Article

UK trends of allergic occupational skin disease attributed to fragrances 1996-2015: OCCUPATIONAL SKIN DISEASE ATTRIBUTED TO FRAGRANCE

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Abstract

Background: Fragrances are well known to cause allergic contact dermatitis (ACD). Occupationally related cases occur, with certain groups being at higher risk. Objective: To investigate the incidence of occupationally related cases of cutaneous fragrance allergy and to evaluate trends. Method: Data on incident cases of occupational ACD caused by fragrances between 1996 and 2015 (inclusive) reported to the EPIDERM surveillance scheme were analysed. Results: Of the cases reported to EPIDERM during the study period, 5.2% had ACD attributed to fragrances. The highest annual incidence rates were observed in women. Hairdressers, beauticians and people working in related occupations had a 47-fold higher incidence rate ratio than the reference category (the average of all other occupations combined). Trends analysis suggested a non-significant increase in fragrance allergy over the study period among all occupations, and beauty and food workers, and a slight decrease in healthcare workers. Conclusions: Fragrance allergy is a significant problem in an occupational setting. Although there was no significant change in the incidence of fragrance-related allergic occupational contact dermatitis (OCD) during the 20-year study period, this does not mirror the trend in OCD, which is falling. Fragrance allergy continues to be a major contributor to OCD, and contributes to a greater proportion of cases.

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... In a UK study analyzing OCD 1996-2015, beauticians, hairdressers, and beauty industry workers had a 47 times higher incidence rate ratio of allergy to fragrance when compared to the average rate of all other occupations combined [47]. ...
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Occupational skin disease is common. It affects workers more often than reported. Contact dermatitis, both irritant and allergic, accounts for the majority of occupational skin diagnoses. Occupational contact dermatitis (OCD) frequently affects the hands and may have a profound impact on an employee’s ability to perform a job. Severe OCD can affect a worker’s activities of daily living and can even lead to job loss. Numerous irritants have been described in the workplace, from the common (wet work) to the more obscure (warm, dry air). Several contact allergens may be work-related, and the majority of established occupational allergens are also known nonoccupational allergens. Emerging occupational allergens are continually described in the literature. Patch testing is the gold standard for the workup of allergic contact dermatitis. Patch testing in the setting of OCD may require extended or unique allergen trays, as well as a thorough occupational history and collection of workplace Material Safety Data Sheets (MSDS). These MSDS contain valuable information but may not be complete or accurate. Proof of occupational causation can be aided by employing the Mathias criteria. Certain industries and occupations are associated with higher rates of OCD, and as expected, the industries with direct contact with irritants and allergens are highly represented. The differential diagnosis for occupational dermatitis is broad and should be considered when evaluating an employee with suspected OCD. Some other diagnoses to consider include atopic dermatitis, psoriasis, and manifestations of internal disease, as well as an overlap syndrome of more than one diagnosis. OCD treatment should ideally follow the public health hazard controls’ stepwise approach. Prevention and early intervention are key to promoting occupational health and preventing OCD. Multidisciplinary teams have been successful in the treatment of OCD, and newly described topical treatments may provide additional modalities for use in the occupational setting.
... In addition, although the studies of Loretz et al [11][12][13] are limited to consumer use data from women, it has been reported that allergic contact dermatitis from fragrances is more common in women. 19,20 It should be noted that Api et al 3 used the 90th percentile data presented by Loretz et al [11][12][13] for several products, including pump hair spray, shampoo, conditioner, facial cleanser, and body wash. In contrast, we used the 95th percentile data from Loretz et al [11][12][13] in our analysis. ...
Article
Background: Many chemicals used for fragrance purposes in a diversity of products have allergenic potential. Based on such concerns, industry groups developed concentration limits for use of fragrance chemicals in personal care and cosmetic products. Objective: The aim of this study was to use a quantitative risk assessment to evaluate the potential for skin sensitization induction resulting from daily exposure to fragrance chemicals present in personal care and cosmetic products. Methods: Product-specific dermal consumer exposure levels were calculated based on product use data in US adult females and benchmarked against acceptable exposure levels based on reported no expected sensitization induction levels to determine a margin of safety for each fragrance under evaluation. Conclusions: The results demonstrate an increased risk of skin sensitization induction for several leave-on products (lipstick, solid antiperspirant, eye shadow, face cream) for most of the evaluated fragrance chemicals, particularly under high-use exposure scenarios. In contrast, rinse-off products (shampoo, conditioner, facial cleanser) were not associated with risk of skin sensitization induction. Because the approach was based on maximum use limits for fragrance chemicals with skin sensitization concerns, the results suggest these limits may not be protective, particularly in the United States.
