Validation of specific inhalation challenge for the diagnosis of occupational asthma due to persulphate salts

Do hairdressers comprise a high risk group for genotoxicity? A systematic review

BACKGROUND AND OBJECTIVES

Nowadays, hair dye products are widely used for aesthetic purposes, in which it generates chemical exposure to customers and, mainly, hairdressers. The aim of this systematic review was designed to elucidate the following question: are hair dye products able to induce DNA damage in hairdressers?

METHODS

Studies were included in our analyses if they met the following criteria: (1) studies measuring genetic damage in vivo; (2) studies published in English; (3) studies that provided data clearly presented in scientific standards.

RESULTS

Full manuscripts from 13 studies were carefully selected in this setting. Our results demonstrate that hair dye products may contain chemical agents able to induce DNA strand breaks or chromosome damage since the majority of studies demonstrated positive findings for genotoxicity. A total of 7 studies (out of 13) had strong or moderate rates in the quality assessment. The type of genotoxicity assay and sample selection criteria time influenced the outcome.

CONCLUSION

In summary, our results reveal that hairdressers are occupationally exposed to genotoxic agents. Such findings are very important for protecting these professionals who are continuously exposed to chemicals for long periods.

Respiratory toxicity of persulphate salts and their adverse effects on airways in hairdressers: a systematic review

Objective

To review the literature on respiratory effects of persulfate salts (PS) or hair bleaches in hairdressers and animal models exploring mechanisms behind PS-induced asthma.

Methods

A systematic review according to the PRISMA guidelines was performed. Studies published from 2000 to July 2021 that fulfilled predefined eligibility criteria were retrieved. Data were not quantitatively synthesized due to the heterogeneity of study designs, outcomes and methods.

Results

Forty-two articles were included. PS are indicated as the main cause of occupational rhinitis and asthma in hairdressers, and one of the leading causes of occupational asthma in some European countries. Bleaching products are indicated as the most important factor for development of respiratory symptoms, lung function decline, and leaving the hairdressing profession. Risk estimates from a good quality prospective study showed up to 3.9 times higher risk for wheezing and breathlessness in hairdressers aged ≥ 40 years than in matched controls, and 20 times higher risk in hairdressers to develop respiratory symptoms from exposure to bleaching powder than controls. Pathophysiological mechanisms of the respiratory response to PS are not yet fully elucidated, but may include non-specific and specific immune responses.

Conclusions

Hairdressing is associated with a wide spectrum of respiratory adverse effects, of which bleaching products were indicated as the most hazardous. Preventive measures for reducing inhalatory exposure to PS in hair salons should be re-evaluated, including adopting occupational exposure limits at EU level, and encouraging use of safer bleach formulations.

PROSPERO registration number

CRD42021238118.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-022-01852-w.

Identification of Pen m 4 as a potential cause of occupational asthma to Gammarus shrimp

We present the case of a 34-year-old male patient employed for 8 years in a company manufacturing and packaging animal feed. The patient developed occupational asthma to dry Gammarus powder. The diagnosis was confirmed by specific bronchial provocation test. The determination of specific IgE antibodies was positive for Pen m 4, a sarcoplasmic calcium binding protein, with a level of 6.7 ISU-E. The sensitization to Pen m 4 described here may identify a new allergen causing occupational asthma in these workers.

Genotoxic risk assessment in professionals working hairdressers area using buccal micronucleus assay, in Aydın City, Turkey

The aim of this study was to determine the genotoxic risk of professional hairdressers in Aydın City, Turkey, through investigating the micronucleus frequencies in buccal mucosa epithelial cells. All the hairdresser working hairdresser area were included in the genotoxic risk group (GRG = 20) in Aydın City, Turkey. The control group (CG = 20) comprised healthy individuals matching the gender and age of the GRG. Buccal mucosal scraping from all the 40 subjects of GRG (10 women and 10 men) and CG (10 women and 10 men) was stained with Giemsa stain and observed under light microscope (×40) for the presence of micronuclei (M 10 N) and karyolysis, pyknosis, condensed chromatin, karyorrhexis, nuclear bud, and binucleates in the exfoliated epithelial cells. There are significance between the incidence of MN in GRG and CG (P = <0.005) using one-way ANOVA, Kolmogorov-Smirnov Z test, and Spearman Rank Correlation Tests.

Specific inhalation challenge: the relationship between response, clinical variables and lung function

INTRODUCTION

The specific inhalation challenge (SIC) is considered the gold standard for the diagnosis of occupational asthma (OA). However, its use is not standardised, and the intensity of exposure is regulated empirically. The aim of this study was to identify clinical variables and/or pulmonary function variables able to predict the scale of patients' response to SIC.

MATERIAL AND METHODS

All patients who underwent SIC at our centre between 2005 and 2013 were studied. Anthropometric characteristics, atopic status, type of causal agent, latency times, pulmonary function tests and SIC results were analysed.

