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Occupational contact allergy: The European perspective – analysis of patch test data from ESSCA between 2011‐2020
Abstract
Background:
Occupational skin diseases have led the occupational disease statistics in Europe for many years. Especially occupational allergic contact dermatitis is associated with a poor prognosis and low healing rates leading to an enormous burden for the affected individual and for society.
Objectives:
To present the sensitization frequencies to the most relevant allergens of the European baseline series in patients with occupational contact dermatitis (OCD) and to compare sensitization profiles of different occupations.
Methods:
The data of 16022 patients considered having OCD after patch testing within the ESSCA network between January 2011 and December 2020 were evaluated. Patients (n=46652) in whom an occupational causation was refuted served as comparison group.
Results:
The highest percentages of OCD were found among patients working in agriculture, fishery and related workers, metal industry, chemical industry, followed by building and construction industry, health care, food and service industry. Sensitizations to rubber chemicals (thiurams, carbamates, benzothiazoles) and epoxy resins were associated with at least a doubled risk of OCD. After a decline from 2014 onwards, the risks to acquire an occupation-related sensitization to methyl(chloro)isothiazolinone (MCI/MI) and especially to methylisothiazolinone (MI) seem to increase again. Sensitization rates to formaldehyde were stable, and to methyldibromo glutaronitrile (MDBGN) slightly decreasing over time.
Conclusions:
Among allergens in the European Baseline Series, occupational relevance is most frequently attributed to rubber accelerators, epoxy resins and preservatives. This article is protected by copyright. All rights reserved.
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Background: Allergic contact dermatitis (ACD) is one of the most
common skin diseases with a high prevalence rate of 15%-20% over
the general population. This high prevalence results in a large cost for
the healthcare system and greatly affects the quality of life of the
affected patients, highlighting the relevance for the development of
preventive strategies.
Objective: Screening of a panel of molecules (confidential) for their
capacity to avoid the adverse outcome pathways (AOP) evoked by
standard human skin allergens, using the non-animal approaches for
skin sensitization hazard, currently ongoing approval by the Organisation
for Economic Co-operation and Development (OECD).
Methods: The THP-1 cell line was used as a dendritic cell
(DC) surrogate. Then, and in accordance with the OECD guidelines for
skin sensitization assessment, 3 non-animal approaches were performed
(maturation of THP-1 cells through up-regulation of the CD54
and CD86 protein levels by flow cytometry, reactivity of allergens
towards cysteine and lysine residues using in-house developed solid
matrixes and increase on Nrf2-dependent genes through RT-PCR)
aiming to uncover whether selected molecules could prevent key
molecular events evoked by 3 well-known skin allergens: 1-fluoro-
2,4-dinitrobenzene (DNFB), Methylisothiazolinone (MI) and hydroxyisohexyl
3-cyclohexene carboxaldehyde (LI).
Results: Our results indicate that one of the molecules tested (reference
TOX1) inhibited the up-regulation of CD54 evoked by DNFB, MI
and LI in 70.95% and 59%, respectively. The dendritic cell maturation
marker CD86 was also inhibited in 49.21% and 11% after cells culture
with the skin allergens DNFB, MI, and LI, respectively. In chemico
studies also reveals that TOX1, TOX2, TOX3 decreased lysine and
glutathione depletion evoked by strong allergens. Furthermore, recent
studies reveal that tested molecules decreased the expression of
Nrf2-dependent genes in human keratinocytes.
Conclusion: The results obtained highlight three molecules able to
chemically sequester skin allergens and consequently with the potential
to prevent the development of key events involved in the AOP for
ACD.This work is the first step in proof-of-concept work that will generate
important insights in the preventive value of new medical
devices, acting as skin barriers. The successful development of the
proposal might allow the translation of this technology into a marketable/
clinical application
Background:
The practical importance of two recently described epoxy hardener allergens - 1,3-benzenedimethanamine, N-(2-phenylethyl) derivatives (1,3-BDMA-D) and hydrogenated formaldehyde benzenamine polymer (FBAP) - as occupational allergens remains to be defined.
Objectives:
To describe patients diagnosed at the Finnish Institute of Occupational Health (FIOH) with positive reactions to 1,3-BDMA-D or FBAP.
Methods:
We searched FIOH's patch test files from January 2017 to December 2020 for patients examined due to suspected occupational contact allergy to epoxy compounds. We analysed the patch test results and sources of exposure to various epoxy hardeners and focused on occupations, symptoms, and the sources of exposure to 1,3-BDMA-D and FBAP.
Results:
During the study period, 102 patients were examined at FIOH for suspected occupational contact allergy to epoxy compounds. Of these, 19 (= 18 %) were diagnosed with contact allergy to 1,3-BDMA-D (n=10) or FBAP (n=12). The largest occupational group was sewage pipe reliners (n=8). Seven different hardener products contained FBAP, whereas 1,3-BDMA-D was only present in one hardener used by spray painters.
Conclusions:
A substantial number of patients with suspected occupational epoxy resin system allergy tested positive to in-house test substances of 1,3-BDMA-D and/or FBAP. This article is protected by copyright. All rights reserved.
Protective gloves are an elementary component of personal protective equipment in many occupations and are intended to protect the hands from various hazards (e.g., wetness, chemicals, mechanical forces, or thermal stress). This is particularly important when other occupational safety measures (e.g., technical-organizational measures) cannot be implemented or are insufficient. However, it is not uncommon for protective gloves themselves to become a problem, as some of their ingredients (e.g., rubber accelerators) can cause allergic reactions. Accelerators in rubber gloves include thiurams, dithiocarbamates, thiazoles, guanidines, and thioureas. If no alternative means of protection are available, this may even result in abandoning the profession. This article is about rubber accelerators, which are often contained in protective gloves made of different rubber materials (e.g., natural rubber (latex) and nitrile rubber) and may cause delayed-type allergies, as well as related challenges, problems, and solutions for occupational skin protection.
Introduction
Painters and varnishers (“painters”) are exposed to various contact allergens and skin irritants, and therefore, at risk to develop occupational dermatitis (OD).
Objective
To describe the spectrum of occupational sensitizations in painters and revise corresponding current patch test recommendations.
Patients and Methods
Retrospective analysis of Information Network of Departments of Dermatology (IVDK) data from 2000 to 2019 with focus on male painters with OD, aged 20-59 years (n=557) in comparison to age-matched male painters without OD (n=422) and male OD patients that have had never worked as painters (n=13862).
Results
Male painters with OD have a significantly higher rate of allergic contact dermatitis and face dermatitis than male patients with OD working in other professions. Positive patch tests to epoxy resin, methylisothiazolinone (MI), and methylchloroisothiazolinone (MCI)/MI were significantly more frequent in painters with OD than in the other groups. Epoxy resin sensitization was significantly associated with face dermatitis.
Conclusions
Epoxy resin, MI and MCI/MI represent most important occupational sensitizers in painters. In addition to baseline, resins and glues, and industrial biocides series, patients’ own workplace materials should be tested in painters with suspected OD.
This article is protected by copyright. All rights reserved.