... While in the United Kingdom fragrance allergy seems to be on the decline, this was not the case with regard to occupational contact dermatitis related to fragrances, which remained stable, hairdressers and therapists being the occupations with the highest incidence rates [83]. In contrast, according to a Danish follow-up study involving 1496 patients with occupational hand eczema or contact urticaria, fragrances only ranked after rubber additives, biocides, hairdressing chemicals, nickel and epoxy resins regarding the share of sensitised patients [84]. ...
Article
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Contact allergy (sensitisation) and allergic contact dermatitis (ACD) resulting from it have a considerable public health impact. For the present review, all pertinent articles were systematically searched via Medline and Web of Science™; additionally, all available issues of the journals “Contact Dermatitis” and “Dermatitis” were manually searched, covering the years 2018–2019, thereby extending and re-focusing a previous similar review. New allergens, or previously described allergens found in a new exposure context or of other current importance, are described in sections according to substance classes, e.g., metals, preservatives, fragrances. As a common finding in many investigations, a lack of information on product composition has been noted, for instance, regarding a newly described allergen in canvas shoes (dimethylthiocarbamylbenzothiazole sulfide) and, most notably, absence of co-operation from manufacturers of glucose-monitoring devices and insulin pumps, respectively. These latter devices have been shown to cause severe ACD in a considerable number of diabetic patients caused by the liberation of isobornyl acrylate and N,N’-dimethylacrylamide, respectively, as demonstrated by an international collaboration between dermatologists and chemists. Improved and complete ingredient labelling for all types of products, and not just as we have with cosmetics at present (apart from full listing of fragrance substances) in Europe, must be put on the legislative agenda.
Chapter
Occupational contact dermatitis is the most frequent type of skin diseases caused by occupational factors. The frequency varies considerably among professions and is highest in hairdressers, chefs, food handlers, and healthcare workers. Numerous irritants and contact allergens have to be considered in the pathogenesis and are often highly specific for a particular profession. Therefore, in-depth information on the working environment must be obtained for the diagnostic work-up. Careful patch testing, particularly with the worker’s own materials, must be performed to identify relevant contact allergens. The prognosis depends on the diagnosis: slight forms of irritant contact dermatitis can usually be well improved with gloves and avoidance of major irritants. If an occupational contact allergen cannot be eliminated, or exposure to it be reduced, the worker frequently has to give up this occupation. Combined forms of allergic and irritant contact dermatitis, which are not rare, are the most difficult to treat. A multidisciplinary approach including dermatologists, allergists, technicians, and patient education is necessary.
Chapter
Fragrances are used in many types of products. They are composed of 10–300 individual fragrance ingredients, many of which may be allergens. Fragrance allergy is frequent, also in adolescents. In this chapter, an overview is given of the epidemiology of fragrance allergy, the causative allergens, the chemicals and naturals, and the exposures. The diagnosis of fragrance allergy can be difficult, but the three current diagnostic preparations, fragrance mix I and II (FM I and FM II) and Myroxylon pereirae (balsam of Peru) are helpful. Further individual substances of relevance for testing will be commented upon, and advice on how to inform the patient will be given.
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Allergic contact dermatitis to fragrance is common. The prevalence of fragrance allergy in the general population is between 0.7% and 2.6%. In patch-test populations, the positive reaction rate to fragrances ranges from 5% to 11%. The most common fragrance screeners in most baseline series include fragrance mix 1, fragrance mix 2, and Balsam of Peru. The addition of hydroxyisohexyl 3-cyclohexene carboxaldehyde, hydroperoxides of limonene, and hydroperoxides of linalool to screening series can further aid in the diagnosis of fragrance allergy. In the proper clinical setting, supplemental patch testing with an additional fragrance or essential oil series should be considered.
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Occupation contact dermatitis (CD) is a common inflammatory skin condition impacting every professional industry in the United States. It is associated with significant personal and professional distress, loss of revenue, and decreased productivity. Occupational CD is further subdivided into irritant CD and allergic CD. Frequently, workers may suffer from a combination of both types. Numerous workplace exposures are implicated, but there are several themes across professions, such as CD related to frequent handwashing and wet work. A detailed occupational history, physical examination, and patch testing can help to make the diagnosis. Treatment includes identification of the substance and avoidance, which often is quite challenging.
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Allergic contact dermatitis caused by fragrances and formaldehyde is common (1,2), but pustular dermatitis as a manifestation of contact allergy is rare (3). We report a case of therapy‐resistant rosacea for which (occupational) contact allergy to fragrances, and to a lesser extent formaldehyde, was identified as an aggravating factor. This article is protected by copyright. All rights reserved.
