Current Allergy and Asthma Reports (2023) 23:201–212

https://doi.org/10.1007/s11882-023-01070-5

Occupational Hand Dermatitis

Theodora K. Karagounis1   · David E. Cohen1

Accepted: 25 January 2023 / Published online: 7 February 2023

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023

Abstract
Purpose of Review  Occupational hand dermatitis is a common work-related disorder of the skin. Prevention and management
of this disease is critical to improving workers’ quality of life and for occupation-specific retention.
Recent Findings  This is a critical review of the current literature on occupational hand dermatitis. Occupational dermatitis
continues to have a high prevalence among workers although the overall incidence may be slowly decreasing. Irritant contact
dermatitis due to wet work exposure is the most common cause of occupational hand dermatitis. Healthcare workers, hairdress-
ers, and metal workers are at particularly high risk for this disease. While some prevention programs have been ineffective in
mitigating occupational hand dermatitis, other more resource-intensive initiatives may have benefit.
Summary  Continued research is needed on ways to manage wet work exposures and on scalable, effective prevention programs
for occupational hand dermatitis. The spectrum of culprit contact allergens continues to evolve, and vigilance for potential
occupation-specific allergens remains important.

Keywords  Occupational hand dermatitis · Hand dermatitis · Contact dermatitis · Occupational dermatitis · Allergic contact
dermatitis · Irritant contact dermatitis

Introduction The goal of this review is to critically examine literature over

Hand dermatitis is a debilitating skin condition with a signif-
icant impact on morbidity and the capacity to perform activi-
ties of routine daily living and work. It is characterized in
acute forms as erythema, scale/crust, erosions, vesicles, and
bullae with variable edema and in chronic forms as persis-
tent redness, scaling, lichenification, fissures, and erosions
(see Fig. 1). In both settings, variably intense pruritus can
be present. Occupational hand dermatitis, by its nomencla-
ture, is caused, provoked, or exacerbated by exposures in the
workplace setting. The disease is often multifactorial with
more than one type of dermatitis occurring at the same time
and may depend on the presence of pre-existing dermatoses
or disorders of skin barrier function. Identifying the specific
dermatosis and distinguishing individual contributors to the
hand dermatitis, although often challenging, is important
to deploy appropriate avoidance protocols and operational
countermeasures, as well as a foundational therapeutic plan.
* Theodora K. Karagounis
theodora.karagounis@nyulangone.org
1
The Ronald O. Perelman Department of Dermatology, New
York University Grossman School of Medicine, New York,
NY, USA
the past 3 years on occupational hand dermatitis and relate
it to our current understanding of the disease and clinical
practice. Note, while this review provides background on
the topic, it does not aim to be a comprehensive overview.
Occupational hand dermatitis includes irritant contact der-
matitis (ICD) and allergic contact dermatitis (ACD) manifest-
ing on the hands and caused by workplace exposures. ICD
occurs due to direct cytotoxic effect of an adverse chemical or
physical assault on the viable cellular components and non-
viable barrier constituents of the skin. These events trigger
activation of the innate immune response and proinflamma-
tory signaling cascades with resultant dermatitis [1••]. ACD
is caused by allergen-specific T cell activation and represents
a type IV delayed-type hypersensitivity reaction. ACD begins
with a sensitization phase, during which a low-molecular-
weight hapten binds to an epidermal protein and triggers the
innate immune response and activation of skin dendritic cells.
These dendritic cells engulf the hapten-self protein complex,
migrate to the draining lymph node, and present the complex
to T cells, thus priming them against the allergen. Allergen-
specific T cells then proliferate with the development of effec-
tor and memory subsets. Upon re-exposure to the allergen, a
robust inflammatory response manifested as dermatitis occurs
(also known as the elicitation phase) [1••].

13
Vol.:(0123456789)

202
Fig. 1  Allergic contact dermatitis on the hand to multiple fragrances
Contact urticaria (CU) and protein contact dermatitis
(PCD) are less common causes of hand skin disease that can
be elicited by workplace exposures. CU manifests as pruritic
wheals that appear within 60 min of exposure and resolve
within 24 h. CU is a type I immediate-type hypersensitivity
reaction and can occur through an IgE-mediated reaction to
an allergen, which requires previous sensitization (immuno-
logic CU), or through substance-triggered direct mast cell
activation and histamine release (non-immunologic CU)
[1••]. PCD typically begins as a pruritic wheal soon after
skin-allergen contact and then progresses to an eczematous
dermatitis. The pathophysiology of PCD is poorly understood
but thought to have components of type I and IV hypersensi-
tivity reaction and is often caused by high-molecular-weight
proteins (in contrast to ACD) [1••].
Epidemiology
Occupational hand dermatitis is common. The most recent
data released by the US Bureau of Labor Statistics showed
the incidence rate of occupational skin diseases in 2020 was
1.8 per 10,000 full-time equivalent workers per year, second
13
Current Allergy and Asthma Reports (2023) 23:201–212
only to respiratory diseases among nonfatal occupational
illnesses [2]. According to the Center for Disease Control
(CDC), 90–95% of occupational skin diseases are contact
dermatitis [3]. Up to 80% of cases of occupational contact
dermatitis involve the hands [4], and thus occupational hand
dermatitis represents a significant burden of all occupational
disease. ICD is more common than ACD, but the specific
distribution depends on geographic location [4]. CU and
PCD are much less common.
In the UK, the EPIDERM surveillance system tracks
reported cases of occupational dermatitis by dermatologists
and occupational physicians [5]. Interestingly, review of the
past 20 years of EPIDERM data shows a steady decline in
reported number of occupational contact dermatitis cases
[6]. The authors of the 2021 EPIDERM report note this
may be due to “reporting fatigue” or tendency of physicians
to report fewer cases over time; however, when adjusting
for this phenomenon, the authors nevertheless suggest a
downward trend in all occupational skin diseases between
1996 and 2019. The authors speculate the falling incidence
may be due to decreased use of powdered latex gloves
and reduced exposure to chromates in cement following
the introduction of European legislation in 2005. At the
same time, the authors note an increase in ACD caused by
acrylates among beauticians [6].
Risk Factors
Skin barrier dysfunction, such as atopic dermatitis, increases
the risk of development of contact dermatitis. This dysfunc-
tion not only facilitates cutaneous penetration of irritants and
allergens, but also promotes a local inflammatory milieu
conducive to the development of dermatitis. A systematic
review and meta-analysis examined the risk-modifying effect
of atopic dermatitis on hand dermatitis with a sub-analysis
on occupational hand dermatitis. The risk of occupational
hand dermatitis did, indeed, increase by approximately
threefold in persons with atopic dermatitis compared to
those without the disease (1-year odds ratio 4.31; 95% CI
2.08–8.91 and lifetime prevalence odds ratio 2.81; 95% CI
2.08–3.79) [7]. In light of these results, practitioners should
consider counseling atopic patients on best practices to
reduce hand dermatitis in the workplace.
Exogenous factors, such as wet work, have also been
shown to increase risk of occupational hand dermatitis [8].
Using a cross-sectional questionnaire in the Netherlands,
a recent study reaffirmed the association of wet work with
occupational hand dermatitis but found that description
of job tasks rather than job title provided a more accurate
representation of risk of hand dermatitis. In particular,
contact with fluids, use of gloves, and high frequency
Current Allergy and Asthma Reports (2023) 23:201–212 203
of hand washing represented high risk occupational wet
work exposures [9]. Notably, the authors also found that
non-occupational wet exposures, such as frequent hand
washing outside of work, also contributed to risk of hand
dermatitis [9]. Thus, when evaluating patients with poten-
tial occupational hand dermatitis, exposures outside of the
work setting, such as recreational and domestic activities,
must also be considered.
Diagnosis
Occupational hand dermatitis is associated, by definition,
by exposure at work. Identifying a culprit and determin-
ing a specific connection between a patient’s presentation
and an exposure can be challenging. The Mathias criteria
were first outlined in 1989 and continue to provide a reli-
able and rigorous framework for establishing occupational
causation [10]. The Mathias criteria consist of seven ques-
tions (see Table 1). Answering “yes” to four or more of
the questions yields a 50% or greater probability of an
occupational cause [10].
Patch testing remains the gold standard for diagnosing
ACD and is useful in identifying potential culprit aller-
gens causing occupational hand dermatitis. Patch testing
is a 4-to-5-day procedure. Test allergens are placed under
occlusion in synthetic chambers (termed patch) on the
back for 2 days. Patches are removed at 48 h, and the skin
is assessed for an irritant reaction. The skin is then re-
evaluated around 24 to 120 h later to assess for an allergic
reaction. Negative results should not immediately elimi-
nate the diagnosis of ACD; clinicians may contemplate
the breadth, vehicle, and concentrations of the chemicals
in the allergen battery, relatedness of the allergen series to
the patient’s occupational exposures, any intrinsic or noso-
comial immunosuppression, or the possibility of a newly
emergent or not previously recognized allergen. Also, ICD
can be clinically similar and may not provoke a positive
patch test despite a disease relatedness to an occupational
chemical or physical assault. At the same time, an analysis
of the European Surveillance System on Contact Aller-
gies showed that among patients ultimately diagnosed with
ICD, patch testing still may yield positive results [12].
Careful consideration must be given to whether allergens
are relevant to the patient when performing patch testing.
Common Occupational Allergens
Several allergens as assessed by patch testing are commonly
implicated in occupational hand dermatitis:
Methylisothiazolinone
Methylisothiazolinone (MI) caused a contact allergy
epidemic in the 2010s, peaking at 20% of patch-tested
patients testing positive in some countries to this aller-
gen in 2013–2014 [13–15]. Since then, European regula-
tory bodies moved to remove MI from leave-on cosmetic
products, while in the USA, measures have been taken to
reduce the concentration and thus the risk of sensitization
and elicitation [16]. A careful analysis of the epidemiology
of MI contact allergy shows an overall decline in patients
testing positive to MI; however, when evaluating specific
occupations, the authors find that the prevalence of MI
contact allergy has continued to rise in some occupations,
including painters [14]. Indeed, high concentrations of MI
continued to be used in paints [17]. When evaluating a
patient with hand dermatitis with positive patch test to
MI, paint as well as personal care products may represent
important exposure sources.
Nickel
Nickel is the most common allergen detected by patch
testing in North America with a positivity rate of 17.5%
among patch-tested patients [18]. Despite the ubiquity of
this contact allergen, few studies have been published on
the role of nickel in occupational skin disease. A recent
study examined this question and found the rates of occu-
pationally related nickel allergy were stable over time
and most commonly affected the hands [19]. A wide vari-
ety of occupations were associated with nickel allergy
including hairdressers, cosmetologists, machine workers,
and healthcare workers. The most common sources of
nickel were phones, machinery, tools, and work weara-
bles (such as glasses, badges, and clips) [19]. The use of
the dimethylglyoxime test (nickel spot test) may provide
benefit in identifying potential clandestine sources of
nickel in the workplace.
Fragrances
Fragrances are the second to third most common family of
allergens to cause ACD (depending on the specific population
evaluated) [18, 20]. One study found when testing for specific
fragrances, citral, and hexyl cinnamal were more likely to be
associated with an occupational exposure. Citral allergy was also
more common in patients with hand eczema [21]. Unfortunately,
data was not provided on the specific occupations that accounted
for this association. The authors note that citral provides a citrus
aroma and is commonly found in household products.
13

