Prognosis and work absence due to occupational contact dermatitis

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Occupational contact dermatitis: Return to work using a multidisciplinary clinic model

BACKGROUND

Occupational contact dermatitis often results in work disruption. Return-to-work (RTW) is an important outcome.

OBJECTIVE

The objective of this study was to determine RTW outcomes and factors associated with such outcomes using a multidisciplinary clinic model.

METHODS

Chart abstraction was performed for 194 workers who received RTW assistance over a 6-year period. Elements abstracted included demographic and diagnostic information and information about the RTW program including principles, program components, barriers, and facilitators.

RESULTS

Of the 902 workers seen for dermatologic assessment, 194 received RTW assistance. At initial assessment, 37% were not working because of their skin disease, and at follow-up, 7% were not working because of their skin disease. The RTW plan components included a graduated or trial of RTW, specific recommendations for avoiding exposure, personal protective equipment, skin management, and ongoing skin monitoring. Principles associated with successful RTW included good communication and the availability of modified work and a worker adherence to the plan. Barriers included lack of modified work, unresponsive employers, and ongoing skin problems.

CONCLUSIONS

Specific approaches are important to identify if RTW is to be successful for workers with occupational contact dermatitis.

Exploratory study to determine if risk factors for occupational skin disease vary by type of food processing operation

BACKGROUND

Occupational skin disease (OSD) is a common health issue in the food processing sector. However, risk factors for OSD are suspected to differ according to the nature of the operation.

OBJECTIVE

To ascertain if the risk factors for OSD vary depending on the type of food processing operation, namely meat processing vs. a commercial bakery.

METHODS

Participants were asked to answer questions regarding workplace exposures and the current skin condition of their hands. Bivariate analyses were conducted to identify differences between the two participating operations.

RESULTS

The meat processing workers were more likely to have wet work exposure, used hand sanitizer more often and changed their gloves more frequently. These findings from meat processing represented a statistically significant difference compared to the commercial bakery workers. Also, workers from meat processing reported more severe skin symptoms.

CONCLUSIONS

Risk factors for OSD apparently differ between types of food processing operations. Differences in the nature of skin symptoms were also found between the two participating operations. It is therefore suggested that future studies examining OSD within the food processing sector should evaluate this health effect based on the nature of operations rather than the sector as a whole.

Occupational Dermatitis and Urticaria

Occupational contact dermatitis is the most common occupational skin disease (OSD), and most of them are irritant in nature. There is less information available about contact urticaria than contact dermatitis. There are several strategies to prevent OSD, although workplace studies suggest there are gaps in their use in the workplace. Because early detection leads to improved outcomes, screening for dermatitis in industries such as health care would be useful. Both diagnosis and management involve 2 components: the actual disease diagnosis and medical treatment and the work-relatedness and management of the workplace to reduce exposures.

A scoping review to identify strategies that work to prevent four important occupational diseases

BACKGROUND

Despite being largely preventable, many occupational diseases continue to be highly prevalent and extremely costly. Effective strategies are required to reduce their human, economic, and social impacts.

METHODS

To better understand which approaches are most likely to lead to progress in preventing noise-related hearing loss, occupational contact dermatitis, occupational cancers, and occupational asthma, we undertook a scoping review and consulted with a number of key informants.

RESULTS

We examined a total of 404 articles and found that various types of interventions are reported to contribute to occupational disease prevention but each has its limitations and each is often insufficient on its own. Our principal findings included: legislation and regulations can be an effective means of primary prevention, but their impact depends on both the nature of the regulations and the degree of enforcement; measures across the hierarchy of controls can reduce the risk of some of these diseases and reduce exposures; monitoring, surveillance, and screening are effective prevention tools and for evaluating the impact of legislative/policy change; the effect of education and training is context-dependent and influenced by the manner of delivery; and, multifaceted interventions are often more effective than ones consisting of a single activity.

CONCLUSIONS

This scoping review identifies occupational disease prevention strategies worthy of further exploration by decisionmakers and stakeholders and of future systematic evaluation by researchers. It also identified important gaps, including a lack of studies of precarious workers and the need for more studies that rigorously evaluate the effectiveness of interventions.

