Contact Dermativis 1992: 26: 341-345 A prospective study of the development of hand eczema in an automobile manufacturing industry (Ove Krasrissen Department of Dermatology, Uddevalla Hospital, Sweden We have not been able to find any prospective study of the risk of developing occupational dermatitis in the car manufacturing industry, To try to define individual predictive risk factors for the develop- ment of hand eczema and to determine the prevalence of hand eczema within 1 year in an automobile manufacturing industry, we investigated prospectively 1564 new employees during one year of employ- ment, Only persons with previous atopic dermatitis or hand eczema were restricted to dry and clean workplaces. The employees were personally interviewed and examined before their employment Written questionnaires were used at 3 and 12 months to obtain information on type of work, exposure, protection and hand dermatitis, All patients developing hand eczema were examined. ‘and followed to determine the course and consequence of their eczema, The risk turned out to be only 4% on average, but significantly higher in females (6%), Certain sections within the factory such aas wet work (canteen/kitchen and cleaning) and work in the paint shop with high exposure to org: solvents carried significantly higher risks. Heavy exposure to mineral oil, a known risk factor, was efiectively counteracted by the extensive use of protective gloves 10 yield a lower than averas prevalence in the press and body shop. Individual risk Factors for the development of hand ecrema ‘were previous hand eczema, atopic dermatitis, but also wool intolerance and hay fever as isolated phenomena. Most cases of hand eceema were mild, of irritant contact type and only 1 emp developed an allergic contact dermatitis due 10 the working environment, This study is the first large-scale prospective investigation of occupational hand eczema in employees. in the automobile manufacturing industry patch tested Key words: prospective study; occupational; hand eczema; automobile manufacturing industry: epi= demiology; individual risk factors; atopy; hay fever; woo! intolerance; irritant contact dermatitis, Accepted for publication 19 November 1991 To give good vocational guidance, the adviser been thoroughly investigated to quantify the needs to have a good knowledge of both which prevalence and risk of eczema and very few individuals may be at risk of developing hand such investigations have been prospective eczema and the innate probability of con- Automobile manufacturing plants belong to tracting skin disorders in different jobs. It is the bigger industries with many thousand et thus desirable to map out the potential risk of —_ployees. To my knowledge, only | retrospe developing hand eczema in different occu- study has previously looked in det pations and if possible to find out whether question of work-related ecze certain individuals are more prone to develop industry employees (2). Given the opportunity, this condition than others in these jobs. So far I wanted to investigate in a prospective manner only a limited number of occupations have the risk of acquiring hand eczema in newly ive I into the in automobile32 KRISTENSEN employed workers in different workplaces within a car manufacturing company Material and Methods Patient material As part of a pre-employment interview, 3596 individuals were interviewed at some time dur- ing the years 1985-1988, They were personally questioned in detail as to family history of atopy, previous allergic manifestations, skin diseases and examined by specially trained nurses, In taking the history, special attention was paid to elicit markers of atopy, previous hand cezema and to record earlobe piercing and a history of metal sensitivity Written questionnaires were sent out at 3 and 12 months after their employment and returned to the medical department. The workers were asked in a multiple choice fashion in which section they worked, how many times a day they washed their hands, how much they regarded themselves as being exposed to wet work, organic soly mineral oil, They were questioned as to whether they protected their hands, with what kind of gloves and how much they used the protection offered. Workers who sought medical attention for Hand eczema or volunteered in the ques- tionnaire that they had developed eczema on the hands were patch tested and personally erviewed and examined by the author. Based on the combined information on pa- tient atopic history, exposure, the site of skin symptoms, morphology and the results of patch testing, the eczema was classified into 6 different categories (atopic hand eczema, num- mular hand eczema, pompholys, irritant con- tact dermatitis, allergic contact. dermatitis, hyperkeratotic dermatitis of the palms). Employed for more than 1 year, and thus available for follow-up, were 1564 workers, 988 male and 567 female. The workers were placed in different parts of the factory accord- ing to the needs of the company and the skills and interests of the employees. Individuals ts and with a history of atopic dermatitis or previous hand eczema were restricted to workplaces where contact with foodstuff, organic solvents, detergents, and water could be avoided or minimized Lost 10 follow-up were 2032. Many had never accepted employment or