RESULTS

Two hundred and one patients (51% men) were assessed, of whom 86 (43%) had positive SIC. In the patients with positive results, 29 (34%) were exposed to high molecular weight (HMW) agents and 57 (64%) to low molecular weight (LMW) agents. Patients with a positive SIC exposed to HMW agents had a higher fall in FEV₁ after SIC compared with those exposed to LMW agents (p=0.036). The type of asthmatic reaction after SIC also differed between the groups (p=0.020). The logistic regression analysis showed that patients with a higher PC₂₀ before SIC were less likely to have severe decreases in FEV1 after SIC after adjusting for potential confounders (OR=0.771, 95% CI 0.618 to 0.961, p=0.021).

CONCLUSIONS

The scale of the response to SIC is influenced mainly by the degree of bronchial hyper-responsiveness, regardless of whether the causative agent is HMW or LMW, or whether the response is early or late.

Work-Related Asthma

OBJECTIVE

Summarize developed evidence-based diagnostic and treatment guidelines for work-related asthma (WRA).

METHODS

Comprehensive literature reviews conducted with article critiquing and grading. Guidelines developed by a multidisciplinary expert panel and peer-reviewed.

RESULTS

Evidence supports spirometric testing as an essential early test. Serial peak expiratory flow rates measurement is moderately recommended for employees diagnosed with asthma to establish work-relatedness. Bronchial provocation testing is moderately recommended. IgE and skin prick testing for specific high-molecular weight (HMW) antigens are highly recommended. IgG testing for HMW antigens, IgE testing for low-molecular weight antigens, and nitric oxide testing for diagnosis are not recommended. Removal from exposure is associated with the highest probability of improvement, but may not lead to complete recovery.

CONCLUSION

Quality evidence supports these clinical practice recommendations. The guidelines may be useful to providers who diagnose and/or treat WRA.

Optimizing diagnostic tests for persulphate-induced respiratory diseases

BACKGROUND

Persulphates from hair bleaching products are considered the major cause of occupational-rhinitis and asthma in hairdressers. The specific inhalation challenge (SIC) is considered 'reference standard' for diagnosing persulphate-induced asthma and rhinitis; however, the currently validated method of performing SIC with persulphate powder is time consuming with a duration of up to 4 days. The value of skin prick tests (SPTs) and histamine release tests (HRTs) with persulphates is unknown. The aim of this study was to establish a novel rapid SIC with persulphate powder to test for both rhinitis and asthma simultaneously in 1 day. In addition, we assessed the suitability of SPTs and HRTs for detecting persulphate-induced respiratory diseases.

METHODS

The study population included 19 hairdressers with a history of work-related rhinitis and/or asthma symptoms, 12 symptomatic controls (10 with concurrent allergic asthma and rhinitis and two with non-allergic asthma), and 40 healthy controls. A previous severe asthmatic reaction and/or anaphylactic reaction to persulphates was considered an exclusion criterion for hairdressers. The 19 hairdressers and 12 symptomatic controls had SIC performed with 3 × 5 min exposures to potassium persulphate powder in a provocation chamber. All participants, including the 40 healthy controls, were subjected also to SPTs and HRTs with three persulphate salts at concentrations of 2-20 % and 0.03-1 %, respectively.

RESULTS

None of the symptomatic controls had a nasal or bronchial response to SIC with potassium persulphate. Six hairdressers presented a nasal and two a bronchial response. No severe reactions occurred. No positive SPTs were recorded, neither among hairdressers, symptomatic controls, nor healthy controls. All three groups showed nonspecific non-IgE mediated histamine release to persulphates in HRT.

CONCLUSIONS

The proposed method for performing SIC showed a high specificity for detecting persulphate-induced asthma and rhinitis. The rapid SIC was able to produce positive nasal and bronchial responses in symptomatic hairdressers without any severe reactions occurring. SPTs and HRTs cannot predict asthma or rhinitis caused by persulphates.

Occupational Respiratory and Musculoskeletal Symptoms among Egyptian Female Hairdressers

Hairdressing is associated with exposure to a variety of harmful agents which have been linked to respiratory and musculoskeletal disorders in hairdressers. This study aimed to identify respiratory and musculoskeletal disorders in hairdressers compared to office workers. A cross-sectional study was conducted on 80 female hairdressers and 50 matched controls. A structured questionnaire was used to collect information on personal and occupational data, hairdressing activities, the presence of respiratory symptoms and the prevalence of musculoskeletal pain in the past 12 months. Reported symptoms were compared between hairdressers and controls. The associations between self-reported symptoms and hairdressing activities were investigated. Hairdressers were more likely to report symptoms than controls particularly for those who were older, with higher body mass index and longer duration of work as hairdresser. There were significant associations between frequent hair treatments (bleaching, dye and wave) and hand dermatitis (P < 0.001), running nose (P < 0.05), eye irritation (P < 0.01) and phlegm (P < 0.05). Elbow pain and shoulder and back pain were the most prevalent musculoskeletal pains in the past 12 months (13.8 and 12.5% respectively), back and knee pains were the most frequent chronic pain (7.5%), hand and wrist pain led 12.5% of hairdressers to visit a doctor and shoulder pain and back pain indicated a period of sickness absence in 13.8% of hairdressers. Musculoskeletal disorders were associated with manual handling, prolonged standing, strenuous shoulder movements and awkward body posture. Hairdressing is associated with increased risk to respiratory and musculoskeletal disorders due to adverse work conditions.

