Occupational contact dermatitis: Retrospective analysis of North American Contact Dermatitis Group Data, 2001 to 2016

Prevalence of Occupational Contact Dermatitis Among Dental Personnel Using the Nordic Occupational Skin Questionnaire-2002: A Prospective Cross-Sectional Study

BACKGROUND

Occupational skin disease (OSD), such as contact dermatitis, is widespread among dental professionals; however, reports regarding its prevalence have inconsistent findings and methodology. Therefore, we conducted a cross-sectional survey using a self-reported questionnaire to estimate the prevalence of work-related and occupational exposure-induced skin diseases.

METHODOLOGY

A self-administered questionnaire, based on the validated Nordic Occupational Skin Questionnaire-2002, was distributed to 15 dental clinics in Israel in the first half of 2022. The questionnaire included questions about the occupation, exposure, and history of atopic disease, dry skin, and hand/arm and wrist eczema, as well as participant demographics.

RESULTS

Overall, 312 dental professionals completed the questionnaires. Response rate was 80%. The lifetime prevalence of self-reported skin symptoms was 19.23%. Significant risk factors included exposure to metal objects, odds ratio (OR): 2.43, 95% confidence interval (CI): [1.02, 5.78]; p < .05, dry skin (OR: 3.54, 95% CI: [1.93, 6.5]; p < .001), itching when sweating (OR: 2.89, 95% CI: [1.39, 6]; p < .05), contact urticaria (OR: 10.67, 95% CI: [4.46, 25.49]; p < .001), hay fever (OR: 2.25, 95% CI: [1.14, 4.42]; p < .05), allergic symptoms (OR; 2.33, 95% CI: [1.18, 4.58]; p < .05), and asthma (OR: 4.8, 95% CI: [2.17, 10.36]; p < .001).

CONCLUSIONS

This is the first study to use the NOSQ-2002 among dental professionals. Our study provides a better understanding of the prevalence and consequences of OSDs among dental personnel by utilizing the validated tool NOSQ-2002.

New causes of occupational allergic contact dermatitis

PURPOSE OF REVIEW

Occupational allergic contact dermatitis (OACD) is an important work-related skin disease. Information about the causative agents comes from many sources, including patch test databases, registries, case series and case reports. This review summarizes new information about common causative allergens and diagnosis.

RECENT FINDINGS

Common causes of OACD include rubber components, epoxies and preservatives. New exposure sources for these allergens continue to be described. Often these exposure sources are related to the changing world around us, such as allergens related to smartphones and technology, and personal protective equipment-related exposures during the COVID-19 pandemic. New allergens are also being described, some of which are related to known allergens (e.g. a new epoxy or acrylate component).Accurate diagnosis is critical to effective management of OACD, which may include removing the worker from exposure to the causative allergen. Safety data sheets may not contain complete information and patch testing with specialized series of allergens and workplace materials may be necessary.

SUMMARY

This review provides current evidence about causes of OACD and important aspects of diagnosis. This is important for clinical practice to ensure cases of OACD are not missed.

Standard and Expanded Series Patch Testing Update by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC)

After the meeting held by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) back in October 2021, changes were suggested to the Spanish standard series patch testing. Hydroxyethyl methacrylate (2% pet.), textile dye mixt (6.6% pet.), linalool hydroperoxide (1% pet.), and limonene hydroperoxide (0.3% pet.) were, then, added to the series that agreed upon in 2016. Ethyldiamine and phenoxyethanol were excluded. Methyldibromoglutaronitrile, the mixture of sesquiterpene lactones, and hydroxyisohexyl 3-cyclohexene (Lyral) were alo added to the extended Spanish series of 2022.