Occupational skin disorders in a subset of Nigerian hairdressers

Introduction

Hairdressing is associated with a wide range of disorders. This is particularly true in the African hairdresser, who is saddled with the responsibility of ‘taming’ the rather difficult-to-manage African hair, and is thus exposed to a wide range of chemical, biological and physical materials in the hair grooming process. We therefore sought to determine the prevalence and pattern of occupational skin disorders among hairdressers in Ibadan, one of the oldest and largest cities in Nigeria.

Methods

This was a cross sectional study of hairdressers conducted in 2013 in Ibadan, Nigeria. Hairdressers and their apprentices were interviewed using a structured questionnaire, following which a thorough physical examination was performed to identify any skin disorder.

Results

A total of 226 hairstylists were recruited. The prevalence of occupational skin disorders in the study was 68.13%. The prevalence of specific skin disorders was 32.74% for nail disorders; 28.75% for traumatic skin disorders; and 2.64% for hand dermatitis.

Conclusion

There is a high prevalence of occupational skin disorders among hairdressers, and this may have personal and public health implications.

Testing the Hand Dermatitis Screening Tool in the Home Health Care Sector

Workers exposed to wet work are at an increased risk for occupational contact dermatitis and may benefit from screening to detect early disease. The objective of this study was to assess the prevalence of hand dermatitis in home care workers, identify factors that influence presence of disease, and explore feasibility and importance of workplace screening in the home care sector. Following institutional ethics approval, nurses, personal support workers, and rehab therapists at one large home care provider in Ontario, Canada, self-screened for hand dermatitis using the Hand Dermatitis Screening Tool and accompanying photo guide and completed a short feasibility evaluation. Of the 220 participants, 18% had a positive screen for hand dermatitis and 77% reported exposure to wet work. In all, 93% of participants reported using the tool took less than 2 minutes and 84% reported screening for hand dermatitis is important. In conclusion, prevalence of hand dermatitis in home care workers is higher than reported in the general population. Workplace screening for hand dermatitis was deemed important, and the tool was feasible to use in the home care sector.

Cement-Induced Chromate Occupational Allergic Contact Dermatitis

BACKGROUND

Hexavalent chromium in cement is a common cause of occupational allergic contact dermatitis (OACD).

METHODS

Analysis of patch test data during 1999 to 2013 was done. Patients with cement-induced chromate OACD filled the Dermatology Life Quality Index, graded 1 to 5.

RESULTS

Of 4846 consecutive patients who were patch tested, 146 (3%) were chromate-sensitive. Of 46 (31.5%) who presented with chromate OACD, 27 (59%) had cement-induced chromate OACD. The proportion of chromate-sensitive patients with clinically relevant cement exposure increased from 7.7% in 2002 to 2004 to 28.7% in 2011 to 2013 (P = 0.04). The median age of presentation was younger than for other chromate-sensitive patients (32 vs 42 years). Hand eczema (88.9%) was the most frequent clinical presentation. Of the 27 with cement-induced chromate OACD, 21 (77.8%) had ongoing dermatitis at the time of the review. Although 14/27 (51.9%) changed their occupation to avoid exposure to cement, symptoms persisted in 9/14 (64.3%). Prolonged exposure to cement before development of symptoms was associated with chronicity. All the symptomatic patients experienced at least a moderate effect on their quality of life (grade 3 or higher on the Dermatology Life Quality Index).

CONCLUSIONS

We recommend the adoption of the European legislation in Israel, to reduce the prevalence of chromate OACD from cement.

Occupational skin disease among Australian healthcare workers: a retrospective analysis from an occupational dermatology clinic, 1993-2014

BACKGROUND

Healthcare workers (HCWs) are at risk of developing occupational skin disease (OSD).

OBJECTIVES

To ascertain the causes of OSD in Australian HCWs in a tertiary referral clinic.

METHODS

A retrospective review was performed of patients assessed at the Occupational Dermatology Clinic in Melbourne from 1993 to 2014.

RESULTS

Of 685 HCWs assessed in the clinic over a period of 22 years, 555 (81.0%) were diagnosed with OSD. The most common diagnosis was irritant contact dermatitis (ICD) (79.1%), followed by allergic contact dermatitis (ACD) (49.7%). Natural rubber latex allergy was also relatively frequent (13.0%). The major substances causing ACD were rubber glove chemicals (thiuram mix and tetraethylthiuram disulfide), preservatives (formaldehyde, formaldehyde releasers, and isothiazolinones), excipients in hand cleansers, which are hard-to-avoid weak allergens, and antiseptics. ACD caused by commercial hand cleansers occurred more frequently than ACD caused by alcohol-based hand rubs (ABHRs). Occupational ICD was mostly caused by water/wet work and hand cleansers, and environmental irritants such as heat and sweating.

