occdermwoemahpl6 2012.ppt [read-only]contact dermatitis!contact dermatitis (cd) is reported to...

Occupational DermatologyOccupational DermatologyHeather P. Heather P. LampelLampel, MD, MPH, FAAD, MD, MPH, FAAD

Duke UniversityDuke UniversityAssistant Professor of DermatologyAssistant Professor of Dermatology

June 27, 2012June 27, 2012

PLEASE STAND BY - WEBINAR WILL BEGIN AT 12:00pm (Pacific Time)FOR AUDIO: Call: 866-740-1260 / Access Code: 764 4915#

Western Occupational and Environmental Medical AssociationCME Webinar - June 27, 2012

Disclosures

!! SmartHealthSmartHealth"" TRUE TestTRUE Test

!! I will be discussing off-label use ofI will be discussing off-label use ofpatch testing and off-label treatment ofpatch testing and off-label treatment ofcontact dermatitiscontact dermatitis

Objectives!! Emphasize the importance of occupationalEmphasize the importance of occupational

contact dermatitiscontact dermatitis!! Discuss the epidemiology of contactDiscuss the epidemiology of contact

dermatitis in the occupational settingdermatitis in the occupational setting!! Differentiate irritant from allergic contactDifferentiate irritant from allergic contact

dermatitisdermatitis!! Understand the role of patch testing inUnderstand the role of patch testing in

diagnosisdiagnosis!! Explore common occupational allergensExplore common occupational allergens!! Outline treatment options and long-termOutline treatment options and long-term

management of occupational contactmanagement of occupational contactdermatitisdermatitis

Why should we care?

!! Occupational skin disease is a Occupational skin disease is a ““hothot””topictopic

AI-Hoqail R. Use of diesel oil for removal of tar from bitumen burns. Annals of Burns and Fire Disasters. 10:3; September 1997.

Healthy People 2020

““Reduce occupational skin diseases orReduce occupational skin diseases ordisorders among full-time workersdisorders among full-time workers””

http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx

ACOEM Core Competencies-Clinical Dermatology!! OEM physicians canOEM physicians can

provide earlyprovide earlyrecognition, diagnosis,recognition, diagnosis,and management ofand management ofthese disorders andthese disorders andmake necessarymake necessaryrecommendations torecommendations tominimize theirminimize theiroccurrence both in theoccurrence both in theworkplace and at homeworkplace and at home

!! Diagnose primaryDiagnose primaryirritant-inducedirritant-induceddermatosesdermatoses

!! DifferentiateDifferentiateoccupational skinoccupational skindisorders by history,disorders by history,examination, andexamination, anddiagnostic evaluationdiagnostic evaluation

!! Diagnose andDiagnose anddetermine the cause ofdetermine the cause ofallergic contactallergic contactdermatitis (includingdermatitis (includingurticaria), particularlyurticaria), particularlythose caused bythose caused bycommon antigens suchcommon antigens suchas latex, epoxyas latex, epoxymonomer, and nickelmonomer, and nickel

http://www.acoem.org/uploadedFiles/Publications/OEM_Competencies/ACOEM%20OEM%20COMPETENCIES.pdf

ACOEM Core Competencies-Clinical Dermatology (con’t)!! Manage occupational andManage occupational and

environmental skin injuries andenvironmental skin injuries anddermatosesdermatoses

!! Treat and prevent recurrence of contactTreat and prevent recurrence of contactdermatitisdermatitis

http://www.acoem.org/uploadedFiles/Publications/OEM_Competencies/ACOEM%20OEM%20COMPETENCIES.pdf

Epidemiology of OccupationalContact Dermatitis

http://www.pennmedicine.org/encyclopedia/em_PrintArticle.aspx?ptid=1&gcid=000869

Contact Dermatitis

!! Contact dermatitis (CD) is reported to accountContact dermatitis (CD) is reported to accountfor up to 30% of all occupational disease infor up to 30% of all occupational disease inindustrialized nationsindustrialized nations

!! CD is the most common occupational skinCD is the most common occupational skindisorderdisorder"" About 90-95% of all cases of occupational skinAbout 90-95% of all cases of occupational skin

diseasesdiseases

Occupational ContactDermatitis Epidemiology!! Incidence rate of 0.5-1.9 cases per 1000 full-Incidence rate of 0.5-1.9 cases per 1000 full-

time workers per yeartime workers per year!! 1 year prevalence estimate of 10%1 year prevalence estimate of 10%!! Lifetime prevalence rate of 20%Lifetime prevalence rate of 20%!! Likely underestimated due to underreportingLikely underestimated due to underreporting

"" Mild cases specificallyMild cases specifically

Occupational ContactDermatitis Epidemiology!! HandsHands are usually involved are usually involved

"" 80-90% of cases80-90% of cases"" Great impact on Great impact on quality of lifequality of life

!! True epidemiologic data are lackingTrue epidemiologic data are lacking"" No standardization of data, methods of collectionNo standardization of data, methods of collection"" UnderreportingUnderreporting

Occupational ContactDermatitis Epidemiology!! US Bureau of Labor Statistics 2000 estimatedUS Bureau of Labor Statistics 2000 estimated

41,800 cases of Occupational CD41,800 cases of Occupational CD!! This is felt to be underreportedThis is felt to be underreported

"" Estimates are closer to 400,000 to 2 million casesEstimates are closer to 400,000 to 2 million casesper yearper year

!! 1985 Mathias estimated annual costs of1985 Mathias estimated annual costs ofOccupational CD to be between $222 millionOccupational CD to be between $222 millionand $1 billionand $1 billion

Occupational ContactDermatitis Epidemiology!! Survey of established cases of OccupationalSurvey of established cases of Occupational

CD, reported that over one year:CD, reported that over one year:"" 19.9% reported prolonged sick leave19.9% reported prolonged sick leave"" 23% experienced job loss23% experienced job loss

What percent of all contactdermatitis is allergic versusirritant?

