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França K, Yu J. Allergic contact dermatitis and irritant contact dermatitis from medical devices used by patients with insulin-dependent diabetes mellitus. J Eur Acad Dermatol Venereol 2024; 38:1234-1235. [PMID: 38924616 DOI: 10.1111/jdv.20089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Katlein França
- Dr. Frost Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - JiaDe Yu
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Moon RJ, Rowland AC, Davies JH. Hyperpigmentation at diabetes technology sites may be indicative of evolving Addison's disease. Arch Dis Child 2024; 109:432. [PMID: 38336458 DOI: 10.1136/archdischild-2023-326750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Rebecca J Moon
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Amy C Rowland
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Justin H Davies
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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3
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Velasco-Amador JP, Prados-Carmona Á, Navarro-Triviño FJ. [Translated article] Medical Devices in Patients With Diabetes and Contact Dermatitis. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T280-T287. [PMID: 38242434 DOI: 10.1016/j.ad.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/08/2023] [Indexed: 01/21/2024] Open
Abstract
The development and commercialization of glucose sensors and insulin pumps has revolutionized the management of diabetes. These devices have been linked to multiple cases of contact dermatitis in recent years, however, giving rise to a growing interest in identifying the sensitizing allergens. Isobornyl acrylate was clearly identified as one of the main allergens responsible for contact dermatitis among users of the FreeStyle glucose sensor and was subsequently removed from the product ingredients. Remarkably, however, it is still used in most other sensors on the market. The common adhesive ingredients colophony and abietic acid derivatives have also been shown to be sensitizing agents. New components under study, such as dipropylene glycol diacrylate, N,N-dimethylacrylamide, and triethylene glycol methacrylate have recently been identified as allergens, though they are not commercially available for clinical testing. The benefits offered by glucose sensors and insulin pumps may be offset by sensitization to product ingredients, in some cases forcing discontinuation and diminishing quality of life. Dermatologists should play a role in this clinical and research scenario, offering case-by-case guidance to endocrinologists on skin care and possible alternatives for patients with glucose sensors and insulin pumps who develop contact dermatitis. They should also collaborate with the manufacturers developing these devices.
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Affiliation(s)
- J P Velasco-Amador
- Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, Spain
| | - Á Prados-Carmona
- Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, Spain
| | - F J Navarro-Triviño
- Unidad de Eczema de Contacto e Inmunoalergia, Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, Spain.
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4
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Cichoń M, Myśliwiec M, Trzeciak M. Role of acrylates in the development of contact dermatitis in diabetic patients-A Polish dermatology tertiary centre experience. Contact Dermatitis 2024; 90:126-133. [PMID: 37840370 DOI: 10.1111/cod.14436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND In recent years, an increasing number of contact dermatitis cases triggered by acrylates contained in diabetes medical devices have been reported. Acrylates seem to play a major role in the development of irritant contact dermatitis and allergic contact dermatitis (ACD) in diabetic patients. OBJECTIVES To study a group of patients with contact dermatitis caused by diabetes medical devices with a focus on acrylates as possible allergens responsible for contact dermatitis. PATIENTS AND METHODS Fifteen patients with diabetes mellitus type 1 and contact dermatitis from diabetic devices were patch tested to 25 acrylate allergens. RESULTS Three patients (20%) reacted to the following allergens: three patients reacted to isobornyl acrylate (IBOA) and one of them additionally to 2-hydroxyethyl acrylate (2-HEA); results were of clinical relevance. All three patients were using insulin pumps and glucose sensors (GS)-in one patient contact dermatitis was towards the insulin pump and the GS, in one patient only towards the insulin pump and in one patient only towards the GS. Twelve patients (80%) did not show any skin reaction towards the allergens tested. CONCLUSION A majority of diabetic patients showed no reactions towards any acrylate allergen tested; yet, the presence of untested allergens must be kept in mind. IBOA proved to be a cause of ACD in diabetes patients. 2-HEA might be another culprit allergen, but its presence in the devices must first be confirmed.
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Affiliation(s)
- Mikołaj Cichoń
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Małgorzata Myśliwiec
- Department of Paediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Gdansk, Poland
| | - Magdalena Trzeciak
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
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5
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S126-S144. [PMID: 38078575 PMCID: PMC10725813 DOI: 10.2337/dc24-s007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
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.
