Occupational hand dermatitis in a tertiary referral dermatology clinic in Taipei

Use of protective gloves by hairdressers: A review of efficacy and potential adverse effects

Occupational hand eczema is common among hairdressers, and protective gloves are important in limiting exposure to irritants and allergens. Various glove types may differ in their protective ability, and their use may lead to hand eczema due to skin irritancy and allergy. MEDLINE was searched for studies investigating permeation of gloves to irritants and allergens used in the hairdressing trade, as well as adverse effects of glove use affecting hairdressers. Forty-four studies were identified; nine reported on permeation. Of those, two in vitro studies found nitrile rubber (NR) gloves to give the best protection when handling hair dyes. Polyethylene (PE) gloves had the lowest reported break-through time. The prevalence of sensitization to rubber materials in European hairdressers was as follows: thiuram mix, median 2.5% (range 0%-8.2%), weighted average 3.0% (95% confidence interval [CI] 3.0%-3.1%); mercapto mix, median 0.4% (range 0%-3.3%), weighted average 0.5% (95% CI 0.47%-0.50%), mercaptobenzothiazole, median 0.6% (range 0%-6.6%), weighted average 0.7% (95% CI 0.6%-0.7%), NRL-type I allergy, median 1.3% (range 1%-16.4%), weighted average 4.0% (95% CI 3.6%-4.5%). In conclusion, NR gloves provide the best skin protection for hairdressers, although natural rubber latex (NRL) and polyvinylchloride (PVC) gloves may be sufficient in most cases. PE gloves are not recommended. Synthetic rubber gloves with low or no levels of accelerators are preferred.

Prevalence and risk factors of occupational hand dermatoses in electronics workers

The electronics industry is becoming an important mainstream in the workforce in some developed countries and in Taiwan. Among patients with occupational hand dermatitis in northern Taiwan, workers from electronics industries were one of the most important groups. We conducted a field investigation to determine the prevalence, patterns and risk factors of occupational hand dermatoses among electronics workers. The survey was conducted in five electronics plants using a self-administered questionnaire on skin symptoms and risk factors. Skin examination and patch testing were followed for those with symptoms compatible with hand dermatitis. A total of 3070 workers completed the questionnaire. Among them, 302 (9.8%) reported to have symptoms (itching and with either redness/scaling) compatible with contact dermatitis on hands. Hand dermatitis was associated with working in the fabrication unit and personal history of atopy and metal allergy, as well as the following job titles: wafer bonding, cutting, printing/photomasking, softening/degluing, impregnation and tin plating. Among those with reported hand dermatitis, 183 completed skin examination and patch testing, 65/183 (35.5%) were diagnosed as having irritant contact dermatitis (ICD) and 7/183 (3.8%) allergic contact dermatitis. The most important allergens were nickel, cobalt and phenylenediamine. In conclusion, Taiwanese electronics workers have a high risk of having hand dermatitis, especially ICD. Preventive efforts should be focused on the workers with risk factors or at certain worksites.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contact dermatitis of the hands: Cross-sectional analyses of North American Contact Dermatitis Group Data, 1994-2004

BACKGROUND

Hand dermatitis, including irritant and allergic contact dermatitis (ACD), is common.

OBJECTIVE

To evaluate allergens, relevant irritants, sources and occupations associated with hand contact dermatitis using North American Contact Dermatitis Group (NACDG) data.

METHODS

A cross-sectional analysis of 22,025 patients patch tested between 1994 and 2004.

RESULTS

Hand involvement was found in 6953 patients; 959 had ACD as the only diagnosis. In these 959 patients, the 12 most frequent relevant allergens were quaternium-15 (16.5%), formaldehyde (13.0%), nickel sulfate (12.2%), fragrance mix (11.3%), thiuram mix (10.2%), balsam of Peru (9.6%), carba mix (7.8%), neomycin sulfate (7.7%), bacitracin (7.4%), methyldibromoglutaronitrile/phenoxyethanol 2.0% (7.4%), cobalt chloride (6.5%), and methyldibromoglutaronitrile/phenoxyethanol 2.5% (6.3%). Rubber allergens were most commonly associated with occupation. One third of patients with hand ACD had identifiable relevant irritants.

LIMITATIONS

Cross-sectional analyses prevent evaluation of causal associations.

CONCLUSION

In NACDG patients with hand ACD, the most common allergens included preservatives, metals, fragrances, topical antibiotics, and rubber additives.

