Allergic and irritant reactions to rubber gloves in medical health services. Spectrum, diagnostic approach, and therapy

Making Glove Decision Less of a White Knuckling Experience: A Systematic Review and Inventory of Glove Accelerator Contents

Background

Accelerators in medical gloves are a common cause of allergic contact dermatitis among healthcare workers.

Objective

A systematic review of medical and nursing literature, patch testing reports, and chemical analyses of gloves was conducted to assess accelerator contents reported in the literature and to identify accelerator-free gloves.

Methods

A systematic literature search was performed in OVID Medline and OVID EMBASE. Hand-searching of reference lists of articles in the field and author input generated the remainder of articles assessed.

Results

We present an inventory of accelerator contents of gloves and accelerator-free glove options as reported in the literature as a clinical reference tool to assist allergen-free glove selection for individuals suffering from allergic contact dermatitis due to rubber accelerators.

Limitations

Pertinent limitations of our review include lack of predefined study exclusion criteria and screening of the studies identified in the search by 1 review author only.

Conclusion

The glove inventory we provide summarizes the available literature regarding medical and surgical glove accelerator content, describing gloves both by brand and manufacturer as well as by accelerators.

Surgery-Related Contact Dermatitis: A Review of Potential Irritants and Allergens

Surgical procedures utilize an increasing number of medical products including antiseptics, anesthetics, gloves, suture materials, tissue adhesives, topical antibiotics, and bandages. Many of these products have irritant potential. Allergic contact dermatitis has also been reported. This review covers preoperative, operative, and postoperative exposures that may result in contact dermatitis. Testing with standard patch panels such as T.R.U.E. Test and the North American Contact Dermatitis Group 65 allergen series does not evaluate for all relevant contactants. A thorough understanding of potential exposures is vital to effectively evaluate a patient with surgery-related contact dermatitis. A systematic approach is needed to ensure that standard patch panels and supplementary patches adequately address each encountered contactant.

Fundamentals of the knowledge about chemical additives present in rubber gloves

BACKGROUNDS

One of the most frequent causes of allergic contact dermatitis of occupational origin are rubber additives, which are present in Personal Protective Equipment (PPE). The most allergenic additives of natural and synthetic gloves are thiurams, carbamates and mercapto group.

OBJECTIVE

To investigate the state of knowledge about the chemical additives used in the manufacture of synthetic rubber gloves.

METHODS

This was a qualitative research study in which professionals working in the manufacture, research, prescription and commercialization of gloves answered an open questionnaire.

RESULTS

30 individuals were interviewed: 4 researchers in occupational medicine, 5 occupational physicians, 2 occupational safety technicians, a rubber workers' union physician, an occupational safety engineer, a pro duction engineer of rubber gloves, 4 importers of gloves, a manufacturer of gloves, 3 businessmen who sell PPE, 3 salesclerks working in stores that sell PPE, 2 businessmen who own stores that sell products for allergic individuals, and 3 dermatologists.

CONCLUSION

Knowledge of the chemical composition of rubber gloves is scant. The labeling of gloves, with the description of their chemical composition, would facilitate choosing the best type of glove for each person. This low-cost action to businesses would be a gain from the standpoint of public health, with huge repercussions for users of rubber gloves.

Anaphylaxis caused by latex surgical gloves immediately after starting surgery -A case report-

Anaphylaxis is an acute and fatal systemic allergic reaction to an allergen, and it can be an unpredictable and life-threatening cause during anesthesia. Latex is the second most common cause of anaphylaxis following the use of neuromuscular blocking agents during general anesthesia or surgery. We report on a 67-year-old male who had undergone surgery under general anesthesia without any problem but who presented with severe intraoperative anaphylaxis to latex surgical gloves. This case emphasizes the need for anesthesiologists to quickly diagnose and properly manage an allergic reaction in patients under general anesthesia.

Latex glove use by food handlers: the case for nonlatex gloves

There is increasing concern that continued exposure to latex products can predispose individuals, particularly those who are atopic (allergy prone), to latex allergy. Latex allergy as a serious hazard has been well documented in the health care industry. There are also well-documented cases of food handlers who have had allergic reactions after the use of latex gloves. The contamination of food with latex proteins by food handlers using latex gloves can also result in potentially severe allergic reactions in latex-allergic consumers. We review latex allergy and present the case for avoiding latex glove use by food handlers in the food and hospitality industries. Adopting the use of nonlatex gloves has benefits for workers, consumers, and the food industry.

