Is skin exposure to water mainly occupational or nonoccupational? A population-based study.

BACKGROUND: Skin exposure to water is considered to contribute to hand eczema. Knowledge about total water exposure during a day is scanty. OBJECTIVES: To investigate self-reported water exposure at work as well as throughout the day. METHODS: Skin exposure to water was assessed from two questionnaire-based health surveys: the nationwide Environmental Health Survey 2007 (EHS), which enquired about water exposure throughout the day, and the Stockholm Public Health Survey 2006 (PHS), which probed water exposure at work. Answers from 19,667 individuals (EHS) and 18,318 individuals (PHS) were available for analysis. RESULTS: In total, 22% of respondents (women 30%, men 12%) reported skin exposure to water more than 20 times during an entire day (EHS) compared with 6% (women 8%, men 4%) at work (PHS). In a univariate analysis, using a merged file comprising data from the EHS and the PHS, water exposure more than 20 times a day was more common in the EHS (prevalence proportion ratio 3·570, 95% confidence interval 3·353-3·802). In multivariate models the variables studied did not fulfil the criteria for being confounders. Water exposure at work declined with increasing age in both women and men (P < 0·0001) as did water exposure during the entire day in men (P < 0·0001). However, women were equally exposed during the entire day across age groups (P = 0·205). CONCLUSIONS: High water exposure over the entire day was found to be considerably more frequent than exposure at work. Thus, a significant proportion of water exposure seems to occur outside work. This should be considered in prevention of hand eczema and when counselling patients with hand eczema in clinical practice.

Tobacco smoking and hand eczema: a population-based study.

BACKGROUND: Tobacco smoking has been proposed to promote hand eczema. OBJECTIVES: To examine the association between tobacco smoking and hand eczema and to investigate a possible dose-response relation. METHODS: A national environmental health survey was performed in 2007. A questionnaire was mailed to 43,905 individuals and responses were obtained from 25,851 (59%). Questions on 1-year prevalence of hand eczema and on previous and current smoking were included. Respondents were asked to report number of cigarettes per day and to provide information on history of atopy and frequency of hand exposure to water. RESULTS: In total, answers regarding smoking and hand eczema were obtained from 25,428 individuals. Of regular daily smokers, 10·0% reported hand eczema vs. 9·1% of nonsmokers (P = 0·0951). A history of atopy showed the strongest influence on the occurrence of hand eczema: prevalence proportion ratio (PPR) 3·46. The PPR for hand eczema among individuals smoking > 15 cigarettes per day was 1·25 and 1·40 in uni- and multivariate analysis, respectively. Age, history of atopy, sex and water exposure were found to be confounders but not effect modifiers. A dose-response relation between level of smoking and 1-year prevalence of hand eczema was revealed with a PPR of 1·05 (P < 0·001) for the continuous variable of smoking habits, indicating a significantly increased prevalence of hand eczema among individuals with higher consumption of tobacco. CONCLUSIONS: An association between heavy smoking and hand eczema was confirmed. It is important to consider the level of exposure, as a dose-response relation was revealed, and to be aware of confounding factors.

Does tobacco smoking influence the occurrence of hand eczema?

BACKGROUND: Tobacco smoking is known to influence various inflammatory skin diseases and an association between tobacco smoking and hand eczema has been proposed in some studies. OBJECTIVES: To examine a possible association between reported current tobacco smoking and the occurrence of hand eczema. SUBJECTS AND METHODS: Previously collected questionnaire data on the occurrence of hand eczema in three occupational cohorts and corresponding controls from the general population were studied. The questionnaires used included questions on 1-year prevalence of hand eczema and questions on smoking habits. For one occupational group, hairdressers and their controls, information on amount of smoking was obtained. Information on age, sex and history of atopy was also available. RESULTS: In total, answers regarding smoking and hand eczema were obtained from 13,452 individuals. Out of 3493 smokers, 437 (12.5%) reported hand eczema compared with 1294 out of 9959 nonsmokers (13.0%) (P = 0.51). With regard to the number of cigarettes smoked, 22.6% of the hairdressers smoking more than 10 cigarettes per day reported hand eczema compared with 17.4% of those smoking 0-10 cigarettes per day (P = 0.01). Corresponding figures for the controls were 14.5% and 11.7%, respectively (P = 0.06). CONCLUSIONS: No clear association was found between 1-year prevalence of hand eczema and smoking. Heavy smoking, more than 10 cigarettes per day, may give a slightly increased risk of hand eczema. Further studies with information on the amount of tobacco consumption and on possible confounders are needed to evaluate smoking as a risk factor for hand eczema.