had terminated their employment with the company within the of follow-up due to various reasons such as compulsory service in the armed forces or changed employer. To our knowledge, no one left the company due to skin problems, ye Patch tests All employees who developed hand eczema were patch tested with a standard series of allergens obtained from Hermal, West Ger- many. Apart from a few supplementary com- pounds, the allergens were mainly those of the European standard series, The allergens placed in Finn Chambers (Epitest, Finland) were ap- plied to the upper back using the method de- scribed by Pirilii & Férstrém (3). They were removed after 2 days and readings were made 1 day later. Evaluation of the tests was as follows: + = erythema and infiltration; ++ = erythema, in- iltration and papules; + + +—erythema, in- filtration, papules and vesicles. Statistical evaluation All info lysed using 7° test for various differences. id ana- nation was data processed a Results The age distribution of employees showed a marked preponderance of young workers. The distribution of risk factors among employees is shown in Fig. 1. The distribution (males females) in the different parts of the company can be seen in Fig. 2. In principal, (total:males/ females) were distributed between 8 different workplaces: canteen/ kitchen (22:2, they 20), cleaning (47:5/42), paint shop (227:103, 124), accessories (63:56/7), press and body shop (379:284/95), final assembly (627:414HAND ECZEMA IN A CAR FACTORY = atopic dermatitis mates Fig. 1. % of employees with different risk factors 213), textiles (84:29/55), other jobs (106:94/ 12). A preponderance of women was noted in canteen/kitchen, cleaning, textiles, and paint shop. In the questionnaire, the employees were personally asked to grade subjectively the de- gree of exposure to potential risk factors in the different workplaces, by choosing no, moder- ate or high exposure, The degree of prophy- laxis with protective gloves varied profoundly depending on the type of work and the indi- vidual Of the 1564 employees, 69 (4%), 35 out of 988 males (4%) and 34 out of $67 females (6), developed hand eczema within the period of observation. The frequency was significantly higher in females (p <0.05). The I-year period prevalence of hand ec- zema in the different sections varied (Fig. 3) and wet work (canteen/kitchen and cleaning) cantoenviichen {] ieaning [] oe pom no in other jabs males >a “sho umber 0 Fig. 2. Distribution of employees between different workplaces M3 and/or female sex constituted a bigger risk of 5% and 11% respectively. Exposure to organic solvents (paint shop) also carried a significant- ly increased risk of on average 8% (p <0.01) The data here showed statistically significant differences in the risk of developing hand der- matitis between the two sexes. The risk in a male worker was 4% (4/103) as opposed to a (15/124). Workers in the press and body shop (predominantly males), who are more than averagely exposed to mineral oils but often use protective gloves, showed a statistically significantly lesser period prevalence of 3% compared to the average of 4% (p<0.05), Ear piercing had been performed in 81% of all females and 17% complained of metal intoleranc were 17% and 1% ‘The distribution of hand eczema diagnoses in relation to sex is shown in Table 1. An estimate of dermatitis risk in a hypothetical worker with one of various risk factors is shown in Table 2 Overall, the severity of the dermatitis was mild or moderate and only 3 employees (4%), all females with hand eczema, needed to be on sick leave for | to 4 weeks due to this con- dition, 4 of the patients (6%) had to be trans- ferred to another workplace within the com- pany due to hand eczema, The eczema in $8 patients was judged as solely work-related, partly work-related in 9 and not work-related in 3. Contact allergy was detected in 12/70 patients in whom it was female worker's of 12 In men, the corresponding figures i ‘paint snop — [atopic hand eczema rummutar ti Oe other jobs tieraic vantact dermati ‘etcentage of employees Fig. 3. Distribution of hand eczema diagnoses related (o different workplaces.ua KRISTENSEN Table J. Distribution of hand eczema diagnoses in relation to sex Type of eczema Total 0) Females (9) o 35 34 irritant contact dermatitis 436d 2 0 3 (68 allergic contact dermatitis 3 4 1 4 2 6 atopic hand eczem ? 10 4 u 3 9 nummular hand eczema u 16 6 7 5 15 pompholyx 4 6 3 9 1 3 hhyperkeratotic dermatitis of the palms 0 0 0 0 0 0 judged work related in 4, In a single male patient with no history of skin disease, contact eczema developed after handling black rubber tyres. Contact allergy could be confirmed with positive reactions to the tyre und PPD-black- rubber-nix. This was the only case of allergic contact dermatitis that we could prove to be solely caused by the working e1 vironment Discussion Different Swedish studies of the prevalence of na show a wide variation, from 2! hand ecz (4);in the 1960s to 11% in the latest large-scale survey in the 19805 (1), Several authors have clearly shown that atopics are more prone to develop hand dermatitis, expecially in certain risk occupations (5, 6, 7), and the increasing prevalence of atopic disease may well be one important explanation for the increased fre quency of hand eczema The overall hand eczema