Dr Michael Howard1 MCIEH
1Lecturer in Environmental Health, King’s College, London.
Correspondence: Health and Life Sciences, Franklin-Wilkins Building, 150 Stamford St,
London. SE1 9NN. Telephone 020 7848 4413
This paper reviews the published literature and epidemiological data on contact dermatitis with a view to establishing the importance of the disease in hairdressers.
Occupational contact dermatitis is one of the most common occupational diseases in western countries and is especially prevalent in hairdressers. This is suggested by both the published literature and the epidemiological data. The Labour Force Survey (LFS) and EPIDERM (which collates reports from consultant dermatologists) both show that significant numbers of people in the UK continue to suffer from serious occupationally induced dermatitis. Although the epidemiological data clearly indicate that hairdressers are exposed to the most important risk factors for occupational dermatitis, and are major sufferers of the disease, formal reporting through RIDDOR is very low. It is important that enforcement authorities and their inspectors do not to see the absence of RIDDOR reports as an indicator that the disease is unimportant.
Rates, however, appear to be declining. For people who have ever worked in Great Britain, the LFS estimated that the prevalence rate of work-related skin problems was significantly lower in 2001/02 than in 1995 (SWI 01/02). However, the 2003/04 rate of 0.071% of people ever employed was similar (i.e., not statistically significantly different) to that of 0.088% in 2001/02. The incidence of occupational dermatitis reported to EPIDERM in all industries fell by 16% between 1998 – 2000 and 2001 – 2003. In hairdressers rates reported through EPIDERM fell by 41% in the same period.
The major preventive and management strategies for occupational dermatitis are environmental health interventions. This paper is, therefore, intended to be of interest to Environmental Health Practitioners and others who promote appropriate intervention strategies and techniques.
Key words: Contact dermatitis, environmental health, interventions, epidemiology, hairdressers, workplace.
In many western countries occupational contact dermatitis has been the most, or the second most, frequently occurring occupational disease in recent years (Bauer et al, 2004, Burnett et al, 1998, Karjalainen et al, 1998, Cherry et al, 2000). It is characterised by symptoms such as redness, oedema and vesiculation, thickening of the skin and hyperkeratosis (Rycroft, 1995).
In addition to these physical symptoms, victims may suffer the social stigmata associated with a visible skin disease. The hands, which are often affected, are used in communication and expression and the unsightliness of dermatitis can lead to major psychological problems such as anxiety, low self-esteem and social phobia (Van Coevorden et al, 2002). The disease can, besides affecting people’s life outside work, prevent manual work and cause significant disability and economic loss both to the victim and to society as a whole (Mathias 1985). The prognosis for those suffering from occupational hand dermatitis is often poor as the disease tends to run a long lasting and chronic relapsing course (Hogan et al, 1990).
This paper reviews the published literature on the nature and epidemiology of contact dermatitis in hairdressers, one of the occupational groups most affected. The various data sources available for investigating the incidence and prevalence of the disease will be explained and examined. Although accurate determination of the numbers of sufferers is difficult, as the different sources each have different strengths and weaknesses, the importance of the disease will assessed.
Some of the research reported in this paper was funded by the UK Health and Safety Executive. The findings helped to inform the HSE policy development process and have contributed to an increased emphasis on dermatitis in hairdressers by the enforcement agencies. The opinions and conclusions though are those of the author and do not necessarily reflect HSE policy.
Dermatitis in hairdressers
Irritant contact dermatitis is most common in workers who frequently engage in wet work and suffer continued unprotected, low-grade exposure to water and mild detergents Rycroft (1995). This, of course, applies to hairdressing workers. Irritant contact dermatitis is more common generally than allergic contact dermatitis. Hairdressers are exposed to both.
Hand dermatitis is twice as common in women as in men (Meding and Swanbeck 1987). Van Coevorden et al (2002) have observed that greater exposure of women to wet work probably contributes to this. Women are particularly at risk as many womendominated occupations involve extensive wet work (Meding, 2000). Using the Occupational Injury Information system in Sweden, Meding found that women reported occupational dermatitis more often than men, and females seemed to report a higher degree of discomfort than males. In the UK 89% of hairdressers and 69% of barbers were found to be female (Habia, 2004). Similarly, Cherry et al (2000) point out that the EPIDERM data show high rates of dermatitis for women in hairdressing and that personal protective equipment itself (in this case latex gloves) was a significant causal factor for contact dermatitis.
