Skin diseases - 1,481 entries found
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Latza U., Haamann F., Baur X.
Effectiveness of a nationwide interdisciplinary preventive programme for latex allergy
This study describes a nationwide awareness campaign aimed at reducing exposure to powdered high-protein latex gloves among health care workers in Germany and evaluates the effectiveness of the programme. Data on compensation claims for latex-related skin and airway diseases were compared before and after implementation of the programme. A survey on change in glove use was also conducted after implementing the programme. The number of compensation claims for latex-induced skin diseases increased from 664 at the start of the programme in 1996 to 884 in 1998, and then decreased to 567 in 1999 and 204 in 2002. Similar decreases were observed for respiratory diseases. This programme was found to be effective and can be regarded as a model for the reduction of other occupational diseases such as bakers' or isocyanate asthma.
International Archives of Occupational and Environmental Health, June 2005, Vol.78, No.5, p.394-402. Illus. 47 ref.
http://www.springerlink.com/media/lp3ef1rrqr5xxmylwa7w/contributions/j/3/3/1/j3314532m7844317.pdf [in English]
Sell L., Flyvholm M.A., Lindhard G., Mygind K.
Implementation of an occupational skin disease prevention programme in Danish cheese dairies
The purpose of this study was to evaluate the efficiency of a programme to reduce occupational skin diseases in the cheese industry. The programme involved training activities and elements from an occupational health-management system. The effects were studied by telephone interviews using a questionnaire on work and exposure. The study population consisted of all employees at five cheese plants, divided into an intervention group participating in the programme and a non-participating control group. At baseline in October 2002, 557 employees were surveyed (participation rate of 83.8%). At follow up one year later, 650 current and former employees answered (participation rate of 81.8%). At follow up, skin symptoms were reduced significantly in all cheese factories, and significant increases in the use of gloves and moisturizing creams were observed in the intervention group.
Contact Dermatitis, Sep. 2005, Vol.53, No.3, p.155-161. Illus. 22 ref.
Cavallo D., Ursini C.L., Setini A., Chianese C., Cristaudo A., Iavicoli S.
DNA damage and TNFα cytokine production in hairdressers with contact dermatitis
This study examined the possible correlation between exposure of hairdressers to irritants and allergens and direct-oxidative DNA damage, production of tumour necrosis factor alpha (TNFα) and allergic inflammatory disease. The evaluation involved 19 hairdressers with hand contact dermatitis, including 14 with allergic contact dermatitis (ACD) and five with irritant contact dermatitis (ICD), together with a control group of 19 persons working in administrative services. Determinations included TNFα serum levels and a direct-oxidative DNA damage test. Serum levels of TNFα in hairdressers with ACD were significantly higher than controls, with a correlation to exposure level. Significantly more DNA damage in ICD hairdressers with higher exposure was found as compared to controls. These findings suggest a relationship between exposure and direct-oxidative DNA damage, TNFα production and allergic inflammatory disease.
Contact Dermatitis, Sep. 2005, Vol.53, No.3, p.125-129. 17 ref.
Kaukiainen A., Riala R., Martikainen R., Estlander T., Susitaival P., Aalto-Korte K.
Chemical exposure and symptoms of hand dermatitis among construction painters
In this study on the prevalence of hand dermatitis in construction painting in Finland, a cross-sectional questionnaire survey was conducted among 1000 male construction painters and 1000 male carpenters (response rates 60.6% and 60.4%, respectively). Two definitions for hand dermatitis symptoms were used: "liberal" (more than two symptoms), and "strict" (more than three symptoms). Responses were subjected to statistical analysis. Painters reported more symptoms of hand dermatitis than carpenters (previous 12-month prevalence with liberal criteria 22.5% and 14.2% respectively; with strict criteria 13.3% and 6.4% respectively). A dose-response relationship was found for reporting symptoms and exposure to several solvent-based and water-based paints. Overall, painters reported a significantly higher prevalence of symptoms of hand dermatitis than carpenters, with putties and plasters emerging as significant risk factors.
Contact Dermatitis, July 2005, Vol.53, No.1, p.14.21. 32 ref.
Cahill J., Keegel T., Dharmage S., Nugriaty D., Nixon R.
Prognosis of contact dermatitis in epoxy resin workers
Among workers who attended an occupational dermatology clinic between 1993 and 2003, 40 were diagnosed with allergic contact dermatitis from epoxy resins. Twenty of these patients were followed up for at least two years post-diagnosis to establish prognosis. Patients completed a telephone questionnaire based on variables considered of importance for prognosis. All patients reported improvement in their skin condition since diagnosis. Twelve of the 20 patients had applied for workers' compensation and all claims were successful. Sixteen had ceased working with epoxy resins. Of these, nine reported complete healing and seven reported ongoing dermatitis. Factors that may be associated with a poor prognosis are age, atopy, duration of symptoms and severity at diagnosis. The prognosis of allergic contact dermatitis from epoxy resins is not always favourable, even if a worker ceases exposure.
Contact Dermatitis, Mar. 2005, Vol.52, No.3, p.147-153. 42 ref.
Kiec-Swierczynska M., Krecisz B., Swierczyska-Machura D., Zaremba J.
An epidemic of occupational contact dermatitis from an acrylic glue
Dermatological examinations were performed in 81 workers involved in the manufacture of electric coils for television displays. They had worked for four years in contact with a UV-curing glue containing various acrylates. Acrylate-specific dermal lesions were detected in 21 of these workers. Occupational irritant contact dermatitis was diagnosed in 12 of the workers and occupational allergic contact dermatitis in the other nine. Twelve reacted to acrylates. Cross-reactions with methacrylates were not observed. The highest number of positive tests was obtained with triethyleneglycol diacrylate (10) and diethyleneglycol diacrylate (9).
Contact Dermatitis, Mar. 2005, Vol.52, No.3, p.121-125. 18 ref.
Aalto-Korte K., Mäkela E.A., Huttunen M., Suuronen K., Jolanki R.
Occupational contact allergy to glyoxal
Allergic contact dermatitis from glyoxal has been described in several occupations. In this study, data from patients in the dermatology department of the Finnish Institute of Occupational Health from 1998 to 2004 were analysed for allergic reactions to glyoxal. Twenty patients had allergic reactions to glyoxal on patch testing. Five of the patients worked in dentistry and four of these had present exposure to glyoxal. Nine patients were machinists without obvious exposure to glyoxal. The case of a grinder with work-related facial dermatitis is described in detail. The chemical analysis of air samples from his workplace revealed 9.4-21µg/m3 glyoxal. Glyoxal was found to be present in the metalworking fluid used. The remaining six patients worked in miscellaneous occupations and had no present exposure to glyoxal. It is recommended that glyoxal be added to the antimicrobial patch test series.
