The Science of the Total Environment 270 Ž2001.

89᎐96

Occupational dermatitis in a highly industrialized

Italian region: the experience of four occupational
health departments

M. Crippab,U , A. Baruffini d, L. Belleri b, A. Cirlac ,

P. Leghissaa , R. Pisati c , A. Pomesano a , R. Valsecchi a
a
` Operati¨ a Ospedaliera di Medicina del La¨ oro, Azienda Ospedaliera Ospedali Riuniti di Bergamo, ¨ ia Largo Barozzi
Unita
1, 24128 Bergamo, Italy
b
` Operati¨ a Ospedaliera di Medicina del La¨ oro, Azienda Ospedaliera Spedali Ci¨ ili di Brescia, P. le Spedali Ci¨ ili 1,
Unita
25123 Brescia, Italy
c
` Operati¨ a Ospedaliera di Medicina del La¨ oro, Azienda Ospedaliera Istituti Ospitalieri di Cremona, Viale Concordia
Unita
1, 26100 Cremona, Italy
d
` Operati¨ a Ospedaliera di Medicina del La¨ oro, Azienda Ospedaliera Ospedale di Circolo di Lecco, Corso Promessi
Unita
Sposi 1, 23900 Lecco, Italy

Accepted 14 April 2000

Abstract

There is a need for several research centers to carry out coordinated large-scale evaluation of the spread of
occupational irritant and allergic dermatitis. The Occupational Health Departments of Bergamo, Brescia, Lecco and
Cremona therefore decided to join their experiences and bring together all the cases of occupational irritant and
allergic dermatitis diagnosed by these Departments between 1993 and 1998. In this period, 1169 cases of occupatio-
nal dermatitis were diagnosed, subdivided into 768 cases of allergic contact dermatitis ŽACD., 337 of irritant contact
dermatitis ŽICD., 54 of urticaria and 10 of airborne contact dermatitis, and there has not been a trend towards
increase of occupational dermatitis over the years. Our population included 724 males and 445 females and average
latency after the beginning of exposure to occupational allergens was 8.01 years for ACD, 6.4 for ICD, 3.22 for
urticaria and 5.57 for airborne contact dermatitis. The frequency of atopy was 33.9% in females and 19.5% in males.
The frequency of atopy was particularly high Ž89%. in subjects with urticaria. Among subjects with allergic
dermatitis, 362 had had only one sensitization while 406 had had two or more sensitizations. The working areas
where we found the highest number of ACD were metal working industry, building, health care workers and
hairdressers and the frequency of ICD was high in metal workers and health care workers. Most of the cases of

U
Corresponding author. Servizio di Medicina del Lavoro, Azienda Spedali Civili di Brescia, P. le Spedali Civili 1, 25123 Brescia,
Italy. Tel.: q39-30-3995660; fax: q39-30-3996080.
E-mail address: crippa@cci.unibs.it ŽM. Crippa..

0048-9697r01r$ - see front matter 䊚 2001 Elsevier Science B.V. All rights reserved.
PII: S 0 0 4 8 - 9 6 9 7 Ž 0 0 . 0 0 7 8 3 - X
90 M. Crippa et al. r The Science of the Total En¨ ironment 270 (2001) 89᎐96

urticaria were diagnosed in health care workers Ž68.5%. and the main causing agent was latex. These are only
preliminary data but occupations at risk and the substances expected to be the most frequent etiological agents do
not differ significantly from those reported in the literature. It is hoped that as a result of this project there will be in
the future: standardization of diagnostic procedures, uniform assessment of allergological risk in working environ-
ments not yet fully investigated, standardization of preventative measures and proper evaluation of their effective-
ness. 䊚 2001 Elsevier Science B.V. All rights reserved.

Keywords: Occupational dermatitis; Allergic contact dermatitis; Irritant contact dermatitis; Urticaria; Frequency; Causative agents

