Contact allergy to preservatives in patients with occupational contact dermatitis and exposure analysis of preservatives in registered chemical products for occupational use.

PURPOSE: The aim of the study is to investigate risk factors for sensitization to preservatives and to examine to which extent different preservatives are registered in chemical products for occupational use in Denmark. METHODS: A retrospective epidemiological observational analysis of data from a university hospital was conducted. All patients had occupational contact dermatitis and were consecutively patch tested with 11 preservatives from the European baseline series and extended patch test series during a 5-year period: 2009-2013. Information regarding the same preservatives in chemical products for occupational use ('substances and materials') registered in the Danish Product Register Database (PROBAS) was obtained. RESULTS: The frequency of preservative contact allergy was 14.2% (n = 141) in 995 patients with occupational contact dermatitis. Patients with preservative contact allergy had significantly more frequently facial dermatitis (19.9 versus 13.1%) and age > 40 years (71.6 versus 45.8%) than patients without preservative contact allergy, whereas atopic dermatitis was less frequently observed (12.1 versus 19.8%). Preservative contact allergy was more frequent in painters with occupational contact dermatitis as compared to non-painters with occupational contact dermatitis (p < 0.001). This was mainly caused by contact allergy to methylisothiazolinone and contact allergy to formaldehyde. Analysis of the registered substances and materials in PROBAS revealed that preservatives occurred in several product categories, e.g., 'paints and varnishes', 'cleaning agents', 'cooling agents', and 'polishing agents'. Formaldehyde and isothiazolinones were extensively registered in PROBAS. CONCLUSIONS: The extensive use of formaldehyde and isothiazolinones in chemical products for occupational use may be problematic for the worker. Appropriate legislation, substitution, and employee education should be prioritized.

Occupational allergic contact dermatitis diagnosed by a systematic stepwise exposure assessment of allergens in the work environment.

BACKGROUND: Information on the presence of contact allergens and irritants is crucial for the diagnosis of occupational contact dermatitis. Ingredient lists and Material Safety DataSheets (MSDSs) may be incomplete. OBJECTIVES: To evaluate the workability of a systematic exposure assessment in consecutive patients with suspected occupational contact dermatitis, and to study how it could potentially aid correct diagnostic classification. METHODS: A tool for systematic stepwise assessment of exposures in the work environment was developed, consisting of six steps spanning medical history and workplace visits. The programme included 228 consecutive patients diagnosed with occupational contact dermatitis; all patients underwent a clinical examination, the stepwise exposure assessment, and extensive patch and prick testing. RESULTS: Of the participants, 48.2% were classified as having occupational allergic contact dermatitis. The diagnosis was made at the stepwise exposure assessment for 50.0% of patients at Step 1 (medical history) and for 34.5% at Step 2 (ingredient labelling/MSDS). We found 132 different occupational allergens of relevance to the patients' eczema, of these, 78.0% were allergens not included in the European baseline series. CONCLUSIONS: Systematic stepwise exposure assessment provides information that results in the identification of occupational allergies caused by allergens not included in the European baseline series in a substantial number of patients.

Psychosocial work environment among immigrant and Danish cleaners.

INTRODUCTION: Non-Western cleaners have been shown to have poorer health than their Danish colleagues. One reason could be a poorer psychosocial work environment. However, it is unknown if differences in self-reported psychosocial work environment exist between non-Western and Danish workers within the same social class. The aim of this study was to investigate such differences among cleaners with the hypothesis that the non-Western compared with Danish cleaners would report a generally poorer psychosocial work environment. METHODS: Two hundred and eighty-five cleaners (148 Danes and 137 non-Western immigrants) from 9 workplaces in Denmark participated in this cross-sectional study. The cleaners' immigrant status was tested for association with psychosocial work environment scales from the short version of the Copenhagen Psychosocial Questionnaire (COPSOQ) using ordinal logistic regression. RESULTS: Models adjusted for age, sex, BMI, smoking, workplace, and perceived physical work exertion showed that non-Western cleaners compared with Danish cleaners reported significantly higher scores with regard to Predictability (OR = 3.97), Recognition (OR = 1.92), Quality of Leadership (OR = 1.81), Trust Regarding Management (OR = 1.72), and Justice (OR = 2.14). CONCLUSIONS: This study showed that non-Western immigrant cleaners reported a statistically significantly better psychosocial work environment than Danish cleaners on a number of scales. Therefore, the hypothesis of non-Western immigrants reporting worse psychosocial work environment than their Danish colleagues was not supported.

Associations between psychosocial work environment and hypertension among non-Western immigrant and Danish cleaners.

