Allergic contact dermatitis in hairdressers: frequency and source of sensitisation

ARTICLE

Occupational dermatoses (irritant and allergic contact dermatitis, contact urticaria, nail changes) are very common skin diseases among hairdressers and allergic contact dermatitis is one of the most frequent. Because of their work, which requires continual contact with water, shampoos, hair dyes and permanent wave solutions, hairdressers may develop irritant skin lesions. Damaged skin is easier for the allergens to penetrate and develop an allergic contact dermatitis. Other important key factors are the lack of adequate protective measures and the rapid microclimatic changes during working time [1].

The aim of this study was to evaluate the frequency, the age distribution and the source of contact sensitisation in a group of 209 hairdressers suffering from contact dermatitis, who consulted us from January 1990 to December 1999.

Materials and methods

This study involved 209 hairdressers, 27 males and 182 females, aged from 14 to 72 years (mean age 27.4 years) (Table I).

One hundred and forty-three hairdressers had dermatitis on the hands and 24 of them also had affected forearms; 45 had dermatitis on the face, the ocular region also being involved in 13 of them; 19 had dermatitis on the neck; 5 had a widespread dermatitis and 33 had dermatitis on other sites of the body, probably not related to their work.

The mean duration of the disease was 1.75 year (range: 1 month - 40 years). All the patients were patch tested with the standard series (Trolab-Hermal) and with the hairdressers' series shown in Table II. Our standard series differs from the European standard series because it also includes imidazolidinyl urea 2% pet., petrolatum 100%, disperse yellow 3 pet., disperse red 1 pet., disperse blue 124% pet., thiomersal 0.1% aq., ammoniated mercury 1% pet., 4-4' diaminidiphenylmethane 0.5% pet. Some patients were also tested with other series such as the preservatives, the textile and the rubber series because we thought it advisable according to their work and the site of the dermatitis. The allergens, incorporated in a petrolatum vehicle, were applied using Finn Chambers on Scanpor and fixed with tape to the back of the patients. All the reactions were read at D2 and D3. The scale of evaluation was:

+ for erythema with infiltration;

++ for erythema with infiltration and papules;

+++ for erythema with infiltration, papules and vesicles;

- for negative.

Results

One hundred and thirty-two of the 209 hairdressers tested (63.1%), 21 males and 111 females, aged from 14 to 61 years (mean 25.4 years), showed one or more clinically relevant positive reactions to different allergens (Tables II and III). Seventy-seven patients (36.8%), 7 males and 70 females, showed positive reactions not clinically relevant (20 patients) or had completely negative patch tests (57 patients).

Among the 132 hairdressers, 89 patients (67.4%), 20 males and 69 females, aged from 14 to 54 years (mean 24.5 years), showed one (42 patients) or more (47 patients) positive reactions to the hairdressers' series (Table II).

The other 43 patients (32.5%), 1 male and 42 females, aged from 15 to 61 years (mean 27.3 years), with negative reactions to the hairdressers' series, showed one or more clinically relevant positive reactions to other allergens (Table III).

The site of the dermatitis was on the hands in 79 of the 132 hairdressers with clinically relevant positive patch tests and on the forearms in 6 of them; hands and forearms were involved in 21 patients; 16 patients had dermatitis on the face and 8 were also affected in the ocular region; 11 patients had dermatitis on the neck and 4 had a widespread dermatitis.

The hapten which most frequently caused positive reactions among the 209 hairdressers tested was para-phenylenediamine base (77 patients, 36.8%). The para-derivative compounds, such as para-aminodiphenylamine, o-nitro-para-phenylenediamine and para-toluenediamine sulphate gave positive patch tests in 8, 10 and 29 patients respectively (3.8%, 4.7%, 13.8%).

Eight of the para-phenylenediamine base sensitized patients were also positive to para-aminodiphenylamine, 9 to o-nitro-para-phenylenediamine and 29 to para-toluenediamine sulphate.

Resorcinol gave 2 positive patch tests (0.9%). Twenty-five hairdressers were sensitised to glyceryl monothioglycolate (11.9%), 3 to ammonium thioglycolate (1.4%) and only 1 patient reacted to both substances. Twenty-five patients showed positive reactions to ammonium persulphate (11.9%).

The allergens not included in the hairdressers' series which gave the greatest number of positive reactions were nickel sulphate and disperse yellow 3, blue 124 and red 1. As regards nickel sulphate, we observed the same impact on the two groups shown in Table III but there was a significant difference in the azo-dyes positive patch tests as they were much more numerous in the group of patients with positive reactions to the hairdressers' series.

Discussion

We briefly report where the haptens of the hairdressers' series can be found: para-phenylenediamine base, para-aminodiphenilamine and para-toluendiamine sulphate are primary dye intermediates used in permanent hair colours; the primary intermediates are oxidized in the presence of a developer (containing hydrogen peroxide, most frequently 6% aq.). Resorcinol is a modifying agent (also known as coupler) that reacts with the oxidized primary intermediates to form dinuclear and trinuclear dyes.

