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
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