Characterization of Hairdresser Exposure to Airborne Particles during Hair Bleaching

Respiratory symptoms among hairdressers are often ascribed to the use of bleaching powders that contain persulfate salts. Such salts can act as allergens and airway irritants but the mechanisms behind the negative health effects are not fully known. In order to understand why some hairdressers experience respiratory symptoms during, and after, sessions of hair bleaching, it is of importance to characterize how exposure occurs. In this work we used time and particle size resolved instrumentation with the aim to measure the concentration of particles that hairdressers are exposed to during sessions of hair bleaching. We also used filter samples to collect particles for quantitative determination of persulfate (S2O8(2-)) content and for analysis by light microscopy. Two different types of bleaching powders were used, one marked as dust-free and one without this marking (denoted regular). The time resolved instrumentation revealed that particles <10 µm were emitted, specifically when the regular powder was prepared and mixed with hydrogen peroxide. In contrast to other research our work also revealed that supercoarse particles (>10 µm) were emitted during application of the bleaching, when both the regular and the dust-free powders were used. The measured level of persulfate, sampled in the breathing zone of the hairdressers, was on average 26 µg m(-3) when the regular powder was used and 11 µg m(-3) when the dust-free powder was used. This indicates that use of dust-free powder does not eliminate exposure to persulfates, it only lowers the concentration. We show that the site of sampling, or position of the hairdresser with regards to the hair being bleached, is of high importance in the determination of persulfate levels and exposure. This work focuses on the physical and chemical characterization of the particles released to the air and the results are important for accurate exposure assessments. Accurate assessments may in turn lead to a better understanding of why some hairdressers experience respiratory symptoms from hair bleaching sessions.

Asthma and respiratory symptoms among hairdressers in Denmark: results from a register based questionnaire study

BACKGROUND

Hairdressers are at risk of developing occupational respiratory disorders due to persulfates and other hairdressing chemicals.

METHODS

A register based questionnaire study comprising 7,840 graduates from hairdressing vocational schools was conducted. The postal questionnaire concerned self-reported asthma, airway symptoms, occupation, smoking, and atopic dermatitis.

RESULTS

A response rate of 67.9% was obtained. The hairdressers reported asthma (11.2%), cough (25.3%), nasal congestion (24.0%), and rhinitis (18.2%). Less than 1/3 of all hairdressers with suspected occupational asthma reported their asthma as an occupational disease to the authorities. In total, 27.3% were daily smokers; the smoking pattern was similar between hairdressers with and without asthma. Local exhaust ventilation was only used consistently by 63.8% for permanent waving and hair coloring procedures.

CONCLUSIONS

Asthma and especially respiratory symptoms were commonly reported by hairdressers, but rarely reported as an occupational disease. Local exhaust ventilation was inconsistently used. Our results underline the need for improved measures to ascertain and prevent occupational asthma in hairdressers.

Prick testing with chemicals in the diagnosis of occupational contact urticaria and respiratory diseases

BACKGROUND

Little is known about the use of prick tests with chemicals in diagnosing occupational diseases.

OBJECTIVE

To evaluate the use of prick tests in the diagnosis of occupational contact urticaria, asthma and rhinitis caused by chemicals (undertaken at the Finnish Institute of Occupational Health).

MATERIAL AND METHODS

We retrospectively reviewed the patient and test files for the period 1 January 1991 to 31 May 2011. Prick tests were performed with chemical solutions and human serum albumin (HSA)-chemical conjugates.

RESULTS

Positive prick test reactions to isocyanate-HSA conjugates were associated with isocyanate-specific IgE in all 20 patients, and 17 patients had a relevant occupational disease. Positive reactions to chloramine-T-HSA conjugates in 10 patients also indicated the presence of specific IgE, although occupational diseases were not always diagnosed. Eleven of 17 patients with positive reactions to persulfate solutions were diagnosed with an occupational disease. Methacrylates, colophonium-related substances, amine hardeners, ethanolamines, glutaraldehyde, glyoxal, pyrocatechol and ammonium thioglycolate did not elicit any relevant prick test reactions. No generalized reactions were detected.

CONCLUSION

Prick tests can be safely used for diagnosing contact urticaria, asthma and rhinitis caused by isocyanates, chloramine-T, persulfates, and chlorhexidine, but the results should be carefully interpreted and related to clinical symptoms and other diagnostic tests.

Sputum inflammatory profile before and after specific inhalation challenge in individuals with suspected occupational asthma

BACKGROUND

The aim of this study was to establish the sputum inflammatory profile and changes in levels of leukotriene B₄ (LTB₄) and a panel of Th1/Th2 cytokines in subjects with suspected occupational asthma (OA) following specific inhalation challenge (SIC) to high-molecular-weight (HMW) and low-molecular-weight (LMW) agents.

