Western Occupational and Environmental Medical Association
CME Webinar - June 27, 2012
Occupational Dermatology
Heather P. Lampel, MD, MPH, FAAD
Duke University
Assistant Professor of Dermatology
June 27, 2012
PLEASE STAND BY - WEBINAR WILL BEGIN AT 12:00pm (Pacific Time)
FOR AUDIO: Call: 866-740-1260 / Access Code: 764 4915#
Disclosures
! SmartHealth
" TRUE
Test
! I will be discussing off-label use of
patch testing and off-label treatment of
contact dermatitis
Objectives
!
!
!
!
!
!
Emphasize the importance of occupational
contact dermatitis
Discuss the epidemiology of contact
dermatitis in the occupational setting
Differentiate irritant from allergic contact
dermatitis
Understand the role of patch testing in
diagnosis
Explore common occupational allergens
Outline treatment options and long-term
management of occupational contact
dermatitis
Why should we care?
! Occupational skin disease is a
topic
“hot”
AI-Hoqail R. Use of diesel oil for removal of tar from bitumen burns. Annals of Burns and Fire Disasters. 10:3; September 1997.
Healthy People 2020
“Reduce occupational skin diseases or
disorders among full-time workers”
http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
ACOEM Core CompetenciesClinical Dermatology
!
!
OEM physicians can
provide early
recognition, diagnosis,
and management of
these disorders and
make necessary
recommendations to
minimize their
occurrence both in the
workplace and at home
Diagnose primary
irritant-induced
dermatoses
!
!
Differentiate
occupational skin
disorders by history,
examination, and
diagnostic evaluation
Diagnose and
determine the cause of
allergic contact
dermatitis (including
urticaria), particularly
those caused by
common antigens such
as latex, epoxy
monomer, and nickel
http://www.acoem.org/uploadedFiles/Publications/OEM_Competencies/ACOEM%20OEM%20COMPETENCIES.pdf
ACOEM Core CompetenciesClinical Dermatology (con’t)
! Manage occupational and
environmental skin injuries and
dermatoses
! Treat and prevent recurrence of contact
dermatitis
http://www.acoem.org/uploadedFiles/Publications/OEM_Competencies/ACOEM%20OEM%20COMPETENCIES.pdf
Epidemiology of Occupational
Contact Dermatitis
http://www.pennmedicine.org/encyclopedia/em_PrintArticle.aspx?ptid=1&gcid=000869
Contact Dermatitis
!
!
Contact dermatitis (CD) is reported to account
for up to 30% of all occupational disease in
industrialized nations
CD is the most common occupational skin
disorder
"
About 90-95% of all cases of occupational skin
diseases
Occupational Contact
Dermatitis Epidemiology
!
!
!
!
Incidence rate of 0.5-1.9 cases per 1000 fulltime workers per year
1 year prevalence estimate of 10%
Lifetime prevalence rate of 20%
Likely underestimated due to underreporting
"
Mild cases specifically
Occupational Contact
Dermatitis Epidemiology
!
Hands are usually involved
"
"
!
80-90% of cases
Great impact on quality of life
True epidemiologic data are lacking
"
"
No standardization of data, methods of collection
Underreporting
Occupational Contact
Dermatitis Epidemiology
!
!
US Bureau of Labor Statistics 2000 estimated
41,800 cases of Occupational CD
This is felt to be underreported
"
!
Estimates are closer to 400,000 to 2 million cases
per year
1985 Mathias estimated annual costs of
Occupational CD to be between $222 million
and $1 billion
Occupational Contact
Dermatitis Epidemiology
!
Survey of established cases of Occupational
CD, reported that over one year:
"
"
19.9% reported prolonged sick leave
23% experienced job loss
What percent of all contact
dermatitis is allergic versus
irritant?
Contact Dermatitis Overview
! Irritant
contact dermatitis accounts for
60-80% of all CD
! Allergic contact dermatitis accounts for
remaining 20-40%
Contact Dermatitis Overview
! ACD is a SPECIFIC immunologic
reaction, requiring prior sensitization
Image from: www.dermnet.com
Immunology of Allergic Contact
Dermatitis
Elliott G and Das PK. Using p-Phenylenediamine: A Gateway to Chemical Immunology. Journal of Investigative Dermatology (2010) 130, 641–643.