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

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

Fifteen-year follow-up of hand eczema: persistence and consequences.

BACKGROUND: Hand eczema is a skin disease often with a long-lasting and relapsing course. The long-term prognosis in the general population is unknown. OBJECTIVES: The aims were to examine the extent to which hand eczema had persisted and the medicosocial consequences of the disease. METHODS: In a 15-year follow-up of hand eczema, patients diagnosed in a previous population-based study were sent a questionnaire with 20 questions concerning the persistence and course of the disease, and its occupational and medicosocial consequences. RESULTS: Addresses were available for 1115 persons, of whom 868 answered the questionnaire. Sixty-six per cent of the respondents reported periods of hand eczema and 44% reported symptoms during the previous year, with no sex difference. Twelve per cent reported continuous eczema. However, 74% of those reporting symptoms considered that their hand eczema had improved; of these more were women than men (78% vs. 66%, P < 0.01). Twenty people, 3% of those who were gainfully employed in 1983, reported a change to another occupation because of their hand eczema, 15 of these reporting improvement after the job change. A considerable need for medical consultation was reported, as was the influence on psychosocial functions among those who had eczema the previous year, e.g. sleep disturbances (36%) and hampered leisure activities (72%). Job changes related to hand eczema and psychosocial impairment were also reported by individuals who had not sought medical help for their hand eczema. CONCLUSIONS: This study demonstrates a variable and poor long-term prognosis for hand eczema in the general population. One-third sought medical care during follow-up, while the vast majority with ongoing hand eczema experienced negative psychosocial consequences. For about 5%, the hand eczema gave far-reaching consequences including long sick-leave periods, sick pension and changes of occupation.

Hand eczema in 45 bakers - a clinical study.

The skin of bakers is heavily exposed to dough, spices, water and detergents. This is follow-up of a previous Swedish questionnaire study showing bakers to have a 3-fold increased risk of hand eczema. The aims were to establish diagnoses and to study consequences of hand eczema. From a cohort study of 2226 bakers, a random sample among bakers reporting hand eczema was examined. Of 60 randomly selected bakers reporting a history of hand eczema, 52 attended an examination comprising a standardized interview, documentation of clinical skin signs, patch testing and prick testing with standard and bakery series, and serum analyses. In all, 45 bakers confirmed a history of hand eczema, for which 11 (24%) had been on sick leave, with a median duration of 14 weeks. 13 (29%) had changed their occupation due to skin disease, 19 had positive patch test reactions to standard contact allergens - and 5 to bakery contact allergens. 16 bakers had positive prick tests to standard allergens, 10 to bakery allergens, of whom 9 reacted to flours. Since considerable medical and social consequences of hand eczema are seen, thorough diagnosis of contact allergy and IgE-mediated allergy in bakers, as well as preventive measures, are essential.

Occupational dermatitis in dental personnel: contact dermatitis with special reference to (meth)acrylates in 174 patients.

Between 1995 and 1998, 174 dental personnel were referred as patients to the Department of Occupational and Environmental Dermatology, Stockholm. After clinical examination, 131 were patch tested with the Swedish standard series and 109 with a dental screening series. Furthermore, 137 were tested for IgE-mediated allergy to natural rubber latex (NRL). Hand eczema was diagnosed in 109/174 (63%), 73 (67%) being classified as irritant contact dermatitis and 36 (33%) as allergic. Further diagnoses included other eczemas, urticaria, rosacea, psoriasis, tinea pedis, bullous pemphigoid or no skin disease. 77/131 (59%) had positive reactions to substances in the standard series and 44/109 (40%) to substances exclusive to the dental series. 24/109 (22%) patients had positive reactions to (meth)acrylates, the majority with reactions to several test preparations. Reactions to HEMA (2-hydroxyethyl methacrylate), EGDMA (ethyleneglycol dimethacrylate) and MMA (methyl methacrylate) were most frequent. 9 of the 24 were positive only to (meth)acrylates, the remaining 15 also had reactions to allergens in the standard series. 23 of these had hand eczema and 1 facial eczema. In 17 of the 24 allergic to (meth)acrylates, the dermatitis had started in 1995 or later, in 15 within the previous 12 months. Of 8 who had been sick-listed, 7 also had a history of atopy and 6 were allergic to nickel. The most frequent allergens besides (meth)acrylates were nickel, cobalt, palladium, fragrance mix, colophonium and thiuram mix. Allergy to natural rubber latex was diagnosed in 14/137 (10%). In conclusion, irritant hand dermatitis was the dominant diagnosis. Contact allergy to (meth)acrylate was seen in 22% of the patch tested patients, with reactions to 3 predominant test substances. 1/3 of the patients with allergy to (meth)acrylates had been sick-listed for dermatitis, but in all these cases the (meth)acrylate allergy was seen together with atopy and/or further contact allergies.

