Hi everyone and welcome to today's hands-on tips to improve diabetes care webinar. Today our panel will share their expertise on maintaining skin integrity with use of diabetes devices and we're glad you're here. My name is Andrew Welch. I'll be moderating today's webinar. To share a little bit about myself, I'm an adult endocrinologist at the University of Cincinnati. I'm personally motivated in diabetes by my experience being diagnosed with type 1 diabetes in my first year of medical school during a diabetes workshop where we all checked our fasting blood sugars. My current clinical focus is on type 1 diabetes and diabetes technology. I direct a pediatric to adult transition clinic in partnership with the Cincinnati Children's Hospital and my research focus is on gaps in access to diabetes technology. Next slide. We'll spend the next hour together by following the agenda on the screen. We will be using interactive features during today's session. In the chat box, we will send you important links and information throughout today's session. We also want you to get engaged. We will have two poll questions pop up during the presentations. Please keep an eye out for them. We'll use Zoom Q&A at the end of the presentation for panel questions. If you think of a question as our presenters speak, use the Q&A box on your control panel to type your question. Join us next month on April 8th for the next installment in the hands-on webinar series. Scan the QR code or the link in the chat box to register. And just to clarify, this is heat versus cold counterpoint comparing different therapies, such as cold therapy or heat therapy, around diabetes. Also, this is a double feature because immediately following this webinar, another webinar will begin. This is the Diabetes Technology Interest Group, and they are hosting a webinar at 5 p.m. integrating the use of CGMs in clinical practice, addressing barriers, and optimizing clinical workflow. Register now on the link and in the chat to attend live or receive the recording. Now I'd like to introduce the panelists for today's webinar. You can also click the References button at the bottom toolbar to view their biographies. Kate Haynes, RN, CDCES, has been a diabetes care and education specialist for IU Health for nine years. She spent much of that time as a pump trainer. She currently helps lead a team of 30 educators spanning over seven hospitals and 15 outpatient locations across Indiana. And as I've gotten to know her, I was impressed by her story. And as I've gotten to know her, I was impressed by a story that she told when she was a pediatric patient with type 1 diabetes in her health system. As she got older, she connected with a group called the Students with Diabetes Detreat Program. And that was kind of a precursor to what we now know as the College Diabetes Network. And never having attended diabetes camp, that was the first time that Kate had ever interacted with peers that had diabetes. And immediately she was passionate that she wanted to become a diabetes educator and shaped her nursing career. And I was also touched by how, as she got older, she would find resources that were helpful for her to manage her diabetes. And she would share this with her endocrinologist so that they could share it with other patients. So you can tell that Kate is very passionate about helping people. And I'm very excited to learn more about her experience. Later on in the discussion, Kari Vergette will also join us, and I'll introduce her at that time. All right, my name is Kate Haynes, and I have no disclosures. And give me just a second, and I will share my screen. All right, so today I'm gonna be talking about the prevalence of dermatitis in patients using diabetes devices and how you can help them fight the itch. I'm hoping that by the end of this presentation that you can identify the impact of contact and allergic contact dermatitis for people using diabetes devices. So this is a list of current skin problems that affect people with diabetes devices. In my research, understanding irritant contact dermatitis and allergic contact dermatitis were by far the areas with the greatest knowledge gap. So today we're gonna focus on these conditions. I'm gonna refer to irritant contact dermatitis as ICD and allergic contact dermatitis as ACD throughout my presentation. So we have a poll question for you, true or false, contact and allergic dermatitis are easily differentiated? And we'll give you a second to answer that. You guys are right on the money. This is false. Let me see if I can close this. There we go. We'll see. My slides not wanting to advance. There we go. Sorry about that. Okay, so they are very hard to differentiate because they're more similar. So this figure is from the European Journal of Dermatology, and it breaks down immune mechanisms between the two of them. Both types of dermatitis are induced by skin contact with chemicals. An ICD inflammation is introduced by the toxicity of the chemical, while an ACD inflammation is induced by the activated chemical-specific T cells. The eczema lesions that develop may be very similar, and they both end up developing a very similar inflammatory infiltrate as well. And this is why it can be difficult to differentiate these types of dermatitis, both clinically and histologically. So some things to help you pull them apart. So when we look at ICD, typically we're going to see the skin lesions be limited to the contact site of the diabetes device. But in ACD, we may see those lesions be in previous places where the diabetes device is worn or in other spots on the body. When we look at symptoms, the symptoms are very similar. And in the literature, really the biggest differentiating pieces were burning and ICD, while ACD is typically just itching. When we look at the skin reaction, we're going to see a more immediate response in ICD, except for in the chronic form. We might see a more diffused inflammation. So think about washing our hands in the winter and being exposed to the soaps and hand sanitizers. That's more of a chronic form of ICD. But in ACD, we may not see a reaction for days to weeks after that first