Occurrence of contact allergy and hand eczemas in hospital wet work

Patch Testing as a Corroborative and Diagnostic Tool in Patients Suspected of Contact Allergen Induced Facial Melanosis

Background

Hypermelanosis involving predominantly the face and neck is relatively common and often presents a complex diagnostic problem.

Objective

To study the patterns of facial melanosis in Indian skin and assess the importance of patch testing as a corroborative tool in the diagnosis of facial melanosis.

Subjects and Methods

A total of 50 patients who consented to the study and satisfied the inclusion and exclusion criteria were incorporated in the study. These patients were subjected to a detailed history, clinical, dermoscopic, and histopathological evaluation. Patch testing using the universal series, cosmetic series, and photopatch was done on those who satisfied the inclusion criteria. Suspected allergen "as is" patch testing was done in selected cases.

Results

Facial melanosis as a result of contact dermatitis is a common entity and was seen in the age group of 18-70 years in both the sexes with male to female ratio of 6.5:2.5 indicating a male preponderance. The most common dermoscopic finding was the presence of reticular pigment network seen in 33 (66%) cases. Histopathology showed increased basal melanin in 56% and pigment incontinence in 26% of the cases. The commonest allergen in men was found to be potassium dichromate (15%), while in females it was nickel (20%). Photopatch test was done for all the patients and was positive in five cases (10%). Suspected allergen "as is" patch testing was negative in all the cases.

Conclusions

Facial melanosis as a result of contact dermatitis can be confused with other acquired dermatological conditions causing hyperpigmentation. Therefore, a detailed history of contact with allergens has to be elicited, and if found relevant, has to be confirmed by patch testing.

Contact dermatitis in the cleaning industry

PURPOSE OF REVIEW

The review summarizes recent findings on contact dermatitis in the cleaning industry.

RECENT FINDINGS

Contact dermatitis is still an important issue in cleaning. Recent studies identified cleaning work sites and tasks, as well as specific cleaning products, which incur a risk increase for occupational contact dermatitis in cleaning. Workers involved in cleaning outdoors prevalence ratio [PR 1.85, 95% confidence interval (CI) 1.16-2.96], cleaning common areas of residential buildings (PR 1.77, 95% CI 1.11-2.84), schools (PR 1.84, 95% CI 1.15-2.93) and cleaning building sites (PR 1.87, 95% CI 1.18-2.95) showed significantly higher rates of contact dermatitis. Relevant allergens in cleaning are rubber chemicals and disinfectants. Leading allergens are thiurams (11.6%, 95% CI 9.1-14.1) and formaldehyde (3.4%, 95% CI 2.0-4.7), but contact with metal allergens might also be important. The most likely allergen sources for sensitization against rubber chemicals are protective gloves. High sensitization rates for disinfectants might result from the fact that employees in cleaning often use single-use medical examination gloves while cleaning. These gloves are not resistant to chemicals, which may break through the gloves within a short period of time, depending on glove material and thickness. No differences in sensitization rates and sensitization profiles were seen in cleaners of younger (≤40 years) and older (>40 years) age.

SUMMARY

Prevalence of occupational contact dermatitis is still high in cleaning. Irritant contact dermatitis is prevailing, but allergic contact dermatitis is quite frequent, too. Up to now, prevention strategies in cleaning seem to be insufficient.

Is there room for improvement in the emollients for adjuvant therapy?

Emollients play an important part in the management of patients with dry skin disorders, such as atopy, allergy, eczema, psoriasis or dryness following chemotherapy or radiotherapy. Their use in the treatment of diseased and sensitive skin requires not only an efficient hydrating and lipid-replenishing effect on the skin, but minimal risk for skin irritation or sensitization. This will be influenced by their formulation and number and type of ingredients and, due to the nature of their application, requires clinical testing to ensure their appropriateness for dermatological rather than cosmetic use. A new generation of emollients has been developed for the care of dry, or very dry, and sensitive skin. Among these, Dardia Lipo Line (Intendis GmbH, Berlin, Germany) has been formulated specifically for use in post-therapy preventive skin care. The current clinical evidence for this line of emollients is reviewed here.