Dermatitis de manos

Hand dermatitis is a common skin disease that often has a chronic and relapsing course. Several subtypes of hand dermatitis have been described. In this review, we describe the clinical characteristics of each form of hand eczema, laboratory tests helpful in the diagnosis, and treatment options for this condition.

Prognosis of contact dermatitis in epoxy resin workers

Between January 1993 and February 2002, 40 of 1354 (3%) workers who attended a tertiary referral occupational dermatology clinic were diagnosed with allergic contact dermatitis (ACD) from epoxy resin systems (ER). 20 of these patients were followed up at least 2 years post-diagnosis to establish prognosis. Characteristics collected at diagnosis, including age, atopic status and severity, were compared between the follow-up and not followed-up groups. No significant differences were observed. A clinician contacted patients and administered a telephone questionnaire based on variables identified from the literature, which were considered of importance for prognosis. All patients reported improvement of their skin condition since diagnosis. 12 of the 20 {60%[95% confidence interval (CI) 56-94%]} patients had applied for workers' compensation; all of these claims were successful. 16 had ceased working with ER. Of these, 9 [56% (95% CI 29-80%)] reported complete healing and 7 [44% (95% CI 19-70%)] reported ongoing dermatitis. Although no conclusions could be drawn because of the small sample size, factors that may be associated with a poor prognosis were age, atopy, duration of symptoms and severity at diagnosis. The prognosis of ACD from ER is not always favourable, even if a worker ceases exposure.

Combined exposure to carbon disulfide and sulfuric acid simultaneously increases the risk of hand dermatitis in rayon industry

OBJECTIVE

To evaluate the association between hand dermatitis (HD) and occupational exposure to CS(2) and to determine whether combined exposure to CS(2) and H(2)SO(4) exhibits a higher risk of HD.

METHODS

In all, 110 subjects from a rayon factory were recruited and their exposure was classified into CS(2) exclusively, H(2)SO(4) exclusively, combined exposure, and nonexposure control based on workers' job characteristics. A dermatologist was designated in the diagnosis of HD on palm and dorsal sites for each subject. Other confounding factors including detergent, glove wearing, and participation in wet work were determined using a person-to-person questionnaire interview from 37 randomly selected subjects.

RESULTS

Significant elevated odds ratios (ORs) for HD were found in CS(2) exclusively (44.8, P < 0.01) and combined exposure (49.0, P < 0.001) compared with control. Dose-response trends of ORs for HD were found across control, single exposure, and combined exposure for both CS(2) and H(2)SO(4).

CONCLUSIONS

HD could occur resulting from occupational exposure to CS(2) alone. This study was unable to affirm that the exposure to H(2)SO(4) alone is associated with HD due to limited H(2)SO(4) exposure subjects. The combined exposure to both CS(2) and H(2)SO(4) simultaneously could increase the risk of HD. The control remedy in preventing dermal contact with either CS(2) or H(2)SO(4) among the rayon workers should be performed immediately.

Therapeutic options for chronic hand dermatitis

Hand dermatitis is a common skin condition that often has a chronic and/or relapsing clinical course. Several clinical forms of hand dermatitis have been described, including contact (i.e., allergic and irritant), hyperkeratotic (i.e., psoriasiform or tylotic), frictional, nummular, atopic, pompholyx (i.e., dyshidrosis), and chronic vesicular hand dermatitis. In the present review, therapeutic options for these types of hand dermatitis are discussed in detail, focusing on treatments for recalcitrant hand dermatitis.

A patch test study of 27 crude drugs commonly used in Chinese topical medicaments

Chinese topical medicaments (CTMs) are commonly used in Taiwan and in Southeast Asia. However, a systematic evaluation of contact sensitization potential from CTM has not been carried out to our knowledge. This study was undertaken to investigate the incidence of contact sensitivity to the components of CTM in patients with contact dermatitis from CTM. A screening series of 27 crude drugs most commonly used in CTM as well as a modified European standard series was patch tested in 30 patients. The herbs with the most frequent positive reactions were Flos Caryophylli (see text), Radix Angelicae Pubescentis (see text), Cortex Cinnamomi (see text), Cortex Radix Acanthopanacis (see text), Caulis Impatientis (see text), Resina Draconis/Sanguis Draconis (see text), Fructus Cnidii (see text), Radix Gentiana Macrophyllae (see text), and Rhizoma Ligustici Chuanxiong (see text). Concomitant allergy to colophonium was found in most of these positive reactions. Reducing the concentration and simplifying the compositions of these components, as well as replacement with those of low allergenicity in CTM, such as Rhizoma Arisaematis (see text), Herba Lycopodii (see text), Radix Cyathulae Officinalis (see text), Rhizoma Pinelliae (see text), Radix Angelicae Dahuricae (see text), Herba Dendrobii (see text), Secretio Moschus (see text), and Stigmata Croci (see text), may be advocated. A precise labelling of the dosage of each component and the exact chemical compounds in CTM products could further improve the safety and therapeutic effects of CTM in the future.

