Management of contact dermatitis

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ScienceDirect Journal of Dermatology & Dermatologic Surgery xxx (2015) xxx–xxx

Review Article

Management of contact dermatitis Sultan T. Al-Otaibi ⇑, Hatem Ali M. Alqahtani Department of Family and Community Medicine, University of Dammam, Dammam, Saudi Arabia Received 28 December 2014; accepted 11 January 2015

Abstract Skin disorders compromise more than 35% of all occupationally related disorders. Most of these are contact dermatitis as a result from contact with a chemical substance. Contact dermatitis can be either irritant or allergic type. Each type has a different mechanism while the clinical presentation is the same. Management of contact dermatitis must include both medical treatment and workplace modifications as appropriate to reduce exposure to the causative agents. Physicians should be aware of this preventable medical condition. Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Dermatitis; Contact; Management

Contents 1. 2. 3. 4.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management of contact dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Primary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.1. Engineering control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.2. Personal protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.3. Personal hygiene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.4. Work practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.5. Health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.6. Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.7. Administrative control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.8. Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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⇑ Corresponding author at: University of Dammam, PO Box 2208, Al-Khobar 31952, Saudi Arabia. Tel.: +966 13 8948964; fax: +966 13 8645612. E-mail address: [email protected] (S.T. Al-Otaibi). Peer review under responsibility of King Saud University.

Production and hosting by Elsevier http://dx.doi.org/10.1016/j.jdds.2015.01.001 2352-2410/Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Al-Otaibi, S.T., Alqahtani, H.A.M., Management of contact dermatitis, Journal of Dermatology & Dermatologic Surgery (2015), http://dx.doi.org/10.1016/j.jdds.2015.01.001

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S.T. Al-Otaibi, H.A.M. Alqahtani / Journal of Dermatology & Dermatologic Surgery xxx (2015) xxx–xxx

4.2.

Secondary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.1. Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.2. Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3. Tertiary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.1. Treatment and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.2. Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction

2. Mechanism

Skin is the most commonly injured organ in industry today, whereas skin disorders compromise more than 35% of all occupationally related disorders (Diepgen and Kanverva, 2006). Contact dermatitis is the most common occupational disease in many countries. A challenge is that contact dermatitis is under reported as work related illness. Health care worker should be aware of this occupational illness. It will also require appropriate diagnosis and management. Contact dermatitis (CD) is defined as a reactive eczematous inflammation of the skin which occurs after the direct contact with a chemical but occasionally by biologic or physical agents (Holness, 2014; Chew and Maibach, 2003). Contact dermatitis can be either due to irritation from direct exposure to a substance, irritant contact dermatitis (ICD) or as a result of exposure to allergic substance, allergic contact dermatitis (ACD) (Chew and Maibach, 2003; McFadden, 2014). ICD is the most common form of occupational skin disease which accounts for nearly 80% of CD (McFadden, 2014; Cahill et al., 2004; Lau et al., 2011). ICD can be either acute type due to single exposure of a material such as chemical burns (e.g. hydrofluoric acid, hydrochloric acid, alkali) and also phototoxic ICD (require ultraviolet light A to elicit it) or could be chronic type from cumulative and repetitive exposure to irritant substance (such as solvents, water, soap, detergents, acid, alkali, etc.). ACD includes contact urticaria which is type I hypersensitivity as an immediate but transient localized swelling and redness that occurs on the skin after direct contact with an offending substance such as latex, food (beans, egg, fish), antibiotics (penicillin, neomycin), ingredients of cosmetics and medicaments such as Balsam of Peru and Benzoic acid. ACD also includes contact dermatitis which is type IV hypersensitivity (dermatitis begins within 24– 48 h after contact) e.g. chrome, nickel, epoxy resin, rubber additives, etc. Sometimes ACD could be photoallergic that requires UV light after exposure to allergen. Atopic skin remains the single most important risk factor in an occupational setting (Holness, 2011; Holness et al., 2013; Diepgen, 2006; Keegel et al., 2009; Ibler et al., 2012; Luk et al., 2011; Lysdal et al., 2012).

