Allergic reactions to a hairdressers' series: results from 9 European centres. The European Environmental and Contact Dermatitis Research Group (EECDRG)

Patch Testing with Ammonium Persulfate: The North American Contact Dermatitis Group Experience, 2015-2018

BACKGROUND

Ammonium persulfate (APS), an oxidizing agent used in hair products, manufacturing, and pool/spa water, can cause skin reactions including allergic contact dermatitis.

OBJECTIVE

To characterize positive patch test reactions to APS (2.5% pet).

METHODS

Retrospective analysis of patients tested to the North American Contact Dermatitis Group (NACDG) screening series from 2015-2018.

RESULTS

Of 10,526 patients, 193 (1.8%) had positive patch test reactions to APS. Compared to negative patients, APS-positive patients were significantly more likely to be male (43.2% vs. 28.0%, p<0.0001), have primary hand (30.2% vs. 22.0%, p=0.0064), scattered generalized (25.5% vs. 17.9%, p=0.0064), or trunk dermatitis (8.9% vs. 4.9%, p=0.0123), and occupationally-related dermatitis (22.2% vs. 10.9%, p<0.0001). Over half of the APS-positive reactions were currently relevant (57.0%); 19 (9.8%) were related to occupation, especially (68.4%) hairdressers. Swimming pools/spas (23.3%) and hair care products (19.2%) were the most common APS sources.

LIMITATIONS

Immediate reactions and follow-up testing not captured.

CONCLUSIONS

The proportion of patients positive to APS was 1.8%. APS positivity was significantly associated with male sex and hand dermatitis. Swimming pool/spa chemicals are important sources of APS exposure.

Angioedema Masqueraders

Angioedema is a common reason for referral to immunology and allergy specialists. Not all cases are in fact angioedema. There are many conditions that may mimic its appearance, resulting in misdiagnosis. This may happen when a clinician is unfamiliar with conditions resembling angioedema or when there is a low index of clinical suspicion. In this article, we explore a list of differential diagnoses based on body parts, including the lips, the limbs, periorbital tissues, the face, epiglottis and uvula, as well as the genitalia, that may pose as a masquerader even to an experienced eye.

Are gloves sufficiently protective when hairdressers are exposed to permanent hair dyes? An in vivo study

BACKGROUND

The use of permanent hair dyes exposes hairdressers to contact allergens such as p-phenylenediamine (PPD), and the preventive measures are insufficient.

OBJECTIVES

To perform an in vivo test to study the protective effect of gloves commonly used by hairdressers.

PATIENTS/MATERIALS/METHODS

Six gloves from Sweden, Italy and Germany were studied: two vinyl, one natural rubber latex, two nitrile, and one polyethylene. The hair dye used for the provocation was a dark shade permanent dye containing PPD. The dye was mixed with hydrogen peroxide, and 8 PPD-sensitized volunteers were tested with the gloves as a membrane between the hair dye and the skin in a cylindrical open chamber system. Three exposure times (15, 30 and 60 min) were used.

RESULTS

Eczematous reactions were found when natural rubber latex, polyethylene and vinyl gloves were tested with the dye. The nitrile gloves gave good protection, even after 60 min of exposure to the hair dye.

CONCLUSIONS

Many protective gloves used by hairdressers are unsuitable for protection against the risk of elicitation of allergic contact dermatitis caused by PPD.

Pyrogallol-associated dermal toxicity and carcinogenicity in F344/N rats and B6C3F1/N mice