The period of exposure to irritants and allergens and the development of dermatitis in hairdressers
The tendency for hairdressers to develop occupational dermatitis increases with their time of exposure to hairdressing work. Budde and Schwanitz (1991) studied a large group [n=4008] of hairdressing trainees in the Netherlands and found that skin changes occurred in 70% of the trainees over the period of training. In 30% severe skin changes occurred. As a result of contact dermatitis 20% were forced to give up their job. In Germany, Uter et al (1998) demonstrated that the prevalence of contact dermatitis increased steadily during the period of training of apprentice hairdressers and the incidence was several times higher in hairdressing apprentices than in a control group of office apprentices.
The progressive nature of contact dermatitis in hairdressers was confirmed in a study by Holm and Veierod, (1994) who found a higher prevalence in experienced hairdressers than in trainees. Majoie et al (1996) also found that the prevalence of dermatitis increased with the time of exposure.
Uter et al (1999), in an a cohort study involving 2352 hairdressing apprentices, found that more than two hours per day of wet work was the major and significant risk factor in the causation of occupational irritant hand dermatitis
Hairdressing chemicals and practices
The frequency of shampooing has been correlated with the occurrence of hand dermatitis (Shiao et al, 1997). Meyer et al (2000) found that fragrances and cosmetics caused irritant and allergic dermatitis and soaps and wet work caused irritant dermatitis. Lee and Nixon (2001) concluded that wet work was important in the development of irritant contact dermatitis. It is not clear whether exposure to water alone is the specific cause of irritant contact dermatitis or whether the presence of surfactants is also important.
Several researchers have reported dermatitis arising from specific irritants (Smith et al, 2002; Lodi et al, 2000). Allergic responses to specific sensitisers have also been found (Iorizzo et al, 2002; Chan and Goh, 2001; Assier-Bonnet and Revuz 1999; Kenerra et al, 1999; Niinimaki et al, 1998; Leino et al, 1998 [who also found sensitivity to human dandruff]; Brauel et al, 1995; Serra-Baldrich et al, 1995; Peters et al, 1994; Guo et al, 1994; Vanderwalle and Brunsveld, 1994; Frosch et al, 1993; Parra, 1992; Reygane, 1991). As for the chemicals involved, Lee and Nixon (2001) found that para-phenylenediamine may be responsible for up to 60% of the cases of allergic occupational dermatitis in hairdressers and glycerylthioglycolate for up to 30%. They also found that contact with nickel (e.g. scissors) was not a significant factor although nickel sulphate allergy has been demonstrated in hairdressers by other researchers (Dickel et al, 2002).
Xie et al (2000) found, in experiments using guinea pigs, that sensitisation and cross sensitisation reactions were produced by hair dye related chemicals. Fautz et al (2002) found that hairdressers, known to be sensitised to common hair dye allergens, showed no cross-reaction allergy to the so-called new generation hair dyes. This suggests that these may be safer alternatives in the short term.
Prognosis and protection
Contact dermatitis is a particularly debilitating disease. Once it is present, either as irritant or allergic contact dermatitis, the prognosis is poor (Rosen and Freeman 1993). Sensitivity varies from individual to individual and the role of atopy – the tendency of an individual to develop several allergies – remains unclear (Crippa et al, 2001).
Reducing the risk of contact dermatitis among hairdressers is difficult. Methods such as reducing the amount of wet work each day (Uter et al, 1999), preemployment screening and the use of protective gloves have been suggested (Vanderwalle 1994), although the extent to which each of these can be used in practice may be limited. Vanderwalle (1994) has proposed the use of vinyl gloves, as contact dermatitis has been caused by immediate hypersensitivity reactions to latex gloves (Sajjachareonpong et al, 2002).