The mechanism of contact dermatitis depends on its type (Cahill et al., 2004; Keegel et al., 2009). ICD is characterized by skin damage which could be mild to severe depending on the causative agent as a result of direct, local, toxic effect on the cellular elements of the skin. This leads to removal of the lipid film, denaturation of keratin of the skin, release of lysosomal enzymes and inflammatory response. Contact urticaria occurs through either allergic (immunologic) or non-allergic (non-immunologic) mechanism. Allergic contact urticaria is mediated by an IgE mechanism leading to a cascade of events causing inflammation of the skin. In non-immunologic contact urticaria a direct effect on the blood vessel wall occurs with release of vasoactive substances leading to hives (McFadden, 2014). Allergic contact dermatitis arises from a cell mediated delayed hypersensitivity reaction. Sensitization is initiated after an agent or hapten combines with skin protein to form a complete antigen. This antigen is processed by epidermal Langerhans cells, then T lymphocytes interact with Langerhans’ cell processed antigen. Later on T lymphocytes release lymphokines which serve as mediators of inflammation (Holness, 2014). 3. Clinical presentation It is impossible to differentiate between ICD and ACD clinically (Chew and Maibach, 2003). However, acute ICD is manifested by red, swollen, itchy, painful and ulcerated skin. Hydrofluoric acid burns are associated with hypocalcemia, and hypomagnesemia. While chronic ICD is characterized by eczematous skin eruption, erythema, dryness, cracking and fissuring of the skin. Secondary infection may supervene. It mainly involves the back of the hands including the fingers and the finger webs and subsequent involvement of the palm (Ibler et al., 2012; Luk et al., 2011; Lysdal et al., 2012). Contact urticaria appears as hives occurring within a few minutes up to an hour of skin exposure to the offending agent. Allergic contact dermatitis is characterized by redness, itching and scaling of the skin at the site of the contact, but very frequently involvement of the eyelids

Please cite this article in press as: Al-Otaibi, S.T., Alqahtani, H.A.M., Management of contact dermatitis, Journal of Dermatology & Dermatologic Surgery (2015), http://dx.doi.org/10.1016/j.jdds.2015.01.001


occurs. Later on vesiculation and oozing of the affected part occur (McFadden, 2014). 4. Management of contact dermatitis Information on the workplace health and safety hazards and prevention measures is the key component of modern occupational medicine policies and practice. The occurrence of contact dermatitis serves as a warning that preventive measures at the workplace likely need to be improved. Prevention of contact dermatitis includes the following: 4.1. Primary prevention 4.1.1. Engineering control It aims to enclose, contain or isolate the potential irritant or allergens. Such measures should receive the top priority wherever feasible (Geier et al., 2011). Chemical substitution is an alternative way to replace the allergen and irritant agents with less noxious substance (required by law) Schnuch et al., 2012. Also work practice which uses stainless steel (hardly release nickel), nickel, tin, and white gold causes very few reactions in nickel sensitive patients, so these patients can work in these jobs (Keegel et al., 2009). If skin exposure occur through air in the form of particulate, dust, mist or vapor, local and general ventilation may be sufficient. 4.1.2. Personal protection 4.1.2.1. Protective clothing. Protective clothing such as gloves, boots and aprons is available in a number of fabrics or materials. Protective clothing should be guided by considering the physical and chemical resistance properties, flexibility and skin surface to be exposed. Gloves often protect well but many organic substances and solvents penetrate them readily, therefore this issue should be taken into consideration when selecting the appropriate gloves for a particular work practice (Ibler et al., 2012). Clothing should be periodically inspected and discarded if holes and tears are found. Disposable clothing is required for protection against allergens and irritant substances. Protective clothing may occasionally cause contact dermatitis rather than prevent it, through nonspecific irritation from sweat entrapment and friction of clothing against the skin (Holness et al., 2013). Occlusion of chemical allergen beneath the protective clothing enhances cutaneous absorption of the substance leading to ACD (e.g. allergy to accelerator and antioxidants in rubber from wearing rubber gloves). Gloves should always be worn over clean hands to avoid accidental occlusion of the allergen and irritants against the skin. Protective clothing should not be used unless engineering controls are feasible (Holness et al., 2013). 4.1.2.2. Barrier creams. The clinical effectiveness of such preparation is controversial and unsupported by clinical studies. Water resistant barrier creams contain hydrophobic substance such as silicone, which protects against water

