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Occupational contact dermatitis accounts for 95% of all cases of occupational skin disease with irritant contact dermatitis (ICD) constituting 80% to 90% of these cases. Health care workers, hairdressers, and food service workers are typically most affected by occupational ICD of the hands as these occupations require frequent hand hygiene and/or prolonged exposure to water, also known as "wet work." In the context of the current COVID-19 pandemic, frequent hand hygiene has become a global recommendation for all individuals, and new workplace guidelines for hand sanitization and surface sterilization are affecting occupations not previously considered at risk of excessive wet work including grocery or retail workers, postal workers, sanitization workers, and others. In this review, we discuss the etiology and pathogenesis of occupational ICD with additional focus on treatment and interventions that can be made at an institutional and even national level for education and prevention of ICD resulting from frequent hand hygiene., Competing Interests: The authors have no funding or conflicts of interest to declare., (Copyright © 2021 American Contact Dermatitis Society. All Rights Reserved.)

Competing Interests: The authors have no funding or conflicts of interest to declare.

Background: The epidemiology of nickel allergy in occupational settings is not well understood., Objective: The aim of the study was to characterize occupationally related nickel allergy (ORNA)., Methods: This is a retrospective cross-sectional analysis of 44,378 patients patch tested by the North American Contact Dermatitis Group from 1998 to 2016. Characteristics of individuals with ORNA were compared with those with non-ORNA (NORNA)., Results: A total of 7928 (18.2%) individuals were positive to nickel sulfate 2.5%. Two hundred sixty-eight (3.4%) had ORNA. As compared with NORNA, ORNA was statistically associated with the male sex (41.0% vs 12.9%, P < 0.001), a diagnosis of irritant contact dermatitis (22.4% vs 12.0%, P < 0.001), and no history of eczema (81.7% vs 75.7%, P = 0.0217). The most common sites of ORNA dermatitis were hand (39.9%) and arm (18.1%), which were significantly more common than in NORNA (P < 0.0001). Sixteen industry categories and 22 occupation categories were identified for ORNA; the most common industries were durable goods manufacturing (24.6%) and personal services (15.7%), and the most frequent occupations were hairdressers/cosmetologists/barbers (14.3%), machine operators (9.3%), and health care workers (7.1%). Overall 30% of ORNA occupations were in metalworking. Of 215 ORNA sources identified, instruments/phones/other equipment (16.3%), vehicles/machinery (15.8%), and tools (15.3%) were the most common., Conclusions: Occupational nickel allergy is distinct from nonoccupational nickel allergy.

Background: The evidence on the safety of topical preparations containing emulsifiers is limited., Objectives: The aims of the study were to assess (1) the prevalence of sensitization to some emulsifiers commonly found in topical products, (2) the sensitization to emulsifiers in relation to sex, age, and predisposing factors, and (3) the frequency of concomitant sensitization to other common allergens., Methods: All consecutive patients presenting to the Allergy Unit of our Dermatological Department for allergological investigation were enrolled. All patients were patch tested with the Italian Società Italiana di Dermatologia Allergologica Professionale ed Ambientale baseline series and an additional emulsifiers series. Doubtful patch test reactions were not considered., Results: Of 310 patients, 50 (16%) were sensitized to emulsifiers with 72 positive reactions. Lauryl polyethylene glycol/polypropylene glycol-18/18 methicone gave 26 positive reactions, glyceryl oleate 19, myristyl alcohol, and Amerchol L101 11. Concomitant sensitization to emulsifiers was found in 16 patients. Patients allergic to emulsifiers showed concomitant allergic reactions to allergens commonly found in cosmetics. No significant differences by sex, age, atopic diathesis, and clinical pattern at presentation were noticed., Conclusions: Contact allergy to emulsifiers is more frequent than reported. Patients allergic to emulsifiers show frequent positive patch tests to other constituents of cosmetics and topical products.

