ARTICLE
Methacrylates present in various types of adhesives have occasionally
caused sensitization [1-11]. Here we report on a patient who developed
a strong allergic dermatitis from a methacrylate in an adhesive used to
fix an electrosurgical earthing plate to the skin during an operation
involving electrosurgery. The causative chemical turned out to be 2-hydroxyethyl
methacrylate (2-HEMA).
Case report
A highly (meth)acrylate allergic, 48-year-old female patient (Table
I; patch testing and scoring according to the recommendations
of the International Contact Dermatitis Research Group) underwent surgery
for nodular struma. Before surgery she informed the hospital personnel
in writing about her contact allergies including her allergy to (meth)acrylates.
Three days after her operation she developed an itching dermatitis on
her left thigh. She came to our attention 18 days after the operation,
and presented with an oozing, highly pruritic dermatitis, 8 x 19 cm in
width on her left thigh (Fig.
1). We asked her to contact the hospital where she had been operated
on. They informed that they had used an electrosurgical earthing plate
on the left thigh during the operation to allow electrosurgery. The instructions
for use clearly indicated that the pad should not be used for (meth)acrylate
allergic patients. We later consulted the manufacturer who informed us
that the pressure-sensitive adhesive of the pad contained 2-HEMA to which
the patient earlier had shown an allergic patch test reaction (Table
I). The patient was negative on patch testing to other (meth)acrylates
present in the pad.
Despite treatment with potent local corticosteroids, the area of dermatitis
had not healed completely two months after the surgery.
Discussion
There are several types of synthetic organic adhesives based on acrylates,
methacrylates and epoxy diacrylates (vinyl resins) (Table
II). Anaerobic acrylic sealants [1-3] and cyanoacrylates in "crazy
glues" [4-7] have caused several cases of sensitization. Allergic contact
dermatitis has been reported from ultraviolet-cured acrylate [8]. UV-cured
glues have also been used to attach the needle into the plastic catheter
of insulin pump infusion sets, and allergy from (meth)acrylates have have
been reported [9-11]. Methyl methacrylate (MMA) can be used to glue together
parts of acrylate plastic or parts of other plastic products. Metal and
glass glues may contain liquids based on 2-hydroxypropyl methacrylate,
2-HEMA and other methacrylates [12-14]. Sculptured acrylic nails are moulded
onto the natural nail with various types of sensitizing (meth)acrylates
and cyanoacrylates [15, 16]. Dental bonding agents based on (meth)acrylates
and epoxy acrylates are widely used in dentistry [17, 18].
Cronin [12] reported allergic contact dermatitis
from a window sealant. The manufacturers disclosed that the sealant was
based on butyl acrylate, a methacrylate and acrylic acid. Fregert [13]
saw a patient allergic to ethyl- and butyl acrylates from a "small-joint
sealant" for tightening joints in wooden window frames. The sealant contained
a monomer and polymer of ethyl acrylate, and solvents. The allergic patch
test reaction caused by butyl acrylate could have been caused by cross-sensitization
or concomitant sensitization, because butyl acrylate may have been present
as an impurity. We have earlier reported a patient sensitized to such
a glue [14]. This glue contained 24.6% 2-HEMA to which she was allergic
on patch testing. Tosti et al. [19] described three carpenters
who became sensitized from wood paints and glues. On patch testing, one
reacted to butyl acrylate, one to 2-ethoxyethyl methacrylate, and one
to a phthalate. The glues used in construction work may contain similar
acrylate polymers as in acrylate latex paints, which may sensitize [20].
Foulds and Koh [21] reported contact allergy to 1-acetyl-2-phenylhydrazine
in a dimethacrylate acrylic sealant. Accordingly, compounds other than
the acrylates may sensitize in acrylate adhesives.
Acrylate compounds, such as methyl-, ethyl-, ethylhexyl- and butyl acrylates
and methacrylates, and their mixtures, are used mainly in glues whose
function is based on the hydrogen bond. These glues are used for example
in various adhesives, stickers and envelopes. Jordan [22] had several
patients who became sensitized to the acrylates in surgical tape, and
Daecke and coworkers reported contact urticaria from acrylic acid in Fixomull®
tape [23]. Marren and coworkers had a case closely resembling ours; the
patient had allergic contact dermatitis from 2-HEMA from a transcutaneous
electrical nerve stimulation (TENS) hydropad, said to improve conduction
during TENS [24].
Our patient had an established allergy to several
(meth)acrylates including methacrylates, dimethacrylates and epoxy diacrylates.
Adhesive glues often contain acrylates e.g. 2-hydroxyethyl acrylate
(2-HEA) but our patient was negative on patch testing to 2-HEA. Accordingly,
it was evident that the strong allergic contact dermatitis reaction was
caused by 2-HEMA. 2-HEMA is a well known contact sensitizer [25-27].
Just before submitting this report, three articles on allergic reactions
from adhesives of similar plates came out in an issue of Contact Dermatitis
[28-30]. In one of the articles [28], the patient apparently became actively
sensitized by the plate, and the allergic reaction appeared within one
week. In the other article [29], four patients had developed an allergic
reaction. Three of them had earlier been sensitized to acrylics from sculptured
nails, whereas one may have been sensitized from the plate. The article
did not reveal how many days after the operation the allergic reaction
started in the "actively" sensitized patient. In the third article [30],
the causative agent remained unknown, as the patient was not available
for further patch testings. The patients in the reports of Miranda and
coworkers [28] and Jagtman [29] reacted to the two acrylic components
of the adhesive that had been revealed by the manufacturer, namely 2-HEA
and 2-HEMA, as well as many other (meth)acrylates. Our patient was allergic
to 2-HEMA but not to 2-HEA, but it is possible that the adhesive contains
undeclared (meth)acrylates, as has been the case with many acrylic products
[31]. Jagtman [29] suggested that ethyl acrylate (EA) could be used as
a screening agent for acrylate allergy, but it would not have revealed
the cause in our patient, and has been less often positive in our patients
than e.g. 2-HEMA [27].
Patients should be questioned about possible acrylic sensitivity before
methacrylate containing-electrosurgical earthing plates are used, but
in view of the cases of active sensitization [28, 29] it seems that the
adhesive should be made safer.
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