Contact Dermatitis Medical - Epidemiology:

Contact Dermatitis

Medical - Epidemiology: Contact Dermatitis

The purpose of this literature review is to provide a medical epidemiology and overview of contact dermatitis, with concentration focusing on the risks and complications associated with contact dermatitis among workers in the construction industry, and with attention to Irish laws in place meant to protect workers from exposure to irritants that may result in contact or allergic contact dermatitis.

Much of the work conducted in the past has focused on the study of ICD or irritant contact dermatitis, a temporary condition known to cause symptoms ranging from redness of the skin, inflammation and itching to the development of sores and blisters on the skin (Hogan & May, 2007; CCOHS, 1997; Goldner, 1994; Royal College of Physicians, 1995). Prolonged exposure to a substance may lead to a process referred to as "sensitization" which increases individual's odds of developing allergic contact dermatitis, a less commonly studied but increasingly prevalent form of contact dermatitis resulting in similar symptoms, but a condition that may affect an individual for a lifetime (Hogan & May, 2007; Goldner, 1994). Health care agencies have long known that certain populations are more at risk for developing allergic contact dermatitis than others, including individuals working in the construction industry (Royal College of Physicians, 20050.

Questions the literature review focuses on include: (1) defining what contact dermatitis is; (2) distinguishing the differences between allergic contact dermatitis and irritant contact dermatitis; (3) assessing the level of protections provided to workers against contact dermatitis; (4) review of Irish law and its relevance with respect to allergic and irritant contact dermatitis among the public and construction workers; and (5) an overall review of the construction industry and efforts within the industry aimed at reducing the risk of developing allergic contact dermatitis through adequate training, protection and review of hazardous working conditions. To answer these questions and inquiries, a comprehensive review of literature is provided that reviews each of these questions as reflected in the scientific and governmental literature available on contact dermatitis among citizens and construction workers alike.

The purpose of this investigation is to determine the prevalence of contact dermatitis and what actions may be necessary to mitigate risk or provide additional resources for those most at risk for contagion with this known disease.

Significance of Study

As more and more construction workers develop symptoms of allergic contact dermatitis, it is more important than ever that researchers focus on ways and methods they can prevent occupational hazards from reducing one's capacity to work or their quality of life. Among the important facts noted in the literature review is the increasing prevalence of contact dermatitis in Ireland and other areas where legislation has been slow to enforce some health and occupational acts that would protect workers from exposure to chemical irritants. Cited in this literature review are cases suggesting that Irish buildings and drinking water are among the primary causes for allergic or irritant contact dermatitis among workers and civilians alike. This serves to emphasize the need for a complete review of contact dermatitis, including its many forms, and an evaluation of the current legislation in place to assess its relevance and whether legislation needs to be improved to protect workers from developing debilitating forms of this condition.

Critical Evaluation Literature Review Contact Dermatitis Allergic & Irritant

Allergic Contact Dermatitis

There are multiple studies suggesting the prevalence of allergic contact dermatitis is on the rise, especially abroad, including within the European Union and Ireland, where federal regulations are in place, but not necessarily strictly enforced to provide workers adequate protections against risk factors leading to the development of allergic contact dermatitis (Royal College of Physicians, 2005; Hogan & May, 2007; Cohen & Cohen, 1998). It is important when examining contact dermatitis one distinguish between the types of contact dermatitis most likely to affect construction workers. Thus, this literature review focuses on allergic contact dermatitis, a currently understudied phenomenon, and irritant contact dermatitis, two known forms of contact dermatitis most prevalent in the construction, house building and related industries (Cohen & Cohen, 1998; 3).

There is ample evidence suggesting may do not distinguish between allergic and irritant contact dermatitis. While the two diseases are related, it is important to distinguish between the two because one (allergic) may prove more damaging to an individual in the long-term, reducing their quality of health and increasing their sensitization and immune response to exposure to other toxins in the industry (Cohen & Cohen, 1998, p. 4).

Allergic dermatitis or ACD is not the same as contact dermatitis resulting from exposure to a common irritant. Rather, ACD results when a person has a specific sensitivity to a known substance, and develops delayed onset allergic symptoms (Hogan & May, 2007). Many people mistakenly refer to allergic contact dermatitis as contact dermatitis or ICD, which results from damage occurring from a chemical that would cause damage to anyone's skin, regardless of whether they had a known sensitivity to the chemical or agent in question.