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soluble substances such as acids, alkali and dye. On other hand, oil or solvent resistant barrier creams protect against dust, oils, greases and solvents. The manufacturer’s instruction should be followed when these barrier creams are applied. Many barrier creams facilitate the removal of sticky oils, greases, thus decrease the need to wash with irritating water and soap (Uter et al., 2012). Barrier creams should be used on normal skin as they cause aggravation of dermatitis if applied to inflamed skin (Geier et al., 2011). Qaternium-18 bentonite lotion was found to be effective in preventing or diminishing experimentally produced poison ivy and poison oak (Arrandale et al., 2012). 4.1.3. Personal hygiene Washing hands with mild soap and water suffice to remove allergen and irritants from the skin. Sometimes abrasive soap which works by peeling the stratum corneum is used to remove oil and greases from the skin or waterless hand cleaners which contain organic solvents are used in these situations. Abrasive and waterless soap should be only applied to the palm where the skin is thick and should be restricted if simple water and mild soap do not suffice (Nicholson et al., 2010; Smedley, 2010). Overuse or misuse of skin cleaning agents can cause or aggravate contact dermatitis (Adisesh et al., 2013). Industrial solvents should not be used for skin cleansing. Eating, drinking and smoking at the workplace should be prohibited except in the designated resting area to avoid contamination with allergen and irritant substances. Personal hygiene should also include regular washing or cleaning protective clothing because of the risk of skin contact with allergen or irritant especially when clothing is soiled (Adisesh et al., 2013). 4.1.4. Work practice It includes covering the work surface with protective or absorbent towels or sheets, cleaning the work surface with appropriate industrial cleaner and sweeping or vacuuming of dust and particulate (Holness et al., 2013). Application of skin moisturizer is advised where the work practice exposes the individual to water based irritants such as cutting oils or solvents. White petroleum is an excellent skin moisturizer and is as effective as any other type of barrier cream but has the disadvantage of greasiness which makes gripping the tools difficult if applied liberally to the palm. Cross reactions occur between many chemically related substances, hence important in the prevention of allergic contact dermatitis (Nicholson et al., 2010). 4.1.5. Health education It aims to promote awareness and identify work activities in which exposure to allergens and irritants is likely. Job training should teach recognition of early symptoms and signs of contact dermatitis, proper use of protective clothing and barrier cream and personal and work hygiene.


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Instruction of employees in the emergency procedure is necessary in case of accidental contamination from high risk work. Training involves the use of videotape, lectures and others. Worker education should be initiated before placement in the job and should be periodically repeated. Supervisors should be included in the education program with intensive education and safety training to serve as on the job teachers and reinforcing safety issues. It was found that worker’s understanding of the diagnosis and patient education is essential to improving the outcome of contact dermatitis (Lysdal et al., 2012; Bourke et al., 2009). 4.1.6. Motivation It is an important but frequently neglected aspect of prevention program. So, despite education, some workers are not motivated to observe preventive practice because they do not consider themselves at risk for contact dermatitis. Efforts should be aimed to stimulate self motivation and consider personal life style and convince exposed workers that they are at risk. The active support of union and safety officials is a critical element of motivational efforts (Schnuch et al., 2012). On the other hand, employer motivation should aim that safe work will increase worker satisfaction and productivity or decrease cost from worker compensation point of view (Schnuch et al., 2012). 4.1.7. Administrative control This includes work shift rotation or spreading the high risk activities of work more evenly among employees to minimize exposure to allergen and irritant substance. A job change, unless it means complete avoidance of specific allergen such as epoxy resin is unlikely to lead to clearing of contact dermatitis (Adisesh et al., 2013; Bourke et al., 2009). This should be the last thing to be tried if all the above preventive strategies are not feasible. 4.1.8. Regulation Warning signs or labels should be placed in all containers or products in which hazardous chemical or substances may be encountered. The health hazard should be described clearly in the Material Safety Data Sheet (MSDS). There is no present regulatory requirement governing skin exposure to potential hazards (Holness, 2004; Adisesh et al., 2002; Cahill et al., 2005; Johnansen et al., 2011). 4.2. Secondary prevention 4.2.1. Diagnosis The diagnosis of ICD is made by exclusion, based on accurate, thorough medical history and careful clinical examination of the patient. It is important to obtain exposure history from work, from home and hobbies. Patch tests with a standard tray and a special environmental allergen will verify or rule out allergic components

