Occupational contact dermatitis in nurses with hand eczema

Occupationally related dermatitis is a common problem in nurses, who are exposed to a wide variety of allergenic and irritant substances. In a group of 44 nurses with hand dermatitis (40 female, 4 male), 18 were thought to have a predominantly allergic contact dermatitis, 15 an irritant dermatitis, 7 other form of eczema, 3 atopic dermatitis and one pompholyx. 10 of the 15 irritant cases were diagnosed as occupational. Of the 18 patients with allergic contact dermatitis, the allergens were thought to be occupationally relevant in 8 cases. In 6 of these 8 the dermatitis was due to natural rubber latex (3) or other rubber chemicals (3). 2 had additional evidence of immediate-type hypersensitivity to natural rubber latex (one was patch test allergic to latex, the other to thiuram mix). Natural rubber latex allergy, both delayed and immediate, is a significant problem, and nurses at risk should be tested for both types of hypersensitivity, as well as being patch tested to standard, rubber and medicaments series.     

Prevalence, incidence and course of eczema on the hands and forearms in a sample of the general population

In 1979, the inhabitants of a geographically defined area were examined for skin disorders of the hands and forearms. In 1982 this cohort was invited for re-examination. In persons with eczema, patch testing was performed. Irritant factors were found to play a rôle in 73% of the cases, whereas a contact allergy could be detected in 30%. The must frequent allergens were nickel sulphate (20%), potassium dichromate (6%), land cobalt chloride (4%). In some persons with a definite history of allergy to metals, no positive patch test with nickel, chromate or cobalt could be obtained; other mechanisms may be involved. Significantly more positive patch tests were found among persons with an eczema of longer than 2 years duration compared with persons, with eczema present for a shorter period of time, indicating that many cases of eczema are primarily of irritant nature, but later complicated by sensitisation. In 41%, the eczema was healed. A poor healing tendency was observed in those with a combination or irritant and allergic eczema. Relatively few ascribed healing to medical treatment.     

Flexural allergic contact dermatitis to benzalkonium chloride in antiseptic bath oil

Benzalkonium chloride (BAK) is an acknowledged irritant but has also been identified as a cause of allergic contact dermatitis. The antiseptic bath emollient Oilatum Plus (Stiefel, High Wycombe, U.K.) contains a relatively high concentration of 6% BAK. We describe six patients who presented with flexural eczema, particularly involving the anogenital area, who had a history of using Oilatum Plus. Patch testing showed all six to have a type 4 allergy to BAK as well as other allergens. Avoidance of Oilatum Plus led to a resolution of the flexural eczema in each case.     

Hand eczema in car mechanics

To estimate the prevalence of hand eczema, a questionnaire was distributed to 901 male car mechanics. Of the 801 persons who responded, 15% reported hand eczema on some occasion in the previous 12 months, and 57% admitted dry skin on the hands. In a 2nd part of the study, those who reported hand eczema were examined and patch tested with a standard series and a special "car mechanics' series". The most common diagnosis was irritant contact dermatitis, 55%, and 2nd was allergic contact dermatitis, 19%. 35/105 (33%) had a total of 51 positive patch test reactions, all to substances in the standard series, except for 2 persons who reacted to oxidized d -limonene. The most frequent reactions were to thimerosal (9%), nickel (8%) and colophony (5%). One plausible explanation for the high prevalence of nickel allergy was the common use of nickel-plated tools. 5 individuals had a history of contact urticaria, but scratch tests were negative. It was concluded that car mechanics are at high risk for contact dermatitis on the hands, irritant as well as allergic.     

Contact eczema produced by a β-adrenergic blocking agent (alprenolol)

In a pharmaceutical industry, several cases of allergic contact eczema caused by the beta-adrenergic blocking agent alprenolol (Aptin) have appeared. This report deals with 12 men and two women who developed eczema during work with the substance. In 13 of the 14 cases, the induction time for sensitization was less than 1 year. The skin reactions were very florid. After healing they could be reproduced by very small quantities of the substance. In one case, eczema could also be produced after ingestion of Aptin tablets. All the cases were transferred to other work within the factory. An intensive programme was implemented to remove dust from the working areas. Despite this, isolated new cases still appear. Some employees in contact with the substance also experienced mucous membrane symptoms. These symptoms could not be shown to have an allergic aetiology, but were considered to be irritant reactions. Alprenolol must be considered a very strong contact allergen.     

Skin and respiratory tract symptoms in veterinary surgeons

Chronic or relapsing irritant eczema of the hands was the main complaint in 34 veterinary surgeons. 9 had contact allergic eczema of occupational character. In 8 cases, the allergies were probably due to antibiotics contaminating the skin during the administration of treatment. Contact allergy to penicillin was observed in 5 cases, to neomycin in 2 and to streptomycin in 1 case. Sensitivities to other work-related substances such as rubber chemicals, antiseptics and local anaesthetics were found in 6 cases. Multiple contact allergies, in particular to different penicillins, were seen frequently. Obvious work-related immediate reactions of probable allergic type were present in 10 cases, but were confirmed with positive RAST or prick test in only 2 cases.     

