Loddé et al.

Journal of Occupational Medicine and Toxicology (2017) 12:4
DOI 10.1186/s12995-017-0150-0

CASE REPORT Open Access

Occupational contact dermatitis from
protein in sea products: who is the most
affected, the fisherman or the chef?
B. Loddé1,2,3,5* , P. Cros4, A. M. Roguedas-Contios4, R. Pougnet1,2,3,5, D. Lucas5, JD. Dewitte1,2,3,5 and L. Misery4,5

Abstract
Background: Protein contact dermatitis has frequently been reported in case studies (usually in cases
involving contact with seafood products), but there are very few descriptive series.
The objectives of this present study were firstly to determine the incidence of protein contact dermatitis
among fishermen in France and compare it with data from onshore work involving seafood exposure.
Second, to discover what factors could explain any differences.
In order to answer these questions we analysed data from the French national occupational disease
surveillance and prevention network (RNV3P) and occupational diseases declared to the French National
Network for Monitoring and Prevention of Occupational Disease. This retrospective study was done for a
13 year period.
Case presentation: Between 2000 and 2012, we only found eight cases of protein contact dermatitis in the
French network. There were no cases of protein contact dermatitis in the seafaring population. The eight
cases from the French network are essentially allergies to different fish and chefs are the professionals most
affected. Atopy is present in half of these cases.
In the seafaring population we found several cases of allergic delayed-time contact dermatitis due to
bryozoans and to gloves but no protein contact dermatitis.
Conclusions: Chefs who have to cook seafood are more at risk of occupational protein contact dermatitis
than fishermen. We think that skin protection (that is to say glove wearing) is better implemented in the
fishing sector than in the catering profession on shore in France.
Keywords: Maritime, Seafood, Contact dermatitis

Bakcground Gell and Coombs classification) [2]. The delayed reac-
Protein contact dermatitis is an allergic dermatitis first tion is the subject of controversy, however, because of
described in 1976 by Hjorth and Roed-Petersen [1]. It is the frequent negative results of delayed-reading tests
likely to be under-recorded, as the diagnosis requires the and the clinical symptoms that occur immediately
association of the presence of specific clinical signs following contact with the allergen [3, 4]. Hence, the re-
(which can appear in different forms) with a protein- action is mainly considered as an immediate hypersensi-
type trigger factor examined by a specific dermato- tivity reaction caused by high molecular weight proteins
allergological evaluation. penetrating the epidermis. This penetration is facili-
Its physiopathology involves a type 1 allergic reaction tated by the alteration of the epidermis due to, for
mediated by IgE, and in some cases an associated de- example, previous atopic dermatitis or irritant contact
layed type 4 hypersensitivity reaction (according to the dermatitis [5–7].
Protein contact dermatitis is characterised by clinical
* Correspondence: Brice.lodde@chu-brest.fr lesions resembling chronic or recurrent eczema. There
1
Université Européenne de Bretagne, Rennes, France
2
Université de Brest, EA 4686 – CS 93837 – 29238, Brest Cedex 3, France
may be exacerbations in the form of an urticarial or blis-
Full list of author information is available at the end of the article tering rash that becomes itchy after contact with a
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

