Hairdressers' skin exposure to hair dyes during different hair dyeing tasks.

BACKGROUND: The high risk of occupational skin disease among hairdressers, caused by skin exposure to irritants and sensitizers, such as hair dye substances, is of great concern. OBJECTIVES: The aim of the present study was to assess how the various tasks involved in hair dyeing contribute to hairdressers' exposure to hair dye, in order to enable the formulation of well-founded recommendations on working routines that will reduce exposure and prevent occupational disease. METHODS: Skin exposure to hair dye was measured for 20 hairdressers applying highlights and all-over hair colour with the hand rinsing technique. Resorcinol was used as a proxy for hair dye exposure. RESULTS: Applying hair dye and cutting the newly dyed hair were the tasks that contributed most to exposure in treatments for highlights. After cutting all-over-coloured hair, all hairdressers had measurable amounts of hair dyes on both hands. CONCLUSIONS: Hairdressers are exposed to hair dye ingredients during all steps of the hair dyeing procedure. Cutting newly dyed hair contributes significantly to exposure. For the prevention of occupational disease resulting from hair dye exposure, we suggest cutting hair before dyeing it, and wearing gloves during all other work tasks.

Scoring of Hand Eczema: Good Reliability of Hand Eczema Extent Score (HEES).

There is good agreement between dermatological staff and patients using the Hand Eczema Extent Score (HEES). The aim of this study was to assess inter- and intra-observer reliability of the HEES in dermatologists and intra-observer reliability of the HEES in patients with hand eczema. Six dermatologists assessed 18 patients twice. Only the hands of the patients were visible to the assessors. Patients performed a self-assessment twice. Inter- and intra-observer reliability was tested with intraclass correlation coefficient (ICC). The mean HEES score for all dermatologists' assessments was 21.0 (range 3.6-46.3). The corresponding mean scores for all patients' own assessments were 24.9 (range 4.0-54.0). Inter-observer reliability in the dermatologists' observations ICC classification was very good, median value 0.82 (range 0.56-0.92). The overall intra-observer reliability for the 6 dermatologists' ICC classification was very good (range 0.88-0.94). Intra-observer reliability in the patients' 2 self-assessments ICC classification was very good (ICC 0.95). In conclusion, HEES is a reliable tool for both dermatologists and patients to grade the extent of hand eczema.

Water Exposure on the Hands in Adolescents: A Report from the BAMSE Cohort.

Water exposure on the skin of the hands has previously been studied in adults. The aim of this study was to investigate self-reported water exposure in adolescents in the BAMSE cohort in Stockholm, Sweden. A questionnaire including a question on daily water exposure on the hands was answered by 3,091 adolescents at age 16 years. Exposure < 10 times/day was reported by 28.7% and < 20 times/day by 3.1%; boys had somewhat higher exposure than girls (p = 0.03). In a multivariate analysis, adolescents with dry skin reported higher exposure (adjusted odds ratio (ORadj) 1.4; 95% CI 1.2-1.7), while no statistically significant exposure differences were found in relation to hand eczema or atopic dermatitis. Reported exposure may be considered as baseline exposure during a period of life with limited occupational and domestic duties.

Disability Pensions due to Skin Diseases: A Cohort Study in Swedish Construction Workers.

Disability pensions due to skin diseases in Swedish male construction workers were studied by linking data from pension registers and an occupational health service. Incidence rates of disability pensions for cement workers, painters and plumbers were compared with 2 control groups. A total of 623 disability pensions were granted during 4 decades of follow-up. The main diagnoses were eczema (36%) and psoriasis (49%). Pensions were mostly granted in the age range 55-64 years. Among painters, cement workers and plumbers the incidence rates for disability pensions were 33.3, 24.5 and 20.4 cases/100,000 person-years, respectively, compared with 13.7 and 9.2 cases/100,000 person-years in control groups. Relative risks were highest for eczema, and were notable for psoriasis. Attributable fractions for eczema were 90% in cement workers and painters and 75% in plumbers compared with control groups. Attributable fractions for psoriasis in the occupational groups studied were in the range 54-67%. In conclusion, eczema and psoriasis have a high impact on loss of work ability, as reflected by disability pensions.

