STUDY
Is Cigarette Smoking Dangerous for Chronic Hand Eczema in Housewives? Cataldo Patruno, PhD, MD, Fabio Ayala, MD, Orlando Zagaria, MD, and Nicola Balato, MD Background: Chronic hand eczema is defined as a persistent (96 months’ duration) noninfectious skin inflammation of the hands. It is twice as common in women as men. Although genetic factors have been considered, greater exposure of women to wet work, such as housework, is assumed to be the most likely explanation. It has been debated whether lifestyle factors may be associated with chronic hand eczema. Objective: The objective of this study was to evaluate the influence of cigarette smoking on housewives for the development of chronic hand eczema. Methods: We analyzed 516 housewives 18 years or older. Two hundred fourteen were affected by chronic hand eczema, and 302 were control subjects. Both patients and control subjects were divided into 2 subgroups, smokers and nonsmokers. An anonymous questionnaire was submitted to each woman. Conclusions: No significant differences emerged between ‘‘smokers’’ and ‘‘nonsmokers’’ concerning the incidence of chronic hand eczema. In addition, the smokers were mainly affected by a milder (‘‘almost clear’’) form of the disease. On the other hand, ‘‘severe’’ forms of chronic hand eczema might be more frequent in nonsmokers when compared with smokers. This study suggests that smoking is not associated with onset of chronic hand eczema, but with less severe chronic hand eczema.
C
hronic hand eczema (CHE) is defined as a persistent (96 months’ duration) noninfectious skin inflammation of the hands. It is a common condition, with a point prevalence of 1% to 5% in the adult population.1,2 Chronic hand eczema is twice as common in woman as men, with the highest prevalence in young women.1,2 Although genetic factors have been considered as a reason for this difference, greater exposure of women to wet work, such as housework, is assumed to be the most likely explanation.1 Chronic hand eczema has a considerable public health impact because it tends to run a long relapsing course. Moreover, the vast majority of patients experience negative psychosocial consequences.1 Indeed, it may partially or completely prevent the performance of manual work, resulting in disability and economic loss. The incidence of notified, usually severe, occupation-related cases is estimated to be greater than 0.7 per 1000 per year.3 Higher prevalence has been documented in specific occupational groups, such as nurses, hairdressers, and bakers.2,3 These estimates usually exclude housewives, probably the most frequent occupational group affected. From the Dipartimento di Medicina clinica e Chirurgia, Sezione di Dermatologia, Universita` di Napoli Federico II, Napoli, Italy. Address reprint requests to Orlando Zagaria, MD, Dipartimento di Medicina clinica e Chirurgia. Sezione di Dermatologia clinica, Universita` di Napoli Federico II, Via S. Pansini, 5 80131 Napoli, Italy. E-mail: [email protected]. The authors have no funding or conflicts to declare. DOI: 10.1097/DER.0000000000000054 * 2014 American Contact Dermatitis Society. All Rights Reserved.
Chronic hand eczema may vary in severity and appearance over time. Usual clinical signs are redness, edema, scaling, vesicles, erosion, desquamation, hyperkeratosis, and fissures. Recently, various clinical classifications have been proposed.4Y7 Recurrent vesicular, hyperkeratotic, desquamative, and nummular eczema are the main patterns. Under an etiological point of view, both predisposing endogenous and external factors play a role in hand eczema. The most common external cause of CHE is contact with agents causing irritant contact dermatitis. Allergic contact dermatitis is less common than irritant contact dermatitis and reflects a contact allergy to a specific substance, mainly rubber, nickel, or fragrances.8,9 As far as clinical differentiation is often difficult, patch testing becomes an important diagnostic tool.9Y11 Atopic dermatitis (AD) may be an endogenous cause of CHE. One third to one half of patients with hand eczema are diagnosed to have AD. Moreover, the hand may be the sole localization of AD.2 Respiratory atopy does not seem to be associated with CHE.7,8 Not rarely, CHE has more than 1 cause. On the other hand, in many cases, no cause is found. It has been debated whether lifestyle factors may be associated with CHE. Particularly, previous studies investigating the role of tobacco smoking gave divergent results.12Y16 For example, Meding et al12 did not find any clear association in 13,452 subjects asked by means of a questionnaire, with the risk of CHE being slightly elevated in subjects who smoked more than 10 cigarettes per day. Thyssen et al13 showed that tobacco smoking was positively associated with CHE among adults in the general population
Patruno et al ¡ Smoking and Chronic Hand Eczema
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
201
DERMATITIS, Vol 25 ¡ No 4 ¡ July/August, 2014
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in Denmark. Light smokers (G15 per day) seemed to have a higher prevalence of hand eczema than heavy smokers (915 per day). The present study aimed to evaluate the association of cigarette smoking and CHE in housewives.
