fox FRCPCH1
REFERENCES
1. Callender V, St Surin-Lord S, Davies E, Maclin M. Postinﬂammatory
hyperpigmentation: etiologic and therapeutic considerations. Am J Clin
Dermatol. 2011;12:87–89.
2. Zenorola P, Bisceglia M, Lomuto M. Ashy dermatosis associated with
cobalt allergy. Contact Dermatitis. 1994;31:53–54.
FIGURE 1. PIH was present at all sites where the skin prick
testing had been performed 7 months before.
From the 1Department of MRC & Asthma UK Centre in Allergic Mechanisms
of Asthma, Division of Asthma, Allergy and Lung Biology, King’s College
London, Guy’s and St Thomas’ NHS Foundation Trust, London, United
Kingdom; 2St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS
Foundation Trust, London, United Kingdom.
Correspondence to: Adam T. Fox, FRCPCH, Consultant Paediatric Allergist,
Department of Paediatric Allergy, Level 2, Stairwell B, St Thomas’ Hospital,
London SE1 7EH, United Kingdom. Telephone: +44 (0) 20 71889525/6.
Fax: +44 (0) 20 71889782. E-mail: adam_fox@btinternet.com.
Copyright  2012 by World Allergy Organization
WAO Journal  May 2012 57
3. Lachapelle JM, Maibach HI. Patch Testing and Prick Testing: A Practical
Guide Ofﬁcial Publication of the ICDRG. Berlin, Germany: Springer;
2009:60.
4. Vidal C, González-Quintela A. Multiple ﬁxed drug eruption due to in-
tradermal test with metamizole. Allergy. 2007;62:712–713.
5. Norrman G, Fälth-Magnusson K. Adverse reactions to skin prick testing in
childrendprevalence and possible risk factors. Pediatr Allergy Immunol.
2009;20:273–278.
6. Lierl MB. Isolated late cutaneous reactions to allergen skin testing in
children. Ann Allergy Asthma Immunol. 2000;84:294–298.
Letter to the Editor WAO Journal  May 2012
58  2012 World Allergy Organization


Adverse reactions to skin prick testing in childrendprevalence and possible risk factors. Pediatr Allergy Immunol.

by World Allergy Organization WAO Journal

Isolated late cutaneous reactions to allergen skin testing in children. Ann Allergy Asthma Immunol.

Letter to the Editor WAO Journal

Multiple ﬁxed drug eruption due to intradermal test with metamizole.

Postinﬂammatory hyperpigmentation: etiologic and therapeutic considerations.

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Postinflammatory Hyperpigmentation After Skin Prick Testing

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