Contact dermatitis caused by glucose sensors-15 adult patients tested with a medical device patch test series

Practical Approaches to Continuous Glucose Monitoring in Primary Care: A UK-Based Consensus Opinion

INTRODUCTION

Type 2 diabetes (T2D) imposes significant personal challenges and societal costs. Continuous glucose monitoring (CGM) is recognised as a state-of-the-art tool, but remains underutilised. Adoption of CGM in primary care should be informed by a broader understanding of the technology's capabilities and limitations.

METHODS

An expert panel was convened to review current literature and clinical experience to provide practical approaches to CGM for primary care practitioners and discuss the technology's value in the routine management of T2D. The goals were to review and reach consensus on the current state of CGM in non-specialist practice settings and on strategies for successfully initiating and maintaining people on CGM.

RESULTS

Initiation and maintenance of CGM therapy can be successfully conducted in primary care settings. CGM therapy should include proper patient selection, proper setting of expectations, and evidence-based adjustments to therapy. Most patients are likely to see quick, meaningful, and lasting improvements in their diabetes, along with a better understanding of their condition and greater motivation for successful management. Retrospective report interpretation is feasible and intuitive. Barriers to adoption and sustained use include cost, technological limitations, behavioural or psychological factors, and therapeutic inertia. Addressing these barriers is critical to enable better access to CGM. Continuous glucose monitoring can be leveraged by primary care teams to inform treatment decisions and also by patients to inform diabetes self-management.

CONCLUSION

CGM should be considered for all people with T2D. The recommendations provided here should simplify adoption and maintenance use of CGM in primary care and maximise the glycaemic and psychosocial benefits of the technology.

Allergic contact dermatitis caused by glucose sensors and insulin pumps: A full review: Part 2. Case reports and case series, clinical features, patch test procedures, differentiation from irritant dermatitis, management of allergic patients and (proposed) legislation

During the past 8 years, a large number of reports have appeared on allergic contact dermatitis to glucose sensors and insulin pumps in paediatric and adult patients with type 1 diabetes mellitus. Isobornyl acrylate in one particular sensor sensitised many hundreds of (published) individuals, and many other allergens were discovered in a large number of sensors and pumps. Diagnostic procedures with patch tests proved very complicated, as manufacturers showed a serious lack of cooperation with dermatologists in providing information on the ingredients of their products and samples for patch testing. This two part article provides a full and detailed review of all aspects of the subject of allergic contact dermatitis to glucose sensors and insulin pumps. Part 1 provided a general introduction to sensors and pumps, a survey of the cutaneous adverse reactions that they have caused, a full account of the allergens in the diabetes devices and an overview of the glucose sensors and insulin pumps that have caused allergic contact dermatitis. This part 2 presents all published case reports and case series, clinical features of allergic contact dermatitis, patch test procedures, differentiation from irritant dermatitis, management of allergic patients and (proposed) legislation.

Allergic contact dermatitis caused by glucose sensors and insulin pumps: A full review: Part 1: Sensors and pumps, adverse cutaneous reactions, allergens, and diabetes devices causing allergic contact dermatitis

During the past 8 years, a large number of reports have appeared on allergic contact dermatitis to glucose sensors and insulin pumps in paediatric and adult patients with type 1 diabetes mellitus. Isobornyl acrylate in one particular sensor sensitised many hundreds of (published) individuals, and many other allergens were discovered in a large number of sensors and pumps. Diagnostic procedures with patch tests proved very complicated, as manufacturers showed a serious lack of cooperation with dermatologists in providing information on the ingredients of their products and samples for patch testing. This two-part article provides a full and detailed review of all aspects of the subject of allergic contact dermatitis to glucose sensors and insulin pumps. Part 1 begins with a general introduction to sensors and pumps, followed by the cutaneous adverse reactions that they have caused and a full account of the allergens in the diabetes devices. In addition, an overview of the glucose sensors and insulin pumps that have caused allergic contact dermatitis is presented. Part 2 presents all published case reports and case series, clinical features of allergic contact dermatitis to sensors and pumps, patch test procedures, differentiation from irritant dermatitis, management of allergic patients and (proposed) legislation.