ACD was first defined by researcher Jadassohn, who used a "patch test" to identify chemicals he was allergic to; this research led to the later development and popularity of "patch" testing (Hogan & May, 2007; Larkin & Rietschel, 1998). With time researchers developed a modern version of this test, now known as the "thin-layer rapid use epicutaneous" or "TRUE" test (Hogan & May, 2007, p.1). A common example of a delayed onset ACD case is a situation where a healthcare worker becomes allergic or sensitive to latex, a chemical often used in the healthcare environment and other work settings.

There are certain chemicals known as common triggers for ACD. As in other contact related reactions, cytokines are important when evaluating allergic contact dermatitis because they are responsible for regulating intercellular adhesion molecules, including interleukin 8 (Hogan & May, 2007, p. 1).

According to the National Health and Nutritional Examination Survey, also referred to as the NHANES, just under 14 people of every 1,000 people are diagnosed with ACD, with roughly 8 million people visiting their doctor for a confirmed diagnosis of allergic contact dermatitis (Hogan & May, 2007; Larkin & Rietschel, 1998).

In other countries, dermatitis is as common or more common; a Dutch study for example, suggested that 12 of every 1000 people would develop some form of ACD during their lives, whereas in Sweden less than 3 of every 1,000 people succumb to ACD (Hogan & May, 2007, p.1). McFadden & Basketter (2000) note that within Europe and in Ireland there exist many instances of cases where construction workers developed allergic contact dermatitis due to pre-existing chemicals and toxins in older building and from exposure to unsanitary conditions resulting from lax labor laws meant to protect employees. Pathologically, many people with ACD will develop symptoms several days following exposure to the allergen, making diagnosis sometime difficult. Others may not react severely on first contact with a potential allergen, but may react more severely with frequent exposure (Hogan & May, 2007). This subject is explored in greater depth in the third section, where the relationship between contact dermatitis and the construction industry is examined in detail.

Cohen & Cohen (1998) describe erythema multiforme, one of many reactions associated with allergic contact dermatitis resulting in hypersensitivity occurring closely after exposure to an allergen or infection. The researchers note that while erythema multiforme may result from an allergy to nickel and other common allergens, there is only one report of findings suggesting EM occurs following Rhus contact dermatitis (p. 140). This merely shows there is much to be learned yet about allergic contact dermatitis and the likelihood that one's sensitivity to certain substances will give rise to more or less severe reactions when an individual is exposed to a known allergen once, or over prolonged periods.

In a retrospective study of 732 patients referred for patch testing, Cohen et al., (1997) found that patch testing is a valid and useful tool for defining one's allergies and the likelihood that one will experience contact dermatitis, and to what severity, in the workplace and in other environments (p. 916). Of the patients examined for this study, roughly 1/2 experienced positive reactions the researchers, and "deemed clinically relevant. " percent demonstrated "clinically relevant" reactions after evaluated using a standard series of patch tests exclusively to known allergens (Cohen, et al., 1997, p. 917) the researchers suggested that 20 allergens are most likely to cause allergic contact dermatitis within the United States, and that the patch test when used alone is a limited tool, although helpful if combined with other testing methods in assessing one's risk factors for contracting allergic contact dermatitis.

The Canadian Center for Occupational Health and Safety (1007) defines allergic contact dermatitis, often referring to it as "occupational contact dermatitis" suggesting it is a primary cause for local inflammation of the skin with accompanying pain, redness and formation of blisters (CCOHS, 1997, p. 1). Allergic contact dermatitis often, according to the CCOHS, develops in stages, where a construction worker or other worker may be exposed daily to a substance or substances that are known as allergens that may not immediately cause a skin reaction.

Like other researchers, the CCOHS notes that allergic reactions including inflammation, redness and formation of blisters may only appear after prolonged exposure to possible allergens; for some this may mean exposure to a substance for a few days before symptoms arise, for others exposure throughout a lifetime may result in some minor dermatitis (CCOHS, 10007). Typically, as others have confirmed, exposure is first necessary, then a process referred to as sensitization, where a worker may become "sensitized" to a compound they work with, the penetration of the epidermal layer of the skin, following an allergic reaction, a process which can take up to four weeks (CCOHS, 1997).