Periorbital dermatitis: Causes,differential diagnoses and therapy

Periorbital dermatitis is common and frequently difficult to treat. Patients with periorbital dermatitis often suffer severely because their disease is in such a visible location. Because of the variety of clinical appearance, the differential diagnostic considerations are often difficult. We examined the causes of periorbital dermatitis and compared the data of 88 patients from the Department of Dermatology, University Hospital Erlangen to those of the German IVDK (Information Network of the Departments of Dermatology). Between 1999 and 2004, predominant causes of periorbital dermatitis were allergic contact dermatitis (Erlangen 44 %, IVDK 32 %), atopic eczema (Erlangen 25 %, IVDK 14 %), airborne contact dermatitis (Erlangen 10 %, IVDK 2 %) and irritant contact dermatitis (Erlangen 9 %, IVDK 8 %). Less frequent causes for secondary eczematous periocular skin lesions were periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris. Female gender, atopic skin diathesis and age of 40 years and older were identified as risk factors for periocular dermatitis. Common elicitors of periorbital allergic contact dermatitis were leave‐on cosmetic products (face cream, eye shadow) and eye drops with the usual allergens being fragrances, preservatives and drugs. Exact identification of relevant contact allergens and allergen elimination are essential for successful treatment. Calcineurin inhibitors are the first‐line therapy for facial atopic eczema. They may be also effective in periocular eczematous lesions of other origins although they are not approved for such use.     

Occupational dermatitis in Danish gardeners and greenhouse workers

The aim of the study was to assess the distribution of different types of occupational eczema among employees in floristry and detect the allergens most commonly involved. Based on a postal questionnaire, 253 gardeners and greenhouse workers with occupational skin symptoms and 52 randomly-selected without symptoms were examined and patch tested. Routine tests comprised the standard series, the Compositae mix, feverfew and 3 fungicides, with additional testing based on case records. 184 persons from the symptom group and 1 from the random group had occupational eczema. Irritant occupational contact eczema was suspected in 150 persons (59%). Nevertheless, 48% of the 250 persons patch tested had at least 1 positive reaction, most frequently to nickel, followed by Compositae which were positive in 25 cases (10%), of whom 24 were possibly occupationally sensitized. 13 persons from symptom group had positive reactions to fungicides. Occupational allergic eczema was suspected in 43 persons (17%), most often caused by plants belonging to the Compositae, Geraniaceae and Liliaceae families. New plant sensitizers were Exacum affine and Begonia lorraine. Exposure to specific plant species seemed to be the most important eliciting factors in both allergic and irritant occupational dermatitis in floristry, and preventive measures should include reduction of contact with plants.     

Olive oil – contact sensitizer or irritant?

Adverse cutaneous reactions to topically applied olive oil are seldom reported, and positive patch tests to it are mostly regarded as allergic. To evaluate such "positive" patch test reactions. 77 female (mean age: 44 years) and 23 male eczema patients (mean age: 46 years) were prospectively patch tested with freshly prepared olive oil. Tests were performed openly (including ROAT) as well as using Al-tests® and Finn Chambers® on Scanpor®. 5 patients (2 male) showed "positive" test reactions (all patients at the Al-test® site. 3 at the Finn Chamber® site. I with ROAT). In only 1 patient could the reaction be classified as probably allergic, in contrast to previous reports. In conclusion, olive oil is very weakly irritant in general, but bears relevant irritant capacity when applied under occlusive conditions. Therefore, olive oil appears to be less than suitable for the topical therapy of patients with venous insufficiency and associated eczema of the lower extremities.     

Hand eczema: causes, course, and prognosis I

Background:  Hand eczema is a common dermatosis. The course is often protracted. The prognosis is not well described.
Objective:  To describe in detail a consecutive cohort of hand eczema patients with regard to aetiology and morphology as well as the dynamics of the hand eczema.
Patients and Methods:  This prospective study included 522 consecutive patients (175 men and 347 women with hand eczema) seen in 1 year in a private practice of dermatology. 425 (81%) of the patients were patch tested in relation to the current study. Most of the remainder had been previously patch tested.
Results:  38% had mild dermatitis, 49% had dermatitis of moderate severity, and 11% had severe dermatitis. 23% had had dermatitis for more than 10 years. 33% had irritant contact dermatitis, 13% of the men and 20% of the women had allergic contact dermatitis, and 15% of the men and 16% of the women had atopic dermatitis. For 34% of the men and 29% of the women, the dermatitis was certainly or possibly occupational. There was no relationship to smoking.
Conclusions:  The majority of this cohort of hand eczema patients had long-standing disease. Irritant contact dermatitis was the most common aetiological diagnosis.     

