Occupational dermatitis in hairdressers: do they claim workers compensation?

Contact Dermatitis Original Article COD Contact Dermatitis Occupational dermatitis in hairdressers: do they claim workers compensation? Georgina Lyons 1, Tessa Keegel 2,3, Amanda Palmer 1 and Rosemary Nixon 1 1 Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation, 3053 Melbourne Australia, 2 Monash Centre for Occupational and Environmental Health, Monash University, 3181 Melbourne, Australia, and 3 McCaughey Centre, Melbourne School of Population Health, The University of Melbourne, 3181 Melbourne, Australia doi:10.1111/j.1600-0536.2012.02152.x Summary Background. Hairdressers are one of the largest occupational groups attending our Occupational Dermatology Clinic. However, few seek workers compensation for their occupational dermatitis. Objectives. To retrospectively analyse and compare workers compensation claims data and diagnosed disease data for occupational contact dermatitis in hairdressers from 1993 to 2009, for the state of Victoria, Australia. Patients/materials/methods. Data from the Occupational Dermatology Clinic database, the Compensation Research Database and the Australian Bureau of Statistics were used in this study. Results. The clinic database identified 157 hairdressers and apprentices with a confirmed diagnosis of occupational contact dermatitis assessed between 1993 and 2009. Forty-six unique claims for occupational contact dermatitis from 46 individuals were identified from the Compensation Research Database over the same time period. Hairdressers in the 15 24-year age group were significantly over-represented in the claims data relative to the diagnosed disease data (p <0.01). The median cost per claim was AU$1421, and the median time off work per claim was 20 days. Conclusion. Increased efforts are needed to reduce the incidence of occupational contact dermatitis in hairdressers in Australia, and to ensure that hairdressers with occupational contact dermatitis are aware of their compensation entitlements. Reliance on workers compensation data for disease surveillance may lead occupational health and safety regulators to underestimate the magnitude of the problem of occupational contact dermatitis in the hairdressing profession. Key words: allergy; apprentice; hair dye; hand eczema; irritant; patch testing; p-phenylenediamine; workers compensation. Occupational contact dermatitis (OCD) is one of the most common work-related diseases in the developed Correspondence: Rosemary Nixon, 1/80 Drummond Street, Carlton, Victoria 3053, Australia. Tel: +61 3 9623 9400; Fax: +61 3 9639 3575. E-mail: rnixon@occderm.asn.au Conflicts of interest: The authors have declared no conflicts of interest. This research was supported by funding of a Development Grant from WorkSafe Victoria and the Transport Accident Commission (TAC), through the Institute for Safety, Compensation and Recovery Research (ISCRR). Accepted for publication 7 July 2012 world (1 3). The Spot study performed by our group in 2005 reported an OCD incidence rate of 20.5 cases per 100 000 workers for the state of Victoria, Australia (4). Hairdressing has long been associated with OCD. In 1898, Cathelineau described 18 cases of occupational dermatitis in French hairdressers caused by p-phenylenediamine (5). The sensitization of hairdressers by p-phenylenediamine was considered to be such a significant public health concern that the substance was prohibited in Germany in 1906, and later in Sweden in 1943 and France in 1951 (5). In more recent times, OCD prevalence rates as high as 50% have been reported in Contact Dermatitis, 68, 163 168 163

the hairdressing profession (6), and several studies have identified hairdressing as the highest-risk occupation for OCD (1, 7, 8). Skin problems tend to present early in a hairdresser s career, and it would appear that many hairdressers are unaware of, and ill-equipped to manage, the skin hazards inherent in their occupation (9 11). Wet-work, chemical irritants (including shampoos, cleaning agents, and hydrogen peroxide), and physical factors, such as sweating and exposure to heat from hair drying, all have deleterious effects on the skin barrier (12, 13) and can lead to the development of irritant contact dermatitis. Exposure to allergens, often following the development of irritant contact dermatitis, can result in sensitization. Commonly encountered allergens in hairdressing include p-phenylenediamine in hair dye, glyceryl monothioglycolate and ammonium thioglycolate in perming solutions, ammonium persulfate in hairdressing bleach, fragrances and preservatives (e.g. formaldehyde) in hair care products, and rubber accelerators (e.g. thiurams, mercaptobenzothiazoles, and carbamates) in gloves (8, 13). Unlike in most other professions, allergic contact dermatitis is more common than irritant contact dermatitis in the hairdressing profession (8, 10, 14). OCD in Hairdressers and Workers Compensation In most developed countries, employees with OCD are eligible for workers compensation. This is often likely to involve time away from work with avoidance of exposure to occupational irritants and allergens, which is often critical for skin healing. The provision of financial compensation helps to reimburse treatment costs and loss of income. Even when no time off work is required, successful