Pyrogallol (CAS No. 87-66-1), a benzenetriol used historically as a hair dye and currently in a number of industrial applications, was nominated to the National Toxicology Program (NTP) for testing based on the lack of toxicity and carcinogenicity data. Three-month and two-year toxicity studies to determine the toxicity and carcinogenicity of pyrogallol when applied to naïve skin (i.e. dermal administration) were conducted in both sexes of F344/N rats and B6C3F1/N mice. In the three-month studies, adult rodents were administered pyrogallol in 95% ethanol five days per week for 3 months at doses of up to 150 mg/kg body weight (rats) or 600 mg/kg (mice). Based on the subchronic studies, the doses for the two-year studies in rats and mice were 5, 20 and 75 mg/kg of pyrogallol. All mice and most rats survived until the end of the three-month study and body weights were comparable to controls. During the two-year study, survival of dosed rats and male mice was comparable to controls; however survival of 75 mg/kg female mice significantly decreased compared to controls. The incidences of microscopic non-neoplastic lesions at the site of application were significantly higher in all dosed groups of rats and mice and in both the 3-months and two-year studies. In the two-year study, hyperplasia, hyperkeratosis and inflammation tended to be more severe in mice than in rats, and in the mice they tended to be more severe in females than in males. The incidence of squamous cell carcinoma at the site of application (SOA) in 75 mg/kg female mice and SOA squamous cell papillomas in 75 mg/kg male mice were greater than controls. Pyrogallol was carcinogenic in female mice and may have caused tumors in male mice.

[Endemic air-borne contact dermatitis? Frequent occurrence of a rare contact allergy in a waste collection facility]

Numerous cases of work-related air-borne contact dermatitis of the face were encountered in a waste collection facility. Potential allergens contained in the dust at the facility could be identified. In 5 of 7 symptomatic workers a type-IV sensitization to p-aminodiphenylamine could be documented. Since there is no commercial patch test preparation for p-aminodiphenylamine available, it had to be prepared for each patient individually. After identifying the allergen, a change in the work routine led to a reduction of dust emissions and afterwards no cases of air-borne contact dermatitis of the face recurred.

Contact allergy epidemics and their controls

Contact dermatitis can be severe and lead to sick leave as well as significant healthcare expenses. The aim of this review is to present the published knowledge on 6 historical epidemics of contact allergy to apply this knowledge on the prevention and control of future contact allergy epidemics. A historical review is performed on nickel, chromium, methyl-chloro-iso-thiazolinone/methyl-iso-thiazolinone, methyl-di-bromo glucaro-nitrile, formaldehyde, and para-phenylenediamine. The first cases of contact dermatitis are mostly occupational, whereas consumer cases appear later. There is often a latency period from the first cases are observed until an epidemic occurs, and the problem is recognized. Finally, no one seems to take responsibility of dealing with the situation, and there are no attempts of regulation until an epidemic is consolidated among consumers for many years. Steps should be taken to prevent contact allergy epidemics. It is essential that dermatologist, scientists, administrators, and consumers organize and structure known methods to accelerate the control of emerging contact allergens.

Contact allergy to para-phenylenediamine in a permanent eyelash dye

We present the case of a 30-year-old atopic lady with a known history of intolerance to several materials, including dark stockings, who developed a severe dermatitis on the eyelids and peri-orbital regions, as well as a conjunctivitis after having her eyelashes tinted by a beautician with a permanent black eyelash and eyebrow dye (Combinal, Dr Temt Laboratories, Austria). Patch tests revealed positive reactions to para-phenylenediamine (PPD), both diluted 0.01% and 1% in pet., to the eyelash dye (tested semiopen as is) and to some of the azo-dyes tested. The permanent eyelash dye did contain PPD, the use of which is illegal but seems to be a common practice. The patient had most probably been sensitized through nylon stockings containing azo-dyes, with PPD itself cross-reacting to them. With the growth in popularity of tattooing and permanent make-up, doctors should be aware of the new uses of this old allergen. Moreover, although many manufacturers have made great efforts to improve cosmetics concerning their safety, some of them remain uninformed about cosmetic legislation or do not respect it at all. Because many of these products are acquired via internet, lack of legislation about this shopping modality is also a serious problem.

MnSOD polymorphisms in sensitized patients with delayed-type hypersensitivity reactions to the chemical allergen para-phenylene diamine: A case–control study

