A preliminary report of the occupation of patients evaluated in patch test clinics.

BACKGROUND: The interplay between the occupational environment and worker's skin can result in contact dermatitis of both irritant and allergic types. Other forms of dermatitis can also be influenced by occupational exposures. OBJECTIVE: The aim of this study is to compare the occupations and allergens of occupational contact dermatitis cases with nonoccupational contact dermatitis cases. METHODS: Diagnostic patch testing with allergens of the North American Contact Dermatitis Group and occupational coding by the National Institute for Occupational Safety and Health methods. RESULTS: Of 2,889 patients referred for evaluation of contact dermatitis, 839 patients (29%) were found to have occupational contact dermatitis. Of the 839 cases deemed occupational, 455 cases (54%) were primarily allergic in nature and 270 cases (32%) were primarily irritant in nature. The remaining 14% were diagnoses other than contact dermatitis, aggravated by work. The occupation most commonly found to have allergic contact dermatitis was nursing. Allergens strongly associated with occupational exposure were thiuram, carbamates, epoxy, and ethylenediamine. CONCLUSION: Some contact allergens are more commonly associated with occupational contact dermatitis. Nursing and nursing support are occupations most likely to be overrepresented in contact dermatitis clinics.     

Occupational contact dermatitis

The dermatologist should be aware of the many facets of occupational skin diseases, which can be caused by physical, chemical, and biological insults. The most common manifestation of occupational skin diseases is contact dermatitis (both irritant and allergic). Three factors point out the importance of occupational skin diseases as diseases that have a public health impact: 1) occupational skin diseases are common; 2) they often have a poor prognosis; and 3) they result in a noteworthy economic impact for society and for an individual. They are also diseases amenable to public health interventions. Specific industries and exposures may put a worker at risk of occupational contact dermatitis. The accuracy of the diagnosis of occupational contact dermatitis is related to the skill level, experience, and knowledge of the medical professional who makes the diagnosis and confirms the relationship with a workplace exposure. Prevention of occupational contact dermatitis is important, and a variety of prevention strategies are available.     

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 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.     

Contact dermatitis from dielectric fluids in electrodischarge machining

We report an outbreak of irritant contact dermatitis in the aerospace industry from electrodischarge machining (EDM). 20 workers doing EDM developed irritant contact dermatitis from the dielectric fluid used in EDM, a form of precision metal machining that is widely used in mould making and precision engineering. Dielectric fluid contains hydrocarbons that are aromatic, paraffinic or naphthenic and are skin irritants. Irritant contact dermatitis from dielectric fluid has not been reported previously. EDM will become more widespread and occupational dermatitis from dielectric fluid is likely to become more prevalent in the future. Our experience was that irritant contact dermatitis from dielectric fluid can be prevented by simple preventive measures such as personal hygiene and health education.     

Relationship of occupation to contact dermatitis: Evaluation in patients tested from 1998 to 2000

BACKGROUND: Both irritant and allergic contact dermatitis can be influenced by occupational and nonoccupational environmental exposures. OBJECTIVE: The aim of this study is to compare the occupations and allergens of occupational contact dermatitis cases with nonoccupational contact dermatitis cases. METHODS: Diagnostic patch testing was conducted with the 50 screening allergens of the North American Contact Dermatitis Group and occupational coding by the Surveillance Branch of the National Institute of Occupational Safety and Health. RESULTS: Of the 5,839 patients patch tested for contact dermatitis, 1,097 (19%) were deemed to be occupationally related. Of the occupational cases, 60% were of allergic and 32% were of irritant origin. The hands were the primary body part affected in 64% of allergic occupational cases and 80% of irritant occupational cases. Epoxy resin was the only allergen tested that was associated more with an occupational exposure than nonoccupational exposure. The allergens encountered most frequently in the occupational cases were carba mix, thiuram mix, epoxy resin, formaldehyde, and nickel. The medical field is overrepresented in the data compared with other occupations. CONCLUSIONS: Occupational contact dermatitis frequently was found to be multifactorial and associated with several specific allergens and occupations.     