claimants are reimbursed for the costs of treatments, including medical fees and pharmaceutical agents. Lodging a workers compensation claim has the secondary benefit of alerting insurers and regulators to the occurrence and impact of occupational disease; however, according to the literature, workers compensation datasets typically under-report the frequency of occupational skin disease (2, 3, 15, 16). There have been no studies examining the relationship between the incidence of OCD in hairdressers and the number of workers compensation claims for OCD in hairdressers in Australia. We wished to investigate whether the high number of OCD cases seen in hairdressers and hairdressing apprentices at a tertiary referral occupational dermatology clinic in Victoria, Australia would be accurately reflected in workers compensation data for the same region (the state of Victoria), and whether trends over time would correlate between the two datasets. Methods We searched the Occupational Dermatology Clinic database for all hairdressers who had attended the Occupational Dermatology Clinic between January 1993 and December 2009, diagnosed with significantly workrelated OCD by the clinic occupational dermatologist (R. Nixon). This included hairdressers with a diagnosis of allergic contact dermatitis, irritant contact dermatitis or contact urticaria related to exposure to latex or ammonium persulfate. All patients attending the Occupational Dermatology Clinic were tested to the extended European baseline series (Chemotechnique Diagnostics, Vellinge, Sweden), hairdresser series, as well as the workers own samples, appropriately diluted. Patch tests were applied with Finn Chambers on Scanpor tape (Epitest, Tuusula, Finland), and were removed after 48 hr, with test readings performed on day 2 and day 4. On day 4, the diagnosis was discussed with the patient, including its work-relatedness, and their eligibility to apply for workers compensation. If they indicated their willingness to submit a worker s compensation claim, a Certificate of Capacity was completed, which is essential for the initiation of a worker s compensation claim in Victoria. Occupational Dermatology Clinic Database The Occupational Dermatology Clinic database contains demographic, clinical, patch testing and diagnostic data for all patients seen at the Occupational Contact Dermatitis clinic, based at the Skin and Cancer Foundation, Melbourne, Australia. Individuals working in the Hairdressing or Beauty industry presenting at the clinic between 1 January 1993 and 31 December 2009 inclusive were selected from the Occupational Dermatology Clinic database. Individual records were then reviewed to select only those working as hairdressers or hairdressing apprentices at the time of their clinical appointment, and only incident cases were included. Year of diagnosis, sex, age, hairdresser or apprentice status, and body site of initial dermatitis were also sourced from the Occupational Dermatology Clinic database. Compensation Research Database The Compensation Research Database contains workers compensation claims data for the state of Victoria, Australia, between 1 January 1986 and 31 December 2009. For the purposes of this study, we restricted claims to those lodged between 1 January 1993 and 31 December 2009, the same period as for the data extracted from the clinic database. We qualitatively checked any records 164 Contact Dermatitis, 68, 163 168

that were classified as hairdressers employed in industries other than hairdressing (e.g. contract staff services and education), and assessed these as legitimate claims from hairdressing employees. Descriptive analyses were undertaken for both the Occupational Dermatology Clinic database and Compensation Research Database datasets by year of claim/year of diagnosis, sex, age, initial site of dermatitis, and whether or not the individual was a qualified hairdresser or an apprentice. For the Compensation Research Database workers compensation claims, the total days away from work, employer segment (based on the employer s annual turnover: small, <$1 million; medium, $1 million to $20 million; large, >$20 million; and government) and total cost per claim (reported in 2009 Australian dollar equivalent values) were also obtained. The incidence rate for the clinic data and the claims rate for the workers compensation data were calculated as rate equals number of new cases or claims/population at risk in a period of time using the midpoint year method (17). The number of persons in Victoria employed as hairdressers from the midpoint year 2001 as reported by the Australian Bureau of Statistics Census 2001 (18) was used as the denominator. Where appropriate, categorical variables were compared by use of the two sample test of proportions. Significance was set at 0.05, and all tests were two-sided. All analyses were performed with STATA v11.2 and SPSS v18.0. The study was approved by the Human Research Ethics Committee based at Monash University (HREC CF11/2190 2011001218). Results The Occupational Dermatology Clinic database identified 156 hairdressers with a diagnosis of significantly workrelated OCD assessed between 1 January 1993 and 31 December 2009. According to the Compensation Research Database workers compensation data, between 1 January 1993 and 31 December 2009, there were 46 hairdressers