Patch Testing for Hand Dermatitis-20 years Experience Chun-Hsuan Ho Chee-Ching Sun Mei-Ping Tseng Chia-Yu Chu

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1 Patch Testing for Hand Dermatitis-20 years Experience Chun-Hsuan Ho Chee-Ching Sun Mei-Ping Tseng Chia-Yu Chu Hand dermatitis is the most frequently recognized occupational skin disease. Comprehensive understanding of the epidemiology of hand dermatitis is crucial to be able to make a correct diagnosis or give appropriate recommendations for its management. From 1983 to 2002, among those referred to Contact Clinic at National Taiwan University Hospital, a total of 2568 patients were patch-tested. We recruited 716 cases of hand dermatitis with relevant contact history. After interview following a standardized questionnaire, patch testing with the European standard series and suspected allergens was administered. Among the 716 patients with hand dermatitis, the peak age group of male was years of age and that of female was years of age. Forty-eight percent (60.1 in men and 42.6 in women) of hand dermatitis was related to occupation. Builder, office workers, housewife, hairdresser and doctor/nurse/healthcare professionals were the most common types of occupation. Allergic contact dermatitis accounted for 38.2 in males and 33.5 in females. Overall, including occupational and non-occupational hand dermatitis, potassium dichromate and nickel sulphate were the first-rank allergens in male and female patients, respectively. (Dermatol Sinica 24: , 2006) Key words: Hand dermatitis, Occupational dermatitis, Epidemiology potassium dichromate nickel sulphate ( 24: , 2006) From the Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan Accepted for publication: March 28, 2006 Reprint requests: Chia-Yu Chu, M.D., Department of Dermatology, National Taiwan University Hospital, 7, Chung-Shan South Road Taipei, Taiwan TEL: FAX: chiayuju@seed.net.tw 238 Dermatol Sinica, Dec 2006

2 Hand dermatitis (HD) is a very common disease at contact dermatitis clinics. According to our previous study, it was also the most frequent occupational dermatoses in Taiwan. 1 In some working environments, the hand skin is vulnerable to damage resulted from contact with irritants or allergens. In the most patients, this troublesome skin disease may disturb their life activities and affects the working performance enormously. HD is often the result of a combination of factors and can be difficult to diagnose despite a thorough history and physical examinations. As being well-trained dermatologists, it is necessary for us to have a comprehensive understanding of this important problem in our daily practice. Many epidemiological studies have investigated the prevalence of HD in the general population. 2-8 It is indeed difficult to make a conclusion or comparison between these studies due to differences in the selected populations, such as race, work, gender, and age, but the statistical information from these descriptive research really indicate abundant background knowledge about the clinical management of HD. However, the epidemiology of HD in Taiwan is unknown. There is lack of practical or statistical information that helps us to have better management of HD and refine our treatment. In this retrospective study, we recruited those cases of HD with highly suspected allergic contact dermatitis (ACD) seen at the National Taiwan University Hospital (NTUH) s Contact Clinic with HD over a 20-year period. The aim of this article is to define the demographic features, such as age and sex; clinical presentations including history of HD, atopy history, common allergens, final diagnosis and relevance of occupation of this tertiary referral population. MATERIALS AND METHODS Patients All patients were referred to our clinic by certificated dermatologists, occupational physicians or general clinicians, from 1983 to They came from the whole island and included Taiwanese, Hakka, aborigine and immigrants from Mainland China. Among the patients with HD seen in this clinic, suspected cases of contact allergy were included in our study group. After having been interviewed by a dermatologist following a standardized questionnaire, the patients data, e.g., sex, age, diagnosis, associated symptoms, history of HD and relevance of occupation or life style, had been carefully recorded during this period. We retrospectively reviewed all the reports and clinical pictures of these patients. Patch testing Patch testing was performed with the European standard series, and extended trays were added according to possible exposure at work. The tests were applied to Finn Chambers (Epitest Ltd., Helsinki, Finland), which were fixed to the upper back of each individual with Scanpor tape by 3M tapes. The patches were removed after 2 days and the sites were examined for evidence of reaction at 2, and 3 or 4 days after the initial application. The reading at 3 or 4 days was considered positive if the reaction was equal to or stronger than a palpable erythema, according to the guidelines of the International Contact Dermatitis Research Group (ICDRG). 9 Statistics Besides being saved in the questionnaires, all these outcomes were summarized as a numerical code and keyed into the database of the computer server. We used Student s t-test for comparison of the frequency of hand dermatitis, diagnosis or occupations between different groups. The demographic data of all patients and X2 test for analyzing statistical significance of gender difference were calculated by SAS software (version 8.01, SAS Institute, Cary, N.C., USA). RESULTS Demographic data During this 20-year period, a total of 2568 patients seen at the Contact Clinic have received patch testing. Among them, we recruited 716 cases (28 ) with hand dermatitis that Dermatol Sinica, Dec