Contact Dermatitis Overview

!! IrritantIrritant contact dermatitis accounts for contact dermatitis accounts for60-80%60-80% of all CD of all CD

!! AllergicAllergic contact dermatitis accounts for contact dermatitis accounts forremaining remaining 20-40%20-40%


!! ACD is a SPECIFIC immunologicACD is a SPECIFIC immunologicreaction, requiring prior sensitizationreaction, requiring prior sensitization

Image from: www.dermnet.com

Immunology of Allergic ContactImmunology of Allergic ContactDermatitisDermatitis

Elliott G and Das PK. Using p-Phenylenediamine: A Gateway to Chemical Immunology. Journal of Investigative Dermatology (2010) 130, 641–643.


!! 90% of the population can be sensitized90% of the population can be sensitizedto certain antigens such asto certain antigens such asdinitrochlorobenzenedinitrochlorobenzene


!! What percent of North AmericanWhat percent of North AmericanCaucasian adults are allergic to RhusCaucasian adults are allergic to Rhusantigen?antigen?"" 25%25%"" 40%40%"" 60%60%"" 75%75%

www.duke.eduwww.gmcsc.orgwww.ohio-nature.com


!! IrritantIrritant contact dermatitis is contact dermatitis isNONSPECIFICNONSPECIFIC

!! Requires no prior sensitizationRequires no prior sensitization!! Clinically can be difficult to distinguishClinically can be difficult to distinguish

ICD from ACDICD from ACD

http://www.skincareguide.ca/glossary/i/irritant_contact_dermatitis.html

Common OccupationalIrritants!! AlkalisAlkalis

"" SoapsSoaps"" DetergentsDetergents"" CleansersCleansers

!! AcidsAcids

!! HydrocarbonsHydrocarbons"" PetroleumPetroleum"" OilsOils

!! SolventsSolvents

Common OccupationalIrritants!! Frictional DermatitisFrictional Dermatitis

!! Repetitive handlingRepetitive handlingof objects orof objects ormaterialsmaterials

!! LikelyLikelyunderappreciatedunderappreciated

!! ExamplesExamples!! FabricFabric!! PaperPaper!! Metal objectsMetal objects!! DrivingDriving

Common OccupationalIrritants!! GlovesGloves

!! Prolonged contact with skin affects theProlonged contact with skin affects theepidermal barrierepidermal barrier

!! May be irritant itselfMay be irritant itself!! May make epidermal barrier moreMay make epidermal barrier more

susceptible to allergens or other irritantssusceptible to allergens or other irritants

Ramsing DW, Agner T: Effect of glove occlusion on human skin (II). Long-term experimental exposure. Contact dermatitis 1996; 34:258-62.

ACD vs ICD

Feature ACD ICD

Pain, burning ++ ++++(Early)

Erythema ++++ ++++

Vesicles ++++ +

Pustules + +++

Hyperkeratosis ++ ++++

Itch ++++(Early) +++(Late)

ACD vs ICD

Feature ACD ICDFissuring ++ ++++

Sharp demarcation Yes Yes

Necrotic keratinocytes + +++

Dermal Edema ++++ ++++

Lymphocytic infiltrate ++++ ++++

Neutrophilic infiltrate + +++

Photo Quiz

Allergic or Irritant Contact Dermatitis?Allergic or Irritant Contact Dermatitis?

Allergic or Irritant?

Dermaamin.com

Irritant

Dermaamin.com


http://hardinmd.lib.uiowa.edu/pictures22/dermnet/contact_dermatitis_04rhus080105.jpg

Allergic

http://hardinmd.lib.uiowa.edu/pictures22/dermnet/contact_dermatitis_04rhus080105.jpg


Skincareguide.com

Irritant

Skincareguide.com

Allergic


http://www.cdc.gov/niosh/topics/skin/occderm-slides/ocderm10.html

Allergic and Irritant

http://www.cdc.gov/niosh/topics/skin/occderm-slides/ocderm10.html

Debunking the myths…

webseoanalytics.com

CD Misconceptions

!! Allergy only develops to newAllergy only develops to newexposures/productsexposures/products

CD Misconceptions

!! Allergy only develops to newAllergy only develops to newexposures/productsexposures/products"" FALSEFALSE"" Allergy can develop after years of using theAllergy can develop after years of using the

same productsame product

CD Misconceptions

!! If a change in chemical/productIf a change in chemical/productexposure does not clear the rash, thatexposure does not clear the rash, thatproduct is not etiologicproduct is not etiologic

CD Misconceptions

!! If a change in chemical/productIf a change in chemical/productexposure does not clear the rash, thatexposure does not clear the rash, thatproduct is not etiologicproduct is not etiologic"" FALSEFALSE"" There are many cross-reactants in otherThere are many cross-reactants in other

products, it is best to have NO exposuresproducts, it is best to have NO exposuresto topicals/cross-reactors when clearing ato topicals/cross-reactors when clearing arashrash

CD Misconceptions

!! If product exposure is bilateral, theIf product exposure is bilateral, theeruption should be bilateraleruption should be bilateral