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Purpose of review: The purpose was to highlight recent findings especially concerning new and old allergens, trends, diagnosis and causes of contact allergy. Recent findings: Nickel is still the most frequent cause of contact allergy in women and piercings remain an important risk factor. Countries with a long history of regulation of contact allergens have the lowest level of contact allergy to nickel and chromium in Europe. Among the most frequent causes of fragrance contact allergy is terpenes, which are oxidized such as limonene, linalool and in some countries: geraniol. Methylisothiazolinone is still causing considerable problems due to hidden exposures. Acrylates are emerging allergens and 2-hydroxyethyl methacrylate has been included in the 2019 update of the baseline series, as many new cases are seen due to long-lasting nail polish based on acrylates and glue (isobornyl acrylate) in insulin pumps. More than 10 new allergens have been described, which need to be considered in diagnosing contact allergy. Summary: Allergic contact dermatitis is a frequent problem, it also constitutes a challenge to diagnose due to many potential contact allergens. The main culprit allergens remain the same, new significant causes are found especially within acrylates.
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The toxicology of fragrance materials is largely well understood. Although most are benign, a minority have the potential to cause adverse health effects, notably allergic contact dermatitis resulting from skin sensitization. As a consequence, industry guidelines have banned certain materials and strictly limited the use of others. Recently, data have been published that have been interpreted to suggest that inhalation of fragrances is associated with the occurrence of a variety of health effects, ranging from headaches to asthma attacks. In this review, the evidence basis for these assertions is examined critically and the biological basis and mechanistic plausibility for causation by fragranced products of these health effects is explored. This review concludes that respiratory effects, including irritation and allergy appear highly unlikely to occur by this route. While some sensory/psychosomatic effects are possible, this does not explain the very high rates of adverse effects reported in the recently published questionnaire studies, which this review concludes are more likely to be attributed to methodological weaknesses. Ultimately, it is concluded that adverse health effects arising from fragrance inhalation are uncommon and remain to be identified and confirmed by methodologically rigorous epidemiological investigations supported by a convincing biological and mechanistic basis.
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Contact dermatitis and contact allergy are common medical conditions. But how common are they? Are certain populations, e.g., certain occupations, more affected than others? Are reactions to specific contact allergens more prevalent than to other allergens or more common in a particular subgroup? This chapter presents some basic epidemiologic principles which are important in population-based or clinic-based studies on contact dermatitis. The chapter deals with methodological issues in the analysis of clinical epidemiological studies, i.e., among patients undergoing patch testing. Common pitfalls are addressed, and factors important for the occurrence of contact dermatitis and/or contact allergy are discussed. Examples of studies on contact allergy as well as contact dermatitis in general are presented.
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The currently used fragrance mix in the European baseline patch test series (baseline series) fails to detect a substantial number of clinically relevant fragrance allergies. To investigate whether it is justified to include hydroxyisohexyl 3-cyclohexene carboxaldehyde (Lyral) and fragrance mix 2 containing hydroxyisohexyl 3-cyclohexene carboxaldehyde, citral, farnesol, coumarin, citronellol, and alpha-hexyl cinnamal in the European baseline patch test series. Survey of the literature on reported frequencies of contact allergy and allergic contact dermatitis from fragrance mix 2 and hydroxyisohexyl 3-cyclohexene carboxaldehyde (Lyral) as well as reported results of experimental provocation test. Fragrance mix 2 has been demonstrated to be a useful additional marker of fragrance allergy with contact allergy rates up to 5% when included in various national baseline patch test series. Of the fragrance substances present in fragrance mix 2, hydroxyisohexyl 3-cyclohexene carboxaldehyde is the most common sensitizer. Contact allergy rates between 1.5% and 3% have been reported for hydroxyisohexyl 3-cyclohexene carboxaldehyde in petrolatum (pet.) at 5% from various European centres when tested in consecutive dermatitis patients. From 2008, pet. preparations of fragrance mix 2 at 14% w/w (5.6 mg/cm(2)) and hydroxyisohexyl 3-cyclohexene carboxaldehyde at 5% w/w (2.0 mg/cm(2)) are recommended for inclusion in the baseline series. With the Finn Chamber technique, a dose of 20 mg pet. preparation is recommended. Whenever there is a positive reaction to fragrance mix 2, additional patch testing with the 6 ingredients, 5 if there are simultaneous positive reactions to hydroxyisohexyl 3-cyclohexene carboxaldehyde and fragrance mix 2, is recommended.