Characteristics of wet work in nurses

BACKGROUND OBJECTIVES

Nursing is known for its high prevalence of hand dermatitis, mainly caused by the intense exposure to wet work in nursing activities. We aimed to study the characteristics of wet work exposure in nursing.

METHOD

Trained observers monitored the duration and frequency of different wet work activities in 45 randomly chosen nurses from different wards during a morning shift, using a method of continuous observation based on labour-observation techniques.

RESULTS

Wet work in intensive care units accounted for 24% of the overall morning shift duration, with a frequency of 49 incidents. This was 16% in dialysis wards, with a frequency of 30 incidents, and 9% on regular wards, with a frequency of 39 incidents. The wet work activities had short mean duration cycles. The mean duration of occlusion by gloves was 3.1 min on regular wards and 6.7 min in intensive care units.

DISCUSSION

The characteristics of wet work in nurses differed substantially, depending on the ward. According to the German regulation TRGS 531, our observations classify nursing as a wet work occupation, due to the frequency of wet work rather than its duration. The mean duration of occlusion in our observations was short, which makes an occlusion-induced irritating effect doubtful. Reduction in wet work exposure in nursing on regular wards could focus on the reduction of the frequency of hand-washing and patient-washing. We suggest increasing the use of gloves for patient washing. Although this will increase exposure to occlusion from gloves, it may reduce the frequency of exposure to water and soap by about a quarter.

Characteristics of wet work in the cleaning industry

Wet work is the main cause of occupational contact dermatitis in the cleaning industry. Dermatologists and occupational physicians need to base their primary and secondary prevention for workers in the cleaning industry on the characteristics of wet work exposures. We quantified the burden of wet work in professional office cleaning activities with a continuous standardized observation by trained observers of 41 office cleaners. Duration and frequency of wet work exposure and of different cleaning activities were assessed. Wet work made up 50% of such cleaning work. Within a typical 3-hr shift, a mean frequency of 68 episodes of wet work was observed, which classifies office cleaning as wet work. Skin exposure to irritants was markedly different among cleaners who did the same cleaning activities. Reduction in skin irritation can be achieved by training the workers. Because this group of workers, who have a low level of education, has a high risk of developing irritant hand dermatitis, a special effort on training and instruction should be made. A reduction of exposure can be achieved by: using gloves more often; using gloves for a shorter period of time; using gloves while doing activities that otherwise cause the skin to be in contact with water and cleaning substances and washing hands with water only, reserving soap for when the hands are visibly dirty.

Exposure of the hands to wet work in nurses

Prevention of hand dermatitis among nurses can be achieved by reduction of wet-work exposure. A preventive programme should be based on knowledge of exposure levels. An accurate method to assess such exposure levels is needed. Duration and frequency of wet-work activities were assessed by a questionnaire, in various parts of the health care sector. In addition, a randomly chosen sample from this population was observed for the duration and frequency of wet work. In contrast to the questionnaire, the observation method showed less than half the duration of wet work. Observation detected almost double the frequency that was reported with the questionnaire. Gloves were observed to be used daily in special care units for short time periods. A questionnaire does not accurately assess the quantity of wet-work activities. On regular wards, the exposure to irritants is mainly associated with the frequency of wet hands, rather than the duration of wet hands. We assume that the short-term use of gloves on special care units does not cause an increased risk of hand dermatitis. Preventive programmes can focus on decreasing the frequency of wet hands by encouraging the use of gloves; the use of gloves should not only be advised to prevent infections but also to protect against hand dermatitis.

Occupational allergy in medical doctors

Allergic diseases have increased in many developed countries including Japan. Doctors are also at risk for allergic diseases from exposure to allergens in working conditions and hospital environments. We investigated the factors relating to occupational allergy in doctors. Self-administered questionnaires were mailed to all doctors (n=895) who had previously graduated from School of Medicine, Fukui Medical University. Data from 307 responders (response rate: 34.3%, male 241, female 66, mean age +/- S.D., 30.8 +/- 4.2) were analyzed. Eighty-nine doctors stated that they had occupational allergy including contact dermatitis, allergic rhinitis and/or asthma. Fifty-four had contact dermatitis caused by surgical gloves; 77 had contact dermatitis from disinfectants, e.g. 23 from chlorhexidine gluconate; 21 from povidone iodine; and 15 from ethanol. Fifteen doctors experienced allergic rhinitis and/or asthma caused by handling laboratory animals. Univariate analysis showed that profession (surgical doctors) and past histories of allergic diseases (rhinitis, sinusitis, or atopic dermatitis) were significantly related to occupational allergy in doctors, but that gender, smoking or physical exercise were not significantly related to it. A logistic regression analysis showed that past histories of allergic diseases and the profession of surgical doctors were significantly related to occupational allergy, but that gender, age or smoking were not significantly related to it. The results of the present study suggest that past history of allergic diseases is a factor predisposing to occupational allergy in doctors. It is necessary and possible to extend more prophylactic measures for doctors, especially for surgeons, because exposure to responsible agents and materials for them can be more frequent.