According to the score on the Fagerstro¨m test, each smoking patient was classified as ‘‘minimally,’’ ‘‘moderately,’’ or ‘‘highly’’ dependent. 19 Moreover, we arbitrarily divided smokers into 3 groups, based on the number of cigarettes smoked per day: 1 to 10 cigarettes, 11 to 20 cigarettes, and 21 to 30 cigarettes.
MATERIALS AND METHODS
Statistical Analysis
The study was approved by the ethics committee of Universita` di Napoli Federico II. Written informed consent was obtained from all participants prior to the beginning of the study. We conducted an observational study analyzing 516 housewives 18 years or older. Two hundred fourteen were affected by CHE, and 302 were control subjects. Both patients and control subjects were divided into 2 subgroups, smokers and nonsmokers. An anonymous questionnaire (Figs. 1A, B) was submitted to each woman. The questionnaire was in 2 parts. The first part investigated age, job, hobbies, drug consumption, presence, duration and severity of hand eczema, and history of atopy and other dermatological diseases. Severity of eczema was assessed always by the same dermatologist by using the Physician Global Assessment (PGA) score.17,18 The disease was classified as ‘‘absent,’’ ‘‘almost clear,’’ ‘‘mild,’’ ‘‘moderate,’’ or ‘‘severe’’ disease. The second part of the questionnaire was submitted exclusively to women who smoked. Indeed, it investigated the habit to smoke, such as the duration and the severity of dependence. The severity of the dependence was investigated by means of the Fagerstro¨m test19 (Fig. 1B), usually used in determining appropriate smoking cessation treatment.
Data were described statistically in terms of mean, frequencies, and percentages where appropriate. Comparisons between groups were practiced using Fisher exact test.
RESULTS Five hundred sixteen patients were recruited. The mean age was of 45.5 years (range, 18-83 years); 214 (41.5%) of 516 were affected by CHE, and 302 (58.5%) of 516 were control subjects. All data concerning hobbies, drugs, and other dermatological diseases did not show any significant differences between patients affected by CHE and control subjects. Fifty-six (10.8%) of 516 individuals claimed positive anamnesis for AD: 26 (12.1%) of 214 patients of the CHE group and 30 (9.9%) of 302 control subjects, without significant differences (P = 0.48). Seventy-two of 214 CHE patients (33.6%; 95% confidence interval, 28.7%Y38.4%) and 106 of 302 (35.1%; 95% confidence interval, 31.6%Y38.6%) control subjects were smokers; no statistical significance was found between the 2 groups (P = 0.859). As far as PGA is considered (Table 1), in 21 (29.2%) of 72 patients of the CHE smoker group, the disease was classified as
Figure 1. A and B, Questionnaire submitted to each housewife.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Patruno et al ¡ Smoking and Chronic Hand Eczema
203