among new employees was rather low (4%) and even below average when com- r period prevalence of Table 2. The estimated risk of developing hand ec zema in newly employed automobile workers car rying different risk factors compared to an average risk of # Risk factor % povalue previous hand eczema 2 or pic dermatitis 4 ool wool intolerance "1 0.02 00: NS. NS. ay fever 9 hia 9 ary skin 8 pared to the findings of a recent large epide- miologic survey by Meding (1) in th bouring city of Gothenburg. One conceivable reason for this could be that the majority of the workers were young and that @ lon; neigh- ger period of time is needed to develop eczema However, we could find tio tendeney for the onset of eczema to be more frequent in the 2nd half of the patients (82%) developed th the Ist 6 months, In the thesis by Meding (1), of eczema onset was about the same for les irrespective of age, but more frequent women comps F of follow-up, as most eczema within alln ed to older fe- among your males. A lower incidence than expected could also be explained by the restriction of workers with earlier hand eczema or atopic dermatitis, to dry and clean workplaces. As in this study, a significantly higher preva- lenee of hand dermatitis among females is documented by several other researchers in different prevalence studies (1, 4, 8). Ear pierc- al intok was very common among female employees. However, the increased prevalence of hand dermatitis in females could not be linked to ng as well as subsequent me ance metal sensitivity. The degree of wet work per- formed at home, a risk factor for youn; women as shown by Nilsson (7), was not inves- tigated. As the py and previous hand eczema among the sexes was about the ame, a contributing factor to the higher female risk could be this gender’s predominance in the following workplaces with « more than aver- age risk of hand eczema: canteen /kitchen and cleaning. That gender by itself seems to beHAND ECZEMA IN A CAR FACTORY 45 important is corroborated from the paint shop data, which show that significantly more fe- males (12%) than males (4%) develop hand dermatitis in that workplace. Sections with a higher than average risk were, as expected, those with wet work such as canteen /kitchen and cleaning. Work in the paint shop with its heavy exposure to organic solvents and, to a lesser degree, even frequent hand washing and wet work doubled the risk, but anamnestic exposure to organic solvents per se among all workers did not inerease the risk significantly. Neither could we detect any clear-cut correlation between the risk of de- veloping hand dermatitis among all workers and frequency of hand washing, exposure to wet work, mineral oils, use of protective gloves, ear piercing or anamnestic metal sensi- tivity. The established risk Factor, exposure to mineral oil, was effectively counteracted by the extensive use of protective gloves to yield a lower than average prevalence in the press and body shop, Considering predictive risk factors, we found the following to be statistically sig- nificant in order of importance: previous hand eczema, atopic dermatitis, hay fever and wool intolerance, Several researchers have reported a significant relationship be- tween previous atopic dermatitis and the de- velopment of hand eczema (1, 4-7). Hay fe- ver and wool intolerance as phenomena may be predictive risk fa well. We have not, however, had access to more advanced statistical analysis, and thus have not been able to elucidate the com- plexity of the interplay of different risk fi tors in the same individual The most frequent diagnoses in both sexes were, in order of prevalence, irritant contact dermatitis, nummular hand eczema and atopic hand eczema isolated tors as Acknowledgements The author thanks Gunnar Lindberg, MD, Centre for Public Health Research, Karlstad, Sweden for valuable help with data processing and statistics and Professor Bert Bjérkner, De- partment of Occupational Dermatology, M mé Allminna Sjukhus, Sweden, for reviewing the manuscript. I especially thank the nurses at Saab Scania, Trollhattan, Sweden, without whose help this study would not have been possible, Reterences |. Meding B. Epidemiology of hand eczema in ‘an industrial city. Acta 1990: 70 «suppl. 153). Sinitsyn B 1, Logunov V P, Fedotov VP. Epi- demiology and path ‘of occupational skin diseases. in automobile factory. worke Vestn Dermatol Venerol W988: I: S659. 3. Pirild V, Forstrém L. The chamber test, practi- cal method for all-round patch testing. deta Al- ergot 1966: 21- 481-486, 4. Agrup G. Hand eczema and other hand derma toses in South Sweden, gic 1969: 49 (suppl. 61. 5. Rystedt I. Hand eczema and long term prognosis, in atopic dermatitis, deta Dermato-venereologica 1985; 65 (suppl. 117). 6; Lammintausta K. Ris factors for had derma. itis in wer work. Academie dissertation, Turku 1982. Nilsson E, Individual and environmental risk factors for hand eczema in. hospital workers. Acta Dermato-venereologica 1986: 65: (suppl. 128), 8. Kavli G, Forde © H. Hand dermatoses in Trom- si, Contact Dermatitis 1984: 10: 174-177. Dermato-venereologica Acta Dermato-venereola~ Adress: O Depariment of Dermatology Uddevalla Hospital S-451 80 Uddevalla Sweden KristensenThis document is a scanned copy of a printed document. 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