Background
In recent years, skin reactions secondary to the use of medical devices (MD), such as allergic contact dermatitis have increasingly been observed (e.g. to continuous blood sugar monitoring systems, insulin pumps, wound dressings, medical gloves, etc.): this is regarded as a developing epidemic. Lack of labelling of the composition of MD, as well as frequent lack of cooperation of manufacturers to disclose this relevant information, even when contacted by the clinician for the individual case of an established adverse reaction, significantly impede patient care.
Objectives
To advocate for full ingredient labelling in the implementation of EU regulation for MD.
Methods
This position paper reviews the scientific literature, the current regulatory framework adopted for MD to date, and the likely impact, including some costs data in case of the absence of such labelling.
Results
Efforts made by several scientific teams, who are trying to identify the culprit of such adverse effects, either via asking for cooperation from companies, or using costly chemical analyses of MD, can only partly, and with considerable delay, compensate for the absence of meaningful information on the composition of MD; hence, patient management is compromised. Indeed, without knowing the chemical substances present, physicians are unable to inform patients about which substances they should avoid, and which alternative MD may be suitable/tolerated.
Conclusion
There is an urgent need for full and accurate labelling of the chemical composition of MD in contact with the human body.
Background
Studies on patch testing with workplace materials and evaluation of current occupational relevance of positive patch test (PT) reactions are scarce in patients with occupational dermatitis (OD).
Objectives
To identify frequent sensitizations with occupational relevance and to determine the value of patch testing with workplace materials in OD patients.
Patients and Methods
Results and clinical data of 654 patients with suspected OD patch tested between 2013 and 2017 were analyzed.
Results
Occupational allergic contact dermatitis was diagnosed in 113 (17.3%) patients. Mechanics had the widest range of occupational sensitizations. Sensitization to epoxy resin was rated occupationally relevant in almost all handicraft trades. Among positive PT reactions to workplace products, those to water‐based metal working fluids and leave‐on cosmetic products were most frequent. Despite frequent testing, protective gloves only rarely elicited positive reactions. Preservatives and rubber compounds were most frequently identified as currently occupationally relevant.
Conclusions
Rubber allergy is occupationally relevant especially in healthcare workers and cleaners. Generally, preservatives including formaldehyde‐releasers are important allergens in OD patients. Leave‐on cosmetic products must not be forgotten as allergen sources. Patch testing both, workplace materials and standardized test preparations, has a complementary value and is beneficial for the diagnostic work‐up of OD patients.
This article is protected by copyright. All rights reserved.
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.
Background:
Sensitization to methylisothiazolinone (MI) has seen an exceptional epidemic, mainly attributed to its use in cosmetics.
Objectives:
To trace the epidemic of MI allergy 2009-2018), and to analyse a possible change of patients' characteristics.
Methods:
IVDK-data of patients patch tested between 2009 and 2018 with MI (0.05 % aq.) were analysed by referring to anamnestic items and sensitization frequencies.
Results:
Overall, 4.9% reacted positive to MI. Comparing sensitization to MI in three periods (2009, 2013/14 and 2017/18), there was an increase to 7% in 2013 and a decrease to 3.4% in 2018. The MOAHLFA Index for the period 2013/14 is characterized by a lower proportion of occupational dermatitis, and a higher proportion of face dermatitis. The period 2017/18 is characterized by increases of occupational dermatitis and hand dermatitis, and a decrease of face dermatitis. Painters, personal care workers, and hairdressers were particularly affected. Sensitization in hairdressers and personal care workers (mostly cosmeticians) decreased after the peak in 2013/14, whereas sensitization to MI in painters continued to increase.
Conclusions:
After an unprecedented epidemic of MI-allergy mainly caused by its use in cosmetics, the continuous use of MI in industrial applications, e.g. paints, and subsequent sensitization remain a matter of concern. This article is protected by copyright. All rights reserved.
Purpose of Review
The purpose of this review is to provide an update on occupational contact dermatitis including gaps in knowledge and practice. Occupational contact dermatitis is the most common occupational skin disease.
Recent Findings
New sources of exposure for known allergens and new allergens are continually being reported. Through clinical databases and surveillance systems, effects of prevention efforts or introduction of new allergens or new uses of known allergens can be monitored. Though the diagnostic process is clear, there are delays in workers seeking care. As early detection and intervention improves outcomes, screening should be implemented. Gaps in primary prevention in the workplace are identified and should be addressed to reduce the burden of disease.
Summary
Surveillance systems support the prevention mandate. Understanding limitations of our knowledge and identifying gaps in practice can lead to initiatives to address research and practice needs and improve prevention of occupational dermatoses.
Background:
Skin diseases constitute up to 40% of all notified occupational diseases in most European countries, predominantly comprising contact dermatitis, contact urticaria, and skin cancer. While insufficient prevention of work-related skin diseases (WRSD) is a top-priority problem in Europe, common standards for prevention of these conditions are lacking.
Objective:
To develop common European standards on prevention and management of WRSD and occupational skin diseases (OSD).
Method:
Consensus amongst experts within occupational dermatology was achieved with regard to the definition of minimum evidence-based standards on prevention and management of WRSD/OSD.
Results:
By definition, WRSDs/OSDs are (partially or fully) caused by occupational exposure. The definition of OSD sensu stricto additionally includes diverging national legal requirements, with an impact on registration, prevention, management, and compensation. With the implementation of the classification of WRSD/OSD in the International Classification of Diseases (ICD) 11th Revision in future, a valid surveillance and comparability across countries will be possible. Currently, WRDS and OSD are still under-reported. Depending on legislation and regulations, huge differences exist in notification procedures in Europe, although notification is crucial to prevent chronic and relapsing disease. Facilities for early diagnosis, essential for individual patient management, should be based on existing guidelines and include a multidisciplinary approach. Patch testing is essential if contact dermatitis persists or relapses. Workplace exposure assessment of WRSD/OSD requires full labelling of product ingredients on material safety data sheets helping to identify allergens, irritants and skin carcinogens. Comparable standards in primary, secondary and tertiary prevention must be established in Europe to reduce the burden of WRSD/OSD in Europe.
Conclusion:
The adoption of common European standards on prevention of WRSD/OSD will contribute to reduce the incidence of OSD and their socio-economic burden.
Background:
Rubber additives constitute an important group of contact allergens, particularly in certain occupations.
Objectives:
To collect information regarding the current practice of using a 'rubber series' in Europe, and discuss this against the background of evidence concerning the prevalence of allergy in order to derive a recommendation for a 'European rubber series'.
Methods:
The following were performed: (i) a survey targeting all members of the COST action 'StanDerm' consortium, (ii) analysis of rubber contact allergy data in the database of the European Surveillance System on Contact Allergies, and (iii) a literature review.
Results:
Information from 13 countries was available, from one or several departments of dermatology, and occasionally occupational health. Apart from some substances tested only in single departments, a broad overlap regarding important allergens was evident, but considerable variation existed between departments.
Conclusions:
An up-to-date 'European rubber series' is recommended, with the exclusion of substances only of historical concern. A 'supplementary rubber series' containing allergens of less proven importance, requiring further analysis, is recommended for departments specializing in occupational contact allergy. These should be continually updated as new evidence emerges.
Allergic contact dermatitis caused by rubber allergens is common, and causes significant patient morbidity. Contemporary data are important to allow appropriate preventive measures and identification of contact allergy trends.
To describe the pattern of patch test reactivity to rubber allergens, including those in the European baseline series.