CD Misconceptions

!! If product exposure is bilateral, theIf product exposure is bilateral, theeruption should be bilateraleruption should be bilateral"" NOT NECESSARILYNOT NECESSARILY"" Common misconception held by MDsCommon misconception held by MDs"" There are many aspects affecting end-There are many aspects affecting end-

product eruptionproduct eruption

CD Misconceptions

!! ACD is NOT patchy- it is usually theACD is NOT patchy- it is usually thesame intensity at all areas of exposuresame intensity at all areas of exposure

CD Misconceptions

!! ACD is NOT patchy- it is usually theACD is NOT patchy- it is usually thesame intensity at all areas of exposuresame intensity at all areas of exposure"" FALSEFALSE"" Again, many factors affect the presentingAgain, many factors affect the presenting

eruption patterneruption pattern

CD Misconceptions

!! Adult onset Adult onset ““eczemaeczema””

CD Misconceptions

!! Adult onset Adult onset ““eczemaeczema””"" If no history of eczema as a child, likelyIf no history of eczema as a child, likely

ACDACD"" Especially if on hands, face, neckEspecially if on hands, face, neck

“The greatest abuse of patchtesting is failure to use the test.”!! Coleman, 1982Coleman, 1982

Patch testing

!! Intended to detect allergens relevant toIntended to detect allergens relevant toeruptioneruption

!! Is at least a week-long processIs at least a week-long process!! Detects Type IV allergic reactionDetects Type IV allergic reaction

(delayed-type hypersensitivity)(delayed-type hypersensitivity)!! Requires at least 2-3 visits to clinic forRequires at least 2-3 visits to clinic for

complete testingcomplete testing

T.R.U.E. Test

!! Thin-layer Rapid Use EpicutaneousThin-layer Rapid Use EpicutaneousTestTest

!! Allerderm productAllerderm product!! Only FDA-approved patch testingOnly FDA-approved patch testing

productproduct!! 29 allergens with an additional 729 allergens with an additional 7

recently FDA-approvedrecently FDA-approved!! Comes pre-filledComes pre-filled

T.R.U.E. Test!! Nickel SulfateNickel Sulfate!! Wool AlcoholsWool Alcohols!! Neomycin SulfateNeomycin Sulfate!! Potassium DichromatePotassium Dichromate!! Caine MixCaine Mix!! Fragrance MixFragrance Mix!! ColophonyColophony!! Paraben MixParaben Mix!! Negative ControlNegative Control!! Balsam of PeruBalsam of Peru!! EthylenediamineEthylenediamine

DihydrochlorideDihydrochloride!! Cobalt DichlorideCobalt Dichloride

!! p-tert-Butylphenolp-tert-ButylphenolFormaldehyde ResinFormaldehyde Resin

!! Epoxy ResinEpoxy Resin!! Carba MixCarba Mix!! Black Rubber MixBlack Rubber Mix!! Me- Cl- IsothiazolinoneMe- Cl- Isothiazolinone

(MCI/MI)(MCI/MI)!! Quaternium-15Quaternium-15!! MercaptobenzothiazoleMercaptobenzothiazole!! p-Phenylenediaminep-Phenylenediamine!! FormaldehydeFormaldehyde!! Mercapto MixMercapto Mix!! ThimerosalThimerosal!! Thiuram MixThiuram Mix

T.R.U.E. Test!! Diazolidinyl ureaDiazolidinyl urea!! Imidazolidinyl ureaImidazolidinyl urea!! BudesonideBudesonide!! Tixocortol-21-Tixocortol-21-

pivalatepivalate!! Quinoline mixQuinoline mix

Dermnetnz.org

TRUE versus Chamber

!! TRUE testing is helpful, but manyTRUE testing is helpful, but manypatients have at least one relevantpatients have at least one relevantallergen not detected by TRUE testingallergen not detected by TRUE testing

!! Consider referral for more extensiveConsider referral for more extensivepatch testing if no improvementpatch testing if no improvement

Patch testing

!! Step 1: Take extensive exposure historyStep 1: Take extensive exposure history"" Include home exposures, work tasks andInclude home exposures, work tasks and

exposures, implants, intermittentexposures, implants, intermittentexposures, MSDS if appropriateexposures, MSDS if appropriate

!! Step 2: Determine allergen panelStep 2: Determine allergen panel"" Would be pre-determined if only TRUEWould be pre-determined if only TRUE

Test is availableTest is available

Patch testing

!! Step 3: Prepare allergen tray asStep 3: Prepare allergen tray asappropriateappropriate"" TRUE test is pre-preparedTRUE test is pre-prepared

Patch testing

!! Step 4: Apply patches to backStep 4: Apply patches to back"" Back must be clear of rashBack must be clear of rash"" Patches are markedPatches are marked"" Securing paper tape is usedSecuring paper tape is used

Patch testing

!! Step 5: Patches removed in 48 hoursStep 5: Patches removed in 48 hours"" Variability in how this is doneVariability in how this is done"" Areas remarkedAreas remarked"" Reactions noted- IrritantReactions noted- Irritant

Patch testing

!! Step 6: Patches read at 3-7 days afterStep 6: Patches read at 3-7 days afterapplicationapplication"" Our clinic reads at 4 daysOur clinic reads at 4 days"" Consider delayed read for late reactorsConsider delayed read for late reactors

Patch testing

!! Step 7: Determine clinical relevanceStep 7: Determine clinical relevance"" Consider the Mathias Criteria for OccupationalConsider the Mathias Criteria for Occupational

casescases!! Excellent tool for ascertaining occupational causationExcellent tool for ascertaining occupational causation

"" Keep in mind that irritant CD remains a diagnosisKeep in mind that irritant CD remains a diagnosisof exclusion, and dermatitis may be both ICD andof exclusion, and dermatitis may be both ICD andACD, multifactorial, etc.ACD, multifactorial, etc.