Tert-butylhydroquinone and tert-butylcatechol positivity as warning lights of skin sensitization to tert-butylphenol derivatives in adhesives and diabetes devices

INTRODUCTION

Tert-butylphenol (TBP) derivatives, antioxidants in adhesives and diabetes devices, may provoke allergic contact dermatitis (ACD).

OBJECTIVES

The objective of this study is to report sensitization to TBP derivatives in medical devices and to highlight that tert-butylhydroquinone (BHQ) and tert-butylcatechol (TBC) are potential screeners in this regard.

METHODS

Fifteen patients with ACD from adhesives and diabetes devices were patch tested to different TBPs: BHQ 1% pet., TBC 0.25% pet., BHA 2% pet., BHT 2% pet., 4-tert-butylphenol (TBP) 1% pet. and 2,4-di-tert-butylphenol (di TBP) 1% pet. The culprit devices (medical adhesives, sanitary pads, diabetes devices) and TBP patch preparations were analysed using gas chromatography-mass spectrometry (GC-MS).

RESULTS

BHQ (9/13), TBC (7/13), and to a lesser extent BHT (3/15), BHA (2/15) and TBP (2/13) gave positive reactions. Seven patients had developed ACD from adhesives and diabetes devices, respectively, and one patient from sanitary pads. GC-MS analyses of the medical devices and patch test materials confirmed the presence of the patch-test positive TBPs, or chemically related derivatives, or, interestingly, tert-butylbenzoquinones (BBQ) were found, that is, spontaneously formed, highly reactive TBP metabolites, likely (pseudo-) cross reacting with the patch tested TBPs.

CONCLUSION

TBPs might be overlooked sensitizers in medical devices, and BHQ and TBC are potential screeners in this regard.

Insulin Pump Therapy and Adverse Skin Reactions With Focus on Allergic Contact Dermatitis in Individuals Living With Diabetes Mellitus: A Systematic Review and Clinical-Based Update

BACKGROUND

The use of insulin pumps (continuous subcutaneous insulin infusion [CSII]) in individuals living with type 1 diabetes (T1D) improves disease control. However, adverse skin reactions may hamper compliance. We aimed to assess the relationship of insulin pumps, particularly that of infusion set therapy, used in children and adults with T1D and dermatitis including allergic contact dermatitis (ACD).

METHODS

A systematic search of PubMed, and EMBASE, of full-text studies reporting dermatitis in persons with diabetes using a CSII was conducted from 2020 to 2023. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at the Department of Occupational and Environmental Dermatology, Malmö, Sweden (YMDA) was also performed highlighting the diagnostic process.

RESULTS

Among the 391 screened abstracts, 21 studies fulfilled the inclusion criteria. Seven studies included data on children only, four studies were on adults, and nine studies reported data on both children and adults. Participants were exposed to a broad range of pumps. Dermatitis was rarely specified. Up to 60% of those referred to a university hospital due to skin reactions possibly related to insulin pumps had an ACD.

CONCLUSIONS

The review and our findings indicate that there is not sufficient focus on contact allergy in the primary toxicological evaluations of substances used also for insulin pump therapy products and that possible adverse skin reactions are not correctly followed up in the clinical setting.

Deriving a point of departure for assessing the skin sensitization risk of wearable device constituents with in vitro methods

Wearable devices are in contact with the skin for extended periods. As such, the device constituents should be evaluated for their skin sensitization potential, and a Point of Departure (PoD) should be derived to conduct a proper risk assessment. Without historical in vivo data, the PoD must be derived with New Approach Methods (NAMs). To accomplish this, regression models trained on LLNA data that use data inputs from OECD-validated in vitro tests were used to derive a predicted EC3 value, the LLNA value used to classify skin sensitization potency, for three adhesive monomers (Isobornyl acrylate (IBOA), N, N- Dimethylacrylamide (NNDMA), and Acryloylmorpholine (ACMO) and one dye (Solvent Orange 60 (SO60)). These chemicals can be used as constituents of wearable devices and have been associated with causing allergic contact dermatitis (ACD). Using kinetic DPRA and KeratinoSens™ data, the PoDs obtained with the regression model were 180, 215, 1535, and 8325 μg/cm2 for IBOA, SO60, ACMO, and NNDMA, respectively. The PoDs derived with the regression model using NAMs data will enable a proper skin sensitization risk assessment without using animals.