Occupational irritant and allergic contact dermatitis among healthcare workers

Contact dermatitis is the most frequent occupational dermatosis and non-specific irritants in addition to specific Type IV sensitization are involved. We reviewed our database for data from 1994 to 1998 and selected 360 consecutive patients working in healthcare environments and experiencing contact dermatitis at their hands, wrists and forearms. We found that allergic contact dermatitis and irritant contact dermatitis were considered to be work-related in 16.5% (72/436) and 44.4% (194/436) of diagnoses, respectively. Occupational irritant contact dermatitis is due to exposure to a wide range of irritants in the workplace, such as soaps, solvents, cleansers and protective gloves, which conspire to remove the surface lipid layer and/or produce cellular damage. In this study the major relevant aetiological agents that induced occupational allergic contact dermatitis were: nickel sulphate (41 patch positivities), components of disinfectants [glutaraldehyde (5) and benzalkonium chloride (7)] and rubber chemicals [thiuram mix (15), carba mix (9) and tetramethylthiuram monosulphide (6)]. The best treatment for allergic contact dermatitis is to avoid those allergens causing the rash. Whenever this is not possible, contact with them needs to be reduced using properly selected protective gloves. Finally, subjects with atopic dermatitis should avoid 'wet work' and contact with irritants, because atopic dermatitis is significantly associated with irritant contact dermatitis.     

A single accidental exposure may result in a chemical burn, primary sensitization and allergic contact dermatitis

It is known from experimental studies that antigenic potency and the concentration of antigen determine whether exposure to an antigen will result in sensitization. A single accidental exposure to concentrated antigen may therefore induce primary sensitization. The purpose of this report was to collect clinical cases in which a single exposure had resulted in contact dermatitis suspected to be allergic. Only patients without previous relevant skin symptoms were included. Patch testing was used to demonstrate sensitization. 6 patients developed occupational allergic contact dermatitis from accidental exposure. Patch testing revealed allergy to diglycidylether of bisphenol A epoxy resin, poly functional aziridine hardener, methyl acrylate, phenol-formaldehyde resin, and methylchloroisothiazolinone/methylisothiazolinone (Kathon LX), respectively. Furthermore, 2 patients developed allergic contact dermatitis from their first exposure to tear gas chemicals, namely omega-chloroacetophenone and ortho-chlorobenzylidene malonitrile. A single exposure can therefore induce both sensitization and subsequent allergic contact dermatitis without further exposure. The allergens described must be considered strong allergens. The skin should immediately be cleaned if an accidental splash with such an allergen has taken place.     

Detection of occupational allergic contact dermatitis by patch testing

Occupational allergic contact dermatitis (OACD) is an important medical and occupational health problem. If undiagnosed, the disease may persist and even spread widely, resulting in severe and permanent disability to the worker, who may be deprived of his legal right to compensation. OACD is not uncommon in China, although many dermatologists fail to establish the connection between disease and working conditions, because they think that the diagnosis of OACD is the work of occupational medicine and that special diagnostic methods are required. The Ministry of Health and Ministry of Labour and Social Security of China have issued a new law recently to emphasize the prevention and treatment of occupational disease. It requires physicians to make an accurate diagnosis and report of occupation-related diseases. In this study, we have successfully investigated 14 cases of OACD in our hospital by patch testing the patients with a standard series of allergens and investigating by questionnaire the suspected offending occupational allergens. During a 2-year period (2001-2003), 14 patients with suspected allergic contact dermatitis were investigated and confirmed as having OACD. OACD may develop in many different occupations. In this study, nickel, 4-phenylenediamine, fragrance mix, black rubber mix, colophonium, epoxy resin and thiuram mix were identified by patch testing as the main offending allergens in such patients. These results indicate that patch testing plays a vital role in the diagnosis and identification of occupational allergens, and our study shows that OACD can often be diagnosed by patch testing patients with a standard series. The clinician should be alert to recognize the offending allergens of OACD by referring to patch testing all patients with clinically suspected contact dermatitis, and then educating the sensitized worker in how to avoid further exposure to the causative allergens.     