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6
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Genève P, Adam T, Delawoevre A, Jellimann S, Legagneur C, DiPatrizio M, Renard E. High incidence of skin reactions secondary to the use of adhesives in glucose sensors or insulin pumps for the treatment of children with type 1 diabetes. Diabetes Res Clin Pract 2023; 204:110922. [PMID: 37769906 DOI: 10.1016/j.diabres.2023.110922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/11/2023] [Accepted: 09/23/2023] [Indexed: 10/02/2023]
Abstract
AIMS To evaluate the incidence of the skin reactions secondary to continuous subcutaneous insulin infusion (CSII) or continuous glucose monitoring (CGM), sensors and the characteristics of affected children with type 1 diabetes. METHODS An observational, retrospective, single-centre study included 198 children with type 1 diabetes, (46% girls, mean age 11.75 years). A standardised questionnaire was completed with the patient during current care to evaluate the skin reactions (mean and percentage), the type of reaction, their impact and the treatment) and the characteristics of affected children with univariate and multivariate analysis. RESULTS Sixty-seven children (33.8%) reported active skin reactions: 45 children with CSII (30.4%) and 46 with CGM (23.5%). Children with skin reactions were younger (mean age 10.6 yo versus 12.34 yo, p < 0.05), with a younger age at the diagnosis of diabetes (5.59 yo versus 7.08 yo, p < 0.05). Atopy was more frequent in the group with skin reactions (76.1% versus 54.1% p < 0.05). On multivariate analysis, only the personal history of atopy was associated with skin reactions: OR 2.56 [1.16-5.97] (p < 0.05). CONCLUSION This study confirms the high incidence of skin reactions to adhesive devices used in the treatment of type 1 diabetes in children.
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Affiliation(s)
- P Genève
- Pediatric Endocrinology and Diabetology Unit, Children's Hospital, University Hospital of Nancy, France
| | - T Adam
- Department of Allergology, Children's Hospital, University Hospital of Nancy, France
| | - A Delawoevre
- Pediatric Endocrinology and Diabetology Unit, Children's Hospital, University Hospital of Nancy, France
| | - S Jellimann
- Pediatric Endocrinology and Diabetology Unit, Children's Hospital, University Hospital of Nancy, France
| | - C Legagneur
- Pediatric Endocrinology and Diabetology Unit, Children's Hospital, University Hospital of Nancy, France
| | - M DiPatrizio
- Pediatric Endocrinology and Diabetology Unit, Children's Hospital, University Hospital of Nancy, France
| | - E Renard
- Pediatric Endocrinology and Diabetology Unit, Children's Hospital, University Hospital of Nancy, France; INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France.
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7
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Kalus A, Shinohara MM, Wang R, Baran JD, Dong X, Khakpour D, Lu J, Hirsch IB. Evaluation of Insulin Pump Infusion Sites in Type 1 Diabetes: The DERMIS Study. Diabetes Care 2023; 46:1626-1632. [PMID: 37450710 DOI: 10.2337/dc23-0426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Continuous subcutaneous insulin infusion (CSII) for type 1 diabetes is increasing in use. Pump site failures are common, but little is known about skin changes from pump use. Using noninvasive optical coherence tomography (OCT), OCT angiography (OCTA), and skin biopsies, we evaluated skin changes from chronic insulin infusion. RESEARCH DESIGN AND METHODS In this cross-sectional study, OCT operating at a 1,310-nm central wavelength with a bandwidth of 100 nm was performed immediately before skin punch biopsies were collected at three sites: the current site, with the infusion set removed at time of OCT and biopsy; the recovery site, with the infusion set removed 3 days before biopsy; and the control site, which was never used for any insulin infusion or injection. RESULTS OCT and OCTA identified characteristics of increased inflammation and vessel density at pump sites compared with control sites. Histologic analysis of pump sites showed differences in skin architecture, including fibrosis, inflammation (including increased tissue eosinophils), and fat necrosis. Immunohistochemical staining showed differences between infusion and control sites regarding staining of ILGF-I and transforming growth factor-β3. CONCLUSIONS These findings support allergic sensitization as a potentially common reaction at CSII sites. The leading candidates causing this include insulin preservatives, plastic materials, and adhesive glue used in device manufacturing. The inflammatory response caused by these common allergic responses may result in tissue changes responsible for the infusion site failures seen frequently in clinical practice.
