Contact dermatitis prevalence among hairdressers and beauticians in

Contact dermatitis prevalence among hairdressers and beauticians in the city of Oran, Algeria Medjane R. , Benzian W. Occupational health department, Oran university hospital (EHUO), Algeria Research Laboratory Health and Environment (LRSE), University Oran 1, Algeria

INTRODUCTION • Hairdressers and in a lesser extent beauticians are more exposed to occupational contact dermatitis. • The incriminated substances are mostly ingredients contained in cosmetics related to allergic contact dermatitis and rarely occupational contact urticaria. • Occupational contact dermatitis among hairdressers and beauticians is frequent, 30% to 35% of active hairdressers are affected. • In Algeria, we dont have sufficient data on skin problems in the hairdressing and beauty industry. To this end, we started gathering and analyzing data in Oran to better understand this skin condition.

AIMS • To evaluate the prevalence of contact dermatitis in the hairdressing and beauty industry. • To describe the different clinical patterns seen.

METHODS We conducted a descriptive transversal study between February and June 2015. 1. The studied population Ø Inclusion criteria: ü Profession: hairdresser or beautician currently active. ü Gender: female. ü Age: 18 years old or above. ü Worked for more than a year and less than 10 years. ü Affected area: face, hands and for arms. ü Skin lesions appearance: less than a year. Ø Exclusion criteria: ü Other skin conditions: mycosis, psoriasis…

• Clinical exploration: • Medical Questionnaire: Personal information: age, hairdressing center. Data related to the work place: years of work, tasks done. Past jobs with a dermatological risk. Nature and frequency of tasks (shampooing, dyes…) Allergic Personal or family history (atopic dermatitis, urticaria, asthma…). dermatological issues within the last 12 months (acute eczema, rash, urticaria…) according Table 1. ü Existence of current skin conditions (acute eczema, chronic eczema, rash and irritation…) ü Clinical signs established after questioning of medical examination , their evolution, frequency, is it affected by wearing gloves? ü Protection means used: gloves, creams … ü ü ü

Contact dermatitis diagnostic criteria Distinction criteria Frequency Apparition delay Subjective symptoms Irritative dermatitis Allergic dermatitis Collective Rapid Burning sensation Individual 24 to 96 hours Almost constant pruritus Clinical aspects - Acute phase: Erythematous squameusous lesions. - Chronic Phase : skin xérosis, eythématous squamous dermatitis, reactionnal hyperkeratosis, crevasses, loss of fingerprints. - Acute phase: erythema and edema, followed by papules, and vesicles , blisters and scabs. - Chronic Phase : lichenified skin, fissurated et pigmented skin. Lesions limits Widespread on the skin , not limited to the contact area Well limited and confined to the (usually back hands, fingers ). contact area. Possible lesions in farther areas (wrists, for arms, ……. ). Epicutaneous tests Negative Positive for the allergen 6

• Physical examination Conducted by an occupational medicine specialist , we look for skin and nail lesions, especially on the hands, for arms and face. A dermatologist was consulted in case of doubt. • Workplace study A workplace study was conducted in a hairdressing training center. The aim of this study was to learn the different work activities and tasks performed and identify the products used. • Epicutaneous tests The epicutaneous tests were performed in the Occupational Medicine Department in the EHU-Oran. The standard series from The International Contact Dermatitis Research Group (ICDRG) was used. It tests for 28 allergens that cause the majority of ACDs. The reading was done at the 48 th and 96 th hour. The ICDRG and EECDRG scoring code was used.

Statistical analysis Data was collected on Excel and analysed on the SPSS 20 software.

Results 1. Studied population Job Repartition

2. Occupational dermatitis • • 51 Subjects surveyed were found to have dermatitis, 40 of them (23%) by physical examination and 11 (6%) by anamnesis. The cases were classified as following: – Irritant contact dermatitis in 31 cases (17%) – Allergic contact dermatitis in 8 cases (5%) – Traumatic dermatitis in 11 cases (6%) all related to work activities. • • • Calluses in 6 cases (3%) on friction points with poorly adapted instruments. Thermal burns in 2 cases (1%) with hair dryers. Scars in 3 cases (2%) by scissors on the index and middle fingers.

