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Michaels BS, Ayers T, Brooks-McLaughlin J, McLaughlin RJ, Sandoval-Warren K, Schlenker C, Ronaldson L, Ardagh S. Potential for Glove Risk Amplification via Direct Physical, Chemical, and Microbiological Contamination. J Food Prot 2024; 87:100283. [PMID: 38679200 DOI: 10.1016/j.jfp.2024.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 04/17/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
This review focuses on the potential direct physical, chemical, and microbiological contamination from disposable gloves when utilized in food environments, inclusive of the risks posed to food products as well as worker safety. Unrecognized problems endemic to glove manufacturing were magnified during the COVID-19 pandemic due to high demand, increased focus on PPE performance, availability, supply chain instability, and labor shortages. Multiple evidence-based reports of contamination, toxicity, illness, deaths, and related regulatory action linked to contaminated gloves in food and healthcare have highlighted problems indicative of systemic glove industry shortcomings. The glove manufacturing process was diagramed with sources and pathways of contamination identified, indicating weak points with documented occurrences detailed. Numerous unsafe ingredients can introduce chemical contaminants, potentially posing risks to food and to glove users. Microbial hazards present significant challenges to overall glove safety as contaminants appear to be introduced via polluted water sources or flawed glove manufacturing processes, resulting in increased risks within food and healthcare environments. Frank and opportunistic pathogens along with food spoilage organisms can be introduced to foods and wearers. When the sources and pathways of glove-borne contamination were explored, it was found that physical failures play a pivotal role in the release of sweat build-up, liquefaction of chemical residues, and incubation of microbial contaminants from hands and gloves. Thus, with glove physical integrity issues, including punctures in new, unused gloves that can develop into significant rips and tears, not only can direct physical food contamination occur but also chemical and microbiological contamination can find their way into food. Enhanced regulatory requirements for Acceptable Quality Limits of food-grade gloves, and the establishment of appropriate bioburden standards would enhance safety in food applications. Based on the information provided, together with a false sense of security associated with glove use, the unconditional belief in glove chemical and microbiological purity may be unfounded.
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Affiliation(s)
- Barry S Michaels
- B. Michaels Group Inc., 487 West River Road, Palatka, FL 32177, USA.
| | - Troy Ayers
- Eurofins Microbiology Laboratories Inc., Des Moines, IA 50321, USA
| | | | | | | | | | - Lynda Ronaldson
- Eagle Protect PBC, South Lake Tahoe, CA 96150, USA; Eagle Protect Ltd. Christchurch 8011, New Zealand
| | - Steve Ardagh
- Eagle Protect PBC, South Lake Tahoe, CA 96150, USA; Eagle Protect Ltd. Christchurch 8011, New Zealand
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2
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Li ZM, Pal VK, Kannan P, Li W, Kannan K. 1,3-Diphenylguanidine, benzothiazole, benzotriazole, and their derivatives in soils collected from northeastern United States. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 887:164110. [PMID: 37178851 PMCID: PMC10330497 DOI: 10.1016/j.scitotenv.2023.164110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/08/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
1,3-Diphenylguanidine (DPG), benzothiazole (BTH), benzotriazole (BTR), and their derivatives are high-production-volume chemicals widely used in tires, corrosion inhibitors and plastic products. Vehicular traffic is an important source of these chemicals in the environment. Despite this, little is known about the occurrence of these chemicals in roadside soils. In this study, we determined the concentrations, profiles, and distribution patterns of 3 DPGs, 5 BTHs, and 7 BTRs in 110 soil samples collected from northeastern United States. We found widespread occurrence of 12 out of the 15 analytes measured in roadside soils, at detection frequencies ≥71 % and median concentrations in the range of 0.38-380 ng/g (dry weight). DPGs were the predominant chemicals accounting for 63 % of the sum concentrations of three chemical classes determined, followed by BTHs (28 %) and BTRs (9 %). The concentrations of all analytes (except for 1-, 4-, and 5-OH-BTRs) exhibited significant positive correlations (r: 0.1-0.9, p < 0.01), suggestive of their common sources and/or similar environmental fates. Higher concentrations of DPGs, BTHs and BTRs were found in soils from highways, rubberized playgrounds, and indoor parking lots than those from gardens, parks, and residential areas. Our findings suggest the release of DPGs, BTHs and BTRs from rubber products, especially automobile tires. Further studies are needed to investigate the environmental fate and toxicities of these chemicals to humans and wildlife.
