Occupational dermatitis causing days away from work in U.S. private industry, 1993

Trends in occupational and work-related contact dermatitis attributed to nickel, chromium and cobalt in the UK: findings from The Health and Occupation Research network 1996-2019

BACKGROUND

Occupational exposure to metals such as nickel, chromium and cobalt can be associated with contact dermatitis, which can adversely affect an individual's health, finances and employment. Despite this, little is known about the incidence of metal-related occupational contact dermatitis over prolonged periods of time.

OBJECTIVES

To investigate the medically reported trends in the incidence of work-related contact dermatitis attributed to nickel, chromium and cobalt in the UK.

METHODS

Incidence and trends in cases of occupational contact dermatitis caused by nickel, chromium or cobalt between 1996 and 2019 (inclusive), reported to the EPIDERM surveillance scheme, were investigated and compared with trends in the incidence of occupational contact dermatitis attributed to agents other than the aforementioned metals. A sensitivity analysis restricting the study cohort to cases attributed to only one type of metal was also conducted.

RESULTS

Of all cases reported to EPIDERM during the study period, 2374 (12%) were attributed to nickel, chromium or cobalt. Cases predominantly comprised females (59%), with a mean (SD) age (males and females) of 38 (13) years. Cases were most frequently reported in manufacturing, construction, and human health and social activity industries. The most frequently reported occupations were hairdressing, and sales and retail (assistants, cashiers and checkout operators). The highest annual incidence rate of contact dermatitis was observed in females (2.60 per 100 000 persons employed per year), with the first and second peak seen in those aged 16-24 and ≥ 65 years, respectively. A statistically significant decrease in the incidence of occupational contact dermatitis attributed to metals over the study period was observed for all occupations (annual average change -6.9%, 95% confidence interval -7.8 to -5.9), with much of the decrease occurring between 1996 and 2007. Similar findings were obtained in the sensitivity analyses.

CONCLUSIONS

Over a period of 24 years, there has been a statistically significant decline in the incidence of metal-related occupational contact dermatitis in the UK. This could be attributed not only to improvements in working conditions, which have reduced metal exposure, but could also be due to the closure of industries in the UK that might have generated cases of contact dermatitis owing to metal exposure.

Application of Inorganic Nanomaterials in Cultural Heritage Conservation, Risk of Toxicity, and Preventive Measures

Nanotechnology has allowed for significant progress in architectural, artistic, archaeological, or museum heritage conservation for repairing and preventing damages produced by deterioration agents (weathering, contaminants, or biological actions). This review analyzes the current treatments using nanomaterials, including consolidants, biocides, hydrophobic protectives, mechanical resistance improvers, flame-retardants, and multifunctional nanocomposites. Unfortunately, nanomaterials can affect human and animal health, altering the environment. Right now, it is a priority to stop to analyze its advantages and disadvantages. Therefore, the aims are to raise awareness about the nanotoxicity risks during handling and the subsequent environmental exposure to all those directly or indirectly involved in conservation processes. It reports the human-body interaction mechanisms and provides guidelines for preventing or controlling its toxicity, mentioning the current toxicity research of main compounds and emphasizing the need to provide more information about morphological, structural, and specific features that ultimately contribute to understanding their toxicity. It provides information about the current documents of international organizations (European Commission, NIOSH, OECD, Countries Normative) about worker protection, isolation, laboratory ventilation control, and debris management. Furthermore, it reports the qualitative risk assessment methods, management strategies, dose control, and focus/receptor relationship, besides the latest trends of using nanomaterials in masks and gas emissions control devices, discussing their risk of toxicity.

Occupational Dermatitis and Urticaria

Occupational contact dermatitis is the most common occupational skin disease (OSD), and most of them are irritant in nature. There is less information available about contact urticaria than contact dermatitis. There are several strategies to prevent OSD, although workplace studies suggest there are gaps in their use in the workplace. Because early detection leads to improved outcomes, screening for dermatitis in industries such as health care would be useful. Both diagnosis and management involve 2 components: the actual disease diagnosis and medical treatment and the work-relatedness and management of the workplace to reduce exposures.

Interventions for preventing occupational irritant hand dermatitis

BACKGROUND

Occupational irritant hand dermatitis (OIHD) causes significant functional impairment, disruption of work, and discomfort in the working population. Different preventive measures such as protective gloves, barrier creams and moisturisers can be used, but it is not clear how effective these are. This is an update of a Cochrane review which was previously published in 2010.

OBJECTIVES

To assess the effects of primary preventive interventions and strategies (physical and behavioural) for preventing OIHD in healthy people (who have no hand dermatitis) who work in occupations where the skin is at risk of damage due to contact with water, detergents, chemicals or other irritants, or from wearing gloves.

SEARCH METHODS

We updated our searches of the following databases to January 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLlNE, and Embase. We also searched five trials registers and checked the bibliographies of included studies for further references to relevant trials. We handsearched two sets of conference proceedings.