TABLE 1. Severity of CHE Assessed by Means of PGA in Smoker and Nonsmoker Patients (n = 214) Smoker PGA Almost clear Mild Moderate Severe Total
Nonsmoker n (%) 21 29 22 0 72
(29.2) (40.3) (30.5) (0) (33.6)
PGA
n (%)
Almost clear Mild Moderate Severe Total
18 (12.7) 44 (31.0) 66 (46.5) 14 (9.8) 142 (66.4)
‘‘almost clear,’’ in 29 of 72 (40.3%) as ‘‘mild,’’ and in 22 of 72 (30.5 %) as ‘‘moderate’’; no patients of this group had ‘‘severe’’ CHE. On the other hand, in the CHE nonsmoker group, in 18 (12.7%) of 142 cases, the disease was ‘‘almost clear’’; in 44 (31.0%) of 142, ‘‘mild’’; in 66 (46.5%) of 142, ‘‘moderate’’; and in 14 (9.8%) of 142, ‘‘severe.’’ Chronic hand eczema classified as ‘‘almost clear’’ was significantly more frequent in the smoker group (P G 0.05), whereas the ‘‘severe’’ form significantly affected the nonsmoker group (P G 0.01). Differences regarding ‘‘mild’’ and ‘‘moderate’’ disease did not approach statistical significance (P = 0.39 and P = 0.17, respectively). Among 26 patients affected by CHE and with positive anamnesis for AD, 4 of 26 smoked, and all the 4 patients had ‘‘mild’’ disease. On the other hand, 5 of 30 control subjects with positive anamnesis for AD smoked. These data did not show any significant differences. One hundred seventy-eight (34.5%) of the 516 individuals enrolled in the study were smokers. One hundred fifty-two (85.5%) of 178 smoked 1 to 10 cigarettes per day; 22 (12.3%) of 178, 11 to 20 cigarettes; and 4 (2.2%) of 178, 21 to 30 cigarettes. Sixty-four (42.1%) of 152 patients who smoked 1 to 10 cigarettes per day had CHE; 19 (29.7%) of 64 from ‘‘almost clear’’ disease, 23 (36%) of 64 from ‘‘mild’’ disease, and 22 (34.3%) of 64 from ‘‘moderate’’
disease. Among 22 subjects who smoked 11 to 20 cigarettes per day, 8 (36.4%) of 22 were affected by CHE; 2 (25%) of 8 suffered from ‘‘almost clear’’ CHE, and 6 (75%) of 8 suffered from ‘‘mild’’ CHE. None of the subjects who smoked 21 to 30 cigarettes per day had CHE (Table 2). All these differences were not statistically relevant. One hundred thirty-three (74.7%) of 178 smokers were ‘‘minimally dependent’’; 18 (10.1%) of 178, ‘‘moderately dependent’’; and 27 (15.2%) of 178, ‘‘highly dependent,’’ according to the Fagerstro¨m test. Forty-six of 133 smokers who were ‘‘minimally dependent’’suffered from CHE; 6 of 46 from ‘‘almost clear’’ disease, 18 of 46 from ‘‘mild’’ disease, and 22 of 46 from ‘‘moderate’’ disease. Among 18 smokers who were ‘‘moderately dependent,’’ 10 of 18 suffered from CHE, 6 of 10 from ‘‘almost clear’’ disease, and 4 of 10 from ‘‘mild’’ disease. Among 27 smokers who were ‘‘highly dependent,’’ 16 of 27 suffered from CHE, 9 of 16 from ‘‘almost clear’’ disease, and 7 of 16 from ‘‘mild’’ disease. No statistical difference was found, except for the group of ‘‘minimally’’ dependent smokers who were more frequently affected by ‘‘moderate’’ CHE (P G 0.05).