Occupational contact dermatitis to nickel: experience of the British dermatologists (EPIDERM) and occupational physicians (OPRA) surveillance schemes

AIMS

To examine, from occupational surveillance reporting data, whether scheme reporters considered nickel exposure to play a role in occupational contact dermatitis (OCD) in the UK.

METHODS

Data on occupational skin disease in the UK are collected by two occupational disease surveillance schemes, EPIDERM and OPRA. Cases of OCD believed to have relevant nickel exposure reported to EPIDERM or OPRA from February 1993 to January 1999 were studied.

RESULTS

An estimate of 1190 cases of occupational contact dermatitis thought to have relevant nickel exposure (12% of total estimated OCD) was derived from reports by dermatologists, an average of 198 per year. The highest incidence rates were seen in hairdressers (23.9/100 000 workers/year), bar staff (4.7), chefs and cooks (4.4), retail cash and checkout operators (2.8), and catering assistants (2.5). From May 1994 to January 1999, 158 cases of nickel associated dermatitis (1.9% of total OCD cases) were estimated; the most frequently reported occupations were electronic assemblers, nurses, sales assistants, and general assemblers. From July 1997 to January 1999, 547 positive patch tests to nickel were reported; in 195 cases (36%), nickel was felt to be a relevant occupational allergen (for example, coin handling). In hairdressers, nurses, cooks, and beauticians, nickel was usually considered, if relevant at all, to be only one of several causes of dermatitis.

CONCLUSIONS

Up to 12% of total estimated cases of OCD were thought to be due in part to nickel. Results suggest that nickel hypersensitivity is one of several contributors to OCD in subjects with multiple occupational exposures. Coin handling may be a source of OCD to nickel.

The prevalence of chromium allergy in the United States and its implications for setting soil cleanup: a cost-effectiveness case study

Hexavalent chromium [Cr(VI)] elicits allergic contact dermatitis (ACD) among previously sensitized individuals, and some regulatory agencies have suggested the need for Cr(VI) soil standards that are protective of this health end point. To assess the cost effectiveness of implementing ACD-based standards, it is necessary to understand the prevalence of Cr(VI) sensitivity in the general population. More than 30 published studies from 1950 to 1997 were reviewed to determine the prevalence of Cr(VI) sensitivity. No random survey of the general United States (U.S.) population has been performed to date, but the prevalence of Cr(VI) sensitization among North American clinical cohorts (e.g., patients of dermatological clinics) was reported to be 1% in 1996. The prevalence of Cr(VI) sensitivity among the general U.S. population is estimated to be 0.08%. This estimate was calculated by dividing the current U.S. clinical prevalence estimate (1%) by the ratio of Cr(VI) sensitization in clinical vs general populations in The Netherlands (12). A retrospective cost/benefit analysis for sites in Jersey City, New Jersey, suggests that remediation of soils to protect against elicitation of ACD in sensitized individuals is not a cost-effective use of public health resources.

Atopy and other risk factors for UK dentists reporting an adverse reaction to latex gloves

A study was conducted to assess the significance of a personal history of atopy and other risk factors for UK dentists reporting an adverse reaction to natural rubber latex (NRL) gloves. 2535 dentists completed a self-administered questionnaire and, of these, 1034 (group 1) reported an adverse reaction to NRL gloves and 1501 (group 2) did not. Risk factors investigated were: sex, years in clinical practice, exposure to gloves and a history of atopy or food allergy. The signs and symptoms reported by group 1 dentists were recorded. Logistic regression analysis was used to identify a set of risk factors that produced the most discrete model for a dentist reporting an adverse reaction to NRL gloves. A personal history of atopy was a significant risk factor. Dentists with a history of eczema and hand eczema in childhood were most likely to report an adverse reaction to NRL gloves.