Mathias CG. Contact dermatitis and workers’ compensation: criteria for establishing occupationalCausation and aggravation. J Am Acad Dermatol 1989; 20(5):842-8.

Patch testing

!! Step 8: Instruct in avoidance of allergen(s) and cross-Step 8: Instruct in avoidance of allergen(s) and cross-reactorsreactors"" If in topical medicaments, cosmetics, etc. it is best to printIf in topical medicaments, cosmetics, etc. it is best to print

out the CAMP out the CAMP ““safe listsafe list””!! On American Contact Dermatitis Society member webpageOn American Contact Dermatitis Society member webpage!! Mayo Clinic also has a databaseMayo Clinic also has a database

"" Also consider all objects that may contain allergenAlso consider all objects that may contain allergen"" Information (written) and verbal counseling of patient is KEYInformation (written) and verbal counseling of patient is KEY"" May include modified work, increased or alternative PPE,May include modified work, increased or alternative PPE,

modified environment- both home and workmodified environment- both home and work


Mathias Criteria

1.1. Is the Is the clinical appearance consistentclinical appearance consistent with withcontact dermatitis?contact dermatitis?

2.2. Are there Are there workplace exposuresworkplace exposures to potential to potentialcutaneous irritants or allergens?cutaneous irritants or allergens?

3.3. Is the Is the anatomic distributionanatomic distribution of the dermatitis of the dermatitisconsistent with cutaneous exposure inconsistent with cutaneous exposure inrelation to work tasks?relation to work tasks?

4.4. Is there a Is there a temporal associationtemporal association between betweenonset of dermatitis and exposure consistentonset of dermatitis and exposure consistentwith contact dermatitis?with contact dermatitis?


Mathias Criteria

5.5. Are Are non-occupational exposuresnon-occupational exposuresexcludedexcluded as probable causes? as probable causes?

6.6. Does dermatitis Does dermatitis improve away fromimprove away fromworkwork exposure to the suspected exposure to the suspectedallergen or irritant?allergen or irritant?

7.7. Do patch or provocation Do patch or provocation tests identifytests identifya probable a probable causal agentcausal agent??


Mathias Criteria

!! Answer of Answer of ““yesyes”” to to 4 or more4 or more of the 7 of the 7criteria yields a criteria yields a greater than 50%greater than 50%probability of occupational causeprobability of occupational cause

!! Provides a Provides a ““reasonable degree ofreasonable degree ofmedical certaintymedical certainty””


Pearls Regarding Patch Testing

!! Do NOT test when dermatitis anywhereDo NOT test when dermatitis anywhereis acute or severeis acute or severe"" Leads to angry back syndromeLeads to angry back syndrome"" Worsening of existing dermatitisWorsening of existing dermatitis

http://dermnetnz.org/procedures/patch-tests.html


!! Do NOT test when dermatitis is presentDo NOT test when dermatitis is presenton the backon the back

http://www.rash-pictures.com/279-dermatitis-back-man.html


!! What about What about medicationsmedications??"" Wait at least 1 week after d/c of oralWait at least 1 week after d/c of oral

steroidssteroids"" If unable to stop oral steroids, taper toIf unable to stop oral steroids, taper to

10mg/day or less, may cause false-10mg/day or less, may cause false-negative rxnnegative rxn

"" Do not test within 2 weeks of using topicalDo not test within 2 weeks of using topicalsteroids on backsteroids on back

"" Systemic antihistamines do not interfereSystemic antihistamines do not interferewith resultswith results


!! What about What about sunburnsunburn??"" Do not test back within 1-2 weeks ofDo not test back within 1-2 weeks of

sunburn (false-negatives are possible)sunburn (false-negatives are possible)

Wikipedia.org


!! What about What about hairy backshairy backs??"" The patient will need to shave 24-48 hoursThe patient will need to shave 24-48 hours

PRIOR to patch applicationPRIOR to patch application!! DO NOT shave in the office prior to placingDO NOT shave in the office prior to placing

patches- leads to irritant and false-positivespatches- leads to irritant and false-positives

Sbrforum.com


!! What about What about showeringshowering??"" No showering or wetting the back for theNo showering or wetting the back for the

entire testing period, up until the final readentire testing period, up until the final read(at least 5 days)(at least 5 days)

"" Modified work note for outside workers orModified work note for outside workers orheavy laborersheavy laborers


!! Patient comes in convinced that a liquidPatient comes in convinced that a liquidhe works with is the he works with is the ““causecause”” of his rash of his rash

!! He wants you to patch test this, whatHe wants you to patch test this, whatshould you do?should you do?