So called barrier creams have been used in an attempt to reduce the risk of contact dermatitis in hairdressers. Perrenoud et al (2001) conducted a double blind cross-over experiment which took account of atopy and other factors and found that the barrier cream evaluated was not significantly more effective than its vehicle. The presence of aluminium chlorhydrate in the cream was shown to have an effect against irritation. The researchers commented that the cosmetic qualities of the cream seemed, to the participants, to be as important as their real protective and hydrating properties, an important factor in compliance. Early detection of occupational dermatitis is important in managing the occupational risk. Interdigital dermatitis is often a precursor of more severe hand dermatitis in hairdressers (Schwanitz and Uter 2000) and early irritant skin damage has been proposed as a sentinel event for more serious skin disease (Uter, 2001).
Jugenbauer et al (2004) looked at irritant contact dermatitis management by persistent reduction in exposure to skin irritants such as water, detergents and prolonged occlusion by gloves. They found that, among the occupational groups studied hairdressers were the workers most exposed to the irritant contact dermatitis risk factors. They were also those least able to change their occupational exposure.
Ling and Coulson (2002) found that only 9% of the UK hairdressing students that they questioned used protective gloves for shampooing whereas 58% wore gloves for hair perming. 44% said that wearing gloves hindered their work.
Dermatitis in hairdressers in other countries
There is extensive evidence from many countries for the association between occupational dermatitis and hairdressing work. In Germany, hairdressers were found to suffer the highest rate of occupational dermatitis of all occupations (Dickel et al, 2002; Dickel et al, 2001; Budde & Schwanitz, 2001; Dickel, Kuss et al, 2001; Koch, 2001; Frosch et al, 1993).
Occupational dermatitis is also important in hairdressers in Italy, (Iorizzo et al, 2002; Crippa et al, 2001, Guerra et al, 1992, Lodi, 2000; The Netherlands, Vanderwalle et al, 1994), Spain (Serra-Baldrich et al, 1995, Smit, et al, 1994); Greece, (Katsarou et al, 1995); Morocco, (Bichara et al, 1999); Australia, (Lee and Nixon 2001; Rosen and Freeman 1993), Norway, (Holm and Veierod 1994) and Taiwan, (Guo et al, 1994).
Dermatitis in hairdressers’ customers
Hairdressers’ customers have also been found to suffer from contact dermatitis caused by hairdressing chemicals, although they are less at risk than the hairdressers themselves because of their reduced exposure (Guerra et al, 1992, Hsu et al, 2001, Gottlober et al, 2001).
The prevalence and incidence of occupational dermatitis in the UK
Sources of data
Information on the incidence and prevalence of dermatitis in hairdressers is available from a number of sources. Each of these has its strengths and weaknesses and must be considered together to obtain a meaningful picture of the epidemiology of the disease. The sources and their characteristics are explained below.
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995, (RIDDOR) require employers and self employed people to report certain occupational diseases of which dermatitis caused by the use of hairdressing products is one. Reporting rates can be very low, (HSC 2001 (a))
There are a number of voluntary medical occupational health surveillance schemes in which participating specialist doctors report certain occupationally caused conditions. Those most relevant to occupational dermatitis are EPIDERM, to which participating consultant dermatologists report and OPRA, (Occupational Physicians Reporting Activity), (Cherry Meyer, Holt, Chen & McDonald 2000). Very few hairdressers are likely, however, to have access to occupational physician services. McDonald (2002) found that although 43% of employees in the health and social services sector were served by occupational physicians reporting to OPRA, coverage elsewhere was very low.
Infectious skin disease may also be reported via SIDAW (Surveillance of Infectious Disease at Work), (Ross, Cherry, McDonald 1998).
The Labour Force Survey (LFS) is a household survey which periodically collects information from people who say that they have conditions which they think have been caused or made worse by work. These surveys were conducted in 1990, 1995, 2001/02, 2003/04 and as part of the European Union Statistical Office (EUROSTAT) survey in 1998/99. One section of the LFS addresses occupational ill health. This is described as the survey of Self-reported Workrelated Illness (SWI). Labour Force Survey data are, therefore, not dependent upon diagnosis by a specialist doctor or even a medical diagnosis. There are, of course, limitations to data reliant upon selfdiagnosis and cause attribution. The LFS data are collected by face to face and telephone interviews with workers (or their proxies) in their homes. Questions are asked about injuries and ill health caused or made worse, in the opinion of the respondent, by work. The findings show a much higher level of e.g., injuries than are reported via RIDDOR and, therefore provide a basis for the estimates of under-reporting rates referred to earlier. Whilst providing a more complete picture than RIDDOR, the LFS data itself has some limitations as explained above.