Latex allergy: a model for therapy

Allergy to natural rubber latex products emerged as an important clinical condition following an increase in the use of latex gloves for barrier protection in the early 1980s. In addition to latex glove users, other high-risk groups with different latex exposure include spina bifida patients and others with multiple surgical procedures. Subjects with fruit and vegetable allergy are also at risk due to cross-reactive allergens. Following the significant advances in the identification and characterization of common aeroallergens, latex allergy was well placed to become an excellent model of therapy. Awareness of latex allergy and modes of sensitization enabled epidemiological studies to inform allergen avoidance initiatives, substantially reducing inadvertent exposure in major hospitals in Western countries. Spina bifida is often identified in utero or soon after birth, allowing vigorous latex allergen avoidance with enhanced efficacy of primary prevention. However, changing demographics of latex allergy and technological revolution in countries such as China and India are predicted to unleash a second wave of latex allergy reemphasizing the incentive for improved manufacturing procedures for latex products. The desirable high tensile strength and elasticity of natural rubber latex have made the commercial identification of good alternatives very difficult but this would also be attractive for primary prevention. In addition, an effective specific immunotherapy regimen would be valuable for selected high-risk atopic individuals. Current subcutaneous and sublingual immunotherapy schedules have been tested for treatment of latex allergy with evidence of efficacy but the risks of adverse events are high. For such potent allergens as latex, hypoallergenic but T cell-reactive preparations are required for clinical use. Identification of allergenic components of latex products, with generation of monoclonal antibodies and recombinant allergens, allowed sequence determination and mapping of T cell and B cell epitopes. Together, these reagents and data facilitated improved diagnostics and investigation of novel-specific therapeutics. Potential hypoallergenic latex preparations identified include modified non-IgE-reactive allergen molecules and short T cell epitope peptides. The co-administration of adjunct therapies such as anti-IgE or corticosteroids and of appropriate adjuvants for induction of regulatory T cell response offers promise for clinically effective, safe latex-specific vaccines.

Occupational hazards in orthodontics: A review of risks and associated pathology

The purpose of this article was to review the occupational hazards related to the practice of orthodontics. A systematic approach was used to include all risks involved in an orthodontic practice. The classification of hazards was based on major sources of risks by system or tissue and by orthodontic office area (dental chair, laboratory, sterilization area, x-ray developing area). Potentially hazardous factors relate to the general practice setting; to specific materials and tools that expose the operator to vision and hearing risks; to chemical substances with known allergenic, toxic, or irritating actions; to increased microbial counts and silica particles of the aerosols produced during debonding; to ergonomic considerations that might have an impact on the provider's muscoleskeletal system; and to psychological stress with proven undesirable sequelae. The identification and elimination of these risk factors should be incorporated into a standard practice management program as an integral part of orthodontic education. Professional organizations can also assist in informing practitioners of potential hazards and methods to deal with them.

Sensitization to nickel: etiology, epidemiology, immune reactions, prevention, and therapy

Nickel is a contact allergen causing Type I and Type IV hypersensitivity, mediated by reagins and allergen-specific T lymphocytes, expressing in a wide range of cutaneous eruptions following dermal or systemic exposure. As such, nickel is the most frequent cause of hypersensitivity, occupational as well as among the general population. In synoptic form, the many effects that nickel has on the organism are presented to provide a comprehensive picture of the aspects of that metal with many biologically noxious, but metallurgically indispensable characteristics. This paper reviews the epidemiology, the prognosis for occupational and non-occupational nickel allergic hypersensitivity, the types of exposure and resulting immune responses, the rate of diffusion through the skin, and immunotoxicity. Alternatives toward prevention and remediation, topical and systemic, for this pervasive and increasing form of morbidity are discussed. The merits and limitations of preventive measures in industry and private life are considered, as well as the effectiveness of topical and systemic therapy in treating nickel allergic hypersensitivity.

Formaldehyde in reusable protective gloves

Due to the clinical findings in a single patient's case, formaldehyde was suspected to be present in clinically relevant levels in reusable protective gloves. Therefore, 9 types of gloves were investigated with the semi-quantitative chromotropic acid method. It was found that 6/9 gloves emitted some formaldehyde and that 4/9 gloves emitted > or =40 microg of formaldehyde. Most of the formaldehyde was found on the inside of the gloves. To get an indication of the clinical relevance, a comparison with a protective cream declared to contain the formaldehyde-releasing agent diazolidinyl urea was performed by comparing areas of gloves with areas of cream layers with thickness 1-2 mg/cm(2). It was found that the amounts of formaldehyde emitted from the gloves might be in the same range as emitted from a layer of cream.