2ols.com


!! Patient comes in convinced that a liquidPatient comes in convinced that a liquidhe works with is the he works with is the ““causecause”” of his rash of his rash

!! He wants you to patch test this, whatHe wants you to patch test this, whatshould you do?should you do?"" DO NOT TEST UNKNOWNS!DO NOT TEST UNKNOWNS!"" MSDSMSDS"" DeGroot (4300 chemicals for testDeGroot (4300 chemicals for test

concentrations)concentrations)

2ols.com

Allergens

Top 10 Allergens inNorth America!! Nickel sulfateNickel sulfate

!! Balsam of PeruBalsam of Peru

!! Fragrance mix IFragrance mix I

!! Quaternium-15Quaternium-15

!! NeomycinNeomycin

!! BacitracinBacitracin

!! FormaldehydeFormaldehyde

!! Cobalt chlorideCobalt chloride

!! MethyldibromoglutaronitrileMethyldibromoglutaronitrile

!! p-Phenylenediaminep-Phenylenediamine

Zug KA, Warshaw EM, Fowler JF Jr, et al: Patch-test results of the North American Contact Dermatitis Group 2005-2006. Dermatitis 2009;20:149-160

Top Allergens in the Workplace

!! Carba MixCarba Mix

!! Thiuram MixThiuram Mix

!! Epoxy ResinEpoxy Resin


!! NickelNickel

Rietschel RL, Mathias CG, Fowler JF Jr, et al. North American Contact Dermatitis Group. Relationship of occupation to contact dermatitis (OCD): evaluation in patients tested from 1998 to 2000. Am J Contact Dermatitis 2002;13(4):170-6.

Top Allergens in theWorkplace!! Carba MixCarba Mix




!! NickelNickel


Onlygloves.com

cdc.gov

Instructables.com





!! NickelNickel


http://epoxy.fiberglassmoldss.com/epoxy/

Ehow.uk.eu

Wikipedia.com





!! NickelNickel


Travelandleisure.com

Rfid-weblog.com

Formaldehyde-Releasers

!! Carba MixCarba Mix




!! NickelNickel

!! Quaternium-15Quaternium-15!! Imidazolidinyl ureaImidazolidinyl urea

(Germall 115)(Germall 115)!! Diazolidinyl ureaDiazolidinyl urea

(Germall II)(Germall II)!! DMDM hydantoinDMDM hydantoin

(Glydant)(Glydant)!! 2-Bromo-2-2-Bromo-2-

nitropropane-1,3-diolnitropropane-1,3-diol(Bronopol)(Bronopol)

!! Sodium hydroxymethylSodium hydroxymethylglycinateglycinate





!! NickelNickel

Wikipedia.org

The prevalence of ACD tonickel is:!! Greater in women than in menGreater in women than in men!! Greater in younger than older patientsGreater in younger than older patients!! Higher than ACD to palladiumHigher than ACD to palladium!! All of the aboveAll of the above!! None of the aboveNone of the above

Cellphone contact dermatitis with nickel allergy; CMAJ • January 1, 2008; 178 (1)

Dealing with Nickel Allergy

!! Lobbying Congress to pass nickelLobbying Congress to pass nickelstandardstandard

!! Manufacturers would have to limitManufacturers would have to limitcontent of any item with prolonged skincontent of any item with prolonged skincontact to restrict release of nickel tocontact to restrict release of nickel to0.5 mcg/cm per week0.5 mcg/cm per week

!! Similar 2001 legislation in EuropeSimilar 2001 legislation in Europedecreased childhood nickel dermatitisdecreased childhood nickel dermatitisfrom 19% to 6%from 19% to 6%

Dealing with Nickel Allergy

!! Dimethylglyoxime spot testDimethylglyoxime spot test"" Can purchase at www.delasco.comCan purchase at www.delasco.com

!! Barrier coatingBarrier coating"" Nickel Guard (Athena Allergy) is bestNickel Guard (Athena Allergy) is best"" Can also use Beauty Secrets Nail HardenerCan also use Beauty Secrets Nail Hardener"" Super glue not so super (within 7 days consumersSuper glue not so super (within 7 days consumers

had rashes)had rashes)!! AVOID nickelAVOID nickel

"" Take magnet shoppingTake magnet shopping!! Does not attract aluminum, does attract nickelDoes not attract aluminum, does attract nickel

meteorites.wustl.edu

North American ContactDermatitis Group!! Publish update on Publish update on ““most commonsmost commons””!! Pool results from major centersPool results from major centers!! Review trends (increasing andReview trends (increasing and

decreasing reactivity in the population)decreasing reactivity in the population)!! Make changes to recommended traysMake changes to recommended trays

from this population-based datafrom this population-based data

Allergen of the Year 2009

!! Mixed dialkyl thioureasMixed dialkyl thioureas!! Mixed quaternium basesMixed quaternium bases!! Mixed thiuram alkylatesMixed thiuram alkylates!! Mixed tetra-alkyl thiuramsMixed tetra-alkyl thiurams


!! Mixed dialkyl thioureas (MDTU)Mixed dialkyl thioureas (MDTU)"" Used as an accelerant in rubber andUsed as an accelerant in rubber and

antioxidant in neoprene productionantioxidant in neoprene production"" Combination of diethylthiourea andCombination of diethylthiourea and

dibutylthiourea (most prevalent in mix)dibutylthiourea (most prevalent in mix)"" NOT in TRUE test, but present in standardNOT in TRUE test, but present in standard

rubber seriesrubber series


!! Mixed dialkyl thioureasMixed dialkyl thioureas"" Occupational: most commonly on handsOccupational: most commonly on hands

!! Gloves leaching MDTUGloves leaching MDTU"" Non-occupational: most commonly on theNon-occupational: most commonly on the

feetfeet!! Foot supports, athletic shoes leaching MDTUFoot supports, athletic shoes leaching MDTU

"" Sleep apnea masks, wetsuits, neopreneSleep apnea masks, wetsuits, neoprenebraces, gogglesbraces, goggles

Gemplers.comhomehealthmedical.comlowerextremityreview.com


!! BacitracinBacitracin!! Nickel sulfateNickel sulfate!! NeomycinNeomycin!! Polymyxin B sulfatePolymyxin B sulfate


