skin symptoms and work-related skin symptoms among grape farmers in crete, greece
TRANSCRIPT
AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 49:77–84 (2006)
Skin Symptoms and Work-Related Skin SymptomsAmong Grape Farmers in Crete, Greece
Leda Chatzi, MD, PhD,1� Athanasios Alegakis, PhD,2 Sabine Kruger-Krasagakis, MD, PhD,3
and Christos Lionis, MD, PhD1
Background Grape farmers are exposed to a variety of agents capable of inducingoccupational skin disease. We conducted a study to measure the prevalence of skinsymptoms and work-related skin symptoms among grape farmers in the Malevisi region ofCrete and to provide data on associated risk factors.Methods One hundred twenty grape farmers and 100 controls participated in the study.The protocol consisted of a questionnaire, skin prick tests for 16 common allergens, andmeasurement of specific IgE antibodies against 8 allergens.Results Self-reported itchy rash (OR, 2.31; 95%CI, 1.10–4.84, P< 0.05) within the last12 months, and work-related itchy rash (OR, 4.08; 95%CI, 1.01–20.33, P< 0.05) weresignificantly higher in grape farmers than in controls, after adjusting for age and sex.Sensitization to pollens (OR, 4.20; 95% CI, 1.41–12.82, P< 0.01) and allergic rhinitis(OR, 3.06; 95% CI, 1.21–8.28, P< 0.05) were found to be significantly associated withself-reported itchy rash in the grape farmers group.Conclusions Grape farmers reported skin symptoms more frequently than non-exposedcontrols, and IgE-mediated sensitization to pollens was found to be significantlyassociated with the reported symptoms. Further studies are needed to evaluate the impactof specific occupational agents on skin diseases among grape farmers. Am. J. Ind. Med.49:77–84, 2006. � 2005 Wiley-Liss, Inc.
KEY WORDS: grape farmers; skin symptoms; work-related skin symptoms; pollen;sensitization
INTRODUCTION
It is generally agreed that agricultural workers are at high
risk of developing occupational skin disease, since they are
exposed to many different skin irritants and allergens
[O’Malley and Mathias, 1988; Spiewak, 1999]. Inorganic/
organic dust, plant materials, animal dander, pesticides, and
agricultural chemicals, especially under regular exposure,
are capable of causing different types of occupational skin
disease such as contact dermatitis (both allergic and irritant),
contact urticaria, and atopic dermatitis (eczema) [O’Malley
et al., 1988; McCurdy et al., 1989; Gamsky et al., 1992; Guo
et al., 1996; Cole et al., 1997; Spiewak, 1999].
According to Finnish studies, farmers have demon-
strated the highest prevalence of occupational contact
urticaria [Kanerva et al., 1996], and dairy farming has been
found to be an occupational risk factor for hand dermatoses
[Susitaival et al., 1994, 1995]. Among private farmers in
Poland, allergic contact dermatitis was the most common
occupational dermatitis [Spiewak, 2003]. Until now, no
studies have been reported on occupational skin disorders
among agricultural populations in Greece.
There are only a few reports concerning skin diseases
among grape farmers. Gamsky et al. [1992] found that grape
� 2005Wiley-Liss, Inc.
1Clinic of Social and Family Medicine, Department of Social Medicine, Faculty ofMedicine,University of Crete, Heraklion, Crete, Greece
2Biostatistics Laboratory,Faculty ofMedicine,University of Crete,Heraklion,Crete,Greece3Clinic of Dermatology, University General Hospital of Heraklion, Crete, Greece*Correspondence to: Leda Chatzi, Department of Social Medicine, Faculty of Medicine,
University of Crete, P.O. 2208, 71003, Heraklion, Crete, Greece. E-mail: [email protected]
Accepted18 November 2005DOI10.1002/ajim.20247. Published online inWiley InterScience
(www.interscience.wiley.com)
workers were more likely to have skin disorders than were
citrus or tomato workers, and these disorders may be causally
associated with crop-specific exposures and lack of protec-
tive equipment. Similarly, California grape harvesters were
more likely than tomato harvesters to report a rash occurring
in the previous 3 months, but the prevalence of eczematous
skin conditions during physical examinations did not differ in
the two groups [McCurdy et al., 1989]. A recent study among
California farm operators revealed that the highest preva-
lence of self-reported dermatitis was in male grape farmers
[Susitaival et al., 2004].
