Occupational asthmain a hairdressing salonOccupational asthma in a hairdressing salon Table I Details ofemployees ofahairdressing salon Tinters Stylists All Number 11 12 23 Age(y)

Thorax 1986;41:42-50

Occupational asthma in a hairdressing salonAD BLAINEY, S OLLIER, D CUNDELL, RE SMITH, RJ DAVIES

From the Academic Unit of Respiratory Medicine and the Department of Medical Electronics,St Bartholomew's Hospital, London

ABSTRACT Occupational asthma among hairdressers has been recognised for some years and casesof work related asthma due to hair bleaches containing persulphates and hair dyes have beenreported. The extent of the disease among hairdressers remains unknown. An investigation wascarried out on an entire hairdressing salon, which specialised in hair bleaching and colouring andwhich employed 23 staff. On the basis of history and specific and non-specific bronchial provocationtesting, four out of 23 staff were found to have occupational asthma due to the persulphate saltscontained in hair bleaches. Only one of these had a positive skinprick test response to persulphatesalts. Tests for non-specific bronchial reactivity to histamine in this work force were more sensitivefor the diagnosis of asthma than simple lung function tests or recordings of peak flow ratesperformed four times daily for three weeks. The response to these agents was studied in greater detailby specific bronchial provocation tests in 14 members of the salon as well as one hairdresser fromelsewhere with occupational asthma, three individuals with non-occupational asthma, and fournormal subjects. Only those with a history of work related asthma and bronchial hyperreactivityresponded positively, confirming that the response to bleach powders was specific. Studies ofpulmonary mechanics after challenge showed that the response arose from changes in airway calibrenot lung volumes. Measurement of neutrophil chemotactic activity after challenge showedsignificant rises in those affected, suggesting that mast cells may play a part in the pathogenesis ofoccupational asthma due to persulphates.

Hairdressers may be exposed to various chemicalscapable of producing respiratory symptoms and dis-ease. Some are known to have irritant properties andacute respiratory reactions have been described afterexposure to hair sprays,' but others can produceasthma. Persulphate salts, which are widely used asconstituents of hair bleaches, have been shown tocause asthma in hairdressers2 4 and chemicalworkers5; henna6 and other hair dyes containingparaphenylenediamine7 are also thought to be capa-ble of producing asthma in some individuals. Little isknown about the prevalence of asthma due to theseagents or the mechanisms underlying asthma causedby these highly reactive, low molecular weightchemicals.We report the results of an investigation conducted

in a hairdressing salon that specialised in bleachingand colouring hair, in which the employees were fre-quently exposed to high concentrations of bleaching

Address for correspondence: Dr RJ Davies, Department ofRespiratory Medicine, St Bartholomew's Hospital, LondonECIA 7BE.

Accepted 23 July 1985

agents, particularly persulphate salts. We have at-tempted to estimate the nature and prevalence ofwork related respiratory disease in this work force byinterviews, lung function tests, and specific and non-specific bronchial provocation tests. In these andother subjects we have studied the mechanisms andpathogenesis of asthma due to persulphate salts.

Subjects and methods

SUBJECTSAt the time of the survey the salon employed 23 staff,all of whom agreed to participate. They included 12tinters, who specialised in bleaching and colouringhair, and 11 stylists, who did not themselves usebleaches or dyes. Details of these subjects are given intables 1 and 2.The tinters are the group most heavily exposed to

bleaches and dyes. These chemicals are supplied to thesalon in powder form and mixed with hydrogen per-oxide to form a paste, which is then applied to the hairof the client. A fine dust is generated during the mixingof these compounds, which is readily inhaled. Venti-lation appeared adequate in the salon, but in the sep-

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Occupational asthma in a hairdressing salon