Prevalence of dermatitis including allergic contact dermatitis from medical devices used by children and adults with Type 1 diabetes mellitus: A systematic review and questionnaire study

Use of medical devices (MDs), that is, glucose sensors and insulin pumps, in patients with Type 1 diabetes mellitus (T1D) has proven an enormous advantage for disease control. Adverse skin reactions from these MDs may however hamper compliance. The objective of this study was to systematically review and analyse studies assessing the prevalence and incidence of dermatitis, including allergic contact dermatitis (ACD) related to MDs used in patients with T1D and to compare referral routes and the clinical investigation routines between clinics being part of the European Environmental and Contact Dermatitis Research Group (EECDRG). A systematic search of PubMed, EMBASE, CINAHL and Cochrane databases of full-text studies reporting incidence and prevalence of dermatitis in persons with T1D using MDs was conducted until December 2021. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at EECRDG clinics focused on referral routes, patient numbers and the diagnostic process. Among the 3145 screened abstracts, 39 studies fulfilled the inclusion criteria. Sixteen studies included data on children only, 14 studies were on adults and nine studies reported data on both children and adults. Participants were exposed to a broad range of devices. Skin reactions were rarely specified. It was found that both the diagnostic process and referral routes differ in different centres. Further data on the prevalence of skin reactions related to MDs in individuals with T1D is needed and particularly studies where the skin reactions are correctly diagnosed. A correct diagnosis is delayed or hampered by the fact that, at present, the actual substances within the MDs are not declared, are changed without notice and the commercially available test materials are not adequately updated. Within Europe, routines for referral should be made more standardized to improve the diagnostic procedure when investigating patients with possible ACD from MDs.

New device, 'old' allergens. Allergic contact dermatitis caused by the Dexcom G7 glucose sensor

BACKGROUND

Allergic contact dermatitis (ACD) has been reported as an adverse effect from the use of several glucose sensors and insulin pumps from different manufacturers. Isobornyl acrylate (IBOA) has been identified as a major culprit sensitizer, but also other acrylates and (modified) colophonium have been reported as causes of ACD.

OBJECTIVES

To report the two first cases diagnosed with ACD caused by the Dexcom G7 (DG7) glucose sensor.

PATIENTS AND METHODS

Two children with suspected ACD from DG7 were patch tested with our medical device series with an addition of selected test preparations including two variants of modified colophonium - methyl hydrogenated rosinate (MHR) and glyceryl hydrogenated rosinate (GHR). Both patients were also tested with acetone extracts made from different parts of the DG7 sensor. The extracts were analysed by gas chromatography-mass spectrometry (GC-MS).

RESULTS

Both patients tested positive to IBOA, hydroabietyl alcohol and GHR. In addition, patient 1 had a positive reaction to MHR and patient 2 had a positive reaction to colophonium. The GC-MS analyses showed the presence of IBOA and colophonium-related substances in the DG7 extracts.

CONCLUSIONS

Both patients were diagnosed with contact allergy to well-known medical device-related sensitizers. The presence of IBOA and (modified) colophonium in a newly introduced (on the Swedish market in 2023) glucose sensor is remarkable and indicates an inadequate toxicological assessment of the materials used in the sensor.

Allergic contact dermatitis due to 1,6-hexanediol diacrylate in ostomy patients

BACKGROUND

Many people live with ostomies after life-saving surgery. Ostomy patients often suffer from peristomal dermatitis. Allergic contact dermatitis (ACD) has been reported, mostly due to contact allergy (CA) to topical agents.

OBJECTIVES

We present three patients with therapy resistant peristomal dermatitis, suggesting ACD caused by different stoma products.

METHODS

Patch testing was performed with baseline series, additional series, and selected allergens. They were also tested with their own ostomy products as is and separate extracts of the products. Extracts were analysed using Gas Chromatography-Mass Spectrometry (GC-MS).

