COD

Contact Dermatitis • Original Article

Contact Dermatitis

Clinical profile and quality of life of patients with occupational contact dermatitis from New Delhi, India Riti Bhatia1 , Vinod K. Sharma1 , M. Ramam1 , Gomathy Sethuraman1 and Chander P. Yadav2 1 Department

of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi 110029, India and 2 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 110029, India

doi:10.1111/cod.12411

Summary

Background. Data regarding occupational contact dermatitis (OCD) and its effect on quality of life (QOL) in India are limited. Objectives/aims. To evaluate patients with OCD and record the outcome of treatment. Patients/materials/methods. All patients with OCD were evaluated for severity of disease (by the use of physician global assessment) and its effect on QOL (by use of the Dermatology Life Quality Index) questionnaire) at the first visit and after 3 months of treatment. Results. Among 117 patients with OCD, hand eczema was present in 81.2%. Positive patch test reactions were found in 76%. The most common allergens were Parthenium hysterophorus and potassium dichromate. The most frequent diagnosis was occupational allergic contact dermatitis (OACD) (57%), caused by farming and construction work, followed by occupational irritant contact dermatitis (OICD) (24%), caused by wet work. Severe psychosocial distress was recorded in 62.5% of patients. After 3 months of treatment, 83% improved significantly, and 54% had improvement in QOL. Conclusions. Farmers were most frequently affected, followed by construction workers and housewives. OACD was found at a higher frequency than OICD. The most frequent allergens were Parthenium hysterophorus in farmers, potassium dichromate in construction workers, and vegetables in housewives. OCD has a significant impact on QOL. Patch testing, in addition to standard treatment, improves the outcome considerably. Key words: occupational contact dermatitis; parthenium; potassium dichromate.

Skin disorders constitute 20–70% of occupational diseases in various countries (1). Contact dermatitis contributes to the majority of work-related dermatoses. Internationally, the incidence of occupational contact dermatitis (OCD) has been reported to be 1.3–8.1 per 10 000 full-time workers per year in the past two decades

Correspondence: Dr Vinod K. Sharma, All India Institute of Medical Sciences, Room 4070, Teaching Block, 4th Floor, Ansari Nagar, New Delhi 110029, India. Tel: 01126593217. E-mail: [email protected] Financial disclosure: None. Funding sources: None. Conflict of interest: The authors have no conflict of interest to declare. Accepted for publication 10 April 2015

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(2). Commonly affected occupational groups are housekeepers, metalworkers, cleaners, healthcare workers, office workers, construction workers, hairdressers, beauticians, bakers, mechanics, and cooks; however, there is geographical variation in the occupational groups affected (3). Common to most of these occupations is extensive exposure to wet work and irritants. Although studies have been performed on individual occupational groups in India, data on the epidemiology of OCD and its effect on quality of life (QOL) in India are limited. The purpose of this prospective study was to study the common causes of OCD in a tertiary-care centre in India, evaluate the impact of OCD on QOL of patients, and record the outcome after patch testing and treatment.

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OCCUPATIONAL CONTACT DERMATITIS IN INDIA • BHATIA ET AL.