SELECTION CRITERIA

We included parallel and cross-over randomised controlled trials (RCTs) which examined the effectiveness of barrier creams, moisturisers, gloves, or educational interventions compared to no intervention for the primary prevention of OIHD under field conditions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were signs and symptoms of OIHD developed during the trials, and the frequency of treatment discontinuation due to adverse effects.

MAIN RESULTS

We included nine RCTs involving 2888 participants without occupational irritant hand dermatitis (OIHD) at baseline. Six studies, including 1533 participants, investigated the effects of barrier creams, moisturisers, or both. Three studies, including 1355 participants, assessed the effectiveness of skin protection education on the prevention of OIHD. No studies were eligible that investigated the effects of protective gloves. Among each type of intervention, there was heterogeneity concerning the criteria for assessing signs and symptoms of OIHD, the products, and the occupations. Selection bias, performance bias, and reporting bias were generally unclear across all studies. The risk of detection bias was low in five studies and high in one study. The risk of other biases was low in four studies and high in two studies.The eligible trials involved a variety of participants, including: metal workers exposed to cutting fluids, dye and print factory workers, gut cleaners in swine slaughterhouses, cleaners and kitchen workers, nurse apprentices, hospital employees handling irritants, and hairdressing apprentices. All studies were undertaken at the respective work places. Study duration ranged from four weeks to three years. The participants' ages ranged from 16 to 67 years.Meta-analyses for barrier creams, moisturisers, a combination of both barrier creams and moisturisers, or skin protection education showed imprecise effects favouring the intervention. Twenty-nine per cent of participants who applied barrier creams developed signs of OIHD, compared to 33% of the controls, so the risk may be slightly reduced with this measure (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.72 to 1.06; 999 participants; 4 studies; low-quality evidence). However, this risk reduction may not be clinically important. There may be a clinically important protective effect with the use of moisturisers: in the intervention groups, 13% of participants developed symptoms of OIHD compared to 19% of the controls (RR 0.71, 95% CI 0.46 to 1.09; 507 participants; 3 studies; low-quality evidence). Likewise, there may be a clinically important protective effect from using a combination of barrier creams and moisturisers: 8% of participants in the intervention group developed signs of OIHD, compared to 13% of the controls (RR 0.68, 95% CI 0.33 to 1.42; 474 participants; 2 studies; low-quality evidence). We are uncertain whether skin protection education reduces the risk of developing signs of OIHD (RR 0.76, 95% CI 0.54 to 1.08; 1355 participants; 3 studies; very low-quality evidence). Twenty-one per cent of participants who received skin protection education developed signs of OIHD, compared to 28% of the controls.None of the studies addressed the frequency of treatment discontinuation due to adverse effects of the products directly. However, in three studies of barrier creams, the reasons for withdrawal from the studies were unrelated to adverse effects. Likewise, in one study of moisturisers plus barrier creams, and in one study of skin protection education, reasons for dropout were unrelated to adverse effects. The remaining studies (one to two in each comparison) reported dropouts without stating how many of them may have been due to adverse reactions to the interventions. We judged the quality of this evidence as moderate, due to the indirectness of the results. The investigated interventions to prevent OIHD probably cause few or no serious adverse effects.

AUTHORS' CONCLUSIONS

Moisturisers used alone or in combination with barrier creams may result in a clinically important protective effect, either in the long- or short-term, for the primary prevention of OIHD. Barrier creams alone may have slight protective effect, but this does not appear to be clinically important. The results for all of these comparisons were imprecise, and the low quality of the evidence means that our confidence in the effect estimates is limited. For skin protection education, the results varied substantially across the trials, the effect was imprecise, and the pooled risk reduction was not large enough to be clinically important. The very low quality of the evidence means that we are unsure as to whether skin protection education reduces the risk of developing OIHD. The interventions probably cause few or no serious adverse effects.We conclude that at present there is insufficient evidence to confidently assess the effectiveness of interventions used in the primary prevention of OIHD. This does not necessarily mean that current measures are ineffective. Even though the update of this review included larger studies of reasonable quality, there is still a need for trials which apply standardised measures for the detection of OIHD in order to determine the effectiveness of the different prevention strategies.

Clinical profile and quality of life of patients with occupational contact dermatitis from New Delhi, India

BACKGROUND

Data regarding occupational contact dermatitis (OCD) and its effect on quality of life (QOL) in India are limited.

OBJECTIVES/AIMS

To evaluate patients with OCD and record the outcome of treatment.

PATIENTS/MATERIALS/METHODS

All patients with OCD were evaluated for severity of disease (by the use of physician global assessment) and its effect on QOL (by use of the Dermatology Life Quality Index) questionnaire) at the first visit and after 3 months of treatment.

RESULTS

Among 117 patients with OCD, hand eczema was present in 81.2%. Positive patch test reactions were found in 76%. The most common allergens were Parthenium hysterophorus and potassium dichromate. The most frequent diagnosis was occupational allergic contact dermatitis (OACD) (57%), caused by farming and construction work, followed by occupational irritant contact dermatitis (OICD) (24%), caused by wet work. Severe psychosocial distress was recorded in 62.5% of patients. After 3 months of treatment, 83% improved significantly, and 54% had improvement in QOL.