RESULTS

In all three patients we diagnosed CA to 1,6-hexanediol diacrylate (HDDA), +++ in case (C) 1 and 3, ++ in C 2. HDDA was detected in C 2's ostomy pouch adhesive and in C 1's and 3's flange extenders used to improve the adhesion of the ostomy pouches.

CONCLUSION

Therapy resistant peristomal dermatitis should always be suspected of ACD and patch testing, especially with the patient's own products, should be performed.

Contact Allergy to Allergens in the Swedish Baseline Series Overrepresented in Diabetes Patients with Skin Reactions to Medical Devices - A Retrospective Study from Southern Sweden

Allergic contact dermatitis is reported among individuals using continuous glucose monitoring systems and insulin pumps. The aim of this study was to describe contact allergy patterns for allergens in the Swedish baseline series and medical device-related allergens among users. Contact allergy to baseline series allergens and isobornyl acrylate was compared between diabetes patients and dermatitis patients patch-tested at the Department of Occupational and Environmental Dermatology during 2017 to 2020. Fifty- four diabetes patients and 2,567 dermatitis patients were included. The prevalence of contact allergy to fragrance mix II and sesquiterpene lactone mix was significantly higher in diabetes patients compared with dermatitis patients. Of the diabetes patients 13.0% and of the dermatitis patients 0.5% tested positive to sesquiterpene lactone mix (p < 0.001). Of the diabetes patients 7.4% and of the dermatitis patients 2.3% tested positive to fragrance mix II (p = 0.041). Of the diabetes patients 70.4% tested positive to medical device-related allergens. Of the diabetes patients 63.0% and of the dermatitis patients 0.2% were allergic to isobornyl acrylate (p < 0.001). In conclusion, not only medical device-related contact allergies, but also contact allergy to baseline series allergens (fragrance mix II and sesquiterpene lactone mix), is overrepresented in diabetes patients who use medical devices.

A Skin Care Program to Prevent Skin Problems due to Diabetes Devices in Children and Adolescents: A Cluster-Controlled Intervention Study

OBJECTIVE

Diabetes devices that deliver insulin and measure blood glucose levels are cornerstones in modern treatment of type 1 diabetes. However, their use is frequently associated with the development of skin problems, particularly eczema and wounds. Proper skin care may prevent skin problems, yet evidence-based information from interventional studies is missing. Providing this information is the aim of this study.

RESEARCH DESIGN AND METHODS

This cluster-controlled intervention study tested the efficacy of a basic skin care program (including use of lipid cream, removal, and avoidance of disinfection). A total of 170 children and adolescents with type 1 diabetes were included and assigned either to the intervention group (n = 112) or the control group (n = 58). Participants were seen quarterly the first year after device initiation, with clinical assessment and interview in an unblinded setting.

RESULTS

Eczema or wounds were observed in 33.6% of the intervention group compared with 46.6% of control participants (absolute difference, 12.9% [95% CI -28.7%, 2.9%]; P = 0.10). The adjusted odds of wound development were decreased by 71% in the intervention compared with control group (for wounds, odds ratio 0.29 [95% CI 0.12, 0.68]; P = 0.005). In total, only eight infections were seen, without a higher frequency in the intervention group, despite advice to omit disinfection.

CONCLUSIONS

These data indicate our basic skin care program partially prevented diabetes device-induced skin reactions. However, more preventive strategies with other adhesives, patches, and/or types of lotions are needed for optimized prevention.

Isocyanates may contribute to allergic contact dermatitis from diabetes devices and wound dressings

BACKGROUND

Isocyanates are well-known occupational allergens, but can also be present in medical devices.

OBJECTIVES

To highlight that contact sensitization to isocyanates might contribute to allergic contact dermatitis (ACD) from polyurethane (PU)-containing diabetes devices and wound dressings.

PATIENTS AND METHODS

Nineteen patients with suspected allergic contact dermatitis (ACD) from diabetes devices and/or wound dressings were patch tested to an isocyanate series. Four wound dressings, 6 diabetes devices and 4 monomeric isocyanate patch test preparations were analysed with gas chromatography - mass spectrometry (GC/MS).