Water exposure--challenging differences between occupations.

BACKGROUND: Few studies have compared water exposure between different occupations in the general population. OBJECTIVES: To investigate and compare the extent of occupational water exposure, with a focus on service, healthcare and production occupations previously classified as involving a high risk for hand eczema. METHODS: In two public health surveys (2006 and 2010), a validated question regarding occupational water exposure was answered by 18 342 and 15,736 gainfully employed individuals, respectively. RESULTS: Exposure for ≥ 0.5 h/day was reported by 17.5% and 16.3% (p = 0.020) for the respective years, and exposure for > 2 h/day by 7.8% and 7.7% (p = 0.73). Exposure in women was almost twice as high as in men for both years (p ≤ 0.001) and exposure levels (p < 0.001). Exposure for > 2 h/day was more common in high-risk occupations in service and healthcare than in non-high-risk occupations [prevalence proportion ratios of 16.7 (95%CI: 14.0-20.0) and 8.3 (95%CI: 6.9-9.9), respectively]. Exposure was highest in service occupations, where 44.6% reported exposure for > 2 h/day in 2010, and kitchen work, cleaning and hairdressing dominated. In healthcare, the corresponding figure was 22.0%. CONCLUSIONS: Challenging differences in water exposure between occupational groups were found, and extensive water exposure was reported in a number of occupations previously classified as involving a high risk for hand eczema.

Hand eczema and use of snus (moist snuff) - a population-based study.

A possible association between use of snus (Swedish moist snuff) and hand eczema was studied. 27,466 individuals responded to questions regarding hand eczema, tobacco use and other life style factors in a Swedish Public Health Survey in 2006, response rate 58%. Of these persons, 12.2% reported daily snus use (men 22.0%, women 4.3%), 15.5% daily smoking (men 14.4%, women 16.5%). Of snus users 7.5 % reported hand eczema (men 6.5%, women 11.8%), of smokers 11.7% (men 8.6%, women 13.6%) and of non-tobacco-users 9.7% (men 7.9%, women 11.0%). In multivariate analysis hand eczema was significantly less common in snus users, in total prevalence proportion ratio (PPR) = 0.813, in men PPR = 0.820, but significantly more common in smoking women, PPR = 1.238. Physical exercise was a confounder; gender an effect modifier. No positive association was demonstrated between snus use and hand eczema in contrast to the positive association found between smoking and hand eczema in women.

The influence of hydrogen peroxide on the permeability of protective gloves to resorcinol in hairdressing.

BACKGROUND: Hairdressers are exposed to hair dye chemicals, for example resorcinol and hydrogen peroxide. Adequate skin protection is an important preventive measure against occupational skin disease. OBJECTIVES: To examine whether hydrogen peroxide may cause deterioration of protective gloves. METHODS: Permeation of resorcinol through gloves of polyvinylchloride (PVC) (n = 8), natural rubber latex (NRL) (n = 5) and nitrile rubber (NR) (n = 5) was studied in a two-compartment cell, with resorcinol as an indicator for hair dyes. The amount of resorcinol that had permeated was analysed with a high-performance liquid chromatography instrument. Cumulative breakthrough time and permeation rate were compared for hydrogen peroxide-pretreated and untreated gloves. RESULTS: The cumulative breakthrough time was > 1 hr but < 4 hr for all tested gloves. Pretreatment of PVC gloves resulted in a slightly decreased breakthrough time, and pretreatment of NRL gloves decreased the permeation rate. No change was recorded in NR gloves. CONCLUSIONS: Treatment with hydrogen peroxide had a minor effect on permeation in the tested gloves. NR gloves provided the best protection. However, taking the allergy risk of rubber gloves into account, plastic gloves are recommended in hairdressing. PVC gloves may be used, but not for > 1 hr. Disposable gloves should never be reused, regardless of material.

Exposure of hairdressers to ortho- and meta-toluidine in hair dyes.