These files were then anonymised and ar- In France. of the disease. There are 31 of these 2 cases were excluded from our description.000 registered seafarers per year). but there was no mention of occu- hospital centre. 25 cases of occupational skin units in hospitals. which compensates professional sea- products within the group of the working population farers who are officially affected by an occupational that appeared to be the most exposed. occupational skin disease declared under the ENIM sional fishermen seemed. these centres in teaching hospitals spread across the There were no reported cases of protein contact nation. where they are most likely to handle such products. 7].000 employees/year. we also researched all cases of Being at the start of the distribution chain. The allergens were mercaptobenzothiazole. we selected two populations as being affected by protein contact dermatitis caused by in which we could find indicators of occupational fish or crustaceans or sea product. hence often on the hands but also ex. where employees are compensated in cases chived. temic reactions [8]. crustacean. This allowed us to research. to be the group (the social security scheme for maritime professions). which is to say repeated. The Hence. We then asked each centre where the cases had Protein contact dermatitis was first described in this way been coded for the patients’ medical files in order to in 1976 in sandwich preparers [1]. 10th edition). where over 90% patch test and/or specific IgE testing. one clinical exam. This retrospective national study focused on illnesses The main objective of this study was to determine the reported over a 13-year period. and one allergological cupational allergic contact dermatitis is of the order of 7 evaluation done by means of a skin prick test and/or a to 8 cases for 10. weed. tending up to the wrists and forearms [5. Journal of Occupational Medicine and Toxicology (2017) 12:4 Page 2 of 6 product containing proteins. and the other of all dermatitis to sea products (and to other irritants). mollusc or sea- often be considered to be an occupational disease [7]. Among the 145. cases of protein contact diagnosis. analyse them. detergents. are entered and coded by senior doc. concluded by a clinical summary. within the RNVPPP. The files were ana- frequency of protein contact dermatitis linked to seafood lysed by ENIM. the disease code (the International Clas- be non-cutaneous signs. lems that have been referred for expert advice within a and even seaweeds. which are specialised Within this population. disease caused by allergies were found in 13 years. The case record is gen [2] is ingested. Because those who had sought medical advice at a French there was no mention of positive prick-test or positive IgE centre for occupational diseases. RNVPP between 2000 and 2012. When the sponded to an allergic contact dermatitis and for which exposure is intense. are recorded during the consultation. bryozoans. There are rarely digestive signs when the aller. to research differences between Case presentation them and to determine what factors could explain these. or imprecise or question- ucts). at first glance. all of These manifestations are often triggered by contact the cases in which the disease code (CIM-10) corre- with plant or animal proteins present in food. but there are very few descriptive series [9.). we sought to determine the frequency of these focus of the study was on occupational protein contact specific cases of dermatitis amongst those in professions dermatitis. especially among atopic sub. they can the substance code was fish. The lesions are located in they describe cases that have not been resolved by an the contact areas. The patients with typical delayed-time allergic dermatitis have frequently been reported in case studies contact dermatitis and/or irritant contact dermatitis (re- (namely in cases where there is contact with seafood prod. the (occupational) jects (respiratory signs indicating rhinitis or associated substance. these occupational disease centres. The first group consisted of a population appeared imprecise and seemed to be irritant contact of professional French fishermen.293 medical cases registered in the In order to carry out this study. dermatitis in the population of seafarers (there being an All of the patient consultation records obtained from average of about 35. For comparison. Moreover 2 other cases pathologies. company’s activity. etc. . to have seen a senior doctor in order to establish the From an etiologic standpoint. the frequency of oc. and patient’s occupation asthma). A file had to contain at least one detailed history of confirmed occupational diseases. thiuram (a component of protective gloves). sification of Diseases. lated to soaps.Loddé et al. The resulting files are often complex as pational dermatitis caused by fish or crustacean proteins. which was both de. dermatitis. 10]. and there are very rarely any sys. profes. This network identifies all the occupational health prob. most exposed to such proteins. There can For each case. able clinical histories were excluded from our study. The patients had are eczemas [5]. urban general medicine practice. 8 patients were declared scriptive and retrospective. These tors in the French National Network for Monitoring and were all cases of typical allergic delayed-time contact Prevention of Occupational Disease (RNVPPP) [11]. maritime disease. The secondary objectives were to compare the data obtained with data from cases reported during profes- sional activities on land.