contact with the allergen or chemical. But with future contacts with that chemical, the reaction is typically going to happen a lot faster and we're going to see that appear within 24 to 48 hours. When we look at the clinical evolution, typically we're going to see complete recovery with ICD. We may see some irreversible changes in the chronic form. But when we look at ACD, typically these changes are going to be irreversible. Elicitation is going to occur at every new contact with the chemical. And the other thing is that we may have possible cross-activation with other substances or elicitation risk when that same substance is ingested or inhaled by the individual. And I'm going to talk about patch testing a little bit later in the presentation. But typically we're going to find negative patch tests when we look at irritant contact dermatitis. And we're going to see it be positive for allergic contact dermatitis when we're looking for the substance. So when we look at diabetes devices, really we are creating the perfect environment for both ICD and ACD. We've got occlusion of the site. We've got friction from adhesives being peeled off. We've got increased humidity from patients bathing with the devices on. And then acrylates, which are commonly used in device adhesives, are known to be irritants. But they can also cause allergic contact dermatitis in small amounts. And so when we look at the prevalency data across North America and Europe, we see about 20 percent of the general population have some sort of allergic contact dermatitis. This could include allergies to things like nickel, fragrances, adhesives, et cetera. So allergic contact dermatitis isn't probably impacting all of our patients. So who might be more at risk? Current investigations believe genetics are playing a large role. ACD is much more common in family members. Mutations in genes encoding proteins like filigree and the skin barrier may play a role. And this is where patients that also suffer from skin disease like atopic dermatitis may be at increased risk for developing ACD. So what does this prevalence data look like for those that are wearing diabetes devices? So in a more recent review published in the Diabetes Science and Technology, they found that the prevalence data from this device wear and reactions to them was really kind of all over the place, anywhere from 8 to 40 percent. And some of that is just with problems when we're trying to extract the data. And some of these problems were the studies just weren't designed to look at prevalence and population in the first place. Many of the studies came from much smaller observational dermatology studies with limited participants. The larger studies were pulling from self-reported data versus diagnosed findings and often lacked follow up. Contact dermatitis, irritant contact dermatitis and allergic contact dermatitis were often used interchangeably and not clearly differentiated in the studies. And many of the studies didn't take into account a detailed history about pre-existing skin problems such as atopic dermatitis or previous device wear history. So now I'm going to talk about the timing of the flare up because pumps have been commercially available for the last 50 years. And we were seeing reported reactions to nickel, epoxy resin, acrylates appear in articles largely from 1985 to 2001. But most of these items are now outdated and they no longer exist in that space. And so when we started to see things take up was in 2014 when the Freestyle Libre sensor was introduced to Europe. And then again in 2017 when the Freestyle Libre sensor was introduced in the U.S. And that's when we got the first report of allergic contact dermatitis to substances found in the sensor. And so we have about a 16 year gap either where people just weren't talking about it or publishing studies on it. Or we could hypothesize that with the longer wear of sensors we're seeing more reactions. So what was the substance that they found in the Freestyle Libre device? So they found this acrylate called isobornyl acrylate also known as IBOA. And it's unique because it polymerizes when exposed to UV light and that makes it really useful in adhesives and sealants in medical devices. It's also commonly found in these other products that we might run across in everyday life. So the first patient that came into play they started having reactions to their sensor. And this was they came into the office of a provider in Sweden. And they decided to patch test them to just the normal allergen series for Europe. They patch tested them with an acrylate or adhesive series. And then they also patch tested them to a clipping of their Freestyle Libre device. But they were not able to generate the same reactions that they were seeing here on this picture on the very left which was the initial reaction that the patient came in with. And so the provider reached out to Abbott. But they were not very forthcoming with the ingredients for the provider to do further testing. So this patient's diagnosis was really in limbo. A different patient being treated in Belgium for dermatitis related to their Libre sensor was accidentally tested for IBOA and developed a very strong reaction to it. The provider in Sweden heard about this and decided to test the original patient with IBOA using different concentrations of it. And sure enough got a really strong response even from the lowest concentration which you can see in this middle picture. So the provider reached back out to Abbott to ask if IBOA was used in the sensor adhesive. And Abbott said it was not. Knowing that IBOA was probably the culprit, this provider placed a sensor in a water bath and then used gas chromatography to isolate the solution and analyze the solution. And they were able to isolate IBOA. So this suggested that IBOA was used to attach the sensor to the adhesive patch. And then the IBOA was migrating down into the adhesive with wear. And Abbott later confirmed that IBOA was present in the sensor this way. And this unique situation along with an influx of patients forming dermatitis to their freestyle Libre sensors led to IBOA being named contact