Allergic and Irritant Glove-related Diseases in Health Care Workers and Their Prevention

Because the widespread use of gloves by health care workers has induced an increase of both irritant and type I or type IV allergic glove-related diseases, the Italian Society of Preventive Medicine for Health Care Workers set up a working group to collect information about glove composition and to standardize procedures for the diagnosis and prevention of glove-related disease and job-fitness evaluation of employees who will be wearing gloves. In addition, the group made recommendations for educational programs focusing not only on users but also on purchasers, who presently favor glove selection for economic reasons. The group's recommendations are summarized in a consensus document, but cannot be considered definitive. More research is needed to achieve answers to questions raised by the working group, indicated in the consensus document. In particular, diagnostic criteria must be standardized to plan multicenter studies to verify the real extent of the problem, and further studies are needed to verify whether limit values for substances contained in the gloves (e.g., latex proteins, residual chemicals) can be established.

Occupational hand dermatitis in hospital environments

Health care personnel form the 5th category at major occupational risk of skin disease in Italy. The aim of this study was to assess the prevalence and clinical relevance of contact dermatitis in a group of 1301 employees of the Perugia Monteluce Hospital (658 females and 643 males; mean age 39.8 years) who answered a self-administered questionnaire elaborated by the authors. The subjects with anamnestic hand dermatitis and/or atopic mucosal reactions were clinically examined and submitted to skin tests (patch and/or prick tests). Contact dermatitis of the hands and/or forearms occurred in 21.2% and was significantly more frequent (p < 0.001) in women, subjects under 31 years of age, workers in internistic and surgical fields, cleaners and nurses. In the majority of cases (94.9%), the lesions were irritant in origin and mainly related to disinfectants (especially, chlorhexidine gluconate and glutaraldehyde) and gloves (latex proteins and starch glove powder, rather than accelerators and additives of rubber). Finally, atopy seemed to favour the onset of hand dermatitis. The importance of these results for preventive measures of contact dermatitis in hospital employees is discussed.

Exposure characteristics and cutaneous problems in operating room staff

Health care personnel have exposure to a variety of cutaneous irritants and allergens and a high prevalence of cutaneous problems. The objectives of this exploratory study were to characterize the exposures and determine the prevalence of cutaneous symptoms and findings in operating room personnel, and to examine relationships between exposure characteristics and cutaneous outcomes. A questionnaire and standardized hand examination were used to assess the exposures and cutaneous status of operating room personnel. 184 operating room staff (90% of the eligible population) were assessed. Current skin problems were reported by 26%. Hand examination revealed that 9% had findings consistent with eczema and 10% changes of moderate dryness. A variety of preventive practices were being used by those with symptoms or findings. Cutaneous problems are common in operating room personnel. The use of preventive strategies (changing the type of gloves worn or the type of soap used for scrubbing, the use of glove liners and emollients) varied between different groups. These workers might benefit from more education regarding cutaneous hazards, preventive stategies and the importance of appropriate investigation of these problems.

The 12-year prognosis of hand dermatosis in 896 Finnish farmers

In all, 896 Finnish farmers (305 men and 587 women), representing 77% of those reporting hand or forearm dermatosis in a questionnaire survey in 1979, were asked again about their dermatosis and current work in 1991. More than 50% of the study population had left farming since 1979. In 1991, 26% of men and 21% of women had a current dermatosis on the hands or forearms, and altogether, 44% of men and 39% of women reported a hand dermatosis within the past 12 months. Significant determinants of persistent hand dermatosis, in a logistic regression model, were continuation of farm work, history of skin atopy, symptoms of metal allergy, and age under 45 years. Handling cattle, e.g., milking, was considered an exacerbating factor of the dermatosis by 37% of those who had milked sometimes in their lives. In this group, 75% of hand dermatoses in those who had finished milking work had healed. The results indicate that giving up or changing work improves the prognosis of hand dermatosis in farming.