• Nail lesions were found in one case (0, 1%) represented by weak and curved fingernails in both hands. • We found just one case were the skin lesions extended to both for arms, it was classified as an allergic contact dermatitis in both hands.

Dermatitis frequency according to the job position Nail Burns Calloses lesion Scars Irritant Allergic contact Total dermatitis Hairdressers 1 2 4 2 25 5 39 Beauticians s 0 0 0 0 Hairdressers and beauticians 0 0 2 1 6 3 12 Total 1 2 6 3 31 8 51

Treatments received Clinical signs Allergic contact dermatitis Irritant contact dermatitis Traumatic dermatitis Nail lesions n % Erythematous pruritic lesions 1 2. 5 Erythematous squameusous lesions 1 2. 5 Erythematous and fissurated lesions 1 2. 5 Lichenified skin, + crevasses 1 2. 5 Loss of fingerprints. 1 2. 5 skin xérosis, + pruritis 22 55. 0 skin xérosis+ crevasse 1 2. 5 Burns 2 5. 0 Calluses 6 15. 0 Scars 3 7. 5 Weak curved nails 1 2. 5 40 100 Total

Treatments used in contact dermatitis Irritant contact dermatitis Allergic contact dermatitis No treatment 30 0 Local Treatment 1 1 Systemic Treatment 0 0 Local + Systemic Treatment 0 7 Total 31 8 Treatment used

3. Perception of the occupational risks on the overall health • More than 80% of the subjects are aware of the risks related to chemical products usage. Beauticians seem to be less concerned about the risks involved. • All the subjects were not aware of dermatitis being an occupational disease or the procedure to declare it as such. • The extent of knowledge on risks related to chemical products manipulation was as following: – Hairdresser and beautician: 26 (96%) – Hairdressers: 113 (94%) – Beauticians: 3 (11%) • Cutaneous and respiratory allergies were perceived to be the principal risk in 79% (113) of the population , 42% (74) think that the chemical products they use are carcinogenic – Cutaneous Allergies : 138 (79%) – Respiratory Allergies: 139 (79%) – Ocular Allergies: 91 (52%) – Other: 74 (42%)

Family antecedents of allergies Glove usage Irritant contact dermatitis Allergic contact dermatitis Healthy subjects Total Regular usage 7 (22. 0%) 4 (50. 0%) 70 (52. 0%) 81 (46. 0%) Irregular usage 20 (62. 5%) 3 (37. 5%) 41 (30. 0%) 64 (36. 0%) No usage 5 (16. 0%) 1 (12. 5%) 24 (18. 0%) 30 (17. 0%)

Glove types used by workers Contact dermatitis Glove type No contact dermatitis Irritant contact dermatitis Allergic contact dermatitis Not identified 5 (46%) 0 (0 %) 6 (54%) Polyethylene 1 (17%) 0 (0%) 5 (83%) Polyethylene & Latex 8 (28%) 0 (0%) 21 (72%) Caoutchouc 2 (25%) 1 (12. 5%) 5 (62. 5%) Latex 13 (16%) 4 (5%) 66 (79%) Caoutchouc & Latex 1 (25%) 0 (0%) 3 (75%) Latex & Vinyl 0 (0%) 1 (100%) Nitrile 0 (0%) 5 (100%) Vinyl 1 (17%) 4 (66. 7%)

5. Work position study We conducted 4 works position studies : Manicure; Pedicure; Facials and thermobrushing. • Constraints and risks observed : – Mechanic irritation (physical trauma) by repeated friction by the wooden manicure stick. – Posture constraints and straining of the cervical rachis and upper body. – prolonged sitting position. – A permanent standing position. – Repeated motions, – Irritant or Allergic Contact dermatitis.