Protective gloves in Swedish dentistry: use and side-effects.

BACKGROUND: During the 1980s routine wearing of gloves in dentistry was recommended by health authorities in several countries. However, prolonged glove use is associated with side-effects of irritant and allergic origin. OBJECTIVES: To investigate the extent of glove use and self-reported glove intolerance reactions among Swedish dentists, and to examine how far IgE-mediated allergy to natural rubber latex (NRL) occurs in subjects who report rapid itching when in contact with protective gloves. SUBJECTS/METHODS: A postal questionnaire was answered by 3083 of 3500 licensed dentists, a response rate of 88%. Of the dentists who reported rapidly occurring itching of the hands from gloves, 131 of 170 attended a clinical examination including a skin prick test (SPT) and a serological examination (RAST) for IgE-mediated allergy. RESULTS: Seventy-three per cent of the dentists reported daily glove use of more than 2 h, 48% more than 6 h a day, and 6% reported no use. NRL gloves were used most frequently (P < 0.001) and were the main material that elicited symptoms (P < 0.001). Female dentists reported more frequent glove use than males, as did young dentists (P < 0.001) compared with older ones. Females also preferred vinyl gloves. Glove intolerance reactions were reported by 723 (23%) dentists, [females 28%, males 21% (P < 0.001)] and were more common in younger dentists. Of the 417 dentists with reported hand eczema during the previous year, 54% reported glove intolerance, compared with 20% of the dentists without hand eczema (P < 0.001). A logistic regression analysis including hand eczema, age, sex and atopy showed that all these factors contributed significantly to the risk of glove intolerance, and that hand eczema was a stronger factor than atopy. In 15 of 131 (11%) dentists examined for reported glove-related itch, latex allergy was verified by SPT and/or RAST. Glove-related conjunctivitis, rhinitis and asthma, in contrast to skin symptoms, showed a significant association with IgE-mediated allergy to NRL. CONCLUSIONS: Swedish dentists show good compliance with the recommendations for routine glove use. Intolerance reactions are frequently reported, especially by dentists with hand eczema, which emphasizes the need for preventive skin care programmes. Glove-related symptoms from mucous membranes showed a higher association with IgE-mediated allergy to NRL than reported itching of the skin, a fact that should be considered when composing screening questionnaires for NRL sensitization

[Task and task time should dictate the choice of gloves in health care services]. / Uppgiften och arbetets längd bör styra valet av handskar i vården.

Worldwide consumption of medical gloves increased during the 1980's due to the recognized risk of cross infections in medical and dental care. In Stockholm County Council around 1 million pairs of surgical gloves and 18 millions pairs of examination gloves are purchased per year. In the following paper different glove materials and types are presented and also regulations on use and purchase. The protective capacity of gloves and contact hypersensitivity reactions are also discussed and advice is provided on glove usage.

Contact allergy and hand eczema in Swedish dentists.

Hand eczema and contact allergy in Swedish dentists were studied in a multidisciplinary project. The aims of the study were to establish diagnoses, to investigate the occurrence of contact allergy, in particular to (meth)acrylates, and to evaluate certain consequences of hand eczema. A postal questionnaire on skin symptoms, atopy and occupational experience was mailed to 3,500 dentists aged <65 years, and licensed 1965-1995. The response rate was 88%. Among dentists living in 3 major cities, 14.9% (n= 191) reported hand eczema during the previous year. They were invited to a clinical examination, including patch testing with a standard and a dental series. 158/191 (83%) dentists attended, and hand eczema diagnosis was confirmed in 149/158 (94%). Irritant contact dermatitis was diagnosed in 67% and allergic contact dermatitis in 28%. On patch testing, 50% presented at least 1 positive reaction. The most frequent allergens were nickel sulfate, fragrance mix, gold sodium thiosulfate and thiuram mix. 7 (5%) had positive reactions to (meth)acrylates, all to 2-hydroxyethyl methacrylate and 6 also to ethyleneglycol dimethacrylate. 38% had consulted a physician, 4% had been on sick-leave and 1% had changed occupational tasks due to hand eczema. No dentist with allergy to acrylates had been on sick-leave or changed occupation. It is concluded that dentistry is a high-risk occupation for hand eczema, and that irritant contact dermatitis is most common. The prevalence of contact allergy to acrylates was below 1% in the population of responding dentists, and in most cases did not have serious medical, social or occupational consequences.