Contact Dermatitis, May 2005, Vol.52, No.5, p.276-281. 17 ref.
Keegel T., Cahill J., Noonan A., Dharmage S., Saunders H., Frowen K., Nixon R.
Incidence and prevalence rates for occupational contact dermatitis in an Australian suburban area
This study investigated the incidence of occupational contact dermatitis (OCD) for a defined geographical area in Melbourne, Australia. Two methods of data collection were used. In the first method, 30 general practitioners, two dermatologists and one dermatology outpatient clinic within a defined area reported each worker with suspected OCD seen as part of routine practice. With the second method, workers living in the area who were referred to a tertiary referral OCD clinic were included in the study. Patch testing was used to verify suspected cases. The incidence rate for confirmed cases was 20.5 per 100,000 workers. The one-year-period prevalence rate was 34.5 per 100,000 workers. The positive predictive value was highest for the occupational dermatology clinic referrals (63%) compared with reports from the dermatologists and the outpatient clinic (55%) and from general practitioners (43%).
Contact Dermatitis, May 2005, Vol.52, No.5, p.254-259. 18 ref.
Jappe U., Geier J., Hausen B.M.
Contact vitiligo following a strong patch test reaction to triglycidyl-p-aminophenol in an aircraft industry worker: Case report and review of the literature
Epoxy resin systems are a frequent cause of occupational allergic contact dermatitis. A 50-year-old patient developed eczematous skin lesions on the back of his hands, lower arms and eye lids, two months after starting work in aircraft construction. Patch tests showed positive reactions to nickel sulfate and to epoxy resins based on the diglycidyl ether of bisphenol F and on 1,4-butanediol diglycidyl ether. Triglycidyl-p-aminophenol (TGPAP) applied at 1% and 0.1% induced the strongest positive reaction. Four months later, the patient presented with two circular depigmented spots in the former TGPAP-patch test areas. Dermatohistopathology confirmed the diagnosis of contact vitiligo.
Contact Dermatitis, Aug. 2005, Vol.53, No.2, p.89-92. Illus. 9 ref.
Schürer N.Y., Klippel U., Schwanitz H.J.
Secondary individual prevention of hand dermatitis in geriatric nurses
The incidence of hand dermatitis in geriatric nurses is increasing in Germany. A prospective controlled study of a secondary individual prevention (SIP) programme for hand dermatitis was conducted, involving information and training on the proper use of gloves and barrier creams. 209 geriatric nurses with a medical history of hand dermatitis completed questionnaires prior to the start of the programme and three months after its conclusion, including 102 who participated in the SIP and 107 controls who were not offered the programme. Upon completion of the study, 59% of SIP participants were free of hand eczema. Questionnaires three months after study completion revealed skin lesions in 53% of participants and 82% of the controls. There was a significant improvement in the epidermal barrier among programme participants. It is concluded that SIP is effective in preventing hand eczema.
International Archives of Occupational and Environmental Health, Mar. 2005, Vol.78, No.2, p.149-157. Illus. 37 ref.
Rasmussen K., Carstensen O., Pontén A., Gruvberger B., Isaksson M., Bruze M.
Risk of contact allergy and dermatitis at a wind turbine plant using epoxy resin-based plastics
A cross-sectional study was carried out among workers exposed to epoxy resin and other chemicals at a company producing plastic components. Risk factors for occupational contact allergy and dermatitis were investigated. Participants responded to a self-administered questionnaire, were interviewed by an occupational physician and were subjected to dermatological examinations including patch testing. Clinically-diagnosed dermatitis was found among 214 workers (35.8%) and contact allergy to materials used in the workplace was found in 66 workers (10.9% of the total population and 20.3% of those who underwent patch testing), among whom 40 (60.6%) were allergic to epoxy compounds, 25 (37.9%) to hardeners and ten (15.2%) to other workplace materials. Older age and longer duration of employment were individual risk factors for allergy to workplace materials, while work-related allergies and longer duration of employment at the workplace were significant risk factors for dermatitis.
International Archives of Occupational and Environmental Health, Apr. 2005, Vol.78, No.3, p.211-217. 20 ref.
Health effects of occupational exposure to organic solvents and paint compounds
This report describes a questionnaire survey of construction painters and carpenters in Finland to assess the effects of past and recent solvent exposure on neurotoxic symptoms and to evaluate the prevalence of work-related respiratory disorders and hand dermatitis among painters. Two clinical experiments were also carried out to evaluate tests for the screening and evaluation of suspected solvent-induced disorders. Significant associations were found between cumulative intensity of long-term solvent exposure and symptoms of memory, concentration and mood. Solvent exposure in painters was also associated with previously diagnosed psychiatric disorders, hypertension and arrhythmia. Painters reported more asthma-like, rhinitis, laryngeal and eye symptoms than the carpenters and they also had more symptoms of hand dermatitis and chronic bronchitis. An approach for the screening and evaluation of solvent-related nervous system disorders is proposed.
Finnish Institute of Occupational Health, FIOH-Bookstore, Topeliuksenkatu 41 a A, 00250 Helsinki, Finland, 2005. 143p. Illus. Bibl.ref.
Kolsi M., Mansour H.B., Nouaigui H., Ben Laïba M.
Occupational skin diseases: A good understanding of the pathology for better prevention
Les dermatoses professionnelles: une bonne connaissance de la pathologie pour une meilleure prévention [in French]
Contents of this special feature on occupational skin diseases: definition; epidemiology; classification of occupational skin diseases according to the nature of the aetiological agent (chemical, physical, biological); diagnosis; preventive measures; evaluation of the degree of permanent invalidity resulting from occupational skin diseases in Tunisia.
SST - Santé et Sécurité au Travail, Apr. 2005, No.33, p.2-23. Illus. 21 ref.
Aalto-Korte K., Lauerma A., Alanko K.