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Affiliation(s)
- Zhong-Min Li
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016, United States; Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, United States; Wadsworth Center, New York State Department of Health, Albany, NY 12201, United States
| | - Vineet Kumar Pal
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016, United States; Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, United States
| | - Pranav Kannan
- Wadsworth Center, New York State Department of Health, Albany, NY 12201, United States
| | - Wenlong Li
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016, United States; Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, United States; Wadsworth Center, New York State Department of Health, Albany, NY 12201, United States
| | - Kurunthachalam Kannan
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016, United States; Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, United States; Wadsworth Center, New York State Department of Health, Albany, NY 12201, United States.
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3
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Li ZM, Kannan K. Occurrence of 1,3-Diphenylguanidine, 1,3-Di- o-tolylguanidine, and 1,2,3-Triphenylguanidine in Indoor Dust from 11 Countries: Implications for Human Exposure. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2023; 57:6129-6138. [PMID: 37010350 PMCID: PMC10116588 DOI: 10.1021/acs.est.3c00836] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 06/19/2023]
Abstract
1,3-Diphenylguanidine (DPG), 1,3-di-o-tolylguanidine (DTG), and 1,2,3-triphenylguanidine (TPG) are synthetic chemicals widely used in rubber and other polymers. Nevertheless, limited information is available on their occurrence in indoor dust. We measured these chemicals in 332 dust samples collected from 11 countries. DPG, DTG, and TPG were found in 100%, 62%, and 76% of the house dust samples, at median concentrations of 140, 2.3, and 0.9 ng/g, respectively. The sum concentrations of DPG and its analogues varied among the countries in the following decreasing order: Japan (median: 1300 ng/g) > Greece (940) > South Korea (560) > Saudi Arabia (440) > the United States (250) > Kuwait (160) > Romania (140) > Vietnam (120) > Colombia (100) > Pakistan (33) > India (26). DPG accounted for ≥87% of the sum concentrations of the three compounds in all countries. DPG, DTG, and TPG exhibited significant correlations (r: 0.35-0.73; p < 0.001). Elevated concentrations of DPG were found in dust from certain microenvironments (e.g., offices and cars). Human exposure to DPG through dust ingestion were in the ranges 0.07-4.40, 0.09-5.20, 0.03-1.70, 0.02-1.04, and 0.01-0.87 ng/kg body weight (BW)/day for infants, toddlers, children, teenagers, and adults, respectively.
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Affiliation(s)
- Zhong-Min Li
- Department
of Pediatrics, New York University Grossman
School of Medicine, New York, New York 10016, United States
- Department
of Environmental Medicine, New York University
Grossman School of Medicine, New York, New York 10016, United States
| | - Kurunthachalam Kannan
- Department
of Pediatrics, New York University Grossman
School of Medicine, New York, New York 10016, United States
- Department
of Environmental Medicine, New York University
Grossman School of Medicine, New York, New York 10016, United States
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4
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Rehabilitation and Prevention of Hand Eczema. Contact Dermatitis 2021. [DOI: 10.1007/978-3-030-36335-2_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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5
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Aalto-Korte K. Contact Allergy to Protective Gloves. Contact Dermatitis 2021. [DOI: 10.1007/978-3-030-36335-2_74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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6
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Sanghvi AR. COVID-19: An overview for dermatologists. Int J Dermatol 2020; 59:1437-1449. [PMID: 33107038 DOI: 10.1111/ijd.15257] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023]
Abstract
Numerous unexplained pneumonia cases were reported to the World Health Organization (WHO) by Wuhan, China, in December 2020. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a zoonotic pathogen, came into sight, spreading coronavirus disease 2019 (COVID-19) all over the globe. Association of cutaneous signs and symptoms with COVID-19 is being studied worldwide, principally, to determine if these dermatoses can help in early recognition of SARS-CoV-2 infection. These dermatological manifestations can range from erythematous rash, urticaria to livedo reticularis, and acrocyanosis in patients of all age groups. Correspondingly, dermatologists treating COVID-19 patients, suffering from inflammatory dermatoses, with biologics or immunomodulators should exert caution and use specific protocols to adjust the doses of these medications. Prevention of person-to-person transmission of COVID-19 is being promoted universally, with the use of personal protective equipment (PPE), hand washes, and hand sanitizers around the clock. However, an array of cutaneous adverse effects such as contact dermatitis, irritant contact dermatitis, friction blisters, contact urticaria, acne, and infections are associated with the use of PPE. Extra-pulmonary manifestations of COVID-19 are still emerging in the community, and physicians and researchers are working together globally to strengthen the clinical management of these patients. Cases of COVID-19 continue to rise across the world, and an unprecedented approach has been taken to develop effective vaccines and therapeutic strategies against existing and forthcoming mutagenic strains of SARS-CoV-2.