CONCLUSIONS

Understanding the causes of OSD in HCWs is important in order to develop strategies for prevention. We suggest that skin care advice should be incorporated into hand hygiene education. The use of ABHRs should be encouraged, weak allergens in skin cleansers should be substituted, and accelerator-free gloves should be recommended for HCWs with OSD.

Occupational allergic contact dermatitis in a 2-year follow-up study: how well does the patient remember the result of patch testing?

BACKGROUND

Patch testing is mandatory for diagnosing contact dermatitis. It is, however, crucial that patients understand and remember the result of the test.

OBJECTIVES

The aim of our study was to evaluate the impact of patch testing with respect to patients' ability to remember patch test results and the results of natural rubber latex protein allergy after 2 years.

METHODS

One hundred and ninety-nine patients diagnosed with relevant occupational epoxy or rubber chemical contact allergy, or allergy to natural rubber latex protein, were invited to participate in a questionnaire study about their knowledge of contact allergies after 2 years.

RESULTS

The response rate was 75%. Of the respondents, 13% did not remember their occupational contact allergy to rubber chemicals or epoxy. Ability to remember was not significantly influenced by sex or Dermatology Life Quality Index, but was decreased by age >60 years (p < 0.01). Of patients with an additional contact allergy, <36% remembered this correctly. Of patients allergic to natural rubber latex proteins, 50% remembered this correctly.

CONCLUSIONS

The impact of patch testing depends on the patients' ability to understand and remember the results of the test. Attention should be drawn to the importance of this, and patients with increased need for information should be identified.

Contact dermatitis: a practice parameter-update 2015

This parameter was developed by the Joint Task Force on Practice Parameters, which represents the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Contact Dermatitis: A Practice Parameter-Update 2015." This is a complete and comprehensive document at the current time. The medical environment is changing and not all recommendations will be appropriate or applicable to all patients. Because this document incorporated the efforts of many participants, no single individual, including members serving on the Joint Task Force, are authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information or interpretation of this practice parameter by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by the pharmaceutical industry in drug development or promotion. Previously published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available at http://www.JCAAI.org or http://www.allergyparameters.org.

Clinical profile and quality of life of patients with occupational contact dermatitis from New Delhi, India

BACKGROUND

Data regarding occupational contact dermatitis (OCD) and its effect on quality of life (QOL) in India are limited.

OBJECTIVES/AIMS

To evaluate patients with OCD and record the outcome of treatment.

PATIENTS/MATERIALS/METHODS

All patients with OCD were evaluated for severity of disease (by the use of physician global assessment) and its effect on QOL (by use of the Dermatology Life Quality Index) questionnaire) at the first visit and after 3 months of treatment.

RESULTS

Among 117 patients with OCD, hand eczema was present in 81.2%. Positive patch test reactions were found in 76%. The most common allergens were Parthenium hysterophorus and potassium dichromate. The most frequent diagnosis was occupational allergic contact dermatitis (OACD) (57%), caused by farming and construction work, followed by occupational irritant contact dermatitis (OICD) (24%), caused by wet work. Severe psychosocial distress was recorded in 62.5% of patients. After 3 months of treatment, 83% improved significantly, and 54% had improvement in QOL.

CONCLUSIONS

Farmers were most frequently affected, followed by construction workers and housewives. OACD was found at a higher frequency than OICD. The most frequent allergens were Parthenium hysterophorus in farmers, potassium dichromate in construction workers, and vegetables in housewives. OCD has a significant impact on QOL. Patch testing, in addition to standard treatment, improves the outcome considerably.

Occupational skin allergies: testing and treatment (the case of occupational allergic contact dermatitis)

Occupational contact dermatitis, including occupational allergic contact dermatitis, is one of the most common occupational diseases. Making a timely and accurate diagnosis is important to improving the outcome. Taking a work history and patch testing are essential elements in the diagnostic process. Management, based on an accurate diagnosis, must include both medical treatment to address the disease and workplace modifications as appropriate to reduce exposure the causative agents.

