Allergic contact dermatitis caused by glucose sensors in type 1 diabetes patients

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.

Skin Reactions in Children with Type 1 Diabetes Associated with the Use of New Diabetes Technologies-An Observational Study from a Regional Polish Pediatric Diabetes Center

The study aimed to estimate the prevalence of skin problems in children and adolescents with type 1 diabetes (T1D) using insulin pumps (IPs) and/or continuous glucose monitoring (CGM) in our center and analyze their association with various factors. As part of the international ISPAD JENIOUS-initiated SKIN-PEDIC project, we interviewed and examined patients who visited the regional pediatric diabetes center in Opole (Poland) for four weeks regarding the use of IP and/or CGM and the presence of skin problems. Body mass index (BMI) and glycemic parameters were obtained retrospectively from medical records. Among 115 individuals (45.2% girls, 83.5% IP users, 96.5% CGM users), old scars were the most common skin problem (IP users 53.1%; CGM users 66.4%), while ≥2 types of skin problems co-occurred (IP users 40.6%; CGM users 27.3%). Longer IP use was associated with a higher prevalence of skin problems (50% for IP < 1 year, 98.1%-IP 1-3 years, 100% for IP > 3 years; p < 0.001), pointing out extra attention with IP use > 1 year. No significant associations were found between skin problems and gender, age, BMI centile and glycemic parameters. Dermatological complications were common among children using IP and CGM in our center, highlighting the need for vigilant monitoring and early intervention to manage these skin-related issues effectively.

Device-Related Skin Reactions Increase Emotional Burden in Youths With Type 1 Diabetes and Their Parents

BACKGROUND

Skin reactions due to technological devices pose a significant concern in the management of type 1 diabetes (T1D). This multicentric, comparative cross-sectional study aimed to assess the psychological impact of device-related skin issues on youths with T1D and their parents.

METHODS

Participants with skin reactions were matched in a 1:1 ratio with a control group. Diabetes-related emotional distress was evaluated using the Problem Areas in Diabetes-Teen version (PAID-T) for participants aged 11 to 19 years and the Problem Areas in Diabetes-Parent Revised version (PAID-PR) completed by parents. In addition, glucose control was assessed through glycated hemoglobin (HbA1c) values and continuous glucose monitoring (CGM) metrics.

RESULTS

A total of 102 children and adolescents were consecutively recruited. Adolescents with skin issues had higher PAID-T scores compared to those without (79.6 ± 21.1 vs 62 ± 16.8; P = .004). Parents of youths with skin reactions also reported higher PAID-PR scores than the control group (34.0 ± 11.0 vs 26.9 ± 12.3; P = .015). No differences were observed in HbA1c levels (6.9 ± 0.8% vs 6.8 ± 0.8%, P = .555) or CGM glucose metrics between the two groups. Remarkably, 25.5% were forced to discontinue insulin pumps and/or glucose sensors (21.5% and 5.9%, respectively).

CONCLUSIONS

Our study highlighted the increased emotional burden experienced by youths with T1D and their parents due to device-related skin reactions, emphasizing the need for further research and interventions in this crucial aspect of diabetes management.

Janus Polyurethane Adhesive Patch with Antibacterial Properties for Wound Healing

Despite the rapid development of tissue adhesives, flaws including allergies, poor stability, and indiscriminate double-sided adhesive properties limit their application in the medical field. In this work, Janus polyurethane patches were spontaneously prepared by adjusting the difference in the functional group distribution between the top and bottom sides of the patch during emulsion drying. Consequently, poor adhesion was exhibited on the bottom surface, while the top surface can easily adhere to metals, polymers, glasses, and tissues. The difference in adhesive strength to pork skin between the two surfaces is more than 5 times. The quaternary ammonium salt and hydrophilic components on the surface of the polyurethane patch enable the rapid removal and absorption of water from the tissue surface to achieve wet adhesion. Animal experiments have demonstrated that this multifunctional Janus polyurethane patch can promote skin wound closure and healing of infected wounds. This facile and effective strategy to construct Janus polyurethane patch provides a promising method for the development of functional tissue-adhesives.