This process results when allergenic compounds binds to proteins naturally occurring in the skin, and lymphocytes or protective agents within the body react to protect the skin from damage; tissue-damaging chemicals called "lymphokines" may be released, which ultimately result in the symptoms commonly associated with allergic contact dermatitis, including: "Pain, swelling, redness and the formation of blisters" (CCOHS, 1997, p. 1). Pre-existing irritant contact dermatitis may lead to an increased prevalence of allergic contact dermatitis as can cuts in the skin or other tears in the skin which may provide for faster penetration of allergenic compounds (McFadden & Basketter, 2000). Penetration of the epidermal layer of the skin is necessary for allergic contact dermatitis to incur symptoms in the affected individual, as penetration of the skin leads to binding of toxic substances to lymphocytes in the system contributing to the outbreak of redness, swelling or blisters (McFadden & Basketter, 2000).

Among those most at risk include cabinet makers, carpenters, construction and automobile workers, agricultural workers and any workers working with substances that require use of latex gloves or exposure to chromates, rubber, resins, cobalt, cement, chromium, formaldehyde or woods (CCOHS, 1997, p. 1).

The Royal College of Physicians (2005) and other international organizations including the EPA in Ireland are working to providing legislation that focuses on the potential causes for and risk factors for allergic contact dermatitis among construction workers and among manufacturers that may produce substances with toxic agents that may lead to sensitization (CCOHS, 1997, p. 1). Allergic contact dermatitis is more likely to occur in workers or other people who are chronically exposed to a known irritant, those who develop even a single case of ICD or irritant contact dermatitis and those with hereditary risk factors, including a high incidence of allergies within one's family history (Choi, Lee & Cho, 2000, p. 44). In the next section, a review of irritant contact dermatitis is presented along with its relationship to allergic contact dermatitis. The level of research conducted on irritant contact dermatitis is much more prevalent than that of allergic contact dermatitis. It is important to note however, that the research presented on irritant contact dermatitis often suggests that allergic contact dermatitis is more likely to manifest when an individual is exposed to a compound and develops a single case of irritant contact dermatitis. While irritant contact dermatitis typically manifests with quicker onset than allergic contact dermatitis, its symptoms are almost identical in many cases, and the manner in which it manifests in the body are also similar (Choi, Lee & Cho, 2000, p. 45).

Apart from allergic and irritant contact dermatitis there are other forms of dermatitis that may coincide with these diseases or occur separately from them; these include atopic dermatitis, or eczema, which more often results from hereditary causes, increasing the likelihood that an individual or construction worker may become sensitized to a chemical or compound agent resulting in allergic contact dermatitis (Choi, Lee & Choi, 2000, p. 45).

Irritant Contact Dermatitis

There is more literature available on contact dermatitis than on allergic dermatitis; however, one may correlate the research provided on irritant contact dermatitis with that of allergic contact dermatitis as irritant dermatitis may be a risk factor of or cause for the development of allergic dermatitis among affected people (McFadden & Basketter, 2000).

Contact dermatitis as mentioned comes in various forms including "chronic irritant contact dermatitis or ICD (Choi, Lee & Cho, 2000, p. 43). This form of contact dermatitis is associated by inflammation of the epidermal cells in the skin, resulting in redness or erythema, some swelling and at times scaling of the skin (Choi, Lee & Cho, 2000; McFadden & Basketter, 2000). Allergic contact dermatitis is much more common that irritant contact dermatitis (Sarkis, 2000). Much less is known about ICO than about allergic dermatitis in part because there are few exact diagnostic tests currently available for evaluating and properly diagnosing this form of contact dermatitis (Sarkis, 2000). Typically to diagnose ICD, a healthcare worker would have to rule out other "cutaneous diseases" including allergic contact dermatitis, and diagnose patients based on the clinical appearance of the dermatitis and one's exposure to a potential irritant known to cause skin reactions (Sarkis, 2000; Goldner, 1994).

The pathophysiology of ICD includes inflammation occurring from the release of "cytokines" from the cells of the epithelium, typically resulting from contact to a chemical agent (Sarkis, 2000). There are 3 primary changes noticed among patients with ICD: "skin barrier disruption," where the irritant penetrates the skin; cellular changes within the skin's epidermal level; and cytokine release (Sarkis, 2000, p.2). Some of the more common irritants include detergents; an example of ICD may include eczema arises from exposure to cleaning agents (Sarkis, 2000).

Prolonged exposure to any toxic chemical will result in sensitization and subsequent symptoms or disease manifestation, as is the case with ICD. Researchers also note that certain stimuli aside from chemical agents, including exposure to environmental hazards such as ultraviolet light (as in the case of workers working in the sun) may exacerbate the condition (Sarkis, 2000).