204

13
Table 1  Mathias criteria for establishing occupational causation of contact dermatitis
Criterion Yes No Don’t know

1: Is the clinical appearance consistent with
CD?
2: Are there workplace exposures to potential
cutaneous irritants or allergens?
3: Is the anatomic distribution of dermatitis
consistent with cutaneous exposure in
relation to the job task?
4: Is the temporal relationship between First or increased exposure preceded onset or Onset or aggravation preceded the first
exposure and onset consistent with CD?
5: Are nonoccupational exposures excluded as Not likely on the basis of a thorough history or Likely on the basis of a thorough history or
probable causes?
6: Does dermatitis improve away from
work exposure to the suspected irritant or
allergen?
7: Do patch or provocation tests identify a
probable causal agent?
Eczematous morphologic or histologic Noneczematous morphologic or histologic No dermatitis on clinical examination;
findings or Adequate clinical description in findings inadequate clinical description in history or
history or medical records medical records or Noneczematous reaction
sometimes mimicked by CD (e.g., lichenoid
eruptions)
Supported by toxicologic data or clinical Not supported by toxicologic data or clinical Toxicologic properties of the exposure not
experience experience known
Dermatitis is most severe on skin surfaces Dermatitis does not affect skin surfaces with Dermatitis affects skin surfaces with maximal
with maximal exposure (depends on physical greatest exposure exposure but is more severe on other body
form of irritant or allergen) areas (excluding eyelid, facial, genital skin) or
Dermatitis spares skin surfaces with maximal
exposure but affects eyelid, facial, or genital
skin
Onset or aggravation occurred more than
aggravation and Onset or aggravation within exposure or Onset or aggravation occurred 6 months after first or increased exposure
6 months of first or increased exposure more than 3–4 days after last exposure
(exception: initial allergic reaction)
Inadequate history or Exposure to irritants
patch tests patch tests or allergens both within and outside the
workplace
Improvement not a result of concomitant No improvement after more than 1 week away Improvement coincides with medical treatment
medical treatment (e.g., intramuscular from work exposure and No concomitant or Failure to improve may be attributed to
steroid) and Re-exposure causes exposure to other allergens other irritants or allergens or No improvement
exacerbation but away from work exposure < 1 week
Positive reaction, with tests performed Negative reaction, with tests performed Tests not performed according to established
according to established guidelines and according to established guidelines and All guidelines or All potential workplace
Exposure as occurred in the workplace potential workplace allergens tested allergens or irritants not tested

