Occupational contact dermatitis in painters an analysis of patch test data from the Danish Contact Dermatitis Group

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1 Contact Dermatitis Original Article COD Contact Dermatitis Occupational contact dermatitis in painters an analysis of patch test data from the Danish Contact Dermatitis Group Anja P. Mose 1, Michael D. Lundov 1, Claus Zachariae 2, Torkil Menné 2, Niels K. Veien 3, Grete Laurberg 3, Knud Kaaber 4, Christian Avnstorp 5, Klaus E. Andersen 6, Evy Paulsen 6, Charlotte G. Mørtz 6, Mette Sommerlund 7, Anne Danielsen 8, Jens Thormann 9, Ove Kristensen 10,Berit Kristensen 10,BoL.Andersen 11, Susanne Vissing 12, Niels H. Nielsen 13 and Jeanne D. Johansen 1 1 Department of Dermato-Allergology, National Allergy Research Centre, Copenhagen University Hospital Gentofte, 2900 Hellerup, Denmark, 2 Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, 2900 Hellerup, Denmark, 3 Dermatology Clinic, Vesterbro 99, 9000 Aalborg, Denmark, 4 Dermatology Clinic, Bredgade 30, 7400 Herning, Denmark, 5 Dermatology Clinic, Roskildevej 264, 2610 Rødovre, Denmark, 6 Department of Dermatology and Allergy Unit, Odense University Hospital, Odense, Denmark, 7 Department of Dermatology, Århus University Hospital, Århus, Denmark, 8 Dermatology Clinic, Banegårdspladsen 1, 1570 Copenhagen, Denmark, 9 Dermatology Clinic, Skovgade 23C, 7100 Vejle, Denmark, 10 Dermatology Clinic, Bredgade 50, 4400 Kalundborg, Denmark, 11 Dermatology Clinic, Havnepladsen 3A, 5700 Svendborg, Denmark, 12 Dermatology clinic, Gl. Hovedgade 14, 2970 Hørsholm, Denmark, and 13 Dermatology Clinic, Bindeledet 15, 2880 Bagsværd, Denmark doi: /j x Summary Background. Painters are among the occupational groups that most commonly experience occupational contact dermatitis, but few investigations exist concerning this occupation. Objectives. To characterize painters with contact dermatitis and identify the most common allergens associated with the occupation. Materials and methods. All patch test results of 219 painters and 1095 matched controls registered by the Danish Contact Dermatitis Group between 2001 and 2010 were analysed. Results. Hand eczema (p <0.0001) and occupational contact dermatitis (p < ) were observed significantly more often in the painters than in the group of controls. Sensitizations to the following allergens from the European baseline series were associated with the occupation and were statistically significant: methylchloroisothiazolinone/methylisothiazolinone, epoxy resin, formaldehyde, and quaternium-15. Three different isothiazolinones emerged as the most frequent sensitizers of the allergens tested in addition to the baseline series. Conclusions. The results indicate that painters have an increased risk of developing occupational hand eczema. Isothiazolinones and epoxy resin proved to be the two most frequent sensitizers in painters. Key words: allergens; contact dermatitis; epoxy resin; hand eczema; methylchloroisothiazolinone/methylisothiazolinone; occupation; painters; preservatives. Correspondence: Jeanne D. Johansen, Department of Dermato-Allergology, National Allergy Research Centre, University Hospital of Copenhagen Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark. Tel: ; Fax: ; jedu@geh.regionh.dk Conflicts of interest: The authors have declared no conflicts. Accepted for publication 22 January 2012 Previous studies in Germany and the United Kingdom have shown that painters belong to one of the occupational groups in which employees have the highest risk of developing occupational contact dermatitis (1, 2). This is because of exposure to allergens such as preservatives and synthetic resins, rubber chemicals, if rubber gloves are used, or irritants such as solvents, detergents, cleansing agents, and hand cleaners. Contact Dermatitis, 67,