CONCLUSIONS

Farmers were most frequently affected, followed by construction workers and housewives. OACD was found at a higher frequency than OICD. The most frequent allergens were Parthenium hysterophorus in farmers, potassium dichromate in construction workers, and vegetables in housewives. OCD has a significant impact on QOL. Patch testing, in addition to standard treatment, improves the outcome considerably.

Occupational dermatoses by type of work in Greece

Background

To elucidate the relationship between seven occupational dermatoses (ODs) and 20 types of work in Greece.

Methods

This was a prevalence epidemiologic study of certain ODs among 4,000 workers employed in 20 types of enterprise, in 104 companies, in 2006–2012, using data from company medical records, questionnaires, occupational medical, and special examinations. The χ² test was applied to reveal statistically significant relationships between types of enterprises and occurrence of ODs.

Results

A high percentage (39.9%) of employees included in the study population suffered from ODs. The highest prevalence rates were noted among hairdressers (of contact dermatitis: 30%), cooks (of contact dermatitis: 29.5%), bitumen workers (of acne: 23.5%), car industry workers (of mechanical injury: 15%), construction workers (of contact urticaria: 29.5%), industrial cleaning workers (of chemical burns: 13%), and farmers (of malignant tumors: 5.5%). We observed several statistical significant correlations between ODs (acute and chronic contact dermatitis, urticaria, mechanical injury, acne, burns, skin cancer) and certain types of enterprises. There was no statistically significant correlation between gender and prevalence of ODs, except for dermatoses caused by mechanical injuries afflicting mainly men [χ² (1) = 13.40, p < 0.001] and for chronic contact dermatitis [χ² (1) = 5.53, p = 0.019] afflicting mainly women.

Conclusion

Prevalence of ODs is high in Greece, contrary to all official reports by the Greek National Institute of Health. There is a need to introduce a nationwide voluntary surveillance system for reporting ODs and to enhance skin protection measures at work.

The identification of a sensitizing component used in the manufacturing of an ink ribbon

Skin diseases including dermatitis constitute ≈ 30% of all occupational illnesses, with a high incidence in the printing industry. An outbreak of contact dermatitis among employees at an ink ribbon manufacturing plant was investigated by scientists from the National Institute for Occupational Safety and Health (NIOSH). Employees in the process areas of the plant were exposed to numerous chemicals and many had experienced skin rashes, especially after the introduction of a new ink ribbon product. To identify the causative agent(s) of the occupational dermatitis, the murine local lymph node assay (LLNA) was used to identify the potential of the chemicals used in the manufacture of the ink ribbon to induce allergic contact dermatitis. Follow-up patch testing with the suspected allergens was conducted on exposed employees. Polyvinyl butyral, a chemical component used in the manufacture of the ink ribbon in question and other products, tested positive in the LLNA, with an EC3 of 3.6%, which identifies it as a potential sensitizer; however, no employees tested positive to this chemical during skin patch testing. This finding has implications beyond those described in this report because of occupational exposure to polyvinyl butyral outside of the printing industry.

Allergic Potential and Immunotoxicity Induced by Topical Application of 1-Chloro-4-(Trifluoromethyl)Benzene (PCBTF) in a Murine Model

The purpose of the studies in this paper was to evaluate the allergic potential, immunotoxicity, and irritancy of the occupationally relevant chemical, 1-chloro-4-(trifluoromethyl)benzene, also known as parachlorobenzotrifluoride (PCBTF), following dermal exposure in a murine model. Evaluation of the sensitization potential, conducted using the local lymph node assay (LLNA) at concentrations ranging from 50% to 100%, identified a dose-dependent increase in lymphocyte proliferation with a calculated EC3 value of 53.1%. While no elevations in total or specific IgE were observed after exposure to any concentration of the chemical, significant increases in IFN-γ protein production by stimulated draining lymphoid cells were observed, indicating a T-cell-mediated response. Dermal exposure to PCBTF was not found to alter the immune response to a T-cell-dependant antigen. These results demonstrate that PCBTF has the potential to induce allergic sensitization following dermal exposure and based on LLNA results would be classified as a weak sensitizer.

Repressor of GATA negatively regulates murine contact hypersensitivity through the inhibition of type-2 allergic responses

Repressor of GATA (ROG) inhibits Th2 cell differentiation and allergic airway inflammation in the lung. To determine the role of ROG in the pathogenesis of contact hypersensitivity (CHS), a hapten-induced mouse model of CHS using ROG Tg and ROG-deficient (ROG(-/-)) was used. ROG Tg mice showed little ear swelling, while ROG(-/-) mice showed enhanced ear swelling in comparison to wild type mice. Interstitial edema and mast cell degranulation at the local inflammation sites were mild in ROG Tg mice and exacerbated in ROG(-/-) mice. In addition, the serum total IgE and hapten-specific IgG1 levels were increased in ROG(-/-) mice. Adoptive transfer of ROG(-/-) CD4(+) T cells exacerbated CHS in wild type mice, while transfer of ROG Tg CD4(+) T cells resulted in the attenuation of CHS. These results indicate ROG negatively regulates the induction of CHS by controlling the CD4(+) T cell-mediated allergic responses, including IgE generation and mast cell degranulation.