Patients and Methods From January 2012 to August 2013 in New Delhi, India, all patients who presented with dermatitis suggestive of occupational causation were evaluated with a detailed history, clinical examination, and patch testing. Aggravation by work-related exposure and improvement on removal of exposure were recorded, to assess whether occupational factors were the primary causes of disease or made a significant contribution to it. Housewives were included in this study because of their contribution to society with childcare and domestic work. Other studies on OCD have included housewives as an occupational group (4, 5). For all patients suspected of having OCD, patch testing was performed with the Indian Standard Series (ISS), which is approved by the Contact and Occupational Dermatoses Forum of India, and patient’s materials, with pre-test and post-test counselling. Patch testing with cement was performed with the patient’s cement in a 10% aqueous suspension prepared immediately prior to the test. All housewives were tested with vegetables, fruits, and detergents, in accordance with the standard concentrations used in previous studies (6, 7). For vegetables and fruits, fresh juice was used for patch testing. For soaps and detergents, a 1% aqueous suspension was used. In addition, 10 age-matched and sex-matched controls were tested with vegetables, fruits, and detergents. Farmers were also photopatch tested. Photo-testing was not performed. Recording of patch test reactions was performed according to ICDRG guidelines (8). To establish the relevance of positive results, careful re-evaluation of the patient’s history, distribution of rash and exposure to materials at work was performed. A prick test with latex extract was performed in all healthcare workers, according to guidelines (9). A diagnosis of OCD was made on the basis of Mathias’ criteria, which are validated criteria for occupational causation of contact dermatitis (Table 1). Fulfilment of four of seven criteria indicates a reasonable probability (> 50%) of OCD (10). Patients meeting these criteria were recruited. A diagnosis of occupational allergic contact dermatitis (OACD) was made if there was a positive patch test reaction to an allergen found in the workplace that could partly or wholly explain the current OCD. A diagnosis of occupational irritant contact dermatitis (OICD) was made if there was significant exposure to irritants at the workplace that could explain the dermatitis (11). Details of these patients, including age, sex, age at onset of disease, duration of disease, symptoms, precipitating factors, personal and family history of atopy, and treatment, were recorded. Specific sites affected by morphology

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Table 1. Criteria for determining the work-relatedness of skin disease (Mathias) (10) 1. Is the clinical appearance consistent with contact dermatitis? 2. Are there workplace exposures to potential cutaneous irritants or allergens? 3. Is the anatomical distribution of dermatitis consistent with cutaneous exposure in relation to the job task? 4. Is the temporal relationship between exposure and onset consistent with contact dermatitis? 5. Are non-occupational exposures excluded as possible causes? 6. Does dermatitis improve away from work exposure to the suspected irritant or allergen? 7. Do patch or provocation tests identify a probable causal agent?

of the lesions were noted. Assessment of severity of disease was performed at baseline and 3 months after treatment. Physician global assessment (PGA) on a scale of 0–3, 0 being no disease activity and 3 being severe disease activity, was used to assess disease severity. Patients were asked to rate the disease activity as perceived by them on a standard visual analogue scale (VAS) by marking the location on a 10-cm line marked from 0 to 10 (0 meaning no disease, and 10 meaning worst disease). The VAS score was then determined by measuring the distance from the left-hand end of the line to the point that the patient had marked. The scores were graded into five categories of disease severity as follows: none (0–2), mild (2.1–4), moderate (4.1–6), severe (6.1–8), and very severe (8.1–10). QOL of patients was measured pre-treatment and post-treatment with the Dermatology Life Quality Index (DLQI), which is a 10-item self-administered validated QOL instrument that is widely used to estimate QOL in patients suffering from different skin diseases (12). Answers were scored from 0 to 3, and the total DLQI score was calculated by summing the scores of all questions, resulting in a maximum score of 30 and a minimum score of 0. After patch testing, all patients were informed about the cause of their disease, and counselled to avoid exposure to the suspected irritant/allergen. They were advised to wear gloves at the workplace. In addition, the disease was treated with topical steroids and the liberal use of emollients. In cases of severe disease, a short course of oral steroids/immunosuppressants was used. Patients were advised to continue in their occupation, with minor modifications.

Data analysis

Data were recorded on a pre-designed proforma, and managed on a Microsoft Office™ Excel® spreadsheet. Categorical variables were summarized as frequency

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Table 2. Sites of involvement in different occupations

Sites of involvement Hands Dorsa of fingers Palmar fingers Palms Dorsa of hands Fingertips Web spaces Periungual Wrists Legs Face Photo-exposed areasa Sites suggestive of airborne contact dermatitisb

Construction workers (n = 32)

Farmers (n = 32)

Housewives (n = 31)

Others (n = 22)

Number of patients (%)

29* 12 14 7 2 3 0 6 12 5 0 0

3 4 2 16 0 1 0 3 19 24 18 (15.4) 13 (11.1)