Protocol for a randomised trial on the effect of group education on skin-protective behaviour versus treatment as usual among individuals with newly notified occupational hand eczema - the Prevention of Hand Eczema (PREVEX) Trial

Background

The incidence of occupational hand eczema is approximately 0.32 per 1,000 person years. The burden of the disease is high, as almost 60% has eczema-related sick leave during the first year after notification, and 15% are excluded from the workforce 12 years after disease onset. New treatments and prevention strategies are needed.

Methods/Design

Trial design: The PREVEX trial is a randomised, parallel-group, superiority trial.

Participants: All individuals from the Capital Region of Denmark and Region Zealand with a suspected occupational skin disorder notified to the National Board of Industrial Injuries between June 2012 and December 2013 are invited to participate in the trial. Inclusion criteria are: self-reported hand eczema and informed consent. Exclusion criteria are: age <18 years or >65 years; permanent exclusion from the workforce; inability to understand the Danish language; any serious medical condition; and lack of written informed consent. We plan to randomise 742 participants. Interventions: The experimental intervention is an educational course in skin-protective behaviour and written information about skin care related to the participants' specific occupation. Also, a telephone hotline is available and a subgroup will be offered a work-place visit. The experimental and the control group have access to usual care and treatment. All participants are contacted every eighth week with questions regarding number of days with sick leave or other absence from work. 12 months after randomisation follow-up is completed. Objective: To assesses the effect of an educational course versus treatment as usual in participants with newly notified occupational hand eczema. Randomisation: Participants are centrally randomised according to a computer-generated allocation sequence with a varying block size concealed to investigators. Blinding: It is not possible to blind the participants and investigators, however, data obtained from registers, data entry, statistical analyses, and drawing of conclusions will be blinded. Outcomes: The three co-primary outcomes, assessed at 12 months, are: total number of self-reported days with sick leave; health-related quality of life; and subjective assessment of hand eczema severity. Explorative outcomes are: self-reported eczema-related sick leave, absence from work registered by the DREAM-register and by self-report, risk behaviour, knowledge of skin protection and performance management (self-efficacy; and self-evaluated ability to self-care).

Discussion

The PREVEX trial will be the first individually randomised trial to investigate the benefits and harms of group-based education in patients with newly notified occupational hand eczema.

Trial registration

ClinicalTrials.gov Identifier: NCT01899287

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

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

Occupational hand eczema among nursing staffs in Korea: Self-reported hand eczema and contact sensitization of hospital nursing staffs

Occupational hand eczema is frequent in hospital workers, especially in nurses. A comprehensive understanding regarding hand eczema is essential for establishing proper prevention and treatment strategies. The purpose of this study was to identify the risk factors for hand eczema in hospital nursing staffs. A self-administered questionnaire study was performed on hospital nursing staffs at a single general hospital in Korea. In addition, 70 patients with hand eczema underwent patch testing. Five hundred and twenty-five of 700 invited nurses completed the study (response rate, 75.0%). The overall frequency of symptom-based hand eczema was 75.6%, and self-reported hand eczema was 31.0%. Risk factors for hand eczema were young age, history of atopic dermatitis, frequent hand washing (>20 times/day) and long duration of glove wearing (>5 min). Hand eczema was less frequent among frequent hand moisturizer users (>3-4 times/day). Positive patch test reactions were observed in 61.4%. Frequent allergens were nickel sulfate (35.7%), cobalt chloride (28.6%) and thiomersal (21.4%). Among various antibiotics, ciprofloxacin (11.4%), trimethoprim/sulfamethoxazole (11.4%) and gentamicin (7.1%) were revealed as common allergens, in order of frequency. Hand eczema is quite common among hospital nursing staffs. Proper preventive programs and educations are demanded.

Recent advances in the management of hand dermatitis: does alitretinoin work?

Hand dermatitis can cause significant morbidity. It is not only pruritic, painful, and adversely affects manual dexterity, but it is also very visible, resulting in a substantial psychosocial and physical impact. The prevalence of hand dermatitis in the general population is 5% to 10%, and it appears to be twice as common in women than in men. Certain occupations predispose workers to hand dermatitis, especially those that require frequent hand washing or exposure to particular substances such as solvents. Hand dermatitis has a significant economic effect on society, and the socioeconomic and psychologic effect for the individual can be catastrophic. The need for effective management of this condition is, therefore, quite clear; however, historically hand dermatitis is difficult to treat. This contribution reviews the various types of hand dermatitis and how best to manage them and examines the role which the recently introduced drug alitretinoin now plays in managing this clinically challenging condition.