DISCUSSION AND CONCLUSIONS Chronic hand eczema is a common disease in adults. Water, soap, cleaners, detergents, and solvents are the most common irritants that housewives use and are in contact with. As a consequence, housewives who handle these irritants in their work have a higher risk to develop hand eczema. Among environmental factors, the influence of cigarette smoking on CHE has been studied.12Y16 The role of smoke in the development of CHE is unclear, and a sure relationship has not yet been found.12Y16 In our study, we analyzed the influence of cigarette smoking on housewives for the development of CHE. No
TABLE 2. Distribution of CHE in Smoker Group (n = 178)
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
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significant differences emerged between ‘‘smokers’’ and ‘‘nonsmokers’’ patients affected with CHE. According to this result, cigarette smoke does not seem to affect the onset of CHE. Moreover, the results of the study seem to suggest that smoker patients are mainly affected by the milder forms of the disease. Indeed, ‘‘severe’’ CHE was significantly more frequent in nonsmokers when compared with smokers, whereas ‘‘almost clear’’ forms were more frequent in the smoker group. As far as dependence from smoke is concerned, no statistical differences were found, except for a tendency to a more frequent ‘‘moderate’’ disease among the smoker patients who were ‘‘moderately’’ dependent. The anti-inflammatory activity of nicotine has been investigated in some studies. Nicotine seems to be able to decrease the production of TNF-> and cell response to this cytokine.20Y22 Tumor necrosis factor > activity would be mediated by the a7nACh receptor, via Jak2 STAT3 pathway. This pathway is responsible of the production of tristetraprolin (TTP), a protein implicated in the degradation of TNF-> and other proinflammatory molecules.20 Of note is that TTP-knockout mice develop severe inflammatory arthritis, autoimmune dysfunction, and myeloid hyperplasia, demonstrating the importance of TTP in limiting the inflammatory response. Moreover, many studies have investigated the capability of nicotine to reduce inflammation and to improve gut function in ulcerative colitis. The production of proinflammatory cytokines from peripheral macrophages can be attenuated by vagal activity.21,22 Indeed, blockade of vagus nerve signaling significantly enhanced colonic inflammatory mediators in 2 experimental models of colitis,23 an effect that was counteracted by nicotine administration. Activation of the cholinergic antiinflammatory pathway by low-dose nicotine significantly suppresses inflammation in adipose tissue, an important site in mediating obesity-induced inflammation in genetically obese (db/db) and DIO (diet-induced obese) mice.24 In addition, topical application of a paste made from a ground mixture of tobacco leaves, lime, and freeze-dried coffee mixed with water is used in India to treat moderate eczema.25 In conclusion, our data suggest that cigarette smoking seems to be not associated with onset of CHE in housewives. Moreover, ‘‘severe’’ CHE was more frequent in nonsmokers and ‘‘almost clear’’ CHE in smoker patients.
REFERENCES 1. Coenraads PJ. Hand eczema is common and multifactorial. J Invest Dermatol 2007;127:1568Y1570. 2. Thyssen JP, Johansen JD, Linneberg A, et al. The epidemiology of hand eczema in the general populationVprevalence and main findings. Contact Dermatitis 2010;62:75Y87. 3. Diepgen TL. Occupational skin disease data in Europe. Int Arch Occup Environ Health 2003;76:331Y338.
4. Diepgen TL, Andersen KE, Brandao FM, et al. Hand eczema classification: a cross-sectional, multicentre study of the aetiology and morphology of hand eczema. Br J Dermatol 2009;160:353Y358. 5. Lynde C, Guenther L, Diepgen TL, et al. Canadian hand dermatitis management guidelines J Cutan Med Surg 2010;14:267Y284. 6. Menne’ T, Johansen JD, Sommerlund M, et al. Hand Eczema guideline based on the Danish guidelines for the diagnosis and treatment of hand eczema. Contact Dermatitis 2011; 65:3Y12. 7. Coenraads PJ. Hand eczema. N Engl J Med 2012;367:1829Y1837. 8. Warshaw EM, Ahmed RH, Belsito DV, et al. Contact dermatitis of the hands: cross sectional analyses of North American contact dermatitis group data, 1994-2004. J Am Acad Dermatol 2007;57:301Y314. 