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

First International Survey on Diabetes Providers' Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices

BACKGROUND

Advances in diabetes technological devices led to optimization of diabetes care; however, long-lasting skin exposure to devices may be accompanied by an increasing occurrence of cutaneous reactions.

METHODS

We used an open-link web-based survey to evaluate diabetes-care providers' viewpoint on prevalence, management practices, and knowledge related to skin reactions with the use of diabetes technological devices. A post hoc analysis was applied to investigate differences in the level of awareness on this topic in relation to the experience in diabetes technology.

RESULTS

One hundred twenty-five responses from 39 different countries were collected. Most respondents (69%) routinely examine patients' skin at each visit. All the preventive measures are not clear and, mainly, homogenously put into clinical practice. Contact dermatitis was the most frequently reported cutaneous complication due to diabetes devices, and its most common provocative causes are not yet fully known by diabetes-care providers. Almost half of the respondents (42%) had discussed the presence of harmful allergens contained in adhesives with device manufacturers. There is general agreement on the need to strengthen knowledge on dermatological complications.

CONCLUSIONS

Although diabetes-care providers are quite aware of the chance to develop skin reactions in people with diabetes using technological devices, there are still some unmet needs. Large follow-up studies and further dissemination tools are awaited to address the gaps revealed by our survey.

A toddler with systemic contact dermatitis caused by diabetes devices

Continuous glucose monitors (CGM) and insulin pumps have become the preferred treatment option for most young children and adolescents with type 1 diabetes (T1D), by avoiding fingerstick testing and providing real-time glucose measurements. These medical devices and their adhesives contain substances which have been identified as being responsible for allergic contact dermatitis. We describe the case of a toddler who developed severe contact dermatitis from her diabetes devices, leading to secondary infections and hospital admissions. This was followed by the development of a symmetrical exanthema with retroauricular and glutaeal distribution. Patch tests were positive for isobornyl acrylate (IBOA) and 4-tert-butylcatechol (PTBC). Her symmetrical exanthema was interpreted as systemic contact dermatitis due to IBOA and PTBC in her diabetes devices. We suspect that systemic contact dermatitis is an underreported complication in diabetic patients.

Contact Dermatitis to Diabetes Medical Devices

Skin adverse reactions to diabetes medical devices have been reported frequently over recent years. Adhesives attaching glucose sensors and continuous insulin infusion sets to the skin are proven to cause both allergic contact dermatitis and irritant contact dermatitis in patients with diabetes mellitus. Several allergens contained in adhesives and/or parts of medical devices are documented to cause allergic contact dermatitis, with acrylate chemicals being the most common culprit-especially isobornyl acrylate (IBOA), but also 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate or cyanoacrylates. Epoxy resin, colophonium and nickel were also identified as causative allergens. However, repetitive occlusion, maceration of the skin and resulting disruption of the skin barrier seem to have an impact on the development of skin lesions as well. The purpose of this study is to highlight the burden of contact dermatitis triggered by diabetes medical devices and to show possible mechanisms responsible for the development of contact dermatitis in a group of diabetic patients.

Prevalence and Description of the Skin Reactions Associated with Adhesives in Diabetes Technology Devices in an Adult Population: Results of the CUTADIAB Study

Objective: The use of continuous glucose monitoring (CGM) systems and continuous subcutaneous insulin infusion (CSII) devices adhering to the skin can lead to skin reactions. The objective was to determine the prevalence and consequences of skin reactions at CGM or CSII sites in a large unbiased population. Research Design and Methods: This is a cross-sectional multicenter study. All adult patients with diabetes seen in consultation over a period of 7 months and using or having used a system with skin adhesives (in the last 10 years) were included and filled out a self-assessment questionnaire. Results: Among 851 patients, skin reaction was reported in 28% with CGM and 29% with CSII. Patients reporting reactions were more frequently women using CGM and CSII, and CGM users had type 1 more often than type 2 diabetes (P < 0.001). Manifestations were similar for reactions to CGM and CSII: redness and pruritus in 70%-75% of patients with reactions, pain in 20%-25%, and vesicles and desquamation in 12%-15%. Manifestations occurred within the first 24 h of first use in 22%-24% of patients with reactions to CGM and CSII, but after more than 6 months in 38% and 47% of patients with reactions to CGM and CSII, respectively. Device use was definitively stopped in 12% of patients with reactions to CGM (3.2% of all users) and 7% with reactions to CSII (2.1% of all users). Conclusions: Skin reactions were common, with similar presentations in CGM and CSII users. Manifestations suggested skin irritation rather than allergies. These reactions rarely led to the definitive discontinuation of the use of the device.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Automated insulin delivery: benefits, challenges, and recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association