3 were highly suspected to have ACD. The man to woman ratio was 0.74 (304/412) and the age of patients ranged from 3 to 75 years old. Furthermore, the mean age of men with HD (40.2 years) was significantly greater than that of women with HD (32.1 years) (p < ). With Student s t-test, comparison of the results of two gender groups showed there was a significant difference in age distribution between male and female patients. The peak age group of male was years and that of female was years. Overall, the incidence of HD in this population diminished after 50 years of age. The gender and age of the population with HD are listed in Table 1. Patch testing results and clinical features Among the 716 patients in this study, HD was diagnosed most frequently as ACD followed by irritant contact dermatitis (ICD). In order of frequency, the five most common diagnoses among the male patients with HD were ACD (38.2%), ICD due to chemicals (19.4%), frictional dermatitis (15.8%), iatrogenic/factitia (11.5%) and others (10.5%). On the contrary, ICD due to water including keratoderma tylodes palmaris progressiva (KTPP) ranked the second in the female population with hand dermatitis (Table 2). In terms of other associated clinical features, the incidence of atopic dermatitis among the entire population evaluated was rela- 240 Dermatol Sinica, Dec 2006

4 Males Females Diagnosis N % Diagnosis N % ACD ACD ICD ICD chemical water friction chemical Iatrogcnic/factitia friction Others Others Total tively low (1.97% in men and 2.67% in women). One-forth to one-third of our patients with HD had a history of hyperhidrosis including generalized type and palmoplantar type (male group 44.3% v.s. female group 26.8%, p=0.0001). Besides, those with concurrent HD and foot lesions (eg. foot eczema and tinea pedis) accounted for 20.2% of male group and 15.4% of female group (p=0.0023). Comparison of the clinical features among the males and Dermatol Sinica, Dec

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6 females was shown in Table 3. In 716 patients of this study, 343 (47.9%) were diagnosed as having occupational hand dermatitis; these patients, consisting of 173 men and 170 women, accounted for 60% of the male group and 43% of the female group, respectively (p=0.0001,table 3). The relative risk of men for the occupational cases was significantly higher than that of Dermatol Sinica, Dec