Role of protective gloves in the causation and treatment of occupational irritant contact dermatitis

Irritant contact dermatitis of the hands is a significant occupational problem. Management primarily involves cessation of exposure to hazardous substances. Protective gloves can reduce or eliminate exposure of the hands to hazardous substances if used correctly, but if not selected and used correctly, protective gloves can actually cause or worsen irritant contact dermatitis of the hands by increasing exposure of the hands to hazardous chemicals. We present two cases of occupational irritant contact dermatitis of the hands caused by incorrect use of protective gloves. Glove failure can occur by penetration, permeation, or contamination, and all 3 mechanisms were operative in these cases. These cases demonstrate that correct use of gloves is at least as important as selection of gloves made of the appropriate material. By understanding mechanisms of glove failure, clinicians can make more appropriate recommendations for the selection and use of protective gloves in the workplace.     

Occupational allergic airbone contact dermatitis and delayed bronchial asthma from epoxy resin revealed by bronchial provocation test

Diglycidyl ether of bisphenol A (DGEBA) epoxy resins belong to the most common causes of occupational allergic contact dermatitis. DGEBA has on rare occasions caused occupational asthma. Here we present a patient who first developed occupational allergic contact dermatitis (ACD) caused by a single accidental exposure to DGEBA. Then, on continued occupational exposure to DGEBA, the patient developed occupational asthma from DGEBA, in addition to ACD. A bronchial provocation test with DGEBA caused a 36% drop in the peak expiratory flow, reflecting a delayed type of occupational asthma. This bronchial provocation test caused a strong dermatitis of the exposed skin of the face, in accordance with airborne ACD from DGEBA.     

The sex of the individual as a factor in allergic contact dermatitis

Exogenous and endogenous factors have been implicated in allergic contact dermatitis (ACD); this review explores the sex of the individual as a possible endogenous factor. While there is a clinical impression that women are more skin-reactive than men, upon review this hypothesis appears oversimplified. This review explores sex differences in controlled testing of adult ACD, occupational ACD and juvenile ACD. Further, geographical location and socioeconomic and cultural factors in relation to sex differences in allergic contact dermatitis are discussed. We conclude that female sex could be a factor predisposing to allergic contact dermatitis not so much because of possible differences in intrinsic skin characteristics between the sexes, but more because of different exposure patterns. This conclusion has practical consequences regarding product labelling requirements, occupational risk assessment and legislation.     

Environmental and occupational skin diseases in Taiwan.

This presentation focuses on the four most important skin diseases in Taiwan thought to be of environmental and/or occupational origin. The majority of work-related dermatoses are contact dermatitis patients. Among occupational contact dermatitis patients, 58.5% involved irritant and 41.5%, allergic dermatitis. Electronics, hairdressing, medical practice, and construction were the most important occupations causing contact dermatitis. An endemic occurrence of chronic arsenism causing hyperpigmentation, keratosis, and cancer has been reported in Taiwan. Arsenical skin cancers present as multiple lesions at different disease stages. The skin cancers are usually found in non-sun-exposed areas. UVB exerts an inhibitory effect on the proliferation of arsenical cancers; this may explain its non-sun-exposed nature. An outbreak of premalignant and malignant skin lesions was reported among paraquat manufacturers in 1985. The skin lesions were mainly distributed over the sun-exposed areas. Photodamage and photocarcinogenesis revealed a strong association with exposure to bipyridines among paraquat manufacturers. In 1979, a mass poisoning occurred in Taiwan from cooking oil contaminated by polychlorinated biphenyls (PCBs). Over 60% of patients were in grades O-II by the Japanese classification. The blood PCB levels of the Taiwanese patients were found to be higher than those of the Yusho subjects.     

