Wet work and hand eczema in apprentice nurses; part I of a prospective cohort study.

BACKGROUND /OBJECTIVES: Environmental exposure and personal susceptibility both contribute to the development of hand eczema. Here, we report an investigation on wet work exposure and its influence on the risk of developing hand eczema in apprentice nurses. METHODS: A prospective cohort study was performed among 721 Dutch apprentice nurses. Participants recorded wet work exposure and symptoms of hand eczema using specially designed diary cards. RESULTS: For 533 apprentice nurses, a follow-up time of 1-3 years was completed. Diary cards were supplied by 383 students. The 1-year period prevalence of hand eczema was 23% in the first year, 25% in the second year and 31% in the third year of follow-up. Eighty-one new cases of hand eczema developed, most of which occurred during the first year of follow-up. In approximately one-third of the participants, wet work exposure exceeded the national guidelines. Frequent hand washing during traineeships [odds ratio (OR) 1.5; 90% confidence interval (CI) 1.0-2.3], frequent hand washing at home (OR 2.3; 90% CI 1.5-3.7) and having a side job involving wet work (OR 1.6; 90% CI 1.0-2.4) were independent risk factors for hand eczema. CONCLUSION: As a considerable number of apprentice nurses had already developed hand eczema during traineeships, more attention should be paid to skin protection in vocational education.

Filaggrin loss-of-function mutations and atopic dermatitis as risk factors for hand eczema in apprentice nurses: part II of a prospective cohort study.

BACKGROUND/OBJECTIVES: Environmental exposure and personal susceptibility both contribute to the development of hand eczema. In this study, we investigated the effect of loss-of-function mutations in the filaggrin gene (FLG), atopic dermatitis and wet work exposure on the development of hand eczema in apprentice nurses. METHODS: Dutch apprentice nurses were genotyped for the four most common FLG mutations; atopic dermatitis and hand eczema history were assessed by questionnaire. Exposure and hand eczema during traineeships were assessed with diary cards. RESULTS: The prevalence of hand eczema during traineeships was higher among subjects with a history of hand eczema reported at inclusion. Hand washing during traineeships and at home increased the risk of hand eczema. After adjustment for the effects of exposure and FLG mutations, an odds ratio of 2.5 (90% confidence interval 1.7-3.7) was found for a history of atopic dermatitis. In this study, an increased risk of hand eczema conferred by FLG mutations could not be shown, but subjects with concomitant FLG mutations and atopic dermatitis showed the highest risk of hand eczema during traineeships. CONCLUSION: A history of atopic dermatitis, a history of hand eczema and wet work exposure were the most important factors increasing the risk of hand eczema during traineeships.

Quantification of wet-work exposure in nurses using a newly developed wet-work exposure monitor.

Occupational contact dermatitis (OCD) is an important work-related disease. A major cause of OCD is 'wet work': frequent contact of the skin with water, soap, detergents, or occlusive gloves. The German guidance TRGS 401 recommends that the duration of wet work (including use of occlusive gloves) should not exceed 2 h day(-1) and also the frequency of hand washing or hand disinfection should be taken into account. This highlights the need for a reliable method to assess duration and frequency of wet work. Recently, a wet-work sampler has been developed by the University of Aberdeen. The sampler uses the temperature difference (ΔT) generated by evaporative cooling between two sensors: one sensor on the skin and a second one placed 2 mm above the skin. We have evaluated the use of this sampler in a healthcare setting, using direct observation as reference. Twenty-six nurses wore the sampler on the volar side of the middle finger for ∼2 h during their regular daily tasks, while being observed by a researcher. Sampler results were evaluated using various threshold values for ΔT to identify wet events of the hands. The optimal ΔT to discern wet and dry skin differed considerably between individual nurses. Individual results yielded a median sensitivity of 78 and 62% and a median specificity of 79 and 68% for indicating wet skin and glove use, respectively. Overall, the sampler was moderately accurate for identifying wetness of the skin and less accurate for discerning glove use. In conclusion, agreement between observed wet work and device-reported wet events in healthcare settings was not high and further adaptations and developments may be required.