who had successful workers compensation claims for OCD. There were no repeat claims over this time period. Table 1 provides demographic and occupational characteristics of the study participants who had successful workers compensation claims for occupationally related dermatitis. The proportion of workers in the 15 24-year age group claiming workers compensation was significantly higher than that in the clinic data (p <0.01). The total time away from work across all claims, as recorded by the Compensation Research Database, was 2648 days. The median time away from work per claim was 20 days (i.e. 4 working weeks), and the highest amount of time off work reported for an individual claim was 642 days. According to the Compensation Research Database, only one hairdresser who had a successful worker s compensation claim had no days off work. The total recorded cost of all workers compensation claims for hairdressers with OCD between 1 January 1993 and Table 1. Demographic and employment variables Diagnosed disease data (Occupational Dermatology Clinic database) % Workers compensation data (Compensation Research Database) % p-value Sex 156 46 Females 150 96 42 91 Males 6 4 4 9 0.1771 Age group (years) 15 24 108 68 41 89 <0.01 25 34 30 19 5 11 0.2062 35 44 12 8 0 0 45 54 4 3 0 0 55 2 1 0 0 Employment status Apprentice status 70 45 14 30 Hairdresser/other 86 55 32 70 0.07 Employer segment NA Government 1 1 Medium 4 9 Small 41 89 NA, not available. Two-sample test of proportions. Contact Dermatitis, 68, 163 168 165

Table 2. Rate of diagnosis versus rate of workers compensation claims for hairdressers with occupational contact dermatitis (Victoria, Australia) Occupational Dermatology Clinic database No. of diagnoses/ year Rate of diagnosis (per 100 000 hairdressers/year) Compensation Research Database No. of claims/ year Claims rate (per 100 000 hairdressers/year) 1993 8 78.4 3 29.4 1994 10 98.0 4 39.2 1995 8 78.4 3 29.4 1996 8 78.4 4 39.2 1997 7 68.6 4 39.2 1998 6 58.8 1 9.8 1999 5 49.0 0 0 2000 6 58.8 3 29.4 2001 9 88.2 3 29.4 2002 12 117.6 3 29.4 2003 11 107.8 1 9.8 2004 17 166.6 4 39.2 2005 11 107.8 3 29.4 2006 17 166.6 4 39.2 2007 9 88.2 2 19.6 2008 6 58.8 0 0 2009 6 58.8 4 39.2 31 December 2009 was AU$427 080. The median cost per claim was $1421, and the highest individual claim was AU$68 575. Of the workers compensation claimants, 41 hairdressers were employed in small enterprises, 4 were employed in medium enterprises, and 1 was employed in government. The upper limbs (hands and/or arms) were the most common initial site of dermatitis for hairdressers with OCD in both the clinical and workers compensation data, comprising 132 (85%) and 38 (83%) cases respectively. Table 2 and Fig. 1 show the rate of diagnosis and the rate of workers compensation claims for OCD per 100 000 part-time and full-time employed hairdressers per year. Discussion Over the 17-year study period, 156 hairdressers were diagnosed with significantly work-related OCD at the Occupational Dermatology Clinic. In order to present to the clinic, the majority had seen a general practitioner, been referred to a dermatologist, and then subsequently been referred to the Occupational Dermatology Clinic (19). Interestingly, however, only 46 hairdressers claimed workers compensation for OCD over this time period in the state of Victoria, less than one-third of the number of cases diagnosed in our clinic. Number of diagnoses/claims per 100 000 hairdressers 180 160 140 120 100 80 60 40 20 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Diagnostic rate Year Workers' compensation claims rate Fig. 1. Diagnostic and workers compensation claims rates for occupational contact dermatitis in hairdressers, Victoria, Australia. This discrepancy between the high number of cases of OCD diagnosed in hairdressers and the low number of hairdressers with OCD filing for workers compensation corroborates findings in the United Kingdom (20) and Denmark (21, 22), and there are probably several contributory factors. Many hairdressers appear to tolerate OCD to a certain extent, and, indeed, many consider the condition to be part of the job (22), especially as contact dermatitis does not preclude continued work in most cases (23). Demographics may also play a role in the low rate of OCD workers compensation claims in hairdressers. Most hairdressers are female, and women have been shown to be significantly less likely than men to seek workers compensation for any condition (2, 3, 20, 24, 25). The literature suggests that OCD is more common in women than in men, and that women report more discomfort from the symptoms of OCD (20), but the majority of claimants for OCD in workers compensation datasets are male (2, 3). Many hairdressers are selfemployed or work in small businesses, and are less likely to claim (20). Self-employed hairdressers who do not employ staff may not be covered by the WorkCover workers compensation scheme of Victoria (24), and so will not be represented in the workers compensation claims data. A lack of awareness of eligibility to claim workers compensation may be a factor in the low rate of workers compensation claims for OCD in hairdressers (22). The phenomenon of under-reporting for fear of job loss is also well recognized in occupational disease, and is particularly relevant when job markets become restricted 166 Contact Dermatitis, 68, 163 168