1. Introduction together their experiences on this topic and es-

Among occupational diseases as a whole, there
are some for which there is a paucity of data on
the frequency and extent on a large scale. One of
these is allergic contact dermatitis ŽACD.. In an
Italian study ŽSertoli et al., 1999. on 42 839 sub-
jects, performed from 1984 to 1993, the frequency
of ACD was 18.3% in 1984 and 11.4% in 1993.
These data show a decrease of these diseases over
the years; five occupations were reputed to be
responsible for over 60% of total cases of occupa-
tional dermatitis: housewives᎐cleaners, bricklay-
ers, metal working industry, hairdressers and
health care workers. In a Belgian study ŽDooms-
Goossens et al., 1990. on 9765 workers the preva-
lence of ACD was 22%. Goh Ž1989. found that
the frequency of ACD in a population of 721
workers was 31%. In a recent Danish study
ŽHalkier-Sorensen, 1996. performed during the
period 1987᎐1995 the main occupations at risk
and the main causing factors of occupational skin
diseases were examined. These data pointed out
that the occupations at high risk of acquiring skin
diseases are cleaners, cooks ᎐ bakers ᎐ con-
fectionery workers, machine-made industry,
health care workers and office workers. More
frequently available in the literature are case
reports or data from specific occupations Že.g.
hairdressers, health-care workers, etc.. reporting
frequency or causative agents ŽLiss et al., 1997;
Leino et al., 1998; Kujala, 1999..
On 29 January 1999 there was a regional con-
ference at Pavia on ‘Occupational Allergic Der-
matitis and Respiratory Diseases’, diagnosed in
our region between 1993 and 1998.
For the first time six Occupational Health De-
partments of Lombardy had decided to bring
tablish on-going cooperation so as to create an
epidemiological observatory. To continue the
cooperation a Working Group on Occupational
Allergic Diseases was established by the Lom-
bardy Occupational Medicine Association.
After the conference, four Occupational Health
Departments in Lombardy ᎏ Bergamo, Brescia,
Cremona and Lecco ᎏ agreed to collect and
bring together data both on occupational allergic
dermatitis and on irritant contact dermatitis diag-
nosed between 1993 and 1998.
2. Subjects and methods
Data on 1169 subjects affected by allergic or
irritant occupational dermatitis as diagnosed by
the four above-mentioned Occupational Health
Departments during the period 1993᎐1st semester
1998 were collected and put into a common data
base ŽMicrosoft Access 1997.. Then the data were
processed to obtain information on the general
characteristics of this population Žage, gender,
length of employment, frequency of atopy, latency
of symptoms after the beginning of exposure,
etc.., the frequency of allergic and irritant der-
matitis in different working areas, the main
causative agents and the occupations at high risk
of developing occupational dermatitis.
The diagnostic procedures used in the four
Occupational Health Departments were similar.
All patients with eczematous dermatitis were
patch tested with European standard series or
GIRDCA ŽGruppo Italiano di Ricerca Dermatiti
da Contatto Allergiche. series and specific occu-
pational series ŽTrolab, FIRMA Diagent, Lo-
 M. Crippa et al. r The Science of the Total En¨ ironment 270 (2001) 89᎐96 91

Table 1
General characteristics of the population

Gender No. of Age Atopy Length of employment

cases Žmean " S.D.. Žmean " S.D..

Females 445 Ž38%. 28 " 9 151 Ž33.9% of total females. 7"7

Males 724 Ž62%. 36 " 11 141 Ž19.5% of total males. 12 " 11

farma.. Workers with suspected allergy to their
own products, such as metal-working fluids and
gloves, were also tested with these products, fol-
lowing procedures described in Grattan et al.
Ž1989. and von Hintzenstern et al. Ž1991.. The
test material was applied in Finn Chambers on
Scanpor or Curatest ŽLohmann.. The patch tests
were applied on the upper back for 2 days and
readings were taken according ICDRG guide-
lines.
Prick tests Žcommercial extracts Lofarma.
andror specific IgE ŽCAP RAST SYSTEM Phar-
macia. were used for urticaria.
The diagnosis of irritant contact dermatitis
ŽICD. was formulated after allergic dermatitis
had been ruled out Žby negative in vivo or in vitro
allergological tests. and occupational exposure to
irritant agents had been confirmed.
A subject with at least one sensitization to a
common allergen as ascertained by prick test or
serum specific IgE, was considered atopic.
3. Results
Our population included 724 Ž62%. males and
445 Ž38%. females with an average age, respec-
tively, of 36 and 28 years. The average length of
employment was 7 years for females and 12 years
for males. The frequency of atopy in females
Ž33.9%. was higher than in males Ž19.5%. ŽTable
1..
From 1993 to the first semester of 1998, 768
cases of ACD, 337 of ICD, 54 of urticaria and 10
of airborne contact dermatitis were diagnosed.
The cases of ACD were more than twice those of
ICD. The frequency of atopy was extremely high
Ž89%. in subjects with urticaria ŽTable 2.
There was no increase in the total number of
cases of occupational dermatitis over the years in
question ŽFig. 1..
Most of the subjects with urticaria were fe-
males Ž83.3%. while ACD were more frequent in
males Ž65.8%. ŽFig. 2..
Average latency, after the beginning of expo-
sure to substances causing cutaneous pathology,
was 8 years for ACD, 6.4 years for ICD, 3.2 years
for urticaria and 5.5 years for airborne contact
dermatitis. Subdividing our population by gender,
the average latency for ACD and urticaria was
shorter in females than in males: approximately 4
years instead of 9 years.
Of the subjects with ACD, 48.2% Ž362. had one
positive reaction to patch tests while 51.8% Ž406.
had two or more positive reactions.
In our study the occupations at high risk of