Evidence-based guidelines for the prevention, identification and management of occupational contact dermatitis and urticaria

BACKGROUND

Occupational contact dermatitis is the most frequently reported work-related skin disease in many countries. A systematic review was commissioned by the British Occupational Health Research Foundation in response to a House of Lords Science and Technology Committee recommendation.

OBJECTIVES

The systematic review aims to improve the prevention, identification and management of occupational contact dermatitis and urticaria by providing evidence-based recommendations.

METHODS

The literature was searched systematically using Medline and Embase for English-language articles published up to the end of September 2009. Evidence-based statements and recommendations were graded using the Royal College of General Practitioner's three-star system and the revised Scottish Intercollegiate Guidelines Network grading system.

RESULTS

Three thousand one hundred and fifty-five abstracts were identified and screened. From these, 786 full papers were obtained and appraised. One hundred and nineteen of these studies were used to produce 36 graded evidence statements and 10 key recommendations.

CONCLUSIONS

This evidence review and its recommendations focus on interventions and outcomes to provide a robust approach to the prevention, identification and occupational management of occupational contact dermatitis and urticaria, based on and using the best available medical evidence.

Interventions for preventing occupational irritant hand dermatitis

BACKGROUND

Occupational irritant hand dermatitis (OIHD) is an important cause of discomfort in the working population. Different preventive measures are in place but it is not clear how effective these are.

OBJECTIVES

To assess the effect of interventions for preventing OIHD in healthy people who work in occupations where the skin is at risk of damage.

SEARCH STRATEGY

In May 2010, we searched the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLlNE and EMBASE. Conference proceedings, and ongoing trials registers were also searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) studying the effectiveness of barrier creams, moisturisers, gloves, complex educational interventions, and other interventions for the prevention of OIHD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the trials and extracted data.

MAIN RESULTS

Four RCTs involving 894 participants from different occupations were included. The primary outcome was numbers of new cases.One large RCT of 708 print and dye workers compared 2 barrier creams (containing silicone or hydrocarbon) versus no intervention. Fewer workers using barrier creams developed OIHD than those who did not (39.9% versus 45%, (OR 0.75, 95% CI 0.53 to 1.07. P = 0.11) but this was not statistically significant.In 1 RCT of 54 metal workers less developed OIHD when using an after work emollient or a barrier cream compared to no intervention. There was no statistical difference between the groups at different times of follow-up.One RCT of 111 cleaners and kitchen workers compared a moisturiser (Locobase) versus no intervention using a cross-over design. While using the moisturiser no participant developed OIHD. During the control period with no skin treatment, 19 (20.4%) out of 93 participants developed OIHD.One RCT of 21 hairdressers compared a barrier cream containing aluminium chlorohydrate (Excipial protect) versus its vehicle. No participant developed OIHD while the products were used.Only limited side-effects such as transient itching, stinging, and dryness were reported for the interventions.

AUTHORS' CONCLUSIONS

Although the findings of this review were generally positive, no statistical significance was reached. We conclude that at present there is insufficient evidence for the effectiveness of most of the interventions used in the primary prevention of OIHD. This does not mean that current measures are necessarily ineffective, as the limited studies to date have been rather small and of poor quality. Larger well designed RCTs are now needed in different workplaces to establish the effectiveness of various preventative strategies.

Prediction of skin sensitization potential using D-optimal design and GA-kNN classification methods

Modelling of skin sensitization data of 255 diverse compounds and 450 calculated descriptors was performed to develop global predictive classification models that are applicable to whole chemical space. With this aim, we employed two automated procedures, (a) D-optimal design to select optimal members of the training and test sets and (b) k-Nearest Neighbour classification (kNN) method along with Genetic Algorithms (GA-kNN Classification) to select significant and independent descriptors in order to build the models. This methodology helped us to derive multiple models, M1-M5, that are stable and robust. The best among them, model M1 (CCR(train) = 84.3%, CCR(test) = 87.2% and CCR(ext) = 80.4%), is based on six neighbours and nine descriptors and further suggests that: (a) it is stable and robust and performs better than the reported models in literature, and (b) the combination of D-optimal design and GA-kNN classification approach is a very promising approach. Consensus prediction based on the models M1-M5 improved the CCR of training, test and external validation datasets by 3.8%, 4.45% and 3.85%, respectively, over M1. From the analysis of the physical meaning of the selected descriptors, it is inferred that the skin sensitization potential of small organic compounds can be accurately predicted using calculated descriptors that code for the following fundamental properties: (i) lipophilicity, (ii) atomic polarizability, (iii) shape, (iii) electrostatic interactions, and (iv) chemical reactivity.