!! NeomycinNeomycin"" In medicamentsIn medicaments"" ACD in healthcare workers, veterinariansACD in healthcare workers, veterinarians"" Cross-reacts:Cross-reacts:

!! Paromycin, butirosinParomycin, butirosin!! FramycetinFramycetin!! Tobramycin, kanamycinTobramycin, kanamycin!! GentamycinGentamycin!! StreptomycinStreptomycin

Wikipedia.org


!! Dimethyl FumarateDimethyl Fumarate!! No occupational relevance at this timeNo occupational relevance at this time


!! GoldGold!! PropolisPropolis!! Quaternium-15Quaternium-15!! AcrylatesAcrylates

Occupations at High-Risk forHand Dermatitis!! HairdressersHairdressers!! MusiciansMusicians!! Food IndustryFood Industry

workersworkers!! Agricultural workersAgricultural workers!! Factory workersFactory workers!! Electronics workersElectronics workers

!! Cleaners/WashersCleaners/Washers!! HousekeepersHousekeepers!! PrintersPrinters!! BuildersBuilders!! Medical and DentalMedical and Dental

workersworkers

Treating Hand Dermatitis-Step 1!! Recommended short-Recommended short-

term high-potencyterm high-potencytopical steroids fortopical steroids forhands:hands:"" Clobetasol propionateClobetasol propionate

!! OintmentOintment"" Halcinonide ointmentHalcinonide ointment

!! No propylene glycol, noNo propylene glycol, nosensitizerssensitizers

!! ““HalogHalog””

!! For body:For body:"" Short-termShort-term

hydrocortisone 2.5%hydrocortisone 2.5%bid for face, neck,bid for face, neck,axillae, groin,axillae, groin,intertriginous areasintertriginous areas

"" Short-termShort-termtriamcinolone 0.1%triamcinolone 0.1%bid for bodybid for body

Treating Hand Dermatitis-Step 1!! Avoid more than aAvoid more than a

few weeks of potentfew weeks of potentsteroid use topicallysteroid use topically

!! Can thin the skinCan thin the skinmaking hands moremaking hands moresusceptible tosusceptible toallergen/irritant!allergen/irritant!

!! Consider IM steroidsConsider IM steroidsx 1x 1

!! Doxycycline for anti-Doxycycline for anti-inflammatory effectsinflammatory effects

Treating Hand Dermatitis-Step 1!! Barrier creamsBarrier creams

"" Tetrix creamsTetrix creams"" Creams with ceramide, urea andCreams with ceramide, urea and

dimethiconedimethicone"" Studies are variable in demonstrating anyStudies are variable in demonstrating any

benefit from barrier creams whenbenefit from barrier creams whencompared to regular emollientscompared to regular emollients

Treating Hand Dermatitis-Step 1!! Appropriate glovesAppropriate gloves

"" Match task with gloveMatch task with glove"" ““Quick Selection Guide to ChemicalQuick Selection Guide to Chemical

Protective ClothingProtective Clothing”” by Forsberg and by Forsberg andMansdorfMansdorf

"" ACDS website lists glove manufacturersACDS website lists glove manufacturers

Treating Hand Dermatitis-Treating Hand Dermatitis-Step 2 (Maintenance)Step 2 (Maintenance)!! Calcineurin inhibitorsCalcineurin inhibitors

"" Tacrolimus 0.1%Tacrolimus 0.1%"" Pimecrolimus 0.1%Pimecrolimus 0.1%

! Therapeuticmoisturizers" MimyX

! Palmitatemonoethanolamine

" Shea butter" Aquaphor" Petrolatum

! Lower potencysteroids for hands:" Triamcinolone 0.1%" Fluticasone cream or

lotion (great foratopics)

" Hydrocortisonebutyrate lipid cream! (Locoid lipocream)

" Clocortolone cream! (Cloderm)

Treating Hand Dermatitis-Step 3 (Recalcitrant)!! Hand psoralen- ultraviolet A therapyHand psoralen- ultraviolet A therapy

(PUVA)(PUVA)!! Narrow-band UV B therapy (NBUVB)Narrow-band UV B therapy (NBUVB)

!! Often used for recalcitrant body dermatitisOften used for recalcitrant body dermatitis!! Excimer laserExcimer laser

!! 308 nm308 nm

Treating Hand Dermatitis-Step 3 (Recalcitrant)!! MethotrexateMethotrexate!! MycophenolateMycophenolate

mofetilmofetil"" 2-3g/day2-3g/day

recommended forrecommended forcontrolcontrol

!! AcitretinAcitretin"" Best for psoriasiformBest for psoriasiform

hand dermatitishand dermatitis"" 2-4 month course2-4 month course

!! CyclosporineCyclosporine"" 2.5-5 mg/kg daily2.5-5 mg/kg daily

!! AzathioprineAzathioprine"" 1-3 mg/kg daily1-3 mg/kg daily

!! Biologics are notBiologics are nothelpful overallhelpful overall

Summary

!! Allergic and irritantAllergic and irritantcontact dermatitiscontact dermatitiscan be difficult tocan be difficult todistinguishdistinguish

!! We are constantlyWe are constantlybeing exposed tobeing exposed tonew allergens, oftennew allergens, oftenearlier in lifeearlier in life

!! OccupationalOccupationalcontact dermatitis iscontact dermatitis isunderreportedunderreported

!! Patch testing forPatch testing forACD is the goldACD is the goldstandardstandard

!! Can try TRUE test,Can try TRUE test,consider referral forconsider referral forcomprehensivecomprehensivepanelspanels

!! History, history,History, history,historyhistory

Summary

!! Think outside theThink outside theboxbox

!! Try a stepwiseTry a stepwiseapproachapproach"" EliminationElimination"" TreatmentTreatment"" Escalate treatmentEscalate treatment

!! Will be chronic ifWill be chronic ifexposure continuesexposure continues

!! You can make aYou can make ahuge difference inhuge difference inpatientpatient’’s quality ofs quality oflifelife

References

!! Marks et al., 2002. Marks J.G., Elsner P., DeLeo V.A.: Contact and Occupational Dermatology, 3rd ed. StMarks et al., 2002. Marks J.G., Elsner P., DeLeo V.A.: Contact and Occupational Dermatology, 3rd ed. StLouis, Mosby, 2002.Louis, Mosby, 2002.