Occupational allergic contact dermatitis from lichens in present-day Finland
Lichens are abundant in forests, living on trees, soil, stones and rocks. They contain usnic acid and other lichen acids that are contact allergens. Lichens and liverworts cause woodcutter's dermatitis, a form of eczema that appears in the forest on the bare skin areas, especially in cold and wet weather. Occupational allergic contact dermatitis from lichens occurs in forestry and horticultural workers and among pickers of lichens used in fragrances. Lichens can cause immediate allergy, contact urticaria, rhinitis and asthma and probably also photo-allergic contact dermatitis. Lichens are used for the manufacture of oak moss absolute, a fragrance constituent that is one of the commonest contact allergens. Four cases of occupational allergic contact dermatitis from lichens in Finland during the past decade, two in farmers and two in gardeners, are described.
Contact Dermatitis, Jan. 2005, Vol.52, No.1, p.36-38. 15 ref.
Pickvance S., Karnon J., Peters J., El-Arifi K.
The impact of REACH on occupational health with a focus on skin and respiratory diseases
Final report of a study commissioned in 2004 by the then European Trade Union Technical Bureau for Health and Safety (TUTB) and carried out at the University of Sheffield. The study examined the impact of the 2003 European Union REACH (Registration, Evaluation and Authorization of Chemicals) proposal on the health of the EU-25 workforce. It focused on two broad groups of occupational diseases: non-malignant diseases of the skin (dermatitis) and of the respiratory system (asthma and chronic obstructive pulmonary disease). The research involved an estimation of the actual number of cases of occupational skin and respiratory diseases in EU member states, development of scenarios for the number of cases reduced under REACH and a calculation of the economic benefits.
European Trade Union Institute for Research, Education and Health and Safety (ETUI-REHS), Health and Safety Department, Boulevard du Roi Albert II, 1210 Bruxelles, Belgium, 2005. 88p. Illus. 133 refs. Downloadable version free of charge.
http://hesa.etui-rehs.org/uk/newsevents/files/reach-sheffield-complet.pdf [in English]
Dermatitis in a printed-circuit board manufacturing facility
Dermatitis complaints are frequently encountered among workers in the microelectronics industry and have been associated with a variety of physical, chemical and psychosocial causes. Employees working in the silk-screening and kiln-drying areas of a printed-circuit board manufacturer complained of recurrent itching and rashes. This report describes those symptoms and the results of a brief survey of the affected employees, which provided useful data regarding the likely aetiology. A brief epidemiological survey instrument was used to gain information regarding the pattern, duration and frequency of employee symptoms. Data from the survey were used to identify seasonal variations in symptoms that correlated with specific environmental factors in the plant. This brief epidemiological investigation using a self-reported symptom survey was an efficient tool for cataloguing the character, pattern, duration and frequency of complaints that correlated with specific environmental factors in the plant (temperature and low humidity), which were likely causes of the outbreak.
Contact Dermatitis, Feb. 2005, Vol.52, No.2, p.78-81. 9 ref.
Sadhra S., Holloway S., Jackson C.A., Foulds I.
Health and Safety Executive
Development of a field method for the assessment of the effectiveness of barrier creams in preventing skin irritation reactions
This report presents the findings of a study designed to develop a test method using non-invasive bioengineering skin instrumentation for evaluating the effectiveness of barrier creams against chemical skin irritants used in a typical work setting. The test protocols developed can easily be adapted to different industrial settings and may be used to evaluate other barrier creams for other substances. The instruments and test protocols showed that the barrier cream evaluated was effective in protecting the skin from a strong skin irritant and one of the two oils used on the site. Among the instruments used in factory settings, measurements of skin colour and trans-epidermal water loss provided the most reliable and stable data.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2005. viii, 74p. Illus. 18 ref. Price: GBP 20.00. Downloadable version free of charge.
http://www.hse.gov.uk/research/rrpdf/rr300.pdf [in English]
Blome O., Diepgen T.L.
New recommendations for the evaluation of occupational skin diseases
Neue Begutachtungsempfehlungen für beruflich verursachte Hauterkrankungen [in German]
During 2002, 17,848 cases of occupational skin disease were registered by the German mutual occupational accident insurance associations. German occupational disease legislation requires insurance providers to carry out an investigation to determine whether a disease is caused by occupational factors. In order to improve the quality of these evaluations and the transparency of decisions concerning skin diseases, recommendations were published in the form of a document known as the "Bamberg notice" (Bamberger Merkblatt). These recommendations were approved by all parties concerned. This article presents the various aspects that need to be taken into account according to the notice when conducting a medical evaluation aimed at establishing the occupational nature of a skin disease.
Zentralblatt für Arbeitsmedizin, Arbeitsschutz und Ergonomie, Aug. 2004, Vol.54, No.8, p.278-291. Illus. 20 ref.
Ministério do Trabalho e Emprego
Workers' magazine: Occupational dermatoses
Revista do trabalhador: Dermatoses ocupacionais [in Portuguese]
These two videotapes examine the nature and causes of occupational skin diseases and outline a programme of prevention that includes substitution of chemical substances likely to cause skin disease, use of protective equipment and early diagnosis of the disease.
Fundacentro, Rua Capote Valente 710, São Paulo, SP 05409-002, Brazil, [ca. 2004]. Two videotapes (VHS format), 10min and 12min.
Health and Safety Executive
Preventing dermatitis at work - Advice for employers and employees
This booklet explains the causes of occupational dermatitis, highlights industries with the highest risk, and describes duties of employers and employees. Precautionary measures include identification of substances likely to cause dermatitis, selection of alternative chemicals or processes, and use of protective clothing and skin creams. Legal requirements are outlined. Replaces CIS 97-598.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 1996 (reprinted with amendments 2004). 11 p. Illus. 5 ref.
http://www.hse.gov.uk/pubns/indg233.pdf [in English]
Morales-Suárez-Varela M.M., Olsen J., Johansen P., Kaerlev L., Guénel P., Arveux P., Wingren G., Hardell L., Ahrens W., Stang A., Llopis A., Merletti F., Aurrekoetxea J.J., Masala G.