In a cross-sectional study that we conducted in the
Malevisi region in Northern Crete, grape farmers were found
to have a higher prevalence of allergic rhinitis and work-
related respiratory symptoms compared to controls and an
increased allergic sensitization to specific pollens [Chatzi
et al., 2005]. The present study was carried out simulta-
neously with the above study, in order to measure the
prevalence of self-reported skin symptoms and work-related
skin symptoms among the same group of grape farmers, to
test the hypothesis that this occupational group is at increased
risk of reporting skin symptoms compared to non-exposed
controls, and to provide data on associated risk factors.
METHODS
Study Population
This study was conducted from April to November 2002
in the Malevisi region of Northern Crete. Study population
and study methods have been described in detail previously
[Chatzi et al., 2005]. The study population group consisted of
150 grape farmers with no other occupation. They were
randomly selected from 459 grape farmers in the age group of
25–70 years that were listed in the Agricultural Cooperatives
in the Malevisi region. Random sampling was performed
according to random number tables.
The control group consisted of a random sample of 150
employees in the tourist industry living in the Malevisi region
(n¼ 408), in the age group of 25–70 years. This occupational
group was chosen because tourism is the second major
occupation in this region after agriculture.
The study protocol consisted of a questionnaire, skin
prick tests (SPT), and blood sampling for the measurement of
specific IgE antibodies (EIA test). All of the participants were
interviewed before undergoing the allergy tests (SPT, EIA
tests). All participants gave their written informed consent.
The study protocol had been approved by the Ethical
Committee of the University Hospital of Heraklion, Crete.
Questionnaire
The questionnaire included questions on medical and
occupational history [Chatzi et al., 2005]. The history of skin
symptoms (pruritus, itchiness) and skin signs (rash, rash with
vesicles) was indicated by affirmative responses to the
following questions: ‘‘During the last 12 months have you
had complaints of: a) Itchy skin (scratching or rubbing the
skin a lot)? b) Skin redness? c) Itchy red skin? d) Itchy red
skin with vesicles?’’ All questions were asked as ‘‘yes/no’’
questions.
Possible aggravating and etiological factors for the
reported skin symptoms were indicated by affirmative
responses to the following questions: ‘‘Which of the
following factors do you think worsen your symptoms?
Contact with soap, shampoo, and other personal hygiene
products; Contact with detergents or other cleaning products;
Contact with pet animals (cat, dog); Contact with house dust;
Contact with molds; Food consumption; Use of drugs;
Handling plants, flowers; Working in the grape fields; Use of
pesticides’’.
A history of allergic rhinitis and asthma was also
examined in the first part of the questionnaire (medical
history). A history of allergic rhinitis was defined as the
occurrence of two or more nasal symptoms (e.g., rhinorrhea,
sneezing, nasal obstruction, and nasal itching) on most
days during the last 12 months, apart from a cold
[International Rhinitis Management Working Group, 1994;
Wang et al., 2002]. The definition of current asthma was
based on asthma symptoms or medication according to the
questionnaire (attack of asthma during the last 12 months,
having been awakened by an attack of shortness of breath
during the last 12 months, or current use of asthma
medication) [Kogevinas et al., 1999], followed by a positive
bronchodilatation test [Chatzi et al., 2005]. The bronchodi-
latation test was performed using 400 mg salboutamol. An
increase of more than 12% predicted in FEV1 was considered
a positive bronchodilator response [Quanjer et al., 1993].
In the second part of the questionnaire (occupational
history), there were four questions regarding work-related
skin symptoms (pruritus, rash, itchy rash, itchy rash with
vesicles). Work-related symptoms were defined as symptoms
which were present during working hours and which showed
improvement during evenings, weekends, and holidays
[Bohadana et al., 1999; Chatzi et al., 2005]. Occupational
factors such as the number of working hours per day, the
number of years working in grape cultivation, preventive
measures used during working hours (e.g., gloves, mask,
glasses), and the use of pesticides were also examined in the
second part of the questionnaire. At the end of the
questionnaire, there was a list of 50 commonly used
pesticides (brand names), and grape farmers were asked to
identify the pesticides they were currently using. Grape
farmers were also given the opportunity to add other
pesticides that they had used and were not included in the
list. For those who could not remember the brand names of
the pesticides they had used, there were photographs of each
pesticide that was included in the list.