Contact Dermatitis Overview
! 90% of the population can be sensitized
to certain antigens such as
dinitrochlorobenzene
Contact Dermatitis Overview
! What percent of North American
Caucasian adults are allergic to Rhus
antigen?
" 25%
" 40%
" 60%
" 75%
www.ohio-nature.com
www.gmcsc.org
www.duke.edu
Contact Dermatitis Overview
! What percent of North American
Caucasian adults are allergic to Rhus
antigen?
" 25%
" 40%
" 60%
" 75%
www.ohio-nature.com
www.gmcsc.org
www.duke.edu
Contact Dermatitis Overview
! Irritant
contact dermatitis is
NONSPECIFIC
! Requires no prior sensitization
! Clinically can be difficult to distinguish
ICD from ACD
http://www.skincareguide.ca/glossary/i/irritant_contact_dermatitis.html
Common Occupational
Irritants
!
Alkalis
"
"
"
!
Soaps
Detergents
Cleansers
Acids
!
Hydrocarbons
"
"
!
Petroleum
Oils
Solvents
Common Occupational
Irritants
!
Frictional Dermatitis
!
!
Repetitive handling
of objects or
materials
Likely
underappreciated
!
Examples
!
!
!
!
Fabric
Paper
Metal objects
Driving
Common Occupational
Irritants
! Gloves
! Prolonged
contact with skin affects the
epidermal barrier
! May be irritant itself
! May make epidermal barrier more
susceptible to allergens or other irritants
Ramsing DW, Agner T: Effect of glove occlusion on human skin (II). Long-term experimental exposure. Contact dermatitis 1996; 34:258-62.
ACD vs ICD
Feature
ACD
ICD
Pain, burning
++
++++(Early)
Erythema
++++
++++
Vesicles
++++
+
Pustules
+
+++
Hyperkeratosis
++
++++
Itch
++++(Early)
+++(Late)
ACD vs ICD
Feature
Fissuring
ACD
++
ICD
++++
Sharp demarcation
Yes
Yes
Necrotic keratinocytes
+
+++
Dermal Edema
++++
++++
Lymphocytic infiltrate
++++
++++
Neutrophilic infiltrate
+
+++
Photo Quiz
Allergic or Irritant Contact Dermatitis?
Allergic or Irritant?
Dermaamin.com
Irritant
Dermaamin.com
Allergic or Irritant?
http://hardinmd.lib.uiowa.edu/pictures22/dermnet/contact_dermatitis_04rhus080105.jpg
Allergic
http://hardinmd.lib.uiowa.edu/pictures22/dermnet/contact_dermatitis_04rhus080105.jpg
Allergic or Irritant?
Skincareguide.com
Irritant
Skincareguide.com
Allergic or Irritant?
Allergic
Allergic or Irritant?
http://www.cdc.gov/niosh/topics/skin/occderm-slides/ocderm10.html
Allergic and Irritant
http://www.cdc.gov/niosh/topics/skin/occderm-slides/ocderm10.html
Debunking the myths…
webseoanalytics.com
CD Misconceptions
! Allergy only develops to new
exposures/products
CD Misconceptions
! Allergy only develops to new
exposures/products
" FALSE
" Allergy
can develop after years of using the
same product
CD Misconceptions
! If a change in chemical/product
exposure does not clear the rash, that
product is not etiologic
CD Misconceptions
! If a change in chemical/product
exposure does not clear the rash, that
product is not etiologic
" FALSE
" There
are many cross-reactants in other
products, it is best to have NO exposures
to topicals/cross-reactors when clearing a
rash
CD Misconceptions
! If product exposure is bilateral, the
eruption should be bilateral
CD Misconceptions
! If product exposure is bilateral, the
eruption should be bilateral
" NOT
NECESSARILY
" Common misconception held by MDs
" There are many aspects affecting endproduct eruption
CD Misconceptions
! ACD is NOT patchy- it is usually the
same intensity at all areas of exposure
CD Misconceptions
! ACD is NOT patchy- it is usually the
same intensity at all areas of exposure
" FALSE
" Again,
many factors affect the presenting
eruption pattern
CD Misconceptions
! Adult onset “eczema”
CD Misconceptions
! Adult onset “eczema”
" If
no history of eczema as a child, likely
ACD
" Especially if on hands, face, neck
“The greatest abuse of patch
testing is failure to use the test.”