2 In Denmark, the National Board of Industrial Injuries registered a total of 126 cases of occupational skin diseases among Danish painters in the period between 2005 and 2010 (National Board of Industrial Injuries, pers. comm. 2011). Such observations merited a more detailed investigation, as national registries are commonly incomplete, as a result of underdiagnosis and underreporting of the disease (1). The composition of paints has undergone profound changes over time. Today, the professional use of solventbased paints has been almost entirely replaced by the use of water-based paints, which contain significantly lower concentrations of organic solvents (3). The chemistry of modern paints is, however, much more complex than that of their predecessors (4). The use of primarily waterbased paints increases the need for effective preservation, which is known to carry a risk of contact allergy, both in painters (5, 6) and in consumers (7), but also in paint production (8, 9). The problems of occupational contact dermatitis in painters have been addressed in relatively few studies so far (5, 6, 10 12). The recent introduction of the preservative methylisothiazolinone (MI) in high concentrations in paints may potentially increase the problem (13). This also creates a need for an update concerning the characteristics of painters with contact dermatitis and the relationship with different allergens. The aim of this study was to analyse registered patch test data from the Danish Contact Dermatitis Group and hence characterize painters with contact eczema in addition to identifying the most common allergens associated with the profession. Materials and Methods In the present study, patch test results of all painters registered in the National Database for Contact Allergy at the Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Denmark, by the Danish Contact Dermatitis Group between 2001 and 2010, were selected and analysed. Today, the Danish Contact Dermatitis Group consists of a network of privately practising dermatologists and three hospital dermatology departments throughout Denmark. The patients included in this study were patch tested with the European baseline series and, in some cases, with additional allergens, according to each patient s personal history of exposure. Patch tests were applied to the upper back and remained occluded for 48 hr. Readings were performed on D2, D3/D4, and D7, in accordance with the recommendations of the International Contact Dermatitis Research Group (14). Reactions that were scored as 1+, 2+ or 3+ were interpreted as positive reactions, and used for further analyses. The patch test materials utilized may have varied between patients, because different hospital departments and privately practising dermatologists reporting to the National Database for Contact Allergy follow local preferences. The painters were extracted from the database by means of the Danish version of the International Classification of Occupation (Disco) codes (7141 and 7142). Consequently, the definition of painters in this study is as follows: house, automobile and naval painters, artists, sign writers, and paperhangers. Owing to the use of Disco codes, it was not possible to distinguish further between the occupational subgroups. Each painter was matched with 5 other patients, that is, controls, who were not registered as painters in the database. Matching criteria were age, sex, and test year. The painters and their controls were compared by means of the MOAHLFA (Male, Occupational dermatitis, Atopic dermatitis, Hand eczema, Leg dermatitis, Face dermatitis, Age above 40 years) index, which had been routinely registered for each patient by the treating physician. In cases where painters (n = 3) had been retested during the study period, only results from the last patch test were included in the analyses. Allergens from the following main groups in the European baseline series were chosen for comparison between the painters and their matches: metals, preservatives, rubber chemicals, and synthetic and natural resins. Selection was made on the basis of previously known sensitizers commonly found as ingredients in water-based paints (15). Likewise, all additional allergens that the painters had been patch tested with were also extracted from the database. However, because of an extensive list of results, we chose to limit the presentation to the group of allergens with the highest percentage of positive allergic reactions in our group of painters. All data analyses were performed with the statistical software SPSS version The χ 2 -test was applied for the analyses of the MOAHLFA index and the patch test results of allergens selected from the European baseline series. A 5% level of statistical significance was used (p <0.05), with all p-values being two-sided. Results A total of patients were patch tested between 2001 and Out of the total group, 219 patients were registered as painters, with the Disco codes 7141 and The male/female ratio was 2.4 (155 males and 64 females). The youngest painter tested was 16 years of age, and the oldest was 68 years of age; the mean age for whole group was 39 years. 294 Contact Dermatitis, 67,