78 Chatzi et al.
Allergy Tests
Skin prick tests (SPT) were performed, by a trained
physician, on the volar side of the forearm with a
standardized skin test needle for 16 different allergens/
4 groups of allergens (S.A.R.M. Allergens LTD, Rome,
Italy): (A) Pollens: Gramineae mix, Cynodon dactylon,
Compositae mix, Parietaria officinalis, Parietaria Jiudaica,
Parietaria plus, Tree mix, Olive European—the most
prevalent allergenic plants in Crete with known clinical
significance; (B1) House Dust Mites: Dermatophagoides
Farinae, Dermatophagoides Pteronyssinus, (B2) Storage
Mites: Glycyphagus domesticus, Acarus siro; (C) Molds:
Alternaria tenius, Cladosporium herbarum, Mucor mix-
among the most predominant species of molds in agricultural
environments; (D) Animal Epithelium: Cat epithelium.
Histamine and blank solutions were used as controls. The
reaction was evaluated after 15 min. A positive SPT was
defined as the presence of a mean wheal diameter of 3 mm or
more than the negative control.
The enzyme immunoassay method (EIA test) was used
to quantify IgE antibodies against eight different allergens/
four groups of allergens (Cypress diagnostics, CV, Langdorp,
Belgium): (A) Pollens: Grass mix, Parietaria officinalis,
Olive European, Common ragweed; (B) Mites: Dermato-
phagoides Farinae, Dermatophagoides pteronyssinus; (C)
Molds:Moldsmix; (D) Animal epithelium:Cat epithelium. A
positive result was defined as �0.35 EU/ml.
Data Analysis
All data were entered into a database and analyzed with
the SPSS 12.0 (SPSS, Inc., Chicago, IL) statistical software
package. Continuous variables were expressed as mean and
standard deviations (SD). Univariate analysis of categorical
variables was done using the Pearson’s chi-square test.
Multivariate logistic regression models were used to
compare the prevalence rates of skin symptoms and work-
related skin symptoms between the two groups after
adjustment for age and sex.
Multivariate logistic regression models were also used
for the assessment of associations between variables,
considering itchy rash and work-related itchy rash to be
dependent variables. As independent variables, the following
were considered: age (in years, continuous variable), sex
(female, male), use of pesticides (no, yes), use of preventive
measures at work (no, yes), number of working hours per day
(continuous variable), allergic rhinitis (no, yes; as defined
earlier), current asthma (no, yes; as defined earlier), and
allergic sensitization to pollens, mites, molds, and cat
epithelium according to SPT/EIA tests (negative SPT or
EIA test, positive SPT or EIA test). Corresponding multi-
variate logistic regression models were used for control
subjects exclusive of the grape farmers’ occupational factors
(e.g., use of pesticides, use of preventive measures at work,
the number of working hours per day). The results were
expressed as adjusted odds ratios (OR), with 95% confidence
intervals (CI). For all statistical tests a probability equal to or
less than 0.05 was considered significant.
RESULTS
The response rate was 80.0% for the grape farmers (120
out of 150) and 66.7% (100 out of 150) for the control group.
The non-responders from both groups were contacted and
interviewed by telephone and were found to be comparable to
the responders in terms of mean age, sex, and smoking status.
All grape farmers were contacted successfully, whereas two
controls (2/50, 4.0%) could not be contacted. Of the non-
responders, five grape farmers (5/30, 16.7%) and three
controls (3/50, 6.0%) had a history of itchy rash over the
previous 12 months.
The responders from the grape farmers group included
77 women (64.2%) and 43 men (35.8%), with a mean age of
45.6 years (mean� SD age: 45.6� 12.1 years). Of them, 71
(59.2%) had never smoked, and 34 (28.3%) were current
smokers; the rest were ex-smokers. The responders from the
control group included 71 women (71.0%) and 29 men
(29.0%), with a mean age of 34.9 years (mean� SD age:
34.9� 7.4 years). Of them, 32 (32.0%) had never smoked, 59
(59.0%) were current smokers; the rest were ex-smokers.
Grape farmers were older and smoked less than the control
subjects (P< 0.001). There was no significant difference in
sex distribution between the two groups.
Skin Symptoms
The prevalence rates of self-reported itchy rash (OR,
2.31; 95%CI, 1.10–4.84, P< 0.05) and self-reported itchy
rash with vesicles (OR, 6.81; 95%CI, 1.41–32.81, P< 0.01)
within the last 12 months were significantly higher in grape
farmers than in controls, after adjusting for age and sex
(Table I). Regarding work-related skin symptoms, grape
farmers were found to have a significantly elevated odds ratio
for work-related itchy rash (OR, 4.08; 95%CI, 1.01–20.33,
P< 0.05), but not for work-related rash, pruritus, and itchy
rash with vesicles (Table I).