Decreasing incidence of occupational contact urticaria caused by natural rubber latex allergy in German health care workers

BACKGROUND

The development of allergy to natural rubber latex (NRL) is a risk for health care workers. A regulation banning powdered NRL gloves was implemented in Germany in 1998.

OBJECTIVE

This study assesses the effects of this regulation on the development of occupational skin disease caused by NRL in health care personnel working in facilities insured by the German statutory accident insurance company, covering some 1.8 million insured health care workers.

METHODS

We reviewed the annual numbers of reported suspected cases of NRL-induced occupational allergies (mainly contact urticaria) from 1996 through 2002, as well as the number and type of gloves purchased in acute-care hospitals from 1986 through 2002.

RESULTS

The number of purchased nonsterile examination gloves increased by 1387% between 1986 and 2002. The purchase of powder-free NRL examination gloves exceeded that of powdered gloves in 1998. The incidence of suspected cases increased until 1998 and has since decreased by 79.9%. Most suspected cases (67.9%) were identified as occupationally caused.

CONCLUSIONS

Reducing the purchase of powdered NRL gloves is associated with a decrease in suspected and proved cases of occupational contact urticaria caused by NRL. Development of occupationally caused contact urticaria by NRL can be reduced by banning the use of powdered NRL gloves.

Type I latex allergy in health care workers with latex-induced contact urticaria syndrome: a follow-up study

BACKGROUND

Latex allergy is an important occupational health issue among health care workers (HCWs). Secondary prevention in sensitized/allergic individuals involves avoiding exposure to NRL products.

AIMS OF THE STUDY

The aim of this follow-up study is to determine the long-term health consequences in HCWs with type I latex allergy with latex-related contact urticaria syndrome, of providing appropriate information and practical avoidance education.

METHODS

Seventeen HCWs with latex-induced contact urticaria syndrome, as ascertained by the glove use test, were investigated. Initial and follow-up visits included: a detailed questionnaire, skin prick test (SPT) with glove eluates and with commercial latex extract, SPT with common inhalant and food extracts, serum specific immunoglobulin (Ig)E to latex and some foods and the glove use test.

RESULTS

On re-examination, 11 (64.7%) subjects showed positive SPTs to extemporaneous extract and 10 (58.8%) patients showed a positive SPT to commercial extract. Of the nine patients with detectable levels of serum latex specific IgE at first evaluation, four (44.4%) became negative and four were assigned to at least one class lower. Only one (11.1%) employee had higher radioallergosorbent test values than those at the latex allergy diagnosis. At follow-up, the 17 individuals had positive latex challenge results, although the duration of exposure causing a reaction increased.

CONCLUSION

Our study shows that preventive measures are sufficient to induce a reduction of sensitization. Continued avoidance is needed to prevent re-sensitization or adverse reactions on re-exposure.

[Contact urticaria to natural rubber latex in childhood and associated atopic symptoms: a study of 27 patients aged under 15 years]

BACKGROUND

Although natural rubber latex hypersensitivity is considered as a major problem in adult, it may be still misdiagnosed in childhood.

PATIENTS AND METHOD

We collected 27 observations of natural rubber latex contact urticaria in children under 15 Years of age, 21 of them aged under 8.

RESULTS

All of them where atopic and 19 out of 27 presented with other association paroxystic signs of immediate hypersensitivity, that were lately related to latex allergy (i. e. asthma, rhinitis, conjunctivitis, fainting). Cross-allergy to food allergens was present in 33 p. 100. Average level of specific IgE to natural rubber latex was 21.7 kU/l. One to 4 Years follow up confirmed the benefit of latex eviction on urticaria as well as on associated symptoms. It led to the early detection of ficus allergy in 4 of them.

DISCUSSION

This series confirms that atopy is at high risk for natural rubber latex allergy in children. These data suggest that atopic children are exposed too early to latex devices such as pacifiers, toodles of latex toys. Contact urticaria in children must be considered as a possible marker of other respiratory or general symptoms that may have been misconsidered under other etiologies.

A Review of Natural‐Rubber Latex Allergy in Health Care Workers

This brief review of natural-rubber latex (NRL) allergy in health care workers (HCWs) includes the definition of NRL allergy and data on its epidemiology, pathogenesis, diagnostic algorithm, management, long-term outcomes, economic impact, cost-effectiveness of changing facilities to a latex-free environment, and prevention. The data presented suggest that an individual with type I or type IV hypersensitivity to NRL should be able to continue to work in the workplace with careful evaluation and reasonable accommodations. Reducing exposure to latex is a safe and more economical alternative to complete removal of the individual from the place of employment. The use of low-allergen, nonpowdered NRL gloves substantially reduces airborne exposure to latex in most health care settings.