Previously published in Milam E C et al. [11]. “Occupational Contact Dermatitis: An Update.” The Journal of Allergy and Clinical Immunology: In Practice 8(10): 3283–3293
Current Allergy and Asthma Reports (2023) 23:201–212
Current Allergy and Asthma Reports (2023) 23:201–212 205
Rubber
Carbamates and thiurams are commonly used vulcanization
accelerators and often implicated in rubber glove allergies
[22]. Thiurams and dithiocarbamates are chemically closely
related, representing a redox pair, and therefore thought to
cross-react [22]. However, larger studies within European
populations evaluating this cross-reactivity have yielded mix
results [23]. Such studies in North American populations
were lacking. A recent analysis filled this gap and found
over 40% of individuals with positivity to one allergen
were positive to the other [24]. The researchers went on to
find that carba mix and thiuram mix allergies were com-
monly associated with occupation and, in particular, with
exposure to personal protective equipment such as gloves,
which is consistent with prior literature [22]. Interestingly,
the researchers found an overall decrease in the prevalence
of contact allergies to carba and thiuram mix from 1996 to
2001 in North America with stabilization of the prevalence
of disease up until the end of the study period in 2016. The
authors attribute this decrease to changes in manufacturing
practices in the last 20 years [25, 26].
Healthcare Workers
Healthcare workers have an increased prevalence of occupa-
tional contact dermatitis compared to the general population
[27, 28]. This difference is primarily due to the wet work
required of healthcare workers including hand sanitation
and glove-wearing. More frequent and diligent hand sanita-
tion procedures were encouraged and implemented during
the recent COVID-19 pandemic leading to a rise in occupa-
tional hand dermatitis in this population [29–31]. The rate
of reported hand dermatitis symptoms was over 90% in one
study suggesting an immense burden of disease among the
healthcare worker population [30].
A UK and Ireland-based study found the majority of
healthcare workers with occupational skin disease suf-
fered from ICD (59%) due to frequent hand washing [29].
Workers with frequent direct patient contact, namely nurses
and healthcare assistants, were most at risk. Importantly,
the authors note that over 15% of patients presenting for an
occupational dermatosis required time off work due to their
skin disease [29]. This finding highlights the morbidity of
occupational hand dermatitis and its potential to have a large
impact not only on the individual, but also on workplace
productivity, absenteeism, and presenteeism.
ACD also plays an important role in healthcare worker occupa-
tional skin disease. One case report described a healthcare worker
with ACD to tetrahydroxypropyl ethylenediamine, which is found
in hand sanitizer gels and is a chelator [32]. A larger retrospective
study of patch-tested patients found that benzalkonium chloride
positivity was associated with occupational exposure in healthcare
workers likely due to hand sanitizer [33]. These studies highlight
the importance of considering hand sanitizer as a cause of ACD.
Gloves also represent a significant source of ACD. In a study
by Hamnerius et al., rubber additives were the most common
cause of contact allergy in healthcare workers [34]. However,
diagnosing glove-related ACD may be challenging: Santarossa
et al. demonstrate that there is a discrepancy between standard
patch testing, expanded-series rubber additive patch testing, and
direct testing of pieces of gloves [35]. They attribute this differ-
ence to the low sensitivity of patch tests and/or to the presence of
new additives in the gloves. Based on their findings, the authors
call for more precise labeling of glove contents [35]. Goodier
et al. sought to address this specific problem by contacting
surgical glove manufacturers to compile lists of rubber addi-
tives present in each glove [36••]. Carbamates were the most
common accelerator constituent, present in 90.5% of gloves.
Their detailed study provides a useful resource on glove ingre-
dients and aids with the identification of brands that are safe for
patients with ACD to surgical gloves [36••] (see Tables 2 and 3).
Although rare, healthcare workers are at risk of developing
ACD to antibiotics due to frequent exposure. One case series
reports on 4 nurses who had eczematous eruptions, all involving
the hands, and were positive on patch testing to antibiotics [37]. All
4 nurses worked in the surgical department and frequently handled
antibiotic solutions, sometimes with spillage on ungloved hands.
Three nurses improved with avoidance of the culprit antibiotic [37].
Given the high burden of occupational hand dermatitis among
healthcare workers, multiple efforts have been made to attenuate
this disease in this population [38–41]. Unfortunately, attempts
thus far have either had only short-term efficacy or been inef-
fective altogether. The Hand Eczema Trial was a randomized
observer-blinded controlled trial initiated in 2009 in a popula-
tion of healthcare workers with hand eczema. The intervention
group received a consultation with a dermatologist who provided
education on previously diagnosed allergen avoidance and gen-
eral skin-protective behaviors. The control group received no
interventions. Five months post-intervention, the intervention
group had a significantly reduced Hand Eczema Severity Index
(HECSI) scores compared to the control [42]. Graversgaard and
colleagues wanted to probe the long-term effects of this inter-
vention and sent a follow-up questionnaire to the participants
4 years after the initial intervention asking them about their self-
reported eczema severity, quality of life, and knowledge of hand
eczema prevention [41]. Unfortunately, the authors found no dif-
ferences between the intervention and control groups suggesting
the effects of the original study were short-lived [41]. Another
group utilized a different strategy and conducted a trial wherein
healthcare workers were randomized to wards with or without
emollient cream dispensers [39]. The primary outcome of abso-
lute change in HECSI score from baseline was not significantly
different among the two groups [39]. The intervention group did
apply cream significantly more often than the control, but at rates
13

206 Current Allergy and Asthma Reports (2023) 23:201–212

Table 2  Medical exam Product Company

gloves free of accelerators
as advertised by the
manufacturer*,a
Microflex Sensation Nitrile Exam Ansell Healthcare LLC
Micro-Touch NitraFree Nitrile Exam
Low Dermatitis Potential Nitrile Exam CardinalHealth
Tillotson True Advantage Nitrile Exam Gloves Dynarex Corporation
HandPRO FreeStyle1100 Nitrile Exam Hourglass International, Inc
SemperSure Nitrile Exam Sempermed USA, Inc
Reflection Sapphire Sensitive Nitrile PF Violet Blue SmartPractice
Ultimate N-DEX Free Nitrile Powder Free Exam Glove

*Free of thiurams (tetramethylthiuram monosulfide, tetramethylthiuram disulfide, tetraethylthiuram

disulfide, dipentamethylenethiuram disulfide, and dipentamethylenethiuram tetrasulfide), carbamates
(zinc diethyldithiocarbamate, zinc dibutyldithiocarbamate, zinc dimethyldithiocarbamate, and zinc
dibenzyldithiocarbamate), mercapto mix (N-cyclohexylbenzothiazyl sulfonamide and dibenzothiazyl
disulfide, 2-mercaptobenzothiazole), dialkylthioureas (dibutylthiourea, diphenylthiourea, diethylthiourea,
thiourea), and 1,3-diphenylguandine
a
 Modified from Table 8 in Goodier M C et al. [36••]. “Rubber Accelerators in Medical Examination and
Surgical Gloves.” Dermatitis 29(2): 66-76

lower than recommended (measured 0.4 cream applications per
shift, while 2 cream applications per shift were recommended)
perhaps explaining the lack of observed effect [39]. Madan et al.
attempted to combine the previous two interventions in a large
randomized controlled trial involving 2040 nurses wherein the
intervention group received access to a behavioral change pro-
gram in addition to moisturizing creams [38]. Again, no dif-
ferences were observed between the intervention and control
groups. Brans comments on Madan’s study and states that face-
to-face interventions, as in the original Hand Eczema Trial, may
be necessary to have an effect [43]. Graversgaard’s work [41]
suggests that such face-to-face instruction must be repeated over
time to have a long-term effect.
Hairdressers
Hairdressers are at high risk of occupational hand derma-
titis due to frequent wet work and exposure to numerous
allergens and irritants including hair dyes, bleaching and
perming products, shampoo, conditioners, and other hair
cosmetics. A recent literature review shows that hair-
dressers are exposed up to 78 times more frequently to
cosmetic products than ordinary consumers [44]. Hand
dermatitis among hairdressers is common with a life-time
prevalence of 38.2% (95% CI 32.6–43.8). The calculated
incidence was 51.8 cases/1000 person years (95% CI
42.6–61.0) [45].
A recent study examined the long-term impact of hand
dermatitis using data from a Danish prospective cohort study
of hairdressers graduating from 1985 to 2007 [46, 47]. The
authors found that hand dermatitis began early in one’s
career, during apprenticeship. Risk factors include history
of previous positive patch test, history of atopic dermatitis,
and female sex [47]. Two-thirds of hairdressers reported in a
2009–2010 follow-up questionnaire that their hand dermati-
tis had resolved; however, one-third reported severe, persis-
tent symptoms [47]. Hairdressers with persistent symptoms
were more likely to leave the trade early [46]. Interestingly,
the authors went on to find that leaving the trade was almost