(e.g. in times of recession) (3). Other reporting disincentives include the time and inconvenience involved in filing a claim (22), especially for those whose work does not generally involve writing (24). Part-time workers cite current and future job security as a major reason for not seeking workers compensation for their occupational disease (24). Another reason reported for not seeking workers compensation involves witnessing the claims of co-workers being rejected, as, according to the literature, 13 16% of claims for OCD are rejected (3, 25). Unfortunately, the Compensation Research Database could not provide data on the number of rejected claims for OCD in Victoria. Countries such as Germany have not only reported declining rates of hairdressers dermatitis (7) but have streamlined their processes for assessment of workers with suspected occupational dermatitis, so that they are assessed and treated earlier (26). In such an environment, it is not left to the worker to decide whether to lodge a workers compensation claim. Similarly in Denmark, doctors are obliged by law to report any case of occupational disease to the National Board of Industrial Injuries, which then decides whether financial compensation should be awarded (22). Despite this, a recent register-based study by Lysdal et al. (2011) found that only 20.7% of hairdressers with self-reported occupational hand eczema had a report filed (22). The number of hairdressers with OCD seen in our clinic probably represents the tip of the iceberg in terms of the true incidence in the hairdressing industry, as only a small percentage of hairdressers with OCD are referred to and attend a consultant dermatologist (20). In addition, general practitioners or dermatologists assessing the patient may neglect to enquire about occupational exposures (4), and thus fail to diagnose a work-related condition. In a Canadian study of patients with OCD, Holness (2004) found that both general practitioners and dermatologists took an exposure history in only 5% of cases, despite advising a change of job in 12% and 17% of cases, respectively (27). Furthermore, even if an occupational aetiology is suspected, it may require special investigations (e.g. patch testing) that may not be readily available, especially in rural communities. Thus, the true magnitude of the difference between the incidence of OCD in hairdressers and the number of hairdressers seeking workers compensation for OCD is probably much larger than that reported in this study. The demographics of the clinic and workers compensation cohorts were similar; however, the 15 24-year age bracket was over-represented in the workers compensation data relative to the diagnosed disease data (p <0.01). The hands and/or arms were the most common initial site of dermatitis for both the workers compensation claims and the diagnosed disease data. It is of interest that hairdressing apprentices with OCD appeared to be under-represented in the workers compensation data, comprising only 30% of claimants, while accounting for 45% of diagnosed OCD cases. This finding, however, did not reach statistical significance (p = 0.07). The median time off work for hairdressers with successful workers compensation claims for OCD in this study was four working weeks. This was higher than the median time off work for all OCD workers compensation claims Australia-wide (three working weeks) (28), which suggests a greater severity of OCD in the hairdressers than in other workers, which is, in fact, what we have already observed in our clinic cohort (29). The median cost per claim for hairdressers with OCD (AU$1421) was lower than the national median cost per claim for OCD (AU$2613) (27), which may be a function of lower income rates in hairdressing than in other occupations. Some studies have reported a declining trend in occupational dermatitis workers compensation claims in recent years (3). Table 2 and Fig. 1 show a decline in the rate of diagnosis of OCD in hairdressers in Victoria in recent years, after the rate reached a peak of 166.6 cases per 100 000 part-time and full-time hairdressers in 2004, and again in 2006. The trend in rate of diagnosis does not appear to correlate with the trend in OCD workers compensation claims, which varied little over the study time period. Conclusion Our findings suggest that claim rates reported in workers compensation datasets under-represent the true incidence of diagnosed OCD among hairdressers in Victoria, Australia. This corroborates findings in the United States and Europe. Also, trends over time in the rate of diagnosis of OCD in hairdressers do not appear to correlate with the rate of workers compensation claims for the condition. Hairdressers may accept dermatitis as part of the job, be unaware of their compensation entitlements, or be put off by paperwork. Fear of job loss may act as a reporting disincentive, particularly among apprentices and parttime workers. Occupational health and safety authorities should be aware that workers compensation statistics underestimate the impact of OCD in hairdressing. Ongoing efforts directed towards the prevention and treatment of OCD in the hairdressing profession are indicated, particularly among younger workers. Contact Dermatitis, 68, 163 168 167

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