Data collected by the European Surveillance System on Contact Allergies (ESSCA) network between 2009 and 2012 from 12 European countries were analysed.
Contact allergy to thiuram mix declined over the studied time period, with an overall prevalence of 1.87%. The prevalence of allergy to carba mix was 2.29%, and was significantly increasing. Prevalence rates of sensitization to other rubber allergens were largely unchanged. Statistical analysis with the MOAHLFA index confirmed the strong links between rubber allergy and occupational hand dermatitis.
Changing patterns of allergy to rubber additives have been identified. Inclusion of carba mix in the European baseline series may be appropriate.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
The present guideline summarizes all aspects of patch testing for the diagnosis of contact allergy in patients suspected of suffering, or having been suffering, from allergic contact dermatitis or other delayed-type hypersensitivity skin and mucosal conditions. Sections with brief descriptions and discussions of different pertinent topics are followed by a highlighted short practical recommendation. Topics comprise, after an introduction with important definitions, materials, technique, modifications of epicutaneous testing, individual factors influencing the patch test outcome or necessitating special considerations, children, patients with occupational contact dermatitis and drug eruptions as special groups, patch testing of materials brought in by the patient, adverse effects of patch testing, and the final evaluation and patient counselling based on this judgement. Finally, short reference is made to aspects of (continuing) medical education and to electronic collection of data for epidemiological surveillance.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
One of the main health concerns of epoxy resins is their role as skin sensitizer. This sensitization is not uncommon, because the prevalence ranges around 1-12% of the general population.
Perform a cross sectional study in a patch test population from Northeastern Italy to investigate the prevalence of epoxy resins sensitization among patients with suspected contact dermatitis. Subsequently, relate findings to patients' occupation and evaluate time trend of prevalence.
The final study database included 19 088 consecutive patients, tested from 1996 to 2010 in Northeastern Italy.
The overall prevalence of epoxy resins sensitization was 0·89%. Dermatitis most frequently involved hands (40·25%). In both sexes, we find a significant correlation in mechanics, woodworkers, and chemical industry workers; and in males only, among farmers and fishers, construction workers, and unemployed. We found significant increase of sensitization in construction workers in the analyzed period.
The overall prevalence of sensitization to epoxy resins in Northeastern Italy is in line with other European countries, but we found an increased risk of sensitization in some professions and an increasing trend of prevalence in construction workers. Better preventive actions are strongly advised in higher risk professions, with particular attentions towards building sector.
The European Union (EU) strategy for health and safety at work underlines the need to reduce the incidence of occupational diseases (OD), but European statistics to evaluate this common goal are scarce. We aim to estimate and compare changes in incidence over time for occupational asthma, contact dermatitis, noise-induced hearing loss (NIHL), carpal tunnel syndrome (CTS) and upper limb musculoskeletal disorders across 10 European countries.
OD surveillance systems that potentially reflected nationally representative trends in incidence within Belgium, the Czech Republic, Finland, France, Italy, the Netherlands, Norway, Spain, Switzerland and the UK provided data. Case counts were analysed using a negative binomial regression model with year as the main covariate. Many systems collected data from networks of 'centres', requiring the use of a multilevel negative binomial model. Some models made allowance for changes in compensation or reporting rules.
Reports of contact dermatitis and asthma, conditions with shorter time between exposure to causal substances and OD, were consistently declining with only a few exceptions. For OD with physical causal exposures there was more variation between countries. Reported NIHL was increasing in Belgium, Spain, Switzerland and the Netherlands and decreasing elsewhere. Trends in CTS and upper limb musculoskeletal disorders varied widely within and between countries.
This is the first direct comparison of trends in OD within Europe and is consistent with a positive impact of European initiatives addressing exposures relevant to asthma and contact dermatitis. Taking a more flexible approach allowed comparisons of surveillance data between and within countries without harmonisation of data collection methods.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
This review aims to provide a clinically useful update regarding the role of formaldehyde (FA) and its five main releasers (FRs) quaternium‐15, diazolidinyl urea, DMDM hydantoin, imidazolidinyl urea and 2‐bromo‐2‐nitropropane‐1,3‐diol (bronopol) in contact allergy and allergic contact dermatitis. These ubiquitous preservatives are still often, and sometimes undeclared, present in cosmetics, pharmaceuticals, medical devices, household detergents and chemical (industrial) products. In Europe, the use of free FA and quaternium‐15 in cosmetics is forbidden and contact allergy rates have been found to be stable to decreasing. However, FA/FRs still readily provoke localized (e.g., facial/hand), airborne and generalized dermatitis, and may also complicate atopic and stasis dermatitis, or result in nummular dermatitis. Seborrheic‐, rosacea‐ and impetigo‐like dermatitis have recently been reported. For a correct diagnosis, FA 2% aq. (0.60 mg/cm2) should be used, and particularly the FRs bronopol 0.5% pet. and diazolidinyl urea 2% should be patch tested separately in a baseline series. If sensitization to FA occurs, both FA and FRs should preferably be avoided, except perhaps for bronopol in case it tests negatively. If a patient reacts to one or more FRs (such as bronopol, or diazolidinyl/imidazolidinyl urea), but not to FA, then the specific FR(s) should be avoided. This article is protected by copyright. All rights reserved.
Background:
Formaldehyde is an important contact sensitiser. Formaldehyde releasing substances induce positive reactions in formaldehyde-allergic patients, but there are also reactions independent of formaldehyde allergy. In an earlier study, stronger formaldehyde reactions lead to more positive reactions to quaternium-15.
Objectives:
To analyse patterns of positive patch test reactions to formaldehyde and different formaldehyde releasers.
Methods:
Patch test files of 1497 patients investigated during a period of November 2007 - August 2020 were retrospectively reviewed for positive reactions to formaldehyde and its releasers. Almost all (≥99.3%) patients during the study period were tested with a formaldehyde dilution series and 6 formaldehyde releasers.
Results:
93 patients tested positive to formaldehyde. 80% of these had positive reactions to at least one formaldehyde releaser, most often benzylhemiformal. There were only 9 independent contact allergies to formaldehyde releasers. There were only two reactions to 2-bromo-2-nitropropane-1,3-diol, and they occurred in formaldehyde-negative patients. In patients with extreme (+++) reactions to formaldehyde, concomitant positive reactions to any of the other 11 investigated formaldehyde releasers were more common than in patients with milder formaldehyde reactions.
Conclusions:
Strong formaldehyde reactions were associated with positive reactions to formaldehyde releasers. This article is protected by copyright. All rights reserved.
Background
Patch-testing is an important diagnostic tool for suspected allergic contact dermatitis (ACD) in occupational settings.
Objective
Provide an overview of occupational skin disease (OSD) and analysis of occupational ACD in North American patients undergoing patch-testing 2001-2016.
Methods
Patients with OSD were analyzed for frequency of allergic reactions to a screening series of allergens, occupational relevance, location of skin disease, and exposure sources. Demographic and occupation/industry information was recorded.
Results
Of 38,614 patients evaluated, 4471 (11.6%) had OSD, of whom 3150 (70.5%) had ACD. The most common occupationally related allergens included rubber accelerators, preservatives and bisphenol A epoxy resin. Hands (75.8%), arms (30.0%) and face (15.9%) were common sites of dermatitis.. The most affected occupations were service workers and machine operators.
