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A nonatopic female secretary developed hand dermatitis after 1 year of full-time work with telefax paper. Her dermatitis improved on sick leave and vacation and relapsed at work. Patch testing showed allergic reactions to several fragrances, balsam of Peru, colophony and neomycin. In 3 patch test sessions, her own telefax papers gave a doubtful reaction which persisted for 4 days, but it could not be determined whether the reactions were allergic or irritant. The colophony content of the telefax paper was about 1%, and it was possible that colophony in the telefax paper was responsible for the weak path test reactions. Accordingly, the contact dermatitis would have been allergic. The patient has now been relocated, does not handle telefax paper, and is symptomless. We concluded that our patient had an occupational hand contact dermatitis induced by telefax paper and possibly caused by colophony allergy.

Irritant contact dermatitis caused by occupational contact with nitroglycerin has been known since the end of the last century. Nitroglycerin is an allergen, and the transdermal drug delivery systems for nitroglycerin recently used to treat angina pectoris have sensitized. 4 patients with allergic contact dermatitis caused by nitroglycerin from explosives are described, and 1 patient who was sensitized by transdermal nitroplaster. On patch testing, dynamite and/or the explosive components nitroglycerin, ethylene glycol dinitrate and dinitrotoluene gave allergic reactions. The following concentrations and vehicles are suggested for patch testing: nitroglycerin 0.5-2% pet., dinitrotoluene and ethylene glycol dinitrate 0.1-0.5% pet. Persons exposed to nitroglycerin at work should try to avoid skin contact by using protective gloves. It is advisable that those who have become allergic to nitroglycerin should wear disposable protective gloves when handling explosives.

An urticarial reaction associated with high fever developed in a welder on four occasions while he was welding steel profiles filled with polyurethane. The fumes emitted during pyrolysis of polyurethane and inhaled by the patient probably caused the urticarial reaction. Provocation tests with two pyrolysis products, 4,4-diphenylmethane diisocyanate and 4,4-diaminophenylmethane, were negative. This case demonstrates the difficulty in detecting the cause of urticaria induced by airborne chemicals.

In addition to previously presented patients with allergic contact dermatitis from cycloaliphatic epoxy resins (ERs), during 1974-1990, we have seen 4 patients with allergic contact dermatitis (ACD) caused by products containing uncured non-diglycidyl-ether-of-bisphenol-A ER. The patients were negative on patch testing with the standard ER based on diglycidyl ether of bisphenol A (DGEBA-ER). The following non-DGEBA-ERs were included in the causative agents: heterocyclic dimethylhydantoin ER, phenol novolak ER, and brominated ER. We were unable to specify the type of ER in an epoxy primer used by the 4th patient. Apart from the ACD caused by the brominated ER, 1 of the patients also had IgE-mediated occupational rhinitis caused by methyl hexahydrophthalic anhydride (MHHPA), an epoxy hardener. The diagnosis was verified by positive prick tests and specific IgE determinations with MHHPA. Intense rhinitis evoked by a bronchial challenge with MHHPA confirmed the diagnosis. We stress the importance of performing patch testing with the relevant epoxy resins to which the patient has been exposed, in addition to patch testing with the standard ER.

Skin and respiratory symptoms developed within 2 months of exposure in a patient involved in the commercial production of shiitake mushrooms. A diagnosis of contact urticaria and allergic contact dermatitis from shiitake mushrooms was confirmed by prick and patch tests. The respiratory symptoms, their timing, the presence of precipitating IgG antibodies to shiitake spores and increased amounts of inflammatory cells and T lymphocytes in bronchoalveolar lavage indicated allergic alveolitis (mushroom worker's disease). A generalized exanthem developed in a second patient after eating raw shiitake mushrooms. Reactions to prick and patch tests with shiitake mushrooms were negative. The skin eruption in this patient corresponded to the previously reported shiitake-induced toxicodermia.