Background: The prevalence of chromate allergy has declined worldwide in the last decades., Objectives: The aim of the study was to assess tendencies in chromate allergy in northern Israel and its possible causes., Methods: Retrospective analysis of patch test data during 1999-2013 and a review of the medical records of patients with chromate allergy were conducted., Results: A total of 4846 consecutive patients were patch tested, of whom 146 (3%) were found to be chromate sensitive. The prevalence of chromate allergy decreased significantly from 4.7% in 1999-2001 to 2.8% in 2002-2004 (P = 0.02). Since then, no significant fluctuations have occurred. A gradual and consistent decline in chromate allergy was recorded among women from 4.8% in 1999-2001 to 2.3% in 2008-2010. Cement (18.4%) was the most frequent source of exposure and was mainly observed in men. The frequency of clinically relevant cement exposure increased significantly from 7.7% in 2002-2004 to 28.7% in 2011-2013 (P = 0.04), whereas the frequency of relevant detergent exposure decreased significantly from 25% in 1999-2001 to 5.7% in 2011-2013 (P = 0.04). Hand (68.5%) was the most frequently involved anatomical site., Conclusions: The prevalence of chromate allergy in northern Israel is stable in the general population and gradually decreasing among women. These changes may be caused by reduced exposure to water-soluble hexavalent chromium in detergents but not in cement.

Background: Occupational skin diseases are common. The occurrence of occupational skin diseases represents a failure of primary prevention strategies that may include the use of personal protective equipment, most commonly gloves., Objective: The objective of this study was to describe current glove use and education practices related to gloves in workers being assessed for possible work-related hand dermatitis., Methods: Participants included consecutive patients being assessed for possible work-related hand dermatitis. A self-administered questionnaire obtained information on demographics, workplace characteristics and exposures, glove use, and education regarding gloves., Results: Ninety percent of the 105 participants reported using gloves. Only 44% had received training related to glove use in the workplace. Major gaps in training content included skin care when using gloves, warning signs of skin problems, and glove size. If the worker indicated no glove training received, the majority reported they would have used gloves if such training was provided., Conclusions: Although the majority of workers being assessed wore gloves, the minority had received training related to glove use. Particular gaps in training content were identified. Those who had not received training noted they would likely have used gloves if training had been provided.

Background: Workers are exposed to potential irritants and allergens with constant introduction of new industrial chemicals in the workplace., Objective: Characterize the final diagnoses, demographics, occupations, exposures, clinical presentations, patch test results, dermatologic histories, and risk factors of workers evaluated for suspected work-related allergic contact dermatitis (ACD)., Methods: A retrospective chart review of 310 workers' compensation independent medical examinations evaluated for suspected work-related ACD was performed. Workers were seen in a community dermatology clinic in Portland, Oregon, from 2005 to 2014. Evaluation included history, physical examination, patch testing, and further diagnostic workup when indicated., Results: Hand dermatitis was the most common presentation (n = 148, 47.7%). Prevalent occupations included health care workers (n = 51, 16.5%), custodial staff (n = 41, 13.2%), and machinists (n = 36, 11.6%). Allergic contact dermatitis (47.5%) was more common than irritant contact dermatitis (ICD) (38.9%) in those diagnosed as having occupational skin disease (n = 185). The highest-frequency work-related allergens were thiuram mix (21 of 88, 23.9%), carba mix (20 of 88, 22.7%), potassium dichromate (9 of 88, 10.2%), and epoxy resin (9 of 88, 10.2%)., Conclusions: Allergic contact dermatitis and ICD are common occupational skin disorders. In this population of workers' compensation referrals, ACD was more common, with 73.3% of those cases work related, compared with 86.7% of ICD. Blue collar work and wet work were risk factors for the development of ACD and ICD.