Industry Derived Occupational Exposure Limits: A Survey of Professionals on the Dutch System of Exposure Guidelines.

The Netherlands' system for occupational exposure limits (OELs) encompasses two kinds of OELs: public and private. Public OELs are set by the government. Private OELs are derived by industry and cover all substances without a public OEL. In parallel, the regulation concerning the Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH) has introduced an exposure guidance value similar to the OEL, namely the Derived No-Effect Level (DNEL) for workers' inhalation exposure. This study aimed to investigate issues encountered by occupational health professionals regarding private OELs, and how they perceive the DNELs for workers in relation to private OELs. Towards this aim, we sent out a web-based questionnaire to the members of the Dutch professional organization for occupational hygienists (Nederlandse Vereniging voor Arbeidshygiëne [NVVA], n = 513) and to members of the Dutch professional organization for safety engineers (NVVK, n = 2916). Response rates were 27% (n = 139) and 7% (n = 198), respectively. More occupational hygienists (59%) than safety engineers (17%) reported to derive private OELs themselves. Our respondents reported several challenges with the derivation of private OELs. Fifty-one percent of the occupational hygienists and 20% of the safety engineers stated to see a role of REACH Registrants' worker DNELs as private OELs. However, more than half of our respondents were undecided or unfamiliar with worker DNELs. In addition, stated opinions on where worker DNELs fit in the hierarchy of private OELs varied considerably. To conclude, both these professional groups derive private OELs and stated that they need more guidance for this. Furthermore, there is a lack of clarity whether worker DNELs may qualify as private OELs, and where they would fit in the hierarchy of private OELs.

Characterization of silver particles in the stratum corneum of healthy subjects and atopic dermatitis patients dermally exposed to a silver-containing garment.

Silver is increasingly being used in garments to exploit its antibacterial properties. Information on the presence of silver nanoparticles (AgNPs) in garments and their in vivo penetration across healthy and impaired skin from use is limited. We investigated the presence of AgNPs in a silver containing garment and in the stratum corneum (SC) of healthy subjects (CTRLs) and individuals with atopic dermatitis (AD). Seven CTRLs and seven AD patients wore a silver sleeve (13% Ag w/w) 8 h/day for five days on a forearm and a placebo sleeve on the other forearm. After five days, the layers of the SC were collected by adhesive tapes. The silver particles in the garment and SC were characterized by scanning electron microscopy with energy dispersive X-ray analysis (SEM-EDX) and atomic force microscopy (AFM). AFM and SEM revealed the presence of sub-micrometre particles having a broad range of sizes (30-500 nm) on the surface of the garment that were identified as silver. On the SC tapes collected from different depths, aggregates with a wide range of sizes (150 nm-2 µm) and morphologies were found. Most aggregates contained primarily silver, although some also contained chlorine and sulfur. There was no clear difference in the number or size of the aggregates observed in SC between healthy and AD subjects. After use, AgNPs and their aggregates were present in the SC at different depths of both healthy subjects and AD patients. Their micrometre size suggests that aggregation likely occurred in the SC.

Pilot study on the identification of silver in skin layers and urine after dermal exposure to a functionalized textile.

