Allergy at working places - UiT on working place - laboratory...Allergy at working places ... Allergic contact dermatitis: caused by type IV allergic reaction Atopic eczema: can have

Rosemarie Braun, Skindep., Unn 2010 1

Allergy at working places

Rosemarie BraunSkin Dep.University Hospital Northern Norway


Outline

Allergy - background / definitions

Allergic diseases/symptoms/evaluation/tests

Current allergies derived from occupation

Handle allergy:PreventionInitiatives when allergy occurs


Immune System

normaly: immune system protects against microorganisms

Cells and molecules from the immune system areimportant weapons in defence against disease and injuries.


Allergy - Definition

Immune system reacts on ”wrong” (harmless) substances(Allergens)

Once developed - after sensibilisation - allergy is usuallylife-long


Eczema= inflammation reaction in the skin

Allergy related eczema:

Allergic contact dermatitis: caused by type IV allergic reaction

Atopic eczema: can have relation to type I allergy


Atopic eczema

”childhood eczema”

often first appearance in childhood

Failure in the defence system of the skin, physically, chemically and immunologically, genetic disposisjon


Atopy

tendency to hypersensitivity of skin and mucosa ofeyes and airways

tendency to produce antibodies against allergens (type I allergy)


Skin cells

T-lymphocytes

Langerhans` cells

Other antigen-presenting cells

Keratinocytes (immunregulating)

High endothelian cells

Mastcells (IgE –receptor)


Allergy - cause

Important predisposing factors

Inheritance (atopi, type I allergy)

Environment

contact with irritants and allergens

early contact with allergens protects against type I allergy?


Types of AllergyType I IgE + mastcells or basophils

Type II Antibody and Antigen on cell surface

Type III Immun complex Antigen-Antibody activatescomplement

TYPE IV sensitized T - lymphocytes + macrophages


Distribution

Scandinavia30-40% gets an allergic disease/allergic symptoms?


Is Allergy increasing ???In case....what could be the cause?

Air pollution?

Smoking habits?

Diet?

Infection pattern?

Vaccination?

Contact with new and ”strange” substances?

More registration?


Type I Allergic reactionsRhino-conjunctivitis (Mucus conjunctiva and upper airways)

Hay-fever, Clear flux from nose and eyes, itch, red eyes, tight nose, sneeze

Urticaria, localized or generalized

Astma bronchialis (Mucus lower airways)Tight lower airways, cough, wheezing, breezing difficulties

Anaphylactic reaction

Ev. eczema

These symptoms er not necessarily caused by an allergic reaction, canbe hypersensitivity


Type I Allergic reactions forts.

Atopic eczema?

Other ekczema-type reactions ?


Rhinoconjunctivitis Symptoms

Tight nose

Water thin clear flux from the nose

Sneeze

Itching from both eyes and nose

Injection in conjunctiva (red eyes)


Allergic Urticariarare, most urticaria is idiopatic

Itching rash, swelling

localizedfaceeyelidtounge

Generalized Urticaria (nettle rash)

After sensibilisation quick reaction on allergen contact, lesions comeand go, disappears during few hours


Akutt urticaria


Urticaria with varying morphology


Urticaria with different morphology


Allergic Asthma

Allergens are inhaled

Inflammation:swellingtight airwaysproduction of mucus


Asthma,contin.

Symptomsattacs with chest tightness and breathing difficultycoughwheezing


Allergic symptoms from the wholebody

Anaphylaxis


Anaphylaxis

Acute allergic reaction with one or several life-threateningcharacteristics

Common causesfood (peanuts, shellfish)medicaments (antibiotics)Bee, wasp bite


Type IV allergic reaction

Allergic contact dermatitis

Constitute about 25% of all contact dermatitis

Often related to occupation


Symptoms Type IV all. Reaction:

eczema


Diagnosis: Contactallergy

Anamnesis, anamnesis, anamnesis !!!

Patchtest positiv AND clinical relevant

Demonstrate that pasient is exposed for material tested positiv


Allergic contact dermatitis, contin.

Chemicals used in laboratory work

Common allergens

Metals (nickel, chrome, cobolt)rubbervarious contents in cosmetics (lanolin, parfumes)


Airborne ContactdermatitisNot cloth-covered skin hud – face, neck, arms, hands:

Dvs. exposed skin regions incl. shadow locations

Obs. Powders, aerosols

D.D. Photodermatitis: shadow locations not/ little affected


Id - reaction

Secundary spreeding of eczema to skinlocalisations which er not directly in contact withthe allergen.

Sees espesially with :

Medicaments

Metals


Obs !!!