9. Templet JT, Hall S, Belsito DV. Etiology of hand dermatitis among patients referred for patch testing. Dermatitis 2004;15:25Y32. 10. Laxmisha C, Kumar S, Nath AK, et al. Patch testing in hand eczema at a tertiary care center. Indian J Dermatol Venereol Leprol 2008;74:498Y499. 11. Patruno C, Ayala F, Balato A, et al. Pitfalls in patch testing. Expert Rev Dermatol 2010;5:293Y298. 12. Meding B, Alderling M, Albin M, et al. Does tobacco smoking influence the occurrence of hand eczema? Br J Dermatol 2009;160:514Y518. 13. Thyssen JP, Linneberg A, Menne´ T, et al. The effect of tobacco smoking and alcohol consumption on the prevalence of self-reported hand eczema: a cross-sectional population-based study. Br J Dermatol 2010;162:619Y626. 14. Montne´mery P, Nihlen U, Lofdahl CG, et al. Prevalence of hand eczema in an adult Swedish population and the relationship to risk occupation and smoking. Acta Derm Venereol 2005;85:429Y432. 15. Beer WE. Eczema exacerbated by smoking. Contact Dermatitis 1984;10:48Y49. 16. Montne´mery P, Nihlen U, Goran LC, et al. Prevalence of self-reported eczema in relation to living environment, socio-economic status and respiratory symptoms assessed in a questionnaire study. BMC Dermatol 2003;3:4. 17. Weistenho¨fer W, Baumeister T, Drexler H, et al. An overview of skin scores used for quantifying hand eczema: a critical update according to the criteria of evidence-based medicine. Br J Dermatol 2010;162:239Y250. 18. Agner T, Andersen KE, Brandao FM, et al. Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. Contact Dermatitis 2008;59:43Y47. 19. Heatherton TF, Kozlowski LT, Frecker RC, et al. The Fagerstro¨ m test for nicotine dependence: a revision of the Fagerstro¨m Tolerance Questionnaire. Br J Addict 1991;86:1119Y1127. 20. Joe Y, Kim HJ, Kim S, et al. Tristetraprolin mediates the anti-inflammatory effects of nicotine in LPS-stimulated macrophages. J Biol Chem 2011;286: 24735Y24742. 21. Wang H, Yu M, Ochani M, et al. Nicotinic acetylcholine receptor alpha7 subunit is an essential regulator of inflammation. Nature 2003; 421:384Y388. 22. Wang H, Liao H, Ochani M, et al. Cholinergic agonists inhibit HMGB1 release and improve survival in experimental sepsis. Nat Med 2004;10: 1216Y1221. 23. Ghia JE, Blennerhassett P, Kumar-Ondiveeran H, et al. The vagus nerve: a tonic inhibitory influence associated with inflammatory bowel disease in a murine model. Gastroenterology 2006;131:1122Y1130. 24. Wang XFYZ, Xue B, Shi H. Activation of the cholinergic anti-inflammatory pathway ameliorates obesity-induced inflammation and insulin resistance. Endocrinology 2011;152:836Y846. 25. Davies P, Levy S, Pahari A, et al. Acute nicotine poisoning associated with a traditional remedy for eczema. Arch Dis Child 2001;85:500Y502.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Is Cigarette Smoking Dangerous for Chronic Hand Eczema in Housewives? Cataldo Patruno, PhD, MD, Fabio Ayala, MD, Orlando Zagaria, MD, and Nicola Balato, MD Background: Chronic hand eczema is defined as a persistent (96 months’ duration) noninfectious skin inflammation of the hands. It is twice as common in women as men. Although genetic factors have been considered, greater exposure of women to wet work, such as housework, is assumed to be the most likely explanation. It has been debated whether lifestyle factors may be associated with chronic hand eczema. Objective: The objective of this study was to evaluate the influence of cigarette smoking on housewives for the development of chronic hand eczema. Methods: We analyzed 516 housewives 18 years or older. Two hundred fourteen were affected by chronic hand eczema, and 302 were control subjects. Both patients and control subjects were divided into 2 subgroups, smokers and nonsmokers. An anonymous questionnaire was submitted to each woman. Conclusions: No significant differences emerged between ‘‘smokers’’ and ‘‘nonsmokers’’ concerning the incidence of chronic hand eczema. In addition, the smokers were mainly affected by a milder (‘‘almost clear’’) form of the disease. On the other hand, ‘‘severe’’ forms of chronic hand eczema might be more frequent in nonsmokers when compared with smokers. This study suggests that smoking is not associated with onset of chronic hand eczema, but with less severe chronic hand eczema.