Hogan & May (2007) note that allergic contact dermatitis or ACD is a leading occupational hazard and illness, with most individuals affected demonstrating symptoms in their hands or from eye exposure (Lawley & Kubota, 1991, p. 265); this is one reason why prevent care and proper training is important for individuals who are at risk for developing dermatitis resulting from chronic exposure to chemical or other known irritants or allergens. Among the forms of contact dermatitis most prevalent among construction workers include the hands, eyes, lungs, head and neck; preservatives and formaldehydes are often to blame (Diepgen & Coenraads, 1999, p. 500).

Critical Evaluation Literature Related to Construction Industry and Dermatitis

This portion of the literature review includes an in-depth look at dermatitis in the construction or house building industry. Many health experts agree that contact dermatitis is more prevalent among construction workers than among workers in other industries, contributing to higher rates of work-related disease including skin diseases (Sarkis, 2000). Some research suggests that the risks associated with "wear and tear" as well as exposure to chemical irritants leading to allergic reactions are more to blame for deaths than serious injury or falls among this class of workers (Sarkis, p. 2).

Sarkis (2000) notes that construction workers are more at risk for allergic reactions and contact dermatitis that may contribute to multiple other skin diseases (p.2). To prevent the spread of disease, Sarkis recommends construction workers perform the following preventive measures: (1) identify allergens in the work environment so that workers are aware of potential hazards before exposure, (2) use substitute chemicals when available to decrease the risk of exposure, (3) provide personal protection equipment and (4) ensure educational programs and protocols are available to protect workers (p. 2).

Other researchers confirm the risks and consequences of contact allergy and irritancy associated with allergic reaction to chemicals and other hazards in the workplace. McFadden & Basketter (2000) note contact dermatitis presents a real danger to workers consistently exposed to hazardous material, with some workers becoming hypersensitive to products they come into contact with almost daily as part of their occupation (p. 124). Such rapid contagion is often referred to as sensitization (Kligman, 1966, p. 395). Still others note hat work-related irritant contact dermatitis will always present a risk to construction workers, making it more important than ever that workers in the construction business adopt safe job habits and policies and procedures that adequately train and protect employees from chronic illness associated with exposure to chemical agents (Goldner, 1994, p. 39).

Contact Dermatitis, Construction and the Irish

According to the Irish National Industrial Safety Organisation and multiple other health and safety agencies in Europe, case studies suggest in Ireland and related areas roughly 20% of construction accidents results from falls, but the largest number of accidents were related to reports of injury and illness from exposure to unsafe Irish building sites, which, according to the Minister for Labour, were among "the most dangerous places to work" through 1988 (McGarr, E., 2006).

Eireann (1991) notes that the Irish Office of the Attorney General and other agencies have been looking into Irish domestic law to define "damage" which under section 21 of the Civil Liability Act of 1961 suggests this includes loss of life or personal injury to persons that requires compensation, and provides that manufacturers or produces of items that may damage someone or cause injury liable in tort (p. 1). This legislation was recently discussed in a case involving contact dermatitis. As recently as 1985 the Irish law and the European Community have been working to provide remedies to employees including construction workers injured through no fault of their own by use of faulty products or defective products where damage is incurred, including in the form of contact dermatitis resulting from working with an irritant (Eireann, 1991, p. 1). Other laws that work to protect Irish citizens and regulations include those imposed by the National Standards Authority of Ireland who encourages companies that manufacture and product products and services to achieve ISO 9000 standardization, so they are able to produce quality goods in a safe work environment (Eirann, 1991, p. 1).

Among the cases tried early by courts included a 1936 case where a plaintiff contracted allergic dermatitis resulting from wearing products manufactured with excess sulphite (Eirann, 1991, p. 1). In this case a manufacturer may be guilty of many faults including negligence or "res ispa loquiter" (Eirann, 1991, p. 1). In Ireland, under S. 8(1) of the Safe, Health & Welfare at Work Act of 2005, employers are required to "so far as is reasonable practicable" ensure the safety and health or welfare of employees working at a company, including reviewing any dangers a construction or other worker may be exposed to by working with chemical irritants that may resulting in dermatitis (IOSH, 2005, p. 1). Still, some have argued that such laws are not stringent enough to protect workers, as the term "reasonably practicably" can be interpreted differently by the courts, whether in Ireland, the UK or the States.