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In statistical models of dependence, the effect of a categorical variable is typically described by contrasts among parameters. For reporting such effects, quasi-variances provide an economical and intuitive method which permits approximate inference on any contrast by subsequent readers. Applications include generalised linear models, generalised additive models and hazard models. The present paper exposes the generality of quasi-variances, emphasises the need to control relative errors of approximation, gives simple methods for obtaining quasi-variances and bounds on the approximation error involved, and explores the domain of accuracy of the method. Conditions are identified under which the quasi-variance approximation is exact, and numerical work indicates high accuracy in a variety of settings.
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Background: There is a significant rate of sensitisation worldwide to the oxidised fragrance terpenes limonene and linalool. Patch testing to oxidised terpenes is not routinely carried out; the ideal patch test concentration is unknown. Objectives: To determine the best test concentrations for limonene and linalool hydroperoxides, added to the British baseline patch test series, to optimise detection of true allergy and minimise irritant reactions. Methods: During 2013-2014, 4563 consecutive patients in 12 UK centres were tested to hydroperoxides of limonene in petrolatum (pet.) 0.3%, 0.2% and 0.1%, and hydroperoxides of linalool 1.0%, 0.5% and 0.25% pet. Irritant (IR) reactions were recorded separately from doubtful (?+) reactions. Concomitant reactions to other fragrance markers and clinical relevance were documented. Results: Limonene hydroperoxide 0.3% gave positive reactions in 241 (5.3%) patients, irritant reactions in 93 (2.0%) and doubtful reactions in 110 (2.4%). Linalool hydroperoxide 1.0% gave positive reactions in 352 (7.7%), irritant reactions in 178 (3.9%), and doubtful reactions in 132 (2.9%). 119 patients with crescendo reactions to 0.3% limonene would have been missed if only tested with 0.1%. 131 patients with crescendo reactions to 1.0% linalool would have been missed if only tested with 0.25%. In almost two-thirds of patients with positive patch tests to limonene and linalool the reaction was clinically relevant. The majority of patients did not react to any fragrance marker in the baseline series. Conclusions: We recommend that limonene hydroperoxides be tested at 0.3% and linalool hydroperoxides at 1.0% in the British baseline patch test series. This article is protected by copyright. All rights reserved.
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Background: Geriatric nurses (GN) have a high risk of occupational contact dermatitis (OCD), with chronic irritant contact dermatitis predominating. However, allergic contact dermatitis is an important issue as well. Little is known whether the relevant occupational allergen spectrum reported in the 1990s, including fragrances, preservatives, rubber chemicals and ingredients of surface disinfectants to be the most common sensitizers in GN, is still valid. Objectives: To monitor the current allergen spectrum in GN with OCD and verify the validity of the patch test recommendations (baseline-, preservative-, ointment base-, rubber-, disinfectant, series and fragrances) in GN with suspected OCD given by the German Contact Dermatitis Research Group (DKG). Methods: Retrospective analysis of IVDK data (2005-2014) of 743 female GN with OCD, in comparison to 695 GN without OCD. Results: GN with OCD reacted significantly more frequently to both fragrance mixes, hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC), thiuram mix, zinc diethyldithiocarbamate and mercaptobenzothiazole than GN without OCD. Reactions to MDBGN, methylchloroisothiazolinone/methylisothiazolinone and oil of turpentine occurred substantially, but not significantly more frequently among GN with OCD. The latter may be due to former use of a special alcoholic liniment in geriatric care. Among material from the patients' workplaces, tetrazepam was a frequent allergen, due to dust exposure from pill crushing. Furthermore, occupationally used protective gloves, body care products as well as surface disinfectants were often tested positively. Conclusions: The general allergen spectrum in GN with OCD is unchanged, so the DKG patch test recommendations are still valid. Prevention of occupational sensitization should focus on fragrance-free hygiene and body care products, usage of accelerator-free protective gloves and avoidance of drug dust exposure.