C
hronic hand eczema (CHE) is defined as a persistent (96 months’ duration) noninfectious skin inflammation of the hands. It is a common condition, with a point prevalence of 1% to 5% in the adult population.1,2 Chronic hand eczema is twice as common in woman as men, with the highest prevalence in young women.1,2 Although genetic factors have been considered as a reason for this difference, greater exposure of women to wet work, such as housework, is assumed to be the most likely explanation.1 Chronic hand eczema has a considerable public health impact because it tends to run a long relapsing course. Moreover, the vast majority of patients experience negative psychosocial consequences.1 Indeed, it may partially or completely prevent the performance of manual work, resulting in disability and economic loss. The incidence of notified, usually severe, occupation-related cases is estimated to be greater than 0.7 per 1000 per year.3 Higher prevalence has been documented in specific occupational groups, such as nurses, hairdressers, and bakers.2,3 These estimates usually exclude housewives, probably the most frequent occupational group affected. From the Dipartimento di Medicina clinica e Chirurgia, Sezione di Dermatologia, Universita` di Napoli Federico II, Napoli, Italy. Address reprint requests to Orlando Zagaria, MD, Dipartimento di Medicina clinica e Chirurgia. Sezione di Dermatologia clinica, Universita` di Napoli Federico II, Via S. Pansini, 5 80131 Napoli, Italy. E-mail: [email protected]. The authors have no funding or conflicts to declare. DOI: 10.1097/DER.0000000000000054 * 2014 American Contact Dermatitis Society. All Rights Reserved.
Chronic hand eczema may vary in severity and appearance over time. Usual clinical signs are redness, edema, scaling, vesicles, erosion, desquamation, hyperkeratosis, and fissures. Recently, various clinical classifications have been proposed.4Y7 Recurrent vesicular, hyperkeratotic, desquamative, and nummular eczema are the main patterns. Under an etiological point of view, both predisposing endogenous and external factors play a role in hand eczema. The most common external cause of CHE is contact with agents causing irritant contact dermatitis. Allergic contact dermatitis is less common than irritant contact dermatitis and reflects a contact allergy to a specific substance, mainly rubber, nickel, or fragrances.8,9 As far as clinical differentiation is often difficult, patch testing becomes an important diagnostic tool.9Y11 Atopic dermatitis (AD) may be an endogenous cause of CHE. One third to one half of patients with hand eczema are diagnosed to have AD. Moreover, the hand may be the sole localization of AD.2 Respiratory atopy does not seem to be associated with CHE.7,8 Not rarely, CHE has more than 1 cause. On the other hand, in many cases, no cause is found. It has been debated whether lifestyle factors may be associated with CHE. Particularly, previous studies investigating the role of tobacco smoking gave divergent results.12Y16 For example, Meding et al12 did not find any clear association in 13,452 subjects asked by means of a questionnaire, with the risk of CHE being slightly elevated in subjects who smoked more than 10 cigarettes per day. Thyssen et al13 showed that tobacco smoking was positively associated with CHE among adults in the general population
Patruno et al ¡ Smoking and Chronic Hand Eczema
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
201
DERMATITIS, Vol 25 ¡ No 4 ¡ July/August, 2014
202
in Denmark. Light smokers (G15 per day) seemed to have a higher prevalence of hand eczema than heavy smokers (915 per day). The present study aimed to evaluate the association of cigarette smoking and CHE in housewives.
According to the score on the Fagerstro¨m test, each smoking patient was classified as ‘‘minimally,’’ ‘‘moderately,’’ or ‘‘highly’’ dependent. 19 Moreover, we arbitrarily divided smokers into 3 groups, based on the number of cigarettes smoked per day: 1 to 10 cigarettes, 11 to 20 cigarettes, and 21 to 30 cigarettes.
MATERIALS AND METHODS
Statistical Analysis
The study was approved by the ethics committee of Universita` di Napoli Federico II. Written informed consent was obtained from all participants prior to the beginning of the study. We conducted an observational study analyzing 516 housewives 18 years or older. Two hundred fourteen were affected by CHE, and 302 were control subjects. Both patients and control subjects were divided into 2 subgroups, smokers and nonsmokers. An anonymous questionnaire (Figs. 1A, B) was submitted to each woman. The questionnaire was in 2 parts. The first part investigated age, job, hobbies, drug consumption, presence, duration and severity of hand eczema, and history of atopy and other dermatological diseases. Severity of eczema was assessed always by the same dermatologist by using the Physician Global Assessment (PGA) score.17,18 The disease was classified as ‘‘absent,’’ ‘‘almost clear,’’ ‘‘mild,’’ ‘‘moderate,’’ or ‘‘severe’’ disease. The second part of the questionnaire was submitted exclusively to women who smoked. Indeed, it investigated the habit to smoke, such as the duration and the severity of dependence. The severity of the dependence was investigated by means of the Fagerstro¨m test19 (Fig. 1B), usually used in determining appropriate smoking cessation treatment.