Table 3  Surgical gloves free of Product Company

accelerators as advertised by the
manufacturer*a
GAMMEX Non-Latex Neoprene Surgical Glove Ansell Healthcare LLC
GAMMEX Non-Latex Sensitive Synthetic Sensoprene Surgical Glove
DermAssure Green Powder-Free Neoprene Surgical Glove Medline Industries, Inc
Biogel NeoDerm Neoprene Surgical Glove Mölnlycke Health Care US LLC
*
Free of thiurams (tetramethylthiuram monosulfide, tetramethylthiuram disulfide, tetraethylthiuram
disulfide, dipentamethylenethiuram disulfide, and dipentamethylenethiuram tetrasulfide), carbamates
(zinc diethyldithiocarbamate, zinc dibutyldithiocarbamate, zinc dimethyldithiocarbamate, and zinc
dibenzyldithiocarbamate), mercapto mix (N-cyclohexylbenzothiazyl sulfonamide and dibenzothiazyl
disulfide, 2-mercaptobenzothiazole), dialkylthioureas (dibutylthiourea, diphenylthiourea, diethylthiourea,
thiourea), and 1,3-diphenylguandine
a
 Modified from Table 9 in Goodier M C et al. [36••]. “Rubber Accelerators in Medical Examination and
Surgical Gloves.” Dermatitis 29(2): 66–76

13
Current Allergy and Asthma Reports (2023) 23:201–212 207
two times higher in hairdressers with a positive patch test to
hair dye than to other allergens, perhaps due to inability to
avoid hair dye compared to other allergens [46].
Two recent studies probed potential preventative measures
for occupational hand dermatitis in this population. One study
found that up to 18% of hairdresser apprentices have evidence
of hand dermatitis on clinical examination at the start of voca-
tional school [48]. They suggest that educational interventions
may be helpful in this high-risk group. Another study took a
different approach, by utilizing a chemically modified ver-
sion of p-phenylenediamine (PPD) [49]. PPD with an added
methoxymethyl side chain (ME-PPD) has a significantly lower
sensitization potency in a local lymph node assay as compared
to the original PPD molecule [50]. Studies investigating cross-
reactivity of ME-PPD with PPD through open-use test found
30–48% of PPD-allergic individuals reacted to ME-PPD [51,
52]. Of subjects with a history of PPD-allergy and negative
open use test to ME-PPD, 76% tolerated multiple ME-PPD-
containing hair color treatments over the course of 1 year
without symptoms [53]. Similar studies investigating whether
hairdressers with occupational ACD to PPD are tolerant of
ME-PPD have not been conducted. A recent study on typi-
cal hairdresser occupational exposure to ME-PPD found lev-
els were below predicted concentrations for sensitization [50].
The authors suggest ME-PPD represents a potential alternative
to PPD-containing dyes for avoidance of the development of
occupational ACD.
Metalworkers
Metalworkers also represent a high-risk population for occu-
pational hand dermatitis due to their exposure to wet work and
a variety of contact allergens including metals, oils, greases
and rubbers, and preservatives in cutting oils. Data for this
group is scant, but the Information Network of Departments
of Dermatology (a German, Swiss, and Austrian consortium
on the clinical epidemiology of contact allergy) found that of
patch-tested metalworkers, near 90% had hand dermatitis [54].
The spectrum of culprit allergens among metalworkers remains
largely unchanged compared to prior research. Compared to a
control group, metalworkers were more likely to be allergic to
MI, formaldehyde, monoethanolamine, iodopropynyl butylcar-
bamate, and colophonium. Cutting metalworkers demonstrated
particularly high rates of allergy with 12.6% testing positive
to monoethanolamine (common ingredient in metal working
fluids) and 11.4% testing positive to colophonium (used in
adhesives and varnishes).
Several studies have investigated hand dermatitis pre-
vention programs for metalworkers. In a study comparing
metalworkers who participated in an educational interven-
tion versus a control group, the authors found a significant
decrease in hand eczema in the intervention group [55]. The
intervention included multiple in-person training sessions
and provision of skin care products [55]. In a separate study,
the authors investigated the utility of secondary and tertiary
individual prevention programs for metalworkers. Patients
in the secondary prevention program participated in an edu-
cational seminar on skin protection and saw a dermatologist
for two visits. Patients in the tertiary prevention program
were admitted as inpatients for 3 weeks for intensive man-
agement followed by a 3-week outpatient program with a
dermatologist. The authors found both programs improve
hand eczema severity scores [56]. Patients in the secondary
prevention program had lower disease scores at the end of
the study than the patients in the tertiary prevention pro-
gram; however, the patients in the tertiary prevention pro-
gram experienced a larger decrease in severity score over
time. These studies show that preventative programs can be
helpful; however, intensive resources are required. Despite
these costs, an analysis showed that the tertiary prevention
program with inpatient admission was cost-effective in the
German healthcare system, when considering the cost of
re-training individuals who leave their profession [57]. Such
programs may be feasible where governments take on the
cost of retraining but may not be scalable to countries that
do not sponsor trade education.
Other Occupations
Several recent studies report on allergen trends within other
specific occupations with high prevalence of hand dermatitis.
Perhaps not surprisingly, propolis was found to be a common
allergen among beekeepers with nearly 30% of patch-tested
beekeepers testing positive for this allergen [58]. Painters were
found to be more likely to test positive to epoxy resin and MI
compared to the general population [59]. As noted previously,
MI is found in high concentrations in paints (see “Methyliso-
thiazolinone” section). Dental personnel were found to have
increased rates of glutaraldehyde, thiuram mix and carba mix
allergy likely due to exposure to gloves, dental materials, and
sterilizing solutions [60]. Acrylates also remain a common
allergen among dentists due to exposure to acrylic compounds
used in dental prostheses [60]. Veterinarians and veterinary
assistant staff were found to have high rates of occupational
hand dermatitis due to wet work. This population also had an
increased rate of contact urticaria, attributed to their contact
with fur-bearing animals [61].
Contact Urticaria and Protein Contact Dermatitis
CU has frequently been observed in occupational settings and
commonly involves the hands. A large variety of agents have
been reported to cause CU including animal and plant products,
13

