MAUDE Adverse Event Report: HOLLISTER INCORPORATED NEW IMAGE CONVEX CERAPLUS SKIN BARRIER WITHOUT TAPE BORDER

Model Number 15302

Device Problem Biocompatibility (2886)

Patient Problem Hypersensitivity/Allergic reaction (1907)

Event Date 02/01/2018

Event Type  Injury  

Manufacturer Narrative

Biocompatibility testing has been performed in accordance with iso 10993 and materials were found to be non-sensitizers.Lot number not provided so dhr review is not possible.Sample not returned so a sample evaluation is not possible.Trend data reviewed and no adverse trend observed.

Event Description

It was reported that an end user started to observe irritation under his ostomy barrier and tape and went to the dermatologist about it in (b)(6) 2018.He switched to a tapeless product but still had problems.The dermatologist said he was experiencing an allergy to the product.The allergy was confined to under the appliance and experienced skin redness and itching.The doctor prescribed triamcinolone acetonide cream.The area began to improve almost immediately.

• Brand Name: NEW IMAGE CONVEX CERAPLUS SKIN BARRIER WITHOUT TAPE BORDER
• Type of Device: NEW IMAGE CONVEX CERAPLUS SKIN BARRIER WITHOUT TAPE BORDER
• Manufacturer (Section D): HOLLISTER INCORPORATED; 2000 hollister drive; libertyville IL 60048 3781
• Manufacturer (Section G): HOLLISTER INCORPORATED; 366 draft avenue; stuarts draft VA 24477 9998
• Manufacturer Contact: linda wisowaty ; 2000 hollister drive; libertyville, IL 60048-3781 ; 8473602170
• MDR Report Key: 7494965
• MDR Text Key: 107620249
• Report Number: 1119193-2018-00018
• Device Sequence Number: 1
• Product Code: EXB
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: N/A
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,consum
• Reporter Occupation: Patient
• Type of Report: Initial
• Report Date: 05/03/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Lay User/Patient
• Device Model Number: 15302
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 04/13/2018
• Initial Date FDA Received: 05/08/2018
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 57 YR
• Patient Weight: 84