Under the Industrial Injuries Scheme, which is administered by the Department of Work and Pensions, people who are suffering from certain occupational disease and have suffered relevant occupational exposure may claim compensation. Occupational dermatitis is one of the diseases for which a claim may be made.
Prevalence and incidence
Within the limitations of the recording schemes, the data appear to show an overall reduction in occupational dermatitis in hairdressers and workers generally. For people who have ever worked in Great Britain, the LFS estimated that the overall prevalence rate of work-related skin problems was statistically significantly lower in 2001/02 than in 1995 (SWI01/02). However, the 2003/04 rate was of a similar order (i.e., not statistically significantly different) to that in 2001/02. The survey undertaken in 2003/04 estimated that the overall prevalence of work-related skin problems was 31,000 people ever employed.
A total of 2,115 new cases of occupational dermatitis per year, in people from all industries, was recorded via EPIDERM in 1998-2000. This reduced to 1,779 cases in 2001-3 (HSE 2004) indicating a reduction in the incidence of new cases of nearly 16%. Although these data are not directly comparable with the LFS data, they do indicate that only a very small proportion (around 5.7% in the 03/04 comparison) of cases eventually reach consultant dermatologists and thus the EPIDERM statistics. Naturally, those that reach consultant dermatologists are likely to be the most serious.
There is good evidence that hairdressers and barbers suffer from a high level of occupational dermatitis. In the period 1988-2000, 156 cases of occupational dermatitis in hairdressers were reported to EPIDERM each year. This represents an incidence of 169 cases per 100,000 workers, the highest of all occupational groups (HSC 2001(b)). Thus, 7.4% of all cases reported by consultant dermatologists to EPIDERM were diagnosed in hairdressing employees. Around 17% of all cases of occupational contact dermatitis reported to the EPIDERM scheme by consultant dermatologists and occupational physicians between November 1994 and September 1995 occurred in hairdressers and beauticians (Adishesh et al, 2002).
In 2000-2003, 130 cases per year of occupational dermatitis in hairdressing workers were reported via EPIDERM representing 99 per 100,000 workers (HSE 2004), a reduction of 41% on the 1998-2000 figure. This still makes hairdressing the highest risk occupation for occupational dermatitis (apart from flower arrangers and florists where the small number of cases, only 13 per year, make the data unreliable).
In the years from 1998 to 2002 an average of only five cases per year of occupational dermatitis in hairdressers were recorded by the Industrial Injuries Scheme.
Only 506 cases of occupational dermatitis were reported to HSE and Local Authorities, under RIDDOR, from all industry sectors in 1998/99 (HSC 2001 (b)). This figure, of course, includes cases from the manufacturing sector where reporting rates are significantly higher (60%, HSE, 2000) than in the local authority enforced sector (28%, HSC 2001 (a)). Relatively few of the 506 reported cases, therefore, are likely to have been from the local authority enforced sector. Similarly only five cases per year of occupational dermatitis in hairdressers have been reported via RIDDOR between 1999 and 2002 (Michael Knowles, HSE Statistical Unit, pers. comm.).
It is interesting that although occupational dermatitis caused by hairdressing products is a reportable disease under RIDDOR, very few reports have been made. So although hairdressers appear to be the occupational group suffering most from occupational dermatitis, the enforcing authorities receive very few reports. This may explain why inspectors and enforcing authorities have not in the past been especially aware of this issue and perhaps have not give it the attention that it deserves.
A factor which may contribute to the under reporting of occupational dermatitis in hairdressers is the proportion of hairdressers that are self-employed. This happens both in single hairdresser businesses and in situations where self-employed hairdressers operate from their own “chair” in a larger operation. Reporting rates under RIDDOR for self-employed workers are thought to be very low, less than 5%, (HSE 2000).