MATERIAL AND METHODS

Fifty-one consecutive subjects undergoing SIC for suspected OA were enrolled. Sputum induction was performed the day before and 24 h after exposure to the offending agent. Total and differential cell counts were assessed. LTB₄ and a 10 Th1/Th2 cytokines were measured in sputum supernatant.

RESULTS

Thirty-four patients tested positive to SIC and were diagnosed with OA (in 10 due to HMW agents and in 24 to LMW agents). SIC was negative in 17 subjects. As compared to baseline an increase was found in the percentage of sputum eosinophils and neutrophils, and in IL-10 concentration after SIC (p = 0.0078, p = 0.0195, and p = 0.046, respectively), and a decrease was seen in LTB₄ level (p = 0.0078) in patients with OA due to HMW agents. An increase in the percentage of sputum neutrophils after SIC (p = 0.0040) was observed in subjects without OA exposed to LMW agents. IL-8 levels after SIC were higher in patients without OA compared with patients with OA (p = 0.0146).

CONCLUSION

When conducting airway inflammation studies in OA, patients should be divided according to the causal agent (HMW or LMW). In OA patients exposed to HMW agents, an increase in the number of neutrophils can be found in parallel to the increase of eosinophils, although this does not contradict an IgE-mediated mechanism. Exposure to LMW agents can result in increased neutrophilic inflammation in patients with airway diseases unrelated to OA. There is variability in the responses observed in patients with OA exposed to LMW agents.

Occupational eczema and asthma in a hairdresser caused by hair-bleaching products

Occupational allergic contact eczema and asthma caused by bleaching agents is seen in hairdressers. Bleaching agents contain persulfate salts, which are known to induce immediate reactions such as rhinitis, asthma, contact urticaria, and anaphylaxis. The immunologic mechanism is not, however, fully understood. The specific inhalation challenge test is considered to be the gold standard for diagnosing occupational asthma and rhinitis. However, this test is not always accessible. Therefore, the diagnosis of occupational allergic asthma caused by persulfate salts is made by combining a clinical history, a diagnosis of asthma, and a positive skin prick test (SPT). Standardized methods for performing SPT with persulfate salts are warranted. A case of a young hairdresser with occupational asthma and hand eczema caused by persulfate salts is presented, and the procedure for performing the SPT with ammonium persulfate and potassium persulfate is described in detail.

Work-related airway symptoms, nasal reactivity and health-related quality of life in female hairdressers: a follow-up study during exposure

Objectives

Hairdressers often complain of work-related rhinitis (WR). They are infrequently sensitized to persulphates. The cause and mechanism of the symptoms and the effects on their health-related quality of life (HRQoL) remains unclear. The objectives were to follow female hairdressers with WR mainly from bleaching powder regarding nasal reactivity to persulphate and to evaluate symptoms, HRQoL and inflammatory markers in nasal lavage during a working period after vacation and compared with hairdressers without symptoms and pollen allergic women.

Methods

Skin prick tests to persulphate were performed in the hairdressers. Participants kept a diary of symptoms and of work tasks (hairdressers only). They completed HRQoL questionnaires. Eosinophil cationic protein (ECP) in nasal lavage fluid was examined. The symptomatic hairdressers performed nasal challenges with persulphate before and after the exposure.

Results

Skin prick tests were negative. Although the nasal reactivity to persulphate did not change a steady increase in nasal symptoms, especially blockage, and in ECP was noticed in the symptomatic hairdressers. The HRQoL deteriorated in the symptomatic hairdressers indicating an effect on their working situation and daily life. The atopics had more, but varying symptoms (itching, sneezing and secretion).

Conclusions

The difference in the clinical picture between the symptomatic hairdressers and the pollen allergic women, the increase in symptoms and ECP in the nasal lavage support the view that a sensitization to hairdresser chemicals by a mechanism not yet understood is operating. The deterioration of the HRQoL in the symptomatic hairdressers indicates a considerable effect on their life.

Occupational non-immediate type allergic asthma due to ammonium persulfate

While numerous cases of immediate-type occupational asthma due to persulfates with positive skin prick test reactions to ammonium persulfate are well documented, few non-immediate type reactions have been described in the literature. We report the case of an atopic worker who developed work-related asthmatic symptoms shortly after he began his job in persulfate production. The diagnosis of asthma was corroborated by methacholine testing. The patient showed a positive patch test reaction to ammonium persulfate, while skin prick test was negative. He presented an isolated late symptomatic airway obstruction after a cumulative dose of 0.6 mg ammonium persulfate administered by a dosimeter method. An immunologic mechanism was demonstrated by a significant increase in exhaled nitric oxide and the number of eosinophils in induced sputum. These findings suggest that isolated late bronchial reactions to persulfates are mediated by eosinophilic inflammatory responses.