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Lopushinsky KM, Gill N, Shea WK, Elliott JF, Straube S, Dytoc MT. Making Glove Decision Less of a White Knuckling Experience: A Systematic Review and Inventory of Glove Accelerator Contents. J Cutan Med Surg 2020; 24:386-398. [DOI: 10.1177/1203475420919398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Kaitlyn M. Lopushinsky
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Navjeet Gill
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Whitney K. Shea
- Discipline of Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, Canada
| | - John F. Elliott
- Division of Dermatology, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, University Dermatology Centre, Edmonton, AB, Canada
| | - Sebastian Straube
- Division of Preventive Medicine, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marlene T. Dytoc
- Division of Dermatology, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, University Dermatology Centre, Edmonton, AB, Canada
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Rehabilitation and Prevention of Hand Eczema. Contact Dermatitis 2020. [DOI: 10.1007/978-3-319-72451-5_71-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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9
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Aalto-Korte K. Contact Allergy to Protective Gloves. Contact Dermatitis 2020. [DOI: 10.1007/978-3-319-72451-5_74-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Dejonckheere G, Herman A, Baeck M. Allergic contact dermatitis caused by synthetic rubber gloves in healthcare workers: Sensitization to 1,3-diphenylguanidine is common. Contact Dermatitis 2019; 81:167-173. [PMID: 30891769 DOI: 10.1111/cod.13269] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The frequency of allergic contact dermatitis has significantly increased in healthcare workers since the transition from latex to synthetic rubber gloves, with 1,3-diphenylguanidine being identified as the most frequently implicated allergen. OBJECTIVES To highlight the role of 1,3-diphenylguanidine as the culprit allergen in contact allergies to synthetic rubber gloves, to propose recommendations for patch testing, and to discuss alternatives for sensitized subjects. MATERIALS AND METHODS Patch test data from healthcare workers who developed hand dermatitis after wearing rubber gloves and who reacted positively to glove samples and rubber additives were collected from September 2010 to December 2017 in a Belgian hospital. RESULTS A total of 44 caregivers were included in this study. Patch tests showed that: (a) 84% of the study population reacted positively to carba mix; (b) 86% reacted positively to 1,3-diphenylguanidine; and (c) 13 (30%) reacted positively to thiuram mix. Half of the subjects reacted positively to gloves containing 1,3-diphenylguanidine, whereas none reacted to accelerator-free gloves. CONCLUSION The most commonly identified allergen was 1,3-diphenylguanidine, far ahead of thiurams, which were previously described as the most sensitizing accelerators. The use of 1,3-diphenylguanidine-free gloves is recommended. No subject reacted to gloves without accelerators, thus confirming their efficiency among accelerator-sensitized patients. We recommend that 1,3-diphenylguanidine be added to the European baseline series.
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Affiliation(s)
- Guillaume Dejonckheere
- Department of Dermatology, Cliniques universitaires Saint-Luc, Brussels, Belgium and IREC (Institut de Recherche Experimentale et Clinique) Pôle Pneumologie, ORL, Dermatologie, Université Catholique de Louvain, Brussels, Belgium
| | - Anne Herman
- Department of Dermatology, Cliniques universitaires Saint-Luc, Brussels, Belgium and IREC (Institut de Recherche Experimentale et Clinique) Pôle Pneumologie, ORL, Dermatologie, Université Catholique de Louvain, Brussels, Belgium
| | - Marie Baeck
- Department of Dermatology, Cliniques universitaires Saint-Luc, Brussels, Belgium and IREC (Institut de Recherche Experimentale et Clinique) Pôle Pneumologie, ORL, Dermatologie, Université Catholique de Louvain, Brussels, Belgium
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11
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Hamnerius N, Pontén A, Björk J, Persson C, Bergendorff O. Skin exposure to the rubber accelerator diphenylguanidine in medical gloves-An experimental study. Contact Dermatitis 2019; 81:9-16. [PMID: 30724364 DOI: 10.1111/cod.13238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dermatitis caused by occupational contact allergy to rubber additives such as diphenylguanidine (DPG) in medical gloves is a hazard for healthcare workers. Both the duration of exposure to medical gloves and the number of gloves used per day vary. The use of alcoholic skin disinfectants before glove donning is mandatory. OBJECTIVES To assess whether skin exposure to the rubber accelerator DPG released from glove material is influenced by alcoholic hand disinfectants, time, and pH. METHODS With the use of ethanol washes, the amount of DPG left on the hands after wearing of gloves for 60 minutes was measured, and comparisons between hands exposed and not exposed to alcoholic disinfectant before glove donning were made. With the use of artificial sweat buffered at pH 4, 5, and 6, DPG release from the insides of gloves at different times was measured. RESULTS The use of alcoholic disinfectant prior to polyisoprene glove donning increased the amount of DPG recovered from the hands. Of the DPG released from polyisoprene gloves into artificial sweat, almost 84% was released within 10 minutes. pH did not influence the rate of release. CONCLUSIONS The use of alcoholic disinfectant increased skin exposure to the rubber accelerator DPG. Even a short duration of use of gloves results in substantial exposure to DPG.