208
fragrances, cosmetics, preservatives, medications, and metals
[62]. CU can manifest with systemic symptoms, and therefore a
careful review of symptoms, including pulmonary and gastroin-
testinal, is important when evaluating patients with this disease.
PCD is rare; however, when observed, this disease is often
triggered by occupational exposure and present on the hands.
The four classic groups of proteins known to cause PCD are
fruits/vegetables/spices/plants, animal proteins, grains, and
enzymes [63]. Reflective of these groups, the occupations most
likely to suffer from PCD are food and animal handlers. Prick
and scratch tests are the most sensitive for this condition as
patch tests often yield a negative result, likely due to inability
of large proteins to penetrate the intact skin barrier [64].
In a Finnish study, 10% of patients with occupational skin
disease were diagnosed with CU and/or PCD (the authors were
unable to distinguish between the two diseases given the regis-
try data) [65]. Most cases were due to animal-derived materi-
als, followed by plant products, and chemicals. Farm workers
were most at risk for CU/PCD followed by food-workers such
as cooks, bakers, and food machine operators [66]. A separate
study found that almost half the patients presenting with occu-
pational CU or PCD have concomitant occupational airway
disease [67]. Therefore, it is important to screen patients pre-
senting for CU or PCD for pulmonary symptoms.
A German study investigating the epidemiology of CU
found that it is commonly caused by an occupational trigger
[68]. The distribution of occupations in the Germany study
was different from the Finnish with healthcare workers being
most represented, possibly due to the study’s focus on CU
without PCD and the different study population. Common
CU triggers included gloves, disinfectants, and rubber (other
than gloves) [68]. A separate study found the self-reported
rate of CU was up to 8.2% in a survey of healthcare workers
[69] suggesting this may be a high-risk population for CU.
Multiple recent case reports describe novel occupational
CU triggers including diethyl phthalate in hand sanitizers
among healthcare workers [70], indigo dye in natural hair
dyes among hairdressers [71], pork among slaughterhouse
workers [72], buckwheat among food handlers [73], and leg-
ume pests among farmers [74].
A recent French study focusing on occupational contact
dermatitis caused by artichokes observed 2 cases due to PCD
[75]. The hands were involved in both cases. One study subject
worked packing frozen vegetables. The other was a farmer of
artichokes and chrysanthemums. This study highlights arti-
chokes as a newly reported etiology of occupational PCD.
Prognosis
Occupational hand dermatitis can have a significant impact
on one’s quality of life and persistence of symptoms is more
likely to lead to career change [46]. Multiple factors affect the
13
Current Allergy and Asthma Reports (2023) 23:201–212
prognosis of occupational hand dermatitis [76]. Interestingly,
a recent study found that while history of atopic dermatitis and
positive patch tests may be risk factors for the development of
disease, these are not factors that predict disease persistence.
Rather lifestyle factors were found to influence prognosis.
Greater than 4 h of exercise a week was positively associ-
ated with clearance of disease, while smoking and stress were
negatively associated with disease clearance in a multivariate
analysis [76]. Change of profession was also associated with
remission. Thus, counseling on lifestyle factors and sensible
hygiene and protective or avoidance practices may be impor-
tant in clearing occupational hand dermatitis.
The importance of addressing persistent symptoms is
further supported by Passlov’s recent study on how hand
dermatitis impacts patients’ quality of life [77]. The authors
find that hand eczema causes measurable impairment of
hand strength and dexterity with consequent impairment of
ability to perform activities of daily living. The authors go
on to show improvement in these measures with improve-
ment of hand dermatitis severity [77].
Interventions
Skin protective behaviors are critical in preventing and man-
aging occupational hand dermatitis. A recent study showed
a dose–response relationship between decreasing wet work
and improvement of hand dermatitis suggesting that limit-
ing wet work may lead to hand dermatitis clearance [78]. A
Cochrane review on preventing occupational irritant hand
dermatitis concluded that evidence was insufficient to con-
fidently assess effectiveness of interventions but did note
that moisturizers with or without barrier creams may result
in a protective effect [79].
If avoidance of an allergen or wet work within a profession
is not possible, some patients may choose to leave their profes-
sion. Multiple studies have shown that change in profession
does result in improvement in occupational hand dermatitis
[76, 78, 80•]. However, while eczema severity scores improve,
Carøe et al. observed in their cohort of patients that job change
had a concurrent negative effect on overall quality of life [80•].
Interestingly, the authors found that if work procedures rather
than profession was changed, both eczema and overall qual-
ity of life scores improved [80•]. This finding highlights the
importance of working with patients and employers to find
ways for patients to remain at their current jobs if desired.
We discuss above hand dermatitis prevention programs
within the context of specific occupations. Several studies
have examined the utility of such programs in a broader con-
text. PREVEX, a randomized controlled trial investigated
the effect of a 2-h educational program on skin protective
behavior compared to a control group [81]. Patients diag-
nosed in Denmark with an occupational skin disease were
Current Allergy and Asthma Reports (2023) 23:201–212 209
recruited. A follow-up questionnaire was administered 1 year
later revealing that the intervention resulted in increased
knowledge of skin-protective behaviors but decreased self-
efficacy (or belief in one’s capacity to effect self-change)
[81]. The authors conclude that the intervention was overall
insufficient to have an impact on hand dermatitis. These
results mirror studies previously discussed (see “Healthcare
Workers” section) that showed brief educational programs
had little impact on occupational hand dermatitis preven-
tion. Only intensive educational programs (as discussed in
the “Metalworkers” section) may be effective. A Cochrane
review on interventions for preventing occupational irritant
hand dermatitis found that there was insufficient evidence to
assess effectiveness of educational programs [79].
Whenever possible, primary prevention, such as sys-
tem and operational changes that serve to reduce human
exposure to allergens and irritants is most preferable (e.g.,
closed versus open systems). Another strategy is to reduce
the dependency on human hands as direct tools of trade.
Secondary measures such as gloves that prevent allergen
or irritant permeability to the skin and emollients to foster
barrier integrity all serve to mitigate hand dermatitis caused
by exogenous sources.
For patients in which changing roles to avoid occupa-
tional hand dermatitis triggers is not possible or is not fully
effective, treatment options exist. Multiple case reports and
series show the efficacy of dupilumab, an IL-4 receptor sub-
unit inhibitor, in treating ICD and/or ACD [82–84]. Several
of the reported cases include patients with hyperkeratotic
hand dermatitis clearing with dupilumab despite contin-
ued occupational exposure [82, 83]. However, for others,
dupilumab failed to improve occupational hand dermatitis
due to ACD to a rubber additive [85]. Other therapeutics
developed for atopic dermatitis and specifically hand eczema
are on the horizon including systemic and topical Janus
kinase inhibitors whose broader mechanisms of action may
prove effective in the complex pathophysiology of occupa-
tional and non-occupational hand eczema. The evolution of
treatment will depend, in part, to a greater understanding of
the ambiguous pathophysiology of ACD to different aller-
gens that likely transcend the dogmatic views of solely Th1
lymphocytes and their attendant cytokines [86–88].
Conclusions
The wealth of literature over the past 3 years on occupational
hand dermatitis shows that occupational hand dermatitis is
an enduring worldwide problem and is a large unmet medical
issue. Scalable effective prevention programs remain elusive
and wet work continues to contribute to an epidemic of ICD.
System changes can influence reactivity to allergens and
possible dermatitis. Future work should focus on effective
and implementable occupational hand dermatitis prevention
programs and on methods to mitigate the consequences of
wet work. Continued research is also needed on the ever-
evolving spectrum of allergens that cause occupational skin
disease so as to best diagnose and manage occupationally
caused ACD.
Declarations 
Conflict of Interest  TK has no conflicts of interest to disclose. DC
declares the following disclosures: Consultant for and honoraria
from Ferndale Laboratories, Asana [past], Medimetriks [past],
Leo, UCB, Novartis [past], Dermavant [past], SFJ, FIDE (FIDE
receives industry sponsorship from AbbVie, Almirall, Amgen,
Arcutis, Arena, Bausch and Lomb, Bristol-Myers Squibb, Celgene
Dermavant, Dermira, Janssen, Kyowa Hakko Kirin, LEO, Lilly,
Novartis, Ortho Dermatologics, Pfizer, Sanofi Genzyme, Regeneron,
Sun Pharma, UCB, Valeant). DC participates in Cosmetic Ingredient
Review (CIR). DC has or has had stock or stock options in Dermira
[past], Medimetriks [past], Brickell Biotech [past], Kadmon [past],
Evommune, Timber. DC is or was on the Board of Directors of
Kadmon [past], Timber, Evommune, Dermira [past].
Human and Animal Rights and Informed Consent  This article does not
contain any studies with human or animal subjects performed by any of
the authors. Standard dermatology clinic photography consent utilized for
patient photos. None of the photos contain identifiable features.
References
Papers of particular interest, published recently, have
been highlighted as:
• Of importance
•• Of major importance
1•• Scheinman PL, Vocanson M, Thyssen JP, Johansen JD, Nixon
RL, Dear K, et al. Contact dermatitis. Nature Reviews Disease
Primers. 2021;7(1). Excellent overview on pathophysiology of
contact dermatitis.
2 Survey of Occupational Injuries and Illnesses Data [Available
from: https://​www.​bls.​gov/​iif/​nonfa​tal-​injur​ies-​and-​illne​sses-​
tables.​htm#​charts. Accessed 6 Dec 2022.
3 Skin Exposures and Effects [Available from: https://​www.​cdc.​
gov/​niosh/​topics/​skin/. Accessed 6 Dec 2022.
4 Belsito DV. Occupational contact dermatitis: etiology, preva-
lence, and resultant impairment/disability. J Am Acad Dermatol.
2005;53(2):303–13.
5 Cherry N, Meyer JD, Adisesh A, Brooke R, Owen-Smith V,
Swales C, et al. Surveillance of occupational skin disease: EPI-
DERM and OPRA. Br J Dermatol. 2000;142(6):1128–34.
6 Work-related ill health and occupational disease in Great Britain
Available from: https://​w ww.​h se.​g ov.​u k/​stati​stics/​c ausd​i s/​
derma​titis/​skin.​pdf. Accessed 6 Dec 2022.
7 Ruff SMD, Engebretsen KA, Zachariae C, Johansen JD, Silverberg
JI, Egeberg A, et al. The association between atopic dermatitis and
hand eczema: a systematic review and meta-analysis. Br J Derma-
tol. 2018;178(4):879–88.
13