RESULTS

Eight patients reacted to isocyanates and corresponding amines: 3 to isophorone diisocyanate (IPDI), 4 to 4,4'-diaminodiphenylmethane (MDA), 4 to 2,4-toluene diisocyanate (TDI) and 1 to polymeric methylene diphenyl diisocyanate (PMDI). Three of 4 wound dressings contained isocyanates (MDI, TDI and/or IPDI), whereas 5 of 6 diabetes devices contained 4,4'-methylene diphenyl diisocyanate (MDI), and one of them also IPDI. None of the medical devices contained 1,6-hexamethylene diisocyanate (HDI). Contrary to IPDI, and especially MDI, only the concentration of the TDI patch test preparation corresponded approximately (80%) to its label.

CONCLUSION

Patch tests with isocyanates may be worth-while in patients with suspected ACD from PU-containing medical devices. Besides MDA, and PMDI, also TDI might potentially be a marker for MDI-sensitization. This article is protected by copyright. All rights reserved.

Contact dermatitis in children caused by diabetes devices

BACKGROUND

Insulin pump and glucose monitoring devices improve diabetes mellitus (DM) control and enhance patients' quality of life. However, a growing number of adverse cutaneous reactions related to the use of these devices has been reported.

OBJECTIVE

To investigate the culprits of localized contact dermatitis in pediatric patients with diabetes caused by insulin pump and glucose monitoring devices.

METHODS

Retrospective analysis of 15 pediatric patients patch tested as part of a clinical investigation for skin reactions associated with insulin pump and glucose monitoring devices RESULTS: Seven patients had positive patch test reactions to isobornyl acrylate (IBOA) and five had positive reactions to benzoyl peroxide (BP). Positive patch test reactions to materials from the glucose sensor and/or insulin pump were seen in 10 of the 15 patients. Three had positive reactions to adhesive remover wipe from Smith and Nephew Remove and four had reactions to EMLA plaster.

CONCLUSION

A high share of patients showed positive reactions to IBOA and/or their medical devices (insulin pumps or glucose devices). A third of patients showed positive reactions to benzoyl peroxide. The presence of additional unidentified allergens cannot be excluded, highlighting the importance of access to a full description of the chemical composition of the devices. This article is protected by copyright. All rights reserved.

Contact allergy to the Dexcom G6 glucose monitoring system -role of 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate in the new adhesive

BACKGROUND

Skin reactions to the glucose monitoring systems Dexcom G5 and G6 have been rare. In 2019, the components of the adhesive were exchanged for better skin fixation. Since then, more and more patients experienced severe skin reactions. A few months ago, 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate (MBPA) was identified as a new component in the adhesive of the G6 model. Furthermore, it was suspected that isobornylacrylate (IBOA) was also a component of the exchanged adhesive.

OBJECTIVES

Our objective was to investigate if MBPA plays a major role in the increasing skin problems of patients without a history of IBOA-sensitization. Furthermore, our aim was to examine whether IBOA is contained in the newer model adhesive and may also contribute to allergic contact dermatitis (ACD).

PATIENTS AND METHODS

Five patients with a newly occurred ACD caused by the glucose monitoring system Dexcom G6 were investigated. Patch testing including MBPA in 3 different concentrations, as well as IBOA were performed. Gas chromatography-mass spectrometry of the newer system Dexcom G6 was carried out.

RESULTS

All patients were shown to be sensitized to MBPA, while MBPA 0,5% showed the strongest reaction. On the other hand, IBOA was tested negative.

CONCLUSION

In our study group MBPA was observed to be the triggering allergen of the recently changed adhesive.