Workers with Occupational Contact Dermatitis: Work Outcomes and Return to Work Process in the First Six Months following Diagnosis

Workers with occupational contact dermatitis may have poor outcomes that impact their health, work, and quality of life. While there is information available on overall return to work, little is known about the actual return to work process. The objectives of the study were to describe the return to work experience and work outcome in workers with contact dermatitis following diagnosis. 78 workers with occupational contact dermatitis were followed for 6 months after assessment. Information collected included clinical presentation and status, the return to work process and work outcomes. Six months after assessment, 38% were not working, almost all because of their skin problem. Of the 62% working 32% had changed job, most because of their skin problem. Limited advice to enable return to work and communication were reported. These findings suggest that there are gaps in return to work programs for occupational contact dermatitis and further research is needed.

A review of the impact of occupational contact dermatitis on quality of life

Occupational contact dermatitis (OCD) is the most common occupational skin disease in many countries. We reviewed the current evidence on how OCD impacts on quality of life (QoL). The three commonly used QoL questionnaires in OCD were the Short-Form Health Survey (SF-36), the Dermatology Life Quality Index (DLQI), and the Skindex. Despite the availability of a variety of validated QoL instruments, none of them is specific to OCD or entirely adequate in capturing the impact of OCD on QoL. Nonetheless, the results of this paper do suggest a significant impact. Use of QoL measures in clinical settings will provide patients with an opportunity to express their concerns and assist clinicians to evaluate the effectiveness of management beyond the clinical outcomes. This paper also highlights the lack of a disease-specific QOL instrument and the importance of developing a validated measure to assess QOL in OCD, enabling comparison across countries and occupational groups.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Hand Eczema Trial (HET): Design of a randomised clinical trial of the effect of classification and individual counselling versus no intervention among health-care workers with hand eczema

Background

Hand eczema is the most frequently recognized occupational disease in Denmark with an incidence of approximately 0.32 per 1000 person-years. Consequences of hand eczema include chronic severe eczema, prolonged sick leave, unemployment, and impaired quality of life. New preventive strategies are needed to reduce occupational hand eczema.

Methods/Design

We describe the design of a randomised clinical trial to investigate the effects of classification of hand eczema plus individual counselling versus no intervention. The trial includes health-care workers with hand eczema identified from a self-administered questionnaire delivered to 3181 health-care workers in three Danish hospitals. The questionnaire identifies the prevalence of hand eczema, knowledge of skin-protection, and exposures that can lead to hand eczema. At entry, all participants are assessed regarding: disease severity (Hand Eczema Severity Index); self-evaluated disease severity; number of eruptions; quality of life; skin protective behaviour, and knowledge of skin protection. The patients are centrally randomised to intervention versus no intervention 1:1 stratified for hospital, profession, and severity score. The experimental group undergoes patch and prick testing; classification of the hand eczema; demonstration of hand washing and appliance of emollients; individual counselling, and a skin-care programme. The control group receives no intervention. All participants are reassessed after six months. The primary outcome is observer-blinded assessment of disease severity and the secondary outcomes are unblinded assessments of disease severity; number of eruptions; knowledge of skin protection; skin-protective behaviour, and quality of life.

Trial registration

The trial is registered in ClinicalTrials.Gov, NCT01012453.

Cost-effectiveness of oral alitretinoin in patients with severe chronic hand eczema--a long-term analysis from a Swiss perspective

BACKGROUND

The impact on patients suffering from chronic hand eczema (CHE) is enormous, as no licensed systemic treatment option with proven efficacy for CHE is available. Alitretinoin is a novel agent which showed high clinical efficacy in patients with severe, refractory CHE. We assessed the cost-effectiveness of alitretinoin for CHE patient treatment from a Swiss third party payer perspective. A further objective of this study was to determine the burden of disease in Switzerland.

METHODS

A long-term Markov cohort simulation model was used to estimate direct medical costs (euro) and clinical effectiveness (quality adjusted life years, QALYs) of treating severe CHE patients with alitretinoin. Comparison was against the standard treatment of supportive care (optimised emollient therapy). Information on response rates were derived from a randomized controlled clinical trial. Costs were considered from the perspective of the Swiss health system. Swiss epidemiological data was derived from official Swiss Statistic institutions.