A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialised for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organisations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organisation has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonisation of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organisations for confirmation.

Automated Insulin Delivery: Benefits, Challenges, and Recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association

A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialized for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organizations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organization has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonization of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organizations for confirmation.

Continuous glucose monitoring (CGM) satisfaction and its effect on mental health and glycemic control in adults with type 1 diabetes

Background and aim

A continuous glucose monitoring (CGM) helps the user stay continuously informed about blood glucose levels and reach the right target range. This study aimed to compare glycemic control and mental health of adults with type 1 diabetes with or without CGM and to examine their experiences using it.

Methods

Patients were included in the survey, whether or not they had used a CGM. Standardized questionnaires were used to assess mental health, problems with disease management, hypoglycemia attitudes and behavior, as well as glucose monitoring satisfaction.

Results

277 people participated in the study. CGM users (61.3%) had a more favorable glycemic control than those who were not. No differences were observed between the 2 groups in mental health and in response to hypoglycemic events; however, users reported more disease-related problems. CGM users reported they felt more open and free about diabetes, however, the pain and skin irritation caused by the device was disturbing and it was difficult to cope emotionally with the constant thought and worrying about diabetes.

Conclusions

CGM did not show clear satisfaction among users, however, less fear of hypoglycemia, fewer depression symptomology and improved glycemic control indicate better clinical status, which is one of the most important goals of disease management.

Evaluation of the FreeStyle Libre, a flash glucose monitoring system, in client-owned cats with diabetes mellitus

Objectives

Home blood glucose monitoring using a portable blood glucose meter is important in the management of feline diabetes mellitus, but taking blood samples may be stressful for owners and cats. A flash glucose monitoring system measuring interstitial glucose, such as the FreeStyle Libre, overcomes some of these drawbacks. The aim of this study was to evaluate the practical use and analytical and clinical accuracy of the FreeStyle Libre in 41 client-owned diabetic cats.

Methods

In this prospective study, interstitial glucose concentrations were measured with the FreeStyle Libre and compared with blood glucose concentrations measured with a portable blood glucose meter (AlphaTRAK) on days 1, 7 or 8 and 14 after application of the device. Cat behaviour during application, location, skin reaction at the attachment site and owner satisfaction were assessed. Accuracy was determined by fulfilment of ISO 15197:2013 criteria, including Bland–Altman plotting and error grid analysis.

Results

Placing the device was easy, with 70% of cats showing no reaction. Most sensors were placed on the thoracic wall. Skin reactions at the attachment site were not present or mild in almost all cats. Owners were very satisfied with the use of the FreeStyle Libre. Median functional life of the sensor was 10 days (range 1–14). Good correlation was found between interstitial and blood glucose measurements (rho[r] = 0.88, P <0.0001). Fifty-three percent of interstitial glucose concentrations were within a maximum deviation of 15% from blood glucose concentrations and 92.7% were within the safe risk zones 0 and 1 of the surveillance error grid.

Conclusions and relevance

The flash glucose monitoring system was easy to use and owners of diabetic cats were satisfied with its use. Although the device did not completely fulfil ISO requirements, it is sufficiently accurate for glucose monitoring in diabetic cats.

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.

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.