Allergic Contact Dermatitis, an Important Skin Reaction in Diabetes Device Users: A Systematic Review

ABSTRACT

Diabetes management has undergone many advances over the years, including the introduction of devices that allow patients to monitor blood glucose and administer insulin. Although these devices have improved patients' quality of life, they are associated with adverse reactions.A systematic literature search was performed up to May 2020 in PubMed, Cochrane, and Embase databases, with no temporal restrictions. Articles were screened by title, abstract, and full text as needed. A manual search among the references of the included articles was also performed.Two hundred sixty-five articles were identified, and 50 studies met inclusion criteria. Several cases of allergic contact dermatitis due to the use of insulin infusion systems and blood glucose monitoring have been reported. Acrylates, methacrylates, and colophonium, as well as, in particular, isobornyl acrylate, represent the main allergens responsible.Skin reactions, in particular allergic contact dermatitis, are a very common adverse event caused by insulin pumps and glucose sensors, which may lead to discontinue the usage of these devices with serious consequences for the patients. Collaboration between specialists, specifically between dermatologists and diabetologists, with patients and manufacturers is essential for the correct management of diabetes devices and potential related skin reactions.

Outbreak of Occupational Allergic Contact Dermatitis from a Smartphone Screen Protector Glue

Background

Sensitization to acrylates is a concern in the occupational/environmental dermatology field.

Objective

To describe an occupational allergic contact dermatitis (ACD) outbreak from a smartphone screen protector glue.

Methods

Thirteen affected workers of a chain store selling phone screen protectors were investigated in five Spanish dermatology departments. The glue datasheet and label were assessed. A chemical analysis of the glue was performed. Based on this, some patients underwent additional testing.

Results

All patients (all female, mean age: 25) had severe fingertip dermatitis.

The datasheet/label indicated that the glue contained isobornyl acrylate (IBOA), a “photoinitiator” and polyurethane oligomer. The company informed us that the ingredients were polyurethane acrylate, “methacrylate” (unspecified), acrylic acid, hydroxyethyl methacrylate, propylmethoxy siloxane, and photoinitiator 184. Isobornyl acrylate (or IBOA) and N,N‐dimethylacrylamide (DMAA) were patch tested in eight and two cases, respectively, with negative results.

A chemical analysis revealed 4‐acryloylmorpholine (ACMO); isobornyl methacrylate (IBMA), and lauryl acrylate in one glue sample. Seven patients were patch tested with dilutions of the identified substances and six of seven were positive for ACMO 0.5% pet.

Conclusion

An outbreak of occupational ACD, likely from ACMO in a glue is described. Further investigations are needed to corroborate the role played by each compound identified in the chemical analyses.

Modern diabetes devices for continuous blood sugar measuring: Limitations due to contact allergies

During the past years, diabetes diseases have increased significantly worldwide. However, new technologies such as continuous glucose measurement using a subcutaneous sensor are developing just as rapidly. A continuous improvement in insulin pump therapy is also contributing to an improved quality of life. A common feature of these modern devices for diabetes therapy is that they remain fixed in place on the skin for several days. In recent years, skin reactions, in particular pronounced contact dermatitis due to the devices and their adhesives have been increasingly reported. In particular, isobornyl acrylate, which used to be included in a glucose measurement sensor set, was identified as a main allergen. Development of contact allergy can result both in a necessity to quit the measuring system and in allergic cross-reactions to other systems.

Allergic contact dermatitis caused by dipropylene glycol diacrylate in the Omnipod® insulin pump

BACKGROUND

Cases of allergic contact dermatitis (ACD) caused by isobornyl acrylate (IBOA) in the Omnipod® insulin pump have previously been reported.

OBJECTIVES

To present three cases of patients with ACD caused by a new allergen in the pump, and results from chemical analyses.

METHODS

Omnipod pumps from different batches were analysed by gas chromatography-mass spectrometry. Aimed testing, with the department's medical device (MD) series and substances identified in the pump including dipropylene glycol diacrylate (DPGDA) at 0·01% and 0·1% in petrolatum (pet.), was performed. Patch testing also included extracts from the device, the adhesive patch as is, and allergens from baseline series.

RESULTS

All patients tested positive to 0·1% DPGDA in pet., and two patients additionally to a 0·01% concentration. DPGDA was found in extracts of the Omnipod pumps brought by the patients. An Omnipod pump from an earlier batch contained tripropylene glycol diacrylate, IBOA, N,N-dimethylacrylamide, di(ethylene glycol)ethyl ether acrylate (DEGEA) but no DPGDA. One of the patients reacted positively to all of these allergens except DEGEA, which was not tested.