Contact and chemical sensitivities in the hospital environment

As surgeons, otolaryngologists tend to most be interested in operative procedures and leave the hospital environment to the care of administrators and the nursing staff. Given the dangers that are present, it would seem prudent to spend some time considering the agents that used in patient care and in operating suites, to minimize the risk to patients and co-workers.

Prevention of latex allergy among health care workers: evaluation of the extractable latex protein content in different types of medical gloves

BACKGROUND

Since the 1980s, there has been increased use of latex gloves by health care workers and a concomitant increase of irritant and allergic reactions. The total protein content and the latex allergenic protein content in different types of medical gloves commonly used in our hospital were evaluated to acquire information useful for preventing latex allergy in our hospital personnel.

METHODS

The total protein content and the allergic latex protein contents were evaluated with Lowry modified method and RAST inhibition assay in samples and extracts of 29 different types of medical gloves.

RESULTS

The highest concentrations of total proteins and allergenic latex proteins were found in examination powdered latex gloves and in surgical powdered latex gloves; a significant amount of latex proteins was found in some brands of nitrile gloves.

CONCLUSIONS

The clear association between the total protein levels and the allergenic latex protein levels suggests that the gloves with highest total protein content have the greatest allergenic potential. Therefore, it is recommended that manufacturing companies should provide package inserts including the total protein contents and possibly allergenic latex protein levels. They should declare whether they have added latex to their nitrile glove formulation. RAST-inhibition assays directly on glove samples instead of glove extract seems to be a good reliable and faster alternative for the evaluation of the allergenic potential of latex gloves.

Occupational allergies caused by latex

Allergy to natural rubber latex is an important cause of occupational allergy in healthcare workers. Disposable medical gloves are the major reservoir of latex allergens, particularly powdered gloves, in healthcare delivery settings. Diagnosis of latex allergy requires a history of exacerbation of cutaneous, respiratory, ocular, or systemic signs and symptoms after exposure to natural rubber latex products; and evidence of sensitization by patch testing, skin testing, measurement of latex-specific IgE antibodies, or challenge testing. Optimal management of latex allergy involves education concerning cross-reacting allergens, reduction of cutaneous or mucosal contact with dipped rubber products, and minimization of exposure to latex aeroallergens in work environments.

Clinical and laboratory-based methods in the diagnosis of natural rubber latex allergy

The accurate diagnosis of hypersensitivity to natural rubber latex is the initial step in the effective management of individuals with latex allergy and in ensuring the quality of epidemiologic studies. The diagnostic algorithm used in the evaluation of an individual with suspected latex allergy begins with a comprehensive clinical history during which risk factors (atopy, food allergies, hand dermatitis) and temporal relationships between symptoms and natural rubber product exposure are identified. If type IV hypersensitivity is suspected because of the delayed nature (hours to days) and confinement of symptoms to the skin-latex product contact areas, patch testing can be conducted to confirm the presence of activated T cells with specificity for rubber chemicals. If type I hypersensitivity is suspected because of ocular, upper and lower airway, and/or systemic symptoms that have rapid onset (minutes) after a definable latex exposure, a confirmatory skin or blood test for IgE antibody may be conducted to verify a state of sensitization within the individual. The definitive diagnosis would then be made only after consideration of the individual's clinical history and confirmatory in vivo and/or in vitro laboratory test results. If discordance remains between highly convincing latex-associated symptoms as identified in the history and repetitively negative confirmatory IgE antibody test results, then one of several types of in vivo provocation tests may be performed for adjudication. This overview examines the current state of the art in both in vivo and in vitro diagnostic methods for latex-specific IgE antibody detection in skin and blood. The performance, advantages, and limitations of each diagnostic method are compared.

Latex allergy: the perspective from the surgical suite

Latex allergy in the perioperative setting presents unique challenges to the health care system. Specific needs of the latex-sensitive patient are paramount, but consideration must also include the impact on health care workers vis-a-vis latex sensitization, environmental allergen control, and barrier protection against blood-borne pathogens. It has been well documented that the greatest source of latex aeroallergen in the surgical setting is latex gloves (both sterile and nonsterile). Levels of latex aeroallergen correlate strongly with use of high-allergen and powdered gloves, total number of gloves used, and the hours of activity in a given environment. A significant reduction in aeroallergen (>10-fold) can be achieved by switching to low-allergen gloves. Ready availability of and encouragement to use nonlatex alternatives when appropriate can further reduce exposure to latex allergens. Since 1998, the Food and Drug Administration has required all medical devices (or their packaging) that contain natural rubber latex to be so labeled. In addition, industry has responded with a host of latex-free products for use in patient care. This has helped eliminate a great deal of confusion about which products are safe for use with latex-sensitive individuals. However, despite significant efforts to educate the public and the health care industry regarding latex allergies, considerable misinformation persists. Provision of a completely latex-free environment in most surgical suites may be unrealistic, but every effort should be made to minimize the unnecessary exposure of patients and health care workers to latex allergens in this high-risk arena.

