Allergic contact dermatitis from 2-hydroxyethyl methacrylate in an adhesive on an electrosurgical earthing plate

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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