9 22 10 0 8 3 2 1 0 0 0 0

13 10 4 5 1 0 0 5 6 1 0 1 (0.8)

95 (81.2) 54 (46.2) 48 (41.0) 30 (25.6) 28 (23.9) 11 (9.4) 7 (5.9) 2 (1.7) 15 (12.8) 37 (31.6) 30 (25.6) 18 (15.4) 14 (11.2)

a Photo-exposed areas: forehead, extensors of forearms, and dorsa of feet. b Airborne contact dermatitis sites: face, neck, antecubital fossa, and popliteal fossa. * p < 0.05.

(%). Quantitative variables were summarized as mean ± standard deviation (SD). The qualitative score across different occupations in patients with OCD was compared by the use of one-way analysis of variance. Kendall’s tau was used to determine associations between QOL and disease severity across the categories of OCD. Fisher’s Exact test was used to determine associations of occupational category with DLQI grading and PGA scoring. Mosaic plotting was used to show the changes in DLQI grade and PGA score before and after 3 months of treatment, and the statistical significance was determined by the use of chi-square tests with marginal homogeneity (Stuart Maxwell). STATA™ 12.0 statistical software was used for data analysis. In this study, a p-value of < 0.05 was considered to be statistically significant.

beauticians (2 males; 1 female), leather factory worker (1), priest (1), and automobile worker (1). The mean age at onset of disease was 34.9 ± 12.7 years. It was lowest in healthcare workers (24.8 ± 3 years) and highest in farmers (44.6 ± 12 years). The majority of patients had disease onset below the age of 50 years (102/117). The minimum duration of symptoms was 15 days, seen in a painter, and the maximum duration of symptoms was 30 years, seen in a housewife. Hand eczema was present in 81.2% of OCD patients. The involvement of various sites according to occupation is shown in Table 2. The correlation of involvement of dorsa of fingers with construction work was highly significant (p < 0.001). Patch test results

Results This study included 117 patients with OCD (64 males and 53 females) with a mean ± SD age of 40.3 ± 13.3 years. The youngest patient was aged 18 years, and the oldest was aged 75 years. There were 60 (51.2%) patients aged < 40 years. Participants in this study included both skilled workers (healthcare workers, leather workers, and masons) and unskilled workers. The occupational groups with the greatest numbers of patients were construction workers (31 males; 1 female) and farmers (22 males; 10 females), followed by housewives (31). The construction workers included masons (27/32), labourers (2/32), plumbers (1/32), and tile layers (2/32). The next most common occupation was healthcare professionals (8 females; 1 male), followed by painters (6 males; 1 female),

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A total of 105 patients showed patch test reactivity; however, 13 patients showed irritant reactions [garlic (11), paraben (1), and radish (1)], and were excluded from patch test result analysis. Among patients with positive reactions, the majority showed positivity for a single allergen (35%), and an equal number of patients were positive for two or more allergens (20.5%). The highest number of positive reactions was seen with Parthenium hysterophorus (32/117 patients), followed by potassium dichromate (31/117 patients) (Table 3). Among vegetables, the highest number of positive reactions was seen with garlic (8/31), followed by cucumber (3/31) and tomato (3/31). Among the 3 healthcare workers with positive reactions to latex gloves, a positive prick test reaction was seen in 2 patients. The third patient, who was prick test-negative, showed a positive patch test reaction with thiuram mix

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Table 3. Patch test positivity according to occupation Numbers of patients with positive patch test reactions

Serial number Compound 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Potassium dichromate 0.5% Parthenium hysterophorus Parthenolide 0.1% Colophonium 20% Cobalt chloride 1% Nickel sulfate 5% Thiuram mix 1% Fragrance mix 8% p-Phenylenediamine 1% Mercapto mix 2% 2-Mercaptobenzothiazole 2% Epoxy resin 1% Myroxylon pereirae resin 25% Nitrofurazone 1% Neomycin sulfate 20% Lanolin alcohol 30% Chlorocresol 1% Vegetables Latex gloves Cement Hair colour Handwash Glue Dipentene 10% Leather Paint Turpentine oil 20% Isopropyl alcohol 10% Triclosan