Anaphylaxis and severe systemic reactions caused by skin contact with persulfates in hair-bleaching products

BACKGROUND

Persulfates have been reported to cause both delayed-type and immediate skin reactions. They may also cause immediate reactions of the mucous membranes of the bronchial system through inhalation, leading to asthma and rhinitis. Anaphylactic reactions caused by contact with persulfates are rare. The mechanism of immediate reactions caused by persulfates is unclear.

OBJECTIVES

To report 2 cases with systemic reactions after skin contact with persulfates, and to propose a test protocol for diagnosing immediate reactions caused by persulfates.

METHODS

Prick tests with serial dilutions of ammonium and potassium persulfate were performed. Patch tests were also performed with the two agents. Persulfate-specific IgE was detected with two different IgE immunoblotting techniques.

RESULTS

Prick tests were positive with ammonium and potassium persufate, but no specific IgE was detected in the serum. Patch tests showed early positive reactions to both persulfates in 1 patient.

CONCLUSIONS

Prick tests and patch tests can be valuable in the testing of patients with a suspicion of an immediate-type reaction caused by persulfates. The mechanism of these reactions remains unclear.

The current diagnostic role of the specific occupational laboratory challenge test

PURPOSE OF REVIEW

Classically, the specific occupational challenge test has been considered as the reference test in the diagnosis of occupational asthma. The present study assesses the usefulness of this test for diagnosing this disease and compares it with other diagnostic methods.

RECENT FINDINGS

Occupational asthma is the most frequent work-related respiratory disease in developed countries. Its correct diagnosis is vitally important not only from the medical point of view, but also in view of the disease's major socio-economic repercussions both for the patient and for society as a whole. Diagnosis is based on clinical suspicion of bronchial asthma and of a possible association with the patient's occupation. Various diagnostic strategies have been proposed, including clinical history, immunological test, spirometry, the study of peak flow, the methacholine test and the specific occupational challenge test, as well as studies of bronchial inflammation using noninvasive methods.

SUMMARY

The specific occupational challenge test remains the reference test for the diagnosis of occupational asthma for causal agents of both high and low molecular weight.

Utility of exhaled breath condensate pH for diagnosing occupational asthma

INTRODUCTION

The current reference standard method for diagnosing occupational asthma (OA) is specific inhalation challenge (SIC) with the suspected agent. The alternative method is serial peak expiratory flow (PEF) monitoring. Nevertheless, PEF does not have optimal sensitivity and specificity for this purpose. The aim of this study was to evaluate the utility of exhaled breath condensate (EBC) pH for the diagnosis of OA.

MATERIAL AND METHODS

A prospective study was performed in 37 subjects with suspected OA. Serial PEF monitoring was carried out for 2 weeks at work and for 2 weeks off work. At the end of each period, the EBC pH and the methacholine concentration resulting in a 20% FEV(1) decrease (PC20) were measured. SIC was subsequently performed. PEF graphs were interpreted visually by 3 experienced independent readers.

RESULTS

Seventeen patients tested positive with SIC. Receiver-operating characteristic curves showed that a decrease in EBC pH greater than 0.4 units during the period at work compared to the off-work period achieved the most satisfactory sensitivity (40%, CI 19.4-66.5) and specificity (90%, CI 66.9-98.2) for diagnosing OA. When EBC pH findings were added to PEF results, the diagnostic yield of PEF generally increased. Other test combinations (e.g. EBC pH plus PC20 or EBC pH plus PC20 plus PEF) did not improve diagnostic performance.

CONCLUSIONS

Acidification of EBC pH at work and adding the EBC pH measurement to PEF monitoring during periods at work and off work may be useful for improving the diagnosis of OA.

Diagnostic utility of exhaled breath condensate analysis in conjunction with specific inhalation challenge in individuals with suspected work-related asthma

BACKGROUND

Establishing the role of exhaled breath condensate (EBC) analysis in work-related asthma (WRA), and more specifically, in conjunction with specific inhalation challenge (SIC), is difficult.

OBJECTIVE

To measure EBC pH, and nitrite/nitrate concentrations before and after SIC in individuals with suspected WRA exposed to either high-molecular-weight (HMW) or low-molecular-weight (LMW) agents and evaluate whether these changes are useful to distinguish between occupational asthma (OA) and work-exacerbated asthma (WEA).

METHODS

One hundred twenty-five consecutive workers undergoing SIC were enrolled. Exhaled breath condensate was collected at the end of the baseline day and 24 hours after exposure to the offending agent. In all EBC samples, pH was measured, and nitrite and nitrate concentrations were determined.

RESULTS

Specific inhalation challenge was positive in 66 individuals, who were then diagnosed with OA. Work-exacerbated asthma was diagnosed in 14, and in 45 patients establishing a direct relationship between the symptoms and work exposure was not possible. In patients with WEA, EBC pH values after SIC were significantly lower than those before SIC (P = .0047). Using the receiver operating characteristic (ROC) curve, we found that an EBC pH decrease of greater than 0.4 units after SIC achieved the most satisfactory sensitivity 79% (confidence interval [CI]: 49-94) and specificity of 100% (CI: 68-100), considering only patients with asthma and without OA. A decrease in EBC pH of 0.4 or more common in those exposed to HMW agents (8/19, 42%) than in those exposed to LMW agents (7/47, 15%).