RESULTS

Annual costs of alitretinoin treatment accounted for 2'212 euro. After a time horizon of 22.4 years, average remaining long-term costs accounted for 42'208 euro or 38'795 euro in the alitretinoin and the standard treatment arm, respectively. Compared with the standard therapy, the addition of alitretinoin yielded an average gain of 0.230 QALYs at the end of the simulation. Accordingly, the incremental cost-effectiveness ratio resulted in 14'816 euro/QALY gained. These results were robust to changes in key model assumptions.

CONCLUSION

The therapy for CHE patients is currently insufficient. In our long-term model we identified the treatment with alitretinoin as a cost-effective alternative for the therapy of CHE patients in Switzerland.

Current acceptance and implementation of preventive strategies for occupational hand eczema in 1355 metalworkers in Germany

BACKGROUND

The effectiveness of a skin care programme is based mainly on the effectiveness of the products used and the frequency and diligence of the application of skin care products.

OBJECTIVES

The present cross-sectional study was aimed at evaluating the implementation and acceptance of generally recommended skin protective means at the workplace.

METHODS

We included in our study 1355 metalworkers, employed in 19 factories, mainly of small or medium-size. The majority of participants were male (96.7%, n = 1310). The investigation included a standardized interview and a dermatological examination of the hands.

RESULTS

More than half of all participants (52.4%) had suffered from skin problems of the hands at some time. Three hundred and ninety-six subjects (29%) indicated they followed the skin protection regimen as it was generally recommended, i.e. the use of barrier creams in combination with moisturizers. A similar number of participants (28%) denied any use of protective creams. In general, compliance in men was significantly poorer than in women. Participants with past or present history of hand eczema used both barrier creams and moisturizers significantly more often. The skin condition of the hands, examined using a quantitative score, did not differ significantly in the four subgroups defined by different skin protection measures. While acceptance of protective measures was limited, these were available in all factories.

CONCLUSIONS

Although barrier creams and moisturizers are highly recommended as effective means to prevent irritant contact dermatitis in Germany, our data prove that the compliance of application in this group at special risk for hand eczema is extremely low.

Occupational contact dermatitis in Australia: diagnostic and management practices, and severity of worker impairment

The aims of this study were to compare treatment and referral practices between general practitioners (GPs) and dermatologists and to evaluate predictors for occupational contact dermatitis (OCD) disease severity measured in terms of worker impairment. Data were collected from 181 patients recruited for a larger study of OCD. Information about treatment recommendations and usual referral practices are reported for 123 patients. Data from patients, diagnosed with work-related skin disease, were modelled for severity of worker impairment. GPs were more likely to treat a patient independently, referring if the patient did not improve, whereas dermatologists were more likely to refer for patch testing on initial presentation. Dermatologists were more likely to recommend gloves and GPs were more likely to recommend soap avoidance/substitution. 2 GPs and no dermatologists reported recommending the best practice combination of moisturizers, topical corticosteroids and soap substitutes. When adjusted for all variables including age, sex, duration and diagnostic subgroup, workers with atopy as a cofactor had the most severe impairment. This study suggests that in Australia, patients with suspected OCD are initially managed within general practice, few clinicians recommend best practice treatments for OCD, and that atopy is associated with severity. These findings have implications for health resource allocation, clinician education, and the pre-employment counselling of atopic patients.

Patients with occupational contact dermatitis in Israel: quality of life and social implications

One of the most common occupational diseases is skin disease caused as a result of contact with work-related materials or exacerbated by them. Although occupational-related skin disease is a common condition, it is not considered to be a serious one and, therefore, has not received satisfactory attention in the psycho-social literature or in the social work profession. In our study, 70 occupational contact dermatitis (OCD) patients were interviewed by telephone regarding psychological, social, economic, and subjective issues related to the disease. All patients reported to be affected in their daily living activities, self-image, economic status, and in their interpersonal relationships in the family. Our study seeks to highlight the problems of this population group and serve as a vehicle to facilitate patient's rights.

Medical and psychosocial outcome of patients with occupational contact dermatitis in Israel

BACKGROUND

Although the medical, financial and prognostic factors of occupational contact dermatitis (OCD) have been addressed, studies on the social outcome of OCD are sparse.

OBJECTIVE

To define the medical and psychosocial outcome of patients with OCD.

METHODS

Workers with OCD were interviewed by telephone using a questionnaire that included questions about the occupation, dermatological disease, sick leave, present working status and disability claims, and questions related to the subjective perceptions of OCD in all areas of psychosocial functioning and quality of life.