of contact dermatitis. Also correct, pure and stable patch test material is essential for accurate patch test results and can form the basis for prevention of allergic contact dermatitis through screening (Goulden and Wilkinson, 2000). If the patch test gives a positive result, a determination should be made to decide whether the allergen is relevant to the work environment. If the patch test gives a negative result, and if ACD suspected, the clinical history should be reviewed and questioned whether or not the appropriate allergen has been tested. Systemic steroids can suppress the result of the patch test if the dose of prednisone is more than 30 mg daily taken by the patient prior to patch testing. Other possibilities for negative patch test include: incorrect concentration of the allergen used for testing, contact urticaria and photo-contact dermatitis (Johnston, 2009; Geier et al., 2006; Wang et al., 2011). A visit to the workplace may be needed to identify physical irritants such as temperature, humidity or mechanical irritants and/or chemical allergens and irritants. Workplace provocation test can be carried out if the patch test is still negative and ACD is suspected (Aalto-Korte et al., 2012; Geier et al., 2004; Houle et al., 2012; Slodowink et al., 2009). Pre-placement screening to exclude a new employee at risk of developing contact dermatitis (such as atopy as a risk factor for ICD) is a waste of time, money and effort and even ethically unaccepted. The American with Disability Act discourages employer from denying work to persons with skin diseases as long as they are able to do the job. Patch testing of healthy new employees without a history of contact dermatitis has no value and is even dangerous with respect to patch test sensitization (Saary et al., 2005). On the other hand, vocational guidance should be considered and the choice of career should begin in children with atopy as early as age of 10 years. At the age of 14 most youngsters have a good idea about their choice of occupation. Therefore, parents should attempt to direct children with atopy away from most irritating occupations such as hairdressing and auto-mechanics (Saary et al., 2005). 4.2.2. Surveillance Surveillance centers of contact dermatitis clinic should be accessible to those who suffer from contact dermatitis. Such centers can cooperate for collection of the patients’ data and identify new problem at an early stage through health questionnaire and medical examination of the skin for prevention of contact dermatitis (Nicholson et al., 2010; Smedley, 2010). 4.3. Tertiary prevention 4.3.1. Treatment and management The treatment of contact dermatitis depends on its stage. The acute phase is best treated with astringent soak



and topical or systemic steroids and an antihistamine. Surgical debridement and skin grafting may be needed in very rare cases specifically when big ulcers develop as a result of strong acid or alkali accidents at work. The chronic phase is managed by moisturizing creams for skin dryness in addition to topical steroids. Antibiotics may be needed if there is evidence of secondary infection. In all cases protection and avoidance of irritants and allergens should be implemented (Diepgen et al., 2009; John et al., 2011). 4.3.2. Rehabilitation When preventive and therapeutic measures fail, assessment of skin impairment and disability should be carried out. Rehabilitation efforts should be aimed to restore economic and vocational usefulness of the worker. The worker may need to receive workers’ compensation and disability benefit after establishing occupational causation while considering retraining for a new job. The cost of early consideration for rehabilitation may be financially beneficial (Weisshaar et al., 2013; Van Gils et al., 2012a,b; Gomez et al., 2011; Holness, 2003). To sum up, prevention of contact dermatitis is a multidisciplinary approach. Primary prevention of contact dermatitis is the single most important preventive measure to reduce employees’ exposure to irritant or allergen substance. Once a prevention program is in place, work practice must be reviewed to ensure protective clothing being used. On the other hand, secondary and tertiary preventive measures have not proved particularly effective. Conflict of interest None declared. Acknowledgments The authors are most grateful to Dr. Sarah Hasan Al-Breiki, Dermatology Consultant at King Fahad Hospital of the University, Al-Khobar, Saudi Arabia for reviewing this manuscript. References Aalto-Korte, K., Suuronen, K., Kuuliala, O., et al., 2012. Occupational contact allergy to monomeric isocyanates. Contact Dermatitis 67 (2), 78–88. Adisesh, A., Meyer, J.D., Cherry, N.M., 2002. Prognosis and work absence due to contact dermatitis. Contact Dermatitis 46, 273–279. Adisesh, A., Robinson, E., Nicholson, P.J., Sen, S., Wilkinson, M., 2013. U.K. standards of care for occupational contact dermatitis and contact urticaria. Br. J. Dermatol. 168, 1167–1175. Arrandale, V.H., Liss, G.M., Tarlo, S.M., et al., 2012. Occupational contact allergens. Are they also associated with occupational asthma? Am. J. Ind. Med. 55, 353–360. Bourke, J., Coulson, I., English, J., 2009. Guidelines for the management of contact dermatitis: an update. Br. J. Dermatol. 160, 946–954. Cahill, J., Keegel, T., Nixon, R., 2004. The prognosis of occupational contact dermatitis. Contact Dermatitis 51, 219–226.