Table 2
Occupational dermatitis diagnosed from 1993 to 1998 Žfirst semester.

Type of dermatitis No. of % No. atopic %

subjects subjects

Allergic contact dermatitis ŽACD. 768 65.6 171 22

Irritant contact dermatitis ŽICD. 337 28.7 70 21
Urticaria 54 4.5 48 89
Airborne contact dermatitis 10 1.2 3 30
Total 1169
92 M. Crippa et al. r The Science of the Total En¨ ironment 270 (2001) 89᎐96

Fig. 1. Distribution of allergic and irritant dermatitis over the period 1993᎐1998 Žfirst semester only..

acquiring ACD are: Ž1. metal-working industry,
including metallurgical industry, electroplating
and mechanical processing that employs metal-
working fluids Že.g. turning, drilling and mill cut-
ting. with 212 cases Ž27.6% of total ACD.; Ž2.
building and construction with 164 ACD Ž21.3%.;
Ž3. health-care workers with 98 cases Ž12.7%.;
and Ž4. hairdressers with 77 ACD Ž10%.. In Table
3 the frequency of ACD in different occupations
is reported while in Table 4 the substances giving
positive patch test reactions in the above-men-
tioned occupations are shown. In these tables the
heading ‘others’ mainly includes single heteroge-
neous substances, many of which were not occu-
pational.
In our experience urticaria is particularly fre-

Fig. 2. Distribution of dermatitis by gender.

 M. Crippa et al. r The Science of the Total En¨ ironment 270 (2001) 89᎐96 93

Table 3 Health Departments on this topic and some con-

Frequency of ACD in different working areas
siderations can be drawn.
Working area No. cases % Žtotal Many of us had expected an increase in these
of ACD ACDs 768. diseases over the years studied, but we found no
increase. Atopy has been confirmed to be a pre-
Metal-working ind. 212 27.6
disposing factor for IgE-mediated allergy Žlatex
Buildingrconstruction 164 21.3
Health-care workers 98 12.8 allergy in particular.. Its frequency was extremely
Hairdressers 77 10 high Ž89%. in subjects with urticaria. At this
Textilerclothing ind. 42 5.5 regard it is interesting to note that most of the
Foodstuff ind. 20 2.6 subjects with urticaria were females Ž83.3%. and
Chemical ind. 15 2
they were prevalently health-care workers sensi-
Plastic ind. 14 1.8
Electromechanical ind. 10 1.3 tized to latex.
Rubber ind. 9 1.2 Our data on the occupations at risk and the
Cleaners 9 1.2 substances expected to be the most frequent etio-
Woodrfurniture ind. 8 1.1 logical agents do not differ significantly from those
Others 90 11.6
reported in the literature.
For ACD the most frequent occupational sensi-
tizing agents are substantially the same as those
quent in health-care workers Ž37 casesr68.5%. reported in other studies ŽHeese et al., 1991;
and in 96% of these cases it is due to latex. The Hatch and Maibach, 1995; Stingeni et al., 1995;
most important causative agents are natural Leino et al., 1998; Uter et al., 1998; Guo et al.,
rubber gloves and elasticized fabrics ŽTable 5.. 1999; Sertoli et al., 1999..
Airborne contact dermatitis is less frequent More than 50% of the subjects were multisen-
than other types of allergic dermatitis, and it is sitized, and besides positive reactions to occupa-
mainly due to epoxy resin ŽTable 5.. tional substances, sensitizations to extra-occupa-
ICD are very common in the metal working tionalrubiquitous aptens were reported.
industry Ž127 casesr37.6%., mainly due to the use We found a particularly high number of posi-
of metal-working fluids, degreasing products and tive reactions to nickel sulfate. We think that,
with the exception of some specific occupations
solvents. They are also common among health-
Že.g. electroplating, the metallurgical industry and
care workers Ž78 casesr23.1%. due to glove lubri-
mechanical processing., it is generally difficult to
cant powder, disinfectants and detergents. Other
evaluate the real role of occupational exposure in
occupations at risk are textile workers, hair-
determining the sensitization to this common
dressers, cleaners and building workers. These
apten.
occupations prevalently involve wet work ŽTables Also, for ICD we found data on the types of
6 and 7.. occupations and the causative agents similar to
those reported in the literature ŽHogan, 1991;
Avnstorp, 1996; de Boer and Bruynzeel, 1996;
Majoie et al., 1996; Tupker, 1996..
4. Conclusions In conclusion, our data seem to confirm that
occupations with the highest number of both al-
lergic and irritant dermatitis are the metal-work-
These are only preliminary data and they can- ing industry, health-care workers, building and
not provide information on the prevalencerinci- construction, hairdressing and the textile industry.
dence of ACD and ICD. Some aspects of occupa- In fact 76% Ž888. of the total cases of occupatio-
tional dermatitis could have been examined more nal dermatitis were found in these working areas,
closely. However, this is the first attempt, in our therefore preventive measures must be systemati-
region, at cooperation among Occupational cally adopted in these occupations.
 94
Table 4