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Affiliation(s)
- Andrea Kalus
- Division of Dermatology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Michi M Shinohara
- Division of Dermatology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Ruikang Wang
- Department of Bioengineering, University of Washington, Seattle, WA
| | - Jesica D Baran
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Xiaofu Dong
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Dori Khakpour
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Jie Lu
- Department of Bioengineering, University of Washington, Seattle, WA
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA
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8
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Cichoń M, Trzeciak M, Sokołowska-Wojdyło M, Nowicki RJ. Contact Dermatitis to Diabetes Medical Devices. Int J Mol Sci 2023; 24:10697. [PMID: 37445875 DOI: 10.3390/ijms241310697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
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.
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Affiliation(s)
- Mikołaj Cichoń
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Magdalena Trzeciak
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
| | | | - Roman J Nowicki
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
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9
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S111-S127. [PMID: 36507635 PMCID: PMC9810474 DOI: 10.2337/dc23-s007] [Citation(s) in RCA: 129] [Impact Index Per Article: 129.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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10
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. 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. Diabetologia 2023; 66:3-22. [PMID: 36198829 PMCID: PMC9534591 DOI: 10.1007/s00125-022-05744-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Richard M Bergenstal
- International Diabetes Center and HealthPartners Institute, Minneapolis, MN, USA
| | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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11
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. 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. Diabetes Care 2022; 45:3058-3074. [PMID: 36202061 DOI: 10.2337/dci22-0018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
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12
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Tauschmann M, Forlenza G, Hood K, Cardona-Hernandez R, Giani E, Hendrieckx C, DeSalvo DJ, Laffel LM, Saboo B, Wheeler BJ, Laptev DN, Yarhere I, DiMeglio LA. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes technologies: Glucose monitoring. Pediatr Diabetes 2022; 23:1390-1405. [PMID: 36537528 PMCID: PMC10107687 DOI: 10.1111/pedi.13451] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Martin Tauschmann
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregory Forlenza
- Pediatric Diabetes Division, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Korey Hood
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Elisa Giani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Christel Hendrieckx
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia Victoria, Melbourne, Victoria, Australia.,School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Daniel J DeSalvo
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lori M Laffel
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, Massachusetts, USA.,Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Banshi Saboo
- Department of Diabetology, Diabetes Care and Hormone Clinic, Ambawadi, Ahmedabad, Gujarat, India
| | - Benjamin J Wheeler
- Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand.,Paediatrics Department, Southern District Health Board, Dunedin, New Zealand
| | | | - Iroro Yarhere
- Endocrinology Unit, Paediatrics Department, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Linda A DiMeglio
- Division of Pediatric Endocrinology and Diabetology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
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13
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Alves da Silva C, Bregnhøj A, Mowitz M, Bruze M, Andersen KE, Sommerlund M. Contact dermatitis in children caused by diabetes devices. Contact Dermatitis 2022; 87:406-413. [PMID: 35634681 DOI: 10.1111/cod.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - Anne Bregnhøj
- Department of Dermatology and Venereology, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Mowitz
- Department Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Magnus Bruze
- Department Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Klaus Ejner Andersen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette Sommerlund
- Department of Dermatology and Venereology, Aarhus University Hospital, Aarhus, Denmark
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14
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Renard E, Riveline JP, Hanaire H, Guerci B. Reduction of clinically important low glucose excursions with a long-term implantable continuous glucose monitoring system in adults with type 1 diabetes prone to hypoglycaemia: the France Adoption Randomized Clinical Trial. Diabetes Obes Metab 2022; 24:859-867. [PMID: 34984786 DOI: 10.1111/dom.14644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/07/2021] [Accepted: 01/01/2022] [Indexed: 11/28/2022]
Abstract