210
8 Behroozy A, Keegel TG. Wet-work exposure: a main risk
factor for occupational hand dermatitis. Saf Health Work.
2014;5(4):175–80.
9 Brands MJ, Loman L, Schuttelaar MLA. Exposure and work-
related factors in subjects with hand eczema: data from a cross-
sectional questionnaire within the Lifelines Cohort Study. Contact
Dermatitis. 2022;86(6):493–506.
10 Ingber A, Merims S. The validity of the Mathias criteria for
establishing occupational causation and aggravation of contact
dermatitis. Contact Dermatitis. 2004;51(1):9–12.
11 Milam EC, Nassau S, Banta E, Fonacier L, Cohen DE. Occupa-
tional contact dermatitis: An Update. J Allergy Clin Immunol Pract.
2020;8(10):3283–93. https://​doi.​org/​10.​1016/j.​jaip.​2020.​08.​004.
12 Loman L, Uter W, Armario-Hita JC, Ayala F, Balato A, Ballmer-
Weber BK, et al. European Surveillance System on Contact
Allergies (ESSCA): characteristics of patients patch tested and
diagnosed with irritant contact dermatitis. Contact Dermatitis.
2021.
13 Isaksson M, Ale I, Andersen KE, Elsner P, Goh CL, Goossens A,
et al. Multicenter patch testing with methylisothiazolinone and
methylchloroisothiazolinone/methylisothiazolinone within the
International Contact Dermatitis Research Group. Dermatitis.
2017;28(3):210–4.
14 Schnuch A, Schubert S, Lessmann H, Geier J, Ivdk. The meth-
ylisothiazolinone epidemic goes along with changing patients’
characteristics - after cosmetics, industrial applications are the
focus. Contact Dermatitis. 2020;82(2):87–93.
15 Uter W, Amario-Hita JC, Balato A, Ballmer-Weber B, Bauer
A, Belloni Fortina A, et  al. European Surveillance System
on Contact Allergies (ESSCA): results with the European
baseline series, 2013/14. J Eur Acad Dermatol Venereol.
2017;31(9):1516–25.
16 Burnett CL, Bergfeld WF, Belsito DV, Klaassen CD, Liebler DC,
Marks JG, et al. Amended safety assessment of methylchloroi-
sothiazolinone and methylisothiazolinone as used in cosmetics.
International Journal of Toxicology. 2021;40(1_suppl):20S-33S.
17 Thomsen AV, Schwensen JF, Bossi R, Banerjee P, Giménez-
Arnau E, Lepoittevin JP, et al. Isothiazolinones are still widely
used in paints purchased in five European countries: a follow-up
study. Contact Dermatitis. 2018;78(4):246–53.
18 DeKoven JG, Warshaw EM, Zug KA, Maibach HI, Belsito DV,
Sasseville D, et al. North American Contact Dermatitis Group
patch test results: 2015–2016. Dermatitis. 2018;29(6):297–309.
19 Warshaw EM, Schlarbaum JP, DeKoven JG, Silverberg JI, Zug
KA, Marks JG Jr, et al. Occupationally related nickel reactions: a
retrospective analysis of the North American Contact Dermatitis
Group data 1998–2016. Dermatitis. 2019;30(5):306–13.
20 Diepgen TL, Ofenloch RF, Bruze M, Bertuccio P, Cazzaniga
S, Coenraads PJ, et al. Prevalence of contact allergy in the gen-
eral population in different European regions. Br J Dermatol.
2016;174(2):319–29.
21 Sanchez-Pujol MJ, Docampo-Simon A, Mercader P, Gonzalez-
Perez R, Hervella-Garces M, Sanz-Sanchez T, et al. Frequency
of sensitization to the individual fragrances of fragrance mix I
and II according to the factors included in the MOAHLFA index.
Contact Dermatitis. 2021;84(6):395–406.
22 Kersh AE, Helms S, de la Feld S. Glove-related allergic contact
dermatitis. Dermatitis. 2018;29(1):13–21.
23 Warburton KL, Bauer A, Chowdhury MM, Cooper S, Kręcisz
B, Chomiczewska-Skóra D, et al. ESSCA results with the base-
line series, 2009–2012: rubber allergens. Contact Dermatitis.
2015;73(5):305–12.
24 Warshaw EM, Gupta R, Silverberg JI, Maibach HI, DeKoven
JG, Taylor JS, et al. Positive patch test reactions to carba mix
and thiuram mix: the North American Contact Dermatitis Group
experience (1994–2016). Dermatitis. 2021;32(3):173–84.
13
Current Allergy and Asthma Reports (2023) 23:201–212
25 Crepy MN. Rubber: new allergens and preventive measures. Eur
J Dermatol. 2016;26(6):523–30.
26 Crepy MN, Lecuen J, Ratour-Bigot C, Stocks J, Bensefa-Colas L.
Accelerator-free gloves as alternatives in cases of glove allergy
in healthcare workers. Contact Dermatitis. 2018;78(1):28–32.
27 Ibler KS, Jemec GB, Flyvholm MA, Diepgen TL, Jensen A,
Agner T. Hand eczema: prevalence and risk factors of hand
eczema in a population of 2274 healthcare workers. Contact
Dermatitis. 2012;67(4):200–7.
28 Lan CC, Tu HP, Lee CH, Wu CS, Ko YC, Yu HS, et al. Hand
dermatitis among university hospital nursing staff with or with-
out atopic eczema: assessment of risk factors. Contact Dermati-
tis. 2011;64(2):73–9.
29 O’Neill H, Narang I, Buckley DA, Phillips TA, Bertram CG,
Bleiker TO, et al. Occupational dermatoses during the COVID-
19 pandemic: a multicentre audit in the UK and Ireland. Br J
Dermatol. 2021;184(3):575–7.
30 Guertler A, Moellhoff N, Schenck TL, Hagen CS, Kendziora
B, Giunta RE, et al. Onset of occupational hand eczema among
healthcare workers during the SARS-CoV-2 pandemic: compar-
ing a single surgical site with a COVID-19 intensive care unit.
Contact Dermatitis. 2020;83(2):108–14.
31 Lan J, Song Z, Miao X, Li H, Li Y, Dong L, et al. Skin damage
among health care workers managing coronavirus disease-2019.
J Am Acad Dermatol. 2020;82(5):1215–6.
32 Blomberg M, Jørgensen CCL, Bregnhøj A, Ahrensbøll-Friis U,
Zachariae C, Sommerlund M, et al. Occupational allergic con-
tact dermatitis caused by tetrahydroxypropyl ethylenediamine in
hand disinfectants. Contact Dermatitis. 2022;87(1):114–6.
33 Dear K, Palmer A, Nixon R. Contact allergy and allergic contact
dermatitis from benzalkonium chloride in a tertiary dermatology
center in Melbourne, Australia. Contact Dermatitis. 2021.
34 Hamnerius N, Svedman C, Bergendorff O, Bjork J, Bruze M,
Engfeldt M, et al. Hand eczema and occupational contact aller-
gies in healthcare workers with a focus on rubber additives. Con-
tact Dermatitis. 2018;79(3):149–56.
35 Santarossa M, Larese FF. Improving the diagnosis of allergic
contact dermatitis using patch test with gloves. Dermatitis.
2018;29(1):49–51.
36•• Goodier MC, Ronkainen SD, Hylwa SA. Rubber accelera-
tors in medical examination and surgical gloves. Dermatitis.
2018;29(2):66–76. Useful resource with list of accelerators
in major glove brands.
37 Pinheiro V, Pestana C, Pinho A, Antunes I, Goncalo M. Occupa-
tional allergic contact dermatitis caused by antibiotics in health-
care workers - relationship with non-immediate drug eruptions.
Contact Dermatitis. 2018;78(4):281–6.
38 Madan I, Parsons V, Ntani G, Coggon D, Wright A, English J,
et al. A behaviour change package to prevent hand dermatitis in
nurses working in the National Health Service: results of a cluster
randomized controlled trial. Br J Dermatol. 2020;183(3):462–70.
39 Soltanipoor M, Kezic S, Sluiter JK, de Wit F, Bosma AL, van
Asperen R, et al. Effectiveness of a skin care programme for
the prevention of contact dermatitis in healthcare workers (the
Healthy Hands Project): a single-centre, cluster randomized con-
trolled trial. Contact Dermatitis. 2019;80(6):365–73.
40 Soltanipoor M, Rustemeyer T, Sluiter JK, Hines J, Frison F, Kezic
S. Evaluating the effect of electronic monitoring and feedback on
hand cream use in healthcare workers: Healthy Hands Project.
Contact Dermatitis. 2019;80(1):26–34.
41 Graversgaard C, Agner T, Jemec GBE, Thomsen SF, Ibler KS.
A long-term follow-up study of the Hand Eczema Trial (HET):
a randomized clinical trial of a secondary preventive programme
introduced to Danish healthcare workers. Contact Dermatitis.