Data were described statistically in terms of mean, frequencies, and percentages where appropriate. Comparisons between groups were practiced using Fisher exact test.
RESULTS Five hundred sixteen patients were recruited. The mean age was of 45.5 years (range, 18-83 years); 214 (41.5%) of 516 were affected by CHE, and 302 (58.5%) of 516 were control subjects. All data concerning hobbies, drugs, and other dermatological diseases did not show any significant differences between patients affected by CHE and control subjects. Fifty-six (10.8%) of 516 individuals claimed positive anamnesis for AD: 26 (12.1%) of 214 patients of the CHE group and 30 (9.9%) of 302 control subjects, without significant differences (P = 0.48). Seventy-two of 214 CHE patients (33.6%; 95% confidence interval, 28.7%Y38.4%) and 106 of 302 (35.1%; 95% confidence interval, 31.6%Y38.6%) control subjects were smokers; no statistical significance was found between the 2 groups (P = 0.859). As far as PGA is considered (Table 1), in 21 (29.2%) of 72 patients of the CHE smoker group, the disease was classified as
Figure 1. A and B, Questionnaire submitted to each housewife.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Patruno et al ¡ Smoking and Chronic Hand Eczema
203
TABLE 1. Severity of CHE Assessed by Means of PGA in Smoker and Nonsmoker Patients (n = 214) Smoker PGA Almost clear Mild Moderate Severe Total
Nonsmoker n (%) 21 29 22 0 72
(29.2) (40.3) (30.5) (0) (33.6)
PGA
n (%)
Almost clear Mild Moderate Severe Total
18 (12.7) 44 (31.0) 66 (46.5) 14 (9.8) 142 (66.4)
‘‘almost clear,’’ in 29 of 72 (40.3%) as ‘‘mild,’’ and in 22 of 72 (30.5 %) as ‘‘moderate’’; no patients of this group had ‘‘severe’’ CHE. On the other hand, in the CHE nonsmoker group, in 18 (12.7%) of 142 cases, the disease was ‘‘almost clear’’; in 44 (31.0%) of 142, ‘‘mild’’; in 66 (46.5%) of 142, ‘‘moderate’’; and in 14 (9.8%) of 142, ‘‘severe.’’ Chronic hand eczema classified as ‘‘almost clear’’ was significantly more frequent in the smoker group (P G 0.05), whereas the ‘‘severe’’ form significantly affected the nonsmoker group (P G 0.01). Differences regarding ‘‘mild’’ and ‘‘moderate’’ disease did not approach statistical significance (P = 0.39 and P = 0.17, respectively). Among 26 patients affected by CHE and with positive anamnesis for AD, 4 of 26 smoked, and all the 4 patients had ‘‘mild’’ disease. On the other hand, 5 of 30 control subjects with positive anamnesis for AD smoked. These data did not show any significant differences. One hundred seventy-eight (34.5%) of the 516 individuals enrolled in the study were smokers. One hundred fifty-two (85.5%) of 178 smoked 1 to 10 cigarettes per day; 22 (12.3%) of 178, 11 to 20 cigarettes; and 4 (2.2%) of 178, 21 to 30 cigarettes. Sixty-four (42.1%) of 152 patients who smoked 1 to 10 cigarettes per day had CHE; 19 (29.7%) of 64 from ‘‘almost clear’’ disease, 23 (36%) of 64 from ‘‘mild’’ disease, and 22 (34.3%) of 64 from ‘‘moderate’’
disease. Among 22 subjects who smoked 11 to 20 cigarettes per day, 8 (36.4%) of 22 were affected by CHE; 2 (25%) of 8 suffered from ‘‘almost clear’’ CHE, and 6 (75%) of 8 suffered from ‘‘mild’’ CHE. None of the subjects who smoked 21 to 30 cigarettes per day had CHE (Table 2). All these differences were not statistically relevant. One hundred thirty-three (74.7%) of 178 smokers were ‘‘minimally dependent’’; 18 (10.1%) of 178, ‘‘moderately dependent’’; and 27 (15.2%) of 178, ‘‘highly dependent,’’ according to the Fagerstro¨m test. Forty-six of 133 smokers who were ‘‘minimally dependent’’suffered from CHE; 6 of 46 from ‘‘almost clear’’ disease, 18 of 46 from ‘‘mild’’ disease, and 22 of 46 from ‘‘moderate’’ disease. Among 18 smokers who were ‘‘moderately dependent,’’ 10 of 18 suffered from CHE, 6 of 10 from ‘‘almost clear’’ disease, and 4 of 10 from ‘‘mild’’ disease. Among 27 smokers who were ‘‘highly dependent,’’ 16 of 27 suffered from CHE, 9 of 16 from ‘‘almost clear’’ disease, and 7 of 16 from ‘‘mild’’ disease. No statistical difference was found, except for the group of ‘‘minimally’’ dependent smokers who were more frequently affected by ‘‘moderate’’ CHE (P G 0.05).