AIM To assess the glucose control outcomes of the implantable Eversense real-time continuous glucose monitoring (CGM) system compared to self-monitoring of blood glucose or intermittently scanned CGM in patients with type 1 (T1D) or type 2 diabetes (T2D). PATIENTS AND METHODS This was a randomized (2:1), prospective, national, multicentre study. All participants, aged >18 years and on multiple daily insulin injections or insulin pump treatment, had a sensor inserted, which was activated only in the "enabled" group. Included patients had T1D or T2D with a glycated haemoglobin (HbA1c) level > 8% (64 mmol/mol) (Cohort 1) or T1D with a time spent with glucose values below 70 mg/dL (3.8 mmol/l) (TBR<70 ) for >1.5 h/d during the previous 28 days (Cohort 2). The primary outcomes were HbA1c change at D180 (Cohort 1) or change in time spent with glucose values below 54 mg/dL (TBR<54 ) during the period of Day (D)90 to D120 (Cohort 2). A covariance model (analyses of covariance) was used for endpoint analyses. RESULTS Overall, 149 patients were included in Cohort 1 and 90 in Cohort 2. In Cohort 1, the adjusted mean difference (enabled - control) in HbA1c at D180 was -0.1% (95% confidence interval [CI] -0.4; 0.1; P = 0.341). No significant difference in time with values in the range 70 to 180 mg/dL or time with values above range (>180 mg/dL) was observed. In Cohort 2, the mean adjusted difference in TBR<54 was -1.6% (95% CI -3.1; -0.1; P = 0.039) during D90 to D120 and remained at -2.6% (95% CI -4.5; -0.6; P = 0.011) during D150 to D180 (prespecified secondary outcome). The CGM system was found to be safe. CONCLUSION This study shows that the Eversense CGM system can significantly decrease TBR<54 in patients with T1D prone to hypoglycaemia.
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Affiliation(s)
- Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, INSERM Clinical Investigation Centre 1411, Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Jean-Pierre Riveline
- Department of Diabetes and Endocrinology, Lariboisiere University Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris, INSERM UMRS-1138, Paris, France
| | - Hélène Hanaire
- Department of Diabetology, Metabolic Diseases and Nutrition, Toulouse University Hospital, Toulouse, France
| | - Bruno Guerci
- Department of Endocrinology, Diabetology and Nutrition, Brabois Hospital and University of Lorraine, Vandoeuvre Lès Nancy, France
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15
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Allergic Contact Dermatitis, an Important Skin Reaction in Diabetes Device Users: A Systematic Review. Dermatitis 2022; 33:110-115. [PMID: 35245221 DOI: 10.1097/der.0000000000000861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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16
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Abstract
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.
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17
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Holt RIG, DeVries JH, Hess-Fischl A, Hirsch IB, Kirkman MS, Klupa T, Ludwig B, Nørgaard K, Pettus J, Renard E, Skyler JS, Snoek FJ, Weinstock RS, Peters AL. The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2021; 64:2609-2652. [PMID: 34590174 PMCID: PMC8481000 DOI: 10.1007/s00125-021-05568-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycaemia, behavioural considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that healthcare professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors. Graphical abstract.
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Affiliation(s)
- Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.
- Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - J Hans DeVries
- Amsterdam UMC, Internal Medicine, University of Amsterdam, Amsterdam, the Netherlands
- Profil Institute for Metabolic Research, Neuss, Germany
| | - Amy Hess-Fischl
- Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Irl B Hirsch
- UW Medicine Diabetes Institute, Seattle, WA, USA
| | - M Sue Kirkman
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Tomasz Klupa
- Department of Metabolic Diseases, Center for Advanced Technologies in Diabetes, Jagiellonian University Medical College, Kraków, Poland
| | - Barbara Ludwig
- University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | | | - Eric Renard
- Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, Inserm, Montpellier, France
| | - Jay S Skyler
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Frank J Snoek
- Amsterdam UMC, Medical Psychology, Vrije Universiteit, Amsterdam, the Netherlands
| | | | - Anne L Peters
- Keck School of Medicine of USC, Los Angeles, CA, USA
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18
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Holt RIG, DeVries JH, Hess-Fischl A, Hirsch IB, Kirkman MS, Klupa T, Ludwig B, Nørgaard K, Pettus J, Renard E, Skyler JS, Snoek FJ, Weinstock RS, Peters AL. The Management of Type 1 Diabetes in Adults. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2021; 44:2589-2625. [PMID: 34593612 DOI: 10.2337/dci21-0043] [Citation(s) in RCA: 217] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/25/2021] [Indexed: 02/03/2023]
Abstract
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycemia, behavioral considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management, and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that health care professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors.