Dermatologist and family practitioner practice patterns for occupational contact dermatitis

Medical practitioners have a role in the recognition of occupational contact dermatitis. The longer the duration of symptoms before diagnosis, the poorer the outcome. Our objective was to understand practice patterns, barriers and needs for early diagnosis of occupational contact dermatitis. A survey to obtain information on practice patterns was developed based on the literature and interviews with dermatologists and family practitioners. The survey was sent to all dermatologists and a random sample of 600 family practitioners in Ontario. Fifty-seven per cent of dermatologists and 9% of family practitioners report seeing more than 20 patients per year with occupational contact dermatitis. The majority of practitioners report taking a workplace exposure history. Barriers to taking a workplace exposure history include time constraints and lack of knowledge. Reasons for referral to specialists include a lack of expertise, testing facilities and knowledge about workers' compensation, time constraints and inadequate reimbursement, whereas lack of access to specialists is a barrier for referral. Although most practitioners identify a need for further education, a low volume of patients and time constraints are key barriers to continuing education. Opportunities are identified to improve educational initiatives and health services delivery for occupational contact dermatitis, tailored to each practitioner group.

Patients with occupational contact dermatitis in Israel: quality of life and social implications

One of the most common occupational diseases is skin disease caused as a result of contact with work-related materials or exacerbated by them. Although occupational-related skin disease is a common condition, it is not considered to be a serious one and, therefore, has not received satisfactory attention in the psycho-social literature or in the social work profession. In our study, 70 occupational contact dermatitis (OCD) patients were interviewed by telephone regarding psychological, social, economic, and subjective issues related to the disease. All patients reported to be affected in their daily living activities, self-image, economic status, and in their interpersonal relationships in the family. Our study seeks to highlight the problems of this population group and serve as a vehicle to facilitate patient's rights.

Medical and psychosocial outcome of patients with occupational contact dermatitis in Israel

BACKGROUND

Although the medical, financial and prognostic factors of occupational contact dermatitis (OCD) have been addressed, studies on the social outcome of OCD are sparse.

OBJECTIVE

To define the medical and psychosocial outcome of patients with OCD.

METHODS

Workers with OCD were interviewed by telephone using a questionnaire that included questions about the occupation, dermatological disease, sick leave, present working status and disability claims, and questions related to the subjective perceptions of OCD in all areas of psychosocial functioning and quality of life.

RESULTS

Seventy workers (64.3% males and 35.7% females) were interviewed. Forty per cent had stopped working and one-third had taken sick leave because of OCD. Forty-seven (67.1%) were currently working while 23 (32.8%) were unemployed. Disability compensation was claimed by only 41.4% and was received by 24.3%. Eight workers (11.4%) had persistent postoccupational dermatitis (PPOD). Loss of employment affected the occupational area of the workers' lives (100%), and also interpersonal relationships (45.7%), relationships within the family (18.6%), daily functioning (45.7%) and mental health (24.3%).

CONCLUSIONS

Considerable working time is lost because of unemployment or sick leave due to OCD. Only a small proportion of eligible patients with OCD apply for disability compensation and an even smaller proportion receive it. Our study demonstrates the significance of OCD to the psychosocial aspects of workers' lives and emphasizes that the assessment of OCD outcome should relate not only to the medical but also to the psychosocial aspect of the disease.

Contact Dermatitis and Workforce Economics

The roots of education in patch testing begin with Jadassohn and have been passed down through generations of dermatologists through didactic teachings and mentoring. Currently, we are faced with workforce economics tipping the balance of dermatology toward cosmetic and surgical practices. This imbalance is easily found in the subspecialty of contact dermatitis, where the current demand for patch test services is on the rise and the number of new dermatology-based patch test providers cannot keep up with the current demand. Steps are being made to remedy this discrepancy through societies and fellowships, yet the question remains: were the steps in time and were they big enough?

Occupational skin disease in Sweden - a 12-year follow-up

The aim of this project was to study the long-term prognosis of occupational skin diseases in Sweden. In 1999, a questionnaire was sent to 623/655 individuals who in 1987 reported occupational skin disease to the Social Insurance Office. 394 answered the questionnaire, and 123 non-responders were interviewed by telephone, giving 517 participants (83%), 323 females and 194 males. 85% reported skin symptoms after 1987, 70% during the previous year. 28% considered themselves recovered, of those with nickel allergy only 12%. In a logistic regression model, skin atopy was the strongest unfavourable factor for the prognosis followed by contact allergy and female sex. 66% had consulted a doctor after 1987 and the majority, 82%, had performed occupational changes - most common was change of jobs, 44%. Those who had changed jobs reported less sick leave. The conclusion is that occupational skin diseases have a clear tendency to end up as chronic conditions with a majority reporting symptoms at a 12-year follow-up. The skin disease had influenced the occupational situation for the majority (82%) and for 15% resulted in exclusion from the labour market through unemployment or disability pension.

Hand dermatitis: uncommon presentations

Hand dermatitis is a common diagnosis seen in dermatologic and general practice. It can present with typical morphology, but uncommon manifestations are possible. This review reports on common and uncommon presentations of irritant and allergic hand dermatitis focusing on uncommon localizations, time course, and morphology such as follicular, pustular, bullous, ulcerous, exudative erythema multiforme-like, purpuric, lichenoid, pigmented, and depigmented skin lesions. Clinical diagnosis can be challenging. Even histopathology is not always very helpful. Thorough evaluation of the patient's history and investigation of clinical morphology are the cornerstones of diagnosis.