BACKGROUND: Carcinogenic aromatic amines derived from hair dyes have recently received new attention. One of these is ortho (o)-toluidine, which is classified as carcinogenic to humans. OBJECTIVES: To clarify exposure of hairdressers to potentially carcinogenic aromatic amines, including o-toluidine. METHODS: We measured eight potentially carcinogenic aromatic amines in the blood of 295 hairdressers, 32 users of hair dyes and 60 controls. The study was restricted to female non-smokers. Lifestyle data were collected for all participants using self-administered questionnaires. Blood samples were taken for analysis of ortho-, meta (m)- and para (p)-toluidine; 2-, 3- and 4-ethylaniline, 2,3- and 3,4-dimethylaniline as haemoglobin adducts. The samples were analysed with gas chromatography-tandem mass spectrometry. RESULTS: Generally, adduct concentrations were in the range of 0-200 pg/g haemoglobin. A comparison of the adduct concentrations found in hairdressers, consumers and controls showed no statistically significant differences. However, for hairdressers, o- and m-toluidine concentrations increased significantly with the weekly number of hair waving (p=0.020) and permanent hair dyeing treatments (p=0.026), respectively. o-Toluidine and m-Toluidine concentrations also tended (p=0.076 and 0.080, respectively) to increase with the frequency of light-colour permanent hair dye treatments. CONCLUSIONS: Hairdressers who use light-colour permanent hair dyes, other permanent hair dyes and hair waving treatments seem to be exposed to o- and m-toluidine as indicated by associations with the number of treatments performed. Analyses of hair waving and hair dye products should be performed to identify the possible sources of exposure to o- and m-toluidine.

Hand eczema and health-related quality of life; a comparison of EQ-5D and the Dermatology Life Quality Index (DLQI) in relation to the Hand Eczema Extent Score (HEES).

BACKGROUND: Health-related quality of life (HRQoL) is associated with the extent and severity of hand eczema. We still lack a consensus about which HRQoL instrument to use as the standard, and how to measure the extent and severity of hand eczema. OBJECTIVES: To compare the Dermatology Life Quality Index (DLQI) with EQ-5D (a standardized instrument for use as a measure of health outcome), and to evaluate how the Hand Eczema Extent Score (HEES) relates to these instruments. METHODS: Ninety-three patients (61 females) were included. The HEES was recorded by a dermatologist, and the DLQI and EQ-5D by the patients. The results were analysed with factor analysis and non-parametric statistics. RESULTS: The DLQI and EQ-5D showed decreased HRQoL. Using factor analysis, we could not establish an association between the DLQI and EQ-5D. There were, however, correlations between the DLQI and the HEES (0.31), the EQindex and the HEES (-0.32), the DLQI and the EQVAS (-0.62), and the DLQI and the EQindex (-0.67) (the EQVAS and the EQindex are calculated from EQ-5D). CONCLUSIONS: We could not link factors in the DLQI to EQ-5D, which has previously been done for SF-36 (Short Form 36). On the basis of this, we cannot recommend EQ-5D over SF-36 for hand eczema studies. The DLQI correlates with the EQVAS and the EQindex, and can probably be used as an approximation for EQ-5D. Our findings with the HEES are interesting, as it can be used by patients.

Primary prevention of latex allergy in healthcare-spectrum of strategies including the European glove standardization.

IgE-mediated allergy to natural rubber latex was first noted from rubber gloves in 1979. The initial reports in dermatological journals described contact urticarial reactions; later, severe generalized allergic reactions and asthma were documented. A considerable proportion of the people involved in medical and dental care were found to be sensitized to latex. This article describes and surveys a broad range of primary prevention measures at the local and national levels. Examples are given from paediatrics, dental education, and medical care. National strategies and position papers on latex allergy are presented in which medical professionals, manufacturers and public authorities have cooperated. Special reference is paid to the European work to standardize medical gloves, which led to document EN 455:3.

Validation of self-testing as a method to estimate the prevalence of nickel allergy.