2018;78(5):329–34.
Current Allergy and Asthma Reports (2023) 23:201–212 211
42 Ibler KS, Jemec GB, Diepgen TL, Gluud C, Lindschou Hansen
J, Winkel P, et al. Skin care education and individual counsel-
ling versus treatment as usual in healthcare workers with hand
eczema: randomised clinical trial. BMJ. 2012;345: e7822.
43 Brans R. Hand dermatitis in nurses: is promotion of protective
behaviour ineffective? Br J Dermatol. 2020;183(3):411–2.
44 Symanzik C, Johansen JD, Weinert P, Babic Z, Hallmann S,
Havmose MS, et al. Differences between hairdressers and con-
sumers in skin exposure to hair cosmetic products: a review.
Contact Dermatitis. 2022;86(5):333–43.
45 Havmose MS, Kezic S, Uter W, Symanzik C, Hallmann S, Strahwald
J, et al. Prevalence and incidence of hand eczema in hairdressers-a
systematic review and meta-analysis of the published literature from
2000–2021. Contact Dermatitis. 2022;86(4):254–65.
46 Havmose M, Thyssen JP, Zachariae C, Uter W, Johansen JD.
Occupational hand eczema reduces career length in hairdressers:
a prospective cohort study of Danish hairdressers graduating
from 1985 to 2007. Occup Environ Med. 2022;79(10):649–55.
47 Havmose M, Thyssen JP, Zachariae C, Johansen JD. Long-term
follow-up of hand eczema in hairdressers: a prospective cohort
study of Danish hairdressers graduating from 1985 to 2007. J
Eur Acad Dermatol Venereol. 2022;36(2):263–70.
48 Franic Z, Babic Z, Milic M, Macan J. Skin characteristics of
hairdresser apprentices at the beginning of vocational train-
ing. Dermatitis. 2021;32(6):437–43.
49 Gargano EM, Blomeke B, Gaspari AA, Goebel C. The 2-
methoxymethyl modification of p-phenylenediamine
reduces the sensitization risk for hairdressers to hair dyes-an
occupational hand exposure-based risk assessment. Dermatitis.
2022;33(4):293–301.
50 Goebel C, Troutman J, Hennen J, Rothe H, Schlatter H, Gerberick
GF, et al. Introduction of a methoxymethyl side chain into p-phe-
nylenediamine attenuates its sensitizing potency and reduces the risk
of allergy induction. Toxicol Appl Pharmacol. 2014;274(3):480–7.
51 Schuttelaar ML, Dittmar D, Burgerhof JGM, Blömeke B, Goebel C.
Cross-elicitation responses to 2-methoxymethyl-p-phenylenediamine
in p-phenylenediamine-allergic individuals: results from open
use testing and diagnostic patch testing. Contact Dermatitis.
2018;79(5):288–94.
52 Blömeke B, Pot LM, Coenraads PJ, Hennen J, Kock M, Goebel
C. Cross-elicitation responses to 2-methoxymethyl-p-phenylenedi-
amine under hair dye use conditions in p-phenylenediamine-allergic
individuals. Br J Dermatol. 2015;172(4):976–80.
53 Kock M, Coenraads P-J, Blömeke B, Goebel C. Continuous usage
of a hair dye product containing 2-methoxymethyl-para-
phenylenediamine by hair-dye-allergic individuals. Br J
Dermatol. 2016;174(5):1042–50.
54 Schubert S, Brans R, Reich A, Buhl T, Skudlik C, Schroder-Kraft
C, et al. Contact sensitization in metalworkers: data from the
information network of departments of dermatology (IVDK),
2010–2018. Contact Dermatitis. 2020;83(6):487–96.
55 Reich A, Wilke A, Gediga G, Baurecht H, Rodriguez E, Jakasa
I, et al. Health education decreases incidence of hand eczema
in metal work apprentices: results of a controlled intervention
study. Contact Dermatitis. 2020;82(6):350–60.
56 Brans R, Wilke A, Rodriguez E, Boraczynski N, Weidinger S,
Reich A, et al. Effectiveness of secondary prevention in metal-
workers with work-related skin diseases and comparison with
participants of a tertiary prevention program: a prospective
cohort study. Contact Dermatitis. 2020;83(6):497–506.
57 Andrees V, John SM, Nienhaus A, Skudlik C, Brans R, Augustin
M, et al. Economic evaluation of a tertiary prevention program
for occupational skin diseases in Germany. Contact Dermati-
tis. 2020;82(6):361–9.
58 Oosterhaven JAF, Verbist J, Schuttelaar MLA. Hand eczema
among Dutch beekeepers - a cross-sectional study. J Dtsch Der-
matol Ges. 2019;17(2):158–66.
59 Schubert S, Bauer A, Hillen U, Werfel T, Geier J, Brans R, et al.
Occupational contact dermatitis in painters and varnishers: data
from the Information Network of Departments of Dermatology
(IVDK), 2000 to 2019. Contact Dermatitis. 2021;85(5):494–502.
60 Warshaw EM, Ruggiero JL, Atwater AR, DeKoven JG, Zug KA,
Reeder MJ, et al. Occupational contact dermatitis in dental person-
nel: a retrospective analysis of the North American Contact Der-
matitis Group Data, 2001 to 2018. Dermatitis. 2022;33(1):80–90.
61 Beine A, Gina M, Hoffmeyer F, Lotz A, Nollenheidt C, Zah-
radnik E, et al. Skin symptoms in veterinary assistant staff
and veterinarians: a cross-sectional study. Contact Dermatitis.
2022;87(3):247–57.
62 Giménez-Arnau AM, Pesqué D, Maibach HI. Contact urticaria
syndrome: a comprehensive review. Current Dermatology
Reports. 2022;11(4):194–201.
63 Goossens A, Amaro C, Mahler V. Protein contact dermatitis.
Contact dermatitis. 2021:355–64.
64 Levin C, Warshaw E. Protein contact dermatitis: allergens,
pathogenesis, and management. Dermatitis. 2008;19(5):241–51.
65 Aalto-Korte K, Koskela K, Pesonen M. 12-year data on dermato-
logic cases in the Finnish Register of Occupational Diseases I: dis-
tribution of different diagnoses and main causes of allergic contact
dermatitis. Contact Dermatitis. 2020;82(6):337–42.
66 Pesonen M, Koskela K, Aalto-Korte K. Contact urticaria and
protein contact dermatitis in the Finnish Register of Occupa-
tional Diseases in a period of 12 years. Contact Dermatitis.
2020;83(1):1–7.
67 Helaskoski E, Suojalehto H, Kuuliala O, Aalto-Korte K.
Occupational contact urticaria and protein contact dermatitis:
causes and concomitant airway diseases. Contact Dermatitis.
2017;77(6):390–6.
68 Süß H, Dölle-Bierke S, Geier J, Kreft B, Oppel E, Pföhler C, et al.
Contact urticaria: frequency, elicitors and cofactors in three cohorts
(Information Network of Departments of Dermatology; Network of
Anaphylaxis; and Department of Dermatology, University Hospital
Erlangen, Germany). Contact Dermatitis. 2019;81(5):341–53.
69 Pourani MR, Nasiri S, Abdollahimajd F. Prevalence of hand con-
tact urticaria and related risk factors among healthcare workers
during the COVID-19 pandemic: a self-reported assessment.
Dermatol Ther. 2020;33(6): e14367.
70 Suomela S, Suuronen K. Occupational contact urticaria due
to diethyl phthalate in hand sanitizers. Contact Dermatitis.
2023;88(1):65–6.
71 Haltia T, Jungewelter S, Airaksinen L, Suomela S, Lindström I,
Suojalehto H. Occupational asthma, rhinitis, and contact urti-
caria from indigo (Indigofera tinctoria) hair dye. J Allergy Clin
Immunol Pract. 2021;9(9):3500–2.
72 Jungewelter S, Airaksinen L, Pesonen M. Occupational rhinitis,
asthma, and contact urticaria from IgE-mediated allergy to pork.
Am J Ind Med. 2019;62(1):80–4.
73 Jungewelter S, Airaksinen L, Pesonen M. Occupational buckwheat
allergy as a cause of allergic rhinitis, asthma, contact urticaria and
anaphylaxis-An emerging problem in food-handling occupations?
Am J Ind Med. 2020;63(11):1047–53.
74 Armentia A, Alvarez R, Moreno-González V, Martín B, Fernández
S, Martín S, et al. Occupational airborne contact urticaria, ana-
phylaxis and asthma in farmers and agronomists due to Bruchus
pisorum. Contact Dermatitis. 2020;83(6):466–74.
75 Deydier N, Gourier G, Crépy MN, Roguedas AM, Dewitte JD,
Misery L, et al. Occupational contact dermatitis caused by arti-
chokes. Dermatitis. 2022.
13