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Affiliation(s)
- Nils Hamnerius
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Ann Pontén
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Jonas Björk
- Department of Occupational and Environmental Medicine, Lund University, Lund, Sweden.,Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - Christina Persson
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Ola Bergendorff
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
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12
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Gloves. Contact Dermatitis 2019. [DOI: 10.1007/978-3-319-72451-5_74-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Hand dermatitis is a common condition with a lifetime prevalence of 20%. Glove allergic contact dermatitis (ACD) is a very important dermatitis affecting health care workers, hairdressers, cleaning personnel, kitchen workers, craftsmen, construction workers, laboratory workers, and homemakers. Occupationally related cases may be severe and can result in significant disability. Glove ACD is most commonly due to exposure to rubber accelerators, which are compounds that are added to rubber during production to increase strength and durability. Given the known allergic potential of these compounds, glove manufacturing companies have reformulated gloves leading to the introduction of new rubber allergens. In this review, we will discuss risk factors for glove ACD, both common and uncommon allergens in gloves, common contact allergens that permeate gloves, and patch testing to help uncover the inciting allergen(s).
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Warburton KL, Uter W, Geier J, Spiewak R, Mahler V, Crépy MN, Schuttelaar ML, Bauer A, Wilkinson M. Patch testing with rubber series in Europe: a critical review and recommendation. Contact Dermatitis 2016; 76:195-203. [DOI: 10.1111/cod.12736] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/26/2016] [Accepted: 10/27/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology; University of Erlangen/Nürnberg; 91054 Erlangen Germany
| | - Johannes Geier
- Information Network of Departments of Dermatology (IVDK); University Medical Centre; 37075 Goettingen Germany
| | - Radoslaw Spiewak
- Department of Experimental Dermatology and Cosmetology; Jagiellonian University Medical College; 30-688 Krakow Poland
| | - Vera Mahler
- Department of Dermatology; University Hospital of Erlangen; 91054 Erlangen Germany
| | - Marie-Noëlle Crépy
- Department of Occupational Diseases, Centre Hôtel-Dieu, AP-HP; Paris University Hospital; 75004 Paris France
| | - Marie Louise Schuttelaar
- Department of Dermatology; University Medical Centre Groningen, University of Groningen; 9713 GZ Groningen The Netherlands
| | - Andrea Bauer
- Department of Dermatology, University Allergy Centre, University Hospital Carl Gustav Carus; Technical University Dresden; 01307 Dresden Germany
| | - Mark Wilkinson
- Department of Dermatology; Chapel Allerton Hospital; Leeds LS7 4SA UK
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Abstract
Every year, new contact allergens, chemicals reported to have caused contact allergy/ACD for the first time, are described in literature. In the journals Contact Dermatitis and Dermatitis, 172 such compounds were identified in the period 2008-2015, 119 of which induced ACD. These are presented with the following data: name, synonyms, Chemical Abstracts Service (CAS) number, patch test data, function or class, causative product, number of patients, occupation (in case of occupational ACD), additional clinical data (if applicable), and references. Approximately one third of the new allergens were ingredients of cosmetics, followed by drugs causing occupational ACD (18%), chemicals in rubber, plastics, and paints (9%), drugs causing a drug eruption (9%), as well as chemicals used in laboratories inducing occupational ACD (8%). In 40%, the dermatitis was occupationally acquired. Fifty-three other chemicals causing contact allergy as indicated by positive patch test reactions only are shown without specifics.
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Wiszniewska M, Walusiak-Skorupa J. Recent Trends in Occupational Contact Dermatitis. Curr Allergy Asthma Rep 2015; 15:43. [PMID: 26143395 DOI: 10.1007/s11882-015-0543-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Occupational contact dermatitis (OCD) remains prevalent among workers and impacts quality of life and workability. The purpose of this review is to summarize the recent advances in occupational contact dermatitis as well as potential hazardous agents in the workplaces causing OCD. The review covers new developments in the epidemiology, etiology, diagnosis, and management of occupational contact dermatitis. This article also provides updated information on the prevalence of work-related skin symptoms and on new contact allergens among working population. It is emphasized that in the context of prevention of OCD, special attention should be focused on the identified high-risk occupational groups, especially healthcare workers and hairdressers starting with the apprentices. Current approaches include working out the standards and guidelines to improve the education, knowledge, diagnosis, and management of OCD based on a multidisciplinary team of medical specialists and an employer.
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Affiliation(s)
- Marta Wiszniewska
- Department of Occupational Diseases and Clinical Toxicology, Nofer Institute of Occupational Medicine, 8 Teresy St., 91-348, Lodz, Poland,
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