The most aggravating factors reported by grape farmers
with itchy rash were: contact with plant materials (handling
plants and flowers) (30, 66.7%), work in the grape fields (27,
60.0%), and use of pesticides (25, 55.6%). The control
subjects with itchy rash reported aggravation of their
symptoms when they were exposed to house dust (8,
53.3%), when they were in contact with detergents or other
cleaning products (7, 46.7%), and when they were in contact
with plant materials (7, 46.7%).
For both groups, spring and summer were reported to be
the most prevalent seasons for the manifestation of skin
Skin Symptoms in Grape Farmers 79
symptoms. Itchy rash was more frequently reported in grape
farmers group during May (34, 75.6%), and between April
and May in the control group (7, 46.7%). For grape farmers
work-related itchy rash was more common during June (17,
89.5%), while for the control subjects the respective period
was between May and September.
Seventy-eight (78, 65.0%) grape farmers reported that
they used between 1 and 21 pesticides in their grape
cultivations, with a median of seven pesticides. The majority
of them (74, 94.9%) used the inorganic fungicide ‘‘sulfur
dioxide.’’ Among the other most frequently used pesticides
were the broad spectrum, non-selective systemic herbi-
cide ‘‘glyphosate’’ (67, 85.9%), the organic fungicides
‘‘triadimefon’’ (65, 83.3%) and ‘‘fenarimol’’ (57, 73.1%),
and the carbamate insecticide ‘‘carbaryl’’ (66, 84.6%).
Fifty-nine (59, 49.2%) grape farmers reported that they
took some kind of preventive measures during their work in
grape fields. Of them, 38 (64.4%) reported that they used
gloves, 11 (18.6%) that they used a mask, 7 (11.9%) that they
used a combination of gloves and mask, and the rest that they
used a combination of gloves, mask, and eye protection.
None of the preventive measures used were found to be
significantly associated with work-related skin symptoms
(pruritus, rash, itchy rash, and itchy rash with vesicles).
Allergy Tests
According to the responses to SPT-EIA tests, grape
farmers with a history of itchy rash were more sensitized
to pollens than grape farmers without the symptom (Positive
SPT pollens: OR, 4.25; 95%CI, 1.93–9.34,P< 0.001/Positive
EIA pollens: OR, 2.24; 95%CI, 1.00–5.07, P< 0.05).
Regarding sensitization to the other groups of allergens (mites,
molds, cat epithelium), there were found no significant asso-
ciations between grape farmers with and without the symptom.
Moreover, among grape farmers with a history of itchy
rash or work-related itchy rash, the most prevalent group of
allergens was found to be pollens (77.8%, and 78.9%
respectively). Specifically, the most common sensitizing
allergen among grape farmers with itchy rash wasGramineae
mix (42.2%), followed by Cynodon Dactylon (33.3%), and
Olive European (33.3%). Among grape farmers with work-
related itchy rash, the most common sensitizing pollens were
Gramineae mix and Cynodon Dactylon (42.1%, each),
followed by Composite mix (31.6%).
Similarly, in control subjects with a report of itchy rash
over the previous 12 months and/or work-related itchy rash,
pollens were found to be the most common group of
allergens. However, in this group, the most common
sensitizing pollens were of the Parietaria family [Parietaria
officinalis (20.0%), Parietaria Jiudaica (13.3%), and Par-
ietaria plus (13.3%)]. Based on the responses to SPT-EIA
results, the sensitization to different groups of allergens was
not found to differ significantly between control subjects with
and without itchy rash.
Risk Factors for Skin Symptoms andWork-Related Skin Symptoms in theGrape Farmers Group and Control Group
Multivariate logistic regression analysis showed that
self-reported itchy rash over the previous 12 months was
significantly associated with sensitization to pollens (OR,
4.20; 95% CI, 1.41–12.82, P< 0.01) and allergic rhinitis
TABLE I. Prevalence of Skin Symptoms and Work-Related Skin Symptoms Among Grape Farmers and Controls,Crete,Greece
Grape farmers(n¼120)
Controls(n¼100)
Adjusted OR (95%CI) P valuen (%) n (%)
Pruritusa 54 (45.00) 30 (30.00) 1.42 (0.75^2.68) NSRasha 45 (37.50) 19 (19.00) 1.70 (0.84^3.44) NSItchy rasha 45 (37.50) 15 (15.00) 2.31 (1.10^4.84) <0.05Itchy rashwith vesiclesa 16 (13.33) 2 (2.00) 6.81 (1.41^32.81) <0.01Work-relatedpruritusb 22 (18.33) 5 (5.00) 2.39 (0.77^7.41) NSWork-related rashb 22 (18.33) 6 (6.00) 1.92 (0.65^5.65) NSWork-related itchy rashb 19 (15.83) 2 (2.00) 4.08 (1.01^20.33) <0.05Work-related itchy rashwith vesiclesb
7 (5.83) 1 (1.00) 2.69 (0.26^28.05) NS
Odds ratios with 95% confidence interval for grape farmers, derived from logistic regression models after adjustment for age andsex.aSelf-reported symptoms during the previous12 months.bSymptomswhich were present duringworking hours, and which showed improvement during evenings,weekends, and holidays.