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Cahill, J., Keegel, T., Dharmage, S., Nugriaty, D., Nixon, R., 2005. Prognosis of contact dermatitis in epoxy resin workers. Contact Dermatitis 52, 147–153. Chew, A.L., Maibach, H.I., 2003. Occupational issues of irritant contact dermatitis. Int. Arch. Occup. Environ. Health 76, 339–346. Diepgen, T.L., 2006. The costs of skin disease. Eur. J. Dermatol. 16, 456– 460. Diepgen, T.L., Kanverva, L., 2006. Occupational skin diseases. Eur. J. Dermatol. 16, 324–330. Diepgen, T.L., Elsner, P., Schliemann, S., Fartasch, M., Kollner, A., Skudlik, C., John, S.M., Worm, M., 2009. Guideline on the management of hand eczema ICD-10 Code: L20. L23. L24. L30. JDDG (Suppl. 3). Geier, J., Uter, W., Lessmann, H., Frosch, P.J., 2004. Patch testing with metalworking fluids from the patient’s workplace. Contact Dermatitis 51, 172–179. Geier, J., Lessman, H., Becker, D., et al., 2006. Patch testing with components of water-based metalworking fluids: results of a multicentre study with a second series. Contact Dermatitis 55, 322–329. Geier, J., Krautheim, A., Uter, W., et al., 2011. Occupational contact allergy in the building trade in Germany: influence of preventive measures and changing exposure. Int. Arch. Occup. Environ. Health 84, 403–411. Gomez, P., Kudla, I., Wozniak, G., et al., 2011. The impact of a multidisciplinary team and a dedicated return-to-work coordinator for workers with work-related skin disease. Dermatitis 22 (3), 176. Goulden, V., Wilkinson, S.M., 2000. Evaluation of a contact allergy clinic. Clin. Exp. Dermatol. 25, 67–70. Holness, D.L., 2003. Return-to-work issues for workers with contact dermatitis: results of a stakeholder survey. Contact Dermatitis 49, 273– 275. Holness, D.L., 2004. Health care services used by workers with workrelated contact dermatitis. Dermatitis 15, 18–24. Holness, D.L., 2011. Workers with occupational contact dermatitis: work outcomes and return to work process in the first six months following diagnosis. J. Allergy 2011, 170693. Holness, D.L., 2014. Occupational skin allergies: testing and treatment (the case of occupational allergic contact dermatitis). Curr. Allergy Asthma Rep. 14 (2), 410. http://dx.doi.org/10.1007/s11882-013-0410-8. Holness, D.L., Harniman, E., DeKoven, J., Skotnicki Grant, S., Beaton, D., Nixon, R., et al., 2013. Hand function in workers with hand dermatitis. Dermatitis 24, 131–136. Houle, M.-C., Holness, D.L., DeKoven, J., Skotnicki, S., 2012. Additive value of patch testing custom epoxy materials from the workplace at the Occupational Disease Specialty Clinic in Toronto. Dermatitis 23, 214–219. Ibler, K.S., Jemec, G.B.E., Flyvholm, M.-A., et al., 2012. Hand eczema: prevalence and risk factors of hand eczema in a population of 2274 healthcare workers. Contact Dermatitis 67, 200–207. John, S.M., Skudlik, C., Wulfhorst, B., et al., 2011. An integrated inpatient/outpatient rehabilitation program – the German approach. Dermatitis 22 (5), 301–302. Johnansen, J.D., Hald, M., Andersen, B.L., et al., 2011. Classification of hand eczema: clinical and aetiological types. Contact Dermatitis 65 (1), 13–21. Johnston, G.A., 2009. Standardization of patch tests and the doctors who read them. Br. J. Dermatol. 161, 493–495. Keegel, T., Moyle, M., Dharmage, S., Frowen, K., Nixon, R., 2009. The epidemiology of occupational contact dermatitis (1990–2007): a systematic review. Int. J. Dermatol. 48, 571–578. Lau, M.Y., Burgess, J.A., Nixon, R., Dharmage, S.C., Matheson, M.C., 2011. A review of the impact of occupational contact dermatitis on quality of life. J. Allergy 2011, 964509. Luk, N.-M.T., Lee, H.-C.S., Luk, C.-K.D., et al., 2011. Hand eczema among Hong Kong nurses: a self-report questionnaire survey conducted in a regional hospital. Contact Dermatitis 65 (6), 329–335. Lysdal, S.H., Sosted, H., Johansen, J.D., 2012. Do hairdressers in Denmark have their hand eczema reported as an occupational disease?