! Coleman, 1982
Patch testing
! Intended to detect allergens relevant to
eruption
! Is at least a week-long process
! Detects Type IV allergic reaction
(delayed-type hypersensitivity)
! Requires at least 2-3 visits to clinic for
complete testing
T.R.U.E. Test
! Thin-layer Rapid Use Epicutaneous
Test
! Allerderm product
! Only FDA-approved patch testing
product
! 29 allergens with an additional 7
recently FDA-approved
! Comes pre-filled
T.R.U.E. Test
!
!
!
!
!
!
!
!
!
!
!
!
Nickel Sulfate
Wool Alcohols
Neomycin Sulfate
Potassium Dichromate
Caine Mix
Fragrance Mix
Colophony
Paraben Mix
Negative Control
Balsam of Peru
Ethylenediamine
Dihydrochloride
Cobalt Dichloride
!
!
!
!
!
!
!
!
!
!
!
!
p-tert-Butylphenol
Formaldehyde Resin
Epoxy Resin
Carba Mix
Black Rubber Mix
Me- Cl- Isothiazolinone
(MCI/MI)
Quaternium-15
Mercaptobenzothiazole
p-Phenylenediamine
Formaldehyde
Mercapto Mix
Thimerosal
Thiuram Mix
T.R.U.E. Test
!
!
!
!
!
Diazolidinyl urea
Imidazolidinyl urea
Budesonide
Tixocortol-21pivalate
Quinoline mix
Dermnetnz.org
TRUE versus Chamber
! TRUE testing is helpful, but many
patients have at least one relevant
allergen not detected by TRUE testing
! Consider referral for more extensive
patch testing if no improvement
Patch testing
! Step 1: Take extensive exposure history
" Include
home exposures, work tasks and
exposures, implants, intermittent
exposures, MSDS if appropriate
! Step 2: Determine allergen panel
" Would
be pre-determined if only TRUE
Test is available
Patch testing
! Step 3: Prepare allergen tray as
appropriate
" TRUE
test is pre-prepared
Patch testing
! Step 4: Apply patches to back
" Back must be clear of
" Patches are marked
" Securing
rash
paper tape is used
Patch testing
! Step 5: Patches removed in 48 hours
" Variability in how
" Areas remarked
" Reactions
this is done
noted- Irritant
Patch testing
! Step 6: Patches read at 3-7 days after
application
" Our clinic reads at 4 days
" Consider delayed read for
late reactors
Patch testing
!
Step 7: Determine clinical relevance
"
Consider the Mathias Criteria for Occupational
cases
!
"
Excellent tool for ascertaining occupational causation
Keep in mind that irritant CD remains a diagnosis
of exclusion, and dermatitis may be both ICD and
ACD, multifactorial, etc.
Mathias CG. Contact dermatitis and workers’ compensation: criteria for establishing occupational
Causation and aggravation. J Am Acad Dermatol 1989; 20(5):842-8.
Patch testing
!
Step 8: Instruct in avoidance of allergen(s) and crossreactors
"
If in topical medicaments, cosmetics, etc. it is best to print
out the CAMP “safe list”
!
!
"
"
"
On American Contact Dermatitis Society member webpage
Mayo Clinic also has a database
Also consider all objects that may contain allergen
Information (written) and verbal counseling of patient is KEY
May include modified work, increased or alternative PPE,
modified environment- both home and work
Mathias CG. Contact dermatitis and workers’ compensation: criteria for establishing occupational
Causation and aggravation. J Am Acad Dermatol 1989; 20(5):842-8.
Mathias Criteria
1. Is the clinical appearance consistent with
contact dermatitis?
2. Are there workplace exposures to potential
cutaneous irritants or allergens?
3. Is the anatomic distribution of the dermatitis
consistent with cutaneous exposure in
relation to work tasks?
4. Is there a temporal association between
onset of dermatitis and exposure consistent
with contact dermatitis?
Mathias CG. Contact dermatitis and workers’ compensation: criteria for establishing occupational
Causation and aggravation. J Am Acad Dermatol 1989; 20(5):842-8.
Mathias Criteria
5. Are non-occupational exposures
excluded as probable causes?
6. Does dermatitis improve away from
work exposure to the suspected
allergen or irritant?
7. Do patch or provocation tests identify
a probable causal agent?
Mathias CG. Contact dermatitis and workers’ compensation: criteria for establishing occupational
Causation and aggravation. J Am Acad Dermatol 1989; 20(5):842-8.
