Background: Skin prick test (SPT) and intradermal test (IDT) are standard procedures in the allergy practice that are safe when performed. Individuals with a history of allergic reaction to the COVID-19 vaccine can undergo allergy skin testing for polyethylene glycol and polysorbate 80 to determine their eligibility for the same vaccine or a safe alternative. Hypopigmentation is an infrequent adverse effect of corticosteroids, including triamcinolone acetonide, following local and intralesional treatment. Exposure to high potency corticosteroids for a long duration and the intradermal injection route are risk factors for hypopigmentation. In this case report, we describe the development of hypopigmentation following triamcinolone ID testing. Case report: A 29-year-old lady with a history of immediate severe allergic reaction following the first dose of mRNA COVID-19 vaccine (Pfizer) underwent SPT and IDT for polysorbate 80 and polyethylene glycol. Triamcinolone acetonide and Prevnar 13 were used as an indicator of polysorbate 80. Following a negative SPT, IDT for triamcinolone acetonide was negative at 1:10 of 40 mg/mL and positive at 1:1 of 40 mg/mL. A few days later, she noticed hypopigmented lesions at the site of the intradermal skin test for both concentrations of triamcinolone. The lesions have increased in size since then (see image). The patient was diagnosed with steroid-induced hypopigmentation secondary to triamcinolone IDT injection. Conclusion: Skin hypopigmentation following intraarticular and intralesional triamcinolone injection has been reported previously. However, to the best of our knowledge, this is the first reported case of steroid-induced hypopigmentation following intradermal skin testing. Furthermore, this report highlights that even a low dose of local triamcinolone can cause hypopigmentation. We believe that this case report regarding the rare adverse event will alert clinicians to the potential complication of corticosteroid IDT and help them counsel the patients and provide a thorough explanation before any procedure.

Background: Unverified penicillin allergy has been linked to adverse patient events and increased healthcare expenditure owing to the usage of broad-spectrum, expensive antibiotics. Penicillin allergy test is the gold standard to diagnose penicillin allergy; and in this study, we present data from Qatar which have not been published before. Methods: Patients with a history of penicillin allergy who underwent penicillin allergy testing between January 2015 and December 2020 at the Allergy Division of the Hamad General Hospital were retrospectively reviewed from the division registry. Benzylpenicilloyl-polylysine (PPL) and minor determinant mixture (MDM) kit DAP-penicillin (0.04 mg +0.5 mg)/vial) (penicillin G, amoxicillin (20 mg/vial), and lately clavulanic acid (20 mg/vial) (DAP, Diater, Madrid, Spain) were used for skin and intradermal testing according to published guidelines. Patients with negative skin tests were administered direct oral challenge with amoxicillin/clavulanate (500/125 mg) and observed for 2 hours. Results: Of the 189 charts reviewed, 183 patients had a complete data set for analysis. Patients were predominantly women (n = 132, 72%) with an average age of 42 years. Of these patients, 149 (81.4%) had a history of an immediate allergic reaction to penicillin, 10 had a history of delayed reactions, and 24 had other or undefined reactions. A total of 39 (21.3%) patients were diagnosed with penicillin allergy (30 patients with positive skin test results and 9 using a direct oral challenge). Of the 30 patients with positive skin testing, 5 reacted to PPL, 8 to MDM, 13 to amoxicillin, and 4 to clavulanic acid. Conclusion: Previous studies indicate that 90% patients with a history of penicillin allergy were able to tolerate the drug (10% were truly allergic). Our data showed that 21% were truly allergic to penicillin. This high positive rate can be attributed to the high pretest probability based on the detailed history obtained before the test, which led to the exclusion of patients with symptoms incompatible with penicillin allergy from the test.

Specialist nurses have a crucial role within the allergy and immunology specialty that reflects their competence in an increasingly complex area of work and ability to use advanced diagnostic testing and therapeutic modalities. A specialist nurse in Qatar follows the local Hamad Medical Cooperation (HMC) guidelines and the competency published by the British Society for Allergy and Clinical Immunology (BSACI). Specialist Allergy Nurses Learning domain: Learn and review the written standard operating procedure (SOP) and protocols for all diagnostic and therapeutic allergy procedures, including skin prick testing (inhaled, food, and others), intradermal testing, skin patch testing, penicillin testing, food and drug challenges, different desensitization protocols, and biologics and other medication administration. In addition, learn the protocol for immunotherapy administration and maintain an updated knowledge of trends and developments in the field by reading relevant articles, journals, and related material and attending seminars and conferences, as needed. Maintain a safe work environment: Perform all the above procedures and medication administration with a high grade of competency under physician supervision. Apply quality measures to ensure safety. Furthermore, perform stocktaking by regularly checking procedure requirements, availability of items and consumables, date of expiry of items, and medications. Monitor the patients closely during drug and food allergy challenge procedures and record and report patients’ vitals and reactions to treating physicians. Ensure that a patient stays the required observation time after injection(s). General care: Assess patient needs and suggest solutions to patient care problems. Provide education and resources for the patient and family support as needed. React appropriately and on time during patient reaction situations to mitigate early adverse reactions. Maintain patient, employee, and clinic confidentiality. Specialist Immunology Nurses • Develop specialist knowledge and experience in immunology. •Develop nurse-led clinics for administering immunoglobulin replacement therapy safely and effectively based on patients’ preferences (IV vs. SC and in-hospital vs. home programs). •Coordinate communication between members of the multidisciplinary team to facilitate the appropriate delivery of care. •Provide education and resources for the patient and family support (insurance issues, resources for vaccination recommendations, concerns regarding traveling and vacations, pregnancy, and any other lifecycle changes).