For positive control prick test. A positive test was at least the same size The risk of occupational seafood-based protein contact as the wheal of the positive control test with at least the dermatitis appears to be low in the populations that we same size of the erythema in comparison with the posi. whiting. sions with so few occurrences. Journal of Occupational Medicine and Toxicology (2017) 12:4 Page 3 of 6 Description of the eight cases of occupational protein Concerning patch tests. hake. whiting. seabass. No urticarial reaction For negative control prick test. 96 h later. none of the eight patients mentioned using Argonne Cedex. hake. 000 of whom are chefs). scallop 2 23 male chef 3 years + Salmon. It is therefore difficult to draw statistical conclu- tive control test. scallop 6 33 male chef 13 years . 7 19 male chef . food for fish employee . bass. scallop 8 21 female Pet shop 7 months . one patient was a pet shop which showed sensitivity to nickel in one case. AZ 850008 USA. Four patients had a prior history of skin prob. pollock. tient skin to be pricked through). allergic dermatitis entitling the sufferer to compensation Table 1 Description of the population affected by seafood-based protein contact dermatitis Case Age Sex Occupation Diagnostic latency Atopy Allergen positive testing Allergen negative testing 1 50 male chef 14 months + Salmon Crustaceans. The the exploration. hake. seafood-based protein dermatitis. scallop 4 20 male chef 6 months + Crustaceans Pollock. 000 em. monkfish. The con- crustacean flesh which were then crushed into a solution currence of the clinical history and positivity of the skin with physiologic serum then put into contact with pa. rue Alexis de Tocqueville = 19–50 years). Stallergenes® is commercializing average. scallop 5 25 male chef 4 months . from 4 months to 13 years. seabass. There were Standard European batteries. uct and put in the chamber. patch tests carried out with the fish and crustacean flesh lems (eczema) and one patient was asthmatic (Table 1). Patch testing was also carried out for these 8 patients. pollock. whiting. France). The employee. tor and included a skin prick test. These solutions been diagnosed as irritant contact dermatitis in the pre- and commercial extracts of fish allergens solutions can ceding months.Loddé et al. pollock. They The social security agency for professional seafarers were reported for five patients (Table 1). hake. whiting Crustaceans. has no recorded cases of protein contact dermatitis. In France these devices are essentially average age at the time of diagnosis was 26 years (range provided by Stallergenes® (6. trout. hake. Seven out of the eight patients were chefs or worked At the time of second appointment (48 h later) patch in the catering sector (that is to say about 900. McDowell Rd. and none of the spe- with extracts of foods usually handled for each patient cific IgE testing came back positive for proteins of any (food extracts were prepared by cutting pieces of fish or type (parvalbumin) or for any species of fish. shrimp tions during ingestion of the substances in question for and lobster). None of the patients showed local or systemic reac- cial extracts for five foods (salmon. pollock. Daphnia Shrimp. France). pollock. 36 months. scallop 3 19 female chef 4 months . the occurrence of occupational The patch test procedure was the same for all of them. whiting. whiting. 9% concentration of four out of eight patients reported skin lesions that had codeine phosphate solution was used. The latency of the diagnosis was. The mean-size of the positive control test was 2 mm for the wheal and 30 mm for the erythema (0/0 for the Discussion negative one). physiologic serum was to seafood were reported by the patients. Reactions to salmon were the most frequent. scallops Shrimp. 8 mm diameter aluminium contact dermatitis round finn chambers on Scanpor were used to perform Seventy-five percent of patients (n = 6) were men. used. Salmon. with significant deviations ranging the products of SmartPractice® 3400 E. hake. salmon. studied. Phoenix. and also with commer. + Salmon Crustaceans. trout. They were all negative. By contrast. The pricks were made No scratch tests were performed. tests were removed and third appointment was given ployees (with seasonable variations) per year in France. Pollock Shrimp. hake. Salmon Crustaceans. seabass. trout. were prepared by cutting little pieces of native sea prod- In every case. trout. seabass. whiting. seabass. be purchased at ALK® laboratories (55 271 Varennes en Finally. hake. 200. prick tests hence confirmed the diagnosis. Within this population. the diagnosis was made by a senior doc. on 92160 Antony. gloves when handling fish.