Occupational risk factors for mycosis fungoides: A European multicenter case-control study
The objective of this case-control study conducted from 1995 to 1997 in several hospitals across Europe was to search for possible occupational factors associated with mycosis fungoides (MF), a chronic cutaneous lymphoma. 134 patients aged between 35 and 69 diagnosed with MF were identified and their diagnoses were checked by a second pathologist. Of the 118 histologically-verified cases, 104 were interviewed, of which 76 were definitive cases. 833 colon cancer controls and 2071 population-based controls were also interviewed A high risk of MF for men was observed in non-metallic mineral products industries (odds ratio (OR) 5.3), among glass and ceramics workers (OR 17.9), among technical salesmen (OR 8.6) and in the wholesale trade (OR 3.6). For women, a high risk was found in paper pulp manufacturing (OR 14.4), as well as among government executives (OR 4.8) and railway and road vehicle loaders (OR 3.9).
Journal of Occupational and Environmental Medicine, Mar. 2004, Vol.46, No.3, p.205-211. 28 ref.
Akkan Z., Kalberlah F., Oltmanns J., Schneider K.
Bundesanstalt für Arbeitsschutz und Arbeitsmedizin
Potency assessment of skin sensitizing chemicals using the local lymph node assay
Beurteilung der Wirkstärke hautsensibilisierender Chemikalien anhand des Local Lymph Node Assay [in German]
The local lymph node assay (LLNA) is a relatively recent method for determining the degree of skin sensitization in mice. This study aimed at establishing correlations between results obtained by this method and those of human sensitization studies (human repeat insult patch tests and human maximization tests). For this purpose, results of LLNA tests and human tests were compared for 46 sensitizers. The degree of sensitization induced by these substances ranged through four levels of magnitude. Very good correlations were observed between LLNA tests and human tests. Four classes of classification are proposed for the degree of sensitization (low, medium, strong and very strong).
Wirtschaftsverlag NW, Postfach 10 11 10, 27511 Bremerhaven, Germany, 2004. 303p. Illus. Approx. 250 ref. Price: EUR 23.50.
Goldin M., Fantoni S., Dejobert Y., Leroyer A., Frimat P.
Occupational dermatitis from cutting fluids - Analysis of 32 cases
Les dermatites professionnelles aux fluides de coupe - A propos de 32 cas [in French]
This study had two objectives: firstly, to report on the current status of dermatological allergic diseases induced by cutting fluids and their components and to examine the diagnostic tools available to occupational physicians; secondly, to study occupational outcomes among these employees. It was carried out in the form of a retrospective and descriptive study, including a survey and an allergologic assessment consisting of a standard battery, a battery specific to cutting oils and a telephone questionnaire on socio-professional and medico-legal outcomes. A large proportion of the sample of 32 patients attending a hospital dermatology department were metallurgy workers and mechanics. The majority of the observed lesions consisted of eczematoid dermatitis for the allergens of the biocides/antiseptics group. There was also a strong proportion of family and personal history of atopy. Nine cases were found to be unfit for work, including five cases of dismissal in the absence of possible reclassification within the company. A reclassification or a change of workplace concerned 10 patients among the 27 that continued to practise their occupation.
Archives des maladies professionnelles et de médecine du travail, Dec. 2004, Vol.65, No.7-8, p.531-540. 11 ref.
Occupational skin diseases due to dyes
Dermatoses professionnelles aux colorants [in French]
Occupational skin diseases caused by exposure to dyes affect primarily hairdressers and textile industry workers. Paraphenylene diamine and its derivatives are among the most sensitizing hair dyes, while in the textile sector, the main allergens are found among disperse dyes. The clinical diagnosis and interpretation of allergy tests often pose difficulties in cases of allergic contact eczema to textile dyes. Contents of this review article on occupational skin diseases due to dyes: uses of dyes; their classification; epidemiology of occupational skin lesions caused by dyes; diagnosis in occupational settings; diagnosis in specialized institutions; prevention; compensation.
Documents pour le médecin du travail, 4nd Quarter 2004, No.100, p.565-576. Illus. 82 ref.
http://www.inrs.fr/INRS-PUB/inrs01.nsf/inrs01_search_view_view/955B9977919A0658C1256F7E003E619D/$FILE/ta71.pdf [in French]
Cervantès M.H., Sellier N., Loriot J., Verdier R., Dujols P., Picot M.C.
Perceived risk of occupational skin disease among hairdressers
Perception du risque professionnel cutané chez les coiffeurs [in French]
Occupational dermatoses are frequent among hairdressers and often force these workers to switch to other occupations, losing the benefits of their training. This study was carried out to evaluate the perception of this risk among hairdressers in the French region of Languedoc-Roussillon. A questionnaire was addressed to hairdressers covering their perception of cutaneous risk, their awareness concerning the skin hazards from chemicals and accessories, their daily practice of preventive measures and their skin symptoms. Job observations were also carried out in selected hairdressing salons. Among the 533 hairdressers who responded, 106 presented various dermatological lesions. Hairdressers were generally well-aware of the risks involved, although most were ignorant of the hazards due to nickel. They protected themselves adequately when manipulating hairdyes or bleaching treatments, but not when using products for perms or shampoos.
Archives des maladies professionnelles et de médecine du travail, Oct. 2004, Vol.65, No.6, p.470-479. Illus. 14 ref.
Geier J., Uter W., Lessmann H., Frosch P.J.
Patch testing with metalworking fluids from the patient's workplace
This study consisted of a retrospective analysis of patch test data from the dermatology department of a German teaching hospital between 1992 and 2003. 141 metalworkers had been tested because of suspected occupational contact dermatitis due to metalworking fluids (MWFs). 829 patch tests with 306 samples of MWF had been performed on these workers. Positive reactions to water-based MWFs occurred in 27 patients. From the analysis of reaction patterns, it is concluded that most of these reactions indicated true contact allergy.
Contact Dermatitis, Oct. 2004, Vol.51, No.4, p.172-179. 27 ref.
Skoet R., Olsen J., Mathiesen B., Iversen L., Duus Johansen J., Anger T.
A survey of occupational hand eczema in Denmark
This study involved all 490 women and 268 men compensated for occupational hand eczema in Denmark in the period from October 2001 to November 2002. The most frequent diagnosis was found to be irritant contact dermatitis, mainly caused by wet occupations, in proportions that were similar for men and women, namely 59.7% and 63.1% respectively. The rates of occupational hand eczema were high for bakers, hairdressers and dental assistants. The prevalence of atopic dermatitis was low (16.4%) compared to previous studies among hand eczema patients. The prevalence of occupational allergic contact dermatitis was substantially higher among men than women, the most frequent causes among men being allergy to chromium, rubber additives and nickel.
Contact Dermatitis, Oct. 2004, Vol.51, No.4, p.159-166. 30 ref.