Silver (Ag) is increasingly used in consumer products like functionalized textiles and medical devices owing to its strong antimicrobial activity which is largely assigned to Ag ions released after oxidation of metallic Ag. To increase generation of Ag ions, in various products Ag is often present as nanoparticles. Ideally, Ag ions would remain on the surface of the skin to combat the bacteria and the uptake of Ag into the body should be limited. However, the Ag ions might penetrate across the skin into the body leading to adverse health effects. Data on in vivo uptake of Ag due to dermal exposure are scarce partly caused by the lack of suitable analytical approaches for the determination of Ag in biological matrices, but strongly needed to enable risk assessment of skin exposure to (nano) Ag containing products. With the developed approach, the presence of Ag in a functionalized textile is confirmed by using scanning electron microscopy (SEM). After in vivo dermal exposure to Ag containing textile material under ׳׳in use׳׳ exposure scenarios, the outermost layers of the skin (Stratum Corneum, SC) were sampled by using adhesive tapes with a size of 3.8cm(2). Different leaching and dissolution procedures of Ag from biological samples prior analysis by inductively coupled plasma mass spectrometry (ICPMS) have been evaluated. The developed method results in a limit of detection (LOD) of 2ng Ag per removed SC layer. The method allows the measurement of the Ag concentrations at different depths of the SC enabling the deduction of the percutaneous penetration kinetics. Due to the possible bio distribution within the whole body, an indirect exposure matrix (urine) was studied too. The detection power of the method permits measuring the ultra-trace concentrations of Ag in urine before and after dermal exposure; LOD is 0.010µg Ag/L urine.

Percutaneous penetration of silver from a silver containing garment in healthy volunteers and patients with atopic dermatitis.

Human data on dermal absorption of silver under "in use" scenario are scarce which hampers health risk assessment. The main objective of the present study was to determine percutaneous penetration of silver after dermal exposure to silver containing garment in healthy individuals and atopic dermatitis (AD) patients. Next to assess pro-inflammatory effect of silver in the skin. Healthy subjects (n=15) and patients with AD (n=15) wore a sleeve containing 3.6% (w/w) silver on their lower arms for 8h during 5 consecutive days. The percutaneous penetration parameters were deduced from the silver concentration-depth profiles in the stratum corneum (SC) collected by adhesive tapes. Furthermore, silver was measured in urine samples collected before and after exposure. Inflammatory response was assessed by measuring IL-1α and IL-1RA in the exposed and non-exposed skin sites. Dermal flux of silver in healthy subjects and AD patients was respectively 0.23 and 0.20 ng/cm(2)/h. The urine silver concentrations showed no increase after exposure. Furthermore, exposure to silver did not lead to the changes in the profiles of IL-1α and IL-1RA. Dermal absorption of silver under "real life scenario" was lower than the current reference dose. Furthermore, dermal exposure did not lead to altered expression of inflammatory IL-1 cytokines in the skin.

Revealing barriers and facilitators to use a new genetic test: comparison of three user involvement methods.

We compared three common user involvement methods in revealing barriers and facilitators from intended users that might influence their use of a new genetic test. The study was part of the development of a new genetic test on the susceptibility to hand eczema for nurses. Eighty student nurses participated in five focus groups (n = 33), 15 interviews (n = 15) or questionnaires (n = 32). For each method, data were collected until saturation. We compared the mean number of items and relevant remarks that could influence the use of the genetic test obtained per method, divided by the number of participants in that method. Thematic content analysis was performed using MAXQDA software. The focus groups revealed 30 unique items compared to 29 in the interviews and 21 in the questionnaires. The interviews produced more items and relevant remarks per participant (1.9 and 8.4 pp) than focus groups (0.9 and 4.8 pp) or questionnaires (0.7 and 2.3 pp). All three involvement methods revealed relevant barriers and facilitators to use a new genetic test. Focus groups and interviews revealed substantially more items than questionnaires. Furthermore, this study suggests a preference for the use of interviews because the number of items per participant was higher than for focus groups and questionnaires. This conclusion may be valid for other genetic tests as well.

Individual susceptibility to occupational contact dermatitis.

Occupational Contact Dermatitis (OCD) is one of the most common work-related diseases. High risk occupations are in health care, hairdressing, food sector and metal industry. OCD tends to become chronic; persistent OCD often results in impaired quality of life and loss of work ability. The purpose of this article is to review the present knowledge on the factors which determine individual susceptibility to acquire OCD. Recent discoveries regarding genes involved in the skin barrier, inflammatory response and biotransformation of xenobiotics provide more insight in the individual susceptibility for OCD. Knowledge of the factors which predispose to OCD is useful in occupational health practice for the application of preventive measures and for career guidance for apprentices and workers in high risk occupations.