Dyes such as para-phenylene diamine (PPD) or related para-compounds are very common contact sensitizers in man. The corresponding contact dermatitis in sensitized individuals is a complex and common illness associated with considerable morbidity and social cost. It has been found that oxidative stress from reactive oxygen species (ROS) may play an important role in the pre-immunological phase of allergic contact dermatitis to PPD. Manganese superoxide dismutase (MnSOD) is one of the primary enzymes that directly scavenge potential harmful oxidizing species. A valine (Val) to alanine (Ala) substitution at amino acid -9, occurring in the MnSOD gene, has been associated with various disease risk. The aim of our study was to investigate possible associations of the MnSOD 47 T>C genotype in exon 2 (Ala-9Val) and the 339 T>C genotype in exon 3 (Ile58Thr) with contact sensitization to PPD in humans in a case-control study. The study was performed in 157 unrelated cases and 201 age- and gender-matched controls. The MnSOD genotypes were determined using LightCycler allele discrimination assays. No heterozygous (CT) or homozygous carriers (TT) for the Ile58Thr polymorphism were found. The frequency for the C allele of the Ala-9Val polymorphism was 51% (79/157) in cases and 49% (107/201) in controls. Homozygous CC carriers (Ala/Ala) were 27% (43/157) in cases and 23% (46/201) in controls (odds ratio [OR], 1.3; 95% confidence interval [CI], 0.8-2.1). Stratification into subgroups based on gender and age limited the association to females. Increased risk among homozygous CC carriers (Ala/Ala) was only found in the group of older females (over 45 years, 25% versus 18%; OR, 1.5; 95% CI, 0.7-2.34). These data suggest that the C (Ala) allele of MnSOD modifies contact dermatitis risk among older females, but is not an independent susceptibility factor for contact sensitization to PPD.

Contact dermatitis to hair dyes in a Danish adult population: an interview-based study

BACKGROUND

Contact allergy to hair dye ingredients is a well-known entity seen both in consumers using hair dyes and among hairdressers with occupational contact dermatitis. Surveys show that consumers with even severe adverse skin reactions to hair dyes only rarely contact the healthcare services. The frequency of hair dye-induced skin reactions in the consumer population is unknown.

OBJECTIVES

An epidemiological investigation with the aim of establishing the proportion of hair dye-induced skin reactions was performed in a population-based sample.

METHODS

A representative random sample (n = 4000) was taken of the Danish adult population. Personal interview questions were asked regarding adverse skin reactions to hair dyes, either compatible with a classical allergic eczematous reaction with redness, scaling and itching or a severe allergic reaction with oedema of the forehead and face. The response rate was 65.2%.

RESULTS

A total of 18.4% of the male respondents and 74.9% of the female respondents had at some point dyed their hair. The median age at first hair dyeing was 16 years (range 1-80). Adverse skin reactions to hair dyes compatible with an allergic reaction were reported in 5.3% of individuals who had ever used hair dye. Of these, only 15.6% had been in contact with healthcare services after the hair dye reaction. Having had a temporary tattoo was not a significant risk factor for an adverse reaction to hair dyes.

CONCLUSIONS

The rate of adverse allergic skin reactions to hair dyes was higher than expected from patch-test studies. Only by studying the clinical types of adverse reactions to hair dyes will it be possible to gather a complete epidemiological picture of the nature and extent of the problems related to hair dye ingredients.

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

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

Specific immunoglobulin E in patients with immediate persulfate hypersensitivity

Persulfate salts may cause contact urticaria, allergic and irritant contact dermatitis, rhinitis and asthma. The mechanism of the immediate reactions has been unclear. Positive prick test, skin application and nasal and bronchial provocations identify immediate allergy. There is only 1 previous report of specific binding of immunoglobulin E (IgE) to ammonium persulfate demonstrated by radioallergosorbent test (RAST). In the present study, fresh 2% ammonium and potassium persulfate solutions were used for prick testing. Patients with positive prick tests were further evaluated with open skin application, immunospot and RAST. Prick testing with persulfate salts was performed in a total of 138 patients. 7 patients had a positive reaction to at least 1 persulfate salt. 6 of the patients had had skin symptoms, urticaria, eczema or angioedema, because of contact with hair bleaches. Open application on healthy skin was performed in 4 patients, and 3 out of them had urticarial reactions. The sera of 5 patients were investigated with immunospot and RAST. On immunospot, specific binding of IgE to human serum albumin (HSA)-conjugated ammonium and potassium persulfate was found in 2 patients. 1 immunospot-positive patient also had a positive RAST to ammonium persulfate-HSA conjugate. The mechanism of immediate hypersensitivity to persulfates thus seems to be IgE-mediated at least in some patients.