Technologies for Type 1 Diabetes and Contact Dermatitis: Therapeutic Tools and Clinical Outcomes in a Cohort of Pediatric Patients

The increasing use of technological devices for the management of diabetes is related to the prolonged exposure of patients' skin to chemical and mechanical agents and, consequently, to the increased risk of developing dermatological complications. Among these, contact dermatitis is the most insidious skin disorder. Despite the magnitude of the issue, no universally accepted recommendations on the management of this common complication are currently available. Our observational study aimed to describe all the solutions adopted by patients and their caregivers to treat and prevent the appearance of contact dermatitis and to describe the clinical impact of this cutaneous complication. Twenty-one pediatric patients (mean age 12.1 ± 3.7 years) with type 1 diabetes were recruited in the study. The most common treatment used to treat acute skin lesions was the application of topical corticosteroids, sometimes associated with topical antibiotics (9.5%). In order to prevent the further appearance of dermatitis, the most frequently adopted measure was the use of hydrocolloid and/or silicone-based adhesives, followed by the application of protective barrier films. One patient reported benefit from the off-label use of fluticasone propionate nasal spray. However, only 52.4% of the study participants achieved a definitive resolution of the skin issue, and 38.1% of patients were forced to discontinue insulin pump therapy and/or continuous glucose monitoring. No differences were observed in glycated hemoglobin values between the period before and after the onset of contact dermatitis. Our study confirms the severity of this dermatological complication that may hinder the spread of new technologies for the management of diabetes. Finally, our findings highlight the importance of establishing close collaboration both with pediatric allergy specialists to prescribe the most suitable treatment and with manufacturing companies to ensure that adhesives of technological devices are free of harmful well-known sensitizers.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Skin Involvement in Paediatric Patients with Type 1 Diabetes

Skin involvement is an overlooked aspect in the management of paediatric patients with type 1 diabetes. A comprehensive search of published literature using the PubMed database was carried out using the following key terms: "children," "pediatric/paediatric patients," "skin," "skin disorders," "type 1 diabetes." Dermatological side effects are frequently observed among diabetic children and adolescents. Insulin-induced lipodystrophies and allergic contact dermatitis caused by insulin pumps or glycaemic sensors are the most common skin reactions in these patients. Furthermore, several diabetes-associated skin diseases such as necrobiosis lipoidica, granuloma annulare, vitiligo, and bullosis diabeticorum may already be present in paediatric patients. Paediatric diabetes specialists should pay attention to their patients' skin to recognize these disorders, identify the potential causes, and choose the most suitable treatment. Finally, the evaluation of skin concentrations of advanced glycation end-products using non-invasive diagnostic techniques may be used to assess the risk of chronic complications of diabetes as early as adolescence.

High Frequency of Dermatological Complications in Children and Adolescents with Type 1 Diabetes: A Web-Based Survey

INTRODUCTION

Despite advances in the management of type 1 diabetes (T1D), there is an increasing incidence of skin reactions related to diabetes devices such as patch pumps and glucose sensors. Aim of the present study was to assess the prevalence of dermatological complications in pediatric patients with T1D using technological devices.

METHODS

Online survey regarding skin reactions related to the use of patch pumps and/or glucose sensors was administered to families of children and adolescents (0-17 years) with T1D. Data were collected on demographic characteristics, duration of diabetes, and clinical features of dermatological complications if present.

RESULTS

Our study population consisted of 139 patients (female 51.8%) aged 11.1 ± 3.3 years. More than half (51.1%) experienced skin reactions due to patch pumps or glucose sensors. Dermatological complications were mainly caused by continuous glucose monitoring (56.3% of total). Timing of appearance of dermatological reactions varied from a few days to several months after the introduction of the device. The application of hypoallergenic barrier bandages was the most frequently adopted measure to solve the issue.

CONCLUSIONS

Our study confirmed high frequency of dermatological complications among pediatric patients with type 1 diabetes. Well-designed studies are awaited to provide clear recommendations to minimize the burden of skin issues related to technological devices.