Fingers/ hands can bring allergens to otherlocations !!

especially face


Endogene factors

Regional anatomy

Earlier/present skin disease/injury

Any process which damages the skin affects thebarriere function:

Skin injury, skin disease (atop.dermatitt) raises disposition for irritative Contactdermatitis












If you suspect allergy

Anamnesis: Symptoms and correlation to work

Clinical examination

Allergy Tests


Anamnesis allways most important

Skin or Blood Test:

Just supplementary !!!!!!!!!!!!

Provocation test sjeldom necessary


Blind screening allwaysContraindicated !!!


Test Procedures

standardised

Read testInterprete – evaluate relevance


Test can be good diagnostic help, but

You cannot always trust it !!!! espesially :


Test for Type I allergy

Pricktest

Prick-pricktest

Scratchtest

Spesifikk serum-IgE


Prikktest Intracutantest

Positiv prikk/intracutantest


PRIST

Measuring total amount serum IgE

Not allways coincident with spesific type I allergy

Often high in atopic persons


When testresults come:

Shoot your cat !


Test for TYPE IV ALLERGY

Test done on target organ

BUT:Use test only when positiv anamnesis


Patch test = Epikutantest

Dermatolog with experience to select relevante allergens









Patch test, variant

ROAT

Repeated open application test


Indication for patchtest

Suspiscion that patient has contact allergy


Interprete and judje relevance

NOT an EASY task

False positivFalse negativAdverse reaction

Relevance to work ????


False positiv reaction

Excited skin reactionActive dermatitisStrong test reaction

Irritative reaction


Irritative reaction

can imitate allergic reaction:

Anamnesis

Repeat test


Allergy Testing demandsexperience

Easy to å mount test

Difficult to read test

Nearly impossible to evaluate relevans


Relevant Positiv test

Evidence for exposisjon to antigen (Product declarations)

Can exposisjon explain the clinical picture?


Allergy tested products

Nearly nonsense ???

Every substans is a potentialallergen


Allergi – en vanskelig diagnose


Relevant occupational allergies in laboratorys

Type I Allergies

Laboratory animals

Natural Rubber Latex

Proteins e.g. collagenase, albumin

Medicaments e.g. antibiotics


Relevant occupational allergies in laboratorys

Type IV AllergiesChemicals used at working place

don`t forget airborne allergy !!!

don`t forget transport of allergens byfingers (gloves!) to other skin-lokations


Laboratory animal allergy: type I allegy

10-30% of exposed people develope allergy

mouse and rat allergen (obs. proteins in the urine)

symptomsrhinoconjunctivitisurticariaasthma


Plant proteins from natural rubber latex (plant syrup)

Type I allergi

Cross over allergy with many fruits (kiwi, bananas)

gloves, ballons, condoms, rubber band, swimming goggles, comforter and so on

Occurrence of allergy:approx. 1 % in general populationup to 30 % among eager glove users


Hevea brasiliensis


Symptoms

Whole spectre from rhinoconjunctivitis , asthma, urticaria to anaphylaxis

Cross over allergy with several fruits, e.g. kiwi and banana


Surgeon must change occupation


Chemicals added when processingrubber products

Type IV allergy




Powder on glovesPowder from gloves binds easily to latex particle. Leads to increased dispersion.

Powder used in intraabdominal sugery and evenexamination through body openings can provoceadherences


Intolerances

”idiopatic environmental intolerance”

Unknown causes

Not allergy


How to handle allergy at an laboratoryPrevention

Initiatives when allergy arises


Prevention...How?Avoid any direct contact with allergens - skin and airways

Knowledge about substances one is working with (HMS data sheet)

Reduce spreading over large areas (ventilation, weigh rooms)

As little as possible maintain in dangerous/straining jobs

Protective equipment

Awareness around use of gloves, especially latex


If Occupational Allergy is confirmed

Changes at your working place, adapt working procedures if possible:

Avoid/reduce contact with allergensChange to equipment made of other material Change proceduresprotective equipment


If Occupational Allergy is confirmed cont.

Change working place if necessary

Yrkesrettet attføring = vocational rehabilitation

Apply for approval as occupational disease

Pensjon if the above solutions do not work


Approval of occupational disease

The worker bring forward the demands to the welfareoffice (Trygdekontoret)

Evaluation by spesialist, often more than one

Takes long time, several months

Offers special rights + eventually compensation


Educate the patient and the employer

Allergen source

How avoid allergen

Product compensation

Change work is not easy. Demands a goodreason !!!

Pension (uføretrygd) only if you do not findanother solution

Documents

Allergy at working places - UiT on working place - laboratory...Allergy at working places ... Allergic contact dermatitis: caused by type IV allergic reaction Atopic eczema: can have