Delayed skin testing for systemic medications: helpful or not?

Cutaneous adverse drug reactions (CADR) collectively are delayed drug reactions such as morbilliform drug eruption (MDE) and severe cutaneous adverse reactions (SCAR). Whereas MDE may wane over time, be the result of drug viral interactions and be amenable to slow reintroduction or rechallenge, SCAR are HLA class I restricted, T-cell mediated reactions that demonstrate durable immunity and warrant lifelong avoidance. SCAR such as drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), acute generalized exanthematous pustulosis (AGEP) and generalized bullous fixed drug eruption (GBFDE) often occur in the setting of multiple drugs dosed together. Collectively, they lead to significant morbidity, mortality and drug safety concerns that could severely limit future treatment options. Currently, no single or combination of diagnostic tests for SCAR such as ex vivo or in vitro testing, in vivo (skin testing) or other adjunctive tests such as HLA typing have 100% negative predictive value. In this "Controversies in Allergy Review Article", we review the current literature on delayed skin testing (patch and delayed prick/intradermal test) and critically assess the evidence base of its utility across different drugs and clinical phenotypes of delayed hypersensitivity reactions.

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