Acrylates as a significant cause of allergic contact dermatitis: new sources of exposure

Acrylate monomers have a wide range of applications. Since the 1950s, many reports of occupational origin allergic contact dermatitis due to (meth)acrylate monomers have been published. During last decades, (meth)acrylate allergy has undergone an occupational shift from dentistry toward beauty industry and medical devices. The aim of the study was to conduct a literature review on acrylates as a cause of allergic contact dermatitis, current sources of exposure as well as identification of professional groups with an increased risk of this allergy and methods of effective prevention. Database review: Medline search (PubMed), Wiley Online Library and Web of Science base in years 1956–2019 using the following keywords: acrylates, manicurists, dentists, dental technicians, medical devices, occupational exposure, and allergic contact dermatitis. 204 346 articles containing the term ‘acrylates‘ have been found. They include 2 042 articles with the word ‘manicurists’, 169 919 – ‘dentists’, 218 236 – ‘dental technicians’, 2 427 418 – ‘medical devices’. Fifty-nine articles were chosen based on analysis of abstracts and full texts. In the past allergy to acrylates was mainly of occupational origin and dental technicians were the most often affected professional group. Since the long-lasting manicure has become popular, this problem concerns both manicurists and their customers. Moreover, the new significant trend is non-occupational allergic contact dermatitis caused by medical devices especially dedicated to diabetes patients.

Solution using Stomahesive® wafers for allergic contact dermatitis caused by isobornyl acrylate in glucose monitoring sensors

Isobornyl acrylate (IBOA) has recently caused a number of cases of allergic contact dermatitis (ACD) from its use in medical devices. We would like to enhance the awareness of this issue with the reporting of three Australian cases, involving two adults and a child. We also report a successful solution by using hydrocolloid wafer (Stomahesive®) as a barrier. As IBOA is not usually found on baseline patch test series and does not cross-react with other acrylic monomers, ACD to IBOA may be missed by clinicians.

Extraction With Sweat-Sebum Emulsion as a New Test Method for Leachables in Patch-Based Medical Devices, Illustrated by Assessment of Isobornylacrylate (IBOA) in Diabetes Products

BACKGROUND

The increasing offering of patch-based medical devices is accompanied by growing numbers of reported adverse skin reactions. Procedures for testing leachables according to ISO 10993 may not be optimal for lipophilic substances that can be mobilized on skin by sweat and sebum. We propose an improved extraction method for targeted analysis of leachables using low volumes of a sweat-sebum emulsion. The approach is illustrated by the analysis of isobornylacrylate (IBOA), a compound found in some devices and suspected for allergenic potential.

METHOD

Three patch-based products were tested: an implantable device for continuous glucose monitoring (CGM), an intermittently scanned CGM (isCGM) device, and a micro-insulin pump. Quantification of IBOA was performed by gas chromatography and allergenic potential of IBOA levels was assessed by the KeratinoSens cell assay. Different combinations were used for extraction solvent (isopropanol, 5% ethanol-water solution, and sweat-sebum emulsion), extraction volumes (complete immersion vs partial immersion in 2 mm of solvent), and extraction time (3, 5, and 14 days).

RESULTS

Isobornylacrylate was only found in the isCGM device. About 20 mg/L IBOA were eluted after 3 days in isopropanol but only about 1 mg/L in ethanol-water. Sweat-sebum emulsion dissolves IBOA better and gives a more stable solution than ethanol-water. Decomposition of IBOA solutions requires adjusted extraction timing or correction of results. In the sweat-sebum extract, IBOA levels were about 20 mg/L after 3 days and about 30 mg/L after 5 days, clearly above the threshold found in the KerationSens assay for keratinocyte activation (10 mg/L).

CONCLUSION

Extraction by low volumes of sweat-sebum emulsion can be a superior alternative for the targeted simulating-use assessment of leachables in patch-based medical devices.

Cutaneous Reactions to Continuous Glucose Monitoring and Continuous Subcutaneous Insulin Infusion Devices in Type 1 Diabetes Mellitus

BACKGROUND

Continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) are the standard of care for type 1 diabetes in children. There is little reported on device-related skin complications and treatment options. This study documents cutaneous reactions to CGM and CSII devices in children and young adults with type 1 diabetes.