!! Nelson and Yiannias, 2009. Nelson S.A., Yiannias J.A.: Relevance and avoidance of skin-care productNelson and Yiannias, 2009. Nelson S.A., Yiannias J.A.: Relevance and avoidance of skin-care productallergens: Pearls and pitfalls. Dermatol Clin 2009; 27(3):329-336.allergens: Pearls and pitfalls. Dermatol Clin 2009; 27(3):329-336.

!! Thin-layer rapid-use epicutaneous test. Thin-layer rapid-use epicutaneous test (TRUE-test) : AvailableThin-layer rapid-use epicutaneous test. Thin-layer rapid-use epicutaneous test (TRUE-test) : Availableat:[accessed 03.07.11] http://www.truetest.com/PatientPDF/File18.pdfat:[accessed 03.07.11] http://www.truetest.com/PatientPDF/File18.pdf

!! Zug et al., 2009. Zug K.A., Warshaw E.M., Fowler J.F., et al: Patch-test results of the North AmericanZug et al., 2009. Zug K.A., Warshaw E.M., Fowler J.F., et al: Patch-test results of the North AmericanContact Dermatitis Group 2005-2006. Dermatitis 2009; 20:149-160.Contact Dermatitis Group 2005-2006. Dermatitis 2009; 20:149-160.

!! Emmett EA. Occupational contact dermatitis I. Incidence and return to work pressures. Am J ContactEmmett EA. Occupational contact dermatitis I. Incidence and return to work pressures. Am J ContactDermatitis 2002;13:30Dermatitis 2002;13:30––4.4.

!! Bureau of Labor Statistics. Occupational injuries and illnesses in the United States. [Bulletin 2512].Bureau of Labor Statistics. Occupational injuries and illnesses in the United States. [Bulletin 2512].Washington (DC): US Department of Labor, Bureau of Labor Statistics; 1999.Washington (DC): US Department of Labor, Bureau of Labor Statistics; 1999.

!! Lushniak BD. The epidemiology of occupational contact dermatitis. Dermatol Clin 1995; 13:671Lushniak BD. The epidemiology of occupational contact dermatitis. Dermatol Clin 1995; 13:671––9.9.!! Skoet R, Olsen J, Mathiesen B, et al. A survey of occupational hand eczema in Denmark. ContactSkoet R, Olsen J, Mathiesen B, et al. A survey of occupational hand eczema in Denmark. Contact

Dermatitis 2004;51(4):159Dermatitis 2004;51(4):159––66.66.!! Staton I, Ma R, Evans N, et al. Dermal nickel exposure associated with coin handling and in variousStaton I, Ma R, Evans N, et al. Dermal nickel exposure associated with coin handling and in various

occupational settings: assessment using a newly developed finger immersion method. Br J Dermatoloccupational settings: assessment using a newly developed finger immersion method. Br J Dermatol2006;154(4):6582006;154(4):658––64.64.

!! Veien NK, Menne T. Treatment of hand eczema. Skin Therapy Lett 2003;8(5):4Veien NK, Menne T. Treatment of hand eczema. Skin Therapy Lett 2003;8(5):4––7. 137.7. 137.!! Warshaw E. Therapeutic options for chronic hand dermatitis. Dermatol Ther 2004;4:17240Warshaw E. Therapeutic options for chronic hand dermatitis. Dermatol Ther 2004;4:17240––50.50.!! Schalock PC, Zug KA, Carter JC, et al. Efficacy and patient perception of Grenz ray therapy in theSchalock PC, Zug KA, Carter JC, et al. Efficacy and patient perception of Grenz ray therapy in the

treatment of dermatoses refractory to other medical therapy. Dermatitis 2008;19(2):90treatment of dermatoses refractory to other medical therapy. Dermatitis 2008;19(2):90––4.4.!! Abramovits W, Granowski P. Innovative management of severe hand dermatitis. Abramovits W, Granowski P. Innovative management of severe hand dermatitis. Dermatol Clin 28 (2010)Dermatol Clin 28 (2010)

453-65.453-65.