Scrubbing for cutaneous procedures can be hazardous

Office-based minor cutaneous surgery is a service provided by many medical practitioners. In New South Wales, Australia, it is a legal requirement for practitioners to surgically scrub before donning sterile gloves for all forms of invasive surgery, including minor cutaneous procedures. Frequent scrubbing causes altered skin barrier function, irritant dermatitis and a potential risk of latex sensitization. These adverse effects are associated with significant morbidity and cost. Better tolerated alternatives, including alcohol-based hand rubs, should be considered in preference to traditional surgical scrubs in order to reduce these occupational risks for minor proceduralists. Well-controlled, prospective studies should explore what extent of hand washing is necessary for donning sterile gloves for minor cutaneous surgery.

Latex allergy: historical perspective

The widespread use of powdered latex gloves, following the institution of universal precautions in 1987, increased the occurrence of a host of adverse reactions to natural rubber latex (NRL). Although the most common reactions are irritant or allergic dermatitis reactions to manufacturing chemicals, a spectrum of type I IgE-mediated reactions to NRL proteins are of great concern. IgE-mediated reactions range from contact urticaria to occupational asthma and anaphylaxis, resulting in significant morbidity and potential mortality. At-risk populations include highly exposed groups like health care workers and certain patient groups requiring extensive medical treatment. A significant complicating factor is the association with clinically significant adverse reactions to certain foods because of allergen cross-reactivity. Institution of policies to use only low-protein, powder-free gloves, has resulted in a dramatic reduction of visits to occupational health departments and workmen's compensation claims due to occupational asthma.

Diagnosis of natural rubber latex allergy

The accurate diagnosis of a latex-allergic individual begins with a comprehensive clinical history. Atopy, food allergies, hand dermatitis, and temporal relationships between allergic symptoms and natural rubber product exposure are risk factors that increase the suspicion of latex allergy. If symptoms are temporally delayed (hours-days) and confined to skin-latex product contact areas, Type IV hypersensitivity should be suspected and patch testing may be performed to identify activated T cells that are specific for selected rubber chemical additives. If ocular, upper and lower airway, and/or systemic allergic symptoms are observed with rapid onset (minutes) following a definable latex exposure, Type I hypersensitivity should be suspected. One or several confirmatory tests for latex-specific IgE antibody in the skin or blood may next be performed to verify a sensitized (IgE antibody positive) state. If the clinical history remains discordant with a skin test or blood test result, in vivo provocation tests may be cautiously considered for adjudication. Diagnostic methods for latex-specific IgE antibody detection in skin and blood are overviewed, with a focus on their performance, advantages, and limitations.

Quantitative determination of dithiocarbamates in human plasma, serum, erythrocytes and urine: pharmacokinetics of broccoli sprout isothiocyanates in humans

BACKGROUND

Humans are exposed to substantial quantities of isothiocyanates and glucosinolates from vegetables. Since dietary isothiocyanates are widely regarded as potentially important chemoprotectors against cancer, reliable methods for measuring the plasma and tissue pharmacokinetics of isothiocyanates and their dithiocarbamate metabolites are essential for defining dosing regimens.

METHODS

Isothiocyanates (ITC) and dithiocarbamates (DTC) react quantitatively with 1,2-benzenedithiol to produce 1,3-benzodithiole-2-thione that can be quantified spectroscopically. Although this cyclocondensation reaction has been highly useful for analyzing plant material and urine samples, the determination of DTC/ITC (the total quantity of DTC and ITC components in a sample that react in the cyclocondensation reaction) in blood and tissues has been hampered by their low levels and the high concentrations of proteins that interfere with the cyclocondensation reaction. The protein content of blood and tissues was reduced by the precipitation with polyethylene glycol (PEG) or ultrafiltration, and the sensitivity of the method was increased substantially by the solid phase extraction of the cyclocondensation product.