80 Chatzi et al.
(OR, 3.06; 95% CI, 1.21–8.28, P< 0.05) in the grape
farmers group after adjusting for potential confounders.
Regarding work-related itchy rash, the only significant risk
factor was sensitization to pollens (OR, 4.28; 95%CI,
1.20–19.20, P< 0.05). No significantly elevated risk was
associated with current asthma, sensitization to mites,
molds, and cat epithelium. Similarly, none of the occupa-
tional characteristics (e.g., the use of pesticides, the
number of working hours per day, and the use of preventive
measures) was significantly related to the reported skin
symptoms of grape farmers (Table II).
For the control group, multivariate logistic regression
analysis showed that the only significant risk factor for
reporting itchy rash over the previous 12 months was allergic
rhinitis (OR, 7.41; 95%CI, 2.13–26.08, P< 0.01). Regard-
ing work-related itchy rash, no significant associations were
found.
DISCUSSION
The purpose of the study was to measure the prevalence
of skin symptoms and work-related skin symptoms among
grape farmers in the Malevisi region of Crete and to assess
possible risk factors for these disorders.
The study has shown that grape farmers had high pre-
valence rates of self-reported itchy rash in the last 12 months
and work-related itchy rash compared to the control subjects,
after adjusting for age and sex. The reported prevalence rates
of dermatitis among grape farming populations vary, and it is
difficult to make comparisons since the criteria for skin
diseases are different. There are few reports on dermatitis
among grape farmers; all of them agree that grape workers
reported skin rashes or dermatitis more frequently than other
agricultural workers [McCurdy et al., 1989; Gamsky et al.,
1992; Susitaival et al., 2004].
According to the results from the allergy tests, the most
prevalent group of allergens among grape farmers reporting
itchy rash/ work-related itchy rash was the group of pollens.
Moreover, according to the multivariate logistic regression
analysis, IgE-mediated sensitization to pollens was found to
be significantly associated with self-reported itchy rash and
work-related itchy rash in the grape farmers group. Grape
farming in Crete is a manual agricultural practice, which
requires prolonged contact with various plant materials. The
majority of grape farmers reported that their symptoms
presented in May and June. The blossoming period for most
plants in Crete is from April to June; during this period, grape
farming includes manual activities such as cane turning, leaf
pulling and tipping, thinning, pruning, and girdling. It has
been shown that the factor most strongly associated with a
report of a rash within a 3-month period among California
grape harvesters was working with crop materials [McCurdy
et al., 1989]. It is possible, therefore, that grape farming
activities, including prolonged contact with plant materials,
are associated with increased risk of developing dermatitis
and work-related skin symptoms.
The most common plants around grape fields in Malevisi
region in Northern Crete are grasses, weeds, flowers, and in
some cases, trees (Olive European trees). The most common
sensitizing pollens among grape farmers with skin symptoms/
TABLE II. AssociationsBetweenSelf-Reported ItchyRash andWork-Related ItchyRash andPredictorVariables inGrape Farmers Group,Crete,Greece
Itchy rash
P value
Work-related itchyrash
P valueOR (95%CI) OR (95%CI)
Age 1.04 (0.72^1.08) NS 1.07 (0.81^1.12) NSSex 2.27 (0.76^5.78) NS 2.66 (0.88^8.02) NSAllergic rhinitis 3.06 (1.21^8.28) P< 0.05 1.23 (0.35^4.22) NSCurrent asthma 0.98 (0.18^5.32) NS 1.58 (0.24^10.03) NSSensitization to pollens 4.20 (1.41^12.82) P< 0.01 4.28 (1.20^19.20) P< 0.05Sensitization tomites 1.52 (0.74^3.29) NS 1.63 (0.62^4.48) NSSensitization tomolds 0.34 (0.08^1.78) NS 0.94 (0.14^6.43) NSSensitization to cat epithelium 2.91 (0.37^19.60) NS 1.70 (0.18^14.31) NSUse of preventivemeasures 0.62 (0.23^1.74) NS 0.68 (0.24^2.30) NSUse of pesticides 2.51 (0.82^7.81) NS 1.10 (0.31^4.62) NSWorking hours perday 1.53 (0.53^4.01) NS 1.12 (0.28^3.98) NS
OR, odds ratios with 95% confidence interval, derived from multivariate logistic regression models after adjustment for age, sex,sensitization to different allergens, allergic rhinitis, current asthma, use of pesticides, use of preventive measures, and number ofworking hours per day; NS, not statistically significant.