Mathias Criteria
! Answer of “yes”
to 4 or more of the 7
criteria yields a greater than 50%
probability of occupational cause
! Provides a “reasonable degree of
medical certainty”
Mathias CG. Contact dermatitis and workers’ compensation: criteria for establishing occupational
Causation and aggravation. J Am Acad Dermatol 1989; 20(5):842-8.
Pearls Regarding Patch Testing
! Do NOT test when dermatitis anywhere
is acute or severe
" Leads
to angry back syndrome
" Worsening of existing dermatitis
http://dermnetnz.org/procedures/patch-tests.html
Pearls Regarding Patch Testing
! Do NOT test when dermatitis is present
on the back
http://www.rash-pictures.com/279-dermatitis-back-man.html
Pearls Regarding Patch Testing
! What about
" Wait
medications?
at least 1 week after d/c of oral
steroids
" If unable to stop oral steroids, taper to
10mg/day or less, may cause falsenegative rxn
" Do not test within 2 weeks of using topical
steroids on back
" Systemic antihistamines do not interfere
with results
Pearls Regarding Patch Testing
! What about
sunburn?
" Do
not test back within 1-2 weeks of
sunburn (false-negatives are possible)
Wikipedia.org
Pearls Regarding Patch Testing
! What about
hairy backs?
" The
patient will need to shave 24-48 hours
PRIOR to patch application
! DO
NOT shave in the office prior to placing
patches- leads to irritant and false-positives
Sbrforum.com
Pearls Regarding Patch Testing
! What about
" No
showering?
showering or wetting the back for the
entire testing period, up until the final read
(at least 5 days)
" Modified work note for outside workers or
heavy laborers
Pearls Regarding Patch Testing
! Patient comes in convinced that a liquid
he works with is the “cause” of his rash
! He wants you to patch test this, what
should you do?
2ols.com
Pearls Regarding Patch Testing
! Patient comes in convinced that a liquid
he works with is the “cause” of his rash
! He wants you to patch test this, what
should you do?
" DO NOT
" MSDS
TEST UNKNOWNS!
" DeGroot
(4300 chemicals for test
concentrations)
2ols.com
Allergens
Top 10 Allergens in
North America
!
Nickel sulfate
!
Bacitracin
!
Balsam of Peru
!
Formaldehyde
!
Fragrance mix I
!
Cobalt chloride
!
Quaternium-15
!
Methyldibromoglutaronitrile
Neomycin
!
p-Phenylenediamine
!
Zug KA, Warshaw EM, Fowler JF Jr, et al: Patch-test results of the North American Contact Dermatitis Group 2005-2006.
Dermatitis 2009;20:149-160
Top Allergens in the Workplace
!
Carba Mix
!
Thiuram Mix
!
Epoxy Resin
!
Formaldehyde
!
Nickel
Rietschel RL, Mathias CG, Fowler JF Jr, et al. North American Contact Dermatitis Group. Relationship of occupation to contact dermatitis
(OCD): evaluation in patients tested from 1998 to 2000. Am J Contact Dermatitis 2002;13(4):170-6.
Top Allergens in the
Workplace
!
Carba Mix
!
Thiuram Mix
Onlygloves.com
!
Epoxy Resin
!
Formaldehyde
!
Nickel
cdc.gov
Instructables.com
Rietschel RL, Mathias CG, Fowler JF Jr, et al. North American Contact Dermatitis Group. Relationship of occupation to contact dermatitis
(OCD): evaluation in patients tested from 1998 to 2000. Am J Contact Dermatitis 2002;13(4):170-6.
Top Allergens in the
Workplace
!
Carba Mix
!
Thiuram Mix
!
Epoxy Resin
!
Formaldehyde
!
Nickel
http://epoxy.fiberglassmoldss.com/epoxy/
Ehow.uk.eu
Wikipedia.com
Rietschel RL, Mathias CG, Fowler JF Jr, et al. North American Contact Dermatitis Group. Relationship of occupation to contact dermatitis
(OCD): evaluation in patients tested from 1998 to 2000. Am J Contact Dermatitis 2002;13(4):170-6.
Top Allergens in the
Workplace
!
Carba Mix
!
Thiuram Mix
!
Epoxy Resin
!
Formaldehyde
!
Nickel
Travelandleisure.com
Rfid-weblog.com
Rietschel RL, Mathias CG, Fowler JF Jr, et al. North American Contact Dermatitis Group. Relationship of occupation to contact dermatitis
(OCD): evaluation in patients tested from 1998 to 2000. Am J Contact Dermatitis 2002;13(4):170-6.