RESULTS

Pharmacokinetic measurements were made in four human volunteers who received single doses of about 200 micromol of broccoli sprout isothiocyanates (largely sulforaphane, with lesser amounts of iberin and erucin). Isothiocyanates were absorbed rapidly, reached peak concentrations of 0.943-2.27 micromol/l in plasma, serum and erythrocytes at 1 h after feeding and declined with first-order kinetics (half-life of 1.77+/-0.13 h). The cumulative excretion at 8 h was 58.3+/-2.8% of the dose. Clearance was 369+/-53 ml/min, indicating active renal tubular secretion.

CONCLUSION

A sensitive and specific method for quantifying DTC levels in human plasma, serum, and erythrocytes has been devised. Determinations of ITC/DTC levels are important because: (i) dietary isothiocyanates are of potential value in reducing the risk of cancer, and (ii) humans are extensively exposed to DTC as fungicides, insecticides, pesticides and rubber vulcanization accelerators.

Type IV hypersensitivity reactions to natural rubber latex: results of a multicentre study

BACKGROUND

Positive patch test reactions to natural rubber latex (NRL) have been interpreted as allergic or irritant by different groups. Additives to the NRL test solution have also caused positive reactions in previous studies.

OBJECTIVES

Five centres of the British Contact Dermatitis Group conducted a prospective study on the prevalence of type IV hypersensitivity to NRL, using ammonia-preserved NRL solution for testing.

PATIENTS AND METHODS

A total of 2738 consecutive patients were patch tested. Where clinically indicated, specific IgE was measured or a prick test done.

RESULTS

Twenty-seven patients (1%) had a positive patch test reaction to NRL, which was considered to be allergic and of current relevance in 19 (70%) patients. Fourteen of these also had a positive prick test or specific IgE. Thirteen patients (48%) were male, 19 (70%) atopic and 13 (48%) had eczema on their hands.

CONCLUSIONS

We conclude that delayed-type hypersensitivity to NRL is a problem for a proportion of patients with eczema, particularly on their hands, and that patch testing with ammonia-preserved NRL can be recommended to identify these patients. Patients with a positive patch test should be investigated for contact urticaria to NRL.

Changes in rates of natural rubber latex sensitivity among dental school students and staff members after changes in latex gloves

BACKGROUND

A high rate of sensitization and clinical allergy to natural rubber latex (NRL) gloves has been reported in dental students and staff members.

OBJECTIVE

The purpose of this study was to determine whether a change in glove use from high-protein/powdered to low-protein/powder-free latex gloves at a previously surveyed dental school reduced the prevalence of NRL sensitivity among students and staff members.

METHODS

A cross-sectional study was performed through use of a questionnaire and skin prick testing to low ammoniated NRL extract; the method was similar to that used in a study conducted in 1995. Analyses were performed on the entire groups as well as on a subset of senior students.

RESULTS

A total of 97 subjects (61 students and 36 staff members) completed the questionnaire and underwent skin prick testing; this compared with 131 subjects in 1995. Percentages of subjects reporting asthma symptoms, rhinitis or conjunctivitis, urticaria, or pruritus within minutes of NRL exposure were 4%, 7%, 6%, and 8%, respectively; the corresponding percentages in the 1995 survey were 7% (P = not significant), 13% (P = not significant), 20% (P =.004), and 22% (P =.005). Results were similar for the subset of senior students, but in addition there were also significantly fewer complaints of rhinoconjunctivitis in 2000 than in 1995 (0% and 12%, respectively; P =.007). Of 97 subjects who underwent skin prick testing, 3 (3%) had positive skin prick test responses of 2+ or greater to NRL; this compared with 13 (10%) of 131 subjects in 1995 (P =.03). There were 3 positive skin test responses among staff members in 2000; there were none among students.

CONCLUSIONS

Our results suggest a preventive effect on NRL allergy in dental students from the change to low-protein/powder-free NRL gloves in the dental school.

Allergic contact dermatitis due to thiuram exposure from a fungicide

A 49-year-old man developed a widespread eczematous eruption following contact with plants sprayed with a fungicide. Patch testing revealed a strong reaction to thiuram mix and several of the individual thiuram mix constituents. The fungicide contained tetramethylthiuram disulphide, a thiuram chemical. Thiurams are widely recognized as a cause of rubber-glove allergy; however, they are also used extensively in fungicides.

Sensitisation to natural rubber latex: an epidemiological study of workers exposed during tapping and glove manufacture in Thailand

OBJECTIVES

To estimate the prevalence of sensitisation to natural rubber latex in latex tappers and latex glove factory workers, and to relate this to airborne exposure to latex.