Management interventions and strategies in the hairdressing industry
A number of management interventions have been used including:
Those relating to the use of chemicals
Substitution of the most harmful hairdressing chemicals, e.g., using perming solutions that do not include glycerylthioglycolate.
The use of packaging for hairdressing products that reduces the risk of spillage onto the skin.
Rinsing chemicals from the skin with clean water before they dry.
The prevention of the wearing of hand and arm jewellery when handling hairdressing chemicals.
Those relating to the issue of wet work
The reduction of the amount of wet work when possible.
The use of task rotation and breaks to reduce the duration of wet work.
The provision of non-latex gloves for hair washing
Training for wet work, and skin surveillance.
Personal protective equipment
The mandatory use of gloves for direct contact with hairdressing chemicals and cleaning agents.
The use of gloves for cutting hair after dyeing, (cutting then dyeing is preferred).
The appropriate use of gloves, i.e., worn only on dry skin, used only once, rinsed before removal.
Evaluations of intervention strategies
Dickel, Kuss et al (2002) evaluated the intervention strategies above. Of 997 cases of dermatitis in hairdressers, 856 (85.6%) were confirmed as occupational. The annual incidence in this group declined from 194 in 1990 to 18 in 1999. This tenfold difference was statistically significant, p<0.0001. The authors attributed this to the intervention strategies above and the increased co-operation between stakeholders (employers, employees, product manufacturers etc.).
Schlesinger et al (2001) compared the incidence of contact dermatitis in apprentice hairdressers in Germany between 1989 and 1999. Over the ten years incidence fell by 9% while apprentices leaving the profession through skin disorders reduced from 27% to 11%. The authors attributed these improvements to increased glove usage and the application of skin care products.
Schwanitz et al (2003) evaluated educational interventions in vocational trainee hairdressers and in practising hairdressers. Intervention groups were compared with “matched” controls. In the trainees, skin changes were significantly lower in the intervention group. The severity of skin changes was also lower and fewer people left the profession for this reason. In the practising hairdressers the intervention group showed a reduction in skin disease compared to the control group.
Conclusions and implications for environmental health practitioners
The literature review and the data described in this paper demonstrate that dermatitis is a major occupational health issue for those working in the hairdressing industry. Occupational hand dermatitis is especially prevalent and particularly damaging to sufferers through pain and discomfort, disability and psychosocial and financial harm.
The prognosis for those who suffer from occupational dermatitis can be poor. Once affected, many are likely to experience chronic disease. This is particularly damaging to those in the hairdressing industry as frequent manipulation of scissors and contact with wet hair make working with cracked and irritated hands impossible.
Therapy for serious dermatitis rarely leads to a complete cure. Because of this, the opportunities for rehabilitation of hairdressers with disabling dermatitis back into hairdressing is limited. Interventions designed to reduce the risk of, or manage existing occupational dermatitis, tend to centre upon education, substitution, avoidance and barrier techniques – environmental health interventions. Environmental health practitioners are uniquely positioned to promote these measures.
It is likely that those working in the industry are not well equipped to protect themselves and may not fully appreciate the risks to which they are exposed. Ling and Coulson (2002) found that in their survey of 121 trainee hairdressers in the UK, knowledge was limited and not always translated into practice.
Although the epidemiological data clearly indicate that hairdressers are exposed to the most important risk factors for occupational dermatitis, and indeed are major sufferers of the disease, formal reporting is very low. There have been very few (5 per year) RIDDOR reports for occupational dermatitis in hairdressers in the past few years. Over a similar period, around 130 hairdressers per year were diagnosed with occupational dermatitis by specialist doctors. This clearly indicates that the chief mechanism for bringing this disease to the notice of enforcement authorities is not succeeding. It is important that enforcement authorities and their inspectors do not see the absence of RIDDOR reports as an indicator that the disease is unimportant.
The author acknowledges the financial assistance provided by the UK Health and Safety Executive for part of the work reported here and the specific contributions of the following HSE staff: Michael Knowles, Epidemiology and Medical Statistics Unit, for his contribution to the accuracy of the statistical data; Martin Ball and George Cartlidge, Industrial Chemicals Unit, for their comments on an earlier draft of the paper. The opinions and conclusions though are those of the author and do not necessarily reflect HSE policy.
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