3 Table 1. MOAHLFA index Painters (n = 219) n(%) Controls (n = 1095) n (%) p-value Male 155 (71) 775 (71) 1.00 Occupational 78 (36) 156 (14) < Atopic dermatitis 40 (18) 175 (16) 0.40 Hand dermatitis 126 (58) 475 (43) < Leg dermatitis 9 (4) 44 (4.0) 0.95 Face dermatitis 34 (16) 168 (15) 0.95 Age >40 years 106 (48) 530 (48) 1.00 χ 2 -test. The results according to the MOAHLFA index are shown in Table 1. It shows that the most common anatomical site of dermatitis concerning the painters was the hands (58%). This was followed by the face (16%) and the legs (4%). When these characteristics were compared between the two groups, only hand dermatitis was seen significantly more often (p <0.0001) in the painters. Moreover, the painters had occupational dermatitis significantly more often (p <0.0001) than their controls. A total of 94 painters (43%) and 409 of their controls (37%) had at least one positive patch test reaction. On comparison, this characteristic was of no significance (p = 0.12). Most of the positive patch test reactions in painters with regard to the allergens preselected from the European baseline series were to: nickel sulfate (15%), methylchloroisothiazolinone (MCI)/methylisothiazolinone (MCI/MI) (10%), epoxy resin (8%), methyldibromo glutaronitrile (5%), and formaldehyde (5%) (Table 2). Sensitization to MCI/MI (p <0.0001), epoxy resin (p < ), formaldehyde (p = 0.003) and quaternium-15 (p = 0.004) was found significantly more often in the painters than in their controls. In total, 6 painters were positive to quaternium-15; all of these were also positive to formaldehyde. The percentage of painters sensitized to allergens that are not included in the European baseline series and that are classified as preservatives was especially high. These results are shown in Table 3. The most common allergens among the preservatives were MI (2-methyl- 4-isothiazolin-3-one) (11/41, 27%), octylisothiazolinone (octyl-4-isothiazolin-3-one) (5/21, 25%), and benzisothiazolinone (1,2-benzisothiazolin-3-one) (7/37, 19%). No cases of allergy to acrylates or isocyanates were found among the 15 painters tested with these substances. Discussion In this study, the painters were diagnosed with occupational contact dermatitis and hand eczema significantly more often (p <0.0001) than their controls. This is very much in line with previous studies of painters, which have concluded that they have an increased risk of developing contact dermatitis (1, 2, 11, 12). This is best exemplified by a study performed in northern Bavaria, Germany, which showed that painters belong to one of the 12 occupations with the highest risk of occupational contact dermatitis (16). Similarly, a questionnaire study among 2000 male construction workers showed that painters reported more symptoms of hand dermatitis than carpenters (5). Another study showed that, in a group of 202 construction painters who worked with water-based paint, 25 (12%) painters gave a history of hand eczema and 16 (8%) had current problems (6). These findings show that painters may have an increased risk of developing hand eczema. Four allergens (MCI/MI, epoxy resin, formaldehyde, and quaternium-15) from the European baseline series emerged as important, as contact allergy to these was found significantly more often in the group of painters than in the controls. Other studies have reported similar results. Fisher et al. reported that the most frequent allergens related to work as a painter were the isothiazolinones (6). In our study, 10% of the painters tested positive to MCI/MI, as compared with only 1% of the controls (Table 2). Our results further show that a high percentage of painters tested positive to MI alone (27%), but also to octylisothiazolinone (25%) and benzisothiazoline (19%) (Table 3). These results clearly suggest that there are significant problems with the isothiazolinones that are currently used in paints. Similarly, two recently published cases of airborne allergies caused by MI, resulting in allergic contact dermatitis and asthma, may indicate an undisclosed problem in painters (7). In our study, epoxy resin came second to MCI/MI as the allergen with the highest number of sensitizations in painters. It caused allergic reactions in 8% of the painters (Table 2). Other studies have shown that epoxy resin