Patch testing in Hong Kong

The acceptability and value of patch testing in Hong Kong was studied in 56 cases of suspected dermatitis (CD), 26 cases of endogenous eczema (EE) and 30 cases of unclassified eczema (UE), selected systematically: all those suspected of having CD and 1 in 3 of the others. 81.3% of the 112 patients selected accepted the test. The main reasons for refusal were inconvenience and lack of time for the readings. Of the 91 tested, in 88 they were successfully completed. In 39 patients, the results were negative, while 49 patients reacted to 1 or more allergens. The 2 commonest sensitizers were fragrance-mix (15 patients) and nickel sulphate (14 patients). The "usefulness" of patch testing was defined as it causing the initial clinical diagnosis to be changed. The test was found to be "useful" in 10 cases (21.3%) of those diagnosed as CD in 2 respects: (a) changing the diagnosis from irritant to allergic CD (6 cases) and (b) changing the diagnosis from CD to a suspected substance, to CD to another unsuspected substance (4 cases). For EE and UE, the initial diagnosis was changed to allergic CD in 3 (18.7%) and 7 (28.0%) cases, respectively.     

A survey of occupational hand eczema in Denmark

Occupational hand eczema (OHE) is the most frequently recognized work-related disease in Denmark and the annual cost to society is high. Understanding of the epidemiology of OHE is essential to be able to give appropriate recommendations for its prevention. The study comprised 758 persons, 490 females and 268 males with recognized OHE in the period October 2001 to November 2002. Data were obtained prospectively from the National Board of Industrial Industry Registry and from a self-administered questionnaire (response rate, 82%). The most frequently recognized diagnosis was irritant contact dermatitis (ICD), mainly caused by wet occupations. The proportion of occupational ICD was equal for males and females, 59.7% and 63.1%, respectively. The estimated rates of OHE were high for bakers, hairdressers and dental surgery assistants, and a high proportion of apprentices were found among hairdressers. The prevalence of atopic dermatitis was low (16.4%) compared to previous studies among hand eczema patients. The prevalence of occupational allergic contact dermatitis in the study population was substantially higher among males than females, and the most frequent causes among males were allergy to chromium (leather exposure), rubber additives (gloves) and nickel due to exposure from work tools and metalworking industry.     

Eyelid dermatitis: an evaluation of 150 patients

This study was performed to evaluate eyelid dermatitis in a group of patients of our Allergy Unit between January 1990 and April 1991. Among the 1158 patients seen during this period, 150 had eyelid dermatitis: 135 females and 15 males, with a mean age of 35 years. Of the 150 patients with eyelid dermatitis, 54 had eczema localized to the eyelids only, 49 to the eyelids and face, 19 to the eyelids and hands, and 28 to the eyelids and other sites. 98 patients (65.3%) were diagnosed as having allergic contact dermatitis, 25 (16.6%) irritant contact dermatitis, 21 (14%) atopic dermatitis, and 6 (4%) seborrhoeic dermatitis. Patch test reactions to nickel sulphate, Kathon CG and fragrance-mix occurred more frequently in patients with eyelid dermatitis than in those without.     

Long‐term follow‐up study of occupational hand eczema

Background Long‐term follow‐up studies on the prognosis and consequences of occupational hand eczema (OHE) and the prognostic risk factors for persistent OHE are sparse. Objectives To determine the medical and occupational outcome after a follow‐up of 7–14 years in 605 patients diagnosed with OHE and to identify the prognostic risk factors for the continuation of hand eczema. Methods Patients examined at the Finnish Institute of Occupational Health in 1994–2001 completed a follow‐up questionnaire 7–14 years after diagnosis. Results The hand eczema had healed (no eczema during the last year) in 40% of patients with OHE. The duration of hand eczema before diagnosis was strongly associated with the continuation of eczema. Age, sex and diagnosis (allergic or irritant contact dermatitis) were not associated with the prognosis, but skin atopy, and especially respiratory atopy, were correlated with the continuation of hand eczema. Contact allergies in general were not risk factors for persistent OHE, but the presence of a work‐related chromate allergy was associated with poor healing. A total of 34% of patients had changed their occupation due to OHE, and their long‐term prognosis was better than those who had not. The hand eczema of patients originally in food‐related occupations continued on an unfavourable course. Conclusions In the logistic model, risk factors for the continuation of OHE were a long duration of hand eczema before diagnosis, respiratory atopy, skin atopy, and continuation in the same occupation. Those who ended up changing occupation due to their OHE had a better medical and economic prognosis.     