Construction Farmers Housewives workers (n = 32) (n = 32) (n = 31) 28* 3 0 1 5 2 1 1 0 2 0 1 0 0 1 0 0 – – 2 – – – – – – – – –

1 29* 10 6 1 1 1 0 0 1 1 1 1 1 0 1 0 – – – – – – – – – – – –

1 0 0 1 0 4 0 2 1 0 0 1 0 0 1 0 1 26 – – – – – – – – – – –

Others (n = 22) 3 2 0 0 2 2 3 0 1 0 2 0 0 0 0 0 0 – 3 – 2 1 1 1 1 1 1 1 1

Total number Number of of positive allergens relevant allergens 31 32 10 9 8 8 6 5 3 3 3 3 2 2 2 2 1 36 7 2 2 1 1 1 2 1 1 1 1

30 29 10 7 7 4 6 2 2 2 2 1 2 0 0 0 0 36 7 2 2 1 1 1 2 1 1 1 1

Paraben mix, benzocaine 5%, gentamicin sulfate 20%, clioquinol 5%, black rubber mix 0.6%, p-tert-butylphenol-formaldehyde resin 1%, formaldehyde aq. 1%, polyethylene glycol 400 100% and petrolatum showed negative patch test results. * p = 0.001.

1%. The patch test reactions with patients’ materials are shown in Table 3. Among the 10 controls who were tested with the ISS, vegetables, fruits, and detergents, 2 positive patch test reactions were seen, one each to nickel and green chilli. These were not relevant. There were no irritant reactions. Among a total of 117 patients, the majority (89; 76%) had relevant positive patch test reactions. There were 186 positive patch test reactions, 160 (86.02%) of which were relevant to the current OCD. Among construction workers, there were 53 positive patch test reactions, 47 of which were relevant to their current occupational dermatitis. Housewives showed 48 positive patch test reactions, 38 of which were relevant to the current OCD. Farmers showed 55 positive reactions, and 47 were relevant. The association of positive patch test reactions to potassium dichromate with construction work

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was statistically significant. Similarly, the association of positive patch test reactions to parthenium with being a farmer was statistically significant (Table 3). In the single priest with an airborne contact dermatitis (ABCD) pattern, patch test positivity was seen with fragrance mix. There was improvement when the patient stopped using the materials that he was using for the rituals. The remaining occupational groups showed 30 positive patch test reactions, 28 of which were relevant.

Diagnosis

The most frequent diagnosis was OACD (57%), mainly caused by construction work and farming, followed by OICD (24%), mainly caused by domestic wet work. Combined OACD and OICD was seen in the remaining patients (19%; Fig. 1). A significantly higher number of females

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Fig. 1. Numbers of patients diagnosed with occupational allergic contact dermatitis (OACD), occupational irritant contact dermatitis (OICD), and both OACD and OICD.

were affected by OICD than by OACD (p < 0.0001). This result is attributable to the predominance of females in cleaning and domestic roles. Construction workers showed crusted, exudative plaques over the dorsa of their fingers, distally. This pattern was present consistently in all construction workers. The statistical association of this pattern of contact dermatitis with construction workers’ occupation was highly significant (p < 0.001). Farmers had a higher frequency of OACD, and all cases of OACD showed positivity for P. hysterophorus (100%), 30% showed positive patch test reactions to parthenolide, and 15% showed positive patch test reactions to colophonium. On photopatch testing, 3 patients showed photoaggravation and another 26 showed an allergic reaction to P. hysterophorus. Photo-allergic reactions were not seen. No photo-testing was performed. On the basis of site of involvement (predominantly photo-exposed versus covered sites), farmers were seen to belong to two groups. The chronic actinic dermatitis (CAD)-like pattern (56.2%) was found to be commoner than the ABCD pattern (40.6%) (p < 0.05). In housewives, OACD (16/31) was seen in a slightly higher number of cases than OICD (15/31). There were very few patients who met all of Mathias’ criteria (7/7) for occupational causation. These were all construction workers. Most patients fulfilled four (37/117, 31.9%), five (40/117, 34.5%) or six (31/117, 26.7%) criteria. Rating of disease severity by PGA

The mean score was 2.0 ± 0.6. Most patients had moderate disease (62.4%; Table 4). Of 25 patients with

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severe involvement, 21 (84%) had OACD. Very severe disease was found significantly more often in farmers (p = 0.041).