Routine patch testing with the sesquiterpene lactone mix in Europe: a 2-year experience. A multicentre study of the EECDRG.

To test the screening value of the sesquiterpene lactone (SL) mix in Europe today and describe epidemiological and clinical features of Compositae-sensitive patients, the SL mix 0.1% pet. was included in the standard patch test series in 11 European clinics. 10,695 patients were tested, and 106 (1%) had positive reactions, 74% of which were of current or old relevance. The prevalence of positive reactions varied between 0.1 and 2.7% in different centres. The median age of the 66 females was 51.5 years, and 55.2 in the 40 males. The 20 occupationally sensitized had a higher % of males and a median age of 43 years, whereas 7 UV-sensitive patients had a median age of 72 years. Garden plants were the major suspected sensitizers and the clinical patterns were partly, in accordance with plant dermatoses in general, involving hands, forearms and face, and partly widespread eczema in a large proportion of the patients. More than 1/3 were positive to perfume and/or colophony, possibly reflecting cross-reactivity. With only 1 case of active sensitization and no irritant reactions, the SL mix is a safe allergen and the overall prevalence of positive reactions supports its continued use in the standard patch test series.

Reduction of latex-allergen content in Swedish medical catheter balloons--a survey of 3 years' production.

Anaphylactic reactions after intravascular exposure to natural rubber latex (NRL) have been reported. Thus, there is an urgent need to produce medical devices with the lowest possible latex-allergen content. The latex-allergen concentration in extracts prepared from 92 lots of medical catheter (MC) balloons, manufactured by Nolato Polymer AB, Torekov, Sweden, from April 1993 to March 1996, was measured with an EAI (IgE antibody inhibition) assay. Inhibitory capacity was expressed in arbitrary units/ml (U/ml) in relation to reference NRL sap, given an arbitrary value of 1000 U. Extracts from randomly selected lots were measured for protein by the modified Lowry method. Water leaching, chlorination, and treatment with savinase were used experimentally to study reduction of the latex-allergen content. The latex-allergen content in extract from the regular MC balloons varied from 0.1 to 2.9 U/ml. All the methods used to reduce the allergen content were effective, and increased leaching stabilized the allergen content at a low level. The protein concentration of the extracts varied between 9 and 100 mg/l. No correlation was found between protein and allergen content. As a result of this study, the manufacturer has extended the stage of water leaching in the production process. This study shows that cooperation between immunologists and manufacturers may result in product development and improvement.

Latex allergy from glove powder--an unintended risk with the switch from talc to cornstarch?

The present study aimed to investigate to what extent glove powders of different origins and brands bind and release latex allergens. One mineral talc and five cornstarch powders were used. The allergenic material was sap of Hevea brasiliensis. The powders were incubated together with the natural rubber latex sap, and four series of experiments were performed. The talc showed the highest tendency to bind isotope-labeled proteins. When incubated with a latex allergen solution, it reduced free allergen from 100 to 2 units/ml compared to a reduction to 70-98 units/ml for the cornstarch powders. In contrast to the nonstable binding of allergen to cornstarch, the binding to talc was irreversible. The allergen bound to talc was allergenically intact and, when incubated with serum, reduced the concentration of free IgE antibody to latex to 10% of the initial level. Mineral talc had a high capacity to bind latex allergens firmly. In contrast, cornstarch captured the latex allergen, but the binding seemed less pronounced and was unstable. The replacement of talc by cornstarch as glove-donning powder has coincided with the rapid increase in latex allergy. Mineral talc is heavy and only transiently airborne. Could this difference between talc and cornstarch in latex-allergen-binding pattern and the tendency of the latter to be airborne play an important role in the bioavailability of latex allergen and thus in the epidemic of latex sensitization.

The value and limitations of protective gloves in medical health service: Part III.

The value of protective gloves in the health care environment is well known. However, these gloves are not perfect. Some are permeable to microorganisms and various chemicals, and/or result in side effects for health care professionals. Gloves that offer the greatest protection and least side effects are highly desirable. Limitations of glove use due to side effects, and glove selection and therapeutic alternatives are described in Part III of this three-part series.

The value and limitations of protective gloves in medical health service: part II.

The value of protective gloves in the health care environment is well known. However, these gloves are not perfect. Some are permeable to microorganisms and various chemicals, and/or result in side effects for health care professionals. Gloves that offer the greatest protection and least side effects are highly desirable. Protection against microorganisms and protection against chemicals used in health care are described in Part II of this three-part series.