CONCLUSIONS

Exhaled breath condensate pH in conjunction with SIC may be useful for diagnosing WEA.

Strategy for identification and detection of multiple oxidative modifications within proteins applied on persulfate-oxidized hemoglobin and human serum albumin

Oxidative stress has been suggested as an underlying mechanism of many human diseases. However, definitive evidence for this association has not been presented due to different shortcomings of the methods used to measure biomarkers of oxidative stress. Persulfates are oxidizing agents known to elicit hypersensitive reactions from the airways and skin. Despite a frequent use of persulfates at many work places, no biomarkers for persulfate exposure are available. The aim of this study was to develop a strategy for the identification and detection of multiple oxidative modifications within proteins. This strategy was applied on persulfate-oxidized proteins to identify oxidized peptides suitable for further investigation as biomarkers of persulfate exposure or oxidative stress. A strategy for the identification and the relative quantification of multiple oxidative modifications within proteins was developed. The usage of two software packages facilitated the search for modified peptides to a great extent. Oxidized peptides were relatively quantified using liquid chromatography/tandem mass spectrometry in selected reaction monitoring mode. The result showed that persulfates oxidize tryptophans and methionines resulting in mass shifts of 16 and/or 32 Da. Also, oxidized albumin peptides in nasal lavage fluid samples from subjects challenged with persulfate were detected. The oxidation degree before and after challenge remained constant for peptides containing methionine sulfoxide. For peptides containing oxidized tryptophan the oxidation degree increased after exposure. Some of these oxidized peptides may be suitable as biomarkers; however, further evaluation is required.

Time-dependent proteomic iTRAQ analysis of nasal lavage of hairdressers challenged by persulfate

Hairdressers are frequently exposed to bleaching powder containing persulfates, a group of compounds that may induce hypersensitivity in the airways. The mechanism causing this reaction is not clear. The aim of this study was to identify changes in the nasal lavage fluid proteome after challenge with potassium persulfate in hairdressers with bleaching powder-associated rhinitis. Furthermore, we aimed to compare their response to that of hairdressers without nasal symptoms, and atopic subjects with pollen-associated nasal symptoms. To study the pathogenesis of persulfate-associated rhinitis, the response in protein expression from the upper airway was assessed by time-dependent proteomic expression analysis of nasal lavage fluids. Samples were prepared by pooling nasal lavage fluids from the groups at different time points after challenge. Samples were depleted of high-abundant proteins, labeled with iTRAQ and analyzed by online 2D-nanoLC-MS/MS. Differences in the protein pattern between the three groups were observed. Most proteins with differentially expressed levels were involved in pathways of lipid transportation and antimicrobial activities. The major finding was increased abundance of apolipoprotein A-1, 20 min postchallenge, detected solely in the group of symptomatic hairdressers. Our results suggest there may be differences between the mechanisms responsible for the rhinitis in the symptomatic and atopic group.

Clinical and inflammatory features of occupational asthma caused by persulphate salts in comparison with asthma associated with occupational rhinitis

BACKGROUND

The relationships between asthma and rhinitis are still a crucial point in respiratory allergy and have scarcely been analysed in occupational setting. We aimed to compare the clinical and inflammatory features of subjects with occupational asthma only (OA) to subjects with OA associated to occupational rhinitis (OAR) caused by persulphate salts.

METHODS

The clinical charts of 26 subjects diagnosed in our Unit as respiratory allergy caused by ammonium persulphate (AP), confirmed by specific inhalation challenge (SIC), were reviewed. Twenty-two out of twenty-six patients underwent pre-SIC-induced sputum challenge test (IS) and 24/26 underwent nasal secretion collection and processing.

RESULTS

Twelve out of twenty-six patients received a diagnosis of OA-only and 14/26 of OAR. Duration of exposure before diagnosis, latency period between the beginning of exposure and asthma symptom onset, basal FEV(1), airway reactivity to methacholine and asthma severity did not differ in the two groups. Eosinophilic inflammation of upper and lower airways characterized both groups. Eosinophil percentage in IS tended to be higher in OAR [11.9 (5.575-13.925)%] than in OA-only [2.95 (0.225-12.5)%] (P = 0.31). Eosinophilia in nasal secretions was present both in subjects with OAR [55 (46-71)%] and in subjects with OA-only [38 (15-73.5)%], without any significant difference.

DISCUSSION

Our results indicate that OA because of ammonium persulphate coexists with occupational rhinitis in half of the patients. Unexpectedly, rhinitis did not seem to have an impact on the natural history of asthma. The finding of nasal inflammation in subjects with OA-only without clinical manifestations of rhinitis supports the united airway disease concept in occupational respiratory allergy as a result of persulphates.