Sensitizing potential of triclosan and triclosan-based skin care products in patients with chronic eczema

Triclosan is a lypophilic chlorophenol biocide with broad-spectrum antibacterial and antifungal activity. Triclosan-based topical products have been shown to be tolerated and beneficial in atopic dermatitis. The aim of this study was to evaluate the sensitizing potential of triclosan and triclosan-based creams in patients affected by eczematous dermatitis. Two hundred and seventy-five patients affected by chronic eczema (allergic contact dermatitis, irritant contact dermatitis, atopic eczema, nummular eczema, stasis dermatitis) were patch tested with standard patch test series as well as triclosan and triclosan-based products. Standard patch test series resulted positive in 164 patients (61%), with nickel sulfate, house dust mites, fragrance mix, propolis, thimerosal, myroxylon pereira, potassium dichromate, wool alcohols, and p-phenylenediamine the most common sensitizing haptens. Only two patients developed positive reactions to triclosan (0.7%) and four (1.4%) to triclosan-based products. The present study's results confirm that triclosan is well tolerated and has a very low sensitizing potential even in high-risk patients affected by eczema.     

CONTINUING MEDICAL EDUCATION REVIEW Occupational skin disease in hairdressers

Hairdressers belong to an occupational group that is commonly affected by occupational skin disease, specifically contact dermatitis, which may be allergic or irritant and, less commonly, contact urticaria. Occupational contact dermatitis predominantly affects apprentices, and atopy is a recognized risk factor associated with a poor prognosis. Repetitive wet work leading to irritant contact dermatitis, followed by exposure to allergens and the development of allergic contact dermatitis, are the main factors contributing to occupational contact dermatitis. Once developed, it is often difficult to manage and is a cause of significant morbidity. Early education, training and prevention is the best approach to the management of this disorder that is endemic among hairdressers.     

Occupational contact allergy to cocamidopropyl betaine and its impurities

Background. Contact allergy to cocamidopropyl betaine has been attributed to its impurities dimethylaminopropylamine and cocamidopropyl dimethylamine. Objectives. To describe patients with positive patch test reactions to cocamidopropyl betaine‐related compounds in an occupational dermatology clinic. Methods. We reviewed the 2002–2009 patch test records at the Finnish Institute of Occupational Health for allergic reactions to cocamidopropyl betaine, dimethylaminopropylamine, cocamidopropyl dimethylamine, and oleamidopropyl dimethylamine. Results. Irritant reactions to at least one of the test substances were seen in 39% of the 1092 patients tested. Fifteen (1.3%) patients showed allergic reactions: 13 to cocamidopropyl dimethylamine, 11 to dimethylaminopropylamine, 8 to oleamidopropyl dimethylamine, and 2 to cocamidopropyl betaine. Concomitant reactions to cocamidopropyl dimethylamine, dimethylaminopropylamine and oleamidopropyl dimethylamine were common. Ten of the 15 patients were diagnosed with occupational allergic contact dermatitis caused by cocamidopropyl betaine‐related compounds. The sources of occupational exposure included hair care products, hair colours, perm wave solutions, and liquid soaps. Multiple contact allergies and exposure to several irritant factors were common, and all patients had hand eczema. Conclusions. Patch test reactions to cocamidopropyl betaine‐related compounds are difficult to interpret, owing to extremely common irritant reactions. Cocamidopropyl betaine itself is probably not an allergen. Occupational allergic contact dermatitis caused by cocamidopropyl betaine‐related compounds is relatively rare and, unlike non‐occupational cocamidopropyl betaine‐related allergy, typically manifests as hand dermatitis.     

Venison contact dermatitis

A 37-year-old meat inspector presented with a 5-month history of forearm eczema. His symptoms improved at weekends and over holidays but flared within a day of work. Scratch patch tests were strongly positive to fresh venison diaphragm and venison liver and weakly positive to venison hide and blood, and lamb blood. They were negative to other venison and lamb components. Type IV allergy tests with Standard European and fragrance batteries were negative. The eczema cleared with a change in work role, clobetasol-17-propionate cream, flucloxacillin and aqueous cream. He was then able to return to meat inspecting. Provided he was diligent about applying 'Dermashield' barrier foam and minimizing contact with irritants, his eczema has remained well controlled over the last 4 years. Attention to irritant contact dermatitis is important in the management of protein contact urticaria.     

Industrial airborne irritant or allergic contact dermatitis

Industrial airborne irritant or allergic contact dermatitis is commonly observed in many factories. Examples of airborne irritants include fibres (such as fibreglass or rockwool), various kinds of dust particles (such as cement, slag, sludge, insulating foam, wood chips), acids and alkalis, gasses and vapours. Airborne contact allergens are unequivocally numerous. The clinical symptoms of both irritant and allergic airborne contact dermatitis are reviewed.