Limitations
Our cohort may not reflect the general working population.
Conclusion
This study identified common occupational allergens, exposure sources, and occupations/industries at risk. This information may help the clinician evaluate and manage patients with occupational contact dermatitis.
Background:
Contact dermatitis in construction workers (CWs) is frequent due to the widespread exposure to sensitizing substances and irritating agents and the wet and cold working conditions.
Objective:
Our objectives were to evaluate contact dermatitis characteristics among CWs who underwent patch test in northeastern Italy and to identify related allergens.
Methods:
Seven hundred ninety-five CWs were studied and their data were compared to 2.099 male white-collar workers. The associations between patch test results and occupations were assessed by multivariate logistic regression analysis. Incidence data were calculated from 1996 to 2016.
Results:
CWs with confirmed occupational dermatitis presented an increased risk to be sensitized to potassium dichromate [OR 3.1 (95%IC 2.0-4.8)], to thiurams [OR 8 .6 (95%IC 4.0-18.4)], and to epoxy resins [OR 12.7 (95%IC 6.1-26.4)]. Sensitization to chromate decreased significantly after 2004, following EU regulation of chromate content in concrete, while sensitization to epoxy resins and thiurams increased. The overall incidence of occupational contact dermatitis in CWs decreased significantly.
Conclusion:
Our study demonstrated the effectiveness of EU regulations in reducing chromate sensitization in CWs and the overall incidence of occupational contact dermatitis. However, sensitization to other haptens is increasing, though improvement of protective measures is compulsory.
Background/objective:
This study characterizes concomitant reactions to carba mix (CM) and thiuram mix (TM) in a large North American population. Because thiurams and dithiocarbamates have structural similarity, concomitant reactions are expected.
Methods:
The 1994-2016 North American Contact Dermatitis Group data were analyzed. Patients with a final reaction interpreted as "allergic" to either CM or TM were included.
Results:
A total of 49,758 patients were tested to both CM and TM. A total of 3437 (6.9%) had positive reactions to CM and/or TM including the following groups: CM+ only (n = 1403, 40.8%), TM+ only (n = 1068, 31.0%), or both (n = 966, 28.1%). A total of 47.5% of TM+ patients were positive to CM and 40.8% of CM+ patients were positive to TM. Male sex, occupationally related dermatitis, and hand involvement were significantly more common in individuals positive to CM and/or TM as compared with those who were negative (P < 0.0001). More than 80% of CM+/TM+ reactions were currently relevant. Gloves were the most common source of CM and TM; clothing and footwear were also frequent.
Conclusions:
Carba mix and TM remain important, clinically relevant allergens. Although significant concomitant reaction frequency was demonstrated, more than half of the patients reacting to either CM or TM would have been missed if both had not been tested, underscoring the importance of testing to both.
Background
Health care workers are an important risk group for occupational skin disease (OSD).
Aims
To study diagnoses and causes of health care workers' OSDs in the Finnish Register of Occupational Diseases (FROD) in 2005–2016.
Methods
We searched the FROD for dermatological cases (1) in health care‐related occupations defined by ISCO‐08 and (2) in the industrial branch of health care defined by European industry standard classification system (NACE rev. 2).
Results
Health care workers comprised 19% of all OSD cases in the FROD, and irritant contact dermatitis dominated the diagnoses. Nurses and assistant nurses were the largest occupational groups with incidence rates of 3.3 and 2.7/10000 person years, respectively. Rubber chemicals were by far the most common causative agents of allergic contact dermatitis (ACD) followed by preservatives. The latter mainly comprised isothiazolinones and formaldehyde. Acrylates were important allergens in dental professions. Metals and coconut fatty acid derivatives were the next largest causative groups for ACD. Drugs caused only 1% of the ACD cases.
Conclusions
Workers in different health care occupations don't have a uniform risk for OSD, but they share the risk for ACD due to rubber chemicals and various preservatives.
This article is protected by copyright. All rights reserved.
Background:
Metalworkers occupationally exposed to metals, tools, metalworking fluids (MWFs), technical oils, gloves, skin care products etc. frequently suffer from occupational dermatitis (OD).
Objectives:
To investigate occupational exposure and to identify relevant occupational sensitizers in metalworkers with OD, and to evaluate suitability of current German patch test recommendations for this occupational group.
Patients and methods:
As part of the OCCUDERM project, occupational exposure of 230 metalworkers with suspected OD patch tested in the departments of dermatology in Göttingen and Osnabrück (both Lower Saxony, Germany) in 2012-2017 was recorded by questionnaire. This data, as well as results of patch testing with standardized allergens and with workplace material were analyzed.
Results:
MWFs and skin care products were the most important exposures. Among MWF allergens, most frequently sensitizations to formaldehyde and formaldehyde releasers, colophony/abietic acid, and monoethanolamine were observed. Sensitization to methylisothiazolinone (MI) was frequent, probably as part of the general European epidemic of contact allergy to MI in leave-on cosmetics. Sensitization to glove ingredients only played a minor role.
Conclusions:
The known occupational allergen spectrum could largely be confirmed. In order not to miss relevant sensitizations, patch testing with material from the patients' workplaces in parallel to baseline and MWF series is recommended. Sensitizations diagnosed could not always be linked to particular occupational exposures.
Background:
Methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI) contact dermatitis is a severe problem. The high concentrations of these substances and other isothiazolinones such as benzisothiazolinone (BIT) and octylisothiazolinone (OIT) contained in cleaning products may cause allergic contact dermatitisin sensitized patients.
Objectives:
To evaluate the exposure to isothiazolinones contained in cleaning products on the market and from sensitized patients, and verify the accuracy of labelling.
Methods:
A total of 34 cleaning products were collected (17 supplied by sensitized patients and 17 bought randomly). Analysis was made of the concentrations of MI, MCI, BIT and OIT using liquid chromatography tandem mass spectrometry (LC-MS/MS).
Results:
MI and BIT were the components most frequently detected. Of all the products analyzed, 76.5% contained at least one isothiazolinone. Twelve products had a MI concentration above the permitted level for rinse-off cosmetics. Most of them were coming into direct contact with the skin in daily use. Mislabelling occurred in 8 products.
Conclusions:
Some cleaning products with high concentrations of isothiazolinones may cause cutaneous symptoms in sensitized patients, especially in spray form. The labelling should be correct, also regarding the use of each article. This article is protected by copyright. All rights reserved.
Background
Allergic contact dermatitis has significantly increased in healthcare workers since the transition from latex to synthetic rubber gloves, with 1,3‐diphenylguanidine identified as the most frequently implicated allergen.
Objectives
We aimed to highlight the role of 1,3 diphenylguanidine as culprit allergen in contact allergies to synthetic rubber gloves, to propose recommendations for patch testings, and to discuss alternatives for sensitized subjects.
Materials and methods
Patch‐test data from healthcare workers who developed hand dermatitis after wearing rubber gloves and who tested positive to glove samples and rubber additives were collected from September 2010 to December 2017 in a Belgian hospital.
Results
A total of 44 caregivers were included in this study. Patch tests revealed that: (i) 84% of the study population tested positive to carba mix; (ii) 86% tested positive to 1,3‐diphenylguanidine; (iii) 13 subjects (30%) reacted to thiuram mix. Half of the subjects tested positive to gloves containing 1,3‐diphenylguanidine, whereas none reacted to accelerator‐free gloves.