Relation between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema

BACKGROUND

Epidemiological studies indicate that occupational hand eczema (OHE) often is associated with persistent dermatitis and prolonged sick leave, which may lead to unemployment. Previous studies suggest that OHE caused by allergic contact dermatitis and atopic dermatitis (AD) carries the worst prognosis.

OBJECTIVES

To evaluate and compare the severity and consequences of recognized OHE in different diagnostic and subdiagnostic groups.

METHODS

Between October 2001 and November 2002, all new cases of recognized OHE were identified from the Danish National Board of Industrial Injuries Registry (758 cases). Severity was graded from 0 to 2 depending on the intensity of skin response and the frequency of relapse. To supplement the information from the Registry, we surveyed the study population using a postal questionnaire which included questions about disease duration, sick leave, current occupation and loss of job.

RESULTS

The overall response rate to the questionnaire was 82%. We observed substantially greater severity among those with occupational irritant contact dermatitis (ICD) and AD than for any other diagnoses. Age above 50 years was also associated with increased severity of OHE. Prolonged sick leave due to OHE was reported by 19.9% and was associated with AD and severe OHE. We found a higher proportion of prolonged sick leave among those in food-related occupations (27.2%) compared with those in wet occupations (20.1%) and other occupations (16.5%). Twenty-three per cent reported that they had lost their job at least once during the past 12 months due to OHE. The only strong association with loss of job was food-related occupations.

CONCLUSIONS

Occupational ICD and AD appear to be strongly associated with severity of OHE. AD and severity of OHE were independently associated with prolonged sick leave. Having a food-related occupation appears to be associated with increased risk of loss of job.

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.

Contact dermatitis and quality of life: a structured review of the literature

Quality of life (QoL) assessment has rapidly become an important outcome variable in dermatology research. Even though the importance of the patient's personal morbidity is generally accepted as being important by dermatologists, scepticism and confusion remain about the usefulness of QoL in dermatological research and how it should be measured. QoL assessments in individuals with contact dermatitis are few. A structured review of the literature is presented. All studies reviewed found that contact dermatitis is associated with impaired health-related QoL. Hand eczema appears to be as equally impairing as generalized eczema and an early, confirmed diagnosis is associated with improved QoL. Disease duration, atopic dermatitis, age and gender do not seem to have a major impact on QoL, although contradictory findings exist. Assessment of QoL in contact dermatitis is required for future clinical research and may be a valuable tool to the clinician to evaluate new treatments. A combination of dermatology-specific (e.g. Dermatology Life Quality Index) and generic questionnaires (e.g. the Short Form-36) is supported.

Quality of life in patients with allergic contact dermatitis

BACKGROUND

Allergic contact dermatitis (ACD), a common dermatological disorder, often results in ongoing disease and disability. However, relatively little has been published quantifying the quality of life (QoL) of patients with ACD.

OBJECTIVES

This study was conducted to investigate the impact of ACD on QoL and explore prognostic factors that influence outcomes.

METHODS

A total of 428 subjects with ACD were, at varying times after diagnosis, mailed a QoL questionnaire modified from Skindex-16 to include an additional 5 items pertaining to occupational impact. The QoL scores were correlated with subject demographics, disease characteristics, and management techniques to ascertain factors that impact QoL in subjects with ACD.

RESULTS

The response rate was 35%, with 149 subjects returning the postal survey. Responders reported being bothered most by itching, skin irritation, and persistence of the condition. Of the four scales included in the QoL questionnaire, the emotions scale had the worst composite QoL score, followed by symptoms, functioning, and occupational impact. Patients with ACD of the face were significantly more bothered by the appearance of their skin. Hand involvement and occupationally related ACD were associated with worse QoL scores within the occupational impact and functioning scales. Subjects that had changed jobs because of ACD had more severe QoL impairment than any other group analyzed, with significantly worse scores on 17 of the 21 QoL items. A history of atopic eczema seemed to impart improved outcomes on patients with ACD, and these subjects were less worried about being fired from their jobs. Subjects diagnosed by patch testing more than 36 months after disease onset seemed to have worse QoL scores than those diagnosed earlier in the natural history of the disease. Patients diagnosed by patch testing within the last 6 months had the worst QoL scores, while the best outcomes were reported in subjects patch tested 6 to 12 months ago. A slight decline in QoL was observed 12 months after patch testing, but scores did not diminish back to the level seen immediately after diagnosis.

CONCLUSIONS

ACD has an appreciable effect on QoL, especially when it affects the hands, the face, or is occupationally related. Of the four scales included in our study, the emotions scale suffered the greatest effect. Emotional impact is therefore an important measure of QoL in ACD patients. Outcomes in patients with ACD were improved by early diagnosis and subjects enjoyed their best QoL at 6 to 12 months after patch testing. However, individuals who elected to change jobs because of their skin condition reported significantly worse QoL than those who retained their current positions.