CONCLUSIONS

When suspecting ACD to MDs, DPGDA at 0·1% in pet. should be tested. The contents of Omnipod have changed over time. Patch testing with updated test series and relevance assessment of positive reactions is a delicate task. Children, with lifelong use of MDs, risk contracting many allergies with potential cross-allergies. A question should be raised as to whether these low molecular weight acrylates should be used at all in devices constantly worn on the skin.

Severe allergic contact dermatitis to two different continuous glucose monitoring devices in a patient with glycogen storage disease type 9b

Continuous glucose monitoring (CGM) systems are of great value for patients with disorders of impaired glucose homeostasis, including glycogen storage diseases. We report on an 8-year-old girl with glycogen storage disease type 9b who developed severe allergic contact dermatitis to two different continuous glucose monitoring systems, FreeStyle^® Libre and Dexcom^® G6. Our case highlights the impact of sensitization for pediatric patients, the urgent need for open labeling of components by pharmaceutical and device manufacturers, and the need for avoidance of skin sensitizers in medical devices.

Contact Dermatitis From Glucose Sensors In Spain: A Multicentric Approach

BACKGROUND

Allergic contact dermatitis from glucose sensors may interfere with their ongoing application.

OBJECTIVE

To evaluate a series of Spanish patients with contact dermatitis to glucose sensors regarding former sources of contact allergens, patch test results and outcomes from the ongoing use of the device.

METHODS

A series of patients with contact dermatitis from glucose sensors was investigated in eight dermatology departments across Spain epidemiologic features, brands, latency time to develop dermatitis, the ability to continue using the devices as well as the patch test results.

RESULTS

Thirty patients were evaluated mean age: ²⁰ .⁹³ years. ⁶⁶ .⁷ % were children and ⁶⁶ .⁷ % female. ⁹⁰ .⁰ % used Freestyle Libre FSL. ⁸ /^{26 30} .⁸ % reacted to isobornyl acrylate IBOA and ² /^{20 10} .⁰ % to N,N dimethylacrylamide DMAA. The mean latency time to develop dermatitis was ⁹ months. ¹⁶ /^{29 55} .² % patients continued using the same sensor causing the reaction. ¹³ /^{29 44} .⁸ % were unable to continue using the sensor due to severe reactions. Of them, ⁵ were positive to IBOA, one to IBOA and DMAA; one to DMAA; one to colophony and ¹ to isopropyl alcohol wipes. In one patient the outcome was unknown.

CONCLUSION

The frequency of sensitization to IBOA and DMAA, was lower than in other European series, but similar to a previously published Spanish article. Legislation requiring manufacturers to provide information regarding medical devices composition and cooperate with the investigation of contact dermatitis is urgently needed. This article is protected by copyright. All rights reserved.

Further Evidence of Allergic Contact Dermatitis Caused by 2,2'-Methylenebis(6-tert-Butyl-4-Methylphenol) Monoacrylate, a New Sensitizer in the Dexcom G6 Glucose Sensor

BACKGROUND

Since the spring of 2020, we have seen several patients experiencing severe allergic contact dermatitis (ACD) from the Dexcom G6 glucose sensor after the composition of the sensor's adhesive patch had been changed. We have previously reported the finding of a new sensitizer, 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate, in the Dexcom G6 adhesive patch. Three patients with ACD from Dexcom G6 tested positive to this sensitizer. They were also allergic to isobornyl acrylate, a sensitizer present both in Dexcom G6 and in other medical devices previously used by these patients.

OBJECTIVE

The aim of the study was to report the first 4 cases sensitized to 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate without a simultaneous allergy to isobornyl acrylate.

METHODS

The cases were patch tested their own materials, a medical device series, and 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate in several concentrations.

RESULTS

All 4 cases tested positive to 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate at either 1.0% or 1.5% in petrolatum, whereas 20 controls tested negative to both concentrations.