Photosensitization, skin cancers and occupational exposure to ultraviolet radiation
Photosensibilisation, cancers cutanés et exposition professionnelle aux ultraviolets [in French]
Contents of this review article on photosensitization and skin cancers due to occupational exposure to ultraviolet (UV) radiation: UV radiation and occupational exposure; physiopathology and photochemical reactions; role of UV radiation in skin cancers; epidemiology; diagnosis in occupational settings; diagnosis in specialised institutions; prognosis; prevention and treatment; compensation.
Documents pour le médecin du travail, 1st Quarter 2004, No.97, p.109-119. Illus. 67 ref.
http://www.dmt-prevention.fr/inrs-pub/inrs01.nsf/inrs01_dmt_date_view/?SearchView&Query=([Form]=IntranetObject:Document)+AND+([c_totRef]=69)+AND+([date]=2004)&SearchOrder=4&SearchWV=TRUE&SearchFuzzy=FALSE&Start=1&Count=250&doc_form=recherche_dmt&SearchEnt [in French]
Occupational skin diseases in the food industry
Dermatoses professionnelles dans le secteur de l'alimentation [in French]
The food industry is among the sectors of activity that present the highest risk of occupational skin diseases. Workers are exposed to numerous irritants and allergens including detergents, disinfectants, foodstuffs and gloves, which give rise mostly to contact and irritation dermatitis, but also to allergic dermatitis and photosensitization reactions. Contents of this review article on skin diseases in the food industry: epidemiology; aetiology; diagnosis in occupational settings; diagnosis in specialised institutions; prognosis; prevention; compensation.
Documents pour le médecin du travail, 3rd Quarter 2004, No.99, p.411-422. Illus. 83 ref.
Lérida Arias M.T., Rodríguez Ferreiro M.B., Sanabria Pérez J.G., del Pozo Hernando L.J.
Management of the process of work incapacitation due to contact dermatitis
Gestión por procesos de la incapacidad laboral en dermatitis de contacto [in Spanish]
Contact dermatitis is a frequent cause of work incapacitation accounting for 90 to 95% of occupational skin diseases. This article explores the possibility of managing the process of evaluating the work capacity of patients suffering from contact dermatitis according to "business process redesign" principles. This management technique enables occupational health specialists responsible for workers suffering from contact dermatitis to adopt uniform criteria for evaluating their work capacity.
Medicina y seguridad del trabajo, Sep. 2004, Vol.L, No.196, p.13-21. 7 ref.
Alanko K., Susitaival P., Jolanki R., Kanerva L.
Occupational skin diseases among dental nurses
In this study, 799 female dental nurses in the Helsinki district were surveyed using a computer-assisted telephone interview. A structured questionnaire was used to inquire about skin and respiratory symptoms, atopy, work history, work methods and occupational exposure. The 328 nurses who reported work-related dermatitis on their hands, forearms or face, were invited to an interview by an occupational physician; 245 nurses participated. 31 nurses had previously been diagnosed with an occupational skin disease (OSD). 133 nurses with a suspected OSD were selected for further clinical examinations with prick and patch testing. Among the 107 nurses who participated, 22 new cases of OSD were diagnosed. There were altogether 29 cases of allergic contact dermatitis, 15 of contact urticaria, 12 of irritant contact dermatitis, and one case of onychomycosis. Rubber chemicals and natural rubber latex in protective gloves, as well as dental-restorative plastic materials (methacrylates), were the most common agents responsible for the allergies.
Contact Dermatitis, Feb. 2004, Vol.50, No.2, p.77-82. 26 ref.
Jungbauer F.H.W., van der Vleuten P., Groothoff J.W., Coenraads P.J.
Irritant hand dermatitis: Severity of disease, occupational exposure to skin irritants and preventive measures 5 years after initial diagnosis
A questionnaire survey was carried out on severity of hand dermatitis, exposure to skin irritants and preventive measures five years after initial diagnosis of irritant contact dermatitis (ICD). Of the initial 201 patients with ICD, 172 received the questionnaire five years later and 124 (72%) responded. 50% still had medium and 32% severe hand dermatitis. Patients with severe ICD and high exposure showed low levels of prevention and difficulty in changing their level of occupational exposure. Use of emollients was predominantly therapeutic rather than preventive. Occupation was changed in 57% of cases, of which 46% was permanent.
Contact Dermatitis, Apr. 2004, Vol.50, No.4, p.245-251. Illus. 23 ref.
Preventing skin rash in construction work
In the construction sector in Singapore, 47 workers had occupational skin problems during 2001 and 31 during 2002. This information sheet provides basic guidance on the prevention of skin rashes caused by cement, epoxy resins, thinners, fibreglass and oil. The responsibilities of supervisors and managers with respect to the supply of personal protective equipment, providing washing facilities, ensuring safe work practices and informing workers of the hazards of working with cement, are highlighted.
Occupational Health Department, Ministry of Manpower, 18 Havelock Road, #05-01, Singapore 059764, Republic of Singapore, [c2004]. 2p. Illus.
http://www.mom.gov.sg/MOM/OHD/Publications/1877_factID.pdf [in English]
Kütting B., Drexler H.
Effectiveness of skin protection creams as a preventive measure in occupational dermatitis: A critical update according to criteria of evidence-based medicine
This literature survey examines evidence for the effectiveness of the generally recommended three-step skin protection programme in the prevention of occupational skin disease (skin protection before work, cleaning and skincare after work). Data in the literature are conflicting: some publications report on the positive aspects of skin protection, others stress the negative ones. Not enough data have been accumulated to prove the benefit of skin protection measures under real workplace conditions. It is unclear whether the various in vitro and in vivo methods used are suitable for the simulation of workplace conditions and if these test results can be related to real occupational exposures. For the evidence-based recommendation of skin protection, further studies are needed that evaluate the contribution of each single element of the skincare programme (products, frequency of application and education programme) under daily working conditions.
International Archives of Occupational and Environmental Health, May 2003, Vol.76, No.4, p.253-259. 63 ref.
Matthieu L., Godoi A.F.L., Lambert J., Van Grieken R.