METHODS

One hundred and twenty-one subjects (3-25 years) with type 1 diabetes and CGM and/or CSII use were recruited over a three-month period from the Naomi Berrie Diabetes Center at Columbia University Irving Medical Center. A five-question survey was completed for each subject detailing demographic data, diabetes management, and device-related skin complications.

RESULTS

Sixty percent of subjects reported skin complications related to CGM and/or CSII use. Terms most frequently used to describe cutaneous reactions were "red," "itchy," "painful," and "rash." Subjects who used both CGM and CSII were more likely to report skin problems than those who used only CSII (odds ratio 2.9, [95% confidence interval: 1.2-6.7]; P = .015). There were no associations between skin complications and sex or race/ethnicity. Twenty-two percent of subjects with adverse skin event(s) discontinued use of a device due to their skin problem. Seven percent were evaluated by a dermatologist. Eighty-one percent used a range of products to treat their symptoms, with variable perceived clinical outcomes.

CONCLUSIONS

Skin complications related to CSII or CGM devices are commonly reported in pediatric patients with type 1 diabetes and may lead to interruption or discontinuation of device use. Future studies are needed to elucidate the causes of these reactions and determine the best methods for prevention.

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.

Comparing real-time and intermittently scanned continuous glucose monitoring in adults with type 1 diabetes (ALERTT1): a 6-month, prospective, multicentre, randomised controlled trial

BACKGROUND

People with type 1 diabetes can continuously monitor their glucose levels on demand (intermittently scanned continuous glucose monitoring [isCGM]), or in real time (real-time continuous glucose monitoring [rtCGM]). However, it is unclear whether switching from isCGM to rtCGM with alert functionality offers additional benefits. Therefore, we did a trial comparing rtCGM and isCGM in adults with type 1 diabetes (ALERTT1).

METHODS

We did a prospective, double-arm, parallel-group, multicentre, randomised controlled trial in six hospitals in Belgium. Adults with type 1 diabetes who previously used isCGM were randomly assigned (1:1) to rtCGM (intervention) or isCGM (control). Randomisation was done centrally using minimisation dependent on study centre, age, gender, glycated haemoglobin (HbA_1c), time in range (sensor glucose 3·9-10·0 mmol/L), insulin administration method, and hypoglycaemia awareness. Participants, investigators, and study teams were not masked to group allocation. Primary endpoint was mean between-group difference in time in range after 6 months assessed in the intention-to-treat sample. This trial is registered with ClinicalTrials.gov, NCT03772600.

FINDINGS

Between Jan 29 and Jul 30, 2019, 269 participants were recruited, of whom 254 were randomly assigned to rtCGM (n=127) or isCGM (n=127); 124 and 122 participants completed the study, respectively. After 6 months, time in range was higher with rtCGM than with isCGM (59·6% vs 51·9%; mean difference 6·85 percentage points [95% CI 4·36-9·34]; p<0·0001). After 6 months HbA_1c was lower (7·1% vs 7·4%; p<0·0001), as was time <3·0 mmol/L (0·47% vs 0·84%; p=0·0070), and Hypoglycaemia Fear Survey version II worry subscale score (15·4 vs 18·0; p=0·0071). Fewer participants on rtCGM experienced severe hypoglycaemia (n=3 vs n=13; p=0·0082). Skin reaction was more frequently observed with isCGM and bleeding after sensor insertion was more frequently reported by rtCGM users.

INTERPRETATION

In an unselected adult type 1 diabetes population, switching from isCGM to rtCGM significantly improved time in range after 6 months of treatment, implying that clinicians should consider rtCGM instead of isCGM to improve the health and quality of life of people with type 1 diabetes.

FUNDING

Dexcom.

Complications associated with a flash glucose monitoring system in diabetic cats

OBJECTIVES

Glucose monitoring is an integral part of diabetes management. Interstitial glucose monitoring systems are increasingly commonly being used for this purpose in dogs and cats, including the use of a flash glucose monitoring system (FGMS). The aim of this study was to describe the incidence and nature of complications associated with the use of an FGMS in diabetic cats.