7 women. The most associated jobs in male patients were builder (21.7%), electronic worker (10.9%), office worker(8.2%),doctor/nurse/dentist/healthcare worker (7.9%), student (4.9%) and hairdresser (4.3%), while those in female patients were office worker (20.6%), housewife (19.4%), hair dresser (12.9%), student (9.5%) and electronic worker (8.0%) (Table 4). Among all patients with HD, we identified positive relevant reactions to 72 substances. The top five allergens for males and females were shown in Table 5. Table 6 ranks the leading allergens responsible for HD in the most associated occupations of men and women. DISCUSSION HD forms approximately a quarter (28%) of 2568 patients patch-tested at our Contact Clinic during this study period. In both men and women, the highest proportion of our HD population consisted of young adults. As age increases, the incidence of HD decreases gradually, except the year age group in males. In this older age group, there was a trend towards more occupational cases and a predominance of men (Table 1). Among these yrs old men, the most frequent types of occupation were farmer and builder. This interesting phenomenon might result from their life style, working exposure and damaged skin barrier function due to aging. Previous studies indicated the prevalence of HD in women to be twice that in men. 10, 11 On the contrary, our data showed a higher man to woman ratio (0.74). This variation between population and clinics could be explained by differences of population between contact clinics and normal populations, the different composition of gender in working population or a gender referral bias. In this study, the proportion of occupational HD in men was significantly higher than that in women (60.1% and 42.6%, respectively, p < 0.001). The results were compatible with other studies with similar patient population Some types of occupation are well known to be associated with HD, such as builder, hairdresser, electronic work and doctor/nurse/healthcare professionales were still predominant in the ranking of jobs (Table 4). However, compared to our previous study in 1995, 1 the prevalence of office workers increased enormously and even ranked as the most frequent type of occupation in female population. This is likely to reflect a trend from manual to non-manual employment, with the substitution of service or computer work for manufacturing jobs over the 20-year period. The most frequently recognized diagnosis was ICD (35.2 in men and 55.7 in women) in this study. That is compatible with the report in Europe. 19, 20 However, a recent study investigating the etiology of HD among patients referred for patch testing in United States revealed the most common cause was ACD (54.4%). 17 A trend of referring patients with suspected ACD for patch testing might be the main cause of this discrepancy. The most common allergens in both men and women were shown in Table 5, respectively. That might reflect the occupational predominance of builders, electronic workers, office workers, housewives and hair dressers in this study population. Some occupations had the specific allergens relevant to hand dermatitis, for example, builder (potassium dichromate), hair dresser (paraphenylenediamine dihydrochloride and fragrance), doctor/nurse (Thiuram and alcohol), electronic worker (industrial chemical) etc. (Table 6). The male population showed a very different pattern, with a significantly higher prevalence of occupational ACD compared to females (38.2 in men and 33.5 in women, p<0.001). We also attributed this to the higher rate of metalworking industry and contact with work tools in male patients. Except the high incidence of medicament allergy, our results are similar to a recent allergen study of 200 patients with hand dermatitis in the United Kingdom. 21 Accompanied with popular aromatherapy, complementary and alternative medicine have been very common in Taiwan for a long period. It is convincing that this traditional custom and cultural differences lead to the higher rate of medicament allergy in Taiwan than in western countries. ICD due to 244 Dermatol Sinica, Dec 2006

8 chemical and water were common and important in men (35.2%) and women (55.7%). ICD due to water including KTPP is a common skin disease of women in Taiwan. We attributed this to their traditional overrepresentation in occupations with increased risks of exposure to wet work (such as hair dresser, health care workers and house wife) or because of domestic chores. In Taiwan, the prevalence of patients with atopic dermatitis (AD) increased rapidly in the recent decade, from 5 to 10%. 24 However, in our study, the prevalence of AD (1.97% in males and 2.67% in females) was relatively lower than those of other epidemiological studies of patients with hand eczema, where the prevalence has been estimated at between 22% and 37%. 25, 26 This significant distinction may be interpreted as that atopic patients were educated to avoid irritants or allergens causing HD. Furthermore, because most of the patients referred to our clinic were suspected cases of ACD, those with a history of atopic dermatitis were prone to be treated rather than patch-tested. This result also indicates that the patients at Contact Clinic were characteristic and quite different from the normal population. Finally, Table 3 showed that the concurrent rate of foot eczema was 20.2% in men group and 15.4% in women group. Among those with concurrent hand and foot eczema, the most frequent diagnoses were pompholyx and ACD, reflecting a higher incidence rate of allergic or atopic diathesis, even though there was lack of comparable data from normal population. Because ACD of the hands and/or feet is common, plenty of difficulties often arise in distinguishing endogenous eczema from contact dermatitis clinically. Therefore, patch testing being of much diagnostic help in these situations. Furthermore, hyperhidrosis (44.3%) seems to be highly associated with HD in male population. Hyperhidrosis might deteriorate the normal barrier function of palmar skin and also make them more vulnerable to soluble allergens. 23 The protocol of diagnosis and management should be specialized and tailored to the occupational factors. Since more than half of HD cases may be related to occupation, a thorough history should be taken by a knowledgeable clinician. Potentially relevant allergens in the workplace must be identified and tested. 17 These allergens may not be contained in standard trays. CONCLUSION This epidemiological study for HD patients receiving patch testing simply reflects a special population referred to Contact Clinic. For specific occupations or population, there may be some expectable discrepancy in the statistical results. However, the establishment of background knowledge in this patient group is informative for dermatologists to identify the differences between male and female patients, as well as the common allergens and occupations for HD with suspected contact allergy. REFERENCES 1. Sun CC, Guo YL, Lin RS: Occupational hand dermatitis in a tertiary referral dermatology clinic in Taipei. Contact Dermatitis 33: , Fregert S, Agrup G, Dahlquist I, et al.: Value of history and testing in suspected contact dermatitis. Arch Dermatol 101: , Peltonen L: Nickel sensitivity in the general population. Contact Dermatitis 5: 27-32, Menne T, Borgan O, Green A: Nickel allergy and hand dermatitis in a stratified sample of the Danish female population: an epidemiological study including a statistic appendix. Acta Derm Venereol 62: 35-41, Coenraads PJ, Nater JP, van der Lende R: Prevalence of eczema and other dermatoses of the hand and arms in the Netherlands. Association with age and occupation. Clin Exp Dermatol 8: , Yngvesson M, Svensson A, Isacsson A: Evaluation of a self-reported questionnaire on hand dermatosis in secondary school children. Acta Derm Venereol 77: , Yngvesson M, Svensson A, Johannison A, et al.: Hand dermatosis in upper secondary school pupils: 2-year comparison and follow-up. Br J Dermatol 142: , Bryld LE, Agner T, Kyvik KO, et al.: Hand eczema in twins: a questionnaire investigation. Br Dermatol Sinica, Dec