Article
Background Population-based studies about contact allergy are scarce.Objectives: To obtain reliable estimates of prevalence of contact allergy in the general population in Europe.Methods Cross-sectional study of a random sample from the general population, aged 18 to 74 years, in 5 different European countries (Sweden, The Netherlands, Germany, Italy, Portugal). In total 12,377 subjects were interviewed and a random sample (n=3,119) patch tested to TRUE-test panel 1, 2 and 3 plus fragrance mix II, HICC, and sesquiterpene lactone mix. A positive patch test reaction is considered as contact allergy.ResultsIn total, 27.0% (95% CI 25.5-28.5) had at least one positive reaction to an allergen of the European baseline series with a significant higher prevalence in females compared to males. The highest age-standardized prevalences (≥ 1%) were found for nickel (14.5%; 95% CI 13.2-15.8), thimerosal (5.0%; 95% CI 4.2-5.8), cobalt (2.2%; 95% CI 1.7-2.7), fragrance mix II (1.9%, 95% CI 1.5-2.5), fragrance mix I (1.8% 95% CI 1.4-2.3), hydroxyisohexyl-3-cyclohexene carboxaldehyde (HICC)(1.4%, 95% CI 1.0-1.9), p-tert-butylphenol- formaldehyde-resin (1.3%; 95% CI 0.9-1.7), and p-phenylenediamine (1.0%; 95% CI 0.6-1.3). Only Nickel and Thimerosal showed a statistically significant different prevalence for contact allergy amongst the different European populations. Subjects that reported contact dermatitis in lifetime (age-standardized prevalence 15.1%, 95%CI 13.8-16.3) had an increased risk for contact allergy (OR 1.9, 95% CI 1.5-2.5) the risk of having a contact allergy was not increase in those with atopic dermatitis (prevalence 7.6%, 95% CI 6.7-8.6; OR 1.0, 95% CI 0.7-1.4).Conclusions Contact allergy to at least one allergen of the European baseline series was diagnosed in more than one quarter of the general European population. Therefore measures to improve the primary prevention of contact allergy have to be enforced.This article is protected by copyright. All rights reserved.
Article
Sensitization to fragrance is believed to occur mainly outside the workplace. This study addresses the frequency of fragrance allergy in patch test patients of differing occupations during a 15 year period. The occupation most strongly associated with fragrance allergy in both sexes was health care work (positive tests in 11.7% of males and 10.4% of females). Retired individuals also had high rates of fragrance allergy (11.6% of males and 14.5% of females), and the prevalence of sensitization increased with advancing age. Health care workers and metalworkers had statistically significantly higher rates of allergy to eugenol than did workers in other occupations. Food handlers had significantly higher rates of allergy to cinnamal and cinnamic alcohol. These findings suggest that sensitization to fragrance occurs more frequently in an occupational setting than is generally understood and could have implications for preventive measures.
Article
Background Occupational contact dermatitis is one of the most common occupational diseases in Europe. In order to develop effective preventive measures, detailed and up-to-date data on the incidence, main causes and professions at risk of occupational contact dermatitis are needed.Objectives To describe the pattern of patch test reactivity to allergens in the European baseline series of patients with occupational contact dermatitis in different occupations.Methods We analysed data collected by the European Surveillance System on Contact Allergy (ESSCA) network from 2002 to 2010, from 11 European countries.ResultsAllergens in the European baseline series associated with an at least doubled risk of occupational contact dermatitis include: thiuram rubber chemical accelerators, epoxy resin, and the antimicrobials methylchloroisothiazolinone/methylisothiazolinone, methyldibromo glutaronitrile, and formaldehyde. The highest risk of occupational contact dermatitis was found in occupations classified as ‘other personal services workers’, which includes hairdressers, nursing and other healthcare professionals, precision workers in metal and related materials, and blacksmiths, tool-makers and related trades workers.Conclusions In the planning and implementation of measures aimed at preventing occupational contact dermatitis, the focus should be on the identified high-risk occupational groups and the most common occupational allergies.
Article
Healthcare workers are occupationally exposed to various allergens in protective gloves, surface or instrument disinfectants, drugs, and skin care products. An increased prevalence of sensitization to thiurams, glutaraldehyde, formaldehyde and glyoxal in nurses with occupational contact dermatitis (OCD) has been known since the 1990s. To update the range of occupational allergens in healthcare professionals. We retrospectively analysed patch test data from the Information Network of Departments of Dermatology (IVDK), 2003-2012. Patch test results from 2248 nurses with OCD were compared with those of 2138 nurses without OCD. Significantly increased sensitization rates were found for thiuram mix (6.7%), potassium dichromate (5.7%), methylchloroisothiazolinone/methylisothiazolinone (4.4%), colophonium (3.4%), 2-bromo-2-nitropropane-1,3-diol (1.7%), and zinc diethyldithiocarbamate (1.7%). Patch testing with products from the patients' workplaces gave additional clues to further allergens, for example tetrazepam. The known range of contact sensitization in nurses with OCD has been confirmed. Formaldehyde allergy seems to be less important today. Drugs such as tetrazepam are occupational sensitizers in nurses. The increase in chromium sensitization remains unexplained. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Article
Background Limonene is widely used as a fragrance substance and solvent in cleansing products. Oxidized limonene is a frequent contact allergen among consumers of cosmetics, personal care products, and scented household cleaning products. Less is known about the sources of occupational exposure and occupational contact dermatitis caused by limonene.Objective To report 14 patients with occupational contact allergy to limonene.Methods The patients were examined in 2008–2013. An in-house preparation of oxidized limonene was patch tested as 3% and 5% in petrolatum from 2008 to August 2010, and after this as 3%, 1% and 0.3% pet. From 2012 onwards, a commercial test substance of limonene hydroperoxides was also used. We assessed the patients' occupational and domestic exposure to limonene.ResultsOccupational limonene allergy was observed in workers who used limonene-containing machine-cleaning detergents and hand cleansers, and in workers who used limonene-containing surface cleaners and dishwashing liquids similar to those used by consumers. In 3 cases, the occupational limonene allergy resulted from work-related use of limonene-containing, leave-on cosmetic products.Conclusions Limonene is a frequent occupational sensitizer in hand cleansers and cleaning products. Occupational limonene contact allergy may also be caused by exposure to cosmetic products scented with limonene.