Conclusion
The most commonly identified allergen was 1,3‐diphenylguanidine, far ahead of thiurams, previously described as the most sensitizing accelerators. Using 1,3‐diphenylguanidine‐free gloves is recommended. No subject reacted to gloves without accelerators, thus confirming their efficiency among accelerator‐sensitized patients. We recommend that 1,3‐diphenylguanidine be added into the European baseline series.
This article is protected by copyright. All rights reserved.
Background
Epoxy resin systems (ERSs) are among the leading causes of occupational allergic contact dermatitis.
Objectives
To identify riskful exposures and sources of skin exposure, and to quantify skin exposure to diglycidyl ether of bisphenol A (DGEBA) epoxy monomer, in construction coating work.
Methods
Skin exposure to epoxy chemicals was studied in 5 coating companies through (a) interviews and visual observation, (b) quantifying DGEBA on 12 workers’ skin by tape‐stripping, (c) measuring DGEBA on 23 surfaces by wipe‐sampling, and (d) quantifying DGEBA in new sewage pipe. Acetone extracts of the tapes, wipes and sawdust from a newly hardened sewage pipe were analysed by gas chromatography‐mass spectrometry.
Results
Identified riskful exposures were, for example, mixing ERSs, handling coating pots, and working above shoulder level. Epoxy stains on, for example, tools, equipment and clothing were seen in all workplaces. Protective gloves were of varying quality, and were not always suitable for chemicals. The amount of DGEBA on the workers’ skin varied considerably. All screened tool handles were contaminated. Two‐day‐old epoxy sewage pipe contained 3.2% DGEBA.
Conclusions
Construction coating entails skin contact with ERSs directly and via contaminated surfaces, personal protective equipment, and recently hardened epoxy materials. Observation is a useful method for assessing skin exposure in coating work.
There has been an increasing demand for fresh fruit and vegetables in recent years. Along the processing line in fresh-cut vegetable production, disinfection is one of the most important processing steps affecting the quality and safety, and the shelf-life of the end produce. Although a range of antimicrobial compounds commonly termed biocides or disinfectants are available, chlorine has long been used to disinfect washing waters of fresh-cut vegetables. However, since chlorine reactions with organic matter lead to the production of by-products, alternative disinfectants to chlorine must be evaluated. A synthetic washing water formula has been developed to determine the antimicrobial efficiency of different families of potential disinfectants: quaternary ammonium compounds (QACs) as benzalkonium chloride (BZK), and didecyldimethylammonium chloride (DDAC); isothiazolinones (mixture of methylchloroisothiazolinone and methylisothiazolinone, CMIT:MIT 3:1 and 1:1); and essential oils (carvacrol, CAR). The twin configuration and higher length of the chains of alkyl groups of DDAC compared to BZK have led to a higher antimicrobial efficiency. In both cases, Gram-positive bacteria seemed to be much more sensitive to the QAC attack than Gram-negative. The opposite happened for CMIT:MIT. The chloro-substituted isothiazolinone (CMIT) has been proven to be much more effective than its unsubstituted form (MIT). In addition, in contrast to chlorine, its antimicrobial activity together with that of DDAC was not decreased when increasing the organic matter content of the water. Synergetic antimicrobial effects have been confirmed when combining BZK and CAR. MBC values were determined in SWW, during 90 s of contact time and Salmonella concentration of 103 CFU/mL, corresponding to: 100 (BZK), 30 (DDAC), 50 (CMIT:MIT 3:1), 100 (CMIT:MIT 1:1), 300 (CAR), 75 (BZK)-200 (CAR), and 9 (free chlorine) mg/L. MBC values for inactivating similar concentration of E. faecalis corresponded to: 50 (BZK), and 10 (DDAC) mg/L. Increasing contact times up to 5 min did not lead to higher antimicrobial efficiencies. CMIT:MIT 3:1 together with DDAC, and combinations of BZK-CAR seem to be a plausible alternative to chlorine.
Consumers regularly use household care and personal care products (HC&PCPs). Isothiazolinones are included in HC&PCPs as preservatives and are being held responsible for an epidemic rise in allergic contact dermatitis (ACD). The objective of this study was to assess the origin and extent of dermal exposure in order to evaluate the risk of ACD from isothiazolinones in HC&PCP.
Individual-based aggregate dermal exposure to four isothiazolinones was estimated using the newly proposed Probabilistic Aggregated Consumer Exposure Model–Kinetic, Dermal (PACEM-KD) by combining the reported individual use patterns for HC&PCP in Switzerland (N = 669 (558 adults), ages 0–91) with isothiazolinone concentrations measured in products used by the individual person. PACEM-KD extends the original PACEM by considering exposure duration, product dilution and skin permeability. PACEM-KD-based higher-tier exposure on palms (99th percentile) was 15.4 ng/cm², 1.3 ng/cm², 0.9 ng/cm², and 0.08 ng/cm² for the isothiazolinones 1,2‑Benzisothiazol‑3‑(2H)‑one (BIT), 2‑Octyl‑3(2H)‑isothiazolinone (OIT), 2‑Methylisothiazolin‑3(2H)‑one (MI), and 5‑Chloro‑2‑methyl‑4‑isothiazolin‑3‑one (CMI), respectively. Major sources of exposure to BIT included all-purpose cleaners, dishwashing detergent, and kitchen cleaner, while exposure to OIT mainly stems from a fungicide. For MI, the main contributors were dishwashing detergent and all-purpose wet wipes, and for CMI all-purpose cleaner. A Quantitative Risk Assessment (QRA) for BIT using Sensitization Assessment Factors (SAFs) indicates that around 1% of the Swiss population is at risk to be sensitized by BIT in cosmetics and household chemicals. For isothiazolinones in general the presented higher-tier modelling approach suggests that household cleaners are currently more important sources of exposure than cosmetics.
Background:
The food sector is one of the high-risk areas for occupational irritative and allergic contact eczema.
Objectives:
The present work provides an overview of the main allergens as well as sensitization frequencies and risk in various food industry occupations.
Methods:
The literature on type IV sensitization in the food sector is summarized.
Results:
The relative risk of developing a work-related eczema in food processing is increased by more than 3 times. The comparison group was calculated on the basis of the proportion of documented cases in the IVDK (Informationsverbund Dermatologischer Kliniken) network per 100,000 working persons in relation to the average of the years 2005 and 2010. For this purpose, the average risk of all patients was set as reference to 1. Bakers, pastry chefs, cooks and meat and fish processors are mainly affected. In addition to irritant contact eczema, allergic contact eczema and protein contact dermatitis often occur. Leading haptens (main allergens) are rubber ingredients, but also disinfectants and compositae.
Conclusion:
Only a few contact allergens are responsible for the majority of job-relevant sensitizations in the food industry.