Analysis of Contact Allergens in Polyvinyl Chloride Examination Gloves in the United States

Background: Polyvinyl chloride (PVC) gloves are recommended as a safe alternative for patients with rubber accelerator allergy. However, allergic contact dermatitis to other chemicals in PVC gloves has been reported. Objective: To analyze single-use PVC medical examination gloves in the United States for the presence of potential contact allergens. Methods: Using liquid chromatography-mass spectrometry, 20 unique PVC gloves were analyzed in triplicate for 6 chemicals: benzisothiazolinone, bisphenol A, mono(2-ethylhexyl) maleate, tricresyl phosphate, triphenyl phosphate, and triphenyl phosphite. Results: All 20 PVC gloves contained detectable quantities of benzisothiazolinone (range, 0.001-1.48 parts per million [ppm]), bisphenol A (0.01-0.11 ppm), triphenyl phosphate (0.01-2.11 ppm), and triphenyl phosphite (0.001-0.22 ppm). Eighteen (90%) gloves contained mono(2-ethylhexyl) maleate (0.001-0.14 ppm) and 3 (15%) contained tricresyl phosphate (0.001-0.002 ppm). Conclusions: Known allergens were present in all 20 PVC gloves. However, the detected levels were mostly low and their relationship with sensitization and elicitation thresholds requires further study.

Patch Testing Results From the Massachusetts General Hospital Occupational and Contact Dermatitis Clinic, 2017-2022

Background: Patch testing is gold standard for identifying the source of allergic contact dermatitis (ACD). Objective: To report patch testing results from the Massachusetts General Hospital (MGH) Occupational and Contact Dermatitis Clinic from 2017 to 2022. Methods: Retrospective analysis of patients referred to MGH for patch testing, 2017-2022. Results: In total, 1438 patients were included. At least 1 positive patch test (PPT) reaction was observed in 1168 (81.2%) patients and at least 1 relevant PPT reaction was observed in 1087 (75.6%) patients. The most common allergen with a PPT was nickel (21.5%), followed by hydroperoxides of linalool (20.4%) and balsam of Peru (11.5%). Sensitization rates statistically increased over time for propylene glycol and decreased for 12 other allergens (all P values <0.0004). Limitations: Retrospective design, single institution tertiary referral population, and variations in allergens and suppliers across the study period. Conclusion: The field of ACD is constantly evolving. Regular analysis of patch test data is crucial to identify emerging and diminishing contact allergen trends.

Exploration of associations between occupational exposures and current adult eczema

OBJECTIVES

There is a scarcity of evidence on occupational exposures that may increase eczema in adults. We aimed to investigate potential associations between occupational exposures and eczema in middle-aged adults.

METHODS

A lifetime work history calendar was collected from the Tasmanian Longitudinal Health Study participants when they were at age 53. Their work history was collated with the occupational asthma-specific job exposure matrix to define ever-exposure and cumulative exposure unit-years since no eczema job exposure matrix is available. Eczema was determined using the report of flexural rash that was coming and going for at least 6 months in the last 12 months. Skin prick tests were used to further subgroup eczema and atopic eczema (AE) or non-AE (NAE). Logistic and multinomial regression models were used to investigate the associations.

RESULTS

Eczema prevalence was 9.1%. Current occupational exposure to animals (adjusted OR, aOR=3.06 (95% CI 1.43 to 6.58)), storage mites (aOR=2.96 (95% CI 1.38 to 6.34)) and endotoxin (aOR=1.95 (95% CI 1.04 to 3.64)) were associated with increased risk of current eczema. Furthermore, increased odds of NAE were associated with current exposure to animals (aOR=5.60 (95% CI 1.45 to 21.7)) and storage mites (aOR=5.63 (95% CI 1.45 to 21.9)). Current exposures to isocyanates (aOR=5.27 (95% CI 1.17 to 23.7)) and acrylates (aOR=8.41 (95% CI 1.60 to 44.3)) were associated with AE. There was no evidence of associations between cumulative exposures and eczema prevalence. Cumulative exposure to metalworking fluids (aOR=1.10 (95% CI 1.01 to 1.22)) was associated with NAE and acrylates (aOR=1.24 (95% CI 1.04 to 1.46)) with AE.