allergen of the year in 2020. But I think we all had a lot going on that year. But that's kind of sort of the Oscars for dermatologists to bring awareness to new substances causing dermatitis. So the good news is that according to the manufacturer, in 2020, IBOA is no longer being used in newly produced freestyle Libre devices. Some of the other research that has come out of this is that IBOA doesn't tend to cross-react with other acrylates. So this is something that we worry about in women who get false nails, which have an acrylate base, is that they might cross-react to their Libre sensor. And this just hasn't been shown to be true. They don't really understand why, but it's not cross-reacting. So that's a good thing. And then this also helped IBOA become commercially available for patch testing. And then the unfortunate bad news is that IBOA has been found in omnipods and triggered reactions in patients that were previously sensitized to it while wearing their freestyle Libre device. More than 20 other allergens have been isolated and identified in diabetes devices since that time. And device companies are not required to disclose ingredients to investigating health providers, unfortunately. So when should you recommend your patients get patch testing done? So these are the general consensus guidelines for patch testers. That really, anytime we suspect contact dermatitis, acute or chronic, anytime other forms of chronic dermatitis, eczema are improving with treatment. And then whenever a patient is having skin or mucous membrane eruptions like vesicles, which are typically associated with delayed type hypersensitivity. And then some newer guidelines from a consensus paper about diabetes devices. They're recommending anytime you suspect allergic dermatitis to diabetes devices, you should send them for patch testing. So what is patch testing? I'm not going to read this whole slide, but I wanted you to have it as reference. I think it's really important for patients to understand what you're sending them off to be tested for. But essentially, patch testing uses little aluminum disks or pre-filled filter papers filled with small concentrations of the allergens or chemicals in a vehicle of petrolatum, alcohol, or water. So not only do we want to refer them for patch testing, but we also want to refer them to the right people who can do the right testing. And so we want to refer patients here in the States to the American Contact Dermatitis Society. And so you can find providers in a search engine with contactderm.org, slash find. And it's going to pull up this nice little list where patients can put in their address and how many miles they're willing to travel. And then also with the types of patch testing. And so this is what I would recommend. I would recommend that we are sending patients to be screened for the North American Core 80. And so this is 80 different patch tests, patch test allergens that the patient would be tested for. And this is pretty much the standard of care. And then it would also be a good idea if that patch tester knew how to do extended patch testing so that they know how to do things like adhesive series or other plastic series that are recommended for diabetes devices. And then that they know how to do testing to patients' own devices and how that application works. Unfortunately, the North American 80 isn't FDA approved for pediatrics. And so the true test is the only thing that's available for children that are between six and 17. And this is a much smaller amount of allergens that are tested. It's only 35, but now there's some protocols where these providers can add on two to three additional allergens that they're suspecting the patient is allergic to. So what is the treatment for these patients after they get patch tested? So unfortunately, the treatment for these allergens is avoidance. They need to avoid these allergens completely. And typically, patients are given some form of safe list using this program called CAMP. And essentially, it's going to spit out medications and personal care products that are safe for them to use and that don't contain their allergens. And now it also shows them previous ingredients that they were using and which items might be unsafe for them. Other things that dermatologists are using are going to be biologics like dipilumab and JAK inhibitors to help with underlying atopic dermatitis, and that can also help with itching. So when quitting isn't an option. So for us as diabetes providers, diabetes devices are the standard of care now. We want all of our patients, especially with type 1 diabetes, to be wearing a CGM. And so you are going to have to pry these from some of our patients. They don't want to give up their diabetes devices, especially not for an allergen. So our patients are fighting tooth and nail to try to keep these devices on. And Kerry is going to do a wonderful presentation about talking about more of those practical tips here in a second, but I'm going to be devil's advocate for a little bit and tell you from a dermatology perspective that these can be risky as well. And so most of the time, we're looking at switching patients to an alternative device. But this can be risky because that device may also contain the same allergens or cross-reactors, but this is pretty common practice of trial and error if patients haven't been patch tested. And then using topical steroids, a lot of the literature was showing kind of this off-label fluticasone propionate aqueous nasal solution being applied prior to sensor and pump site insertion, and that works for some patients. It doesn't necessarily work for others. And then patients are also using barrier sprays and wipes, and unfortunately, these have been shown to cause allergic contact dermatitis in patients that are using these same things for stoma care. And then lastly, we typically are recommended bandages, dressings, and underdressings, but these may contain some of the same allergens or cross-reactors, and they could cause problems with insertion and total wear time for the device. And so some things that you can do while, some things your patients can do while