Tuberculosis Skin Test (PPD Skin Test)

  • Medical Author:
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Tuberculosis skin test facts

  • The tuberculosis skin test is also known as the tuberculin test or PPD test.
  • The PPD test is used to determine if someone has developed an immune response to the bacterium that causes tuberculosis (TB).
  • The standard recommended tuberculin test is the Mantoux test, which is administered by injecting a 0.1 mL of liquid containing 5 TU (tuberculin units) PPD (purified protein derivative)into the top layers of skin of the forearm.
  • Skin tests should be read 48-72 hours after the injection.
  • The basis of the reading of the skin test is the presence or absence and the amount of induration (localized swelling).
  • A negative test does not always mean that a person is free of tuberculosis.
  • A person who received a BCG vaccine (administered in some countries but not the U.S.) against tuberculosis may also have a positive skin reaction to the TB test.

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Tuberculosis Diagnosis

Because TB may occur as either a latent or active form, the definitive diagnosis of active TB depends on the culture of mycobacteria from sputum or tissue biopsy. However, it may take weeks for these slow-growing bacteria to grow on specialized media.

What is the tuberculosis skin test?

The tuberculosis skin test is a test used to determine if someone has developed an immune response to the bacterium that causes tuberculosis (TB). This response can occur if someone currently has TB, if they were exposed to it in the past, or if they received the BCG vaccine against TB (which is not administered in the U.S.). The World Health Organization estimates that 2 billion people worldwide have latent TB, while around 3 million people worldwide die of TB each year. The tuberculosis skin test is also known as the tuberculin test or PPD (purified protein derivative) test.

The tuberculin skin test is based on the fact that infection with M. tuberculosis bacterium produces a delayed-type hypersensitivity skin reaction to certain components of the bacterium. The components of the organism are extracted from TB cultures and are the core elements of the classic tuberculin PPD (also known as purified protein derivative). This PPD material is used for skin testing for tuberculosis. Reaction in the skin to tuberculin PPD begins when specialized immune cells, called T cells, which have been sensitized by prior infection, are attracted by the immune system to the skin site where they release chemical messengers called lymphokines. These lymphokines induce induration (a hard, raised area with clearly defined margins at and around the injection site) through local vasodilation (expansion of the diameter of blood vessels) leading to fluid deposition known as edema, fibrin deposition, and attraction of other types of inflammatory cells to the area.

An incubation period of two to 12 weeks is usually necessary after exposure to the TB bacteria in order for the PPD test to be positive. Anyone can have a TB test, and it can be given to infants, pregnant women, or HIV-infected people with no danger. It is only contraindicated in people who have had a severe reaction to a previous tuberculin skin test.

How is the tuberculosis skin test administered?

The standard recommended tuberculin test, known as the Mantoux test, is administered by injecting a 0.1 mL of a liquid containing 5 TU (tuberculin units) of PPD into the top layers of skin (intradermally, immediately under the surface of the skin) of the forearm. The use of a skin area that is free of abnormalities and away from veins is recommended. The injection is typically made using a 27-gauge needle, and a tuberculin syringe. The tuberculin PPD is injected just beneath the surface of the skin. A discrete, pale elevation of the skin (a wheal) 6 mm-10 mm in diameter should be produced when the injection is done correctly. This wheal or "bleb" is generally quickly absorbed. If it is recognized that the first test was improperly administered, another test can be given at once, selecting a site several centimeters away from the original injection.

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What is the method of reading the tuberculosis skin test?

"Reading" the skin test means detecting a raised, thickened local area of skin reaction, referred to as induration. Induration is the key item to detect, not redness or bruising. Skin tests should be read 48-72 hours after the injection when the size of the induration is maximal. Tests read after 72 hours tend to underestimate the size of the induration and are not accurate.

How are skin test results interpreted?

The basis of the reading of the skin test is the presence or absence and the amount of induration (localized swelling). The diameter of the induration should be measured transversely (for example, perpendicular) to the long axis of the forearm and recorded in millimeters. The area of induration (palpable, raised, hardened area) around the site of injection is the reaction to tuberculin. It is important to note that redness is not measured.

A tuberculin reaction is classified as positive based on the diameter of the induration in conjunction with certain patient-specific risk factors. In a healthy person whose immune system is normal, induration greater than or equal to 15 mm is considered a positive skin test. If blisters are present (vesiculation), the test is also considered positive.

In some groups of people, the test is considered positive if induration less than 15 mm is present. For example, an area of induration of 10 mm is considered positive in the following groups:

  • Recent immigrants from high-prevalence areas
  • Residents and employees of high-risk areas
  • IV drug abusers
  • Children under 4 years old
  • Pediatric patients exposed to high-risk adults
  • People who work with mycobacteria in laboratories

An induration of 5 mm is considered positive for the following groups:

  • People whose immune system is suppressed
  • HIV-infected people
  • People with changes seen on chest X-ray that are consistent with previous TB
  • Recent contacts of people with TB
  • People who have received organ transplants

On the other hand, a negative test does not always mean that a person is free of tuberculosis. People who have been infected with TB may not have a positive skin test (known as a false negative result) if their immune function is compromised by chronic medical conditions, cancer chemotherapy, or AIDS. Additionally, 10%-25% of people with newly diagnosed tuberculosis of the lungs will also have a negative result, possibly due to poor immune function, poor nutrition, accompanying viral infection, or steroid therapy. Over 50% of patients with widespread, disseminated TB (spread throughout the body, known as miliary TB) will also have a negative TB test.

A person who received a BCG vaccine (administered in some countries but not the U.S.) against tuberculosis may also have a positive skin reaction to the TB test, although this is not always the case. This is an example of a false positive result. The positive reaction that is due to the vaccine may persist for years. Those who were vaccinated after the first year of life or who had more than one dose of the vaccine have the greatest likelihood of having a persistent positive result than those who were vaccinated as infants.

People who are infected with other types of mycobacteria other than Mycobacterium tuberculosis may also have false-positive TB skin tests.

Are there side effects or risks from having the PPD skin test?

The test typically does not produce side effects. There is a very slight risk of having a severe reaction to the test, including swelling and redness of the arm, particularly in people who have had tuberculosis or been infected previously and in those who have previously had the BCG vaccine. Allergic reactions are also rare complications.

Live bacteria are not used in the test, so there is no chance of developing tuberculosis from the test.

REFERENCE:

United States. Centers for Disease Control and Prevention. "Tuberculin Skin Testing." May 11, 2016. <http://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm>.

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Reviewed on 9/5/2017
References
REFERENCE:

United States. Centers for Disease Control and Prevention. "Tuberculin Skin Testing." May 11, 2016. <http://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm>.

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