The aim of this study was to investigate the validity of self-patch testing for nickel allergy, in order to determine a cost-effective method for surveillance of the prevalence of nickel allergy. Population-based study including patch testing is the most reliable method to study the prevalence of allergy, but it is expensive and has logistical problems. A total of 191 dermatology patients referred to patch testing were provided with a self-test package with written instructions. The self-test was applied on the arm by the patient, on the same day that the regular patch test was applied on the back. The patient evaluated the self-test before patch test reading at the clinic. Patch test at the dermatology clinic detected 46/191 (24%) nickel-positive individuals. The sensitivity of the self-test was 72% (95% confidence interval (CI) 57-84), the specificity 91% (95% CI 85-95), and the proportion of agreement 86% (95% CI 81-91). Thus, in the population studied, the validity of self-testing for nickel allergy was adequate.

Treatment with a barrier-strengthening moisturizer prevents relapse of hand-eczema. An open, randomized, prospective, parallel group study.

Hand eczema influences the quality of life. Management strategies include the use of moisturizers. In the present study the time to relapse of eczema during treatment with a barrier-strengthening moisturizer (5% urea) was compared with no treatment (no medical or non-medicated preparations) in 53 randomized patients with successfully treated hand eczema. The median time to relapse was 20 days in the moisturizer group compared with 2 days in the no treatment group (p = 0.04). Eczema relapsed in 90% of the patients within 26 weeks. No difference in severity was noted between the groups at relapse. Dermatology Life Quality Index (DLQI) increased significantly in both groups; from 4.7 to 7.1 in the moisturizer group and from 4.1 to 7.8 in the no treatment group (p < 0.01) at the time of relapse. Hence, the application of moisturizers seems to prolong the disease-free interval in patients with controlled hand eczema. Whether the data is applic-able to moisturizers without barrier-strengthening properties remains to be elucidated.

Validity of self-reported nickel allergy.

BACKGROUND: To estimate the prevalence of nickel allergy, self-reports are sometimes used in epidemiological studies. Self-reports are practical and may facilitate estimation of prevalence provided that the questions are validated. OBJECTIVES: To investigate the validity of self-reported nickel allergy. METHODS: Three hundred and sixty-nine women, aged 30-40 years, from the general population participated in the study. The participants answered a questionnaire before a clinical examination and patch testing. The two questions being validated were 'Are you sensitive/hypersensitive/allergic to nickel?' and 'Do you get a rash from metal buttons, jewellery or other metal items that come in direct contact with your skin?' RESULTS: Patch test showed nickel-positive reaction in 30% of the subjects. Self-reported prevalence of nickel allergy as indicated by the two respective questions was 40% and 35%. Positive predictive values for the two questions were 59% (95% CI 50-67) and 60% (95% CI 51-69). History of childhood eczema was over-represented among women with 'false-positive' self-reported nickel allergy (P = 0.008). Self-reported hand eczema or 'high wet exposure' did not influence the validity. CONCLUSIONS: The validity of self-reported nickel allergy is low. The questions regarding nickel allergy overestimate the true prevalence of nickel allergy.

Dermatology in public health--a model for surveillance of common skin diseases.

AIMS: The aim was to establish a baseline prevalence of skin conditions of public health importance in the general population and taking the validity of the questions into account. Our model is intended for future surveillance of skin conditions. METHODS: The suggested questions have for the first time been used in Swedish population surveys. A random sample was taken from the general population aged 16 to 84 years of the participating areas. RESULTS: During the past 12 months, hand eczema was reported by 9.4%, childhood eczema by 15.7% and nickel allergy by 13.7% of the population. Hand and childhood eczema questions have previously been validated. Taking the validity into account, the actual population prevalence of hand eczema (11.7%) is underestimated, and the prevalence of atopic childhood eczema (10.0%) is overestimated based on the results of the questionnaire. In addition to presenting prevalence, population survey results can be used for risk analyses. A 10-fold risk of hand eczema in individuals with childhood eczema and self-reported nickel sensitivity is shown in our study. CONCLUSIONS: Questionnaires can be used for epidemiologic surveillance so long as the questions are validated and that the validity is taken into account when estimating the occurrence of the conditions. Public health surveys such as this one lay the basis for future epidemiological surveillance of skin conditions that can be subject to interventions. We propose that these, or similar, questions should be used regularly in population surveys and supplemented by questions on skin exposure.