Table I Details of employees of a hairdressing salon

Tinters Stylists All

Number 11 12 23Age (y)Mean 24 23 24Range 16-37 17-36 16-37

Sex (M:F) 3:8 7:5 10:13Duration of exposure (y)Mean 6.63 5.6 6.2Range 6/12-23

arate back room where the bleaches were handledthere was no air extraction at the point of mixing.Stylists were exposed to the bleaches only after theyhad been mixed and did not handle them in powderform.The salon had been open for only three years, but

some of its staff had been employed as specialisedtinters elsewhere. We have also studied the respiratoryresponse to bleach powder in two asthmatic hair-dressers (subjects 24 and 26) not working at this salon,one of whom had a history of asthma precipitated bybleach exposure, as well as in two non-exposed asth-matics with hyperreactive airways and four non-

exposed non-asthmatic subjects (table 3). All subjectsgave informed written consent to this study.

METHODSAll subjects attended the laboratory while still em-

ployed at the salon and still exposed to bleach powder,for the following:

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QuestionnaireThere is no standardised validated questionnaire forthe diagnosis of asthma. The Medical Research Coun-cil questionnaire on chronic bronchitis was used in thesurvey with additional questions relating to allergicdisease of the respiratory tract. Questionnaires were

administered by two trained interviewers.

Lung function testsSpirometry was performed in triplicate with a Vital-ograph dry bellows spirometer and peak flow wasmeasured with a Wright peak flow meter. FEV1 andforced vital capacity (FVC) were considered normal ifthey were within two standard deviations of predictednormal values.8 In subjects with normal lung functionbronchial provocation testing with histamine was un-dertaken by the method described by Chai etal.9 In-creasing doses of histamine (from 0.25 mg/ml to 25mg/ml) were inhaled at five minute intervals from a deVilbiss 646 nebuliser attached to a Rosenthal-French(Laboratory for Applied Immunology, Baltimore,USA) breath activated dosimeter until the FEV1 hadfallen by 20% of its baseline value or the subject hadinhaled the maximum concentration of histamine.The dose of histamine required to produce a 20% fallin FEV1 was designated the provocation dose,PD20FEV1, and expressed in cumulative breath units(CBU). In our laboratory asthmatic individuals havebeen found to react to doses of 100 CBU or less andpatients with rhinitis alone to doses ranging from 100to 1000 CBU. normal subjects being unreactive.10

Table 2 Clinical details ofpatients studied in the hairdressing salon

No Age Sex Respiratory Nasal Occupational FEVI 0o Histamine Atopy Smoking Duration of Duration of Response to(y) symptoms symptoms symptoms FVC provocation (pack exposure symptoms specific

PD20 years) (y) (URT) bronchial(CBU) (Y) challenge

1 19 F W + + 83 10 + 0.07 2 0.5 +2 22 F 0 0 0 93 > 1000 + 0 5 - 03 22 M 0 + + 85 450 0 0 5 - ND4 25 F S 0 0 88 > 1000 0 11.78 5 2 05 21 M W + + 85 30.5 + 0 3 2.25 +6 19 F C 0 0 96 > 1000 0 6 4 6 07 20 F S + 0 93 200 + 2.5 3 10 08 21 M 0 0 0 91 > 1000 + 10.3 3 - 09 25 M W 0 0 92 7.5 + 3.86 3 10 010 36 F S 0 0 91 > 1000 0 16 12 - ND11 31 M 0 0 0 96 > 1000 + 5.14 16 - ND12 21 M 0 0 0 88 > 1000 + 0 5 - ND13 24 M 0 + 0 95 500 + 0 7 - ND14 22 M 0 + 0 79 140 0 4.1 3 - ND15 24 F W + + 88 7.3 - 1.5 8 1.5 +16 19 M 0 0 0 89 > 1000 0 0 4 - 017 16 F 0 + + 81 220 0 0 0.5 018 17 F 0 0 0 90 > 1000 0 0.86 0.5 - 019 22 F W + + 96 20 + 0 2.5 2 +20 23 F W + 0 89 > 1000 0 10.5 5 2 ND21 37 F C, S 0 + 92 >1000 0 16.1 23 15 ND22 36 M C 0 0 84 > 1000 0 14.7 2 - ND23 17 F W + 0 94 70 + 0.86 0.5 3 0

W-attacks of wheeze, cough, or breathlessness; C-morning cough only; S-exertional dyspnoea only; CBU-cumulative breath units; URT-upperrespiratory tract; ND-not done.