Background: Contact dermatitides occur commonly among health care workers (HCWs)., Objective: To contrast the atopic status and incidence, location, and final diagnosis of skin diseases afflicting HCWs versus non-HCWs (NHCWs) evaluated for suspicion of allergic contact dermatitis (ACD); and among the population diagnosed with ACD, to compare the incidence and occupational relatedness of allergens found in HCWs with the rates observed in NHCWs., Methods: Between July 1, 1994, and May 30, 2014, 2611 patients underwent patch testing by the senior author. Of these, 165 were classified as HCWs based on their primary occupation. Statistical analysis was done using a χ test., Results: Health care workers were more likely than NHCWs to be women and to have hand dermatitis. Women, but not men, HCWs suffered more irritant contact dermatitis. Health care workers had significantly more work-related ACD, especially to formaldehyde, quaternium-15, 2-bromo-2-nitropropane-1,3-diol, cocamide diethanolamine (DEA), thiuram mix, carba mix, thimerosal, benzalkonium chloride, glutaraldehyde, and bacitracin., Limitations: Only patients suspected of having ACD were tested. Our population was geographically limited to metropolitan Kansas City, MO and metropolitan New York, NY., Conclusions: Health care workers suffer more from occupational ACD, especially of the hands, than do NHCWs, including to allergens not present on available standard allergen series.

Background: The prevalence of contact allergy to sodium metabisulfite (SMB) has increased from the range of 1.4% to 1.7% to the range of 3.4% to 6.8% in published series over the past 20 years., Aims: The aims of this study were to review contact allergy to SMB in our cohort and to investigate different concentrations to define the most appropriate concentration for patch testing., Methods: Patient records were reviewed between February 2009 and December 2011 to obtain information on patient demographics, clinical presentation, and prevalence of contact allergy to SMB. Patients attending for patch testing, between January 2012 and June 2013, were tested with 3 strengths of SMB as part of the British standard series (1%, 0.1%, and 0.01%)., Results: Nine hundred ninety-six patients were patch tested to the British standard series including SMB 1% in petrolatum between February 2009 and June 2013, and 70 (7%) were positive. In the prospective group, 380 were tested to 3 concentrations of SMB (1.0%, 0.1%, and 0.01%). Fourteen patients (3.68%) had a positive patch test with 1% SMB, 7 to 0.1% SMB, and 3 to 0.01% SMB. There was exposure to SMB in 10 patients who cleared with avoidance at review 3 months later. The most frequent location of rash included face, hands, vulval, and perianal region., Conclusions: Our study confirms reports of increasing prevalence of SMB allergy. A detailed review of exposure in the prospective study showed that SMB is relevant in most patients, and 1% in petrolatum is the best concentration for patch testing.

Background: Patients with allergic contact dermatitis to 1 antigen have been shown to be at increased risk of developing delayed type hypersensitivity reactions to additional antigens. Both environmental and genetic factors likely influence the risk of sensitization., Objective: The aim of this study was to determine whether polysensitization occurs at a higher frequency than would be expected based on chance and whether polysensitization occurs more often in subsets of patients with hand involvement and atopic dermatitis., Methods: From a database of patch test results from a single practitioner, the probability of having positive reactions to 3 or more unrelated allergens was calculated under the assumption that positive reactions are independent and compared with the observed proportion having positive reactions to 3 or more unrelated allergens. The analysis was repeated excluding patients with leg involvement as a proxy for venous insufficiency dermatitis. The proportion of patients from the polysensitized and nonpolysensitized cohorts with either hand involvement or a history of atopic dermatitis was also calculated., Conclusions: Polysensitization occurs more often than expected based on chance. Polysensitized patients were more likely to have hand dermatitis. Atopic dermatitis was not significantly associated with polysensitization in this analysis. Polysensitized individuals may represent a phenotype with increased genetic susceptibility to sensitization.