Pulmonary toxicity and environmental contamination: radicals, electron transfer, and protection by antioxidants

The atmosphere is replete with a mixture of toxic substances, both natural and man-made. Inhalation of toxic substances produces a variety of insults to the pulmonary system. Lung poisons include industrial materials, particulates from mining and combustion, agricultural chemicals, cigarette smoke, ozone, and nitrogen oxides, among a large number of other chemicals and environmental contaminants. Many proposals have been advanced to explain the mode of action of pulmonary toxicants. In this review we focus on mechanisms of pulmonary toxicity that involve ET, ROS, and OS. The vast majority of toxicants or their metabolites possess chemical ET functionalities that can undergo redox cycling. Such recycling may generate ROS that can injure various cellular constituents in the lung and in other tissues. ET agents include quinones, metal complexes, aromatic nitro compounds, and conjugated iminium ions. Often, these agents are formed metabolically from parent toxicants. Such metabolic reactions are often catalytic and require only small amounts of the offending material. Oxidative attack is commonly associated with lipid peroxidation and oxidation of DNA, and it may result in strand cleavage and 8-OH-DG production. Toxicity is often accompanied by depletion of natural AOs, which further exacerbates the toxic effect. It is not surprising that the use of AOs, both natural in fruits and vegetables, as well as synthetic, may provide protection from the adverse effects of toxicant exposure. The mechanistic framework described earlier is also applicable to some of the more prominent pulmonary illnesses, such as asthma, COPD, and cancer.

Persulphate challenge in female hairdressers with nasal hyperreactivity suggests immune cell, but no IgE reaction

PURPOSE

The aim of this study was to examine the effects of persulphate on the nasal mucosa and on the immune cells in hairdressers suffering from bleaching powder associated rhinitis (BAR) versus subjects with rhinitis not previously exposed to bleaching powder.

METHODS

Fifteen hairdressers (S) with BAR, 14 without symptoms (WS) and 12 atopics (A) with rhinitis but without exposure to bleaching powder were studied. Each performed a nasal challenge with persulphates. Effect parameters were symptom score, acoustic rhinometry, albumin in nasal lavage, subpopulations of lymphocytes in blood and specific serum antibodies.

RESULTS

The S group had a post-challenge increase in nasal symptoms and nasal lavage albumin. The A group reacted to a lesser intent. The S and A groups showed an increase in Th1 cells. An HLA class II cell expression was noticed in both groups of hairdressers. No evidence of a type 1 reaction (immediate type) to persulphate was noticed.

CONCLUSIONS

Persulphate challenge affects hairdressers with BAR, but also atopics. The reaction may be driven by a Th1 cell activation.

Diagnosis and management of work-related asthma: American College Of Chest Physicians Consensus Statement

BACKGROUND

A previous American College of Chest Physicians Consensus Statement on asthma in the workplace was published in 1995. The current Consensus Statement updates the previous one based on additional research that has been published since then, including findings relevant to preventive measures and work-exacerbated asthma (WEA).

METHODS

A panel of experts, including allergists, pulmonologists, and occupational medicine physicians, was convened to develop this Consensus Document on the diagnosis and management of work-related asthma (WRA), based in part on a systematic review, that was performed by the University of Alberta/Capital Health Evidence-Based Practice and was supplemented by additional published studies to 2007.

RESULTS

The Consensus Document defined WRA to include occupational asthma (ie, asthma induced by sensitizer or irritant work exposures) and WEA (ie, preexisting or concurrent asthma worsened by work factors). The Consensus Document focuses on the diagnosis and management of WRA (including diagnostic tests, and work and compensation issues), as well as preventive measures. WRA should be considered in all individuals with new-onset or worsening asthma, and a careful occupational history should be obtained. Diagnostic tests such as serial peak flow recordings, methacholine challenge tests, immunologic tests, and specific inhalation challenge tests (if available), can increase diagnostic certainty. Since the prognosis is better with early diagnosis and appropriate intervention, effective preventive measures for other workers with exposure should be addressed.

CONCLUSIONS

The substantial prevalence of WRA supports consideration of the diagnosis in all who present with new-onset or worsening asthma, followed by appropriate investigations and intervention including consideration of other exposed workers.

[Course of bronchial hyperresponsiveness in patients with occupational asthma caused by exposure to persulfate salts]

OBJECTIVE

Persulfate salts are among the most frequently implicated causes of occupational asthma. The aim of this study was to describe the course of bronchial hyperresponsiveness and immunologic test results in patients with occupational asthma due to persulfate salts.

PATIENTS AND METHODS

Ten patients with occupational asthma due to persulfate salts were studied. Diagnosis was based on specific bronchial challenge tests performed at least 3 years before enrollment. An exhaustive medical and work history was taken during interviews with all patients, and all underwent spirometry and nonspecific bronchial challenge testing. Total immunoglobulin E levels were determined and skin prick tests to several persulfate salts were performed.