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Table 3 Clinical details of control subjects

No Age Sex Respiratory symptoms FEV% Histamine Atopy Smoking Response toFVC provocation (pack specificPD20 years) bronchial

(CBU) challenge

24 19 F Work related asthma 72 <5 + 0 +25 21 F Asthma non-occupational 93 12.5 + 0 026 27 F Asthma non-occupational 92 < 5 0 5 027 24 M Asthma non-occupational 86 20 + 7.5 028 33 M None 91 > 1000 + 10 029 23 F None 93 > 1000 0 0 030 34 M None 89 > 1000 + 2.5 031 31 M None 88 > 1000 0 0 0

All subjects were provided with mini Wright port-able peak flow recorders and diary cards and in-structed in their use. They were asked to record peakexpiratory flow rates (PEF) at least four times dailyfor three weeks both at and away from work. Peakflow charts were plotted and examined for patterns ofwork related asthma according to the criteria of Burgeet al. 1 Variability was calculated for each day by ex-pressing the difference between maximum and mini-mum recordings for that day as a percentage of themaximum value for the day. Variability of more than20% on any day after the first two is usually consid-ered to indicate asthma.12

Immunological testsSkinprick tests were performed according to themethod described by Pepys'3 with four common in-halant allergens (house dust, house dust mite, grasspollen, and Aspergillus fumigatus-Bencard, Brent-ford, Middx) and the resulting weals were comparedwith the site of a negative control. A skin test wealwith a diameter at least 2mm greater than the controlarea was regarded as significant.

Specific occupational testsSkinprick tests with aqueous solutions of ammoniumpersulphate (molecular weight 228 daltons: concen-trations from 10-6 to I mol/l) and potassium per-sulphate (molecular weight 270 daltons: from 10-6 to10 1 mol/l) were performed in all subjects undergoingspecific provocation tests as well as in four male andtwo female healthy atopic subjects aged 17-33 years.Specific bronchial provocation tests were undertakenaccording to a standard method.14 Subjects were ad-mitted to hospital for the duration of the occupationalchallenge. Thirty grams of bleach powder were mixedwith 50 g of lactose and tipped from one tray intoanother 30 cm away in a challenge chamber with inde-pendent air extraction. Subjects were closely moni-tored during the challenge procedure. All subjectswere challenged for 10 minutes unless respiratorysymptoms developed before this time, in which casethe challenge was terminated. Only two subjects un-

derwent challenge for less than 10 minutes-subject 1was challenged for three minutes and subject 24 forfive minutes. Changes in pulmonary function werefollowed in all patients by measuring FEV 1, FVC, andPEF at five minute intervals for the first hour and athourly intervals thereafter. A response was consideredpositive when FEV1 fell by more than 20% of itsbaseline value in the absence of any change in re-sponse to a control challenge of lactose powder aloneconducted on a separate day.

In six subjects detailed studies of pulmonary me-chanics were undertaken. In addition to FEV1, FVC,and PEF, recordings of flow-volume loops, airwaysresistance, lung volumes (measured by the helium re-breathing technique), and single breath carbon mon-oxide transfer were made. Flow-volume loops andairway resistance were recorded at 15 minute intervalsfor the first hour, and hourly thereafter. Lung vol-umes and gas transfer were recorded at two hourlyintervals. Prechallenge lung function tests were per-formed twice before each occupational challenge test.Flow-volume loops were recorded by plotting flow atthe mouth, recorded with a Fleisch pneu-motachograph and Validyne pressure transducer,against lung volumes derived from the plethys-mograph. Airways resistance was measured accordingto the method of Dubois. " Lung volumes and gastransfer were measured with the PK Morgan Respi-rometer. Control challenges were performed usinglactose alone on a separate day according to an iden-tical protocol, and the patient was blind to the natureof the challenge. In all, 21 subjects underwent bron-chial challenge: 14 members of the salon, one hair-dresser with a history of work related asthma (subject24), one hairdresser with asthma that was not relatedto work (subject 25), two non-exposed asthmatic pa-tients (subjects 26 and 27), and four healthy subjects(subjects 28-31). Nine members of the staff of thesalon refused to undergo occupational challenge.