Formaldehyde-Releasers
!
Carba Mix
!
Thiuram Mix
!
!
Epoxy Resin
!
!
Formaldehyde
!
Nickel
!
!
!
!
Quaternium-15
Imidazolidinyl urea
(Germall 115)
Diazolidinyl urea
(Germall II)
DMDM hydantoin
(Glydant)
2-Bromo-2nitropropane-1,3-diol
(Bronopol)
Sodium hydroxymethyl
glycinate
Top Allergens in the
Workplace
!
Carba Mix
!
Thiuram Mix
!
Epoxy Resin
!
Formaldehyde
!
Nickel
Wikipedia.org
The prevalence of ACD to
nickel is:
! Greater in women than in men
! Greater in younger than older patients
! Higher than ACD to palladium
! All of the above
! None of the above
Cellphone contact dermatitis with nickel allergy; CMAJ • January 1, 2008; 178 (1)
The prevalence of ACD to
nickel is:
! Greater in women than in men
! Greater in younger than older patients
! Higher than ACD to palladium
! All of the above
! None of the above
Cellphone contact dermatitis with nickel allergy; CMAJ • January 1, 2008; 178 (1)
Dealing with Nickel Allergy
! Lobbying Congress to pass nickel
standard
! Manufacturers would have to limit
content of any item with prolonged skin
contact to restrict release of nickel to
0.5 mcg/cm per week
! Similar 2001 legislation in Europe
decreased childhood nickel dermatitis
from 19% to 6%
Dealing with Nickel Allergy
!
Dimethylglyoxime spot test
"
!
Can purchase at www.delasco.com
Barrier coating
"
"
"
!
meteorites.wustl.edu
Nickel Guard (Athena Allergy) is best
Can also use Beauty Secrets Nail Hardener
Super glue not so super (within 7 days consumers
had rashes)
AVOID nickel
"
Take magnet shopping
!
Does not attract aluminum, does attract nickel
North American Contact
Dermatitis Group
! Publish update on
“most commons”
! Pool results from major centers
! Review trends (increasing and
decreasing reactivity in the population)
! Make changes to recommended trays
from this population-based data
Allergen of the Year 2009
! Mixed dialkyl thioureas
! Mixed quaternium bases
! Mixed thiuram alkylates
! Mixed tetra-alkyl thiurams
Allergen of the Year 2009
! Mixed dialkyl thioureas
! Mixed quaternium bases
! Mixed thiuram alkylates
! Mixed tetra-alkyl thiurams
Allergen of the Year 2009
! Mixed dialkyl thioureas (MDTU)
" Used
as an accelerant in rubber and
antioxidant in neoprene production
" Combination of diethylthiourea and
dibutylthiourea (most prevalent in mix)
" NOT in TRUE test, but present in standard
rubber series
Allergen of the Year 2009
! Mixed dialkyl thioureas
" Occupational:
! Gloves
most commonly on hands
leaching MDTU
" Non-occupational:
feet
! Foot
most commonly on the
supports, athletic shoes leaching MDTU
" Sleep
apnea masks, wetsuits, neoprene
braces, goggles
lowerextremityreview.com
homehealthmedical.com
Gemplers.com
Allergen of the Year 2010
! Bacitracin
! Nickel sulfate
! Neomycin
! Polymyxin B sulfate
Allergen of the Year 2010
! Bacitracin
! Nickel sulfate
! Neomycin
! Polymyxin B sulfate
Allergen of the Year 2010
!
Neomycin
"
"
"
In medicaments
ACD in healthcare workers, veterinarians
Cross-reacts:
Paromycin, butirosin
! Framycetin
! Tobramycin, kanamycin
! Gentamycin
! Streptomycin
!
Wikipedia.org
Allergen of the Year 2011
! Dimethyl Fumarate
! No occupational relevance at this time
Allergen of the Year 2012
! Gold
! Propolis
! Quaternium-15
! Acrylates
Allergen of the Year 2012
! Gold
! Propolis
! Quaternium-15
! Acrylates
Occupations at High-Risk for
Hand Dermatitis
!
!
!
!
!
!
Hairdressers
Musicians
Food Industry
workers
Agricultural workers
Factory workers
Electronics workers
!
!
!
!
!
Cleaners/Washers
Housekeepers
Printers
Builders
Medical and Dental
workers
Treating Hand DermatitisStep 1
!