O-nitro-para-phenylenediamine is used in semi-permanent hair dyes; it is also called a "direct dye" because it does not require mixing with an oxidant. The semi-permanent formulas deposit and adhere to the hair shaft for about 5 to 10 shampoos because dyes are retained by weak, polar and van der Waals forces.

Ammonium persulphate is a bleaching agent.

Glyceryl monothioglycolate and ammonium thioglycolate are two reducing agents used for acid and alkaline permanent waves as they can break the keratin disulphide bridges and give a different shape to the hair [1, 2].

It is important to point out that the hair dyes, once polymerized, are harmless and so they are no longer allergenic for hairdressers, who can handle dyed hair without gloves [3]. That is not valid for acid perm hair, in fact hairdressers with sensitivity to glyceryl monothioglycolate must wait at least 3 months before handling hair safely (GMTG or a cross-reacting product may be retained in permed hair). Glyceryl monothioglycolate can also contaminate the hairdressing saloon because during permanent waving some of the product can soil hands or other instruments. That would explain the flare-ups of some hairdressers who stopped using GMTG or handling permed hair [3-5].

Table II reports that para-phenylenediamine base, para-toluenediamine sulphate, glyceryl monothioglycolate and ammonium persulphate caused the greatest number of positive reactions and this data confirms the literature because they are known to be strong skin irritants and frequently responsible for allergic contact dermatitis. Ammonium persulphate may cause both skin and respiratory symptoms, but we did not have any respiratory complaints.

Since their introduction in the marketplace, it has been underlined that they were skin sensitisers which necessitate protective measures and, despite the safer formulas sold nowadays, allergic contact dermatitis remains one of the most frequent diseases among occupational dermatoses of hairdressers.

Among the 77 patients positive to para-phenylenediamine base, 14 were also positive to disperse dyes included in our standard series. We detected 10 positive patch tests to disperse red 1, 12 to disperse yellow 3 and 3 to disperse blue 124. Nine patients of these 14 were positive to two azo-dyes and only one was positive to all three. As regards the site of the dermatitis, in 13 patients it was on hands and in 1 patient it was widespread. This last one was the patient who was positive to all three azo-dyes. We did not observe patients who were negative to para-phenylenediamine base but positive to azo-dyes.

From a chemical point of view, azo-dyes can be divided into four groups and the risk of cross-sensitization with para-phenylenediamine base is related to the position of amino-groups in the atomic model; DB124, DR1 and DY3 belong to three different groups [6, 7].

Because all of our patients positive to azo-dyes were also positive to para-phenylenediamine base, we believe that this is a cross-sensitivity. Moreover, the fact that only hands were affected by the disease supports this statement.

The prevalence of nickel sulphate allergy among positive hairdressers is high (58 pts in a group of 132; 43.9%) but this metal is ubiquitous and so it is very difficult to establish if it is an occupational allergen or not. The same applies for fragrances that are widely present in the environment. Probably hairdressers have no increased occupational exposure to nickel even if, it is important to point out, they make frequent use of nickel-plated jewellery and they handle ammonium thioglycolate which can release nickel sulphate from utensils, such as scissors [8, 9].

Certainly occupational nickel exposure might be a key factor contributing to the hairdressers' hand eczema.

Sensitization to other cosmetic ingredients was detected in 39 of 132 positive hairdressers (29.5%). Fragrances and preservatives were most frequently responsible for positive reactions. Among the preservatives, Kathon CG and Euxyl K400 gave the largest number of positive reactions (13 patients; 9.8%).

Sensitivity to formaldehyde and formaldehyde-releasing agents (imidazolidinylurea and quaternium 15) was detected in 8 patients of 132 (6%). Nowadays imidazolidinylurea is more frequently registered in hair care products than quaternium 15 and that is probably the reason why it gave more positive reactions (3 versus 1).

None of our 132 positive hairdressers reacted to cocamidopropylbetaine, an amphotheric surfactant used in rinse-off products and especially in shampoos. Since the literature reports a relatively low frequency of sensitization from cocamidopropylbetaine among hairdressers [10], our data confirm that shampoos are safe from risk of developing allergic contact dermatitis from this amphotheric agent.

Comparing this study to the one of 1992 in which our Clinic participated [11], we have not observed any considerable difference between the two groups of data; the haptens, the sites of the dermatitis and the mean age of the hairdressers affected were almost the same.

During these 10 years other countries did similar studies: in 1996 Shah et al. [12] reported data of a 4-year study (1991/1994) carried out in England on a group of 37 hairdressers. They detected the most frequent patch tests positivities to para-phenylenediamine base (13 patients) and to glyceryl monothioglycolate (10 patients). In 1998 Leino et al. [13] compared the Finnish data on a group of 71 hairdressers with the European multicentric study of 1993 [14] based on a group of 809 hairdressers; in both studies glyceryl monothioglycolate was most frequently responsible for allergic contact dermatitis. Para-phenylenediamine base and ammonium persulphate were also responsible for allergic contact dermatitis but the first gave the larger number of positive patch tests in the European multicentric study and the latter in the Finnish one.