RESULTS

Seventy workers (64.3% males and 35.7% females) were interviewed. Forty per cent had stopped working and one-third had taken sick leave because of OCD. Forty-seven (67.1%) were currently working while 23 (32.8%) were unemployed. Disability compensation was claimed by only 41.4% and was received by 24.3%. Eight workers (11.4%) had persistent postoccupational dermatitis (PPOD). Loss of employment affected the occupational area of the workers' lives (100%), and also interpersonal relationships (45.7%), relationships within the family (18.6%), daily functioning (45.7%) and mental health (24.3%).

CONCLUSIONS

Considerable working time is lost because of unemployment or sick leave due to OCD. Only a small proportion of eligible patients with OCD apply for disability compensation and an even smaller proportion receive it. Our study demonstrates the significance of OCD to the psychosocial aspects of workers' lives and emphasizes that the assessment of OCD outcome should relate not only to the medical but also to the psychosocial aspect of the disease.

Quality of life and depression in a population of occupational hand eczema patients

Occupational hand eczema (OHE) is the most frequently recognized occupational disease in Denmark, and despite governmental attempts to reduce exposure to harmful occupational allergens, the number of new cases has remained almost unchanged since the mid-1990s. Some studies have indicated that OHE has considerable impact on quality of life (QoL) and may lead to depression. The aims of the study were to determine risk factors for low QoL, the frequency and severity of depression among OHE patients and changes in QoL and depression after 12 months of follow up. The study population, 758 patients, comprised all new recognized cases from the Danish National Board of Industrial Injuries Registry between October 2001 and November 2002. All patients received a questionnaire to determine impairment of QoL and depressive symptoms. A similar follow-up questionnaire was posted after 1 year. The response rate was 82% at baseline and 91% at follow up. The mean Dermatology Life Quality Index total score was 5.5 for all patients and 7.8 for severe OHE cases. Severe OHE cases and lower socioeconomic status were independently associated with low QoL. The prevalence of moderate-to-severe depression was 9%. Only minor changes in QoL and depressive symptoms were found after 12 months of follow up.

Contact Dermatitis and Workforce Economics

The roots of education in patch testing begin with Jadassohn and have been passed down through generations of dermatologists through didactic teachings and mentoring. Currently, we are faced with workforce economics tipping the balance of dermatology toward cosmetic and surgical practices. This imbalance is easily found in the subspecialty of contact dermatitis, where the current demand for patch test services is on the rise and the number of new dermatology-based patch test providers cannot keep up with the current demand. Steps are being made to remedy this discrepancy through societies and fellowships, yet the question remains: were the steps in time and were they big enough?

Occupational contact dermatitis: etiology, prevalence, and resultant impairment/disability

Cutaneous irritant and allergic responses account for the vast majority of cases of occupational contact dermatitis (OCD). Although the pathophysiologic responses to these two different exposures are distinct, the clinical differentiation between chronic cumulative irritant contact dermatitis and allergic contact dermatitis can be difficult and frequently requires patch testing. This article reviews the recommended algorithms that clinicians should utilize to assess whether a worker suffers from OCD. The prevalence of OCD, its predisposing factors (both endogenous and exogenous), and prognosis are discussed in depth. Finally, issues surrounding the assessment of impairment and disability resulting from OCD are summarized.

Occupational skin disease in Sweden - a 12-year follow-up

The aim of this project was to study the long-term prognosis of occupational skin diseases in Sweden. In 1999, a questionnaire was sent to 623/655 individuals who in 1987 reported occupational skin disease to the Social Insurance Office. 394 answered the questionnaire, and 123 non-responders were interviewed by telephone, giving 517 participants (83%), 323 females and 194 males. 85% reported skin symptoms after 1987, 70% during the previous year. 28% considered themselves recovered, of those with nickel allergy only 12%. In a logistic regression model, skin atopy was the strongest unfavourable factor for the prognosis followed by contact allergy and female sex. 66% had consulted a doctor after 1987 and the majority, 82%, had performed occupational changes - most common was change of jobs, 44%. Those who had changed jobs reported less sick leave. The conclusion is that occupational skin diseases have a clear tendency to end up as chronic conditions with a majority reporting symptoms at a 12-year follow-up. The skin disease had influenced the occupational situation for the majority (82%) and for 15% resulted in exclusion from the labour market through unemployment or disability pension.