Anne Herman

Allergic contact dermatitis caused by isobornyl acrylate in Freestyle® Libre, a newly introduced glucose sensor

Glucose sensors, such as FreeStyle® Libre, are innovative medical devices developed for diabetes patients as a replacement for classic glucose meters, ensuring continuous glucose monitoring without the disadvantage of regular skin finger pricks.

Allergic contact dermatitis caused by 2-ethyl cyanoacrylate contained in glucose sensor sets in two diabetic adults.

Allergic contact dermatitis caused by 2-ethyl cyanoacrylate contained in glucose sensor sets in two diabetic adults Caroline Peeters1,† , Anne Herman1,† , An Goossens2 , Magnus Bruze3 , Martin Mowitz3 and Marie Baeck1 1Department of Dermatology, Cliniques Universitaires Saint-Luc & Pôle Pneumologie, ORL et Dermatologie Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, 1200 Brussels, Belgium, 2Department of Dermatology, University Hospital, Katholieke Universiteit Leuven, 3000 Leuven, Belgium and 3Department of Occupational and Environmental Dermatology, Lund University, Skane University Hospital, 205 02, Malmö, Sweden

Donkey's milk allergy

DEAR EDITOR, Donkey’s milk allergy is very rare. Donkey’s milk is known for its hypoallergenic properties and is therefore frequently used for children with cow’s milk allergy. A 25-year-old woman with a history of personal atopic dermatitis, allergic asthma and hay fever experienced facial angiooedema 5 min after consuming fresh donkey’s milk for the first time (Fig. 1). She developed dyspnoea and collapsed after a few minutes. The patient required administration of adrenaline and corticosteroids. During her childhood, her atopic dermatitis was treated with different topical treatments including donkey’s milk-based emollients. She never presented reactions to this topical treatment and she had no history of food allergy. Skin prick tests and patch tests with donkey’s milk, cow’s milk and goat’s milk were performed under medical supervision. Skin prick tests read after 20 min showed positive reaction for donkey’s milk (++) (Fig. 2a). Skin prick tests with cow’s milk and goat’s milk remained negative. Additionally, patch tests with donkey’s milk were positive at days 3 and 4 (both ++) (Fig. 2b). Total IgE was normal (23 kU L ) and serum-specific IgEs for cow’s milk, casein, a-lactalbumin and b-lactoglobulin were negative. Dilutions of specific IgE against donkey’s milk were not available. Skin prick and patch tests performed with donkey’s milk in 20 control patients showed no sign of irritation. Due to its hypoallergenic properties, donkey’s milk has proved to be the best alternative in feeding infants affected by cow’s milk allergy, as its chemical composition is comparable with that of human milk. The main allergens in cow’s milk are caseins, followed by b-lactoglobulin and a-lactalbumin. The low allergenicity of donkey’s milk is due mainly to the low casein content. Donkey’s milk is particularly rich in whey proteins. Different authors have studied cross-reactivity between cow’s milk and other mammalian milk. They showed that cross-reactivities between cow’s milk and goat or sheep milk were high, due to the similarity of their protein profiles, unlike mare, camel or donkey milk. We hypothesized that the patient was percutaneously sensitized through repeated contact of her atopic skin with donkey’s milk-based emollients. She subsequently developed immediate hypersensitivity reactions to donkey’s milk. Sensitization in food allergy is traditionally thought to occur via the intestinal tract. In recent years it has been proposed that the primary mechanism for the development of food allergies is epicutaneous sensitization. As this is a mechanism underlying the development of food allergies, Strid et al. proposed the concept that oral antigen exposure promoted immune tolerance rather than sensitization, and that epicutaneous exposure enhanced sensitization. A combination of type I and type IV hypersensitivities is suggested. We demonstrated the type I hypersensitivity mechanism with the positivity of the skin prick test. However, the patch test positivity suggested an associated cellular mechanism. The pathogenesis of food allergy from percutaneous sensitization is yet to be fully elucidated, and further examination of additional cases is needed. Similar cases of immediate reaction secondary to percutaneously sensitization have been described with soy-based ingredients in cosmetic products, mare’s milk-based organic cosmetics and oat proteins contained in topical products. In conclusion, this is the first case of donkey’s milk allergy reported in the literature. Topical cutaneous use of donkey’s milk-based emollients probably leads to sensitization. The patient presented with immediate-type clinical symptoms (angio-oedema); however, skin prick tests and patch tests were positive, suggesting that both type I and type IV reactions were implicated. Donkey’s milk is proposed as an alternative in patients with cow’s milk allergy. It is also frequently used in the topical treatment of atopic dermatitis. Although it Fig 1. Facial angio-oedema.