waiting to be patch tested. So getting into a dermatologist is worse than trying to get into an endocrinologist. It can take a really long time. And these are just some practices that can help prevent sensitization to other chemicals while your patients are waiting for potentially their lesions to be identified as ICD or ACD. And so taking a device break, not what we want to do, but this could potentially prevent the patient from developing allergies to all the ingredients in the adhesives and not just one. So that can help eliminating fragrances, personal care products, their personal care products and laundry detergents, avoiding fabric softeners and dryer sheets. These should kind of be no brainers for patients with skin conditions, but fragrance mix is very high on the common allergen list. And then choosing lotions and soaps that have fewer ingredients, so it's easier to eliminate what might be the cause. Petrolatum is a good option when patients are reporting reacting to everything. Encouraging patients to wear more natural fabrics. Synthetic fabrics tend to have dispersed dyes and formaldehyde and things that don't wash out of the fabrics. And those are pretty high on the list of common allergens. And then avoiding aspartame. This seems kind of weird, but aspartame has a very similar chemical structure to formaldehyde. And a lot of our patients are ingesting diet drinks that have aspartame. And this is one of the most common things that patients with a formaldehyde allergy need to do to help avoid rashes and inflammation. And then using some form of repeat open application testing for some of those recommendations of additional adhesives in a different site than the same site that we're using it for the diabetes device. So doing patch testing, their own patch testing with it first before using it along with the diabetes device. And then Mayo Clinic has a nice app called SkinSafe, which can help reduce the amount of common allergens. And you can scan your product's barcode to see what its level of safety is. All right. Before I wrap up here, I did want to share a few case studies and just how much these allergies can impact our patients with diabetes. So in 2014, a four-year-old with type 1 diabetes presented with scaly lesions on his fingers after playing with stickers. He was also having reactions to both his pump sites and sensor sites. He patch tested positive to colophony, which is an ingredient that has been found in Medtronic pump sites and sensors. And this was incidentally found in the superhero stickers using gas chromatography. The patient avoided playing with these stickers and his lesions resolved. Unfortunately, the patient did have to discontinue pump therapy due to the allergy being so bad. But he was able to restart a Freestyle Libre 2 without having reactions after having this testing. So the second case study, this is from a 13-year-old with a history of type 1 diabetes since the age of seven who presented to the dermatologist for vulvar lesions. And these lesions started with Menarche when she was 12 years old and reappeared with every menstruation despite healing up with topical solutions during the time between cycles. Patient had previously been patch tested a few years before for reactions to her N-Lite sensor that resulted in her being diagnosed with a colophony allergy and had to discontinue use. And these are the pictures that you can see in A and B, her reaction that she had to her sensor. And so due to her previous history of this colophony allergy, the provider reached out to the manufacturer of the feminine pads that she was using. And sure enough, the company confirmed that less than 1% of colophony was being used in the adhesive liner. So luckily, this patient's lesions were resolved by switching to 100% cotton tampons. But that was almost a year that this patient was dealing with that. So some things that you can do to help. We need better design studies and collaborations with dermatology investigators to provide us with high quality prevalence data. And we need legislation for industry transparency with device components and ingredients and at the very least obligatory disclosure of the patch testing products in question to healthcare professionals. So these are the things I hope you take away. Refer your patients for patch testing. Use online resources like contactderm.org. And support device discontinuation if you have to offer extra education and alternatives. The last thing that these patients want to do is give up their devices. So help add that extra support that they need. And this is my contact information. I would be happy to answer questions outside of this talk. And I put a nice QR code of the major article that I used for referencing this presentation. Thanks. Kate, that was phenomenal. I learned so much. And I'm excited to ask you some more questions about it after this. I'd now like to introduce Carrie Burgett. She is an RN, CDCES, who specializes in diabetes technologies with 12 years of experience in pediatric diabetes care and clinical research. As the clinical trials manager at the Barbara Davis Center, she leads studies on advanced diabetes technologies including AID and CGM devices. Passionate about education, she supports clinicians and people with diabetes in optimizing CGM and AID use. She also directs the Panther Program, offering free resources and clinical tools for AID management. I'm already starstruck and I'm so excited to hear what you're going to tell us today. Thank you very much. And wow, what a great presentation, Kate. That was really phenomenal. What I hope to do, and I'm going to see if I can share my screen, is back off of Kate and hope to provide some practical tips and resources that you can take away and hopefully help support your practice as we're trying to support families and all people with diabetes to be successful with devices. We know that skin care is a big part of that and often not a part that gets enough focus. The objectives for this talk would be to discuss some of these tips. How can we educate and support people with diabetes and how to take care of their skin and how to manage their devices