This study comprises 40 patients with skin disorders from current or previous occupational exposure to epoxy resin compounds (ERC) during 1984-1988. ERCs were the 3rd most common cause (32 of 264 cases: 12.1%) of currently relevant allergic contact dermatitis: 23 cases from epoxy resins based on the diglycidyl ether of bisphenol A (DGEBA-ERs), 5 from reactive diluents, 1 from amine hardeners (DETA), and 3 from epoxy acrylates. 2 cases (0.8%) of irritant contact dermatitis were due to ERCs. Methyl hexahydrophthalic anhydride (MHHPA, an epoxy hardener) caused 1 case of contact urticaria. Previously relevant occupational allergic contact dermatitis from DGEBA-ERs was detected in 5 cases. On patch testing, ERC allergens gave the following positive reactions: epoxy resin of the standard series in 35 cases (4.0% of 870 tested), epoxy reactive diluents in 10 (7.1% of 140), cycloaliphatic epoxy resins in 4 (11.1% of 36), epoxy acrylates in 4 (4.5% of 88), and amine compounds commonly used as epoxy hardeners in 17. Despite extensive patch test series, testing with patients' own ERCs remains important.

Type I (immediate) and type IV (delayed) allergic reactions to castor bean developed in a stockroom worker in a coffee roasting plant. The exceptionally strong contact urticarial patch rest reaction persisted for more than 48 hours and was therefore called "long-lasting contact urticaria." Light and electron microscopic observations indicated that eosinophils and mast cells were activated and participated in patch test reactions, which include both type I and type IV allergic reactions. Although patch testing is an absolute prerequisite for an accurate diagnosis of delayed allergy, it should be stressed that skin tests should not be performed with castor bean because of its toxicity and potential danger.

A unique urticarial type I patch-test reaction to castor bean that persisted for more than 48 hours and was followed by a delayed type IV reaction is described. Immunohistochemical and electron microscopic observations indicated involvement of eosinophils and IgE receptors on Langerhans' cells. The authors present a scheme for the role of Langerhans' cells in skin allergy.

The incidence of hand dermatitis and contact allergies was analyzed among dental technicians. A survey was carried out by postal questionnaire. It was returned by 106 technicians (88%); 30 had had skin problems, and 20 (19%) had present eruptions. All 20 were invited to a detailed dermatological investigation, but only seven participated. Epicutaneous tests to prosthetic materials were negative in these patients. The hand eruptions in 4 patients appeared to be irritant. 4 other patients (4%), who had had previous hand dermatitis, had a history of positive patch test reactions to methyl methacrylate, but they had become symptomless and refused to participate in further studies.

Hand protection entails many problems. There is a wide variety of individual differences in the types of skin among human beings, and an even wider variety of chemicals to be handled and working methods to be learned in various workplaces. There are great differences in the degree of experience and education among job applicants and thus in their ability to understand the importance of instructions on safe working methods and the use of personal protective equipment. Therefore, proper employee selection is an important and demanding task for occupational health care personnel and dermatologists. Despite these complexities, an appropriate means of hand protection is essential in the prevention of many skin disorders and injuries.

A dental assistant developed sensitivity to dental restorative materials within 3 months of starting to use them. They contained the epoxy acrylate BIS-GMA, which is the most commonly used dimethacrylate monomer in dental composite restorations. She was positive to a patch test with BIS-GMA, which was the probable allergen, and epoxy resin, but this substance was not present in the materials used, as shown by high performance liquid chromatography. The patient was also allergic to the disinfectant Desimex i containing dodecyl diaminoethyl glycine.

A 35-year-old machinist developed hand eczema from contact allergy to dibutylthiourea, a compound found in a paint and glue remover. Light and electron microscopy of his positive patch test was consistent with allergic contact dermatitis, showing Langerhans cell-mononuclear cell contacts in the epidermis.