Skin exposure in geriatric care - a comparison between observation and self-assessment of exposure.

The aim of this study was to compare observation and self-assessment of skin exposure to irritants during a working day in nursing in geriatric care. The study group consisted of 40 volunteers, 13 nurses, and 27 assistant nurses. Before the start of a working day, the participants completed a questionnaire regarding skin exposure to water, gloves, hand disinfection, and moisturizers. Observers subsequently used a hand-held computer to register the time and frequency of each exposure. The total mean skin exposure time was 96 min per working day, including glove use. The mean exposure time to water was 9 min per working day. A tendency to overestimate was found for all exposures. A strong correlation between self-reports and observations was found for hand disinfection and moisturizers, while a moderate correlation was found for gloves and number of water exposures and a weak correlation for total time of water exposure. Despite the differences between self-assessment and observation of the exposure, we consider the questionnaire to be useful for surveying skin exposure in nursing. Furthermore, the observations in this study suggest that nursing work in geriatric care may comprise limited exposure to water.

Permeability of hair dye compounds p-phenylenediamine, toluene-2,5-diaminesulfate and resorcinol through protective gloves in hairdressing.

Dermal exposure to skin irritants and contact allergens is frequent in hairdressing. Hair dyeing is popular today and involves exposure to highly potent contact allergens, such as p-phenylenediamine (PPD). Use of protective gloves to prevent contact with skin-damaging substances is essential. The aim of the present study was to determine the resistance to permeation by PPD, toluene-2,5-diaminesulfate (TDS) and resorcinol (RES) through protective gloves used in hairdressing in Sweden. The permeation of PPD, TDS and RES through four types of protective gloves made of natural rubber latex (NRL), polyvinylchloride (PVC), nitrile rubber (NR) and polyethene (PE) was tested using the American Society for Testing and Materials (1-inch) test cell. Exposure solutions were 5% PPD (w/v), 0.75% TDS and 10% RES in borate buffer with 0.2 M ascorbic acid. The cumulative breakthrough, the so-called 'time-lag breakthrough' (Lag-BT), and permeation rate were determined for each substance and glove. For the NRL glove, the permeated amounts were below the analytical detection levels for all the tested substances. The NR glove was permeated only by RES, with a Lag-BT of 183 min. The PE glove was the thinnest glove and had a Lag-BT of 32 min for PPD; however, the steady-state permeation rate was only 0.031 nmol cm(-2) min(-1). The PVC glove gave the lowest protection against PPD and RES. TDS did not permeate any of the tested gloves. All the tested gloves were disposable, and all need to be changed often and disposed of after use. In conclusion, if properly used, all the tested gloves give considerable protection against permeation of PPD, TDS and RES.

Hand eczema extent and morphology--association and influence on long-term prognosis.

Hand eczema extent was a strong negative prognostic factor in a previously published follow-up study of 868 individuals. The present aims were to study in the same cohort the association between the extent and the morphology of the hand eczema and to examine whether registering both improves the prediction of long-term prognosis. The cohort was divided into subgroups regarding eczema extent and morphology. An association between eczema extent and morphology was found, with a Spearman's correlation coefficient of 0.36. Thus, widespread eczema clearly tended to be polymorphic, and vice versa. More than two-thirds (68%) of the subjects with visible signs of eczema at the examination ended up in corresponding "high" or "low" subgroups according to extent and morphology. Both widespread eczema and polymorphism were negative prognostic factors, but recording morphology did not significantly add any information to the long-term prognosis for the groups with high or low extent scores. In conclusion, the results show a clear association between extent and morphology of hand eczema, both predicting prognosis. Recording morphology did not add significant information when assessing long-term prognosis. Consequently, our study indicates that preference should be given to uncomplicated assessment of eczema extent in studies on hand eczema.