in a way that does help them keep their skin healthy and prevent problems. Oh, shoot. Sorry, I lost my slides. Do you still see them? Yes, we do. Okay. Sorry about that, y'all. Okay. There it goes. And then, additionally, to discuss some key considerations for placing the device in a to promote skin health and minimize risk of contact irritation. So poll question, true or false, contact irritation may be preventable with appropriate skin care techniques. So I'll give you guys a few moments to think about that. Yeah, so there is some good news. I mean, skincare is a big issue and as Kate really nicely described the impact and kind of etiology of this, it is a really big challenge. But the good news is that for many people, strategies can be employed to promote skin health. While allergic contact dermatitis is much, much more challenging to deal with, the majority of device users actually have irritant contact dermatitis. So the majority of people you see who are having skin issues, it will be irritant. Not always, but for many it is. And so there are lots of things we can do like paying attention to where we're placing devices, how we're prepping the skin. And also importantly, how we're removing the devices. I think that device removal is a big piece that can cause irritation and injury to the skin. And so there's some techniques that are really important to discuss around device removal as well. So this here's a website. This is our Panther Program website. As Andrew mentioned in the intro, I direct the Panther Program at Barbara Davis Center. And the goal of this program really is to translate all the experience that we gain in technology use in the real world everyday practical pieces that we need for clinical care into resources like Clinician to Clinician, practical things you can use in your everyday practice. We have various things on the site, but I wanted to highlight that I'm gonna share our skin solutions resource with you today that can be accessed for free from the website. It goes over some of these tips. So the concerns about skin complications, I mean, Kate already explained very nicely how much of an issue and challenge it can be. But some additional things I wanted to add is that when you're talking about diabetes devices specifically, some things that are really pronounced now is that we're having increased use of diabetes devices, which is phenomenal. That is what we want. We want people using these devices because they are the best options for care of type one diabetes that we have. But because there's increased use, we are now gonna see increased skin issues as well. We also have the recurrent application situation for diabetes. This isn't just you wear this once a month. Ideally, we want people to be wearing these devices all the time, and that creates challenges. And then this trend toward longer wear time. So the longer wear time, I honestly have mixed feelings about sometimes because from a burden perspective and a ease of use perspective, it is really helpful to be able to wear your devices for a longer period of time. But then if you're wearing a sensor on your body for 14 days, can your skin tolerate that? That is a big concern. And so when we think about this move towards longer wear time, and if somebody can't tolerate a device for 14 days, like is insurance gonna cover more devices for that person who can't possibly wear it for that long of a duration? I think that's something we're gonna have to be really, really mindful of as we continue to advance our technologies. And then of course, we have multiple devices. We have pumps and CGM. So all these things together make the skin care situation challenging when you talk specifically about diabetes. So what we have is what we call our skin solutions. And what this is, is just a handout you can use that summarizes tips for preventing skin complications. So it's gonna go over tips for device placement, skin preparation, device adhesion, device removal, and skin healing. So we'll start with the device placement. So this is the very first step to promote skin health is where are we gonna wear these devices? And so some really important pieces when you're kind of working with people with diabetes on where to wear their device is you wanna choose healthy skin. You wanna avoid broken skin, skin that has scabs or cuts or scrapes, and any area that's healing from previous irritations, really helpful to give that site a rest until it is healed. You wanna have sites where you have enough subcutaneous tissue. Really, I'm a proponent of wear the device wherever it works. I don't worry personally too much about labeling and where a device is labeled to be worn. I'm more concerned about, is this a spot that the person can tolerate? Do they have enough tissue in that area to pinch up? If you can pinch up an area, that typically can suggest that you have enough fat to place that device there. Avoid bendy areas, like simple practical things. Like if you're putting your device right at your waistline, you're gonna have a lot more movement in that area, which is gonna increase the chance of irritation. Site rotation, you cannot emphasize site rotation enough. Moving the devices around is essential to skin health. And I work in pediatrics, and so I do understand how big of an issue that can be especially for young children or very lean people. But even just moving the device just a couple inches away from the prior site can make a difference in allowing skin time to heal. When you're talking about skin preparation, there's a lot of things that you can do. So probably the very first most important thing is the skin needs to be clean, but the skin also needs to be dry. This is something that I don't know that we always think about, but you do not want moisture on your skin when you are placing these devices. One for the sticking, of course, it's not gonna stick as well, but more than that, moisture on the skin is going to increase the chance of irritation. And so that's a really, really important point. The other thing is we tend to suggest alcohol for most people when we're telling them to prep their skin for placement of a