Patient-assessed disease severity

The mean VAS score was 6.24 ± 2.28. It ranged from a minimum of 1 to a maximum of 10.

Quality of life

The mean DLQI score was 15.1 ± 5.5. The maximum score was found to be 29, in a farmer. The minimum score was 4, seen in 7 patients with various occupations. There was very large effect on the QOL of the majority of patients (72/116, 62.1%; Table 4). Kendall’s tau correlation coefficient between DLQI grading and PGA scoring was 0.4464 (p < 0.001).

Effect on QOL in various occupations

The mean DLQI score was highest in farmers (16.9 ± 5.8), followed by construction workers (14.6 ± 6.0, Table 4). The difference in DLQI score across various occupations was not statistically significant.

Effect on components of QOL

The most affected domain was work (80%), and the least affected domain was leisure (27%). The feelings component made the maximum contribution to the mean score (4.0 ± 1.6); the other components affected the DLQI score to a lesser extent.

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Table 4. The effects of occupational contact dermatitis on quality of life and disease severity in different occupations

Number of Occupation

patients

DLQI score

Grading of effect on quality of life

Disease severity (physician global

(DLQI scores) in different occupations** , no. (%)

assessment) in different occupations*** , no. (%)

None

Small

(mean ± SD)* (0–1)

(2–5)

Moderate Very large (6–10)

(11–20)

large (21–30)

Extremely Clear

Mild

Moderate

Severe

Total 32

Construction workers

32

14.6 ± 6.0

0

3 (9.3)

4 (12.7)

19 (59.3)

6 (18.7)

0

4 (12.1)

24 (72.8)

4 (12.1)

Housewives

31

13.9 ± 4.2

0

2 (6.4)

4 (13.0)

24 (77.4)

1 (3.2)

0

3 (9.7)

24 (77.4)

4 (12.9)

31

Farmers

32

16.9 ± 5.8

0

1 (3.1)

6 (18.7)

16 (50.0)

9 (28.2)

0

6 (18.8)

13 (40.6)

13 (40.6)

32

3 (15.0)

13 (65.0)

4 (15.0)

0

5 (22.7)

12 (54.6)

72 (61.5)

20 (17.0)

0

Others

22

14.9 ± 5.6

0

2 (5.0)

Total

117

15.1 ± 5.5

0

8 (7.0) 17 (14.5)

18 (15.4) 73 (62.4)

5 (22.7)

22

26 (22.2)

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DLQI, Dermatology Life Quality Index; SD, standard deviation. * p = 0.159 (not significant). ** Fisher’s exact test = 10.778, p = 0.291. *** Fisher’s exact test = 13.11, p = 0.04.

Variation in QOL according to diagnosis

The mean DLQI score in patients diagnosed with OACD was significantly higher (9.5 ± 9.2) than that in patients with OICD (2.8 ± 5.8) (p < 0.05). Treatment and follow-up

After 3 months, 101 patients attended for follow-up. Twenty-four patients (16 farmers, 6 cement workers, and 2 beauticians) had stopped going to work. Twenty-six patients had changed their level of work in the same occupation. Patients with OACD changed their occupation more frequently than patients with OICD (p = 0.003). Disease severity at follow-up: PGA