FS10.7A surveillance network for occupational contact dermatitis utilizing general practitioners

Objectives:  The Surveillance by General Practitioners of Occupational Contact Dermatitis Project (Spot) has been designed to provide disease estimates for occupational contact dermatitis within a defined geographic area in Melbourne, Australia.
Method:  Spot collected reports of occupational contact dermatitis from four separate sources: general practitioners, dermatologists, a Dermatology Outpatient clinic, and an Occupational Dermatology Clinic. Case definition was stratified into two levels, suspected and confirmed. All cases of suspected occupational contact dermatitis reported to Spot were assessed and required to undergo diagnostic confirmation, including appropriate patch testing by an occupational dermatologist. The rates generated by Spot were compared to the rates generated by Victorian workers' compensation data (Victorian Work Cover Authority) for "Contact dermatitis and other and unspecified dermatitis."
Results:  To date, a total of 125 suspected cases have been reported to Spot. 56 cases of occupational contact dermatitis have been confirmed with an incidence rate of 12.5 per 100,000 full‐time workers and a prevalence rate of 28 per 100,000. This can be compared to the rate from Victorian WorkCover Authority of 4 per 100,000 (with information not available for incidence or prevalence).
Conclusions:  Although limited by resources, clinician and worker participation rates, Spot provides a better estimate for occupational contact dermatitis in an Australian urban setting than that currently available through workers' compensation statistics. The information generated by Spot will provide an important contribution towards the characterisation of occupational contact dermatitis in Australia.     

Irritant contact dermatitis: a review

Irritant contact dermatitis is the most common form of contact dermatitis, and yet is often overlooked. Recent progress in understanding the pathogenesis has reignited the interest of clinicians in this area of dermatology. Irritant contact dermatitis is not a homogenous entity, but rather a number of subtypes contributing to different clinical presentations. The diagnosis of irritant contact dermatitis is often clinical, and may only be possible after the exclusion of allergic contact dermatitis with patch testing. There is no readily available diagnostic test. There is an incomplete understanding of the factors which lead to the development of cumulative irritant contact dermatitis and persistent postoccupational dermatitis. We have used the experience from our tertiary referral occupational dermatology clinic to illustrate various aspects of irritant contact dermatitis, and to highlight the difficulty sometimes encountered in making this diagnosis. We believe that increased awareness of the often pivotal role of irritant contact dermatitis, as well as all the other factors contributing to occupational dermatitis, will lead to improvement in outcomes for patients.     

Occupational skin diseases among dental nurses

Out of 923 female dental nurses in the Helsinki district, 799 were interviewed using a computer-assisted telephone interview. A structured questionnaire was used to inquire about skin, respiratory symptoms, atopy, work history and methods, and exposure at work. The 328 nurses, who reported work-related dermatitis on their hands, forearms or face, were invited to an interview by an occupational physician; 245 nurses participated. 31 nurses had previously been diagnosed with an occupational skin disease (OSD). 133 nurses with a suspected OSD were selected for further clinical examinations with prick and patch testing. Among the 107 nurses examined, 22 new cases of OSD were diagnosed. There were altogether 29 cases of allergic contact dermatitis, 15 of contact urticaria, 12 of irritant contact dermatitis, and 1 case of onychomycosis. Rubber chemicals and natural rubber latex (NRL) in protective gloves, as well as dental-restorative plastic materials [(meth)acrylates], were the most common causes of allergy. 42% of the OSD cases in the studied population had been missing from the statistics (Finnish Register of Occupational Diseases). Plastic gloves or NRL gloves with a low-protein content are recommended for dental work. Skin exposure to (meth)acrylates should be avoided.     