device. But honestly, if someone has sensitive skin, alcohol might not be the best choice. It might be better for them to actually clean the area with soap and water and dry thoroughly because alcohol itself is very drying and irritating to the skin. Skin preps can be very, very helpful. And as Kate mentioned, they also might not work for some people. The skin preps themselves might cause irritation, but I have seen this work very well many times. And again, primarily in the context of irritant contact dermatitis and not allergic necessarily. But really what you wanna think about is creating a barrier between the skin and the irritating chemical, which in most cases is the adhesive. And so different ways that you can protect the skin from that exposure. So that could be skin prep wipes. It could also be things like flow nays, like Kate had mentioned. That's something that is in the literature. Some case studies about that being used prior to device insertion to reduce reactions. Using under tapes as well can also be helpful. So some liquid barriers. The idea here is that these liquid barriers are gonna create a clear film on the skin. So essentially a liquid barrier. So a film that's going to, after you apply it to the skin and let it dry, it's gonna create a some level of protection of the skin for being exposed to that adhesive. So these liquid barriers are typically used before insertion. So you would prep the skin with this product and then let it dry and then insert your device after that. And these are some examples. You have Kavalon, you have skin prep, you have skin tack, which will give you extra adhesive as well. And then you have flow nays, which some people do find helps. Physical barriers are also an option. So you can do under tapes or hydrocolloid dressings tend to work pretty well, especially if you're having more of a severe reaction and even sometimes for allergic reactions, sometimes hydrocolloids can help because the hydrocolloid dressings themselves tend to be very gentle on the skin. The challenge with that is how thick it is and can you get the device inserted appropriately? A lot of people will cut holes through it, things like that, where the sensor is being inserted. And then there now is some of these newer silicone options that are actually not adhesive based at all, which I think are really intriguing. This is from Skin Grip and they come matched to various different devices. So you can get one that fits exactly the Freestyle Libre and the Omnipod and the Dexcom, all the different Dexcom versions. You can also get some for infusion sites like your standard 90 degree cannulas, like a AutoSoft 90 or like the Medtronic infusion sets as well. So these are interesting because they're silicone and reusable. So they go underneath the device and then you apply an over tape over the top to keep it in place. So device adhesion. So the challenge we face of course is that we want these devices to stick. And for many people, you need some help getting them to stick, but also wanna protect the skin at the same time. So what do you do there? Again, to promote device adhesion, you really need dry skin and not dry, like flaky dry, I mean, not wet. You want no moisture. Ensuring that the area is dry after cleaning is really, really important. Additionally, you want to cleanse prior because you don't want any oils or lotions as well on the skin that can, one, cause irritation and two, make it harder for the devices to stick. Shaving can help if there is a lot of hair in the area that can help with sticking. And then if you're struggling with irritation but also need sticking, some of these barrier options like Skintac, which will provide you both a barrier between the skin and the tape and also extra adhesive can be a good option. Extra tape sometimes are needed and there's good options out there. Things like Hypofix or more gentle types of tape can be a good option for helping to keep that device attached, but also not creating more skin irritation. Non-tape solutions are also an option. So you can see in this picture, like a wrap that goes around the Dexcom and you can use that to help keep it in place. So a lot of people are starting to use those types of options. Now, device healing and removal. This is something that I really feel like cannot be emphasized enough. So the way that we remove the devices can cause mechanical injury to the skin. So this is super important. So if you're working with somebody and they're saying, you know, while they wear the device, it's not really causing them that much problem. It's more after they take it off and they see these scales and they see eczema lesions and it's itchy and bothering them. It's very likely that it's actually from the way the device is being removed. So the tips for healthy removal of the device is one, this is not a situation where you wanna pull it off like a Band-Aid, in my opinion, in my experience. You wanna use products to help it unstick. So even just home things like baby oil or olive oil, really loosen the adhesive from the skin before attempting to remove the device. And as you're removing tapes, use a low and slow angle is what it's called. So this will minimize the chance of tearing the skin. So gently folding the tape back on itself and keeping a low angle as you remove it can help reduce that injury. Once the sensor is off the skin, then check the site. If it's dry, make sure you're using high quality lotions. Again, lotions that do not have fragrances. For redness, itching, or irritation, you could use hydrocortisone creams. If you have skin tears or pain, you might need an antibiotic cream like a Neosporin. Those would be really important to watch for. And then if you do have some skin issues, it's important to try to leave that space alone. Keep promoting the healing with the lotions or the hydrocortisone or the Neosporin, depending on the situation, and try not to cover it for at least a week so that it can actually get better. And remember that infection is always an issue. So keeping an eye out for pain, pus, warmth, other signs of redness that's spreading or persisting so that you can have treatment as