Prognosis of occupational hand dermatitis in metalworkers

Causes of irritant contact dermatitis after occupational skin exposure: a systematic review

PURPOSE

Irritant contact dermatitis (ICD) is a major cause of occupational disease. The aim was to review the relation between exposure to occupational irritants and ICD and the prognosis of ICD.

METHODS

Through a systematic search, 1516 titles were identified, and 48 studies were included in the systematic review.

RESULTS

We found that the evidence for an association between ICD and occupational irritants was strong for wet work, moderate for detergents and non-alcoholic disinfectants, and strong for a combination. The highest quality studies provided limited evidence for an association with use of occlusive gloves without other exposures and moderate evidence with simultaneous exposure to other wet work irritants. The evidence for an association between minor ICD and exposure to metalworking fluids was moderate. Regarding mechanical exposures, the literature was scarce and the evidence limited. We found that the prognosis for complete healing of ICD is poor, but improves after decrease of exposure through change of occupation or work tasks. There was no substantial evidence for an influence of gender, age, or household exposures. Inclusion of atopic dermatitis in the analysis did not alter the risk of ICD. Studies were at risk of bias, mainly due to selection and misclassification of exposure and outcome. This may have attenuated the results.

CONCLUSION

This review reports strong evidence for an association between ICD and a combination of exposure to wet work and non-alcoholic disinfectants, moderate for metalworking fluids, limited for mechanical and glove exposure, and a strong evidence for a poor prognosis of ICD.

U.K. standards of care for occupational contact dermatitis and occupational contact urticaria

The diagnosis of occupational contact dermatitis (OCD) and occupational contact urticaria (OCU) is a process that involves fastidious clinical and occupational history taking, clinical examination, patch testing and skin-prick testing. A temporal relationship of work and/or the presence of a rash on the hands only raises suspicion of an occupational cause, and does not necessarily confirm an occupational causation. The identification of allergy by patch or prick tests is a major objective, as exclusion of an offending allergen from the environment can contribute to clinical recovery in the individual worker and avoidance of new cases of disease. This can be a complex process where allergens and irritants, and therefore allergic and irritant contact dermatitis, may coexist. This article provides guidance to healthcare professionals dealing with workers exposed to agents that potentially cause OCD and OCU. Specifically it aims to summarize the 2010 British Occupational Health Research Foundation (BOHRF) systematic review, and also to help practitioners translate the BOHRF guideline into clinical practice. As such, it aims to be of value to physicians and nurses based in primary and secondary care, as well as occupational health and public health clinicians. It is hoped that it will also be of value to employers, interested workers and those with responsibility for workplace standards, such as health and safety representatives. Note that it is not intended, nor should it be taken to imply, that these standards of care override existing statutory and legal obligations. Duties under the U.K. Health and Safety at Work Act 1974, the Management of Health and Safety at Work Regulations 1999, the Control of Substances Hazardous to Health Regulations 2002, the Equality Act 2010 and other relevant legislation and guidance must be given due consideration, as should laws relevant to other countries.

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.

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.

Dermal nickel exposure associated with coin handling and in various occupational settings: assessment using a newly developed finger immersion method

BACKGROUND

The role of nickel in causing hand dermatitis in some occupations has been difficult to assess due to problems with reliable measurement of the exposure to nickel in the workplace and lack of a definitive threshold for nickel allergic contact dermatitis. It is not uncommon to find nickel allergy on patch testing but it is difficult to determine whether this is of relevance to occupational nickel exposure or simply a reflection of past exposure to nickel-plated jewellery or other nonoccupational nickel exposure.

OBJECTIVES

To devise a simple and reproducible method to quantify the amount of nickel on the skin and to apply the technique to measure dermal nickel exposure in various occupational settings.

METHODS

A rapid and simple sampling procedure was developed for determination of nickel on the skin of workers potentially exposed to nickel by exposing individuals to nickel-releasing coins and measuring exposure by immersing the exposed thumbs and index fingers directly into graduated sample tubes containing ultrapure water and aqueous nickel extracts. The solutions were analysed by inductively coupled plasma-optical emission spectrometry after stabilization with nitric acid. The method shows advantages over alternatives such as wipe testing and tape stripping in terms of extraction efficiency, speed and ease of operation in the field. A pilot survey of dermal nickel exposure for workers in several occupational settings was conducted.