Hand eczema in Finnish farmers. A questionnaire-based clinical study

In a population of 2005 Finnish farmers, 172 (8.6%) reported hand or forearm dermatoses in a self-administered questionnaire. 138 (80%) of them attended a clinical examination. Skin prick tests (SPTs) were done to 80% and patch tests (PTs) to 77% of the examined farmers. 93% of hand dermatoses were eczema and 70% were considered work-related. Cow allergy was found in 41 of 104 prick- and patch-tested farmers (39%). Immediate allergy to cow epithelium was encountered in a total of 28/41, in 20 with SPTs, and in 8 only with 20 min PTs. Delayed contact allergy to cow dander was found in 27/41. The result suggests that in addition to SPTs using commercial cow epithelium extract, PTs using fresh cow dander should also be done, and both immediate and delayed responses should be read.

Review of the allergic contact dermatitis hazard posed by chromium-contaminated soil: identifying a "safe" concentration

At least 200 sites in the United States contain soil with elevated levels of trivalent and hexavalent chromium [Cr(III) and Cr(VI)]. Although the potential cancer hazard posed by airborne Cr(VI) has been the primary concern for these sites, a soil cleanup standard based on the potential elicitation of allergic contact dermatitis has been proposed for sites in Hudson County, N.J. This paper describes the rationale for identifying a soil concentration of Cr(VI) that should not pose an allergic contact dermatitis hazard-even in sensitized persons. A literature review of eight published patch test studies that evaluated the allergic response to potassium dichromate was conducted. These studies were evaluated for clinical and statistical relevance in establishing a threshold dose of Cr(VI) to which no more than 10% of the subpopulation sensitized to chromium would respond, and that would protect at least 99.84% of the general population. Although each of the studies had certain methodological limitations when evaluated against current test methods, the data set proved useful for deriving an estimated threshold. Using computer data-fitting techniques based on truncated lognormal distributions, a weighted mean 10% threshold of approximately 150 ppm potassium dichromate or 54 ppm Cr(VI) was identified for the eight studies. Due to the types of limitations noted for these studies, this threshold is likely to be somewhat conservative. Test results have shown that between 5 and 10% of the Cr(VI) at concentrations less than about 500 ppm are released from a soil matrix into an isotonic saline solution simulating sweat. Using human sweat as the extractant, it has been shown that only 0.1% of the CR(VI) at concentrations of approximately 1,000 ppm are released from a soil matrix into sweat. Based on 10% solubilization of soil-bound Cr(VI) and the results of our statistical analysis of previous threshold studies, a concentration of approximately 350 to 500 ppm Cr(VI) in soil should be sufficiently low to protect virtually all exposed people, including children, from chromium-induced allergic contact dermatitis.

Formaldehyde is a significant allergen in women with hand eczema

Among patients consecutively patch tested at St John's from 1984-1989, the prevalence rate of formaldehyde sensitivity was 2.2% for men and 3.7% for women. During these 6 years, 117 women were primarily sensitized by formaldehyde, of whom 61 (52%) had hand eczema. Exposure was occupational in 12% and domestic in 88%. Cleaning products were the main source of exposure in the domestic group. 20 women with hand eczema avoided formaldehyde and their hands healed in 2, greatly improved in 11 and were better in 7.

Frequency, spectrum and occupational relevance of type IV allergies to rubber chemicals

3851 consecutive patients patch tested between January 1985 and March 1990 have been analysed for rubber allergies. The incidence of rubber allergy was 3.8% (n = 145). In 80/145 patients (55%), the source of rubber sensitization was occupational, 67 of whom (84%) had acquired allergy from wearing rubber gloves at work. Most of them (36%) were employed in the health services. The most commonly positive rubber-mix in this group was thiuram-mix (72%) followed by carba-mix (25%). 13/80 patients (16%) had occupational rubber allergy from industrial rubber products other than gloves. Patch tests revealed thiuram-mix (62%) as the most commonly positive rubber-mix but, in contrast to the group with glove-induced rubber allergy, black-rubber-mix came second (38%). In 47/145 patients (32%), the source of rubber sensitization was non-occupational; in 18/145 (13%) the origin remained unknown.