necessary for infections is really important. So real quick, again, on this removal technique. So I had talked about how loosening the adhesive, and these are some options for products, like Tack-A-Way would be a product you would buy, or Unisol, but baby oil you can use from home. The other tip about that low and slow angle is while the tape is being removed, you can be pulling the tape at the low and slow angle with one hand, and then using the fingers of your opposite hand to push down on the skin and wipe away with those adhesive removal products kind of as you're pulling the tape off, and that can really, really help. We kind of already talked about this. So finally, I'll finish with, these are some helpful products that we have listed on our Panther Program website, and part of this Skin Solution handout you can access. Many things can be accessed from Amazon. From my knowledge, not a lot of these things are really covered by insurance, but I could be wrong on that. For most people, I think just getting stuff from Amazon is pretty reasonable, or from the drugstore, and there's just so, so many different products out there that it really is a trial and error situation, but lots of different ways that we can teach people, and I would say from the beginning, as they're starting their devices, to be aware of how to take care of their skin in these ways to help optimize the use of their devices and keep their skin healthy and hopefully help them be successful from the beginning. So again, some of the hands-on tips, optimize placement and prep, rotate the sites, clean the skin, consider maybe not using alcohol, just soap and water, make sure that skin is dry, use barrier wipes or hypoallergenic tapes, and try different solutions. So unfortunately, it is a trial and error. We've really got to work with people individually to see what is going to work best for them. I wanted to give a brief shout out to my team at the Barbara Davis Center, and also there's a QR code here if you would like to look at the Panther Program website and access this resource. You can also get there at pantherprogram.org. Okay, thank you very much. Thank you. Thank you very much. Wonderful presentations. These are the five key tips and takeaways, and I wanted to give everyone a moment to read that. And also, this is a great time if you have a question that you would like to ask the panelists, please use the Q&A comment section from the toolbar at the bottom. That's probably preferred over using the webinar chat, but we'll try and get to everyone. I'd also like to thank our panel for the wonderful presentation. And we'll start looking at some of the questions now. The first question is, do people with type 1 diabetes have a greater propensity for contact allergies due to the autoimmune nature of type 1 diabetes? I'll take that one. So in my research, I couldn't find any collaborating studies that could prove that. You would think it would make sense because they're both come from that same immune reaction with the T cells. But there's not really any studies that prove that that's true. Great. The next question was kind of a comment that said, once allergic, always allergic, or can this be a transient issue? Could you maybe mention one more time what kinds of reactions may go away and which may not? Yeah. So typically, like your irritant contact dermatitis, more of like what Carrie was mentioning, those should go away. Topical steroids, and those shouldn't be an issue. So when we talk about allergic contact dermatitis, typically, like once that patient develops that allergy, they're going to react to that same substance for life. So I personally live with allergic contact dermatitis, not to diabetes devices. I was sensitized to more occupational things. But this has affected my life with diabetes. I was having a really awful bout of reactions. And I started reacting to my diabetes devices. And so I had to take a break from wearing my Dexcom sensor for several weeks because I did not want to form an allergy to my Dexcom sensor. And my immune system was just super heightened because I was reacting to all different things. So that's kind of what I was hoping to get across is that sometimes taking those device breaks may help that person not develop a permanent allergy. And I can't say for sure just because I haven't dug into the literature enough. But sometimes if people avoid their allergens for a long time, they can kind of tolerate them. They don't react quite so heightened as they used to. That's just what I've seen in my reading. Great. The next question is, what about using alcohol wipes applied to the sensor patch or pump patch to try to resolve the adhesive to make removal easier? They said, I find both types of device really stick to me. I can jump in on that. Honestly, I think the first rule is whatever works, people should do. So if that works for somebody and the alcohol is not causing skin irritation, then I think that that's fine. I would say, though, that alcohol is very irritating to the skin. So I don't think that would be the first thing I would recommend. If you want to loosen adhesive, I would probably go with something gentler, like one of these adhesive removal products, like a Unisolve, or again, like I said, even just baby oil from home that you can put on a cotton swab to really loosen the adhesive. But if you're using alcohol to loosen adhesive and that's not bothering you and you're not having any reactions, there's no reason to change that necessarily. The next question is important. It's about Eversense. The question is, do you recommend Eversense in people with skin issues and allergies? And I think my personal question is also around, do you have any experience giving people, how do you test to make sure somebody will tolerate the adhesive used for Eversense before they have the implanted device inside of them and it's kind of too late to backtrack? This is a really interesting question because just as a side, I feel like that is a little bit of a challenge with Eversense that while it's great to have an implantable sensor, it doesn't actually eliminate the skin issue, which is what I