INTRODUCTION: Non-Western cleaners have reported better psychosocial work environment but worse health compared with their Danish colleagues. The aim of this study was to compare the association between psychosocial work environment and hypertension among non-Western immigrant cleaners and Danish cleaners. METHODS: Two hundred and eighty-five cleaners from nine workplaces in Denmark participated in this cross-sectional study. The cleaners were identified as non-Western immigrants (n = 137) or Danes (n = 148). Blood pressure was measured in a seated position, and psychosocial work environment was assessed by the Copenhagen Psychosocial Questionnaire (COPSOQ). In each population, multivariate logistic regressions were applied testing for an association between each of the COPSOQ scales and hypertension. RESULTS: Models adjusted for age, sex, BMI, smoking, workplace and physical work exertion showed that high Trust regarding management (OR = 0.50) and high Predictability (OR = 0.63) were statistically significantly associated with low prevalence of hypertension in the Danish population. In the immigrant population, no significant associations were found. Analyses on interaction effects showed that associations between Meaning of work and hypertension were significantly different among the two populations (p < 0.05). CONCLUSIONS: Psychosocial work factors were associated with hypertension among Danes, but not among non-Western immigrants. This divergent association between psychosocial work environment and hypertension between Danes and non-Western immigrant cleaners may be explained by different perceptions of psychosocial work environment.

Health disparities between immigrant and Danish cleaners.

PURPOSE: It is unknown whether immigrants working in the cleaning industry have a poorer health and work ability than cleaners from the native population. The main aim was to investigate differences in objective and self-reported health measures between immigrant and Danish cleaners. METHODS: Three hundred and fifty-one cleaners, consisting of 166 Danes (88% women) and 179 immigrants (74% women) (6 with unknown ethnicity), from 9 workplaces in Denmark participated in the study. Health and work ability were obtained by objective (e.g., BMI and blood pressure) and self-reported measures (e.g., work ability, self-rated health, and musculoskeletal symptoms). In order to investigate differences between Danish and immigrant cleaners, logistic regression analyses and General Linear Models were performed. RESULTS: When controlling for age, sex, workplace, job seniority, and smoking, more Danish compared with immigrant cleaners were current smokers (42% vs. 28%, p < 0.001 (not controlled for smoking)), had hypertension (46% vs. 26%, p < 0.05) and drank more alcohol (3.0 vs. 0.8 units per day, respectively, p < 0.001). Contrary, more immigrants compared with Danish cleaners were measured to be overweight (47% vs. 30%, p < 0.05), reported less than good work ability (57% vs. 42%, p < 0.01), considered it unthinkable/unsure to be able to perform work 2 years ahead (37% vs. 23%, p < 0.01), reported reduced self-rated health (46% vs. 38%, p < 0.01) and everyday pain in the neck/shoulder (28% vs. 11%, p < 0.01), wrist (18% vs. 7%, p < 0.01), and lower back (21% vs. 10%, p < 0.01). There were no differences in self-reported chronic diseases. CONCLUSIONS: Although the health of the cleaners was alarmingly poor, the immigrant cleaners generally had a poorer self-reported health and work ability than the Danish cleaners. These findings highlight the need for occupational health actions among cleaners, particularly tailored to the immigrant subpopulation.

Formaldehyde-releasers: relationship to formaldehyde contact allergy. Part 2: Metalworking fluids and remainder.

We have reviewed formaldehyde-releasers used in metalworking fluids (MWFs) in this and a previous part of a two-part article. These biocides do not appear to be frequent or important sensitizers. Even in highly selected patient groups of metalworkers, mean prevalence rates of sensitivity are low: 0.2% for Tris(hydroxymethyl)nitromethane, 1.6% for tris(N-hydroxyethyl)hexahydrotriazine, 1.9% for Bioban P-1487 and Bioban CS-1246, and 2.8% for Bioban CS-1135. In the case of the Biobans, many reactions may have been irritant. Only N,N'-methylenebis(5-methyloxazolidine) has a fairly high mean score of 4.0% in metalworkers. With the exception of Bioban P-1487, there is a clear relationship between positive patch test reactions to the releasers and formaldehyde sensitivity: 40-70% of reactions to releasers occur in patients sensitive to formaldehyde and may therefore be caused by formaldehyde allergy. There is a lack of reliable data on the clinical relevance of contact allergy to the formaldehyde releasers in MWF. In most studies, no data on relevance were provided and in those that did, relevance was often found for a (very small) minority of the reactions only. Also discussed here are the formaldehyde-releasers MDM hydantoin, methenamine, N-methylolchloracetamide, paraformaldehyde, and Preventol D2.

Formaldehyde-releasers: relationship to formaldehyde contact allergy. Metalworking fluids and remainder. Part 1.