Data on allergic contact dermatitis from acrylates and 4 patients sensitized during routine patch testing are reported. During 1982-1985, we used 7 different acrylates for tests. 1 patient out of 22 (= 4.5%) was sensitized to ethyl acrylate and butyl acrylate (1% pet.). Since September 1985, we have used a commercial (meth)acrylate series containing 28 substances. 3 of 24 patients tested became sensitized to ethyl acrylate, 2-hydroxyethyl acrylate and 2-hydroxypropyl acrylate (0.5% pet.). Because active sensitization with acrylates can be very harmful, it may be necessary to use lower concentrations than recommended. Currently, we test ethyl acrylate, 2-hydroxyethyl acrylate and 2-hydroxypropyl acrylate at 0.167% pet.

Three cases of allergic rhinitis from a vegetable gum, guar gum, have been detected. Two subjects were exposed to fine guar gum powder (Emco Gum 563, Meyhall Chemical AG, Switzerland), an insulator in rubber cables, when opening cables in a power cable laboratory. After 1-2 years' exposure the patients developed rhinitis. Scratch-chamber tests, nasal provocation tests, nasal eosinophilia and a RAST test proved their allergy. A third subject developed allergic rhinitis from another guar gum product (Meyproid 5306, Meyhall Chemical AG) after 2 years' exposure in a paper factory. A positive skin test and nasal provocation test confirmed the diagnosis. A fourth case of possible allergy to guar gum after exposure to Meyproid 5306 in a paper factory is also presented. No final diagnosis was reached in this case (in 1974). The present subjects, only one of whom was atopic, developed allergy within 2 years, although their exposure to guar gum was not especially heavy. Therefore, when handling guar, adequate ventilation facilities should be provided and protective clothing, including a respiratory mask, should be worn.

3 female workers in a brush factory developed contact allergy from a 2-component epoxy glue containing epoxy resin (37% w/w), reactive diluents: i.e., 1,4-butanediol diglycidyl ether (BDDGE) 3%, glycidyl ethers of aliphatic alcohols (Epoxide 8) 0.03% and phenyl glycidyl ether (PGE) 0.01%; and inert fillers. All 3 patients were positive to the resin component of the glue and to BDDGE, indicating that BDDGE was the main allergen. 2 of the patients reacted to PGE, but none to the 3rd reactive diluent (Epoxide 8) in the glue. 2 of the patients did not react to epoxy resin, indicating that BDDGE may be an even stronger sensitizer in humans than epoxy resin, and that it does not cross-react with epoxy resins. Permeation studies revealed that BDDGE penetrates disposable PVC and rubber gloves in less than 30 min; thus, contaminated gloves should be replaced immediately. Reactive diluents should be included in patch test series if contact allergy to epoxy products is suspected.

7 patients were occupationally sensitized to dental composite resin products (DCR): 6 dental nurses and 1 dentist. All had a positive patch test to their DCR. 2 independent types of allergy were seen; (a) aromatic epoxy acrylate, and/or (b) aliphatic acrylates. 4 out of 5 patients reacted to BIS-GMA, the most widely used aromatic epoxy acrylate in DCR, but not the dentist. She and 2 dental nurses were allergic to aliphatic acrylates, including triethylene glycol dimethacrylate (TREGDMA) and triethylene diglycol diacrylate (TREGDA). 4 patients were allergic to epoxy resin (ER) (containing mainly MW 340), possibly an impurity in some DCR. 2 patients were also allergic to methyl methacrylate (MMA): the dentist, had been exposed to MMA, but the nurse's exposure was uncertain. 1 patient was also allergic to rubber gloves, 2 to rubber chemicals but not their gloves, and 5 to disinfectants used. diagnosis was delayed as long as 13 years in spite of previous patch testing. Dermatologists need to use the patients' own DCR and the (meth)acrylate series for patch testing. No dental nurses could continue their occupation, but the dentist could occasionally handle DCR if wearing PVC gloves. Dental personnel need to know about the risks of DCR, and use no-touch techniques and protective gloves.