CONCLUSIONS

The cases reported here provide further evidence of 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate as a relevant culprit sensitizer in patients with ACD from Dexcom G6. However, the initially used patch test concentration (0.3%) did not suffice to elicit positive reactions in these cases, which is why patch testing at 1.5% is recommended.

What Is New in Occupational Allergic Contact Dermatitis in the Year of the COVID Pandemic?

PURPOSE OF REVIEW

This article aims to summarize some recent trends in occupational allergic contact dermatitis (ACD), including dermatitis related to pandemic-level personal protective equipment in healthcare workers, hazards patients may experience when working from home, and occupational perspectives on the recent American Contact Dermatitis Society (ACDS) allergens of the year and ACDS Core Allergen Series updates.

RECENT FINDINGS

Recent ACDS Allergens of the Year may be particularly relevant to healthcare workers, including isobornyl acrylate, which is present in glucose sensors and propylene glycol present in hand cleansers and disinfectants. Lavender, limonene, and linalool, all of which are new additions to the ACDS Core Allergen Series, have been reported as causes for occupational ACD in massage therapists and aromatherapists. Isothiazolinone allergy continues to rise in both consumer and occupational settings. Finally, the COVID-19 pandemic has resulted in a wave of occupational ACD in healthcare workers to personal protective equipment, and revealed new potential allergens for individuals working from home. Occupational allergic contact dermatitis continues to exert a significant occupational disease burden. Remaining aware of the current trends in allergens may allow for earlier recognition, diagnosis, and treatment, subsequently helping our patients to work in healthier and safer environments.

Changes in adhesive ingredients in continuous glucose monitoring systems may induce new contact allergy pattern

BACKGROUND

Medical devices (MD) in close skin-contact for a prolonged time, such as glucose monitoring (CGM) systems, are a risk factor for contact allergy, and there has been an increase in patients using these. Correct diagnosis demands targetted testing.

OBJECTIVES

We report a new allergen in a continuous CGM system in which the adhesive was changed. The allergy pattern of the patients diagnosed is reported.

METHODS

The three patients reported were patch tested with an MD series, own material, and possible allergens found through analysis with gas chromatography-mass spectrometry, comparing analysis from the CGM system before and after change.

RESULTS

The patients were sensitized to isobornyl acrylate (IBOA), found in previously used devices and the present CGM. Apart from IBOA, the culprit allergen was found to be 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate.

CONCLUSION

Allergic contact dermatitis due to CGM systems and insulin pumps are difficult to investigate and require chemical analysis. Because of the lack of information on substances used in the production, and when changes with MDs are initiated, it is difficult to advise patients, especially since they risk sensitization to several allergens. The use of MDs has increased and, thus, the need for collaboration between manufacturers, clinicians, and patient organizations.

Concomitant positive patch test reactions in FreeStyle-allergic patients sensitized to isobornyl acrylate

BACKGROUND

Concomitant positive patch test reactions in patients sensitized to isobornyl acrylate (IBOA) have rarely been documented.

OBJECTIVES

To report concomitant sensitizations in patients with allergic contact dermatitis (ACD) from the glucose sensor FreeStyle Libre and sensitized to IBOA.

METHODS

In 2019, 26 patients with suspected ACD from FreeStyle Libre were patch tested to a baseline series and to a (meth) acrylate series containing IBOA and 2-phenoxyethyl acrylate (PEA) 0.1% pet. Diabetes devices and patch test preparations were analyzed with gas chromatography - mass spectrometry (GC-MS) for the presence of IBOA and PEA.

RESULTS

Of the 26 patients, 18 (69%) were sensitized to IBOA, and eight (44%) and 11 (61%) of these were co-sensitized to sesquiterpene lactones and fragrances, respectively. Ten patients (56%) were co-sensitized to PEA, which, contrary to IBOA, could not be detected in any device. The PEA test material was shown to be contaminated with IBOA.

CONCLUSIONS

Contact allergy to IBOA appears to be declining and IBOA-sensitized patients are most often co-sensitized to sesquiterpene lactones and fragrances. Vigilance is required when patch testing (acrylate) materials obtained from industry, as these might be contaminated and, hence, alter the results and their interpretation.