Allergic contact dermatitis caused by medical devices for diabetes patients: A review

Allergic contact dermatitis caused by medical devices for diabetes patients has been increasingly described in the literature in the last few years. This article reviews the cases of allergic contact dermatitis caused by insulin pumps and glucose sensors reported since the 1970s, the culprit allergen(s), the results of patch tests and/or chromatographic analysis, and preventive measures.

FreeStyle Libre: contact irritation versus contact allergy

1 Brahimi N, Potier L, Mohammedi K. Cutaneous adverse events related to FreeStyle Libre device. Lancet 2017; 389: 1396. 2 Bolinder J, Antuna R, Geelhoed-Duijvestijn P, Kröger J, Weitgasser R. Novel glucose-sensing technology and hypoglycaemia in type 1 diabetes: a multicentre, non-masked, randomised controlled trial. Lancet 2016; 388: 2254–63. 3. Bolinder J, Antuna R, Geelhoed-Duijvestijn P, Kröger J, Weitgasser R. Cutaneous adverse events related to FreeStyle Libre device— Authors’ reply. Lancet 2017; 389: 1396–97. 4 Herman A, Aerts O, Baeck M, et al. Allergic contact dermatitis caused by isobornyl acrylate in Freestyle® Libre, a newly introduced glucose sensor. Contact Dermatitis 2017; published online Aug 14. DOI: 10.1111/cod.12866. by a characteristic, allergic, spreading reaction. This spreading reaction should not be confused with contact irritation, which is strictly confined to the application site and is usually associated with a burning or stinging sensation instead of a profound itch. The onset of the dermatitis (≥2 weeks after the first use of the device) indicated primary sensitisation by isobornyl acrylate, instead of a preexisting allergy to acrylates. Some patients had to discontinue use of the device as, contrary to Bolinder and colleagues’ suggestions, bandages and barrier sprays did not provide any relief, and the use of topical products under the adhesive was not considered a workable solution either. In contact allergy, complete avoidance of or a substantial decrease in exposure to the allergen responsible is the only effective solution, but this requires identification of the allergen, which in turn necessitates cooperation from the manufacturer. The identification of isobornyl acrylate in our case series was only possible by close collaboration with several dermatology departments. Apparent difficulty in obtaining cooperation from pharmaceutical companies and no complete ingredient labels on medical devices such as FreeStyle Libre certainly contribute to incomplete investigations of many similar cases, and potentially to their underreporting. In this regard, more effort by the pharmaceutical industry to aid accurate investigations would be of great value to patients who could benefit from the advantages such devices might offer in controlling their diabetes.

Airborne contact dermatitis in a patient with type I and IV sensitivity to chicory: AIRBORNE CONTACT DERMATITIS - SENSITIVITY TYPE I AND IV

Vegetables, including chicory, can be responsible for allergic reactions, most frequently as IgE-mediated immediate reactions (type I) with urticaria. Delayed hypersensitivity reactions (type IV) in terms of allergic contact dermatitis are also possible, notably because of the sesquiterpene lactones present in many vegetables. Moreover, protein contact dermatitis can occur, and is clinically characterized by eczema, positive scratch test results with food protein, and negative patch test results with the same items. Both atopic dermatitis and occupational exposure, for example in bakers, farmers, and cooks, have been described as risk factors for protein contact dermatitis (1).

Effetti collaterali della cura dei capelli negli utilizzatori

La gamma di prodotti utilizzati dai professionisti per lavare o impreziosire la capigliatura e per modificarne il colore o la forma non e priva di effetti collaterali. Questi effetti sono principalmente dermatiti da irritazione ed eczemi allergici da contatto, che possono influire sul cuoio capelluto, ma anche su nuca, faccia anteriore del collo, fronte e regioni periorbitarie e guance. Tra gli allergeni piu citati, devono essere menzionati la parafenilendiamina (PPD) delle tinture per capelli, il glicerolo monotioglicolato (GMTG) degli acidi permanenti e il persolfato di ammonio dei decoloranti (quest⬢ultimo e responsabile principalmente di orticarie da contatto). Non bisogna dimenticare altri allergeni come la cocamidopropilbetaina tra i tensioattivi nonche alcuni componenti della formulazione, come i conservanti e i profumi (perfino il minoxidil, cosi frequentemente usato dai pazienti).