212
76 Olesen CM, Agner T, Ebbehoj NE, Caroe TK. Factors influenc-
ing prognosis for occupational hand eczema: new trends. Br J
Dermatol. 2019;181(6):1280–6.
77 Passlov HM, Ponten A, Bjork J, Rosen B, Bruze M, Svedman
C, et al. Hand strength and dexterity in individuals with hand
eczema. J Eur Acad Dermatol Venereol. 2020;34(12):2856–62.
78 Caroe TK, Ebbehoj NE, Bonde JPE, Flachs EM, Agner T. Hand
eczema and wet work: dose-response relationship and effect of
leaving the profession. Contact Dermatitis. 2018;78(5):341–7.
79 Bauer A, Ronsch H, Elsner P, Dittmar D, Bennett C, Schuttelaar
MLA, et al. Interventions for preventing occupational irritant
hand dermatitis. Cochrane Database Syst Rev. 2018;4:CD004414.
80• Caroe TK, Ebbehoj NE, Bonde JPE, Vejlstrup SG, Agner T. Job
change facilitates healing in a cohort of patients with occupa-
tional hand eczema. Br J Dermatol. 2018;179(1):80–7. Study
showing job change results in improved hand eczema severity
but overall decrease in quality of life. Staying at the same job
but changing role resulted in both decreased hand eczema
severity and improved quality of life.
81 Fisker MH, Agner T, Sorensen JA, Vejlstrup SG, Lindschou
J, Gluud C, et  al. Simple, low-cost group-counselling pro-
gramme vs treatment as usual for patients with newly notified
occupational hand eczema-exploratory analyses of effects on
knowledge, behaviour and personal resources of the randomized
PREVEX clinical trial. Contact Dermatitis. 2018;79(3):127–35.
82 Loman L, Diercks GFH, Schuttelaar MLA. Three cases of non-
atopic hyperkeratotic hand eczema treated with dupilumab. Con-
tact Dermatitis. 2021;84(2):124–7.
83 Zhu GA, Honari G, Ko JM, Chiou AS, Chen JK. Dupilumab for
occupational irritant hand dermatitis in a nonatopic individual:
a case report. JAAD Case Rep. 2020;6(4):296–8.
13
Current Allergy and Asthma Reports (2023) 23:201–212
84 Goldminz AM, Scheinman PL. A case series of dupilumab-
treated allergic contact dermatitis patients. Dermatol Ther.
2018;31(6): e12701.
85 Crepy MN, Nosbaum A, Bensefa-Colas L. Blocking type 2 inflam-
mation by dupilumab does not control classic (type 1-driven) aller-
gic contact dermatitis in chronic hand eczema. Contact Dermatitis.
2019;81(2):145–7.
86 Virgens AR, Goes HFO, de Carvalho GC, Pietrobon AJ, AC
CCB, Ramos YAL, et al. Perivascular clusters of Th2 cells and
M2 macrophages in allergic contact dermatitis to methylchlo-
roisothiazolinone and methylisothiazolinone. Exp Dermatol.
2022;31(2):191–201.
87 Brans R, Jakasa I, Goc S, John SM, Kezic S. Stratum corneum
levels of inflammatory mediators and natural moisturizing factor
in patch test reactions to thiurams and fragrances and their possi-
ble role in discrimination between irritant and allergic reactions
to hapten mixtures. Contact Dermatitis. 2021;84(5):299–307.
88 Cheng J, Facheris P, Ungar B, Guttman-Yassky E. Current
emerging and investigational drugs for the treatment of chronic
hand eczema. Expert Opin Investig Drugs. 2022;31(8):843–53.
Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Springer Nature or its licensor (e.g. a society or other partner) holds
exclusive rights to this article under a publishing agreement with the
author(s) or other rightsholder(s); author self-archiving of the accepted
manuscript version of this article is solely governed by the terms of
such publishing agreement and applicable law.