The nasal responses to occupational challenge wasrecorded by the technique of anterior rhinometry withthe PK Morgan nasal resistance tester-NART (PKMorgan, Chatham).16 A challenge was considered

44 Blainey, Ollier, Cundell, Smith, Davies



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positive when a three fold or greater rise in nasalresistance in either nostril was recorded in the absenceof change in the control challenge.

Plasma histamine and neutrophil chemotactic activityBlood was taken before challenge with bleach powder;5, 15, and 60 minutes after challenge; and two hourlythereafter from subjects 1, 5, 9, 14, and 25-31. Plasmawas separated immediately and stored at - 70°C untilassayed for histamine with the double isotope radio-enzymatic assay,"7 which in our laboratory has a sen-sitivity down to 0.5 nmol/l and intra-assay andinterassay coefficients of variation of 7% and 15%respectively. Neutrophil chemotactic activity was as-sayed with a modification of the Boyden technique. 18This biological assay has in our laboratory intra-assayand interassay coefficients of variation of 20% and40% respectively. Neutrophil chemotactic activitywas characterised by separation by means both ofa Sephadex G-200 gel filtration column and of aSuperose GB column.

Basophil countsAbout 0.5 ml ofwhole blood was mixed with toluidineblue (containing 0.5 ml of saponin per 11 ml stain) todisrupt red cells. Cells were counted in a standardhaematocytometer.

Statistical methodsComparisons were made where appropriate withFisher's exact test, the x2 test, or the Mann-WhitneyU test.'9

Results

RESULTS OF QUESTIONNAIRESeven subjects complained of symptoms consistentwith a diagnosis of current asthma (more than oneattack of wheezing, cough, or shortness of breathwithin the last year). Symptoms appeared work re-lated in four-that is, they deteriorated at work dur-ing the day and improved at weekends or duringholidays. Three with non-work related symptoms hadhad these before working in the salon. Four othersubjects complained of exertional dyspnoea and oneof these reported greater dyspnoea during the workingday, although she had no work related wheezing.Three others-all cigarette smokers-had a non-productive morning cough on most days.Nasal symptoms (attacks of sneezing or a blocked

or runny nose) were reported by 10 individuals, in fiveof whom lower respiratory symptoms were alsopresent. Only four had nasal symptoms that were re-lated to work and improved away from the salon.

All of those who reported work related respiratorysymptoms had been exposed to bleach powders for at

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least six months before the onset of symptoms, andmany had been exposed to similar compounds beforeworking in this salon, None, however, had developedsymptoms before this employment.

Fifteen subjects were current smokers. Five of theseven with symptoms of asthma were atopic, as wereall three of those with morning cough and all four withexertional dyspnoea. Six out of eight non-smokershad no respiratory symptoms. All subjects with respi-ratory symptoms considered that the bleach powderswere the cause of their respiratory complaints.

LUNG FUNCTIONAll subjects had normal FEV1, FVC, PEF, andFEV1/FVC ratio at the time of testing.

NON-SPECIFIC BRONCHIAL REACTIVITYSix subjects reacted to less than 100 CBU of hista-mine, a level of reactivity consistent with symptomaticasthma.'0 Five reacted to doses of 100-1000 CBU(usually found in patients with rhinitis) and 12 wereunreactive to histamine in the doses used.