CONCLUSIONS

In this exploratory assessment, multiple occupational exposures were associated with current eczema in middle-aged adults. Raising awareness and limiting these exposures during an individual's productive working life will likely have various health benefits, including reducing eczema prevalence.

Prevalence and trend of allergen sensitization in patients with cheilitis referred for patch testing, North American Contact Dermatitis Group data, 2001-2018

BACKGROUND

An updated understanding of allergic contact cheilitis is needed.

OBJECTIVES

To characterize clinical characteristics and allergen relevance in patients with cheilitis referred for patch testing.

METHODS

Retrospective analysis of 43 772 patients patch tested with the North American Contact Dermatitis Group (NACDG) screening series from 2001 to 2018.

RESULTS

Overall, 2094 patients (4.8%) had lips as one of three sites of dermatitis, 1583 (3.6%) had lips as the primary site and 1167 (2.7%) had lips as the sole site of dermatitis. Prevalences of cheilitis at any, primary, and sole sites significantly increased throughout the study cycle from 2001-2002 (2.7%, 2.2% and 1.7%) to 2017-2018 (7.8%, 5.2% and 3.7%). Approximately 60% of patients with any, a primary, or a sole site of cheilitis had one or more positive allergic patch-test reactions compared to 65% of those without cheilitis.

CONCLUSION

Patients with cheilitis who were referred for patch testing had high rates of positive and relevant allergens. More than one in four patients with any, primary, or sole cheilitis had a positive reaction to non-NACDG screening allergens (28.0%, 26.8%, 31.1% vs. 21.6%) compared to patients without cheilitis, emphasizing the need for expanded patch test series in cheilitis.

Occupational contact allergy: The European perspective-Analysis of patch test data from ESSCA between 2011 and 2020

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 16 022 patients considered having OCD after patch testing within the European Surveillance System on Contact Allergies (ESSCA) network between January 2011 and December 2020 were evaluated. Patients (n = 46 652) 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.

Trends in the Prevalence of Methylchloroisothiazolinone/Methylisothiazolinone Contact Allergy in North America and Europe

Importance

The common use of isothiazolinones as preservatives is a global cause of allergic contact dermatitis. Differences in allowable concentrations of methylisothiazolinone (MI) exist in Europe, Canada, and the US.

Objective

To compare the prevalence of positive patch test reactions to the methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) combination and MI alone in North America and Europe from 2009 to 2018.

Design, Setting, and Participants

This retrospective analysis of North American Contact Dermatitis Group, European Surveillance System on Contact Allergies (ESSCA), and the Information Network of Departments of Dermatology (IVDK) databases included data from patients presenting for patch testing at referral patch test clinics in North America and Europe.

Exposures

Patch tests to MCI/MI and MI.

Main Outcomes and Measures

Prevalence of allergic contact dermatitis to MCI/MI and MI.

Results

From 2009 to 2018, participating sites in North America and Europe patch tested a total of 226 161 individuals to MCI/MI and 118 779 to MI. In Europe, positivity to MCI/MI peaked during 2013 and 2014 at 7.6% (ESSCA) and 5.4% (IVDK) before decreasing to 4.4% (ESSCA) and 3.2% (IVDK) during 2017 and 2018. Positive reactions to MI were 5.5% (ESSCA) and 3.4% (IVDK) during 2017 and 2018. In North America, the frequency of positivity to MCI/MI increased steadily through the study period, reaching 10.8% for MCI/MI during 2017 and 2018. Positive reactions to MI were 15.0% during 2017 and 2018.

Conclusions and Relevance

The study results suggest that in contrast to the continued increase in North America, isothiazolinone allergy is decreasing in Europe. This trend may coincide with earlier and more stringent government regulation of MI in Europe.

Patch testing with glucosides: The North American Contact Dermatitis Group experience, 2009-2018

BACKGROUND

Alkyl glucosides are nonionic surfactants that are increasingly used in personal care products.