Prevalence of airway symptoms and total serum immunoglobulin E among hairdressers in Bergen: a four-year prospective study

We examined changes in the self-reported prevalence of respiratory symptoms and total serum immunoglobulin E (IgE) among hairdressers after local exhaust ventilation was installed in some hairdresser salons. We also examined differences in these variables between current and former hairdressers. The survey was a prospective study on 91 female hairdressers and a control group of 80 female office workers. Total serum IgE remained high in the hairdresser groups both in 1995 and 1999 (101 vs. 105 IU/mL blood). The IgE levels among office workers were low in 1995 and 1999. Forty percent of the hairdressers in 1995 had left their profession by 1999, 5.7 times the rate among office workers. The frequency of wheezing in the past year decreased significantly among current and former hairdressers. Our data suggest that hairdressers who remained in their profession were a highly selected and healthy group of workers. The improvement in symptoms might be explained by the reduced exposure resulting from the installation of local exhaust ventilation.

Contact allergy to ingredients of hair cosmetics in female hairdressers and clients - an 8-year analysis of IVDK* data

Not only hairdressers, but also their clients or home-users of hair cosmetic products may become sensitized to one of the product constituents. The present analysis addresses the question whether the pattern of sensitization is different in these 2 groups and includes female patients who consulted with the participating centres of the IVDK (http://www.ivdk.org) between 1995 and 2002, and in whom hair cosmetics have been considered as being causative of their contact dermatitis. Among these, 2 subgroups were identified: (i) patients, currently or previously working as hairdressers, diagnosed with occupational skin disease (H, n = 884) and (ii) patients who never worked as hairdressers, i.e. clients (C, n = 1217). Previous atopic eczema was twice as common among H, who were also much younger (median age 24 versus 46 in C). Analysis of sensitization frequencies and patterns showed the well-known decline of contact allergy to glyceryl monothioglycolate (GMTG) in H from 31.2% to 8.5%. Among the C, 1.7% were allergic to GMTG. Concerning p-phenylenediamine, a steady decline from 27.6% to 17.2% was observed in H, while no trend was found in C (12.6% and 16.6% in the first and the last 2-year period, respectively). Conversely, a very slight decline of p-toluenediamine sensitization was observed in H (from 29.5% to 24.8%), while at the same time a significant increase was noted in C (from 8.7% to 16.7%). A slighter increase was also noted with ammonium persulfate in C (3.1-6.8%), while the proportion of H sensitized remained largely constant at about 26%.

Occupational skin-disease data in Europe

The different occupational health systems and legislations in the countries across Europe makes it difficult for one to sketch a detailed picture for the whole continent. Reporting bias and selection bias have a considerable impact on the perceived prevalence and incidence, while reliable data are hard to extract from official registries. Data from one region in Germany will serve as an example. Comparison with data from other sources yields an estimate of 0.7 to 1.5 cases per 1,000 per year as a gross average, while the problem in specific occupational groups is more pronounced. Reliable data on social and economic impact are very scarce.

Final report on the safety assessment of Ammonium, Potassium, and Sodium Persulfate