is the most common allergen among painters. On the basis of reports of occupational skin diseases in a register in northern Bavaria, Bock et al. found that 6 of 55 painters (11%) had an occupationally relevant allergy to epoxy resin (12). A Finnish study showed that the highest risk of hand dermatitis was found among painters who used solvent-based epoxy and urethane paints on a daily basis (5). As a final point, it is noteworthy that, since 1981, individuals in Denmark have been required to take a course on personal safety if working with epoxy. Our data show that, despite such preventive measures, problems concerning sensitization to epoxy remain. Contact Dermatitis, 67,

4 Table 2. Positive patch test reactions in the painters and the controls to allergens that are included in the European baseline series and that may be present in paints, glues, or putties Positive patch test reactions Concentration (%) Vehicle Painters (n = 219) n (%) Controls (n = 1095) n (%) p-value Potassium dichromate 0.5 Pet. 7 (3) 25 (2) 0.4 Nickel sulfate 5 Pet. 32 (15) 137 (13) 0.4 Cobalt chloride 1 Pet. 8 (4) 28 (3) 0.4 Thiuram mix 1 Pet. 1 (0.5) 13 (1) 0.3 Mercapto mix 1 Pet. 1 (0.5) 7 (1) 0.8 Mercaptobenzothiazole 2 Pet. 1 (0.5) 5 (0.5) 1.0 Methylchloroisothiazolinone/methylisothiazolinone 0.01 Aqua 22 (10) 10 (1) < Formaldehyde 1 Aqua 11 (5) 19 (2) Quaternium-15 1 Pet. 6 (3) 7 (0.5) Paraben mix 15 Pet. 2 (1) 6 (0.5) 0.5 Methyldibromo glutaronitrile 0.3 Pet. 10 (5) 37 (3) 0.4 Epoxy resin 1 Pet. 18 (8) 22 (2) < Colophonium 20 Pet. 6 (3) 28 (3) 0.9 Vehicles for the test material: aqua, deionized water; Pet., white petrolatum. χ 2 -test. All cases of quaternium-15 allergy were also positive to formaldehyde, which means that quaternium-15 was of no independent importance as an allergen in painters. Table 3. Patch test results for some of the additional allergens that the painters were tested with Allergens Total tested Positive patch test reactions n(%) Preservatives Methylisothiazoline (27) (2-methyl-4-isothiazolin-3-one) Octylisothiazolinone 21 5 (25) (octyl-4-isothiazolin-3-one) Benzisothiazolinone 37 7 (19) (1,2-benzisothiazolin-3-one) Bioban P 1487 [mixture of 6 1 (17) 4-(2-nitrobutyl)-morpholine and 4,4-(2-ethyl-2-nitrotrimethylene) dimorpholine] 2-Bromo-2-nitropropane-1,3-diol (bronopol) (5.4) Diazolidinyl urea (4.7) DMDM hydantoin 42 1 (2.4) (1,3-dimethylol-5,5-dimethylhydantoin) Iodopropynyl butylcarbamate (1.9) (3-iodo-2-propynyl-butylcarbamate) Imidazolidinyl urea (1.6) Only the group of allergens with the highest percentage of positive allergic reactions is presented. No cases of contact allergy to acrylates or isocyanates were found. These allergens were not routinely tested, but only tested if they were found to be relevant according to the exposure analysis. Contact allergy to isocyanates is especially seen in the automobile industry and in the production of paints and binders (17). Isocyanates are strong allergens, and may sensitize after just one exposure (18). The diagnosis of contact allergy to isocyanates is difficult to make (19), and cases may easily be overlooked, which may also have been the case in the current investigation, where only 15 painters were tested with isocyanates. Contact allergy to acrylates has been seen in, for example, printers and paint factory workers exposed to ultraviolet lacquers and varnishes (20). Acrylate allergy may also have been underdiagnosed in our investigation. The results of this study also show that formaldehyde is a common allergen among painters, as 11 painters (5%) had been sensitized to this chemical. Similarly, Moura et al. found that formaldehyde had caused sensitization in 5% of a group of painters with occupational dermatitis (11). Consequently, even though formaldehyde is present in only small amounts in many water-based paints and other painters products (21), it evidently still causes a significant number of sensitizations in painters. This might be related to the concomitant use of formaldehyde-releasers in paints (22). Recent studies have shown that patients who are allergic to formaldehyde often have simultaneous contact allergy to a formaldehyde-releaser(s), and that a contact allergy to either can be elicited by the other (23, 24). In line with this, the formaldehyde-releaser quaternium-15 emerged as the fourth most important allergen from the European baseline series causing sensitization in painters. However, this substance is not a typical preservative in paints, and, in all cases of quaternium-15 allergy, cosensitization to formaldehyde was seen. Thus, quaternium-15 was of no independent importance as an allergen in painters. 296 Contact Dermatitis, 67,

