We aimed to develop a structured algorithm for the routine clinical evaluation and management of infusion site reactions (ISRs) in patients with PD treated with CSAI.

Infusion site reactions, including subdermal nodules, cutaneous erythema, and pruritus/pain, are a common occurrence in patients with Parkinson disease (PD) who are treated with continuous subcutaneous apomorphine infusion (CSAI).

An expert roundtable consisting of US movement disorder neurologists with CSAI experience and dermatologists with expertise in inflammatory-mediated skin disorders was convened to review current knowledge of CSAI-related ISRs and to develop recommendations regarding clinical evaluation and management of ISRs that develop during CSAI treatment.

Experts reviewed proposed steps to minimize the development of ISRs, including patient education of proper insertion technique, site rotation, skin hygiene, sterile procedure, and avoidance of problem skin areas. Some patients may be at higher risk of ISRs despite these methods. Experts suggested that a clearer classification system of CSAI-related ISRs be developed, and proposed presence of symptoms, timing, size, erythema, and fluctuance/drainage as factors to include.  Based on classification, management would be determined.  Most nodules can be managed conservatively.  Because infections are uncommon, empiric antibiotics were not felt to be necessary in most circumstances. Patients should be instructed to report ISRs that are not improving, expanding, or associated with systemic symptoms to their healthcare provider.

ISRs are common with CSAI therapy, and probably reflect an inflammatory reaction in sensitized patients. Most ISRs resolve spontaneously, but some require evaluation to exclude infection. Simple steps to try to minimize ISRs are proposed. Although further research will help elucidate the underlying causes of ISRs, experts agreed that most CSAI-related ISRs are self-limited, resolve spontaneously, can be managed by a treating neurologist without dermatologic/medical referral, and do not limit successful continuation of treatment.