Occupational allergic contact dermatitis from bisphenol A in vinyl gloves
Allergic contact dermatitis caused by polyvinyl chloride gloves is rarely reported, and in only two cases was bisphenol A considered to be the responsible sensitizer. In this case report, a patient developed occupational hand dermatitis after the use of a new type of high-density vinyl (HDV) gloves. Patch tests showed positive reactions to both used and new HDV gloves and to bisphenol A. Chemical analysis by gas chromatography-mass spectrometry demonstrated the presence of bisphenol A in the HDV gloves. Replacement by nitrile rubber gloves resulted in complete clearance of the hand dermatitis.
Contact Dermatitis, Dec. 2003, Vol.49, No.6, p.281-283. Illus. 15 ref.
Marqués Aparicio E.R., Valks R., Conde-Salazar L.
Most frequent allergens in the metalworking industry
Alergenos más frecuentes en los trabajadores de la industria metalúrgica [in Spanish]
The aim of this study was to identify the allergens that most frequently cause allergic contact eczema in the metalworking industry. It involved 251 workers who had consulted an occupational dermatology service between 1999 and 2002 for cases of suspected contact dermatitis. Standard battery skin tests were carried out. 106 workers (42%) showed a positive reaction to at least one substance. The most frequent positive reactions were observed for chromium, nickel, thimerosal mix, cobalt, thiuram mix and formaldehyde. Among the 69 patients who were also subjected to patch tests with various cutting fluids, 20 (29%) showed a sensitization reaction, mainly for thimerosal mix, formaldehyde and certain biocides. Injuries affected primarily the fingers, hands and arms.
Medicina y seguridad del trabajo, Dec. 2003, Vol.L, No.193, p.7-14. Illus. 12 ref.
Frick M., Björkner B., Hamnerius N., Zimerson E.
Allergic contact dermatitis from dicyclohexylmethane-4,4'-diisocyanate
From August 1999 to April 2001, there was an outbreak of severe eczema at a factory manufacturing medical equipment. A glue, mainly based on the isocyanate dicyclohexylmethane-4,4'-diisocyanate (DMDI), was suspected as being the cause of the problem. 16 workers with recent episodes of eczema were patch tested with a standard series, an isocyanate series and work material. 13 patients reacted to DMDI, nine to 1,6-hexamethylenediisocyanate (HDI) and four to isophoronediisocyanate (IPDI), all of which are aliphatic isocyanates. None reacted to aromatic isocyanates, diphenylmethane-4,4'-diisocyanate (MDI) or toluenediisocyanate (TDI). One explanation for this pattern could be that aromatic diisocyanates are more reactive and therefore inactivated before penetrating the skin. Five patients reacted to dicyclohexylmethane-4,4'-diamine (DMDA) and five to 4,4'-diaminodiphenylmethane (MDA). Concurrent reactions to DMDA and/or MDA with DMDI could be due to cross-reactivity. The positive reactions to MDA could also be a marker of MDI exposure.
Contact Dermatitis, June 2003, Vol.48, No.6, p.305-309. 17 ref.
Bonny J.S., Yéboué-Kouamé B.Y., Pillah M.A., Wognin S.B., Kouassi Y.M., Tchicaya A.F.
Intolerance to latex gloves among healthcare workers at teaching hospitals in Abidjan
L'intolérance aux gants de latex chez le personnel soignant des centres hospitaliers universitaires d'Abidjan [in French]
The objective of this cross-sectional study was to assess the degree of intolerance to latex gloves among healthcare workers at the three teaching hospitals in Côte d'Ivoire. Subjects included 609 healthcare workers. Data were collected by means of questionnaires, dermatological examinations and skin tests among workers reporting latex intolerance. Among the main findings: 9.8% of the workers reported signs of intolerance to latex gloves; clinical signs were found on 80% of the intolerant subjects, including eczema (39.5%), irritant contact dermatitis (33.3%) and urticaria (27.1%); the most frequent localization was the back of the hands (37.5%) and the most concerned services were paediatrics (16.2%), laboratory and radiology services (12.5%) and surgery (7.4%); concerned workers included nurses (15.8%), physicians (14%) and midwives (9.7%). Skin tests were carried out among 66.7% of workers with signs of latex intolerance, allowing an estimation of the rate of allergy as 2% of the healthcare workers.
Archives des maladies professionnelles et de médecine du travail, Sep. 2003, Vol.64, No.5, p.329-333. 16 ref.
Kožní senzibilizující materiály [in Czech]
Hudallergiframkallande ämnen [in Swedish]
Hautsensibilisierende Stoffe (Hautallergene) [in German]
Pēgés erethismoú (hupereuaisthēsías) tou dérmatos [in Greek]
Sensibilizadores cutáneos [in Spanish]
Nahka sensibiliseerivad ained [in Estonian]
Ihoa herkistävät aineet [in Finnish]
Sensibilisants cutanés [in French]
Bőr érzékenyitők [in Hungarian]
Sostanze sensibilizzanti della cute [in Italian]
Odą jautrinančios medžiagos [in Lithuanian]
Ādas jūtīguma paaugstinātāji [in Latvian]
Huidsensibilisatoren [in Dutch]
Czynniki uczulające skórę [in Polish]
Agentes sensibilizadores da pele [in Portuguese]
Senzibilátory pokožky [in Slovak]
Povzročitelji kožne preobčutljivosti [in Slovenian]
Hudallergifremkaldende stoffer [in Danish]
Occupational skin diseases are estimated to cost the European Union EUR 600 million every year, resulting in around three million lost working days. They affect virtually all industry and business sectors and force many workers to change jobs. The European Agency for Safety and Health at Work is producing a series of fact sheets on occupational safety and health information about dangerous substances for the European Week for Safety and Health at Work 2003. This fact sheet contains information on skin sensitizers as well as preventive measures for skin exposure. Contents: causes of occupational skin problems; allergic skin diseases; skin sensitizers; preventing exposure.