ATOPYEleven subjects were atopic (having one or more pos-itive skinprick test responses), 11 were non-atopic,and one had dermatographism. Five out of six of theasthmatic subjects were atopic. Six atopic subjects hadno symptoms of allergic respiratory disease.

RELATIONSHIP BETWEEN SYMPTOMS ANDNON-SPECIFIC BRONCHIAL REACTIVITYSymptoms of asthma were reported by all six individ-uals who had abnormally increased bronchial reac-tivity, though one with normal reactivity gave ahistory that was consistent with asthma (not workrelated). Spirometric results were normal in all sub-jects. Mean FEV , was lower in those who complainedof respiratory symptoms, but individuals with andwithout symptoms could not be distinguished on thebasis of spirometric measurements alone.

Respiratory symptoms were significantly associatedwith increased bronchial reactivity (p < 0.002) andsmoking (p < 0.05). Even though five of the sevenasthmatic subjects were atopic, seven of the 16 non-asthmatic subjects were atopic, and there was nosignificant relationship between respiratory symp-toms and atopy.

PEAK FLOW CHARTSPeak flow charts were returned by 19 (83%) of thestaff but complete recordings were provided only by12 (52%). Variability ofover 20% on one day or morewas found in four subjects, two of whom had symp-toms of asthma and bronchial reactivity in the asth-matic range. The third subject with variability ofmore



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than 20% had rhinitis but denied respiratory symp-toms. The fourth had normal bronchial reactivity andno symptoms of wheezing but did complain of exer-tional dyspnoea and morning cough. Of the six sub-jects with symptoms of asthma who returnedadequately completed records, four had no days onwhich variability was greater than 20%. Peak flowcharts were examined for the presence of work relatedpatterns of asthma according to the criteria of Burgeet al. " Only one subject (No 1) showed a typical workrelated pattern (fig 1). She also had a positive responseto histamine and specific occupational provocationwith bleach powder.

SPECIFIC BRONCHIAL PROVOCATION TESTSTwenty five bronchial provocation tests withoccupational materials were undertaken in 22 sub-jects. Fourteen members of the salon were challengedwith bleach powder and three were also challengedwith persulphate salts. In addition, three asthmaticsubjects without a history of work related respiratorydisease, one asthmatic hairdresser with work relatedwheezing, and four normal subjects were challengedwith bleach powder.

Positive responses to challenge with bleach powderoccurred in all four employees of the salon with workrelated respiratory symptoms who also had histaminebronchial reactivity in the asthmatic range (subjects 1,5, 15, 19). Challenge also gave a positive result in theasthmatic hairdresser who worked elsewhere (subject24). Challenges with bleach powder had negative re-sults in all other subjects, including the asthmaticswithout a history of work related symptoms (subjects

-ORK" 1WcRN WORK IWOR KFig 1 Peak flow rate (PEF) chart of subject 1: meandaily peak flow rates plotted against time, showing workrelated decline in peak flow rates with weekendimprovement. Shaded areas represent time at work.

Blainey, Ollier, Cundell, Smith, Davies

9, 23, 25-27). A late asthmatic response occurred in allsubjects reacting to bleach powders (fig 2). Typicallythe fall in FEV1 began two to four hours after chal-lenge and returned to normal within eight hours, al-though in subject 1 the response continued for 12hours. No immediate responses were observed. Threeindividuals who had reacted to bleach powder werealso challenged with potassium persulphate powderand identical bronchial responses were observed(fig 2). Positive bronchial responses to bleach powderwere found only in tinters.

Detailed studies of pulmonary mechanics were un-dertaken in three subjects who had a positive responseto bronchial challenge with bleach powder (table 4).Although both FEV1 and FVC fell significantly inthose with a positive response to challenge, lung vol-umes and gas transfer remained unchanged. Nochanges were seen in flow rates at 50% of lung volume(V50) or specific conductance (sGaw) in the first hourin any of the subjects undergoing bronchial challengewith bleach powder (fig 3).