Four cases of contact urticaria from rubber gloves are presented in detail. Three of the four patients, including two atopics had present or previous hand dermatitis. The causative gloves were made of natural rubber. Interestingly, one patient also reacted to her synthetic nitrile rubber gloves which the distributor had sold her as plastic gloves, and explanation for this case is discussed. Contact urticaria should be taken into consideration when there is recalcitrant hand dermatitis in spite of regular use of polymeric protective gloves. Manufacturers should give more accurate and reliable information on the composition of the glove materials to distributors and consumers.

The occurrence of occupational allergic contact dermatitis due to 2,3-epoxypropyl trimethyl ammonium chloride (EPTMAC) is reported and supplemented with immunohistochemical and electron microscopic observations. Four young workers developed hand dermatitis at a factory in which modified, cationic starch is manufactured. EPTMAC, a quaternary ammonium compound used as a cationizing chemical in the process, produced allergic reactions in all four patients in epicutaneous testing. The patients had only been in contact with EPTMAC for a short time (one to three months) before developing allergic eczema, which indicates that EPTMAC is a strong sensitizer. Immunohistochemistry showed that dendritic OKT6+ cells (Langerhans cells) increase in the hair follicles and the peribulbar infiltrate during the allergic patch test indicating that hair follicles might actively be involved in delayed type allergic reactions, possibly as a shunt way for allergens. Using electron microscopy, mitotic immunocompetent cells were found in the epidermis during the allergic patch test.

Over a ten-year period (1974-1983) 542 cases of allergic occupational contact dermatitis were diagnosed in our clinic. Epoxy resins caused 71 cases (13.1%) of occupational allergic contact dermatitis (CD), and three cases (0.6%) of irritant CD. One contact urticaria was caused by an epoxy resin hardener, methyl hexahydrophthalic anhydride. Epicutaneous testing with standard epoxy resin 1% in pet. (mainly oligomer of molecular weight 340) produced allergic reactions in all the patients with allergic CD with the exception of three. These three patients had allergic reactions only to their own resins. Testing the 71 patients of allergic CD with epoxy hardeners produced allergic reactions in 19 (26.8%). None of the patients had separate delayed contact allergy to epoxy hardeners without simultaneous contact allergy to standard epoxy resin.

A short review on organic pigments in plastics as a cause of allergic contact dermatitis is presented. Previously, organic pigments have been reported as provoking allergic pigmented contact dermatitis when used in cosmetics. Here we present the case of a patient who developed allergic contact dermatitis from an organic pigment (Irgalite Orange F2G) in a plastic glove. This shows that organic pigments in plastics can also cause allergic contact dermatitis. The potential sensitizing capacity of organic pigments should be noted.

The number and nature of allergic occupational glove dermatoses were analysed. 542 cases of allergic contact dermatosis were diagnosed during 1974-1983. Amongst these, 68 (12.5%) were caused by rubber or plastic gloves. 2 patients had contact urticaria due to rubber gloves. Gloves were the main cause of occupational allergic rubber eczema, inducing 63 (58.3%) of 108 rubber eczema cases. 38 of them had positive reactions to rubber chemicals and glove material, 14 to glove material only, and 11 to rubber chemicals. 5 cases of allergic eczema from plastic gloves were diagnosed, all due to polyvinyl chloride (PVC). 2 cases of contact urticaria from natural rubber gloves were diagnosed by a provocation test. Epicutaneous testing with material of natural rubber gloves and rubber chemicals was negative. The present study shows that allergy to rubber gloves is usual, while allergy to plastic gloves is rare. Thus, plastic gloves should be used, when possible. Patch testing with protective gloves should always be used when patients develop prolonged hand dermatitis and where the possibility of glove eczema exists.