Skin Symptoms in Grape Farmers 81
work-related skin symptoms were Gramineae mix, Cynodon
Dactylon, Compositae mix, and Olive European. Cynodon
Dactylon andGramineaemixbelong to theGramineae family,
which is a grass family. Plant species from the Graminaea
family (Cynodon Dactylon and Poa Annua) are common
weeds in grape-growing regions [Monteiro and Moreira,
2004], and some of them (Cynodon Dactylon, Lolium
perenne, Agrostis alba) are abundant in grape fields in the
Malevisi region of Crete. A study on the role of Gramineae
pollen on atopic eczema has shown that 66.7% of patients
with atopic eczema and seasonal exacerbations of eczematous
skin lesions had a positive patch test to Dactylis glomerata
(grass pollen) [Darsow et al., 1997]. TheCompositae family is
a flower family. The clinical features of occupational
Compositae dermatitis reflect a variety of allergic (including
type I) and irritant symptoms of both the skin and mucous
membranes (eczema, pruritus, short lived skin irritation,
contact urticaria, and mucous membrane symptoms)
[Gordon, 1999]. A series of studies on occupational dermatitis
in Danish gardeners and greenhouse workers has found
that exposure to specific plant species was the most important
and eliciting factor in both allergic and irritant dermatitis,
and that the most predominant pollens were of the
Compositae and Liliaceae families [Paulsen et al., 1997,
1998; Paulsen, 1998]. The significant associations that were
found between self-reported skin symptoms and allergic
sensitization to pollens among grape farmers constitute an
indication of the potential role of specific pollens as work-
related allergens in the development of occupational plant
dermatitis.
The prevalence of sensitization to grape plant materials
was beyond the scope of the present study. A recent study on
sensitization to grapes among Greek grape workers has
shown that asymptomatic sensitization to grapes was high
and that workers handling grapes were more likely than those
inhaling must vapors or controls to present sensitization
[Kalogeromitros et al., 2004]. Further studies are needed in
order to measure sensitization to grapes among grape farmers
in Crete and possible cross-reactions of Cretan grape
varieties with other plant allergens.
In the present study, allergic rhinitis was found to be
significantly associated with a report of itchy rash over the
previous 12 months. The association between respiratory
atopy and dermatitis has previously been reported in several
studies [Meding and Swanbeck, 1990; Gamsky et al., 1992;
Kristensen, 1992; Susitaival et al., 1994, 2004; Tacke et al.,
1995]. In the present study, allergic rhinitis and asthma were
not self-reported, but the definition of both diseases was
based on standardized and validated epidemiological criteria
[International Rhinitis Management Working Group, 1994;
Kogevinas et al., 1999; Wang et al., 2002; Chatzi et al., 2005].
The association between atopy and atopic dermatitis is
well known, since up to 80% of atopic dermatitis cases are
said to be associated with atopy [Schmid-Grendelmeier et al.,
2001]. Atopic dermatitis severity was found to be positively
associated with the number of positive skin prick test
responses and/or IgE-antibody specificities [Flohr et al.,
2004]. On the other hand, atopic skin diathesis was found to
be a significant risk factor for occupational skin disease
mainly consisting of occupational contact dermatitis of both
irritant and allergic types affecting the hands [Dickel et al.,
2003]. It is difficult to distinguish whether the atopic subjects
in the study, who reported a history of rash, were suffering
from an exacerbation of atopic dermatitis, or rather, were
suffering from a concomitant allergic or irritant contact
dermatitis. This is a common problem even for clinicians,
since both allergic or irritant contact dermatitis can be quite
common in atopic dermatitis [Akhavan and Cohen, 2003].
Clinical evaluation with focus on the distribution areas of the
rash, along with patch testing for specific chemicals could
contribute to differentiating between these three eczematous
skin disorders.