Percentage changes following bronchial challengewith bleach powder in FEV1, FVC, PEF, V50, sGaw,Kco, and TLC for these three subjects, for two sub-jects with asthma not related to work, and two sub-jects without asthma are shown in table 4 and figures3 and 4. Changes in flow rates (FEV1, PEF, V50, andsGaw) were significantly greater in the three subjectswith work related asthma than in the four controls,but there were no significant differences in lung vol-umes or gas transfer.

RESULTS OF NASAL CHALLENGEThe nasal response to occupational challenge wasrecorded in 13 individuals. Positive responses were

FEV,(I)

TIME AFTER CHALLENGE

Fig 2 Bronchial response to specific bronchial provocationtests with bleach powder and persulphate salts in subject 15.

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Table 4 Changes in lung function after bronchial provocation with bleach powder (maximwn percentage change frombaseline after provocation test with bleach or lactose)

AFEV1% AFVC% APEF%I/ PA50% AsGaw% AKCO% ATLC%

Work related Bleach -42.5 -31.0 -35.4 -48.63 -55.3 -8.0 -12.75asthma (n = 3) Lactose -10.2 -9.7 -1.0 -8.75 -12.0 +13.0 -4.00

Non-work related Bleach -7.8 -7.6 -6.5 + 1.80 -9.1 -19.5 -12.60asthma (n = 2) Lactose -4.0 -7.5 -5.1 -10.20 -34.0 -36.0 -3.60

Nornal controls Bleach -4.4 -4.2 -5.3 -5.5 -15.8 -2.75 +3.30(n = 2) Lactose -5.8 -5.4 -3.1 -3.5 -26.5 0 -11.50

A-change; FEV1-forced expiratory volume in one second; FVC-forced vital capacity; Vso-flow rate at 50% of lung volume; sGaw-specific conductance; Kco-transfer coefficient; TLC-total lung capacity.

found in all subjects who had positive responses tobronchial challenge, the peak response occurring atabout the same time as the maximum bronchial re-sponse (fig 5). Responses in those with no history ofwork related rhinitis were negative.

RESULTS OF SKIN TESTS WITH PERSULPHATESALTSSkin tests with persulphate salts were performed on 14members of the salon, six non-exposed atopic subjectsand two exposed hairdressers without a history of

6.0rA-TLC | -

()50140

.. - -'4-~ _

(is 1)3(4 s"3201

0 1 2 3 4 5 6 7TIME (h) AFTER CHALLENGE

Fig 3 Pattern of respiratory reaction after provocationwith bleach powder and placebo in subject 5, who had workrelated asthma. a a bleach powder; .---o placebo.

work related asthma. There was only one positiveresponse in subject I who developed a 3 mm weal andflare to a molar solution of ammonium persulphateand a 10- mol/l solution of potassium persulphate.

MEDIATOR RELEASE AFTER CHALLENGEPlasma histamine concentration did not risesignificantly in subjects with or without work relatedasthma after challenge with bleach powder. In thosewith positive responses to bleach powder there weresignificant rises in serum levels of neutrophil chemo-

TIME AFTER CHALLENGE

Fig 4 Pattern of respiratory response after bronchialprovocation with bleach powder in normal subject 16.

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Blainey, Ollier, Cundell, Smith, Davies

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4

O

1

642 M

O.

a

L nostrilR nostril

0 1 2 3 4 5 6 7TIME (h) AFTER CHALLENGE

2 3

TIME (h)

Fig 5 Nasal response to provocation with bleach powder insubject 19, who had work related asthma and rhinitis.NAR-nasal airway resistance.