Background: Chronic hand eczema is defined as a persistent (>6 months' duration) noninfectious skin inflammation of the hands. It is twice as common in women as men. Although genetic factors have been considered, greater exposure of women to wet work, such as housework, is assumed to be the most likely explanation. It has been debated whether lifestyle factors may be associated with chronic hand eczema., Objective: The objective of this study was to evaluate the influence of cigarette smoking on housewives for the development of chronic hand eczema., Methods: We analyzed 516 housewives 18 years or older. Two hundred fourteen were affected by chronic hand eczema, and 302 were control subjects. Both patients and control subjects were divided into 2 subgroups, smokers and nonsmokers. An anonymous questionnaire was submitted to each woman., Conclusions: No significant differences emerged between "smokers" and "nonsmokers" concerning the incidence of chronic hand eczema. In addition, the smokers were mainly affected by a milder ("almost clear") form of the disease. On the other hand, "severe" forms of chronic hand eczema might be more frequent in nonsmokers when compared with smokers. This study suggests that smoking is not associated with onset of chronic hand eczema, but with less severe chronic hand eczema.

Background: Preservatives are indispensable agents used to prevent bacterial and fungal contamination of cosmetics, personal care products, domestic preparations, and industrial products., Objective: We evaluated patch-test data at the National Skin Centre, Singapore, from 2006 to 2011 to identify the trends in preservative contact allergies., Methods: All patients with suspected contact dermatitis were patch tested to 4 preservatives within the modified European standard series. Patients were also tested with 7 preservatives from our special series if clinically indicated., Results: Three thousand one hundred seventy-seven patients were tested to preservatives in the standard series. Sensitization frequencies were all greater than 1%: parabens (2.58%), methylchloroisothiazolinone/methylisothiazolinone (1.75%), quaternium 15 (1.43%), and methyldibromoglutaronitrile (1.2%). There was no change in trends in sensitization frequencies from 2006 to 2011, with no increase in sensitization frequency to methylchloroisothiazolinone/methylisothiazolinone. The sensitization frequencies for methyldibromoglutaronitrile/phenoxyethanol and diazolidinylurea were 2.03% and 1.37%, respectively, and remained less than 1% for bronopol, imidazolidinyl urea, and 2-phenoxyethanol. A rate of 0% was seen for 1,3-dimethylol-5,5-dimethyl hydantoin and formaldehyde; 9.4% of positive patch-test results became positive only at day 7., Conclusions: Preservatives are common causes of allergic contact dermatitis. This should be considered when introducing new preservatives into the market. Day 7 readings are important to detect late reactions.

Background: Irritant hand dermatitis (IHD) is common in health care workers., Objective: We studied endogenous irritant contact dermatitis threshold by patch testing and exogenous factors such as season and hand washing for their association with IHD in health care workers., Methods: Irritant patch testing with sodium lauryl sulfate (SLS), sodium hydroxide, and benzalkonium chloride at varying concentrations was measured in 113 health care workers. Examination for hand dermatitis occurred at 1-month intervals for a period of 6 months in the Midwestern United States., Results: Positive patch testing to low-concentration SLS was associated with IHD (P = 0.0310) after adjusting for age, sex, ethnicity, season, history of childhood flexural dermatitis, mean indoor relative humidity, and glove and hand sanitizer usage. Subjects with a positive patch test to SLS were 78% more likely to have occurrence of IHD (incidence rate ratio [IRR] = 1.78; 95% confidence interval [CI], 0.92-3.45). Hand washing frequency (≥10 times a day; IRR = 1.55; 95% CI, 1.01-2.39) and cold season (IRR = 2.76; 95% CI, 1.35-5.65) were associated with IHD. No association was found between history of childhood flexural dermatitis and IHD in this population., Conclusions: Both genetic and environmental factors are important in the etiology of IHD and should be considered in designing strategies to protect, educate, and treat susceptible individuals.