M. Crippa et al. r The Science of the Total En¨ ironment 270 (2001) 89᎐96
The most frequent positive patch test reactions in the main working areas

Metal-working ind. Ž212 ACD. Building Ž164 ACD. Health-care workers Ž98 ACD. Hairdressers Ž77 ACD.
Substance Positive Substance Positive Substance Positive Substance Positive
reactions reactions reactions reactions

Ni sulfate 96 K dichromate 148 Ni sulfate c 46 p-Phenylenediamine 41

K dichromate 62 Co chloride 65 Thiuram mix 25 Ni sulfate c 38
MWFa 48 Thiuram mix 33 Glutaraldehyde 17 p-Aminoazo benzene 20
Co chloride 48 Ni sulfate c 16 Thiomersalc 16 Thiomersalb 15
Thiuram mix 19 Epoxy resin 8 Formaldehyde 15 Ammonium persophate 15
Epoxy resin 18 Carba mix 7 Natural rubber gloves 10 p-Toluenediamine 10
p-Phenylenediamine 14 Diaminodiphenyl methane 7 Benzalkonium chloride 5 Kathon CG 6
Formaldehyde 14 p-Phenylenediamine 6 Carba mix 5 Glyceryl monothioglycolate 5
Acrylates Žglues. 13 Thiomersalb 4 Co chloride 5 p-Aminophenol 5
Thiomersalb 11 Fragrances mixb 3 Kathon CG 4 Cocamidopropylbetaine 5
Colophony 7 Others 27 Neomicinec 3 Thiuram mix 4
Carba mix 6 Others 32 Co chloridec 2
Balsam Peru` 5 Others 3
p-Amino azobenzene 5
Others 64
a
Metal-working fluids.
b
Non-occupational aptens.
c
Not sufficient elements to consider this apten as occupational.
 M. Crippa et al. r The Science of the Total En¨ ironment 270 (2001) 89᎐96 95

Table 5 Table 7
Urticaria and airborne contact dermatitis: etiological agents ICD: main etiological agents

Working area Urticaria Ž n s 54. Working area Main etiological agents

Substance No. sensitizations Metal-working industry Metal-working fluids
Degreasing products
Health-care workers Latex 37
Solvents
Textile industry Latex 5
Glass fibers
Hairdressers Latex 3
Microtraumas
Foodstuff industry Latex 1
Acrylic glues
Wheat meal 2
Others Latex 6
Health-care workers Glove lubricant powderrgloves
Disinfectantsrdetergents
Airborne contact dermatitis Ž n s 10. Wet work
Substance No. positive reactions
Textile industry Microtraumas
Electromechanical ind. Epoxy resin 2 Cotton yarn
Metal-working ind. Epoxy resin 1 Viscose yarn
Plastic ind. Epoxy resin 3 Oils
Textile ind. Kathon CG 2
Office workers Colophony 1 Hairdressers Shampoo
Pharmaceutical ind. Indenololo 1 Detergents
Hair dyes and perm products
Hair lotions

Our future aims is to standardize some diag- Cleaners Detergentsrdisinfectants

nostic procedures Že.g. patch testing of products Microtraumas
provided by workers., and to standardize data
collection, analysis and processing so as to create
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