Hay fever, eczema and urticaria in southwest Norway. Lifetime prevalences and association with sex, age, smoking habits, occupational airborne exposures and respiratory symptoms

Information on hay fever, eczema, urticaria, respiratory symptoms, smoking habits and occupational dust or gas exposure was obtained by a self-administered questionnaire from a random sample of 4992 subjects of the general population aged 15-70 years of the Hordaland county, Norway. The response rate was 90% of the sample. The lifetime prevalences of hay fever, eczema and urticaria were 10%, 25% and 9% of the respondents, respectively. Eczema and urticaria were more often reported by women than by men. The lifetime prevalence of hay fever decreased substantially by age in both sexes. A history of hay fever was inversely related to cigarette smoking. The lifetime prevalences of eczema and urticaria were associated with occupational dust or gas exposure after adjusting for sex, age, smoking habits and area of residence. Adjusted odds ratios of respiratory symptoms in subjects with hay fever were almost 2.0 compared with those without.

Patch and prick test study of 593 healthy subjects

593 recruits selected by the Military Health Service as being healthy and without a history of present or previous dermatitis, or ocular refraction defects, were patch tested with the GIRDCA (Italian Research Group on Contact and Environmental Dermatitis) standard series. Of these, 336 were also patch tested with substances used in the processing and dyeing of textiles and prick tested with 8 major allergens. 74 (12.5%) reacted to 1 or more substances. The most frequent sensitizers were: thimerosal (28 cases), ammoniated mercury (7 cases), phenol-formaldehyde resin (6 cases), parabens, nickel and Disperse Red 17 (4 cases each). 113 recruits reacted to 1 or more prick test allergens. We have demonstrated the importance of establishing such reference values in healthy groups for the correct evaluation of data collected from selected groups.

Incidence of immediate allergy to latex gloves in hospital personnel

Latex surgical gloves may cause contact urticaria and serious allergic reactions in sensitized persons, but the frequency of this allergy is not known. In the present study, 512 hospital employees were screened with a latex-glove scratch-chamber test; 23 (4.5%) were suspected and 15 (2.9%) were proven allergic with latex prick and use tests. All of them were doctors and nurses, and 12 had had contact urticaria but no serious symptoms. They could continue their routine work using cotton or vinyl undergloves or special latex surgical gloves. Atopy, hand eczema and surgical work seemed to be predisposing factors. In operating units, 7.4% of the doctors and 5.6% of the nurses were allergic; the frequency was lower in non-operating units and among laboratory personnel. The high frequency of latex glove allergy, especially in operating units, focuses attention on the quality of surgical latex gloves.

Hospital employees and skin problems

A total of 1481 hospital employees answered a questionnaire on atopy, hand eczema, and dry chapped hands. Out of 864 (58.7%) responders, 17% claimed to suffer from hand eczema. There was not significantly more hand eczema among women (17.6%) than men (15.7%). Atopic disposition was present in 17.5% of responders, of whom a significantly higher number (36.4%) claimed to have hand eczema. Dry chapped hands seemed to be a problem in 33.1%, mainly among nurses, assistant nurses and laboratory assistants. Technicians and X-ray assistants (38%) and kitchen workers (35.7%) claimed to suffer significantly more from hand eczema than others. Their working conditions were inspected. Following examination by a dermatologist, irritant contact eczema was diagnosed in 11 of 17, and occupational eczema in 3. None of the janitors or technical workers (all men) had hand eczema.

Contact dermatitis. A review

In recent years, there has been a dramatic rise in our understanding of contact dermatitis. This paper is a review of our knowledge of the mechanisms involved in contact dermatitis and related phenomena, the investigation of these events and the emergence of significant new allergens during the last 5 years.

Hand eczema in hairdressers and nurses: a prospective study. I. Evaluation of atopy and nickel hypersensitivity at the start of apprenticeship

A prospective study of the development of hand eczema was initiated in 86 junior hairdressers and 217 junior nurses. Data obtained at the start of their apprenticeships are presented. None of the junior apprentices presented with hand eczema, but a history of hand eczema was reported by 22/303 (7%) of the students. Almost half of this group (10/22, 45%) could be classified as atopics. Students without a history of hand eczema showed a similar frequency of atopy (17%) as observed in the general population. History of hand eczema was not related to nickel hypersensitivity, as assessed by patch testing. The incidence of nickel hypersensitivity was high in junior hairdressers (26%), compared to junior nurses (12%). Information as to previous contacts with nickel suggested that development of nickel allergy had been promoted by ear-piercing. A lower incidence of nickel hypersensitivity was observed if this potentially sensitizing event had been proceeded by orthodontic treatment with nickel-containing materials. This phenomenon is discussed in terms of orally-induced tolerance.

