The number of skin tests applied at one time will depend on the particular patient and their allergic history. These tests should be performed and observed in 15 to 20 minutes. Additional tests may be applied in sequence. Perform tests on the anterolateral aspect of the upper arm on an area that permits the effective application of a tourniquet proximal to the site of the test. The skin at the site of injection should be disinfected with rubbing alcohol before testing.

Puncture testing: Apply one drop of extract to the skin. Pierce the drop of extract and skin using a sterile hypodermic needle or vaccinating needle. Maintain the needle perpendicular to the skin surface and rock the needle back and forth to produce a small hole without bleeding. Do not rotate or gouge the needle. Remove needle from skin and wipe excess extract from skin surface.

Scratch testing: Using a scarifier or needle, make a scratch 1/16 inch long on the epidermis penetrating the outer cornified area but being careful not to draw blood. Apply one drop of extract to the scratch.

Intradermal testing: Use a separate sterile syringe (tuberculin type equipped with a 27 gauge by 3/8 inch needle with intradermal bevel) for each antigen. The tests are made by injecting 0.02ml of allergen into the epidermis. If the test has been performed properly, the solution should raise a bleb 2 to 3mm in diameter. If the bleb does not appear, the injection was made too deeply.

A negative control consisting of the same solution that the extract was prepared in, should be applied to one of the sites in the same manner as the tests being performed. For example, the negative intradermal control should contain 0.5% (v/v) glycerin, if a 100 BAU/ml concentration grass is used for intradermal testing. Histamine phosphate should be used as a positive control for evaluation of skin testing. Histamine phosphate is available from other manufacturers. See their directions for use, for recommended dosage and interpretation of results.

A positive reaction usually develops in 15 to 20 minutes. The positive response is a wheal and flare reaction that is larger than the negative control and judged on the size of the reaction. Scratch or puncture tests may not elicit as large and well defined reaction as the intradermal. (5)

The following grading system for intradermal testing is recommended (9):

IMMUNOTHERAPY:

The following are two methods of injection therapy:

1\. Pre-seasonal in which treatment is begun three months before seasonal difficulty begins and brought to maintenance dose by injections 4 to 7 days apart and discontinued after that season ends.

2\. Perennial treatment is the recommended mode of therapy in which the patient is, by injection therapy, brought up to tolerated maintenance dose and remains at that dose until amelioration of allergic symptoms occurs. Injections may be given at intervals of 4 to 7 days.

Allergenic extracts must be diluted before use. Normally immunotherapy can be started with a 1 BAU/ml dilution. If a patient appears to be extremely sensitive, based on skin testing results, dilutions of the extract can further be made before injections are started. See Table B for additional information. The following are suggested procedures for making a proper dilution series. Recommended diluents contain 0.9% sodium chloride and 0.4% phenol as a preservative. Dlluents with HSA (Human Serum Albumin) as a stabilizer can also be used. Allergenic extracts should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Perennial treatment may be started using the following dosage and dilution schedule. (Modified from Reference 10) This schedule is only illustrative and may not be applicable to all patients, since the degree of sensitivity to grass allergens differs among individuals. The dose administered must be adjusted based on the patient's sensitivity and tolerance. Initial dose can be based on end point titration using a dose that elicits a 1-2+ reaction. Maintenance dose is based on patient tolerance.

Gradually increase the dose as outlined in the schedule. If you give a dose that causes a mild local reaction (manifested by warmth or redness) repeat the same dose. If the reaction is severe or systemic (manifested as hives, asthma, or hay fever) drop back a dose in schedule and build again. If a severe local reaction or a systemic reaction is again encountered, this should be considered more than the maximum tolerance for this patient. The maintenance dose is the largest dose that relieves symptoms without producing local reactions. The size and interval of doses will vary and can be adjusted as necessary. The normal interval between doses is 4 to 7 days. The usual duration of treatment has not been established. A period of two or three years of injection therapy constitutes an average minimum course of treatment.