tactic activity after challenge, and the serum levelsthree to five hours after challenge were significantlyhigher (p < 0.05) than in asthmatic and non-asthmatic subjects with negative responses to provo-cation with bleach powder (fig6). Sephedex G200column separation of this neutrophil chemotactic ac-tivity showed that it consisted of two peaks, one ofmolecular weight > 74 x 105 daltons < 2 x 106daltons and a low molecular weight fraction of < 200x 103 daltons. Superose GB column separationshowed three distinct high molecular weight peaks- Ix 106,6 x lIO, and 4 x IO' daltons-as well as a lowmolecular weight fraction of < 60 x I03 daltons. Theneutrophil chemotactic activity detected in these sub-jects has the same characteristics as that found in ourlaboratory in the serum of allergic asthmatic subjectsafter bronchial provocation with allergen. Basophilcounts rose in all subjects after provocation withbleach powder, but the differences in basophil countsbetween those with a positive response to challengeand those with a negative response were notsignificant.

Fig 6 Changes in basophils, neutrophil chemotacticactivity, and FEV1 in three subjects with work relatedasthma (A-A), three subjects with asthma not related towork (.---.), andfour normal subjects (.-.) afterbronchial provocation with bleach powder.

Discussion

Four out of 23 staff employed at a hairdressing salondeveloped occupational asthma due to inhalation ofbleach powders containing persulphate salts. All thosewho had developed work related respiratory diseasehad been heavily exposed to bleaches containing per-sulphates in powder form for at least six months be-fore the onset ofsymptoms, although there were in thesalon several individuals who despite equivalent or

greater exposure to bleaches had not developed respi-ratory disease. All those with work related asthmawere tinters, and directly concerned in mixing bleachpowders; none of the stylists had developed work re-lated asthma. Although we could not quantify ex-

posure to bleach powders in this salon, thisobservation suggests that those who had the greatestexposure were most likely to develop work relatedasthma.The results of this small scale study show the value

NAR(kPa I11s)20r n

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of testing for non-specific bronchial reactivity in theassessment of occupational lung disease. Asthma maybe difficult to identify solely on the basis of the history,and some objective assessment is required. In thisgroup spirometric tests performed on a single occa-sion were of no value in distinguishing affected fromunaffected individuals. Peak flow records have beenused to diagnose asthma in the work environment butwere disappointing in this study, identifying only oneindividual with work related asthma.There were several reasons why peak flow record-

ings were insensitive in this study for the diagnosis ofasthma. One of the subjects continued to take inhaledsodium cromoglycate throughout the period of in-vestigation, and peak flow recordings were made onlyfour times a day. The poor completion rate of peakflow records in this study, only about half of whichwere adequate, implies that more frequent recordings,as suggested by Burge et al," would have beendifficult for the busy staff of this salon to complete. Itis difficult to explain why two individuals withoutsymptoms of asthma produced peak flow chartsshowing variability of more than 20% on at least oneday. This degree of variability certainly suggestsasthma, but neither had symptoms of this disease orbronchial reactivity in or near the asthmatic range.Possibly bleach powders were having a non-specificirritant effect on the airways of some individuals, asgrain dust has been shown to do.20 Alternatively,errors may occur in the performance of ambulatorypeak flow meters, which are largely operated un-supervised.

For all these reasons tests of non-specific bronchialreactivity may be of greater value than ambulatorypeak flow records in screening for asthma in an oc-cupational group. Histamine bronchial provocationtests were completed in all individuals surveyed andlow PD20 values were obtained only in patients withsymptoms of asthma.

Bronchial provocation testing with bleach powderconfirmed that the response to these agents wasspecific and not simply an irritant response in individ-uals with hyperreactive airways, since subjects with-out a history of work related asthma but withincreased airways reactivity did not develop airwaysconstriction on inhalation of bleach powder. Detailedstudies of pulmonary mechanics after challenge indi-cated that the response was asthmatic in nature: flowrates declined whereas lung volumes and gas transferwere unchanged. The airway responses to inhaledbleach powders have rarely been studied but in the fewcases adequately described responses were immediate,unlike the asthmatic reactions seen in our study,which were non-immediate. The nasal response tochallenge was similar to the bronchial response, thepeak rises in nasal airway resistance coinciding with