Fruit and vegetable consumption has been widely accepted as an integral component of a healthy diet. A diet including more fresh fruit and vegetables has been achieved due to more availability, diversity, affordability, international trade, electronic communication, urbanization, improved transportation, public education and healthy trends, and improved agricultural practices. However, produce can be contaminated with foodborne pathogens at various points during the production, handling, and packing processes. In this chapter, the most common pathogens involved in outbreaks of contaminated produce at a global level are described. The number of pathogenic outbreaks due to contaminated produce consumption has increased in recent years; consequently, attention to the factors responsible for these outbreaks must be addressed. Produce preharvest and harvest contamination is associated with a critical number of foodborne pathogen outbreaks. Irrigation water from rivers and reservoirs are susceptible to contamination by wild animal or grazing cattle feces, flood and runoff from nearby farms, overflow from animal waste lagoons, and septic tank and sewage pipe leakage. Soils can be contaminated with irrigation water, fecal droppings, and application of improperly composted manure or sewage. Poor hygiene practices by field workers and the absence of on-site sanitary facilities are common produce contamination risks. The application of proper agricultural hygiene and manufacturing practices, and the hazard analysis critical control point system (HACCP) should be properly implemented to control and prevent produce contamination. Communication and cooperation between government agencies must be strengthened for successful international produce trade, and to prevent, detect, and control risks or outbreaks by contaminated produce.
From the economic point of view, occupational skin diseases are relevant to the payers, the patients, and society.
Major cost drivers are treatment costs (direct costs), cost for losses of work productivity (indirect costs), and the patients’ burden of disease (intangible costs).
From the societal view, the great number of persons affected by occupational skin disease is crucial.
Effective treatments for occupational skin diseases reduce the cost burden, and increase work productivity and the patients’ quality of life.
Preventive measures can be cost-effective if applied in time and provided to persons at defined risks.
Cost–benefit evaluation of interventions for occupational skin diseases requires a long-term assessment period.
Background:
Thiurams and dithiocarbamates are structurally related sensitizing rubber accelerators.
Objectives:
To study patterns of simultaneous patch test reactions to thiurams and dithiocarbamates at the Finnish Institute of Occupational Health in 1991-2015.
Methods:
We searched the patch test files for patients with allergic reactions to thiuram mix, its four components, and three dithiocarbamates, and analysed patterns of simultaneous reactions to these test substances.
Results:
We found 155 patients who reacted positively to at least one thiuram or dithiocarbamate in the rubber chemical series. Thirty-four (22%) of these patients reacted positively to some dithiocarbamate derivatives. Twenty-one reacted positively to zinc dimethyldithiocarbamate, 20 to zinc diethyldithiocarbamate, and 1 to zinc dibutyldithiocarbamate. All dithiocarbamate-allergic patients reacted positively to some thiurams, and their thiuram reactions were often strong or extreme positive. Nine thiuram mix reactions turned out to be false-positive reactions, without reactions to the constituents, and 24 patients showed false-negative reactions to thiuram mix during the same time period.
Conclusions:
Dithiocarbamate contact allergy was always connected to thiuram allergy. Screening dithiocarbamate allergy with carba mix thus appears to be unnecessary, but ways to improve the present thiuram mix should be investigated. Meanwhile, individual thiurams are best for diagnosing contact allergy to these accelerators.
Background:
Contact allergy to rubber additives is common, particularly in patients with occupational dermatitis.
Objectives:
To descriptively analyse and compare patch test reactions in patients patch tested both with the baseline series and with an additional 'rubber series' as used in the department.
Methods:
Patch test data from those members of the European Surveillance System on Contact Allergies (ESSCA) network (www.essca-dc.org) who also contributed data on rubber series patch test results were retrospectively analysed.
Results:
Among 29 522 patients patch tested, 2870 were eligible, that is, patch tested both with the baseline series and with a special rubber series. Of these, 8.8% had positive reaction(s) to one of the baseline screening rubber allergens (as compared with 4.2% in all patients), most often to carba mix, 12.3% had positive reaction(s) to allergens from an additional rubber series, and 6.4% had positive reaction(s) to both.
Conclusions:
Additional testing with a dedicated rubber series, containing break-down single ingredients of mixes from the baseline series and additional rubber allergens, is warranted in patients with suspected contact allergy to rubber, to avoid false-negative results.
Background:
Disease registries rely on consistent electronic data capturing (EDC) pertinent to their objectives; either by using existing electronic data as far as available, or by implementing specific software solu- tions.
Objectives:
To describe the current practice of an international disease registry (European Surveillance System on Contact Allergies, ESSCA, www.essca-dc.org) against different state of the art approaches for EDC.
Methods:
Since 2002, ESSCA is collecting data, currently from 53 departments in 12 countries. Departmental EDC software ranges from spreadsheets to comprehensive "patch test software" based on a relational database. In the Erlangen data centre, such diverse data is imported, converted to a common format, quality checked and pooled for scientific analyses.
Results:
Feed-back to participating departments for quality control is provided by standardised reports. Varying author teams publish scientific analyses addressing the objective of contact allergy surveillance.
Conclusions:
Although ESSCA represents a historically grown, heterogeneous network and not one unified approach to EDC, some of its features have contributed to its viability in the last 12 years and may be useful to consider for similar investigator-initiated networks.
Background Epoxy resin systems (ERSs), consisting of resins, reactive diluents, and hardeners, are indispensable in many branches of industry. In order to develop less sensitizing ERS formulations, knowledge of the sensitizing properties of single components is mandatory. Objectives To analyse the frequency of sensitization in the patients concerned, as one integral part of a research project on the sensitizing potency of epoxy resin compounds (FP-0324). Methods A retrospective analysis of data from the Information Network of Departments of Dermatology (IVDK), 2002-2011, and a comparison of reaction frequencies with (surrogate) exposure data, were performed. Results Almost half of the patients sensitized to epoxy resin were additionally sensitized to reactive diluents or hardeners. Among the reactive diluents, 1,6-hexanediol diglycidyl ether was the most frequent allergen, followed by 1,4-butanediol diglycidyl ether, phenyl glycidyl ether, and p-tert-butylphenyl glycidyl ether. Among the hardeners, m-xylylene diamine (MXDA) and isophorone diamine (IPDA) were the most frequent allergens. According to the calculated exposure-related frequency of sensitization, MXDA seems to be a far more important sensitizer than IPDA. Up to 60% of the patients sensitized to hardeners and 15-20% of those sensitized to reactive diluents do not react to epoxy resin. Conclusions In cases of suspected contact allergy to an ERS, a complete epoxy resin series must be patch tested from the start. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Background:
Beside the basic resins, reactive diluents and hardeners are important sensitizers in epoxy resin systems (ERSs). Because of chemical similarities, immunological cross-reactivity may occur.
Objectives:
To analyse concomitant reactivity among reactive diluents and hardeners in the patients concerned, as one integral part of a research project on the sensitizing capacity of ERSs (FP-0324).
Methods:
A retrospective analysis of data from the Information Network of Departments of Dermatology (IVDK), 2002-2011, was performed.
Results:
There was close concomitant reactivity to 1,6-hexanediol diglycidyl ether and 1,4-butanediol diglycidyl ether (1,4-BDDGE), and to phenyl glycidyl ether (PGE) and cresyl glycidyl ether (CGE), whereas reactions to p-tert-butylphenyl glycidyl ether occurred more independently from those to PGE and CGE. Concomitant reactions to butyl glycidyl ether and 1,4-BDDGE may point to a common allergenic compound derived from the metabolism of 1,4-BDDGE. Among the structurally more diverse group of hardeners, there was no evidence of immunological cross-reactions.