Fragrance allergy and hand eczema - a review

Because hand eczema and fragrance allergy are common both among patients and in the general population, simultaneous occurrence by chance must be expected. Fragrances are ubiquitous and a part of many domestic and occupational products intended for hand exposure. The present review is based on a systematic literature research using both a manual and a Medline based search. The search identified 39 studies, including epidemiological patch test studies, general population patch test studies, case studies, and studies of occupational groups. The published data indicate a possible association between fragrance allergy and hand eczema. In future studies, a more detailed exposure assessment is needed, combined with patch test studies among patients with hand eczema tested with relevant fragrance allergens, as well as experimental control exposure studies to specific fragrance allergens on the hands. As exposures to fragrances on the hands are often simultaneous exposures to irritants, this combined exposure approach needs to be considered.

Environmental and occupational skin diseases in Taiwan

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

Dermatoses in cement workers in southern Taiwan

Construction workers are known to have occupational dermatoses. The prevalence of such dermatoses was unknown in Taiwanese construction workers. The objective of this study was to determine the work exposure, prevalence of skin manifestations, and sensitivity to common contact allergens in cement workers of southern Taiwan. A total of 1147 current regular cement workers were telephone-interviewed about skin problems during the past 12 months, work exposure, and personal protection. Among those interviewed, 166 were examined and patch tested with common contact allergens. A high % of cement workers reported skin problems in the past 12 months. More men (13.9%) reported skin problems possibly related to work than women (5.4%). Prevalence was associated with lower use of gloves, duration of work as cement worker, and more time in jobs involving direct manual handling of cement, especially tiling. A high % of dermatitis was noted in the 166 workers examined, which correlated with reported skin problems. On patch testing, construction workers had a high frequency of sensitivity to chromate. Sensitivity to chromate or cobalt was associated with reported skin problems, or dorsal hand dermatitis on examination. These workers' dermatitis was under-diagnosed and inadequately managed. It is concluded that cement workers in southern Taiwan had a high prevalence of skin problems related to cement use. Protective measures, work practice, and physician education should be improved to prevent or manage such problems.

Adverse reactions to fragrances. A clinical review

This article reviews side-effects of fragrance materials present in cosmetics with emphasis on clinical aspects: epidemiology, types of adverse reactions, clinical picture, diagnostic procedures, and the sensitizers. Considering the ubiquitous occurrence of fragrance materials, the risk of side-effects is small. In absolute numbers, however, fragrance allergy is common, affecting approximately 1% of the general population. Although a detailed profile of patients sensitized to fragrances needs to be elucidated, common features of contact allergy are: axillary dermatitis, dermatitis of the face (including the eyelids) and neck, well-circumscribed patches in areas of "dabbing-on" perfumes (wrists, behind the ears) and (aggravation of) hand eczema. Depending on the degree of sensitivity, the severity of dermatitis may range from mild to severe with dissemination and even erythroderma. Airborne or "connubial" contact dermatitis should always be suspected. Other less frequent adverse reactions to fragrances are photocontact dermatitis, immediate contact reactions and pigmentary changes. The fragrance mix, although very useful for the detection of sensitive patients, both causes false-positive and false-negative reactions, and detects only 70% of perfume-allergic patients. Therefore, future research should be directed at increasing the sensitivity and the specificity of the mix. Relevance is said to be established in 50-65% of positive reactions, but accurate criteria are needed. Suggestions are made for large-scale investigation of several fragrances on the basis of literature data and frequency of use in cosmetics. The literature on adverse reactions to balsam of Peru (an indicator for fragrance sensitivity), essential oils (which currently appear to be used more in aromatherapy than in perfumery) and on fragrances used as flavours and spices in foods and beverages is not discussed in detail, but pertinent side-effects data are tabulated and relevant literature is provided.