RESULTS

The study suggested that a 'normal' level of nickel on the skin is <10 ng cm(-2). Coin handling induced an appreciable increase in the amount of nickel on the skin within 2 min. Experiments indicated a linear relationship between coin handling (exposure time) and measured dermal nickel levels following standardized coin handling. A pilot survey, conducted among cashiers, shop assistants, bar staff, hairdressers and workers in the nickel industry revealed dermal nickel concentrations ranging from <0.9 to 7160 ng cm(-2). The levels of nickel on the skin of cashiers, shop assistants, bar staff and hairdressers were below the threshold level for water-soluble ionic nickel for occluded exposure at which 10% of nickel-allergic subjects react (0.01% or 100 parts per million, equivalent to 530 ng cm(-2)) and the five-times higher threshold for unoccluded exposure (500 parts per million). The levels in some nickel platers and nickel refinery workers approached or exceeded these levels. However, few cases of nickel dermatitis are observed in plating and refinery facilities, perhaps due to immune tolerance, self-selection or, for refinery workers, exposure to water-insoluble rather than water-soluble nickel compounds. The elicitation threshold for water-soluble nickel compounds cannot be compared directly with dermal exposure to water-insoluble nickel compounds as the latter release a significantly lesser amount of nickel ions.

CONCLUSIONS

We describe a reproducible, simple and rapid procedure for the assessment of nickel levels in occupationally exposed individuals.

Fifteen-year follow-up of hand eczema: persistence and consequences

BACKGROUND

Hand eczema is a skin disease often with a long-lasting and relapsing course. The long-term prognosis in the general population is unknown.

OBJECTIVES

The aims were to examine the extent to which hand eczema had persisted and the medicosocial consequences of the disease.

METHODS

In a 15-year follow-up of hand eczema, patients diagnosed in a previous population-based study were sent a questionnaire with 20 questions concerning the persistence and course of the disease, and its occupational and medicosocial consequences.

RESULTS

Addresses were available for 1115 persons, of whom 868 answered the questionnaire. Sixty-six per cent of the respondents reported periods of hand eczema and 44% reported symptoms during the previous year, with no sex difference. Twelve per cent reported continuous eczema. However, 74% of those reporting symptoms considered that their hand eczema had improved; of these more were women than men (78% vs. 66%, P < 0.01). Twenty people, 3% of those who were gainfully employed in 1983, reported a change to another occupation because of their hand eczema, 15 of these reporting improvement after the job change. A considerable need for medical consultation was reported, as was the influence on psychosocial functions among those who had eczema the previous year, e.g. sleep disturbances (36%) and hampered leisure activities (72%). Job changes related to hand eczema and psychosocial impairment were also reported by individuals who had not sought medical help for their hand eczema.

CONCLUSIONS

This study demonstrates a variable and poor long-term prognosis for hand eczema in the general population. One-third sought medical care during follow-up, while the vast majority with ongoing hand eczema experienced negative psychosocial consequences. For about 5%, the hand eczema gave far-reaching consequences including long sick-leave periods, sick pension and changes of occupation.

The prognosis of occupational contact dermatitis in 2004

The prognosis of occupational contact dermatitis (OCD) takes into account the extent of healing, effect on quality of life and employment, and financial costs for both the individual and the wider community. We reviewed 15 studies published between 1958 and 2002, reporting the complete clearance of dermatitis (range of 18-72%). 9 of the 15 studies reported a clearance rate of between 18 and 40%. Improvement was reported as an outcome in 3 studies between 1991 and 2002 (range of 70-84%). A number of common variables were identified as of possible influence. These include age, sex, atopy, patient knowledge, disease aetiology, duration of symptoms and job change; clinical, financial and social issues are also described. All of these factors need to be considered when managing a patient with OCD. Improved patient knowledge and early diagnosis may be associated with improved prognosis, whereas job change does not make a significant difference. Some patients will develop persistent post-occupational dermatitis, which has important implications for prognosis and workers' compensation. Only a small proportion of eligible patients receive workers' compensation, even though financially supported healing time soon after diagnosis may result in an improved prognosis.

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

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

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.

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.

Occupational contact dermatitis has an appreciable impact on quality of life

In this study, we examined the impact of occupational contact dermatitis on quality of life. 181 patients, diagnosed with occupational contact dermatitis over a period of 3 years (1996-1999 inclusive), were sent a questionnaire based on the Dermatology Life Quality Index (DLQI) and the Short Form-36 (SF-36). 60 (32%) patients were in industrial occupations and 27 (14%) in health care. An overall response rate of 39% (n=70) was obtained. The median DLQI score was 5, with a mean score 6.6 (SD 6.4), which is similar to that seen in Behçet's syndrome and urticaria. There was no statistically-significant difference between male and female median scores (p=0.98) and no significant correlation between age and DLQI score nor between DLQI score and time from diagnosis. The most problematic quality of life areas were symptoms and feelings. Males scored highest in problems associated with work, relationships and treatment, whereas females scored highest in problems associated with symptoms and feelings, daily activities and leisure. The SF-36 scores showed an association between physical problems and emotional problems affecting work. From this study, it can be seen that occupational contact dermatitis has an appreciable impact on quality of life.