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Affiliation(s)
- Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, U.K. .,Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, U.K
| | - J Hans DeVries
- Amsterdam UMC, Internal Medicine, University of Amsterdam, Amsterdam, the Netherlands.,Profil Institute for Metabolic Research, Neuss, Germany
| | | | | | - M Sue Kirkman
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Tomasz Klupa
- Department of Metabolic Diseases, Center for Advanced Technologies in Diabetes, Jagiellonian University Medical College, Kraków, Poland
| | - Barbara Ludwig
- University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | | | - Eric Renard
- Montpellier University Hospital, Montpellier, France.,Institute of Functional Genomics, University of Montpellier, CNRS, Inserm, Montpellier, France
| | - Jay S Skyler
- University of Miami Miller School of Medicine, Miami, FL
| | - Frank J Snoek
- Amsterdam UMC, Medical Psychology, Vrije Universiteit, Amsterdam, the Netherlands
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19
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Abstract
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.
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20
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Dendooven E, Foubert K, Goossens A, Gilles P, De Borggraeve W, Pieters L, Lambert J, Aerts O. Concomitant positive patch test reactions in FreeStyle-allergic patients sensitized to isobornyl acrylate. Contact Dermatitis 2020; 84:166-174. [PMID: 32965058 DOI: 10.1111/cod.13706] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Ella Dendooven
- Department of Dermatology, University Hospital Antwerp (UZA), Antwerp, Belgium.,Research Group Immunology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Research Group Natural Products and Food - Research and Analysis (NatuRA), Department of Pharmaceutical Sciences, University of Antwerp (UA), Antwerp, Belgium
| | - Kenn Foubert
- Research Group Natural Products and Food - Research and Analysis (NatuRA), Department of Pharmaceutical Sciences, University of Antwerp (UA), Antwerp, Belgium
| | - An Goossens
- Department of Dermatology, University Hospitals KU Leuven, Leuven, Belgium
| | - Philippe Gilles
- Molecular Design and Synthesis, Department of Chemistry, KU Leuven, Leuven, Belgium
| | - Wim De Borggraeve
- Molecular Design and Synthesis, Department of Chemistry, KU Leuven, Leuven, Belgium
| | - Luc Pieters
- Research Group Natural Products and Food - Research and Analysis (NatuRA), Department of Pharmaceutical Sciences, University of Antwerp (UA), Antwerp, Belgium
| | - Julien Lambert
- Department of Dermatology, University Hospital Antwerp (UZA), Antwerp, Belgium.,Research Group Immunology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Olivier Aerts
- Department of Dermatology, University Hospital Antwerp (UZA), Antwerp, Belgium.,Research Group Immunology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
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21
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Ulriksdotter J, Mowitz M, Svedman C, Bruze M. Patch testing and diagnosis when suspecting allergic contact dermatitis from medical devices. Contact Dermatitis 2020; 83:333-335. [DOI: 10.1111/cod.13650] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Josefin Ulriksdotter
- Department of Occupational and Environmental Dermatology Lund University, Skåne University Hospital Malmö Sweden
- Department of Dermatology Helsingborg Hospital Helsingborg Sweden
| | - Martin Mowitz
- Department of Occupational and Environmental Dermatology Lund University, Skåne University Hospital Malmö Sweden
| | - Cecilia Svedman
- Department of Occupational and Environmental Dermatology Lund University, Skåne University Hospital Malmö Sweden
| | - Magnus Bruze
- Department of Occupational and Environmental Dermatology Lund University, Skåne University Hospital Malmö Sweden
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22
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Ulriksdotter J, Svedman C, Bruze M, Glimsjö J, Källberg K, Sukakul T, Mowitz M. Contact dermatitis caused by glucose sensors-15 adult patients tested with a medical device patch test series. Contact Dermatitis 2020; 83:301-309. [PMID: 32608015 DOI: 10.1111/cod.13649] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Josefin Ulriksdotter
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden.,Department of Dermatology, Helsingborg Hospital, Helsingborg, Sweden
| | - Cecilia Svedman
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Magnus Bruze
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Jenny Glimsjö
- Department of Medicine, Blekinge Hospital, Karlskrona, Sweden
| | - Kajsa Källberg
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Thanisorn Sukakul
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden.,Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Martin Mowitz
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
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