European Agency for Safety and Health at Work, http://osha.eu.int, 2003. 2p. Illus. 8 ref.
http://agency.osha.eu.int/publications/factsheets/40/sv/FACTS-40_SV.pdf [in Swedish]
http://agency.osha.eu.int/publications/factsheets/40/en/FACTSN40-EN.PDF [in English]
http://agency.osha.eu.int/publications/factsheets/40/es/FACTS-40_ES.pdf [in Spanish]
http://agency.osha.eu.int/publications/factsheets/40/fr/FACTS-40_FR.pdf [in French]
http://agency.osha.eu.int/publications/factsheets/40/cs/FACT40_CS.pdf [in Czech]
http://agency.osha.eu.int/publications/factsheets/40/da/FACTS-40_DA.pdf [in Danish]
http://agency.osha.eu.int/publications/factsheets/40/de/FACTS-40_DE.pdf [in German]
http://agency.osha.eu.int/publications/factsheets/40/et/FACT40_ET.pdf [in Estonian]
http://agency.osha.eu.int/publications/factsheets/40/el/FACTS-40_EL.pdf [in Greek]
http://agency.osha.eu.int/publications/factsheets/40/it/FACTS-40_IT.PDF [in Italian]
http://agency.osha.eu.int/publications/factsheets/40/lv/FACT40_LV.pdf [in Latvian]
http://osha.lv/ew2003/40.pdf [in Latvian]
http://agency.osha.eu.int/publications/factsheets/40/hu/FACT40_HU.pdf [in Hungarian]
http://agency.osha.eu.int/publications/factsheets/40/lt/FACT40_LT.pdf [in Lithuanian]
http://agency.osha.eu.int/publications/factsheets/40/nl/FACTS-40_NL.pdf [in Dutch]
http://agency.osha.eu.int/publications/factsheets/40/pl/FACT40_PL.pdf [in Polish]
http://agency.osha.eu.int/publications/factsheets/40/pt/FACTS-40_PT.pdf [in Portuguese]
http://agency.osha.eu.int/publications/factsheets/40/sk/FACT40_SK.pdf [in Slovak]
http://agency.osha.eu.int/publications/factsheets/40/sl/Fact40_SL.pdf [in Slovenian]
http://agency.osha.eu.int/publications/factsheets/40/fi/FACTS-40_FI.PDF [in Finnish]
Susitaival P., Flyvholm M.A., Meding B., Kanerva L., Lindberg M., Svensson Å., Ólafsson J.H.
Nordic Occupational Skin Questionnaire (NOSQ-2002): A new tool for surveying occupational skin diseases and exposure
Questionnaire studies are often needed to collect additional data on the epidemiology of occupational skin diseases. A new tool entitled "Nordic Occupational Skin Questionnaire" (NOSQ-2002) for use in surveys on occupational skin diseases and exposures is described. Two NOSQ-2002 questionnaires have been compiled on the basis of existing questionnaires and practical experience. NOSQ-2002/SHORT is a ready-to-use 4-page questionnaire for screening and monitoring occupational skin diseases in a population or workplace. The long version, NOSQ-2002/LONG, contains in addition a pool of questions tailored to specific populations. In addition to the questionnaires, the NOSQ-2002 report includes a comprehensive manual for researchers on planning and conducting a questionnaire survey on hand eczema and relevant exposures. The use of NOSQ-2002 will benefit research on occupational skin diseases by providing more standardized data for comparisons between studies and countries.
Contact Dermatitis, Aug. 2003, Vol.49, No.2, p.70-76. Illus. 46 ref.
Occupational skin diseases caused by Peru balsam
Dermatoses professionnelles au baume du Pérou [in French]
Peru balsam can cause contact urticaria and eczema. Persons occupationally exposed to this substance include physiotherapists, masseurs, veterinarians workers in the food sector (bakers, cooks, market gardeners), farmers, beekeepers and metalworkers. Contents of this article on occupational skin diseases caused by Peru balsam: composition; skin toxicity; sources and uses; epidemiology; diagnosis in occupational settings; confirmation of diagnosis in specialized institutions; prognosis; prevention; compensation.
Documents pour le médecin du travail, 1st Quarter 2003, No.93, p.61-66. Illus. 60 ref.
Li L.F., Sujan S.A., Wang J.
Detection of occupational allergic contact dermatitis by patch testing
This study discusses the diagnosis of occupational allergic contact dermatitis (OACD) at a hospital in China by patch testing the patients with a standard series of allergens and by investigating the suspected offending occupational allergens by means of a questionnaire. During a two-year period (2001-2003), 14 patients were investigated and confirmed as having OACD. In this study, nickel, 4-phenylenediamine, fragrance mix, black rubber mix, colophony, epoxy resin and thiuram mix were identified by patch testing as the main offending allergens. These results indicate that patch testing plays a vital role in the diagnosis and identification of occupational allergens. OACD can often be diagnosed by patch testing of all patients with clinically suspected contact dermatitis with a standard series. Clinicians should then educate the sensitized workers in how to avoid further exposure to the causative allergens.
Contact Dermatitis, Oct. 2003, Vol.49, No.4, p.189-193. 4 ref.
Brown T., Rushton L.
Health and Safety Executive
The development of risk reduction strategies for the prevention of dermatitis in the UK printing industry
The primary objectives of this study were: to identify a range of low cost, practicable and acceptable interventions to reduce the incidence of occupational dermatitis in the UK printing industry; to carry out preliminary testing of the acceptability and efficacy of these interventions on a small scale; to use these preliminary tests to provide information on the variability of the outcomes, which would aid sample size calculations for a future large scale intervention trial; to develop appropriate methodologies for the identification of intervention strategies for use in other occupational and non-occupational situations. This involved a review of the literature of preventative interventions studies in the workplace and the identification of risk reduction interventions specific to the industry through qualitative research, using a series of observational studies and focus groups.
HSE Books, P.O. Box 1999, Sudbury, Suffolk CO10 2WA, United Kingdom, 2003. iv, 76p. Illus. 90 ref. Price: GBP 15.00.
http://www.hse.gov.uk/research/rrpdf/rr158.pdf [in English]
Korinth G., Göen T., Lakemeyer M., Broding H.C., Drexler H.
Skin strain and its influence on systemic exposure to a glycol ether in offset printing workers
The aim of this study was to show whether systemic exposure to glycol ether is higher among printing workers with skin lesions. 28 male printers exposed to 2-(2-butoxyethoxy)ethanol (BEE) were interviewed on their workplace exposure by means of a standardized questionnaire. The systemic exposure was determined by biological monitoring of the main metabolite of BEE (butoxyethoxyacetic acid, BEAA) in urine. Furthermore, a clinical examination of the skin was also carried out, together with measurements of transepidermal water loss, capacitance and skin surface pH. Erythema and scaliness were the most important factors showing an effect on dermal absorption. The mean urinary BEAA excretions for printers with skin lesions on the hands were higher (20.62mg/L for scaliness and 14.40mg/L for erythema) compared to levels for printers without detectable skin lesions (12.08mg/L for scaliness and 13.03mg/L for erythema).