METHODS

Five hundred workers employed in three latex glove factories, 314 tappers, and 144 college students (control group) were studied. The workers in the glove factories were classified into three exposure groups; high, moderate, and low. Personal exposures to natural rubber latex aeroallergens were measured by immunoassay. Symptom questionnaires and skin prick tests with latex allergens (Stallergènes 1:200 w/v) and other common environmental allergens were performed. The criterion for positivity was a wheal reaction at least 3 mm in diameter greater than that to a diluent control.

RESULTS

The geometric mean (GM) concentration of latex in air was 15.4 microg/m(3) for those employed in glove stripping, glove inspections, and packing of powdered gloves. The moderate exposure glove manufacturing group and the tappers had GM concentrations of 2.3 and 2.4 microg/m(3) respectively, compared with United Kingdom users of latex powdered gloves,who had GM concentrations of 0.5 microg/m(3). The prevalence of sensitisation to latex in the tappers and latex glove factory workers was 1.3% and 1.7% respectively. No positive cases were found among the college students. Workers who showed a positive skin prick test to latex were more likely to be atopic. Work related respiratory and dermatological symptoms were found in about 20% of each population studied, but were not related to the presence of positive latex prick tests.

CONCLUSIONS

This study suggests that in the Thai latex industries, latex sensitisation is rare despite high concentrations of airborne exposure and is less prevalent than in the healthcare sector in Europe where skin exposure is greater.

Occupational dermatitis in a highly industrialized Italian region: the experience of four occupational health departments

There is a need for several research centers to carry out coordinated large-scale evaluation of the spread of occupational irritant and allergic dermatitis. The Occupational Health Departments of Bergamo, Brescia, Lecco and Cremona therefore decided to join their experiences and bring together all the cases of occupational irritant and allergic dermatitis diagnosed by these Departments between 1993 and 1998. In this period, 1169 cases of occupational dermatitis were diagnosed, subdivided into 768 cases of allergic contact dermatitis (ACD), 337 of irritant contact dermatitis (ICD), 54 of urticaria and 10 of airborne contact dermatitis, and there has not been a trend towards increase of occupational dermatitis over the years. Our population included 724 males and 445 females and average latency after the beginning of exposure to occupational allergens was 8.01 years for ACD, 6.4 for ICD, 3.22 for urticaria and 5.57 for airborne contact dermatitis. The frequency of atopy was 33.9%, in females and 19.5% in males. The frequency of atopy was particularly high (89%) in subjects with urticaria. Among subjects with allergic dermatitis, 362 had had only one sensitization while 406 had had two or more sensitizations. The working areas where we found the highest number of ACD were metal working industry, building, health care workers and hairdressers and the frequency of ICD was high in metal workers and health care workers. Most of the cases of urticaria were diagnosed in health care workers (68.5%) and the main causing agent was latex. These are only preliminary data but occupations at risk and the substances expected to be the most frequent etiological agents do not differ significantly from those reported in the literature. It is hoped that as a result of this project there will be in the future: standardization of diagnostic procedures, uniform assessment of allergological risk in working environments not yet fully investigated, standardization of preventative measures and proper evaluation of their effectiveness.

Contact dermatitis in students practicing sports: incidence of rubber sensitisation

BACKGROUND

Over the last few years, changes in cutaneous homoeostasis resulting from sports activities have been reported. In particular, alterations in sweating mechanisms, the hydrolipid barrier, and surface bacterial flora, together with exposure to atmospheric conditions and the need to use medicaments, detergents, and other topical substances, predispose subjects to allergic contact dermatitis.

OBJECTIVE

To evaluate the incidence of allergic contact dermatitis in a group of young people practising sports activities.

METHODS

Patch tests were performed to confirm the diagnosis of irritant or allergic dermatitis; in addition, the radioallergoabsorbent test (RAST) to latex was evaluated in the group studied.

RESULTS

Allergic contact dermatitis caused by thiourams (23.3%) and mercaptobenzothiazole (20.9%) was prevalent. Other haptens, such as benzocaine and nickel, which are contained in clothing, equipment, topical medicaments, and creams used for massage, were also allergenic. In two cases, RAST positivity to latex was registered.

CONCLUSIONS

-The results suggest that close contact with sports equipment may increase the incidence of allergic contact dermatitis. Students practising certain sports may have "professional" allergic contact dermatitis to additives used in the production of rubber.