Recommended shortterm high-potency
topical steroids for
hands:
"
For body:
"
Clobetasol propionate
!
"
!
Ointment
Halcinonide ointment
!
!
No propylene glycol, no
sensitizers
“Halog”
"
Short-term
hydrocortisone 2.5%
bid for face, neck,
axillae, groin,
intertriginous areas
Short-term
triamcinolone 0.1%
bid for body
Treating Hand DermatitisStep 1
!
!
Avoid more than a
few weeks of potent
steroid use topically
Can thin the skin
making hands more
susceptible to
allergen/irritant!
!
!
Consider IM steroids
x1
Doxycycline for antiinflammatory effects
Treating Hand DermatitisStep 1
! Barrier creams
" Tetrix
creams
" Creams with ceramide, urea and
dimethicone
" Studies are variable in demonstrating any
benefit from barrier creams when
compared to regular emollients
Treating Hand DermatitisStep 1
! Appropriate gloves
" Match task with glove
" “Quick Selection Guide
to Chemical
Protective Clothing” by Forsberg and
Mansdorf
" ACDS website lists glove manufacturers
Treating Hand DermatitisStep 2 (Maintenance)
!
Calcineurin inhibitors
Tacrolimus 0.1%
" Pimecrolimus 0.1%
"
!
Therapeutic
moisturizers
"
!
Lower potency
steroids for hands:
"
"
MimyX
!
Palmitate
monoethanolamine
Shea butter
" Aquaphor
" Petrolatum
"
"
Triamcinolone 0.1%
Fluticasone cream or
lotion (great for
atopics)
Hydrocortisone
butyrate lipid cream
!
"
(Locoid lipocream)
Clocortolone cream
!
(Cloderm)
Treating Hand DermatitisStep 3 (Recalcitrant)
! Hand psoralen- ultraviolet A therapy
(PUVA)
! Narrow-band UV B therapy (NBUVB)
! Often
used for recalcitrant body dermatitis
! Excimer laser
! 308
nm
Treating Hand DermatitisStep 3 (Recalcitrant)
!
!
Methotrexate
Mycophenolate
mofetil
"
!
2-3g/day
recommended for
control
Acitretin
"
"
Best for psoriasiform
hand dermatitis
2-4 month course
!
Cyclosporine
" 2.5-5 mg/kg daily
!
Azathioprine
" 1-3 mg/kg daily
!
Biologics are not
helpful overall
Summary
!
!
!
Allergic and irritant
contact dermatitis
can be difficult to
distinguish
We are constantly
being exposed to
new allergens, often
earlier in life
Occupational
contact dermatitis is
underreported
!
!
!
Patch testing for
ACD is the gold
standard
Can try TRUE test,
consider referral for
comprehensive
panels
History, history,
history
Summary
!
!
Think outside the
box
Try a stepwise
approach
"
"
"
Elimination
Treatment
Escalate treatment
!
!
Will be chronic if
exposure continues
You can make a
huge difference in
patient’s quality of
life
References
!
!
!
!
!
!
!
!
!
!
!
!
!
Marks et al., 2002. Marks J.G., Elsner P., DeLeo V.A.: Contact and Occupational Dermatology, 3rd ed. St
Louis, Mosby, 2002.
Nelson and Yiannias, 2009. Nelson S.A., Yiannias J.A.: Relevance and avoidance of skin-care product
allergens: Pearls and pitfalls. Dermatol Clin 2009; 27(3):329-336.
Thin-layer rapid-use epicutaneous test. Thin-layer rapid-use epicutaneous test (TRUE-test) : Available
at:[accessed 03.07.11] http://www.truetest.com/PatientPDF/File18.pdf
Zug et al., 2009. Zug K.A., Warshaw E.M., Fowler J.F., et al: Patch-test results of the North American
Contact Dermatitis Group 2005-2006. Dermatitis 2009; 20:149-160.
Emmett EA. Occupational contact dermatitis I. Incidence and return to work pressures. Am J Contact
Dermatitis 2002;13:30–
2002;13:30–4.
Bureau of Labor Statistics. Occupational injuries and illnesses in the United States. [Bulletin 2512].
Washington (DC): US Department of Labor, Bureau of Labor Statistics; 1999.
Lushniak BD. The epidemiology of occupational contact dermatitis. Dermatol Clin 1995; 13:671–
13:671–9.
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