There was significant improvement after 3 months of treatment (p < 0.0001), as shown in the mosaic plot in Fig. 2. Eighty-four patients showed improvement from baseline, 16 patients showed no change from baseline severity, and 1 patient showed worsening. Worsening of disease occurred in a housewife diagnosed with both OACD and OICD. The presence of atopy (urticaria/rhinitis/asthma) was found to be a significant risk factor for disease that was less responsive to treatment (p < 0.05). Patient-perceived disease severity: VAS

The mean VAS score at the 3-month follow-up visit in 101 patients was 2.85 ± 2.25 (range: 1–9). The correlation between VAS scores and PGA scores, derived by the use of Spearman’s rank correlation coefficient, was found to be 0.4685, reflecting a moderate correlation. QOL at follow-up

There was significant improvement QOL in the patients, and the mean DLQI score decreased by 54.5% (15.8 ± 5.9

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to 7.1 ± 5.1) after treatment (p < 0.0001), as shown in a mosaic plot (Fig. 3).

QOL in individual occupations

Improvement in QOL was seen, in the form of reductions in mean DLQI scores, by 43.5% in construction workers, 55.2% in farmers, 43.4% in housewives, 80.0% in healthcare workers, 77.4% in painters, and 52.6% in the priest.

Discussion The majority of occupations affected by OCD have in common the risk factors for contact dermatitis, that is, extensive exposure to potential allergens, water, solvents/caustic materials, and microtrauma. In the present study, farmers, construction workers and housewives were most affected. The mean age at onset of OCD has been reported to be between 35 and 45 years, with a lower age of onset being seen for OICD and a higher age of onset for OACD (13). Similar results were obtained in the present study. As expected, hands were the most frequent locations of OCD. The frequency of involvement of sites other than hands is at variance with a prior study by Johansen et al., in which face involvement (10.9%) was more frequent than leg involvement (1.9%) (13). The involvement of legs was commoner than reported in western studies, because, in New Delhi, India, workers do not cover their legs, owing to hot weather. The high frequency of involvement of the face in our study is attributable to the fact that many farmers were sensitized to P. hysterophorus, which commonly affects exposed parts such as the face and neck. OICD is often reported as being the more common form of OCD (70% of cases) (14). Kucenic and Belsito, however, found OACD to be commoner (60%) than OICD (34%), as is seen in the present study (15).

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Fig. 2. Prior to treatment, 14.8%, 62.4% and 22.8% of patients had physician global assessment (PGA) scores of 1, 2, and 3, respectively (shown on the x-axis). Post-treatment improvement from baseline PGA scores of 1, 2, and 3, respectively (y-axis), was seen in 60%, 84.1% and 95.6% of patients.

Fig. 3. Prior to treatment, 5.9%, 15.8%, 61.4% and 16.9% of patients had Dermatology Life Quality Index (DLQI) grades of 1, 2, 3, and 4, respectively (shown on the x-axis). Post-treatment improvement from DLQI grades 1, 2, 3, and 4, respectively (y-axis), was seen in 50%, 56.2%, 75.8% and 94.1% of patients.

Patch test positivity ranges from 40% to 80% in patients with OACD, and a similarly high percentage (76.8%) was found in the present study (16, 17). The high prevalence of OACD in our study can be attributed to the widely prevalent weed P. hysterophorus in India, and the allergenicity of cement in India. The high relevance of patch tests may be attributable to the fact that patch

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testing was performed in patients who were suspected of having OCD. Previous studies have shown a low prevalence of patch test positivity for potassium dichromate among cement workers (4–5%) in Europe and the United States, and higher prevalence rates in Taiwan (13%), Poland (23%), and Singapore (40%) (18–21). The high prevalence of