5 In conclusion, the results of this study indicate that painters have an increased risk of contact hand eczema caused by their work. The isothiazolinones and epoxy resin emerged as the most frequent sensitizers in painters with contact dermatitis. Further research regarding the relationship between the painters chemical work environment and contact dermatitis, as well as better protection, is of utmost relevance. Acknowledgements Drs Hans Lomholt and Henrik Sølvsten (Aalborg), Anne Hjorther and Bent Staberg (Rødovre), Aksel Otkjær and Morten Østerballe (Herning), Henrik Thormann (Vejle) and Mads Nielsen and Rune Lindskov (Copenhagen) are gratefully acknowledged for participating in the data collection. References 1 Diepgen T L, Kanerva L. Occupational skin diseases.eur J Dermatol 2006: 16: Cherry N, Meyer J D, Adisesh A, Brooke R, Owen-Smith V, Swales C, Beck M H. Surveillance of occupational skin disease: EPIDERM and OPRA. Br J Dermatol 2000: 142: Wieslander G, Norbäck D, Edling C. Occupational exposure to water based paint and symptoms from the skin and eyes. Occup Environ Med 1994: 51: Hansen M K, Larsen M, Cohr K-H. Waterborne paints. A review of their chemistry and toxicology and the results of determinations made during their use. Scand J Work Environ Health 1987: 13: Kaukiainen A, Riala R, Martikainen R, Estlander T, Susitaival P, Aalto-Korte K. Chemical exposure and symptoms of hand dermatitis in construction painters. Contact Dermatitis 2005: 53: Fisher T, Bohlin S, Edling C, Rystedt I, Wieslander G. Skin disease and contact sensitivity in house painters using water-based paints, glues and putties. Contact Dermatitis 1995: 32: Lundov M D, Mosbech H, Thyssen J P, Menné T, Zachariae C. Two cases of airborne allergic contact dermatitis caused by methylisothiazolinone in paint. Contact Dermatitis 2011: 65: Jensen C D, Thormann J, Andersen K E. Airborne allergic contact dermatitis from 3-iodo-2-propynyl-butylcarbamate at a paint factory. Contact Dermatitis 2003: 49: Gruvberger B, Bruze M, Almgren G. Occupational dermatoses in a plant producing binders for paints and glues. Contact Dermatitis 1998: 38: Högberg M, Wahlberg J E. Health screening for occupational dermatoses in house painters. Contact Dermatitis 1980: 6: Moura C, Dias M, Vale T. Contact dermatitis in painters, polishers and varnishers. Contact Dermatitis 1994: 31: Bock M, Schmidt A, Bruckner T, Diepgen T L. Occupational skin disease in the construction industry. Br J Dermatol 2003: 149: Lundov M D, Thyssen J P, Zachariae C, Johansen J D. Prevalence and cause of methylisothiazolinone contact allergy. Contact Dermatitis 2010: 63: Wilkinson D S, Fregert S, Magnusson B et al. Terminology and contact dermatitis. Acta Derm Venereol 1970: 50: Fisher A A. Paint dermatitis: the role of routine patch test series in detecting contact allergens in paints. Cutis 1995: 56: Dickel H, Kuss O, Blesius C R, Schmidt A, Diepgen T L. Occupational skin diseases in Northern Bavaria between 1990 and 1999: a population based study. Br J Dermatol 2001: 145: Goossens A, Detienne T, Bruze M. Occupational allergic contact dermatitis caused by isocyanates. Contact Dermatitis 2002: 47: Hannu T, Estlander T, Jolanki R. Allergic contact dermatitis due to MDI and MDA from accidental occupational exposure. Contact Dermatitis 2005: 52: Frick-Engfeldt M, Isaksson M, Zimerson E, Bruze M. How to optimize patch testing with diphenylmethane diisocyanate. Contact Dermatitis 2007: 57: Aalto-Korte K, Henricks-Eckerman M L, Kuuliala O, Jolanki R. Occupational methacrylate and acrylate allergy cross-reactions and possible screening allergens. Contact Dermatitis 2010: 63: Dahlquist I, Fregert S. Formaldehyde releasers. Contact Dermatitis 1978: 4: Flyvholm M A. Preservatives in registered chemical products. Contact Dermatitis 2005: 53: Lundov M D, Johansen J D, Carlsen B C, Engkilde K, Menné T, Thyssen J P. Formaldehyde exposure and patterns of concomitant contact allergy to formaldehyde and formaldehyde-releasers. Contact Dermatitis 2010: 63: de Groot A, White I R, Flyvholm M A, Lensen G, Coenraads P J. Formaldehyde-releasers in cosmetics: relationship to formaldehyde contact allergy. Contact Dermatitis 2010: 62: Contact Dermatitis, 67,