Article
Background: Beauticians are exposed to many potential allergens in their occupation. Aim: To identify the sources of occupational skin and respiratory disease reported in beauticians, with an emphasis on acrylate chemicals, and to investigate the trends over time. Methods: We used the Health and Occupation Research (THOR) database to identify occupational disease in beauticians between 1996 and 2011. Trend analysis was carried out to look for any change in the allergens reported over this period. Results: In total, 257 cases of contact dermatitis (CD) in beauticians were identified, which were associated with 502 suspected agents. The most frequently cited source of allergic CD was acrylate chemicals. The trend analysis showed a small average annual percentage increase in work-related CD in beauticians for all agents (1.1%; 95% CI -2.5 to 4.9). There was a small decrease in cases in which acrylates were not cited (-1.7%; 95% CI -5.9 to 2.7), and a statistically significant increase when acrylates were cited (7.4%; 95% CI 0.9 to 14.4). There were 11 cases of occupational asthma. Conclusion: We found an increase in cases of occupational dermatitis associated with acrylates in beauticians over a 15-year period, and describe other causes of occupational dermatitis.
Article
Experimental and clinical studies have shown that fragrance substances act as prehaptens or prohaptens. They form allergens that are more potent than the parent substance by activation outside or in the skin via abiotic (chemical and physical factors) and/or biotic activation, thus, increasing the risk of sensitization. In the present review a series of fragrance substances with well documented abiotic and/or biotic activation are given as indicative and illustrative examples of the general problem. Commonly used fragrance substances, also found in essential oils, autoxidize on contact with air, forming potent sensitizers that can be an important source for contact allergy to fragrances and fragranced products. Some of them can act as prohapten and be activated in the skin as well. The experimental findings are confirmed in large clinical studies. When substances with structural alerts for acting as prohaptens and/or prehaptens are identified, the possibility of generating new potent allergens should be considered. Predictive testing should include activation steps. Further experimental and clinical research regarding activation of fragrance substances is needed to increase consumer safety.
Article
Chefs and food handlers are at high risk of developing occupational skin diseases. Incidence rates per 10,000 workers per year range from 2.9 (butchers/food processing industries) and 6.6 (cooks) to 23.9 (pastry cooks) and 33.2 (bakers). Irritant contact dermatitis is the most prevalent occupational disease in chefs and food handlers, followed by allergic contact dermatitis (most frequently due to compositae (food), thiurams (gloves) and formaldehyde (detergents and disinfectants)). Food handling occupations are also prone to IgE-mediated protein contact dermatitis and immunological (IgE-mediated) and non-immunological occupational contact urticaria. Some food and food additives can trigger several of these mechanisms independently and may induce different clinical pictures. The prerequisite for a successful treatment is the individual identification and exclusion of the disease eliciting allergen(s), as well as implementation of skin protection.
Article
Background. Healthcare workers are at increased risk of developing hand eczema. Objectives. To investigate the prevalence and severity of self-reported hand eczema, and to relate the findings to demographic data, occupation, medical speciality, wards, shifts, and working hours. Patients/materials/methods. A survey of 3181 healthcare workers was performed. Data were analysed with logistic regression. Data on sick leave and notification to the authorities were obtained. Results. The response rate was 71% (2274 of 3181). The 1-year prevalence of hand eczema was 21%, and was positively associated with atopic dermatitis, younger age, male sex (male doctors), and working hours. Eighty nine per cent of subjects reported mild/moderate lesions. Atopic dermatitis was the only factor significantly related to severity. Sick leave was reported by 8% of subjects, and notification to the authorities by 12%. Conclusions. The 21% prevalence of hand eczema in healthcare workers is double the prevalence in the background population. Eleven per cent of hand eczema patients reported severe/very severe eczema. No significant differences were found between professions or medical specialities with respect to prevalence or severity, but cultural differences between professions with respect to coping with the eczema were significant. Atopic dermatitis was related to increased prevalence and severity, and preventive efforts should be made for healthcare workers with atopic dermatitis.