Background: European studies document that occupational contact dermatitis (CD) is common in hairdressers, but studies from North America are lacking., Objectives: The objectives of this study were to estimate the prevalence of occupational CD among North American hairdressers/cosmetologists (HD/CS) and to characterize responsible allergens and irritants as well as their sources., Methods: A cross-sectional analysis of patients patch tested by the North American Contact Dermatitis Group between 1994 and 2010 was conducted., Results: Of 35,842 patients, 432 (1.2%) were HD/CS. Significantly, most of the HD/CS were female (89.8%) and younger than 40 years (55.6%) as compared with non-hairdressers (P < 0.0001). The rates for allergic and irritant CD in HD/CS were 72.7% and 37.0%, respectively. The most common body site of involvement was the hand, and this was significantly more common than in non-HD/CS (P < 0.0001). The most frequent currently relevant and occupationally related allergens were glyceryl thioglycolate, p-phenylenediamine, nickel sulfate, 2-hydroxyethyl methacrylate, and quaternium-15. Hair dyes, permanent wave solutions, and other hair products were common sources of allergens. The North American Contact Dermatitis Group allergen series missed at least 1 occupationally-related allergen in 26.2% of patients., Conclusions: Contact dermatitis in North American HD/CS is common, and occupationally related allergens are those found in HD/CS products. Supplemental hairdressing/cosmetology antigen series are important in detecting all occupationally related allergens in this population.

Irritant contact dermatitis (ICD) from plants is a very common phenomenon as potentially irritant plants and plant products are commonly found in the everyday environment, including the home, garden, workplace, and recreational setting. It is therefore essential to have a basic understanding of the various plant-derived physical and chemical irritants. ICD from plants is commonly divided into mechanical irritant contact dermatitis (MICD) and chemical irritant contact dermatitis (CICD). The common mechanical plant irritants include thorns, spines, glochids, trichomes, and sharp-edged leaves. Many chemical irritants have yet to be elucidated, but known culprits include calcium oxalate, protoanemonin, isothiocyanates, bromelain, diterpene esters, alkaloids, and other chemical irritants such as naphthoquinone and acids. This review details the major plant contributors to MICD and CICD, along with their respective irritants. The clinical presentations seen in ICD (versus other plant dermatoses) will also be described, along with diagnostic considerations and exposure data. We also review mechanisms for the development of ICD and current treatments for ICD from plants.

Background: The prevalence of lanolin sensitivity in referred patients is less than 4%., Objectives: To (1) describe patients with positive patch-test reactions to lanolin, (2) determine clinical and occupational relevance associated with reactions to lanolin and common sources, and (3) examine the frequency of co-reacting allergens., Methods: A retrospective analysis of 26,479 patients patch-tested by the North American Contact Dermatitis Group (NACDG), 1994 to 2006., Results: Overall, 2.5% of patients (643 of 25,811) tested to lanolin alcohol 30% in petrolatum had positive reactions. Prevalence decreased from 3.7% in 1996 to 1998 to 1.8% in 2005 to 2006 (p <.0001); 83.4% of all positive reactions were currently relevant, but only 2.5% were occupationally relevant. Lanolin-positive patients were 1.2 times more likely to be male and 1.4 times more likely to have a history of atopic dermatitis when compared to allergic, but lanolin-negative, patients (p < .0002 and p < .0001, respectively). Cosmetics were the most common source. Lanolin-positive patients were significantly more likely to be co-sensitized to another NACDG standard screening allergen (p <.0001)., Conclusions: The prevalence of allergic patch-test reactions to lanolin in North America patch-test populations is decreasing. Current relevance of reactions was high, but occupational relevance was low. Concomitant reactions were more common in lanolin-positive patients.

Background: Hand dermatitis is a significant problem among inpatient nurses. Accurate population-based data on the prevalence and risk factors for hand dermatitis in this group are lacking., Objective: To determine the prevalence of hand dermatitis in inpatient nurses at a US hospital., Methods: Each nursing unit in a single hospital was visited twice by a single physician. All nurses working at the time of each visit were questioned and examined. No nurses were enrolled twice., Results: Fifty-five percent (92 of 167) of the nurses had hand dermatitis. Among intensive care unit (ICU) nurses, the prevalence was 65% (35 of 54); among non-ICU nurses, the prevalence was 50% (57 of 113). In nurses with self-reported atopic dermatitis, the prevalence was 71% (12 of 17); in nurses without self-reported atopic dermatitis, it was 53% (80 of 150). Data collection on variables such as hand hygiene and glove use relied on subject recall and was considered unreliable. There was a low prevalence of atopic patients., Conclusions: Hand dermatitis affects over 50% of inpatient nurses. Hand dermatitis appears to be more common in the ICU setting and in nurses with a self-reported history of atopy.