9 J Dermatol 142: , Hannuksela M: Epicutaneous testing. Allergy 34: 5-10, Agrup G: Hand eczema and other hand dermatoses in south Sweden. Acta Derm Venereol (Stockh) 49: 1-85, Meding B, Swanbeck G: Prevalence of hand eczema in an industrial city. Br J Dermatol 116: , Smith HR, Armstrong DK, Wakelin SH, et al.: Descriptive epidemiology of hand dermatitis at the St John's contact dermatitis clinic Br J Dermatol 142: , Smith HR, White IR, Rycroft RJ, et al.: Descriptive comparison of isolated hand dermatitis and other populations at St. John's Contact Dermatitis Clinic. Contact Dermatitis 43: 51-52, Li LF, Wang J: Contact hypersensitivity in hand dermatitis. Contact Dermatitis 47: , Nettis E, Colanardi MC, Soccio AL, et al.: Occupational irritant and allergic contact dermatitis among healthcare workers. Contact Dermatitis 46: , Smit HA, Burdorf A, Coenraads PJ: Prevalence of hand dermatitis in different occupations. International Journal of Epidemiology 22: , Templet JT, Hall S, Belsito DV: Etiology of hand dermatitis among patients referred for patch testing. Dermatitis 15: 25-32, Shiao JS, Sheu HM, Chen CJ, et al.: Prevalence and risk factors of occupational hand dermatoses in electronics workers. Toxicology & Industrial Health 20: 1-7, Dirk ME, Debra DF, Kalman L, et al.: Hand dermatitis. J Am Acad Dermatol 47: , Skoet R, Olsen J, Mathiesen B, et al.: A survey of occupational hand eczema in Denmark. Contact Dermatitis 51: , Ruth M, David J G: Contact allergens in 200 patients with hand dermatitis. Contact Dermatitis 48: , Dickel H, Kuss O, Schmidt A, et al.: Occupational relevance of positive standard patch-test results in employed persons with an initial report of an occupational disease. Int Arch Occup Environ Health 75: , Liden C, Bruze M, Menne T. Metals. In.: Textbook of contact dermatitis, Rycroft R J G, Menne T, Frosch P J, Lepoittevin J P, eds, 3rd edition. Springer: Berlin Heidelberg: , Guo YL, Lee CW, Lee YL, et al.: Indoor and outdoor environment, parental atopy, and atopic dermatitis in Taiwanese school children. Epidemiology 16: S57, Bock M, Schmidt A, Bruckner T, et al.: Occupational skin disease in the construction industry. Br J Dermatol 149: , Uter W, Pfahlberg A, Gefeller O, et al.: Risk factor for contact allergy to nickel-results of a multifactoriel analysis. Contact Dermatitis 48: 33-38, Dermatol Sinica, Dec 2006