Article
The composition of water-based metalworking fluids (wb MWF) is complex, and various admixtures may be added before or during usage. Wb MWF may cause irritant as well as allergic contact dermatitis. While several current case reports point towards allergens particularly related to wb MWF, systematic studies have not been performed for several years. From 1999 to 2001, a study on contact allergies among patients with occupational dermatitis (OD) called "Fruhzeitige Erkennung allergener Stoffe bei beruflicher und nicht-beruflicher Exposition" (German acronym: FaSt) was conducted by the Information Network of Departments of Dermatology (IVDK), funded by the employers' liability insurances in Germany (HVBG). The objective of FaSt was to detect sensitization patterns related to particular occupational exposures. Anamnestic and clinical data were gathered using a standardised questionnaire. Patch test results were recorded by computer within the IVDK routine procedure. In addition to descriptive statistical analyses, logistic regression analysis was performed to control the effect of potential confounders. Among the 1842 OD patients in the FaSt study, there were 160 metalworkers exposed to wb MWF, whose data is presented in this paper. A specific allergen pattern of these patients can be described: most frequently, sensitizations to monoethanolamine (MEA), colophony/abietic acid, and fragrance mix were observed. Additionally, cobalt, formaldehyde, formaldehyde releasers and other biocides are important allergens in these patients. Preventive measures and aimed in-depth research may be based on these results. The special MWF test series have to be kept up to date based on exposure information from the MWF industry and on continuous surveillance of the target group.
Article
The bark of the cinnamon tree is used as a spice; its flavour is from an essential oil containing mainly cinnamal. To report new cases of occupational allergic contact dermatitis (ACD) from cinnamon and a novel case of airborne cinnamon contact allergy. We examined the patient material of two dermatological clinics in Helsinki to find cinnamon contact allergic patients and review their clinical records. We found six patients with delayed contact allergy to cinnamon. In four patients, cinnamon was the main cause of occupational ACD. Three of them had dermatitis on their hands and one patient on the face and neck. In the latter case, the exposure was shown to be airborne. In addition, the fifth patient was occupationally sensitized to cinnamon, but it was not the main cause of his hand dermatitis. In the sixth patient, cinnamon allergy was considered to derive from cross-allergy to fragrances. Five of the patients reacted to cinnamal separately and in fragrance mix I. None of the six patients had immediate-type cinnamon allergy. Occupational contact allergy to cinnamon is rare but needs to be considered in workers handling foods. Cinnamal is possibly the main allergen in cinnamon.
Article
Contact and systemic contact-type dermatitis reactions to spices such as nutmeg, mace, cardamom, curry, cinnamon, and laurel may be rare but may well be overlooked. In our experience, patch testing with these spices "as is" is very useful; if there is a positive reaction, testing with dilutions is helpful. Scratch-chamber testing often leads to false-positive irritant reactions. As Hjorth and Niinimäki have pointed out, a positive test to balsam of Peru may indicate a spice allergy, but the absence of such a reaction does not rule it out. In all the cases in our experience, the careful drafting of the anamnesis or case history was critical in the diagnosis.
Allergy to fragrance is the most common cause of cosmetic contact dermatitis and therefore constitutes a significant clinical problem. The widespread use of fragranced materials in skin care and household products is probably the most important reason for the high incidence of fragrance sensitization. This report will summarize the history of fragrance, review how to detect and evaluate fragrance allergy, discuss the problems inherent in patch testing with the fragrance mix and its constituents, describe systemic contact dermatitis from ingestion of certain flavors, and give suggestions for fragrance-sensitive patients. The use of fragrance mix in patch testing has been invaluable in detecting fragrance allergy. Continued investigation into positive patch test responses to fragrance in scented products is essential in helping to identify new fragrance allergens. Additionally, more cooperation is necessary between industry and dermatologists in assisting patients to avoid proven allergens.