OBJECTIVE

To characterize positive patch test reactions to decyl glucoside (5% petrolatum, tested 2009-2018) and lauryl glucoside (3% petrolatum, tested 2017-2018).

METHODS

Retrospective analysis of patients tested by the North American Contact Dermatitis Group.

RESULTS

Of 24,097 patients patch tested to decyl and/or lauryl glucoside, 470 (2.0%) had positive reactions. Compared with glucoside-negative patients, glucoside-positive patients had higher odds of occupational skin disease (13.4% vs 10.1%; P = .0207), history of hay fever (38.5% vs 31.6%; P = .0014), atopic dermatitis (39.0% vs 28.6%; P < .0001), and/or asthma (21.8% vs 16.5%; P = .0023). Most glucoside reactions (83.9%) were currently relevant. The most common source was personal care products (63.0%), especially hair products (16.5%) and skin cleansers (15.2%). Of 4933 patients tested to decyl and lauryl glucoside, 134 (2.7%) were positive to 1 or both; 43.4% (43 of 99) of decyl-positive patients were also positive to lauryl glucoside and 55.1% (43/78) of lauryl glucoside patients were also positive to decyl glucoside.

LIMITATIONS

The cohort predominantly reflects a referral population, and follow-up after testing was not captured.

CONCLUSION

Glucoside positivity occurred in 2.0% of the tested patients. Reactions were often clinically relevant and linked to personal care products. Cross-reactivity was >40%.

Irritant Contact Dermatitis — a Review

Purpose of Review

Recent Findings

Summary

[A Case of Occupational Contact Dermatitis Caused by Rubber Gloves]

A 42-year-old man working at a steel mill recognized itching and erythema on the dorsal surfaces of his hands for 2 weeks prior to his first visit to our department. Lichenized erythematous plaques were observed on the dorsal surfaces of his fingers and hands. A patch testing of the rubber part of the gloves showed a positive reaction. We also conducted a patch testing of metals to exclude a possibility of contact dermatitis mediated by metals as occupational materials. The patch testing of metals showed a positive reaction to zinc, which is not an occupational material in his steel mill, but his rubber gloves contained zinc in the rubber accelerators, which might have been the trigger that caused his allergic contact dermatitis. Contact dermatitis is the most common occupational skin disease, and various materials are the causative agents. Allergic reactions to rubber (latex) are classified into type I allergy and type IV allergy. Type IV allergic reaction is observed in rubber accelerators such as thiuram; however, our case showed that zinc allergy could be a possible causative agent in patients with contact dermatitis due to rubber gloves.

Age-related differences in patch testing results among children: Analysis of North American Contact Dermatitis Group Data, 2001-2018

BACKGROUND

An updated understanding of allergic contact dermatitis is needed, particularly in children.

OBJECTIVES

To compare positive and clinically relevant reactions in children versus adults referred for patch testing.

METHODS

Retrospective analysis of 1871 children and 41,699 adults from the North American Contact Dermatitis Group (NACDG) from 2001-2018.

RESULTS

Both final diagnosis of allergic contact dermatitis (55.2% versus 57.3%; chi square, P = .0716) and prevalence of ≥ 1 currently relevant reaction to a NACDG screening allergen (49.2% vs 52.2%; P = .1178) were similar between children and adults. Currently in children, the most common relevant allergens were nickel sulfate (17.3%), hydroperoxides of linalool (7.8%), methylisothiazolinone (7.7%), cobalt chloride (7.0%), and fragrance mix I (4.9%). Approximately a fifth of children had a positive reaction to a non-NACDG allergen.

CONCLUSION

Over half of children referred for patch testing were diagnosed with allergic contact dermatitis. The most common relevant allergens in children were nickel sulfate, cobalt chloride, and hydroperoxides of linalool. Twenty percent of children had at least 1 positive reaction to allergens/substances not on the NACDG screening series, underscoring the need for comprehensive testing.