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Results from a register-based questionnaire study. Contact Dermatitis 66, 72–78. http://dx.doi.org/10.1111/j.1600-0536.2011.01997.x. McFadden, J., 2014. Immunologic contact urticaria. Immunol. Allergy Clin. North Am. 34 (1), 157–167. http://dx.doi.org/10.1016/ j.iac.2013.09.005. Nicholson, P.J., Llewellyn, D., English, J.S., 2010. Evidence-based guidelines for the prevention, identification and management of occupational contact dermatitis and urticaria. Contact Dermatitis 63, 177–186. Saary, J., Qureshi, R., Palda, V., et al., 2005. A systematic review of contact dermatitis treatment and prevention. J. Am. Acad. Derm. 53, 845–855. Schnuch, A., Geier, J., Lessman, R., et al., 2012. Surveillance of contact allergies: methods and results of the Information Network of Departments of Dermatology (IVDK). Allergy 67, 847–867. Slodowink, D., Williams, J., Frowen, K., Palmer, A., Matheson, M., Nixon, R., 2009. The additive value of patch testing with patients’ own products at an occupational dermatology clinic. Contact Dermatitis 61, 231–235. Smedley, J.on behalf of the OHCEU and BOHRF Dermatitis guideline development groups, 2010. Concise guidance: diagnosis, management

and prevention of occupational contact dermatitis. Clin. Med. 5, 487– 490. Uter, W., Gefeller, O., Geier, J., Schnuch, A., 2012. Methylchloroisothiazolinone/methylisothiazolinone contact sensitization: diverging trends in subgroups of IVDK patients in a period of 19 years. Contact Dermatitis 67, 125–129. Van Gils, R.F., Boot, C.R.L., Knol, D.L., et al., 2012a. The effectiveness of integrated care for patients with hand eczema results of a randomized, controlled trial. Contact Dermatitis 66 (4), 197–204. Van Gils, R.F., Groenewoud, K., Boot, C.R.L., et al., 2012b. Process evaluation of an integrated multidisciplinary intervention programme for hand eczema. Contact Dermatitis 66 (5), 254–263. Wang, M.Z., Farmer, S.A., Richardson, D.M., Davis, M.D., 2011. Patchtesting with hairdressing chemicals. Dermatitis 22, 16–26. Weisshaar, E., Skudlik, C., Scheidt, R., et al., 2013. Multicentre study ‘rehabilitation of occupational skin diseases – optimization and quality assurance of impatient management (ROQ)’ – results from 12-month follow-up. Contact Dermatitis 68, 169–174.