Background: Auto mechanics and machinists presenting with suspected allergic contact dermatitis (ACD) have traditionally been patch-tested with a standard screening tray and a specialty tray such as the Oil and Cooling Fluid Series. While this has proven useful for patch-testing the machinist, there is a need for the development of a more specific allergen testing tray for the auto mechanic., Objective: The objective of the study was to compare clinical features and patch-test results of auto mechanics and machinists with hand dermatitis to evaluate differences in allergen profiles., Methods: We performed a chart review of 33 auto mechanics and 24 machinists referred to our Occupational Contact Dermatitis Clinic from 2002 to 2005 for evaluation of hand dermatitis., Results: With a panel of 84 allergens, 52 positive reactions were detected in 17 cases of ACD in mechanics. The profiles were different from the cases of ACD diagnosed in 10 of 24 machinists., Conclusions: Mechanics and machinists differ in the spectrum of occupational exposures. Patch testing with greater numbers of allergens likely identifies a larger proportion of mechanics with occupationally relevant ACD. Further study is needed to determine the most appropriate allergens to include in a clinically useful "mechanic's tray."

Background: Patients with hand eczema frequently have a history of atopic dermatitis or atopy. No specific morphologic pattern of hand eczema helps distinguish atopic hand eczema from other etiologies. There are few studies of hand eczema prevalence and morphology in a well-defined population of patients with atopic dermatitis., Methods: We evaluated 777 consecutive patients with atopic dermatitis (diagnosed by standard criteria) for hand involvement. An additional 100 patients had further evaluations, including evaluation of the historical and morphologic characteristics of their hand eczema., Results: The prevalence of hand involvement in patients with active atopic dermatitis was 58.9% (458 of 777 patients). Nail dystrophy was present in 16% (124 of 777) of patients. There was a significant trend toward an increasing prevalence of hand involvement with increasing age. Hand eczema tended to involve primarily the dorsal hand surfaces and the volar wrist., Conclusions: The hands are frequently involved in patients with active atopic dermatitis and present unique physical, social, and therapeutic challenges for patients. During the evaluation of patients presenting with hand eczema, the involvement of dorsal hand surfaces and the volar wrist may suggest atopic dermatitis as a contributing etiologic factor.

Background: Hand dermatitis affects many people and has numerous causes. Few reports have looked at the etiology of hand dermatitis across broad demographics., Objectives: The purposes of this investigation were to (1) determine the causes of hand dermatitis in the population patch-tested at a dermatologic referral clinic, (2) report occupations frequently associated with hand dermatitis, and (3) indicate which substances were the more common allergens among individuals evaluated by patch testing for hand dermatitis., Methods: A retrospective analysis of patch-test data on 1,034 patients who were evaluated during an 8-year period was performed., Results: Hand dermatitis affected 32% of all patients who underwent patch testing. Allergic contact dermatitis was diagnosed most often (54.4%), followed by irritant contact dermatitis (27.4%). Among women, irritant contact dermatitis of the hands peaked in the third decade and then diminished whereas allergic contact dermatitis of the hands remained fairly constant among patients between 21 and 60 years of age. In contrast, irritant contact dermatitis and allergic contact dermatitis in men peaked in the fifth decade of life. In both genders, hand dermatitis was rare among those 20 years of age or younger and among those 61 years of age or older. Fifty-six percent of hand dermatitis was related to occupation. Health care workers were most often affected by occupational hand dermatitis. The most common allergens for both occupational and non-occupational hand dermatitis were quaternium-15, formaldehyde, thiuram mix, and carba mix., Conclusions: Since more than half of hand dermatitis cases may be related to occupation, a thorough history should be taken by a knowledgeable clinician. Potentially relevant allergens in the workplace must be identified and tested. These allergens may not be contained in standard trays.