This is part of a series of review articles on formaldehyde-releasers and their relationship to formaldehyde contact allergy. Formaldehyde-releasers used in metalworking fluids (MWF) and a group of releasers not presented in previous articles are discussed. Here, in Part 1 of the article, there is a short overview of the composition and functions of MWF, the function of biocides in them, and adverse reactions to MWF. In addition, the releasers in MWF that have caused contact allergy are presented with CAS, synonyms, molecular formula, chemical structure, applications, patch test studies, and amount of formaldehyde released by them. In Part 2 of the article, the relationship between formaldehyde-releasers used in MWF and formaldehyde contact allergy is discussed as are data on miscellaneous releasers not previously presented, followed by a discussion of Parts 1 and 2 of the article.

Formaldehyde-releasers: relationship to formaldehyde contact allergy. Formaldehyde-releasers in clothes: durable press chemical finishes. Part 1.

This is one of a series of review articles on formaldehyde-releasers and their relationship to formaldehyde contact allergy and in this paper formaldehyde-releasers used as durable press chemical finishes (DPCF) in textiles are discussed. The literature on allergy to DPCF since 1980 is presented in two parts. Part 1 (this article) presents a short historical overview of the problems with formaldehyde in clothes and discusses the chemistry of durable press chemical finishes, legislation in various countries, and studies on the amount of formaldehyde present in clothes. In addition, the DPCF that have caused contact allergy are presented with CAS, synonyms, molecular formula, chemical structure, applications, and patch test studies. In the forthcoming part 2, the frequency of sensitization to DPCF, occupational contact sensitization, relevance of patch test reactions, and relationship to formaldehyde contact allergy will be reviewed, followed by a discussion of both parts of the article together.

Formaldehyde-releasers: relationship to formaldehyde contact allergy. Part 2. Formaldehyde-releasers in clothes: durable press chemical finishes.

This is the second part of a review article on formaldehyde-releasers used as durable press chemical finishes (DPCF) in textiles. The early finishes contained large amounts of free formaldehyde, which led to many cases of allergic contact dermatitis to clothes in the 1950s and 1960s. Currently, most finishes are based on modified dimethylol dihydroxyethyleneurea, which releases less formaldehyde. Nevertheless, recent studies in the United States and Israel have identified patients reacting to DPCF, considered to have allergic contact reactions to clothes, either from formaldehyde released by the DPCF therein or from the DPCF per se (in patients negative to formaldehyde). However, all studies had some weaknesses in design or interpretation and in not a single case has the clinical relevance been proven. The amount of free formaldehyde in most garments will likely be below the threshold for the elicitation of dermatitis for all but the most sensitive patients. The amount of free cyclized urea DPCF in clothes is unlikely to be high enough to cause sensitization. Patch test reactions to formaldehyde-releasing DPCF will in most cases represent a reaction to formaldehyde released from the test material.

Formaldehyde-releasers in cosmetics: relationship to formaldehyde contact allergy. Part 1. Characterization, frequency and relevance of sensitization, and frequency of use in cosmetics.

In this part of a series of review articles on formaldehyde-releasers and their relationship to formaldehyde contact allergy, formaldehyde-releasers in cosmetics are discussed. In this first part of the article, key data are presented including frequency of sensitization and of their use in cosmetics. In Europe, low frequencies of sensitization have been observed to all releasers: 2-bromo-2-nitropropane-1,3-diol 0.4-1.2%, diazolidinyl urea 0.5-1.4%, imidazolidinyl urea 0.3-1.4%, quaternium-15 0.6-1.9% (for DMDM hydantoin no recent data are available). All releasers score (far) higher prevalences in the USA; the possible explanations for this are discussed. The relevance of positive patch test reactions has been insufficiently investigated. In the USA, approximately 20% of cosmetics and personal care products (stay-on products: 17%, rinse-off products 27%) contain a formaldehyde-releaser. The use of quaternium-15 is decreasing. For Europe, there are no comparable recent data available. In the second part of the article, the patch test relationship of the releasers in cosmetics to formaldehyde contact allergy will be reviewed and it will be assessed whether products preserved with formaldehyde-releasers may contain enough free formaldehyde to pose a threat to individuals who have contact allergy to formaldehyde.

Formaldehyde-releasers in cosmetics: relationship to formaldehyde contact allergy. Part 2. Patch test relationship to formaldehyde contact allergy, experimental provocation tests, amount of formaldehyde released, and assessment of risk to consumers allergic to formaldehyde.