Dermatitis from repeated trauma to the skin

A moderate degree of friction is unavoidable in everyday contact between man's skin and his environment. However, excessive friction and other forms of microtrauma can cause various dermatoses as well as lesions of hair and nails. This paper illustrates that microtraumata significantly influence many skin disorders, including those of occupational origin.

Hand dermatitis: practical management and current concepts

hand dermatitis (HD) is a common clinical challenge, its management a clinical art. The vexing problem of etiologies is simplified by classifying causative factors as either exogenous or endogenous. Most patients respond to avoidance of irritants combined with appropriate topical corticoids and lubrication. While certain aspects of treatment must be individualized, many of the protective and lubricating measures are routine. Patient compliance with these routine, and necessarily involved, measures is greatly improved by using printed instruction forms. A minority of patients with HD will challenge the most skilled clinician. At present, technics for determining the role of endogenous versus exogenous factors are not satisfactory. Even repeated and involved patch testing combined with prolonged observation may leave a nagging uncertainty . . . is there an overlooked allergen responsible for this chronic dermatitis? The chronic, endogenous, palmar, vesicular dermatoses represent a stubborn therapeutic problem. Potent corticoids under occlusion, while often effective, tend to produce atrophy. Intralesional corticoids are practical only for small areas. Systemic corticoids, while producing dramatic relief, only postpone the problem, since their side effects preclude long-term usage. At times psoralens and ultraviolet A (PUVA) therapy provides effective control. With perceptive persistence, most chronic HD can be effectively controlled. It is worth the effort, for often it means restoring a social and economic outcast to a useful and happy life.

Occupational dermatoses in hospital cleaning women

In an investigation of 541 members of a hospital cleaning department, a prevalence rate of occupational skin diseases of 15.3% was found. During their hospital employment, 39.1% had a skin disease. Higher prevalence in the younger age groups can be explained by the selection of those with skin diseases for work away from the cleaning department. A large number developed their disease shortly after employment began. This was an indication that the observed prevalent conditions were irritant diseases. The distribution by diagnosis confirms this conclusion in as much as 75% of the occupational skin diseases were irritant dermatitis, 21% allergic contact dermatitis, and 4% monilia of the finger webs. The causes of allergic contact dermatitis were found to be formaldehyde, glutaraldehyde and chloramine in addition to nickel and rubber. Among the causes of irritant dermatitis were detergents, alkaline substances, acids and sodium perborate as well as hypochlorite and hypobromite combinations. In order to reduce occupational skin diseases among cleaning personnel, it is necessary to extend both local and more general prophylactic measures.

Hand eczema in nickel-sensitive female twins. Genetic predisposition and environmental factors

The Danish Twin Register represents a population-based twin sample where the twins enter the Register independently of disease. All female twins born between 1906-30 and available in the Register in January 1978 were sent a questionnaire concerning possible nickel sensitivity. Among 746 pairs living in the eastern part of Denmark, 129 twins from 115 pairs had a possible nickel allergy. Through a subsequent personal visit and, in most cases, patch testing, 34 monozygotic probands from 30 pairs and 45 dizygotic probands from 41 pairs were considered to have a verified nickel sensitivity and fulfilled the restriction criteria for the present study. The prevalence of present or previous hand eczema in both the monozygotic and the dizygotic probands was 41% (95% confidence limits: 30-52%). In 15 of the 32 with hand eczema, this was in the form of a relapsing pompholyx. Analysis of the monozygotic pairs showed that the risk of developing hand eczema in the co-twins seemed independent of whether the proband had nickel allergy and hand eczema or nickel allergy alone. Furthermore, it was found that the number of affected co-twins was comparable with the background population. Thus the association between nickel allergy and hand eczema is probably not due to a common genetic predisposition. Environmental factors seem decisive.