Ammonium, Potassium, and Sodium Persulfate are inorganic salts used as oxidizing agents in hair bleaches and hair-coloring preparations. Persulfates are contained in hair lighteners at concentrations up to 60%, in bleaches and lighteners at up to 22% and 16%, respectively, and in off-the-scalp products used to highlight hair strands at up to 25%. They are used in professional product bleaches and lighteners at similar concentrations. Much of the available safety test data are for Ammonium Persulfate, but these data are considered applicable to the other salts as well. Acute dermal, oral, and inhalation toxicity studies are available, but only the latter are remarkable, with gross lesions observed in the lungs, liver, stomach, and spleen. In short-term and subchronic feeding studies the results were mixed; some studies found no evidence of toxicity and others found local damage to the mucous membrane in the gastrointestinal tract, but no other systemic effects. Short-term inhalation toxicity was observed when rats were exposed to aerosolized Ammonium Persulfate at concentrations of 4 mg/m3 and greater. Ammonium Persulfate (as a moistened powder) was not an irritant to intact rabbit skin, but was sensitizing (in a saline solution) to the guinea pig. It was slightly irritating to rabbit eyes. Ammonium Persulfate was negative in the Ames test and the chromosomal aberration test. No significant evidence of tumor promotion or carcinogenicity was observed in studies of rats receiving topical applications of Ammonium Persulfate. The persulfates were reported to cause both delayed-type and immediate skin reactions, including irritant dermatitis, allergic eczematous dermatitis, localized contact urticaria, generalized urticaria, rhinitis, asthma, and syncope. The most common causes of allergic dermatitis in hairdressers are the active ingredients in hair dyes, and Ammonium Persulfate has been identified as a frequent allergen. A sensitization study that also examined the incidence of urticarial reactions was performed with 17.5% Ammonium, Potassium, and Sodium Persulfate under occlusive patches. At this concentration and exposure conditions, a mixture of these Persulfates was not sensitizing, and application of Ammonium, Potassium, and Sodium Persulfate did not result in an urticarial reaction. In normal use (i.e., not occluded and rinsed off), it was expected that a concentration greater than 17.5% would also be safe. Given the clinical reports of urticarial reactions, however, manufacturers and formulators should be aware of the potential for urticarial reactions at concentrations of Persulfates greater than 17.5%. Based on the available data, the Cosmetic Ingredient Review (CIR) Expert Panel concluded that Ammonium, Potassium, and Sodium Persulfate are safe as used as oxidizing agents in hair colorants and lighteners designed for brief discontinuous use followed by thorough rinsing from the hair and skin.

Occupational contact dermatitis. Recognition and management

Occupational contact dermatitis (OCD) represents 90 to 95% of all occupational dermatoses. The incidence rate of OCD is estimated to be around 0.5 to 1.9 cases per full-time worker per year. However, epidemiologic data are lacking and incidence is probably underestimated, especially in the US. Over the past 20 years, OCD has been the most frequently reported occupational disorder to German social insurance institutions. Critical factors in the management of OCD are recognition of clinical features, knowledge of allergens and irritants present in different occupational fields, knowledge of suitable protection, interpretation of patch test results, and awareness of medicolegal aspects. Management of OCD should be carried out by dermatologists and patch test clinics in cooperation with physicians specialized in industrial medicine. Individuals at high risk of OCD are hairdressers, dental laboratory technicians, other healthcare workers, construction industry workers, metal workers, leather and shoe manufacturers, florists and gardeners, and bakers, caterers, confectioners and cooks.

Hair dye-sensitized hairdressers: the cross-reaction pattern with new generation hair dyes

Hair dye allergies are a frequent cause of occupational skin disease among hairdressers. Conventional hair dyes contain 4-phenylenediamine (PPD), 2, 5-diaminotoluene sulfate (DTS) and 2-nitro-4-phenylenediamine (ONPPD) as allergens. In new generation hair dyes, FD & C and D & C dyes are used in the hair dye formulations. This study investigated the cross-reaction pattern of new generation hair dyes among hairdressers (n = 40) with a known allergy to PPD and/or DTS and/or ONPPD. In the 40 hairdressers no positive reactions were observed to the single FD & C and D & C dyes. In two hairdressers, doubtful reactions were observed to one or more of the hair dye formulations. The data from this study suggest that for hairdressers sensitized to PPD and/or DTS and/or ONPPD this new generation of hair dyes is a safe alternative for use in their salons.

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 disease in hairdressers

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

Allergic contact cheilitis due to effervescent dental cleanser: combined responsibilities of the allergen persulfate and prosthesis porosity

A 55-year-old man with a dental prosthesis for 3 years had had a chronic relapsing cheilitis for more than 1 year. He was patch tested with the European standard series, his own topicals, and the dental cleanser at 10% pet. A relevant positive reaction ++ was found to the cleansing agent, which contained 20% potassium persulfate. The breakdown of the test confirmed sensitivity to this agent and to ammonium persulfate, both positive (++) at 2.5% pet. The patient was free of symptoms after he had avoided the cleanser. Subsequent chemical investigations performed with a fragment of a used dental prosthesis revealed strong adsorption of persulfate, both on the resin and on the dental tartar. Cleansing agents, adsorbed on tartar and porous resins of worn dental prostheses, should be considered as potential sensitizers and consequently patch tested on such patients with chronic cheilitis.