Article
Hand hygiene is one of the basic components of any infection control program and is frequently considered synonymous with hand washing. However, health care workers frequently do not wash their hands, and compliance rarely exceeds 40%. Hand rubbing with a waterless, alcohol-based rub-in cleanser is commonly used in many European countries instead of hand washing. Scientific evidence and ease of use support employment of a hand rub for routine hand hygiene. It is microbiologically more effective in vitro and in vivo, it saves time, and preliminary data demonstrate better compliance than with hand washing. Therefore, a task force comprising experts from the Centers for Disease Control and Prevention and from professional societies is designing guidelines for the use of a hand rub in the United States. Today, most countries of Northern Europe recommend a hand rub for hand hygiene unless the hands are visibly soiled. Side effects are rare and are mainly related to dryness of the skin. This review evaluates the scientific and clinical evidence that support the use of alcohol-based hand rubs in health care facilities as a new option for hand hygiene.
Article
Epidemiological studies have described an increasing prevalence of fragrance allergy and indicated an association with hand eczema. 59 domestic and occupational products intended for hand exposure were subjected to gas chromatography-mass spectrometric (GC-MS) analyses to test the hypothesis that fragrance chemicals known to have the potential to cause contact allergy but not included in fragrance mix (FM) may be common ingredients in these products. A quantitative analysis of 19 selected fragrances was performed by GC-MS. Further analysis of GC-MS data revealed the presence of 43 other fragrance chemicals/groups of fragrance chemicals in the products investigated. Among the 19 target substances the most commonly detected were limonene in 78%, linalool in 61% and citronellol in 47% of the products investigated. The FM ingredients were present in these products with the following frequencies: oak moss (evernic acid methylester) 2%, cinnamic alcohol 2%, cinnamic aldehyde (cinnamal) 3%, isoeugenol 5%, alpha-amylcinnamic aldehyde (amyl cinnamal) 8%, hydroxycitronellal 12%, eugenol 27%, and geraniol 41%. Thus, the chemical analyses of domestic and occupational products indicates that investigation of potential contact allergy related to these products types should consider fragrance allergens additional to those in the FM, since these may occur with high frequency.
Article
Allergic contact dermatitis induced by the occupational use of products containing essential oils has not been studied comprehensively. The aim of the present report was to describe the characteristics, diagnosis, and outcome of 5 patients with occupational contact dermatitis because of essential oils attending our outpatient dermatology clinics over a 2-year period. These patients are added to the 11 cases reported thus far in the literature. The research shows that for proper diagnosis, patch tests with the standard series and the fragrance series should be performed, in addition to tests with the specific oils to which the patients were exposed. Patients should be instructed to avoid the allergens identified. Sensitization to essential oils has important implications for the occupational future of affected individuals.
Article
The ability to measure temporal trends in disease incidence is important, but valid methods are needed. This study investigates UK trends during 1996-2005 in work-related skin and respiratory diseases including non-malignant pleural disease, asthma, mesothelioma and pneumoconiosis and the potential for bias when using surveillance systems for this purpose. The volunteer reporters in three surveillance schemes were specialist physicians for skin diseases, specialist physicians for respiratory diseases and occupational physicians, respectively, who provided monthly reports of new cases of disease which they considered work related. Poisson regression models were used to investigate variation by calendar year (trend), season and reporter characteristics. Separately, temporal patterns in the probabilities of non-response and zero reports were investigated. Annual changes in disease incidences were compared between reporter groups. There was little evidence of change in incidences of non-malignant pleural disease, mesothelioma, skin neoplasia and urticaria, but falls were seen for contact dermatitis and pneumoconiosis. Although the directions of change were similar across reporter groups, the magnitude of annual change in incidence was often inconsistent: for occupational asthma, it was -1.9% (95% CI -5.2 to 1.4) and -12.1% (95% CI-19.5 to -4.1) using respiratory and occupational physician reports, respectively. Response rates were high (approximately 85%), but non-response increased slightly with membership time, as did the probability of a zero return in some groups. Adjustment of results for presumed reporting fatigue led to an upward correction in some calendar trends. As some estimated changes in incidence based on volunteer reporting may be biased by reporting fatigue, apparent downward trends need to be interpreted cautiously. Differences in the population bases of the surveillance schemes and UK health service capacity constraints may also explain the differences in trends found here.
Article
In statistical models of dependence, the effect of a categorical variable is typically described by contrasts among parameters. For reporting such effects, quasi-variances provide an economical and intuitive method which permits approximate inference on any contrast by subsequent readers. Applications include generalised linear models, generalised additive models and hazard models. The present paper exposes the generality of quasi-variances, emphasises the need to control relative errors of approximation, gives simple methods for obtaining quasi-variances and bounds on the approximation error involved, and explores the domain of accuracy of the method. Conditions are identified under which the quasi-variance approximation is exact, and numerical work indicates high accuracy in a variety of settings. Copyright Biometrika Trust 2004, Oxford University Press.
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