RESULTS

At the time of evaluation, 7 patients had avoided workplace exposure to persulfate salts. The bronchial hyperresponsiveness of 3 of those 7 patients had improved significantly. No improvement was observed in patients who continued to be exposed. Specific skin prick tests became negative in 3 patients who were no longer exposed at the time of the follow-up evaluation. Most of the patients continued to report symptoms, although improvements were noted. One patient, however, reported worsening of symptoms in spite of avoidance of exposure.

CONCLUSIONS

Although asthma symptoms and bronchial hyperresponsiveness may persist for patients with occupational asthma due to persulfate salts, their condition seems to improve if they avoid exposure. This course does not seem to differ from that reported for other cases of occupational asthma.

Asthma and hairdressers

PURPOSE OF REVIEW

Hairdressers have an increased prevalence of respiratory diseases and are at high risk of occupational asthma. In this paper we aim to review the most recent findings in respiratory diseases related to the occupation of hairdressing to provide a background for management and prevention.

RECENT FINDINGS

Recent studies have described several cases of occupational asthma and occupational rhinitis in hairdressers. Persulphate salts are the major causal agents. Sensitization to persulphate salts seems more related to an individual hypersusceptibility than to environmental factors. An underlying immunologic mechanism is strongly suggested but not definitively demonstrated. The diagnosis of persulphate asthma is based on the specific challenge, for which standardized methods have been described. Some data show the presence of respiratory disorders in an early stage in apprentices and demonstrate that after diagnosis a proportion of hairdressers with occupational asthma remain symptomatic despite cessation of exposure.

SUMMARY

Careful medical surveillance is recommended for hairdressers and for hairdressing apprentices. Further studies are needed to evaluate the mechanism of persulphate asthma and to determine the relative role of individual risk factors compared with environmental factors in the development of the disease.

Exposure of hairdressing apprentices to airborne hazardous substances

BACKGROUND

Few studies have investigated exposure of hairdressing apprentices to airborne irritants. This study describes exposure levels of apprentices to chemical products used in hairdressing salons in relation with their activity.

METHODS

Following a two stages study design, a group of 300 students completed a questionnaire on their work activities and environment. Among these, a group of 28 subjects volunteered to undergo personal exposure and workplace concentrations measurements over a work shift, during a cold and a hot season, with the agreement of the salon owners. Three chemical substances were studied (ammonia, hydrogen peroxide and persulfates) because they are respiratory tract irritants and because their concentrations could be quantified within a 5 to 8 hour shift period.

RESULTS

Personal exposure values for H2O2 and NH3 (averages [standard deviations] are 0.05 [0.04] and 0.90 [0.76] mg.m(-3), respectively) were greater than workplace ambient air concentrations (corresponding values of 0.04 [0.03] and 0.68 [0.42] mg.m(-3)) for H2O2 and NH3, with no significant seasonal variation. By contrast, workplace concentrations of persulfates (0.019 [0.018] mg.m(-3)) were greater than personal exposure (0.016 [0.021] mg.m(-3), a finding that is consistent with the fact that bleaching is more often undertaken by senior hairdressers. However, all exposure values were lower than the current TLV TWA values. This study also shows that over half of technical spaces where chemical substances used for dying, permanenting or bleaching are manipulated, have no ventilation system, and not even a door or a window opening outside.

CONCLUSION

The study hairdressing salons, on average, were small, the most probable reason why occupational hygiene measures such as appropriate ventilation were too seldom implemented. As a consequence, young apprentices and senior hairdressers experience substantial exposure to known airways irritants.

Occupational Asthma and Occupational Rhinitis in Hairdressers

BACKGROUND

Hairdressers are at risk for occupational respiratory diseases, but the risk factors, causal agents, and underlying mechanisms are not completely defined.

AIM

To describe the features of a large group of hairdressers consecutively referred to our center for suspected occupational asthma (OA) over an 8-year period, the type of occupational respiratory diseases, the etiologic agents, and the diagnostic tests.

RESULTS

Forty-seven hairdressers (mean age, 25 years; range, 17 to 52 years) were studied. On the basis of the response to the specific inhalation challenge (SIC), 24 patients received a diagnosis of OA (51.1%), which was due to persulfate salts in 21 patients (87.5%), permanent hair dyes in 2 patients (8.3%), and latex in 1 patient (4.2%). Thirteen of these 24 patients (54.2%) also received a diagnosis of occupational rhinitis, which was due to persulfate salts in 11 patients (84.6%) and to paraphenylenediamine in two patients (15.4%). Patients with persulfate asthma had a long period of exposure to bleaching agents, a long latent period between the start of exposure and the onset of symptoms, and a prevalent eosinophilic airway inflammation in induced sputum. The skin-prick test with ammonium persulfate performed in a subset of patients gave negative results

CONCLUSIONS

In the present study, we confirmed that persulfate salts are the major agents involved in OA and occupational rhinitis in hairdressers. The positive response to the SIC in only a part of the population of symptomatic exposed workers, the period between the starting of exposure and the onset of symptoms, the type of response to the SIC, and the high frequency of association of asthma with other diseases such as dermatitis and rhinitis suggest an immunologic mechanism that remains to be elucidated.