According to the findings of other epidemiological
studies, a clear association between pesticide exposure and
occupational dermatitis in grape farmers’ group has not been
established [Winter and Kurtz, 1985; McCurdy et al., 1989;
Gamsky et al., 1992; Susitaival et al., 2004]. In the present
study, the use of pesticides has not been found to be
significantly associated with any of the reported skin
symptoms among grape farmers. As we have no data on the
time and the duration of the application of the pesticides, we
cannot assess possible associations between the time of their
use and the manifestation of skin symptoms. Furthermore,
our questionnaire did not include questions regarding
possible associations between the application of pesticides
and skin reactions. The potential role of pesticides in causing
the reported skin symptoms could not be assessed accurately
in this study as the evaluation of a detailed long time exposure
history was beyond its scope.
The present study is a cross-sectional study and cannot
contribute to the identification of causal relationships; it can,
however, suggest associations between the reported skin
symptoms and possible risk factors. Furthermore, as it
involves a small area of research in northern Crete, and a
relatively small sample size of grape farmers, we cannot
make generalizations regarding larger grape-farming popu-
lations.
Another limitation of the study is that it did not include
clinical examination by a dermatologist, and we have no
data on the location, nature, or minimum duration of skin
symptoms. Therefore, we can only discuss self-reported
skin symptoms or positive allergic reactions to specific
allergens; we cannot discuss any specific dermatological
condition. According to the literature review, neither
uniform international criteria, validated in different
populations and countries, nor standards for the definition
of a case of dermatitis in epidemiological studies have been
identified.
82 Chatzi et al.
The healthy worker effect does not seem to have played
an important role in the results presented. None of the grape
farmers that reported a history of itchy rash over the previous
12 months was likely to quit farming because of his/her
symptoms. As grape farming in Crete is a family enterprise, it
is unlikely that a grape farmer would be so affected by skin
rashes that he or she would change occupations. This finding
is consistent with several other studies on allergic and
dermatological disorders in grape farmers [McCurdy et al.,
1989; Gamsky et al., 1992; Chatzi et al., 2005].
In conclusion, our study shows that grape farmers in the
Malevisi region in Northern Crete had a higher prevalence of
self-reported itchy rash and work-related itchy rash com-
pared to non-exposed controls. IgE-mediated sensitization to
pollens was found to be significantly associated with the
reported skin symptoms. To evaluate the role of such
exposures in skin disease, longitudinal studies are needed
along with clinical examination of the reported skin
symptoms and detection of worksite-specific allergens.
ACKNOWLEDGMENTS
We are grateful to all the residents of the Malevisi region
for their participation. Furthermore, we give our special
thanks to Professor Manolis Kogevinas, Senior Lecturer Jean
Peters, and Associate Professor Anna Kalantidi, for fruitful
discussions, valuable comments, and professional advice
during the course of this work.
REFERENCES
Akhavan A, Cohen SR. 2003. The relationship between atopicdermatitis and contact dermatitis. Clin Dermatol 21:158–162.
Bohadana AB, Teculescu DB, Megherbi SE, Pham QT. 1999. Bronchialhyperresponsiveness in farmers: Relation to respiratory symptoms, lungfunction, and atopy. Lung 177:191–201.
Cole DC, Carpio F, Math JJ, Leon N. 1997. Dermatitis in Ecuadoreanfarm workers. Contact Dermatitis 37:1–8.
Darsow U, Behrendt H, Ring J. 1997. Gramineae pollen as triggerfactors of atopic eczema: Evaluation of diagnostic measures using theatopy patch test. Br J Dermatol 137:201–207.
Dickel H, Bruckner TM, Schmidt A, Diepgen TL. 2003. Impact ofatopic skin diathesis on occupational skin disease incidence in aworking population. J Invest Dermatol 121:37–40.
Flohr C, Johansson SG, Wahlgren CF, Williams H. 2004. How atopic isatopic dermatitis? J Allergy Clin Immunol 114:150–158.
Gamsky TE, McCurdy SA, Wiggins P, Samuels SJ, Berman B, ShenkerMB. 1992. Epidemiology of dermatitis among California farm workers.J Occup Med 34:304–310.
Gordon LA. 1999. Compositae dermatitis. Australas J Dermatol40:123–128; quiz 129–130.
Guo YL, Wang BJ, Lee CC, Wang JD. 1996. Prevalence of dermatosesand skin sensitisation associated with use of pesticides in fruit farmers ofsouthern Taiwan. Occup Environ Med 53:427–431.
C Chatzi L, Prokopakis E, Tzanakis N, Alegakis A, Bizakis I, SiafakasN, Lionis C. 2005. Allergic rhinitis, asthma, and atopy amonggrape farmers in a rural population in Crete, Greece. Chest 127:372–378.