This is the second part of an article on formaldehyde-releasers in cosmetics. The patch test relationship between the releasers in cosmetics to formaldehyde contact allergy is reviewed and it is assessed whether products preserved with formaldehyde-releasers may contain enough free formaldehyde to pose a threat to individuals with contact allergy to formaldehyde. There is a clear relationship between positive patch test reactions to formaldehyde-releasers and formaldehyde contact allergy: 15% of all reactions to 2-bromo-2-nitropropane-1,3-diol and 40-60% of the reactions to the other releasers are caused by a reaction to the formaldehyde in the test material. There is only fragmented data on the amount of free formaldehyde in cosmetics preserved with formaldehyde donors. However, all releasers (with the exception of 2-bromo-2-nitropropane-1,3-diol, for which adequate data are lacking) can, in the right circumstances of concentration and product composition, release >200 p.p.m. formaldehyde, which may result in allergic contact dermatitis. Whether this is actually the case in any particular product cannot be determined from the ingredient labelling. Therefore, we recommend advising patients allergic to formaldehyde to avoid leave-on cosmetics preserved with quaternium-15, diazolidinyl urea, DMDM hydantoin, or imidazolidinyl urea, acknowledging that many would tolerate some products.

Formaldehyde-releasers: relationship to formaldehyde contact allergy. Contact allergy to formaldehyde and inventory of formaldehyde-releasers.

This is one of series of review articles on formaldehyde and formaldehyde-releasers (others: formaldehyde in cosmetics, in clothes and in metalworking fluids and miscellaneous). Thirty-five chemicals were identified as being formaldehyde-releasers. Although a further seven are listed in the literature as formaldehyde-releasers, data are inadequate to consider them as such beyond doubt. Several (nomenclature) mistakes and outdated information are discussed. Formaldehyde and formaldehyde allergy are reviewed: applications, exposure scenarios, legislation, patch testing problems, frequency of sensitization, relevance of positive patch test reactions, clinical pattern of allergic contact dermatitis from formaldehyde, prognosis, threshold for elicitation of allergic contact dermatitis, analytical tests to determine formaldehyde in products and frequency of exposure to formaldehyde and releasers. The frequency of contact allergy to formaldehyde is consistently higher in the USA (8-9%) than in Europe (2-3%). Patch testing with formaldehyde is problematic; the currently used 1% solution may result in both false-positive and false-negative (up to 40%) reactions. Determining the relevance of patch test reactions is often challenging. What concentration of formaldehyde is safe for sensitive patients remains unknown. Levels of 200-300 p.p.m. free formaldehyde in cosmetic products have been shown to induce dermatitis from short-term use on normal skin.

Principles and methodology for translation and cross-cultural adaptation of the Nordic Occupational Skin Questionnaire (NOSQ-2002) to Spanish and Catalan.

BACKGROUND: Occupational skin diseases are among the most frequent work-related diseases in industrialized countries. The Nordic Occupational Skin Questionnaire (NOSQ-2002), developed in English, is a useful tool for screening of occupational skin diseases. OBJECTIVES: To culturally adapt the NOSQ-2002 to Spanish and Catalan and to assess the clarity, comprehension, cultural relevance and appropriateness of the translated versions. METHODS: The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) principles of good practice for the translation and cultural adaptation of patient-reported outcomes were followed. RESULTS: After translation into the target language, a first consensus version of the questionnaire was evaluated in multiple cognitive debriefing interviews. The expert panel introduced some modifications in 39 (68%) and 27 (47%) items in the Spanish and Catalan version, respectively (e.g. addition of examples and definitions, reformulation of instructions and use of direct question format). This version was back translated and submitted to the original authors, who suggested a further seven and two modifications in the Spanish and Catalan versions, respectively. A second set of cognitive interviews were performed. A consensus version of both questionnaires was obtained after final modifications based on comments by the patients. CONCLUSIONS: The final versions of the Spanish and Catalan NOSQ-2002 questionnaires are now available at www.NRCWE.dk/NOSQ.

Implementation of an occupational skin disease prevention programme in Danish cheese dairies.

The purpose of this study was to implement an evidence-based prevention programme to reduce occupational skin diseases in a wet work occupation by educational activities and elements from an occupational health-management system. The effects were studied by telephone interviews using a standardized questionnaire (NOSQ-2002) with trade-modified questions on work and exposure. The study population consisted of all employees at 5 cheese dairies. At baseline, October 2002, a total of 557 answered (83.8%). At follow up 1 year later, a total of 650 current and former employees answered (81.8%). At 4 of the 5 dairies, the eczema frequency at baseline was relatively low (11.8% and 5.9% at intervention dairies; 7.0%, 10.4% and 33.3% at comparison dairies). On all the studied dairies, about one-third of the workers reported having 2 or more skin symptoms at baseline. At follow up, skin symptoms were reduced significantly on all dairies. Effects restricted to the intervention dairies included significant increases in the use of gloves and moisturizers. The comparison dairy with high eczema frequency at baseline introduced skin-care products, changed hand soap and mowed employees with skin problems, away from adverse working areas during the intervention period, and the frequency of eczema was significantly reduced at follow up.