METHODS

The medical records of all cats that had placement of a 14-day FGMS during a 1-year period were retrospectively reviewed. Data retrieved included the number of days the sensor remained attached and functional, location of sensor placement and complications associated with the sensor. Complications were defined as early sensor detachment, sensor failure prior to the end of the 14-day monitoring period and dermatologic changes at the sensor site. Descriptive statistics were used to characterize the data.

RESULTS

Twenty cats had a total of 33 FGMSs placed. The majority (30/33 [91%]) of sensors were placed over the dorsolateral aspect of the thorax just caudal to the scapula. Twenty (61%) FGMSs remained attached and functional for the full 14 days. The overall incidence of complications associated with FGMS use was 10/33 (30%). The most frequent complication was early sensor detachment (n = 5/33 [15%]). Mild dermatologic changes (erythema, crusts) were noted with 4/33 (12%) FGMSs. More serious complications (skin erosions, abscess formation) were noted with 2/33 (6%) FGMSs.

CONCLUSIONS AND RELEVANCE

The use of the FGMS is relatively safe in cats, although there are potential complications that owners should be made aware of.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Pediatric allergic contact dermatitis. Part I: Clinical features and common contact allergens in children

Allergic contact dermatitis (ACD), a delayed hypersensitivity skin reaction to environmental allergens, has a prevalence that is similar in children and adults. However, diagnostic testing for ACD in pediatric populations accounts for less than one tenth of all patch tests. The relative infrequency of pediatric patch testing may be attributed to the difficulty in testing in this population, which includes a smaller surface area for patch test placement and maintaining cooperation during patch testing, especially in younger children. Diagnosis can be difficult in children because the appearance of ACD can mimic other common pediatric skin conditions, particularly atopic dermatitis and irritant contact dermatitis. Comprehensive history taking, guided by patient presentation, age group, and location of dermatitis, helps build clinical suspicion. Such clinical suspicion is one of the major reasons behind patch testing, with additional indications being recalcitrant dermatitis and dermatitis with atypical distribution. US pediatric data have shown the top allergens to be metals, fragrances, topical antibiotics, preservatives, and emollients. These trends are important to recognize to guide management and accurate diagnosis, because ACD tends to persist if the allergen is not identified and can affect patients' quality of life.

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.

A review of acrylates: Super glue, nail adhesives, and diabetic pump adhesives increasing sensitization risk in women and children

Allergic contact dermatitis (ACD) is a cutaneous type IV hypersensitivity immune reaction mounted against substances in contact with the skin to which the patient has been sensitized. ACD is common, affecting approximately 72 million Americans per year, and is more common in women. One common contact allergen group is acrylates, which are monomers that are polymerized in the making of glues, adhesives, and plastic materials. It is the monomers that are sensitizing, whereas the final polymers are inert. Acrylates were the 2012 Contact Allergen of the Year with the specific acrylate, isobornyl acrylate, being the 2020 Contact Allergen of the Year. This article reviews the history of acrylate use, epidemiology, and both known and emerging sources of acrylates resulting in ACD.

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

BACKGROUND

Several cases of allergic contact dermatitis (ACD) to the glucose sensor FreeStyle Libre have been reported. Isobornyl acrylate (IBOA) and N,N-dimethylacrylamide (DMAA) are known culprit allergens.

OBJECTIVES

To evaluate patients with suspected ACD to FreeStyle Libre in a standardized manner, present causative allergens, and assess patient-reported implications.

METHODS

A total of 15 patients with suspected ACD to FreeStyle Libre were patch tested with the Swedish baseline series and a new medical device series. IBOA and DMAA were tested at 0.1% and 0.3% in petrolatum (pet.). Readings were performed on day (D) 3 and D7. Background data, details on skin reactions, and associated implications were assessed using a questionnaire.

RESULTS

Thirteen patients were sensitized to IBOA and four to DMAA. Two positive reactions to IBOA and one to DMAA were seen only at 0.3% concentration on D7. Median duration of sensor use before dermatitis onset was 6 months. Half the number of the patients took precautions in everyday life due to sensor-related skin reactions. Six patients discontinued sensor usage.