it appears logical that chefs would be the Additionally.Loddé et al. glove protection may limit exposure suf. there is tions. producing countries such as Norway and South Africa. there are other fac- industry of their own accord so as to prevent their tors that influence the increased risk for protein contact health problem from worsening rather than gone to see dermatitis. during are more sensitizing than proteins from other ocean fish which the risk of injury is also high [12]. Such skin problems are therefore never The population of chefs is the most affected popula- mentioned to a health professional. the population of seasonal that. seafood processing plant [16]. Frequently. (infectious. in It is indeed possible that some fishermen. the explanation may be that having been left out of the search). 15]. cancerous and other non-allergic skin diseases As is the case for fishermen. publications [16–18]. With salmon. Furthermore. in a population of workers such as fishermen. view of skin diseases present in the fishing profession this result is surprising. showed that the intensity and. resulting in the exclusion of a population at risk of de- The simplest explanation could be that the disease did veloping protein contact dermatitis. hide their dermatitis out of fear of the clude the more at-risk workers with atopic symptoms. Kalogermitros of determining their medical fitness for work. these job (for medical reasons) may often make people reluc. which was frequent in the second pational dermatological diseases have only occurred 0 to population of professionals affected by protein contact 5 times per year (25 in 13 years). This hypothesis is protein content. atopy. the study se. fish pro- bark. several studies [16. which may ex- their condition. make it difficult for sufferers to do these jobs. found over duration of exposure are risk factors in fish processing 50% of workers had clinical occupational dermatitis but companies. is very infrequent in the seafaring population related to allergic contact dermatitis based on a delayed. In a study by Aasmoe. over the last 13 years. techniques. 17]. professions see a significant turnover in the labour force tant to talk about their health problems with their regu. France. no cases of protein contact dermatitis diagnosed [1. and thus workers under-report the occupational a relative trivialization of skin problems that are consid. It is therefore possible that the fear of losing one’s cessing jobs are often seasonal ones. most affected occupation. our study is retrospective were recorded. the number of articles do in fact indicate a low prevalence population of workers in seafood processing companies of this disease. aware of addition to a strict medical aptitude filter. tion in our study. Furthermore. Additionally. we could also investigate the question of peeling were the most at risk among 883 employees of a the positive protective influence of the maritime envir. not occur during the study period (13 years). primary protection. The registry is non-exhaustive in its over. there may be an added risk of protein con- fishermen seem very diligent in wearing skin protection tact dermatitis. the liquid from fish. As such. has been recognised as a risk factor in frequently put forward to explain the rarity of this path. Moreover. The study sheds light on the fact or careers [19]. however. ered minor. although a Among the other people working with seafood. and even more so with the doctor in charge isn’t satisfied with the type of work. diseases that could subsequently be of harm to them. When compared to major fish- tional diseases. [20]. In addition. in contrast with results in a number of as it uses the registry for the compensation of occupa. Their positions are then filled exclu. Another explanation that needs to be considered is a which may explain the prevalence of protein contact healthy worker effect: affected workers may have left the dermatitis in our study. applied so as to limit the occurrence of these diseases. doing jobs involving filleting and (bare-handed) shrimp Nonetheless. warrants further investigation. ficiently to avoid triggering sensitivity. contact dermatitis [12–14]. Halkier et al. protein contact dermatitis is still a Among employees of seafood processing companies in little-known disease and is hence probably under. more importantly. 21].6% of the employees said they felt hindered by among French workers since they frequently change jobs their condition [16]. tective clothing in factories may be sufficiently well lem diagnosed as well as to claim for compensation. because the . the In a fish preparation plant. which has a high sively by healthy individuals. first time in 1976. Journal of Occupational Medicine and Toxicology (2017) 12:4 Page 4 of 6 is also low since. Given the preparation onment with regard to sensitivity to seafood proteins. such as wearing gloves and other pro- lects only the patients who chose to have their skin prob. They often handle fish bare-handed. who workers often bypasses occupational medical examina- are accustomed to difficult working conditions. Aasmoe et al. and a rapid shift in career orientation when an employee lar doctor. which perhaps explains the absence of cases only 2. reports of occu. In this context. Given the employment statistics in France. showed that skin reactions par- a doctor about their dermatitis or gone as far as to de. Certain atopic pathologies. The question of whether salmonid proteins gear while carrying out their professional tasks. Moreover. Additionally. seafarer’s doctor revoking their medical clearance to em. those ology in occupations that are particularly at risk [16. such as unstable atopic type contact allergy rather than being related to protein asthma. having been described for the would logically be expected to be the most affected. ticularly increased with the post-mortem age of the fish clare the condition. [13]. These were always dermatitis.