would hope something like that would do. And I'm curious, Kate, if you have any thoughts. I work in pediatrics primarily, so I honestly have really not seen much Eversense use myself. But it's a great question and I'm curious, Kate. I mean, I think a lot of the same principles I discuss if you're talking about irritant contact dermatitis are still going to apply with applying that transmitter to the top and the adhesive. But yeah, let's see what Kate thinks. Yeah, so we see it a little bit more in the adult world and it's becoming a little bit more popular now that the 365 has come out. And really the Eversense is kind of like my kind of last resort for people just because of its availability and currently doesn't have any interoperability with AID systems right now. But they do advertise a silicone-based adhesives. And sometimes you might be able to get a rep to give you some of those sample adhesives. I have a really nice rep and he's given me a box of adhesives. And if I have a patient with me or if it's a patient at another location, I'll mail him some of those adhesive samples. Typically, I encourage patients to wear it for about 10 days because that's usually if you're going to have an allergic contact dermatitis reaction, it's typically going to happen within 10 days. And so I'll ask them to wear it for 10 days, even though that's not how you wear the product. Typically, the product's designed to have that adhesive pulled off every day and a new one applied. And so yeah, it's typically my last resort. But I do think it could be a good option for people and I've had people go that route. Yeah. Another question is, do you know of any manufacturers who are willing to provide samples of adhesive material apart from the device to use in trying various interventions that might allow for them to tolerate? So I know that Dexcom offers their trial patches, so does Omnipod, where you can try one without the needle and use it in that way. So you may just want to reach out to your rep and see if they're able to use it in that way. I think a lot of providers are just using their samples to go ahead and try the device and we're using that to test out your skin. Carrie, I don't know if you're doing anything else in your. Yeah, no, and I interpreted, though, if the question's about the products themselves and not the device, but can you get the companies to send you some samples of skin grip or other types of tapes? I do think you can a lot of the time. I mean, I've gotten skin grip. I was so intrigued by these new silicone under patches that don't use adhesive that we got some samples of those. And I love that they fit, they're the shape of the device. So you don't have to deal as much with all the creative solutions for making it fit to your device. And I was able, they sent some to our clinic when I asked. So yeah, I think you ask and especially if it's like I'm going to share this with patients who would hopefully then be purchasing it. Cost can be an issue with some of these newer things that are kind of expensive, but for many people it's worth the investment. We have about three minutes left. The next question is, I had some patients tell them that the AIP diet, I looked, I think this means the autoimmune protocol diet, helped diminish their reactions. Any evidence that this might be helpful? Minopenticate, I've never heard of that, AIP. So no idea. I haven't heard that, but I will say I did attend the Allergic Contact Dermatitis Society conference a couple of years ago, and they have very little resources. And they almost no dieticians know about some of the diets that their literature supports, like low nickel diets, low cobalt diets, avoiding propylene glycol, and things like aspartame. And there's just not really any dieticians who learn this in school or have this knowledge base, so it's really hard. And just working with a staff of about 15 dieticians, I'm not seeing them have any sort of knowledge base on this, so it would be hard to say. But I mean, if they're trying it and it helps them and it's helping them keep a healthy weight, then by all means. One last question with the last minute here, kind of combining two questions. Are certain body areas more sensitive, devices on the lower leg, upper chest, maybe not typical, but where people will actually put them, and is there a different, more occurrence with different skin types? You know, I think there's so little known about that, and I think it's so personal and individualized, where one person might be able to tolerate a device is gonna be very different where somebody else can. So I don't know that there's an answer to that question or any sites that are more sensitive than others. I really do think it's individualized to each person, which is why I don't personally worry as much about wearing devices in off-label locations, because to me, I'm like, I just want you to wear this and wherever it feels best to you, wherever you can tolerate it. And as far as skin types, there is some evidence like Kate had mentioned about, if you have eczema, you have a greater chance of having reactions to diabetes devices. But outside of eczema, I'm not as aware of any other types of skin conditions that really increase the risk. I don't know, Kate, do you have anything to add? I mean, I think that's why we need more studies. We need more collaborations to really understand how this is affecting our patients directly, just because the research we have now can't really prove a lot of that. Excellent. I feel that this topic is so important and it causes so much distress to people when this is not working well for them and a helpful device becomes a burden when you're worrying about your skin. So I really appreciated all these pearls and hope that we can apply them and help people who use these devices feel less of that burden. Thanks again for the panelists and the wonderful presentations. We hope to see you at the next ADA webinar and take care. Thank you. Bye.

diabetes care

skin integrity

contact dermatitis

patch testing

device placement

adhesive ingredients

skincare strategies

individualized care

legislative advocacy

diabetes devices