CONCLUSIONS

Patients with suspected ACD to glucose sensors should be evaluated with a relevant patch test series containing IBOA and DMAA. Adding the 0.3% pet. concentration is recommended. The reading on D7 is necessary.

Contact Allergy-Emerging Allergens and Public Health Impact

Contact allergy (sensitisation) and allergic contact dermatitis (ACD) resulting from it have a considerable public health impact. For the present review, all pertinent articles were systematically searched via Medline and Web of Science™; additionally, all available issues of the journals "Contact Dermatitis" and "Dermatitis" were manually searched, covering the years 2018-2019, thereby extending and re-focusing a previous similar review. New allergens, or previously described allergens found in a new exposure context or of other current importance, are described in sections according to substance classes, e.g., metals, preservatives, fragrances. As a common finding in many investigations, a lack of information on product composition has been noted, for instance, regarding a newly described allergen in canvas shoes (dimethylthiocarbamylbenzothiazole sulfide) and, most notably, absence of co-operation from manufacturers of glucose-monitoring devices and insulin pumps, respectively. These latter devices have been shown to cause severe ACD in a considerable number of diabetic patients caused by the liberation of isobornyl acrylate and N,N'-dimethylacrylamide, respectively, as demonstrated by an international collaboration between dermatologists and chemists. Improved and complete ingredient labelling for all types of products, and not just cosmetics, must be put on the legislative agenda.

Prevalence and Prevention of Contact Dermatitis Caused by FreeStyle Libre: A Monocentric Experience

OBJECTIVE

Cutaneous adverse events (CAE) from FreeStyle Libre include allergic contact dermatitis (ACD) caused by the allergen isobornyl acrylate (IBOA). We aim to report CAE from this glucose sensor, ACD to IBOA in particular, and the outcome of using barrier films as a prevention.

RESEARCH DESIGN AND METHODS

A monocentric, retrospective review of medical files from adult and pediatric patients with diabetes using Freestyle Libre, in the period between December 2016 and April 2019, was performed with a focus on CAE.

RESULTS

Fifty-seven of 1,036 patients with diabetes (5.5%) were referred to our dermatology department because of CAE from FreeStyle Libre. Thirty-nine of 1,036 (3.8%) had ACD due to IBOA. Only two patients, of whom one sensitized to IBOA, had a benefit from using barrier films.

CONCLUSIONS

CAE occurred in 5.5% of FreeStyle Libre users, and 3.8% suffered from ACD due to IBOA. Barrier films had limited value in the prevention.

Cutaneous Complications With Continuous or Flash Glucose Monitoring Use: Systematic Review of Trials and Observational Studies

BACKGROUND

Continuous glucose monitoring (CGM)/flash glucose monitoring (FGM) use in diabetes management is increasing. Cutaneous complications associated with these devices were reported. We conducted a systematic review to provide an overview of cutaneous complications with CGM/FGM use.

METHODS

We identified observational studies and intervention trials that report on cutaneous complications with CGM/FGM use up to January 14, 2019. Studies were identified through Medline, Embase, and PubMed, or with hand searching of the previous publications. Screening was duplicated and data extracted to consider four main themes: incidence rate and severity, participant perspectives of cutaneous complications, potential solutions, and future directions in diabetic technology relevant to reducing cutaneous complications.

RESULTS

A total of 54 eligible studies were identified. The overall event rate of cutaneous complications reported from 19 trials was one event per eight weeks of sensor wear-time of which 1.5% were considered severe. The most common cutaneous complications were wear-related erythema, itching, and induration. Although skin irritations were the most common cause of CGM/FGM discontinuation, most users experienced less pain or discomfort with CGM/FGM than capillary blood glucose testing. Future technological advances may reduce, but not eliminate cutaneous complications.

CONCLUSION

The incidence rate of reported cutaneous complications with CGM/FGM use from the available literature is low, with one event per eight weeks of sensor wear-time. Reported complication severity was also low, leading to low rates of CGM/FGM discontinuation. However, there appear to be discrepancies between reporting in trial and observational data. Greater constancy in reporting is necessary to understand the frequency of this issue.