1. SKIN PRICK TESTING: WHAT CAN WE STILL IMPROVE? Which Allergens To Use? 22 nd World Allergy Congress Cancún, Mexico Richard W. Weber, M.D. National Jewish Health Denver, Colorado USA

2. DISCLOSURES SPEAKERS BUREAUS:ASTRAZENECA, GENENTECH RESEARCH GRANTS: NOVARTIS, GLAXOSMITHKLINE, PFIZER, MERCK ASSOCIATE EDITOR: ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY ASSOCIATIONS: AAAAI, ACAAI, CAAS NO CONFLICTS OF INTEREST PERTAINING TO SUBJECT MATTER OF THIS TALK

3. General Principles Pollens – Know what’s prevalent in your region – Know what cross-reacts so not to unnecessarily duplicate and expand testing items – Consider unique exposures of the patient, if any Indoor Arthropods & Epidermals – Most have species-specific and cross-reactive allergens, so degree of cross-reactivity is variable Fungi – Insufficient data to make strong recommendations – Alternaria, Stemphylium & Cladosporium have some cross- reactive allergens, as do Penicillium and Aspergillus

4. Family/SubfamilyGenus/SpeciesCommon NameComments PooideaePoa pratensisKentucky blue1. Strong cross-allergenicity based on marked homology of group 1, 2/3, and 5 major allergens 2. Timothy and sweet vernal may each have unique allergens Phleum pratenseTimothy Dactylis glomerataOrchard Festuca rubraFescue Anthoxanthum odorataSweet vernal Lolium perennePerennial ryegrass Phalaris canariensisCanary ChloridoideaeCynodon dactylisBermuda1. Cross-reactivity between members, Bermuda strongest inhibitor 2. Lack of group 2 and 5 allergens accounts for little cross-allergenicity with Pooideae Buchloe dactyloidesBuffalo Distichlis strictaSalt Bouteloua gracilisGrama PanicoideaeSorghum halepenseJohnson1. Lack of group 2 and 5 allergens accounts for little cross-allergenicity with Pooideae 2. More cross-reactivity with Pooideae than Chloridoideae Zea maysCorn Paspalum notatumBahia Saccharum officinarumSugarcane JuncaceaeJuncus effususSoft rush1. Cross-allergenicity within families 2. No cross-reactivity with Poaceae CyperaceaeCyperus esculentusYellow nutsedge Carex aquatilisSedge TyphaceaeTypha latifoliaCattail Typha angustifoliaNarrowleaf cattail AreceaePhoenix dactyliferaDate palm

5. Family/SubfamilyGenus/SpeciesCommon NameComments CupressaceaeJuniperus asheiMountain cedar1. Strong cross-allergenicity within family based on marked homology of group 1 and 2 major allergens 2. Weak cross-allergenicity with angiosperms may be due to group 4 calcium binding proteins Juniperus oxycedrusPrickly juniper Cupressus arizonicaArizona cypress Chamaecyparis lawsoniaPort Orford cypress Thuja plicataWestern red cedar TaxodioideaeCryptomeria japonicaJapanese red cedar Taxodium distichumBald cypress Sequoia sempervirensCoast redwood PinaceaePinus sylvestrisScotch pine1. Weak cross-allergenicity with angiosperms may be due to calcium binding proteins Pinus radiataMonterey pine Pinus strobusWhite pine Picea abiesNorway spruce Tsuga canadensisEastern hemlock Pseudotsuga menziesiiDouglas fir

6. Family/SubfamilyGenus/SpeciesCommon NameComments SapindaceaeAcer negundoBox elderDisparity between A. negundo and other Acer Acer rubrumRed maple MalvaceaeTiliaBasswood (linden) BrassicaceaeBrassica napusOilseed rape EuphorbiaceaeMercurialis annuaAnnual mercury SalicaceaeSalix nigraBlack willowStrong skin test correlations Populus deltoidesEastern cottonwood Populus tremuloidesAspen FabaceaeProspois juliforaMesquite ElaeagnaceaeElaeagnus angustifoliaRussian oliveQuestionable cross-reactivity with Oleaceae UrticaceaeUrtica dioicaNettleLittle cross-reactivity Parietaria judaicaPellitory UlmaceaeUlmus americanaAmerican elm CeltidaceaeCeltis occidentalisHackberry MoraceaeMorus rubraRed mulberry JuglandaceaeJuglans nigraBlack walnutStrong to moderate skin test correlations Carya ovataShagbark hickory Carya illinoensisPecan BetulaceaeBetula verrucosaSilver birch1. Strong cross-allergenicity between Betulaceae members based on homology of group 1 and 2 allergens 2. Fairly strong cross-allergenicity between Betulaceae and Fagaceae members based on homology of group 1 and 2 allergens Alnus glutinosaEuropean alder Corylus avellanaHazelnut (filbert) Carpinus betulusHornbeam Ostrya virginianaEastern hophornbeam FagaceaeFagus sylaticaEuropean beech Quercus albaWhite oak Quercus rubraRed oak

7. Family/SubfamilyGenus/SpeciesCommon NameComments Basal Tricolpates PlantanaceaePlatanus acerifoliaPlanetree Caryophyllanae AmaranthaceaeAmaranthus palmeriPalmer’s amaranth1. Strong cross-allergenicity between amaranths 2. Strong cross-allergenicity between Atriplex species 3. Chenopodioideae members show greater diversity, with variable degrees of reactivity 4. Russian thistle may possess unique allergens Amaranthus retroflexusRedroot pigweed ChenopodioideaeChenopodium albumLamb’s quarter Kochia scopariaBurning bush Salsola pestiferRussian thistle Atriplex canescensWingscale Atriplex wrightiiAnnual saltbush PolygonaceaeRumex acetosellaSheep sorrel

8. Asteridae PlantaginaceaePlantago lanceolataEnglish plantain OleaceaeOlea europaeaOlive1. Strong cross-allergenicity between Oleaceae members due to homology of group 1 allergens 2. Group 3 calcium-binding proteins cross- react within and across families Fraxinus excelsiorEuropean ash Ligustrum vulgarePrivet Syringa vulgarisLilac AsteraceaeAmbrosia artemisiifoliaShort ragweed1. Strong cross-allergenicity between short, giant, western, and false ragweeds 2. Strong cross-allergenicity between Artemisia species 3. Minor to little cross-reactivity between ragweeds and mugwort, marshelder, or cocklebur Ambrosia trifidaGiant ragweed Ambrosia psilotachyaWestern ragweed Ambrosia acanthicarpaFalse ragweed Ambrosia tenuifoliaSlender ragweed Ambrosia bidentataSouthern ragweed Ambrosia ambrosioidesCanyon ragweed Xanthium communisCocklebur Iva xanthifoliaBurweed marshelder Helianthus annuusSunflower Artemisia vulgarisMugwort Artemisia tridentataGiant sagebrush