Poducts used - Shampoo and after shampoo - Hair care products - Permanent liquid - Hair smoothing products - Hair straighteners - Coloring and hair bleaching products - Lacquers - Depilatories - Makeup - Nail polish - Remover - Adhesive nail stickers - Skin Care Products - Detergents for cleaning tools and surfaces and floors - Tools and styling tools …

Epicutaneous tests results Allergens Hairdresser (Subject 1) Beautician and Hairdresser hairdresser (Subject 3) (Subject 2) Cobalt Chloride , 6 H 2 O 1 % + Paraphenylenediamine free Base 1 % ++ Formaldehyde (in water) 1 % + ++ ++ ++ Nickel Sulfate, 6 H 2 O

Subject 1: Test positive for Nickel Sulfate (++) on the right and Formaldehyde (+) on the left. Conclusion: Allergic Contact dermatitis. repaired in the Algerian table occupational diseases N° 43 confirmed by epicutaneous tests.

• Subject 2: Test positive for Nickel Sulfate on the right. • Conclusion: Allergic Contact dermatitis not repaired in the Algerian table occupational diseases.

• Subject 3: Test positive for Nickel Sulfate (++) on the right, PPD (++) on the lower left, for cobalt chloride (+) on the upper left. • Conclusion : Allergic Contact dermatitis repaired in the Algerian table occupational diseases N◦ 64 confirmed by epicutaneous

Discussion • Our study is a descriptive study that evaluated 175 subjects. This number was limited due to the non-colaboration of the responsible authorities (we did not have access to the listing of hair salons in the city of Oran) , many hairdressers and beauticians refused to participate in the study , the difficulty of visiting hair salons in high risk urban areas, nevertheless our sample size is similar to most studies in literature. • In the 51 cases of dermatitis, 39 were hairdressers and no beautician was found to have dermatitis. Crepy et al, found that beauticians are among the 13 professions most exposed to the risk of occupational contact dermatitis.

Occupational contact dermatitis literature review Reference/year Occupational N = hairdressers dermatitis(%) Our study 2015 29 N=175 M. Bichara, coll. 1997 87. 36 N = 95 Guo Y. L 1994 83 N = 98 Rivett et Merrick 1990 74 N : ? Sunaga M 1992 49 N = 306 Palmer T 1996 > 50 N = 86 Pairon J. C 1992 21, 3 (1/4 associated with respiratory signs) N = 86 Pairon J. C 1997 40, 3 hairdressers N 1 = 330 N 2= 278 1, 6 secretary Pairon J. C 1996 36, 2 N = 174 Guerra L. 1992 12, 5 N = 302 Irritant Dermatitis (%) allergic Dermatitis (%) 17 5 6 0, 6 48. 27 29. 31 12. 06 32 53 Traumatic Dermatitis Nail lesion(%) 22, 9 : isolated 12, 4 : associated 13, 7 : isolated 12, 4 : associated 12, 1 9, 2 43, 4 3, 8 hairdressers 17, 2 19 12, 5

Ø 82% of our subjects wear gloves especially for hair dyeing and for some only if the dye color was a dark color, to keep the hands and nails clean. – Almost all of our subjects don’t keep the gloves on while rinsing the hair dye. – Other operations such as hair straightening and Smoothing are always performed with gloves. – Shampooing is not seen as harmful by the majority of hairdressers and is therefore performed without gloves. Ø 117 (67%) subjects use latex gloves and only 4% use vinyl gloves. All the subjects use gloves multiple times a day. Ø It is recommended to not use latex gloves because of the many allergies cases and its permeability to many chemical products used in hairdressing. Ø Vinyl gloves usage (neoprene) should be widespread. Gloves should be changed regularly, at least one pair per client or after becoming wet to avoid maceration.

Conclusion • To conclude our work , we note the lack of health coverage in the hairdressing and beauty industry. • In Algeria, no other scientific study was conducted in this area, which encouraged us to continue this study and complement it with other more detailed investigations. • The work of occupational medicine specialists with hairdressers and beauticians should insist on certain points, remind them that the deterioration of the cutaneous barrier is responsible for occupational dermatitis occurrence and that gloves should be changed as often as necessary. • Vinyl gloves should replace Latex for hair dying and rinsing. • Speading information on Nickel allergies is considered necessary.

Thanks for your attention