Return-to-work barriers for workers with contact dermatitis

There is little information available regarding barriers to return-to-work (RTW) in workers with contact dermatitis. The purpose of this study was to survey occupational health and safety personnel to determine their perceptions regarding RTW barriers for workers with contact dermatitis. The study was conducted during an occupational health and safety research conference attended by stakeholders from labour, management, injured workers, government, safety associations, occupational health and safety practitioners and researchers. The attendees were presented with 3 pictures of varying degrees of work-related hand contact dermatitis and were asked to list the 3 key barriers or challenges in RTW for individuals with contact dermatitis. 21 individuals completed the survey. Issues identified in descending order of frequency were concern of ongoing dermatitis, ability to do the job safely, appearance, ability to accommodate, personal protective equipment, fear that the rash was contagious, workplace attitudes and pain. While some of these issues are potentially common to RTW situations in general, others are more specific to health problems which have a visible manifestation. Increased awareness of and attention to these possible barriers to RTW may lead to better RTW outcomes.     

Occupational contact urticaria and protein contact dermatitis

Irritant dermatitis and eczema are the most prevalent occupational skin diseases. Less common are immediate contact reactions such as contact urticaria and protein contact dermatitis. Occupational contact urticaria can be subdivided into two categories, immunological and non immunological. However, some agents can induce these two types of reactions. Contact urticaria to natural rubber latex is particularly frequent among health care personnel, but contact urticaria to a wide variety of other substances occurs in many other occupations. Among those at risk are cooks, bakers, butchers, restaurant personnel, veterinarians, hairdressers, florists, gardeners, and forestry workers. Protein contact dermatitis in some of these occupations is caused principally by proteins of animal or plant origin, especially among individuals with a history of atopic dermatitis. Diagnosis requires careful interrogation, clinical examination and skin tests (open tests and prick tests with immediate lecture) to identify a particular contact allergen.     

Characteristics of wet work in the cleaning industry

Wet work is the main cause of occupational contact dermatitis in the cleaning industry. Dermatologists and occupational physicians need to base their primary and secondary prevention for workers in the cleaning industry on the characteristics of wet work exposures. We quantified the burden of wet work in professional office cleaning activities with a continuous standardized observation by trained observers of 41 office cleaners. Duration and frequency of wet work exposure and of different cleaning activities were assessed. Wet work made up 50% of such cleaning work. Within a typical 3-hr shift, a mean frequency of 68 episodes of wet work was observed, which classifies office cleaning as wet work. Skin exposure to irritants was markedly different among cleaners who did the same cleaning activities. Reduction in skin irritation can be achieved by training the workers. Because this group of workers, who have a low level of education, has a high risk of developing irritant hand dermatitis, a special effort on training and instruction should be made. A reduction of exposure can be achieved by: using gloves more often; using gloves for a shorter period of time; using gloves while doing activities that otherwise cause the skin to be in contact with water and cleaning substances and washing hands with water only, reserving soap for when the hands are visibly dirty.     

Compositae dermatitis

Compositae dermatitis is an allergic contact dermatitis. The most important allergens in the Compositae family are sesquiterpene lactones (SL), which are present in the oleoresin fraction of leaf, stem, flower and possibly pollen. Compositae dermatitis is most frequently seen in middle-aged and elderly people in patterns reflecting airborne or direct contact with the allergens. The pattern typically starts in summer and disappears in the autumn or winter. Repeated exposure over many years may lead to a chronic and, at times, a disseminated pattern. Seasonal variation does not occur in occupational Compositae dermatitis. In addition to the classically described airborne pattern of face, 'V' of neck, hands and forearms, hand dermatitis is now recognized to be an equally common presentation. This variability of clinical features, and the frequent occurrence of atopic dermatitis and contact allergy to one or more compounds, highlights the need for routine patch testing with sesquiterpene lactone mix 0.1% (Thermal, Hamburg, Germany), combined with aimed patch testing with Compositae plants and extracts. Avoidance of the plants and plant extracts of this large family can be difficult due to its widespread occurrence in flower, herb and vegetable gardens, urban and rural weed population and native vegetation. Importantly, Compositae plant extracts are present in many cosmetics, shampoos, herbal creams and ingested herbal remedies and tonics.