International Rhinitis Management Working Group. 1994. InternationalConsensus Report on the diagnosis and management of rhinitis. Allergy49:1–34.
Kalogeromitros D, Rigopoulos D, Gregoriou S, Mousatou V, Lyris N,Papaioannou D, Katsarou-Katsari A. 2004. Asymptomatic sensitisationto grapes in a sample of workers in the wine industry. Occup EnvironMed 61:709–711.
Kanerva L, Toikkanen J, Jolanki R, Estlander T. 1996. Statisticaldata on occupational contact urticaria. Contact Dermatitis 35:229–233.
Kogevinas M, Anto JM, Sunyer J, Tobias A, Kromhout H, Burney P.1999. Occupational asthma in Europe and other industrialised areas: Apopulation-based study. European Community Respiratory HealthSurvey Study Group. Lancet 353:1750–1754.
Kristensen O. 1992. A prospective study of the development of handeczema in an automobile manufacturing industry. Contact Dermatitis26:341–345.
McCurdy SA, Wiggins P, Schenker MB, Munn S, Shaieb AM,Weinbaum Z, Goldsmith D, McGillis ST, Berman B, Samuels S.1989. Assessing dermatitis in epidemiologic studies: Occupational skindisease among California grape and tomato harvesters. Am J Ind Med16:147–157.
Meding B, Swanbeck G. 1990. Predictive factors for hand eczema.Contact Dermatitis 23:154–161.
Monteiro A, Moreira I. 2004. Reduced rates of residual and post-emergence herbicides for weed control in vineyards. Weed Res 44:117–128.
O’Malley MA, Mathias CG. 1988. Distribution of lost-work-timeclaims for skin disease in California agriculture: 1978–1983. Am J IndMed 14:715–720.
O’Malley M, Thun M, Morrison J, Mathias CG, Halperin WE. 1988.Surveillance of occupational skin disease using the Supplementary DataSystem. Am J Ind Med 13:291–299.
Paulsen E. 1998. Occupational dermatitis in Danish gardeners andgreenhouse workers (II). Etiological factors. Contact Dermatitis 38:14–19.
Paulsen E, Sogaard J, Andersen KE. 1997. Occupational dermatitis inDanish gardeners and greenhouse workers (I). Prevalence and possiblerisk factors. Contact Dermatitis 37:263–270.
Paulsen E, Sogaard J, Andersen KE. 1998. Occupational dermatitis inDanish gardeners and greenhouse workers (III). Compositae-relatedsymptoms. Contact Dermatitis 38:140–146.
Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, YernaultJC. 1993. Lung volumes and forced ventilatory flows. Report WorkingParty Standardization of Lung Function Tests, European Community forSteel and Coal. Official Statement of the European Respiratory Society.Eur Respir J Suppl 16:5–40.
Schmid-Grendelmeier P, Simon D, Simon HU, Akdis CA, Wuthrich B.2001. Epidemiology, clinical features, and immunology of the‘‘intrinsic’’ (non-IgE-mediated) type of atopic dermatitis (constitutionaldermatitis). Allergy 56:841–849.
Spiewak R. 1999. Occupational dermatoses in farmers—A proposal fordiagnostic procedure. Ann Agric Environ Med 6:63–72.
Spiewak R. 2003. Occupational dermatoses among Polish privatefarmers, 1991–1999. Am J Ind Med 43:647–655.
Skin Symptoms in Grape Farmers 83
Susitaival P, Husman L, Horsmanheimo M, Notkola V, Husman K.1994. Prevalence of hand dermatoses among Finnish farmers. Scand JWork Environ Health 20:206–212.
Susitaival P, Husman L, Hollmen A, Horsmanheimo M, Husman K,Hannuksela M. 1995. Hand eczema in Finnish farmers. A questionnaire-based clinical study. Contact Dermatitis 32:150–155.
Susitaival P, Beckman R, Samuels SJ, Schenker MB. 2004. Self-reported dermatitis and skin cancer in California farm operators. Am JInd Med 46:136–141.
Tacke J, Schmidt A, Fartasch M, Diepgen TL. 1995. Occupationalcontact dermatitis in bakers, confectioners and cooks. A population-based study. Contact Dermatitis 33:112–117.
Wang DY, Niti M, Smith JD, Yeoh KH, Ng TP. 2002. Rhinitis: Dodiagnostic criteria affect the prevalence and treatment? Allergy 57:150–154.
Winter CK, Kurtz PH. 1985. Factors influencing grapeworker susceptibility to skin rashes. Bull Environ Contam Toxicol35:418–426.
84 Chatzi et al.