Occupational dermatoses among Polish private farmers, 1991-1999

BACKGROUND

Little is known about work-related skin diseases among Polish self-employed farmers. In the National Register of Occupational Diseases, private farmers are placed in one category together with other agricultural workers, despite fundamental differences in compensation legislation and separate insurance institutions. The Agricultural Social Insurance Fund reports only on numbers of compensated cases. The aim of this study was to create reliable statistics on occupational dermatoses among private farmers.

METHODS

All cases of work-related skin diseases diagnosed from 1991 to 1999 were included in the statistics. Compensation records of the Agricultural Social Insurance Fund were analyzed for diagnoses, causative factors, and health impairment of the skin.

RESULTS

The first occupational dermatosis was registered in 1992. Until the end of 1999, there were 101 cases (63 women and 38 men). The incidence rose from 0.006/10000/year in 1992 to 0.189/10000/year in 1999. Allergic contact dermatitis was the most common diagnosis (86%), followed by infectious skin diseases (10%), irritant contact dermatitis (3%), and urticaria (2%). The most frequently identified causative factors were plant dusts (38%), animal allergens (36%), metals (29%), pesticides (18%), and rubber chemicals (15%). The median impairment due to skin disease was 20% (range 2-36%).

CONCLUSIONS

Since the introduction of workers' compensation, the numbers of occupational dermatoses diagnosed in Polish private farmers have increased rapidly. However, compared to countries with a longer experience in this field, these figures remain low, probably due to low detection of these diseases.

Prognosis and work absence due to occupational contact dermatitis

The consequences of a diagnosis of occupational contact dermatitis (OCD) were investigated using cases available from the voluntary surveillance scheme, EPIDERM. Cases of OCD reported from November 1994 to September 1995 were identified and sampled to give at least 100 cases of allergic, irritant and mixed OCD reported by consultant dermatologists (344 cases) and occupational physicians (377 cases). A questionnaire was sent to the reporting physician to elicit further information. 512 completed questionnaires were returned, of which 510 were eligible for analysis. Among cases reported by dermatologists (n = 286) and occupational physicians (n = 224), 7% (6.3%) had been unemployed and 16.8% (20.1%) had taken sick leave. 3 factors independently predicted time off work in a logistic regression analysis: age OR = 1.25 (95% CI, 1.05-1.49), allergic dermatitis OR = 1.77 (95% CI, 1.13-2.79) and medicolegal assessment OR = 4.42 (95% CI, 2.20-8.89). Overall, 15.7% did not improve clinically between the first and last visit. Those who did not improve had been exposed to the agent for longer (mean 7.6 years) than those who did (5.3 years) (p = 0.09). In patients <or= 45 years, those reported to be atopic failed to improve (25.4%) more often than those not atopic (13.4%) (p = 0.04). The substantial numbers (21%) with time off work and with persistent dermatitis suggest that OCD continues to have a significant impact on workers and their employers.

CD39 is the dominant Langerhans cell-associated ecto-NTPDase: modulatory roles in inflammation and immune responsiveness

CD39, the endothelial ecto-nucleoside triphosphate diphosphohydrolase (NTPDase), regulates vascular inflammation and thrombosis by hydrolyzing ATP and ADP. Although ecto-NTPDase activities have been used as a marker of epidermal dendritic cells (DCs) known as Langerhans cells, the identity and function of these activities remain unknown. Here we report that Langerhans cells in CD39-/- mice express no detectable ecto-NTPDase activity. Irritant chemicals triggered rapid ATP and ADP release from keratinocytes and caused exacerbated skin inflammation in CD39-/- mice. Paradoxically, T cell-mediated allergic contact hypersensitivity was severely attenuated in CD39-/- mice. As to mechanisms, T cells increased pericellular ATP concentrations upon activation, and CD39-/- DCs showed ATP unresponsiveness (secondary to P2-receptor desensitization) and impaired antigen-presenting capacity. Our results show opposing outcomes of CD39 deficiency in irritant versus allergic contact dermatitis, reflecting its diverse roles in regulating extracellular nucleotide-mediated signaling in inflammatory responses to environmental insults and DC-T cell communication in antigen presentation.

Surveillance scheme for occupational skin disease in the Saarland, FRG. First report from BKH-S

Occupational skin disease (OSD) is a significant public health concern. To keep OSDs under surveillance, a register of OSDs (BKH-S) was implemented in 1999 in the Saarland, FRG. We conducted a population-based register study to analyse all initial reports of OSDs reported to the BKH-S. 336 cases were prospectively assessed from July 1999 to June 2001. In 78% (n = 263) of the cases an occupational cause for the skin disease was stated, 91% (n = 240) of which fell within 16 occupational groups. This is equivalent to 6.8 cases per 10,000 workers per year within these occupational groups. Notably, young age groups (median age 35 years) were affected with a female predominance. The most frequent final diagnosis was irritant contact dermatitis (75%) followed by allergic contact dermatitis (34%) and atopic dermatitis (19%). The overall prevalence of occupationally relevant delayed-type reactors was 21% and of immediate-type reactors 17%. Work-related delayed-type sensitizations to potassium dichromate (n = 8) and immediate-type sensitizations to natural rubber latex (n = 11) were the most frequently observed. Questionnaire results showed frequent occupational skin contact with wet work (59%), detergents (48%), and disinfectants (38%). The second valid surveillance scheme for OSD in the FRG has been introduced and can be made available for further analysis.

