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.

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.

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.

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.

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 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.

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.

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.

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.

Incidence of hand eczema in female Swedish hairdressers.

OBJECTIVE: To estimate the occurrence of hand eczema in hairdressers in Sweden. METHODS: The occurrence of hand eczema was estimated in a Swedish longitudinal retrospective cohort study including all female graduates from vocational schools for hairdressers from 1970 to 1995. A stratified sample from the general population acted as controls. A self-administered questionnaire including questions on the occurrence of hand eczema, skin atopy, working periods and number of hair treatments performed per week was sent to the participants. Incidence rate ratios (IRRs) of hand eczema were estimated. RESULTS: The incidence rate of hand eczema in hairdressers was 23.8 cases/1000 person-years, whereas in hairdressers who were aged <25 years it was 37.1/1000 person-years. The corresponding IRR for hairdressers compared with controls was 2.5 (95% confidence interval (CI) 2.2 to 2.8), and that for younger hairdressers was 3.1 (95% CI 2.6 to 3.5). The mean age at onset of hand eczema was 21.6 years for hairdressers and 21.2 years for controls. The 1-year prevalence of hand eczema was 18.0% for hairdressers and 12.1% for controls. A large number of hair treatments involving exposure to skin irritants and sensitisers were reported. The incidence rate of hand eczema was higher among individuals with a history of childhood eczema, both for hairdressers and for controls, giving an (age-adjusted) IRR of 1.9 and 2.2, respectively. The attributable fraction of hand eczema from skin atopy was 9.6%. A synergistic effect of skin atopy and hairdressing was found on the occurrence of hand eczema. The relative excess risk due to interaction was 1.21 (95% CI 0.21 to 2.21; p = 0.01). CONCLUSION: Hairdressers are highly exposed to skin-damaging substances. The self-reported incidence of hand eczema was substantially higher in female hairdressers than in controls from the general population and than that found previously in register-based studies. For many individuals, onset of hand eczema occurs early in life. Only about 10% of the hand eczema cases among hairdressers would be prevented if no one with skin atopy entered the trade.

Occupational skin exposure and hand eczema among dental technicians-need for improved prevention.

OBJECTIVES: The aims of this study were to estimate occupational skin exposure, the use of skin protection, and the incidence of hand eczema among dental technicians. METHODS: In a retrospective cohort study, dental technicians (N=2139) and randomly selected population controls (N=2288) received a postal questionnaire on occupational skin exposure, protective glove use, and hand eczema, including the year of onset. The response rate was 57% for the dental technicians and 58% for the controls. RESULTS: Altogether 80% of the dental technicians reported skin exposure to uncured (meth)acrylates (MA), and 87% had skin contact with grinding dust from MA. Thirty-nine percent used protective gloves when handling uncured MA. Twenty-two percent of the currently employed technicians reported participation in obligatory training concerning the handling of thermosetting plastics, and 58% did not know how long normally used gloves protected the skin against uncured MA. Altogether 48% of the dental technicians and 30% of the controls reported more than 10 hand washings a day (P<0.001). For the dental technicians, the incidence of hand eczema was 8.5 cases/1000 person-years during MA-exposed time. For the controls, the incidence was 3.3. The incidence rate ratio for the men was 3.6 (95% CI 2.3-5.6), and for the women it was 2.4 (95% CI 1.7-3.3). CONCLUSIONS: The work of dental technicians involves frequent and unprotected exposure to MA and frequent hand washings. Dental technicians have twice the risk of hand eczema than the general population. Efforts to improve skin protection and increase participation in obligatory training about handling thermosetting plastics are important.

Fifteen-year follow-up of hand eczema: predictive factors.

The aim of this study was to identify factors of importance for the long-term prognosis of hand eczema in the general population. In a 15-y follow-up, 868 (78%) individuals with hand eczema, diagnosed and clinically examined in a previous population-based study, answered a postal questionnaire with questions concerning persistence of the disease. In a logistic regression model, the extent of eczema involvement at the initial examination was the strongest negative factor for the prognosis, followed by history of childhood eczema and age below 20 y at onset of hand eczema. These factors significantly influenced both the total time with hand eczema during the 15 y follow-up and occurrence of hand eczema the previous year. The predictive factor for hand eczema 15 y later was doubled for an individual with all three risk factors compared with one without them, 72%vs 35%. Contact allergy to any of the standard allergens also related significantly to current hand eczema. In conclusion, the main determinant for a poor long-term prognosis was widespread hand dermatitis at the initial examination. Other important factors were low age at onset of hand eczema, history of childhood eczema, and contact allergy.

Influence of childhood atopic dermatitis on future worklife.

OBJECTIVES: The purpose of this study was to perform a population-based follow-up of people with childhood atopic dermatitis with respect to the possible influence on their worklife. METHODS: Medical records of the school health care services in Stockholm, Sweden, were reviewed for people born between 1960 and 1969. Altogether 600 persons with signs of atopic dermatitis ("cases") and 600 matched controls without eczema ("controls") were identified. Of these people, 405 cases and 378 controls answered a postal questionnaire focusing on choice of job, occupational exposure, past and present skin disease, and change of job due to eczema. RESULTS: The proportions of cases and controls in jobs with a high risk of hand eczema were similar, as was the exposure to water, detergents, chemicals, and hand washing. The self-reported cumulative prevalence of hand eczema was 42% for the cases and 13% for the controls (P<0.001). The 1-year prevalence was 24% for the cases and 9% for the controls (P<0.001). Among the cases, 9% reported a change of job due to eczema compared with 2% of the controls (P<0.001). The corresponding proportions of sick leave were 10% and 2% (P<0.001). CONCLUSIONS: In conclusion, a history of atopic dermatitis in childhood does not seem to influence the choice of job nor hazardous occupational skin exposure. It does, however, mean an increased risk for job changes, sick leave, and medical consultations, mainly due to the increased risk of hand eczema.