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the maximum fall in FEVI (fig 5). Rises in nasal air-way resistance after challenge with lactose were seenin five subjects, but all occurred within the first fewminutes after provocation and presumably resultedfrom an irritant response to lactose. The rise in nasalairway resistance in those who responded to bleachpowder was not seen in the two nostrils simulta-neously, because changes in the opposite nostril weresuppressed by the nasal reflex, as shown by Hasegawaand Kern.2' Recordings of total nasal resistancewould have failed to indicate any change. These re-sults show the value of anterior rhinometry in record-ing the response to nasal challenge.The mechanism of asthma due to bleach powders

containing persulphate salts is unknown. As withother types of occupational asthma, certain featuressuggest an allergic pathogenesis. Only a proportion ofthose exposed were affected, and there was a latentperiod of several months between first exposure andthe onset of symptoms. Skinprick testing with per-sulphate salts, however, gave a positive result in sub-ject I only, in whom a 1 and 10-1 mol/l solution ofammonium persulphate and a 10- 1 mol/l solution ofpotassium persulphate were required to produce a3mm weal. Previous reports have described positiveresponses to skin tests with persulphate salts, in gen-eral at much lower concentrations, in some but not allpatients with occupational asthma due to theseagents. Specific IgE has not been found in the serumof any patients with respiratory disease due to per-sulphate salts.A rise in serum neutrophil chemotactic activity has

been found in various disorders in which allergicmechanisms are important-for example, allergen in-duced asthma22 and cold urticaria.23 While the exactorigin of neutrophil chemotactic activity in man re-mains to be determined, many consider that in vivoneutrophil chemotactic activity is released from mastcells. The significant rise in serum levels of neutrophilchemotactic activity paralleling airflow obstructionsuggests that mast cells may play a part in the patho-genesis of the late asthmatic reaction following in-halation of persulphate salts. The mechanism bywhich mast cell activation may occur in asthma due topersulphates remains unknown. Studies on animalmast cell preparations have shown that persulphatesalts can release histamine directly,24 but on this basisit remains necessary to explain why only someindividuals are affected and not others.Although a study of a single salon cannot be used

to estimate the prevalence of work related respiratorydisease among hairdressers in general, it is clear thatunder some circumstances a substantial proportion ofthe work force may be affected by bleach powderscontaining persulphate salts. Those exposed to thesebleaches should be advised to avoid inhalation of the



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dust. This could be achieved by the provision of ex-tractor hoods at the site where the bleaches are mixed.

We acknowledge with gratitude the assistance of thetechnical staff of the Academic Unit of RespiratoryMedicine, particularly Caroline Gould for help withprovocation testing and Wendy Smart for plasma his-tamine assays. We thank the staff and management ofthe hairdressing salon for their patient cooperation,and Kim Clarke and Laura Roberts for typing themanuscript. ADB was supported by a grant from theChest, Heart, and Stroke Association and RS hadfinancial support from the Medical Research Council.

References

1 Zuskin E, Boujuys A. Acute airway responses to hair-spray preparations. N Engl J Med 1974;290:660-3.

2 Gaultier M, Gervais P, Mellerio F. Deux causes d'asthmeprofessionel chez les coiffeurs: persulfate et soie. ArchMal Prof 1966;27:809- 13.

3 Fisher AA, Dooms-Goosens A. Persulfate hair bleachreactions: cutaneous and respiratory manifestations.Arch Dermatol 1976;112:1407-9.

4 Pepys J, Hutchcroft BJ, Breslin ABX. Asthma due toinhaled chemical agents-persulphate salts and henna inhairdressers. Clin Allergy 1976;6:399-404.

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Occupational asthmain a hairdressing salonOccupational asthma in a hairdressing salon Table I Details ofemployees ofahairdressing salon Tinters Stylists All Number 11 12 23 Age(y)