Health-care workers and latex allergy

Latex hypersensitivity can pose a threat to anyone, but health-care providers are among the high-risk groups for developing latex hypersensitivity. Latex hypersensitivity likely results from health-care workers' increased use of gloves following implementation of universal precautions. It is also believed that the antigenic load of latex gloves causes an increase in latex hypersensitivity resulting from massive production of gloves. Although there are many studies on the prevalence of latex hypersensitivity among health-care workers, there appear to be discrepancies, which may affect the different apparent prevalence. Testing for latex hypersensitivity raises another problem. Latex allergens cannot be identified specifically; therefore, there is no standard test or testing solution that can identify hypersensitive persons. Although latex glove hypersensitivity was first identified in the late 1970s, there remain many uncertainties associated with it; as a result, there is a growing concern among health-care providers. The authors offer several precautions to avoid the development of latex hypersensitivity.

Selected topics related to occupational exposures. Part III. Occupational dermatology

Occupational skin disorders are very common and are a surprisingly frequent cause of lost work time. Failure to suspect an occupational cause can lead to repeated treatment failure and needlessly prolong patient misery and frustration. Primary care providers play a key role in recognizing possible occupational causes and arranging appropriate education, preventive measures, and treatment. Occupational skin conditions often occur in nonindustrial settings in workers such as hairdressers, health care personnel, and food handlers. Irritant contact dermatitis is by far the most prevalent occupational skin condition and is emphasized in this article. Allergic contact dermatitis, infections, skin cancers, and acneform eruptions may also have significant occupational associations. We will present criteria that suggest on occupational exposure, list common offending agents, and review the clinical presentations and relevant pathophysiology. We provide guidance on a directed history and physical examination and suggest when diagnostic testing is most likely to have value. Finally we outline preventive measures such as contact avoidance, barrier creams, and protective gloves and address therapy and indications for referral.

Latex allergy in children: diagnosis and management

Latex allergy is an increasingly common condition, in both children and health care workers who provide care for them. Subpopulations at particular risk include children with spina bifida, children undergoing multiple surgical procedures, and health care workers in the operating theatre. Chemical additives in latex gloves can cause an irritant or allergic contact dermatitis. Latex proteins are responsible for most of the immediate IgE-mediated hypersensitivity allergic reactions. Symptoms range from rhinitis, conjunctivitis and urticaria to anaphylaxis and death. A latex-directed history is the primary method of identifying latex sensitivity, although both skin and serum testing is available and increasingly accurate. (Latex avoidance should be used in all individuals with a positive skin or blood test or a positive history). The most important preventive measure for patients with or at risk for latex allergy is minimizing direct patient exposure to latex products, most notably latex gloves. Recent operating room studies indicate simple preventive measures can dramatically reduce intraoperative reactions. Preoperative prophylaxis with antihistamines and steroids have not been shown to be necessary or effective. Treatment of an allergic reaction begins with immediate removal of any identified source of latex in direct patient contact. Treatment is similar to anaphylaxis from other causes, and may require the use of epinephrine. Everyone caring for the patient at risk for latex allergy must be involved in making their medical environment safe.

Latex allergy: how to identify it and the people at risk

Some patients and staff are more at risk to latex allergy than others. This paper identifies those people and the ways in which their allergy can be confirmed. Recommendations are made for their care and to prevent sensitization occurring.

Changes in bacterial flora associated with skin damage on hands of health care personnel

In a prospective observational study of 40 nurses (20 with diagnosed hand irritation and 20 without), nurses with damaged hands did not have higher microbial counts (P = .63), but did have a greater number of colonizing species (means: 3.35 and 2.63, P = .03). Although numbers were small, nurses with damaged hands were significantly more likely to be colonized with Staphylococcus hominis (P = .03). Fifty-nine percent of S hominis isolates from nurses with damaged hands were resistant to methicillin compared with 27% of isolates from those with healthy skin (P = .14). Twenty percent of nurses with damaged hands were colonized with Staphylococcus aureus compared with none of the nurses with normal hands (P = .11). Nurses with damaged hands were also twice as likely to have gram-negative bacteria (P = .20), entercocci (P = .13), and Candida (P = .30) present on the hands. Antimicrobial resistance of the coagulase-negative staphylococcal flora (with the exception of S hominis) did not differ between the 2 groups, nor did a trend toward increasing resistance exist when compared with other studies during the past decade. Skin moisturizers and protectant products were used almost universally by nurses at work, primarily products brought from home. Efforts to improve hand condition are warranted because skin damage can change microbial flora. Such efforts should include assessment or monitoring of hand care practices, formal institutional policy adoption and control of use of skin protectant products or lotions, and prudent use of latex gloves or more widespread use of powder-free and nonlatex products.