He wrote the first make a better diagnosis of this pathology. Participants of this network are listed in the acknowledgments section.). Indeed.F.. And only Chefs (specifically those who work with seafood) appear anonymous data are given by RNVPPP.). tions from the Gell and Coombs classification. Moreover. . Nantes (Géraut C. Brest (Dewitte J.).). d’Escatha A. France. Fur. Lesage F.J.). Bordeaux (Rinaldo M. including one chef Besançon (Aptel M. the National over a 6-year period in Nancy (France). Petit A.. and the cutaneous symptoms Funding The RNVPPP is a national institution and no funding were necessary to with rare or minimal urticarial reactions [25]. Rouen (Gehanno J. France. France. Ethics approval and consent to participate Conclusion Ethics committee that approved the study is included in RNVPPP. obtain data from it. Grant support: This network was supported by funds from French Agency for In order to corroborate this information.. Lodde B. AMRC. atopy that seems to be a risk factor among chefs avenue FOCH.). while we have seen eight The authors would like to thank the rnv3p members: Angers (Roquelaure Y. it may be less often caught by fishermen at sea work.). The For contact : http://www. only the most complicated cases Prévention des Pathologies Professionnelles (French national occupational seek medical attention in these hospital centres. we can say that Food.). the efficiency of corticoids as opposed to antihistamines.).. Avenue Camille Desmoulins. both were in patients with a filaggrin mutation.). Créteil (Pairon J. four cases of Health Insurance system for employees (CNAM-TS). Competing interests cific IgE and/or the time of the blood testing (sometimes The authors declare that they have no competing interests. within and between hospitals).. Nisse and unresolved aetiology. 4Service de dermato-vénéréologie CHRU Morvan. JDD helped us for the methodology.). especially when the person has already suffered leading to a lower prevalence of associated skin problems from unstable atopic asthma. 2Université de Brest. and occupational disease surveillance and prevention network).). Brest Cedex 29609. Availability of data and materials The DATABASE used for this study is from RNV3P : Réseau National de actions during the ingestion of raw or cooked seafood by Vigilance et de Prévention des Pathologies Professionnelles (French national affected patients [7]. 22. Toulouse (Soulat J. 5Société Française de Médecine is infrequent among fishermen.). the National seafood protein contact dermatitis were reported among health insurance system for agricultural workers (CCMSA) and the French chefs by means of a local awareness network (both Institute for Public Health Surveillance (InVS).).. Rennes. Not applicable. Dutheil F..). All authors read and approved the final manuscript.).D. Berson C. IgE: Immunoglobulin E. leading disease surveillance and prevention network) the population to be made up of all the “worst” cases. ENIM: Etablissement National des ermen.Loddé et al. tion of the allergen) [24]. Clermont-Ferrand (Chamoux A.).fr/ physiopathology is therefore complex and needs to be clarified in order to gain a better understanding and Authors’ contributions BL had the idea of the study and collected data. Gouyet T.).). Brest Cedex 3. this skin disease is perhaps under-diagnosed quignon M. Rollin L.. Indeed. a known risk factor for allergic disease [26. (Lasfargues G.C. Paris-Cochin (Choudat D.. Verdun-Esquer C. Penven E.. 2 thermore. to be at higher risk of occupational protein contact derma- Author details titis than fishermen..). Bobigny-Avicenne (Guillon F. of a description of systemic re. Bonneterre V. as is the case for fish. 2 avenue FOCH. Garches (Ameille J.. France.). Lyon (Pilonchéry-Massardier A.). manuscript. Tours nature of scratch tests (which allow for a better penetra. Haguenoer K. Nancy (Paris C. we were amazed by the absence in our population.F. very later after the beginning of the disease) was not at Consent for publication the maximum synthesize of these specific IgE. LM helped to positive prick test results to seafood had corresponding draft the manuscript and corrected the final version. Hérin F. from Nancy in the RNVPPP [22].. the positive (Caubet A. RNV3P: Réseau National de Vigilance et de disease centres..). Cherbourg (Mar- Finally. Reims (Deschamps F. CHRU Morvan. Bergeret A.F.). Journal of Occupational Medicine and Toxicology (2017) 12:4 Page 5 of 6 species can also be fished in fresh water and produced in frequently a reason for medical unfitness for onboard aquaculture. PC improved the manuscript. specific IgE in the serum. Environmental and Occupational Health & Safety (Anses). 3Service de Santé au Travail work of many chefs warrants further investigation. Rennes tests with more moderate reactions [23].. Dijon (Smolik H. CIM-10: Classification Internationale des Maladies 10ème version (International risk occupations can be explained. Only two cases were reported. Thiebaut A.). which is A request was made to collect anonymous data from this network. cases throughout France in 13 years. EA during fishing activities as compared to the bare-handed 4686 – CS 93837 – 29238.).. Amiens (Doutrellot-Philippon C.). the rarity of this dermatitis even among at. Grenoble (de because of the recentness of its description and complex Gaudemaris R. Argu. Le Havre (Gislard A. Paris-Hôtel-Dieu (Léger D. Limoges (Druet-Cabanac M. Brest 29200.M. the Grenoble university hospital. as well as in the literature.P. the condition is Maritime. classification of diseases 10th edition).. Brest Cedex 29609. Marseille (Lehucher-Michel M.). Dupas D. Lille (Frimat P... Strasbourg (Gonzalez M. Bensefa-Colas L. Montpellier (Roulet A. et Maladies liées à l’environnement.. The influence of glove protection 1 Université Européenne de Bretagne. 27]. by the specificity of the files from occupational Invalides de la Marine (the social security scheme for maritime professions). Poitiers (Ben-Brik E.). in this population and a greater incidence in other groups. may be triggered by a combination of type 1 and 4 reac. Marquignon M.. Acknowledgments which could not be solved in general medical practices.. RP and DL participated in Nevertheless in our study none of the patients with the design of the study.).. Many indeed believe that it C.).anses. Villa ments to support this are the existence of positive patch A. Nourry N. Caen (Clin B. Andujar P.X. Pélissier C.. Perhaps because the explored allergen is not the same for the prick-test and the spe. Paris-Fernand Widal (Garnier R.). France. Saint-Etienne (Fontana L. Prévot-Balensi E. Abbreviations Ultimately. the French Occupational Medicine Society (SFMT).

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