Conclusions:
More detailed knowledge of cross-reactivity among ERS components facilitates the interpretation of patch test results and will allow safer ERSs to be composed in the future.
Methylisothiazolinone (MI) contact allergy is severely affecting consumers with allergic contact dermatitis, owing to its presence in cosmetics, household detergents, and water-based paints, in particular. Data on the true isothiazolinone concentrations in these products are scarce, and labelling may be incorrect.
To report on the MI concentrations in such products marketed in Belgium, in order to verify the accuracy of labelling (when applicable) and compliance with EU regulations.
Thirty cosmetics (18 leave-on and 12 rinse-off), eight detergents and four paints were analysed for MI by the use of high-performance liquid chromatography with ultraviolet detection.
The analysed leave-on, and to a lesser extent the rinse-off, cosmetics, contained MI at concentrations far exceeding the permitted 100 ppm use concentration. Household detergents contained high concentrations of MI, and mislabelling occurred for both cosmetics and detergents. The (limited) data on paints are in line with the existing literature.
Cosmetics and detergents may facilitate contact sensitization because of a (too) high MI concentration, and mislabelling may make its avoidance extremely difficult. Safer use concentrations and correct labelling should be ensured by adequate quality control.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
In Germany, occupational skin diseases rank first in the occupational skin disease statistics for many years. Especially, occupationally acquired contact allergies as well as multi-sensitization are the most important predictors for a poor prognosis and persistent eczema.
To update the spectrum and sensitization frequencies of most frequent allergens from the standard series in Germany in patients with occupationally acquired type IV sensitizations in general and within different occupational groups.
Data of all employed patients (age range: 16-68 years, n = 14234) patch tested between 2003 and 2013 in the German Departments of the Information Network of Departments of Dermatology (IVDK) and diagnosed occupationally acquired contact dermatitis after patch testing were analyzed. The control group was composed of all other patients (n = 31706) within the same time frame, in which occupationally acquired allergic contact dermatitis was negated explicitly.
The prevalence Ratio (PR; indicating risk) was significantly increased for: Thiuram-mix (PR 5.63 95 %CI 4.97-6.4), zinkdiethyldithiocarbamate (PR 6.22 95 %CI 4.76-8.22), mercaptobenzothiazole (MBT) (PR 3.88 95 %CI 3.09-4.89), mercapto-mix without MBT (PR 3.23 95 %CI 2.59-4.03), N-isopropyl-N'-phenyl-p-phenylene diamine (IPPD) (PR 2.3195 %CI 1.87-2.86), epoxy resin (PR 2.82 95 %CI 2.45-3.25), chloromethylisothiazolinone/methylisothiazolinone (MCI/MI) (PR 2.19 95 %CI 1.97-2.42) and compositae mix II (PR 2.05 95 %CI 1.45-2.89). They were the predominant occupational allergens and were at least associated with a doubled risk (PR ≥ 2.0) for acquiring occupationally allergic contact dermatitis. The highest risk increase was identified in employees in the health services, in agriculture, metal industry, food and service industry as well as building trades CONCLUSIONS: A limited number of occupationally relevant allergens cause the majority of sensitizations in the workforce, if standard series allergens are concerned. Data analysis of national and international contact allergy data bases provide valuable information on sensitization rates and profiles in skin risk occupations to implement targeted prevention strategies. To diagnose occupational allergic contact dermatitis in individual cases additional testing of occupation related patch test series as well as patients' own products is commonly inevitable.
Epoxy products are among the most common causes of occupational allergic contact dermatitis. Diglycidyl ether of bisphenol A resin (DGEBA-R) is the most important sensitizer in epoxy systems.
To describe patients with occupational allergic contact dermatitis caused by epoxy products.
Patients with allergic reactions to epoxy chemicals were chosen from test files (January 1991 to June 2014). Only patients with occupational contact allergy to some component of epoxy resin systems were included. We analysed patch test results, occupation, symptoms, and exposure data.
We found a total of 209 cases with occupational contact allergy to epoxy chemicals. The largest occupational groups were painters (n = 41), floor layers (n = 19), electrical industry workers (n = 19), tile setters (n = 16), and aircraft industry workers (n = 15). A total of 82% of the patients reacted to DGEBA-R. Diagnosis of the DGEBA-R-negative patients required testing with m-xylylenediamine, N,N'-tetraglycidyl-4,4'-methylenedianiline, 1,4-butanediol diglycidyl ether, 2,4,6-tris-(dimethylaminomethyl)phenol, diglycidyl ether of bisphenol F resin, N,N'-diglycidyl-4-glycidyloxyaniline, isophoronediamine, 4,4'-diaminodiphenylmethane, diethylenetriamine, and cresyl glycidyl ether. The hands/upper extremities were most commonly affected (69%), but facial symptoms were also frequent (60%).
Allergic contact dermatitis caused by to epoxy products cannot always be diagnosed by the use of commercial test substances. Workplace products need to be tested.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Surveillance is the continuous analysis, interpretation, and feedback of systematically collected data either on an (inter)national level, or on the level of industrial plants.
Occupational contact dermatitis does not separately appear in the general (national) statistics on occupational diseases and injuries; however, the proportion of occupational contact dermatitis among all occupational skin diseases is consistently estimated to be around 80%.
Special registries, or special analyses of “routine” documentation systems generically including this data, enable the assessment of the spectrum of (occupational) contact allergens in different occupations.
Clinical data on the frequency of irritant or allergic contact dermatitis, or on the prevalence of specific contact sensitization, cannot directly be interpreted as estimates of morbidity on the population level. Nevertheless, sufficiently standardized patient data are a valid basis of surveillance, addressing time trends (in subgroups) and risk factor assessment.
Natural and synthetic rubbers containing rubber accelerators are well-known causes of allergic contact dermatitis (ACD). Latex contact urticaria (CU) has been widely reported, especially when powdered latex glove use was commonplace. Consequently, interventions to reduce latex exposure by altering glove manufacture were introduced.
This study aimed to analyse trends in UK-reported incidence of occupational skin disease associated with rubber accelerators.
We analysed cases reported to EPIDERM (part of The Health and Occupation Research network) of occupational ACD caused by natural and synthetic rubber products, between 1996 and 2012.
For the studied period, a decreasing incidence of ACD associated with rubber products was found, with an average annual change of -1.2% [95% confidence interval (CI) -3.1 to 0.7]. The number of cases of latex CU (n = 580) significantly declined. The number of cases of ACD caused by mercapto mix and mercaptobenzothiazole (n = 177) and thiuram mix (n = 603) also declined. Reports of ACD associated with carba mix and its constituents (n = 219) increased significantly, by an average annual percentage of 10.1% (95% CI 6.1-14.2). Twenty-six cases of ACD caused by rarer rubber compounds were identified, highlighting skin disease attributable to less widely recognized chemicals.
These data show a falling reported incidence of occupational ACD attributed to rubber chemicals, but within this a significant rise attributable to the constituents of the carba mix. Clinicians should recognize the changing diversity of chemicals used in rubber manufacturing, and consider including carba mix in their baseline series and testing beyond this in suspect cases to avoid false-negative results.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
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.