DISCUSSION AND CONCLUSIONS Chronic hand eczema is a common disease in adults. Water, soap, cleaners, detergents, and solvents are the most common irritants that housewives use and are in contact with. As a consequence, housewives who handle these irritants in their work have a higher risk to develop hand eczema. Among environmental factors, the influence of cigarette smoking on CHE has been studied.12Y16 The role of smoke in the development of CHE is unclear, and a sure relationship has not yet been found.12Y16 In our study, we analyzed the influence of cigarette smoking on housewives for the development of CHE. No
TABLE 2. Distribution of CHE in Smoker Group (n = 178)
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
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significant differences emerged between ‘‘smokers’’ and ‘‘nonsmokers’’ patients affected with CHE. According to this result, cigarette smoke does not seem to affect the onset of CHE. Moreover, the results of the study seem to suggest that smoker patients are mainly affected by the milder forms of the disease. Indeed, ‘‘severe’’ CHE was significantly more frequent in nonsmokers when compared with smokers, whereas ‘‘almost clear’’ forms were more frequent in the smoker group. As far as dependence from smoke is concerned, no statistical differences were found, except for a tendency to a more frequent ‘‘moderate’’ disease among the smoker patients who were ‘‘moderately’’ dependent. The anti-inflammatory activity of nicotine has been investigated in some studies. Nicotine seems to be able to decrease the production of TNF-> and cell response to this cytokine.20Y22 Tumor necrosis factor > activity would be mediated by the a7nACh receptor, via Jak2 STAT3 pathway. This pathway is responsible of the production of tristetraprolin (TTP), a protein implicated in the degradation of TNF-> and other proinflammatory molecules.20 Of note is that TTP-knockout mice develop severe inflammatory arthritis, autoimmune dysfunction, and myeloid hyperplasia, demonstrating the importance of TTP in limiting the inflammatory response. Moreover, many studies have investigated the capability of nicotine to reduce inflammation and to improve gut function in ulcerative colitis. The production of proinflammatory cytokines from peripheral macrophages can be attenuated by vagal activity.21,22 Indeed, blockade of vagus nerve signaling significantly enhanced colonic inflammatory mediators in 2 experimental models of colitis,23 an effect that was counteracted by nicotine administration. Activation of the cholinergic antiinflammatory pathway by low-dose nicotine significantly suppresses inflammation in adipose tissue, an important site in mediating obesity-induced inflammation in genetically obese (db/db) and DIO (diet-induced obese) mice.24 In addition, topical application of a paste made from a ground mixture of tobacco leaves, lime, and freeze-dried coffee mixed with water is used in India to treat moderate eczema.25 In conclusion, our data suggest that cigarette smoking seems to be not associated with onset of CHE in housewives. Moreover, ‘‘severe’’ CHE was more frequent in nonsmokers and ‘‘almost clear’’ CHE in smoker patients.
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