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patch test positivity for potassium dichromate (81%) in the current study was attributable to the fact that participants were already suffering from contact dermatitis affecting the hands, as in a previous study (22). The prevalence of OACD in construction workers decreased significantly in the Danish database, from 8.9% to 1.3%, after the introduction of ferrous sulfate to cement (23). Previous studies performed in Finland and the United States have indicated that agricultural workers have a high risk of suffering from OCD (24, 25). Occupational dermatoses have been reported in 55–84% of farmers studied in India (26, 27). Internationally, studies have found high levels (86%) of OACD in farmers, similar to the frequency in the present study (90%) (28). Worldwide, the most frequent allergens causing OCD in farmers are plant dusts, animal allergens, metals, pesticides, and rubber chemicals, whereas P. hysterophorus (51–66.6%), Xanthium strumarium (40%), chrysanthemum (23%) and pesticides (26–36%) have been reported in India (26, 27, 29–31). P. hysterophorus was the implicated allergen in 29 farmers. Xanthium and chrysanthemum were not tested. Previous studies have described an evolution of the clinical pattern of parthenium dermatitis from the ABCD pattern to the CAD-like pattern. The CAD-like pattern was predominant in our study (32). Housewives are commonly affected, owing to a long duration of wet work and exposure to allergens. The proportions of cases with OACD (27–66%) and OICD (18–54%) have been shown to be variable in previous studies (33, 34). In the current study, OACD (51.6%) was only slightly commoner than OICD (48.38%). Agrup et al. found a remarkably high rate of patch test positivity, ranging from 50% to 71.4%, whereas studies from India have shown a patch test positivity rate of 40–50% (35, 36). Common allergens causing OCD in domestic workers and cleaners are rubber (20.2%), nickel (17.5%), fragrances, and cosmetics (9.7%) (37). In the present study, patch test positivity was found to be most frequently attributable to vegetables (52%). Healthcare workers are commonly affected, with a prevalence of OCD of ∼ 30% (38). OICD (65%) is commoner than OACD (13.5%) (39). The difference in the prevalence rates of OACD (22.22%) and OICD (33.33%) among heathcare workers was not significant in the present study. The allergens implicated were rubber gloves (both powdered and non-powdered), thiuram mix 1%, spirit, and nickel. There are case reports of sandalwood (Santulum album) dermatitis in priests (40). We saw a single priest with OACD indicated by fragrance mix.

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Occupational changes are not always associated with improvement in OCD. Therefore, before a job change is recommended, every attempt should be made to enable the patient to continue working in the current job by taking all practical steps to limit exposure, and improve patient and employer education (41). Although a variety of validated QOL instruments are available, none of them is entirely adequate for capturing the impact of OCD on QOL. Similarly to the observations made in previous studies, we noticed a large effect on QOL, in 62.1% of patients. The mean DLQI score in our study was higher than the mean score reported in most previous studies (4.5–7.4) (42, 43). The most affected component affected was work, unlike in the previous studies, which found the symptoms and feelings domains to be the most affected (42, 44). This seems to be plausible, as OCD is primarily attributable to work. Lewis et al. reported a higher score of 17.9 in patients with OCD caused by latex gloves, which is comparable to what was found present study (45). The higher impact on QOL in OACD patients than in OICD patients observed in our study has been described previously (46). The improvement in disease severity at follow-up is in agreement with recent studies showing that 78–84% of patients with OCD improve when they are appropriately treated (47, 48). However, there are some studies that have shown a lower rate of improvement in patients with OCD at 1 year of follow-up. A previous study of patients with occupational hand eczema showed persistent severe disease in 25%, improvement in 41%, and unchanged mild/moderate disease in 34%, at follow-up after 1 year (49). Another study, with a follow-up of 12 years, showed that only 28% of respondents had complete resolution, reflecting the poor long-term prognosis in patients with occupational skin disease (50). We are not able to comment on long-term outcome, as our follow-up was limited to 3 months. Although there was significant improvement in QOL at follow-up, the reduction in DLQI scores from baseline was not proportional to clinical improvement. Previous studies have shown improvement in QOL ranging from 21% to 65% at follow-up (50, 51).

Conclusions This study describes the pattern of OCD seen in India. OCD has a significant impact on QOL. Patch testing, in addition to the standard treatment, considerably improves the outcome.

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Clinical profile and quality of life of patients with occupational contact dermatitis from New Delhi, India.

Data regarding occupational contact dermatitis (OCD) and its effect on quality of life (QOL) in India are limited...
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