Contact Dermatitis, Nov. 2003, Vol.49, No.5, p.248-254. Illus. 31 ref.
Occupational dermatoses among Polish private farmers, 1991-1999
The aim of this study was to create reliable statistics on occupational dermatoses among self-employed Polish farmers. For all cases of work-related skin diseases diagnosed from 1991 to 1999, compensation records of the Agricultural Social Insurance Fund were analysed for diagnoses, causative factors and health impairment of the skin. Since the introduction of a compensation system for occupational diseases and accidents in Poland in 1991, occupational dermatoses diagnosed among self-employed farmers have increased rapidly. The first case was registered in 1992. Until the end of 1999, there were 101 cases (63 women and 38 men). The incidence rose from 0.006/10,000/year in 1992 to 0.189/10,000/year in 1999. Allergic contact dermatitis was the most common diagnosis (86%), followed by infectious skin diseases (10%), irritant contact dermatitis (3%) and urticaria (2%). The most frequently-identified causative factors were plant dusts (38%), animal allergens (36%), metals (29%), pesticides (18%) and rubber chemicals (15%). The median impairment due to skin disease was 20% (range 2-36%).
American Journal of Industrial Medicine, June 2003, Vol.43, No.6, p.647-655. Illus. 25 ref.
Work-related eczema of the eyelids
Eczéma des paupières d'origine professionnelle [in French]
Work-related eczema of the eyelids caused by occupational factors is rare. Occupational factors are less likely to be involved than topical cosmetic or ophthalmologic creams. However, an investigation into possible occupational causes is still necessary in order to orient prevention and therapy efforts. Contents of this article on eczema of the eyelid: modes of sensitization; aetiology and exposed occupations; frequency of eyelid contact eczema; diagnosis in occupational settings; confirmation of diagnosis in specialized institutions; prognosis; prevention; compensation.
Documents pour le médecin du travail, 3rd Quarter 2003, No.95, p.365-371. Illus. 65 ref.
Telksniene R., Januskevicius V.
Occupational skin diseases in nurses
The aim of this work was to evaluate the incidence of occupational skin diseases in nurses, their morbidity rate, symptoms, possible causes and relation with occupational environment. The study group consisted of 706 nurses from different departments of a university hospital in Kaunas (Lithuania). A questionnaire and collection of information concerning the use of disinfectants were the main investigation methods. It was found that 47.3% nurses were suffering from occupational skin diseases. Allergic contact dermatitis was found to be the most frequent (28.5%) disease. Irritant contact dermatitis of non-allergic origin was diagnosed in 8.4% of nurses. The main symptoms of occupational skin diseases were itching and reddening. The risk of developing occupational dermatitis was increased by working with aldehydes and hydrogen peroxide as well as by using latex gloves and long working hours.
International Journal of Occupational Medicine and Environmental Health, 2003, Vol.16, No.3, p.241-247. Illus. 7 ref.
Occupational skin-disease data in Europe
The existence of different occupational health systems and legislations in the countries of Europe makes it difficult to obtain a detailed picture of occupational skin diseases for the whole continent. Reporting bias and selection bias have a considerable impact on the perceived prevalence and incidence, while reliable data are hard to extract from official registries. In this article, data from one region in Germany are taken as an example. Comparison with data from other sources yields an estimate of 0.7 to 1.5 cases per 1,000 per year as a gross average, while the problem in specific occupational groups is more pronounced. However, reliable data on social and economic impact are very scarce.
International Archives of Occupational and Environmental Health, June 2003, Vol.76, No.5, p.331-338. Illus. 51 ref.
The importance of occupational skin diseases in the United States
Occupational skin diseases and disorders (OSDs) are the most commonly reported non-trauma-related (acute or cumulative) category of occupational illnesses in the United States. This factor, along with their potential chronicity, their effect on an individual's occupational and non-occupational activities, and the fact that they are preventable, point out the public health importance of OSDs. It can be difficult to obtain accurate epidemiological data for OSDs in the United States, and all sources have their limitations. OSD cases that result in days away from work are important categories to study, since days away from work may be used as an indicator of the severity of a case. Descriptive epidemiology may be used to provide further information on these "more severe" cases, to determine, for example, high-risk industries, occupations, and exposures, and then to use this information to focus prevention strategies.
International Archives of Occupational and Environmental Health, June 2003, Vol.76, No.5, p.325-330. Illus. 22 ref.
Schwanitz H.J., Riehl U., Schlesinger T., Bock M., Skudlik C., Wulfhorst B.
Skin care management: Educational aspects
This article reviews the effectiveness of health education in the primary, secondary and tertiary prevention of occupational skin disorders. The results of three questionnaire studies involving apprentice hairdressers in 1986, 1994 and 1999 clearly show a decrease in skin disorders among those having received primary skin care training. A secondary intervention comprising both medical and educational methods was developed for hairdressers who remained at their workplace despite manifest skin disorders. As a result of the programme, 121 (81%) of the 150 participants healed successfully while continuing their work. A tertiary prevention programme involved occupational skin disease patients treated at the dermatology department of a university hospital, where education also proved to be effective.
International Archives of Occupational and Environmental Health, June 2003, Vol.76, No.5, p.374-381. Illus. 26 ref.
Geier J., Lessmann H., Uter W., Schnuch A.
Occupational rubber glove allergy: Results of the Information Network of Departments of Dermatology (IVDK), 1995-2001
Among the patients with occupational contact dermatitis registered in the Information Network of Departments of Dermatology (known under the German acronym IDVK) during the years 1995-2001, 2047 were patch tested for suspected rubber glove allergy. Reaction frequencies to thiurams, dithiocarbamates, mercaptobenzothiazole (MBT) and its derivatives, thioureas, and 1,3-diphenylguanidine (1,3-DPG) were analysed. Thiurams were by far the most frequent allergens in these patients (16.2% positive reactions). Although manufacturers have increased the use of dithiocarbamates and MBT derivatives in rubber glove production in recent years, these allergens elicited positive reactions in only about 3% of the patients tested, and showed no increasing trend. Thioureas and 1,3-DPG are not widely used in rubber glove production, and play only a minor role in rubber glove contact allergy. Most of the positive reactions to 1,3-DPG are probably false-positive, irritant reactions.
Contact Dermatitis, Jan. 2003, Vol.48, No.1, p.39-44. Illus. 23 ref.
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