Occupational skin diseases in Northern Bavaria between 1990 and 1999: a population-based study

BACKGROUND

Occupational skin diseases (OSDs) account for a large portion of occupational diseases in Europe, but population-based epidemiological studies are missing.

OBJECTIVES

We analysed the initial reports of OSDs in our register of OSDs in Northern Bavaria (BKH-N).

METHODS

A total of 5285 cases were assessed prospectively and registered from 1990 to 1999. As the German Federal Employment Office provides specific occupational data in relation to the total employed population of Northern Bavaria, it was possible to conduct a population-based study that investigated the trend in incidence rates between two study periods (1990-92 and 1993-99) in 24 different occupational groups.

RESULTS

A total of 3097 cases of OSD (median age 25 years) were recorded in the 24 occupational groups. There was a significant decline (P < 0.001) in the overall incidence rate of OSD with 10.7 cases per 10,000 workers per year for the first study period and 4.9 cases per 10,000 workers per year for the second study period. This general trend in incidence rates was also significant for hairdressers and barbers, bakers, health-care workers, cooks and metal processors.

CONCLUSIONS

The BKH-N provides national data based on the notification of OSDs in Germany. The results demonstrate the rank of occupations hazardous for the skin and are helpful for defining target groups for prevention.

Farm-related dermatoses in Iowa male farmers and wives of farmers: a cross-sectional analysis of the Iowa Farm Family Health and Hazard Surveillance Project

Agricultural workers are exposed to a variety of hazards that increase their risk for dermatitis. Nevertheless, the prevalence, patterns, and risk factors for dermatitis have not been well characterized among farmers in the United States. We assessed the prevalence and risk factors for dermatitis among 382 male farmers and 256 wives of farmers in Iowa using a cross-sectional study design. From 1992 to 1994, we collected data on potential risk factors and dermatitis. The results showed that 9.6% of male farmers and 14.4% of wives of farmers reported dermatitis during the previous 12-month period. In multivariable models, a history of allergy (odds ratio [OR], 8.2; 95% confidence interval [CI], 2.0 to 33.3) was strongly associated with dermatitis among male farmers. Among wives of farmers, some college education (OR, 3.4; 95% CI, 1.1 to 9.9) and exposure to petroleum products (OR, 3.1; 95% CI, 1.3 to 7.0) were associated with dermatitis. These results can be used to form preventive efforts in controlling farmwork-related exposures.

Occupational skin diseases

Primary care physicians will likely see a wide variety of occupational skin diseases in their practices, including allergic contact dermatitis, irritant contact dermatitis, contact urticaria, a variety of infectious diseases, and skin cancers. The ideal role of a medical practitioner involved in occupational dermatology is not only to diagnose and treat patients, but also to determine the cause of the occupational skin disease and to make recommendations for its prevention. Making the diagnosis and offering treatment, determining the cause, and recommending measures can be difficult undertakings.

Surveillance of occupational skin disease: EPIDERM and OPRA

Consultant dermatologists in the U.K. have been reporting to EPIDERM, a voluntary surveillance scheme for occupational skin disease, since February 1993; reporting by occupational physicians to the scheme began in May 1994 and was superseded in January 1996 by OPRA (Occupational Physicians Reporting Activity). Currently 244 dermatologists and 790 occupational physicians report incident cases to these schemes. During the 6 years to January 1999 a total of 12, 574 new cases of occupational skin disease was estimated from reports by consultant dermatologists and 10,136 cases estimated from occupational physicians (since May 1994). The annual incidence of occupational contact dermatitis using data from both schemes was 12. 9 per 100,000 workers. The incidence of contact dermatitis per 100, 000 workers increased with age in men from 4.9 (age 16-29 years) to 6.6 (age 45-60 years); in women a higher rate (9.5) was apparent in the younger age group, with lower rates in older female workers. High rates in young workers were associated with wet work and in older workers with exposure to oils. For men, high rates of contact dermatitis were seen in reports from both schemes for chemical operatives, machine tool setters and operatives, coach and spray painters and metal workers. For women, high rates were found for hairdressers, biological scientists and laboratory workers, nurses and those working in catering. The most frequent agents for contact dermatitis were rubber chemicals and materials (14.1% of cases reported by dermatologists), soaps and cleaners (12.7%), nickel (11. 9%), wet work (11.1%), personal protective equipment (6.2%), petroleum products (6.3%), cutting oils and coolants (5.6%), and epoxy and other resins (6.1%). In the 1608 estimated cases of skin cancer all but 4% were attributed to ultraviolet radiation. Cases of contact urticaria attributed to latex peaked in 1996, with a decline in cases since that time.