We can say that the allergens known as strong skin sensitisers remain almost the same both over the course of the years and in different countries. What is changed are the percentages of positive patch tests among the representative samples and it may be due to fashion trends or lack of protective measures. Nowadays, for example, with the introduction of temporary tattoos, which often contain para-phenylenediamine to strengthen the colour, other sources of sensitisation can be considered [15].

Allergic contact dermatitis, and especially hand eczema, leads to work disability and can also force hairdressers to give up their job.

Because people will always desire to dye or perm their hair, it is important to protect, for this purpose, hairdressers' work by acting on the safety of the products used and on the preventive measures.

The use of gloves is necessary to protect hands from water and irritants contained in professional hair cosmetic products, but it may also contribute to the development or worsening of a dermatitis by occlusive effect and exposure to allergens of the glove material.

However it is not always possible to use the gloves (shampooing, for example, is most frequently done with unprotected hands) and sometimes they are not fully protective (GMTG is known to penetrate gloves) [16, 17].

To improve the safety of their job and to prevent allergic contact dermatitis, hairdressers should follow this strategy (1, 4):

- take care of the skin of their hands;

- wear disposable vinyl gloves during working time (neoprene gloves would be more protective but they are cumbersome);

- take off nickel-plated jewellery that may release nickel sulphate;

- clean instruments and material used for work.

Article accepted on 11/12/01

REFERENCES

1. van der Walle HB. Hairdressers. In: Kanerva L, Elsner P, Wahlberg JE, Maibach HI, eds. Handbook of Occupational Dermatology. Berlin: Springer, 2000: 960-8.

2. Angelini G, Rigano L. Dermatite da contatto con cosmetici. In: Angelini G, Vena GA, eds. Dermatologia Professionale ed Ambientale, vol. 3. Brescia: ISED, 1999: 709-21.

3. Fisher AA. Management of hairdressers sensitized to hair dyes or permanent wave solutions. Cutis 1989; 43: 316-8.

4. van der Walle HB. Dermatitis in Hairdressers (II). Management and prevention. Contact Dermatitis 1994; 30: 265-70.

5. Morrison LH, Storrs FJ. Persistence of an allergen in hair after glyceryl monothioglycolate-containing permanent wave solutions. J Am Acad Dermatol 1988; 19: 52-9.

6. Gasperini M, Giorgini S, Farli M, Sertoli A. Dermatiti da contatto con i tessuti. Giorn It Derm Vener 1986; 121: 215-8.

7. Seidenari S, Mantovani L, Manzini BM, Pignatti M. Cross-sensitizations between azo dyes and para-amino compound. A study of 236 azo-dye-sensitive subjects. Contact Dermatitis 1997; 36: 91-6.

8. Shah M, Lewis FM, Gawkrodger DJ. Nickel as an occupational allergen. A survey of 368 nickel-sensitive subjects. Arch Dermatol 1998; 134: 1231-6.

9. Dahlquist I, Fregert S, Gruvberger B. Release of nickel from plated utensils in permanent wave liquids. Contact Dermatitis 1979; 5: 52-3.

10. Armstrong DKB, Smith HR, Ross JS, White IR. Sensitization to cocamidopropylbetaine: an 8-year review. Contact Dermatitis 1999; 40: 335-6.

11. Guerra L, Tosti A, Bardazzi F, Pigatto P, Lisi P, Santucci B, Valsecchi R, Schena D, Angelini G, Sertoli A, Ayala F, Kokelj F. Contact dermatitis in hairdressers: the Italian experience. Gruppo Italiano Ricerca Dermatiti da Contatto ed Ambientali. Contact Dermatitis 1992; 26: 101-7.

12. Shah M, Lewis FM, Gawkrodger DJ. Occupational dermatitis in hairdressers. Contact Dermatitis 1996; 35: 364-5.

13. Leino T, Estlander T, Kanerva L. Occupational allergic dermatoses in hairdressers. Contact Dermatitis 1998; 38: 166-7.

14. Frosch PJ, Burrows D, Camarasa JG, Dooms-Goossens A, Ducombs G, Lahti A, Mennè T, Rycroft RJG, Show S, White IR, Wilkinson JD. Allergic reactions to a hairdressers' series: results from 9 European centres. Contact Dermatitis 1993; 28: 180-3.

15. Tosti A, Pazzaglia M, Corazza M, Virgili A. Allergic contact dermatitis caused by mehindi. Contact Dermatitis 2000; 42: 356.

16. Storrs FJ. Permanent wave contact dermatitis: contact allergy to glyceryl monothioglycolate. J Am Acad Dermatol 1984; 11: 74-85.

17. Tosti A, Melino M, Bardazzi F. Contact dermatitis due to glyceryl monothioglycolate. Contact Dermatitis 1988; 19: 71-2.