Background
The Occupational Contact Dermatitis Disease Severity Index (ODDI) was designed in Australia to measure severity and functional disability in patients with occupational contact dermatitis (OCD) of the hands. The ODDI was translated into the German language with a linguistic validation process. The psychometric properties of the German version of the ODDI are still unclear.Objectives
To report the linguistic validation procedure and to perform a psychometric validation by investigating the validity and reliability of the German ODDI version in a sample of patients with OCD.Methods
Data were drawn from the baseline assessment (T0) and first follow-up (T1) of the German chronic hand eczema (CHE) registry (CARPE). Spearman correlations of the ODDI with reference measures were computed to assess validity. Cronbach's alpha was calculated as a measure of internal consistency, and the intraclass correlation coefficient (ICC) was calculated to assess retest reliability. The smallest real difference (SRD) and minimal clinically important difference (MCID) were calculated to assess sensitivity to change. Physician Global Assessment (PGA) was used as an anchor for the MCID.ResultsFour hundred and twenty-two patients (54.5% female, mean age 45.1 years) were included for analysis. Cronbach's alpha was found to be 0.73. The ICC was 0.79. Correlations between the ODDI total and the Dermatology Life Quality Index (rho = 0.36), and between PGA (rho = 0.48) and patient-assessed disease severity (rho = 0.40), were of moderate strength. The MCID (1.29) was found to be smaller than the SRD (1.87).Conclusions
The German ODDI version is reliable and valid for the measurement of functional impairment and disease severity in patients suffering from OCD.
Background
Occupational Allergic Contact Dermatitis (OACD) is one of the most common occupational skin diseases in developed countries, but data about its temporal trends in incidence remains sparse.
Objective
The aim of this study is to describe OACD trends in terms of industrial activities and main causal agents in France over the period 2001-2010.
Method
Data were collected from the French National Network of Occupational Disease Vigilance and Prevention (RNV3P). All OACD considered probably or certainly associated with an occupational exposure were included in the study. Trends were examined (i) on annual crude numbers of OACD and (ii) on reported odds-ratios of OACD calculated using logistic regression models.
Results
Overall, 3738 cases of OACD were reported and the mean age of OACD cases was 35 years, 52% being women. The most frequent occupations were hairdressers, health care workers, cleaning staff and masons. The total number of OACD cases remained stable over the study period, but increases in OACD related to isothiazolinones (p=0.002), epoxy resins (p=0.012) and fragrances (p=0.005) were observed. Conversely, decreases were noted for cement compounds (p=0.002) and plant products (p=0.031). These trends highlight specific sectors and exposures at risk of OACD.
Conclusion
Trends in OACD depend on the nature of exposure. Observed decreases were consistent with prevention measures taken during the study period, and the increases observed serve to highlight those areas where preventative efforts need to be made to reduce skin allergies in the workplace.This article is protected by copyright. All rights reserved.
Background
Vulcanization of rubber changes its allergen pattern.Objectives
To estimate the contact allergic reactivity profile of users of finished rubber products.Methods
Twenty-four patients with known contact allergy to rubber accelerators were patch tested with 21 compounds found in chemical analyses of vulcanized rubber products. No diphenylguanidine, p-phenylenediamine antioxidants or thioureas were included in the study.ResultsThiuram monosulfides formed during vulcanization showed generally stronger test reactions than the corresponding thiuram disulfides. We also obtained more positive thiuram reactions to the monosulfides than to the disulfides. A positive reaction to a dithiocarbamate was accompanied by a positive reaction to the corresponding thiuram, except for 1 patient. The nitrogen substituents showed only minor differences between the methyl, ethyl and pentamethylene groups, but the butyl derivatives gave, in most cases, a negative response. Dialkylthiocarbamyl benzothiazole sulfides, formed between thiurams and mercaptobenzothiazoles during vulcanization, showed strong test reactions in almost all patients who were sensitive to dithiocarbamates, thiurams, or mercaptobenzothiazoles.Conclusions
We found thiuram monosulfides to be better markers of thiuram sensitivity than the corresponding disulfides or dithiocarbamates. Surprisingly, the dialkylthiocarbamyl benzothiazole sulfides were good markers of both thiuram and mercaptobenzothiazole sensitivity. This is an unexpected finding that needs to be confirmed in a larger study.
Background/aims:
The aim of this study was to obtain insight into the clinical course and prognosis of allergic contact dermatitis (ACD), including potential effects of genetic and environmental factors.
Methods:
Eighty-two patients with previously defined ACD acquired occupationally (OACD) or non-occupationally (NOACD) were patch retested and evaluated for the presence of persistent eczema, atopy and filaggrin mutations.
Results:
The crude risk for the persistence of a positive patch test (PT) reaction was 6.3 times higher (95% CI 3.63-11.0) for PT reactions assessed as '+++' compared to '++' reactions at the first PT. Among the categories of OACD, NOACD, age, gender, atopy, and the number of positive PT reactions at the first and second PT, only OACD (OR 10.0, 95% CI 1.95-51.2) and number of positive PT reactions at retesting (OR 3.85, 95% CI 1.57-9.44) were found to be predictors of persistent eczema.
Conclusions:
Occupationally acquired contact allergy was emphasized as the most important factor in predicting poor prognosis of ACD.
Skin diseases are the most commonly recognized occupational diseases in Denmark, and occupational contact dermatitis (OCD) comprises ∼95% of all cases.
To prevent occupational contact dermatitis, it is important to specifically identify exposures and work routines related to outbreak of the disease. The aim of this study was to give an overview of exposures for patients with occupational contact dermatitis in Denmark in 2010, and relate this to line of work and disease severity.
The study was a descriptive, register-based study including patients with recognized occupational contact dermatitis in Denmark in 2010. Data were obtained from the National Board of Industrial Injuries in Denmark, and comprised information about the skin disease as well as the occupation/industry of employment and exposures.
One thousand five hundred and four patients, 1020 women and 484 men, were included in the study. Irritant contact dermatitis accounted for 70% of all cases; 68% of these were caused by wet work. Forty-six per cent of all patients were employed either in the healthcare sector, in cleaning, or as kitchen workers. Among contact allergies, the most common were to rubber additives from gloves and epoxy in patients employed in the windmill industry.
The data are important for planning preventive efforts in the future. The workers in the healthcare sector, kitchen workers and cleaners constitute almost half of all cases, and future preventive efforts should be directed at these occupations.
No observed event is a special, but not uncommon, result in patch test studies. The interpretation of such findings depends critically on the sample size (n) of the investigation, and is statistically addressed by the use of confidence intervals (CIs).
To define the statistically correct method of calculating a CI with a confidence level of 1 - α, where α denotes the tolerated statistical error probability, for an observed prevalence of 0%.
A literature survey and evaluation of the statistical methods was conducted. The popular statistical software packages spss™ and sas™ were examined with regard to the methods implemented, and the results obtained, for estimating such CIs in this special case.
The evaluation identified [0; 1 - α(1/n) ], which is well approximated by [0; 3/n] for α = 0.05, as an appropriate method to compute a CI with a confidence level of 1 - α. The resulting CI is an exact one, and more efficient than standard solutions. Popular statistical software such as spss™ and sas™ offers only various inefficient or even invalid procedures, but does not include this method.
It is easy to calculate a CI for an observed prevalence of 0% obtained in some studies. Such a CI facilitates the interpretation of such a finding, as it puts the observed zero result into adequate statistical perspective.