References

!! Sprigle AM, Marks JG Jr, Anderson BE. Prevention of nickel release with barrier coatings. Dermatitis. 2008,19(1):28-31.Sprigle AM, Marks JG Jr, Anderson BE. Prevention of nickel release with barrier coatings. Dermatitis. 2008,19(1):28-31.!! Diepgen T.L., Coenraads P.J.: The epidemiology of occupational contact dermatitis. Int Arch Occup Environ Health 72. (8): 496-Diepgen T.L., Coenraads P.J.: The epidemiology of occupational contact dermatitis. Int Arch Occup Environ Health 72. (8): 496-

506.1999.506.1999.!! Keil J.E., Shmunes E.: The epidemiology of work-related skin disease in South Carolina. Arch Dermatol 119. (8): 650-654.1983.Keil J.E., Shmunes E.: The epidemiology of work-related skin disease in South Carolina. Arch Dermatol 119. (8): 650-654.1983.!! Mathias C.G.: Occupational dermatoses. J Am Acad Dermatol 19. (6): 1107-1114.1988.Mathias C.G.: Occupational dermatoses. J Am Acad Dermatol 19. (6): 1107-1114.1988.!! Goh C.L.: An epidemiological comparison between occupational and non-occupational hand eczema. Br J Dermatol 120. (1):Goh C.L.: An epidemiological comparison between occupational and non-occupational hand eczema. Br J Dermatol 120. (1):

77-82.1989.77-82.1989.!! Marks J.G., Elsner P., DeLeo V.A.: Contact & occupational dermatology. 3rd ed Mosby St. Louis, (MO)2002.Marks J.G., Elsner P., DeLeo V.A.: Contact & occupational dermatology. 3rd ed Mosby St. Louis, (MO)2002.!! Holness D.L.: Characteristic features of occupational dermatitis: epidemiologic studies of occupational skin disease reported byHolness D.L.: Characteristic features of occupational dermatitis: epidemiologic studies of occupational skin disease reported by

contact dermatitis clinics. Occup Med 9. (1): 45-52.1994.contact dermatitis clinics. Occup Med 9. (1): 45-52.1994.!! Belsito D.V.: Occupational contact dermatitis: etiology, prevalence, and resultant impairment/disability. J Am Acad Dermatol 53.Belsito D.V.: Occupational contact dermatitis: etiology, prevalence, and resultant impairment/disability. J Am Acad Dermatol 53.

(2): 303-313.2005.(2): 303-313.2005.!! Kanerva L., Estlander T., Jolanki R.: Occupational skin disease in Finland. An analysis of 10 years of statistics from anKanerva L., Estlander T., Jolanki R.: Occupational skin disease in Finland. An analysis of 10 years of statistics from an

occupational dermatology clinic. Int Arch Occup Environ Health 60. (2): 89-94.1988.occupational dermatology clinic. Int Arch Occup Environ Health 60. (2): 89-94.1988.!! Sertoli A., Gola M., Martinelli C., et al: Epidemiology of contact dermatitis. Semin Dermatol 8. (2): 120-126.1989.Sertoli A., Gola M., Martinelli C., et al: Epidemiology of contact dermatitis. Semin Dermatol 8. (2): 120-126.1989.!! Rietschel R.L., Mathias C.G., Fowler , Jr. , Jr.J.F., et al: Relationship of occupation to contact dermatitis: evaluation in patientsRietschel R.L., Mathias C.G., Fowler , Jr. , Jr.J.F., et al: Relationship of occupation to contact dermatitis: evaluation in patients

tested from 1998 to 2000. Am J Contact Dermatitis 13. (4): 170-176.2002.tested from 1998 to 2000. Am J Contact Dermatitis 13. (4): 170-176.2002.!! Nethercott J.R., Holness D.L.: Disease outcome in workers with occupational skin disease. J Am Acad Dermatol 30. (4): 569-Nethercott J.R., Holness D.L.: Disease outcome in workers with occupational skin disease. J Am Acad Dermatol 30. (4): 569-

574.1994.574.1994.!! Mathias C.G., Morrison J.H.: Occupational skin diseases, United States. Results from the Bureau of Labor Statistics AnnualMathias C.G., Morrison J.H.: Occupational skin diseases, United States. Results from the Bureau of Labor Statistics Annual

Survey of Occupational Injuries and Illnesses, 1973 through 1984. Arch Dermatol 124. (10): 1519-1524.1988.Survey of Occupational Injuries and Illnesses, 1973 through 1984. Arch Dermatol 124. (10): 1519-1524.1988.!! Koch P.: Occupational contact dermatitis. Recognition and management. Am J Clin Dermatol 2. (6): 353-365.2001.Koch P.: Occupational contact dermatitis. Recognition and management. Am J Clin Dermatol 2. (6): 353-365.2001.!! Bureau of Labor Statistics : Occupational Injuries and illnesses in the United States. Available at: Bureau of Labor Statistics : Occupational Injuries and illnesses in the United States. Available at: http://www.bls.gov/iifhttp://www.bls.gov/iif!! Lushniak B.D.: Occupational contact dermatitis. Dermatol Ther 17. (3): 272-277.2004.Lushniak B.D.: Occupational contact dermatitis. Dermatol Ther 17. (3): 272-277.2004.!! Mathias C.G.: The cost of ccupational skin disease. Arch Dermatol 121. (3): 332-334.1985.Mathias C.G.: The cost of ccupational skin disease. Arch Dermatol 121. (3): 332-334.1985.!! Cvetkovski R.S., Rothman K.J., Olsen J., et al: Relation between diagnoses on severity, sick leave, and loss of job amongCvetkovski R.S., Rothman K.J., Olsen J., et al: Relation between diagnoses on severity, sick leave, and loss of job among

patients with occupational hand eczema. Br J Dermatol 152. (1): 93-98.2005.patients with occupational hand eczema. Br J Dermatol 152. (1): 93-98.2005.

Thank you!Thank you!

Thank you for participating in today’s webinar.At the conclusion of this call you will receive an email

with a link to a post-webinar questionnaire.

You will need to complete this questionnaire in order toreceive CME for this webinar.

This webinar presentation can be downloaded atwww.woema.org

occdermwoemahpl6 2012.ppt [read-only]contact dermatitis!contact dermatitis (cd) is reported to...

Documents