A long-lasting allergic patch test is a "normal" allergic patch test that remains positive for weeks or months. An immunohistochemical study of immunocompetent cells in the skin in this rare type of patch tests was performed. Most inflammatory cells were T11 positive T-lymphocytes. The majority of these cells were of the helper/inducer phenotype (T4+), but a relative increase of T8+ cells as compared to the initial (1-2d) stages of allergic patch tests was observed. T6+ Langerhans' cells (LCs) were normal or increased in number in the epidermis, while very few dendritic cells displayed Ial antigen in the epidermis, indicating loss of Ial-staining of LCs. High to very high numbers of T6+ cells were found in the dermis. An inflammatory reaction of hair follicles with moderate numbers of T6+ cells in the peribulbar infiltrate was observed indicating that hair follicles might act as shunt pathways for allergens. A defect in down regulation of the contact hypersensitivity reaction and/or a constant antigen stimulation could be responsible for the long-lasting allergic patch tests.

An immuno-histochemical study of immuno-competent cells in the skin during fully developed 3-7 d patch tests was performed. Most inflammatory cells were OKT 11 positive T-lymphocytes. The majority of these cells were of the helper/inducer phenotype (OKT 4+), but in the later stages a relative increase of OKT 8+ cells was seen in 5 specimens out of 20. A focal decrease of OKT 6+ Langerhans cells was observed in the epidermis, while their number increased considerably in the dermis. Also observed was an inflammatory reaction of hair follicles with moderate numbers of OKT 6+ cells in the peribulbar infiltrate. This indicates that hair follicles may possibly act as shunt pathways for allergens.

5 cases of occupational eczema, urticaria and respiratory disease from reactive dyes, occurring during 1977-1987, are reported. The patients, 4 men and 1 woman, were 24-52 years old when examined. They had been working in dye houses or textile plants, and had been exposed to reactive dyes for 8 months to 4 years before symptoms developed. Only 1 of the patients has been able to continue in the same occupation. On patch testing, the 4 patients with eczema reacted positively to 9 commercial dye powders. 2 patients reacted to the same dye, Remazol Schwarz B. On scratch and/or prick testing, the 2 patients who also had respiratory symptoms and/or urticaria reacted positively to the same dyes as on patch testing. The 5th patient, who had urticaria and respiratory symptoms, reacted positively to a dye, Remazol Gold Gelb RNL, but the patch test with that dye was negative. None of the patients was patch-test-positive to para-phenylenediamine (PPD) or to textile dye allergens in a series of organic dyes. Thus, the series of organic dyes has little value in the screening of allergy to reactive dyes. A 1% pet. dilution of commercial dye powder for patch testing and the same concentration in distilled water for prick testing seem to be suitable for the screening of allergy to reactive dyes.

An analysis of 10 years (1974-1983) of statistics was carried out at the Institute of Occupational Health, Helsinki, Section of Dermatology, which is devoted to occupational dermatology. A total of 1,082 cases of occupational skin diseases were diagnosed during this period. Allergic (50.1%) and toxic eczema (47.1%) comprised the majority of occupational cases of dermatosis. The most frequent causes of allergic occupational eczemas were rubber chemicals (19.9%), chromates (18.8%), and epoxy resins (13.1%). If the metals (chromium, nickel and cobalt) were considered as a group, they formed the largest category (28.4%), followed by the plastic materials (27.7%). Detergents (37.8%), followed by organic solvents (16.1%), were responsible for most of the irritant (toxic) eczemas. Occupational skin diseases currently make up about 20% of all occupational diseases in Finland, but the percentage is decreasing.

4 workers developed hand dermatitis in an automated starch modification process plant. 2,3-epoxypropyl trimethyl ammonium chloride (EPTMAC), a quaternary ammonium compound used as a cationizing chemical, produced allergic reactions in all 4 patients. They had only been in contact with EPTMAC for a short time before developing dermatitis, which indicates that EPTMAC is a strong sensitizer. Immunohistochemistry and electron microscopy showed the features of an allergic patch test. An industrial hygiene project was initiated at the factory to prevent new cases. It revealed many risks of skin contact with the process chemicals. Thus an automated process does not guarantee protection.