Received: 8 December 2020 Revised: 7 March 2021 Accepted: 9 March 2021 DOI: 10.1111/cod.13833 ORIGINAL ARTICLE European Surveillance System on Contact Allergies (ESSCA): Characteristics of patients patch tested and diagnosed with irritant contact dermatitis Laura Loman1 | Wolfgang Uter2 | José C. Armario-Hita3 | Fabio Ayala4 | 5 6,7 8 Anna Balato | Barbara K. Ballmer-Weber | Andrea Bauer | 9 10 Andreas J. Bircher | Timo Buhl | Magdalena Czarnecka-Operacz11 | Heinrich Dickel12 | Thomas Fuchs10 | Ana Giménez Arnau13 | Swen M. John14 | Birger Kränke15 | Beata Kręcisz16,17 | Vera Mahler18,19 | Thomas Rustemeyer20 | Anna Sadowska-Przytocka11 | Javier Sánchez-Pérez21 | Kathrin Scherer Hofmeier22 | Sibylle Schliemann23 | Dagmar Simon24 | Radoslaw Spiewak25 | Philip Spring26 | Skaidra Valiukevičienė27 | Nicola Wagner18 | Elke Weisshaar28 | Maria Pesonen29 | Marie L. A. Schuttelaar1 | ESSCA Working Group† 1 Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands 2 Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-University Erlangen/Nürnberg, Erlangen, Germany 3 Department of Dermatology, University Hospital of Puerto Real, University of Cádiz, Cádiz, Spain 4 Department of Dermatology, University of Naples Federico II, Naples, Italy 5 Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy 6 Department of Dermatology, University Hospital Zürich, Zürich, Switzerland 7 Department of Dermatology, University Hospital Zürich and Clinic of Dermatology and Allergology, Kantonsspital St Gallen, Zürich, Switzerland 8 Department of Dermatology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany 9 Department of Dermatology, Allergy Unit, University Hospital Basel, Basel, Switzerland 10 Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany 11 Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland 12 Department of Dermatology, Venereology and Allergology, Ruhr University Bochum, Bochum, Germany 13 Department of Dermatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain 14 Department of Dermatology and Environmental Medicine, Institute for Interdisciplinary Dermatologic Prevention and Rehabilitation (iDerm), University of Osnabrück, Lower Saxony Institute for Occupational Dermatology (NIB), Osnabrück, Germany † The following collaborators of the ESSCA network, in addition to the authors, contributed data to this analysis (per country, in alphabetical order): Austria: Werner Aberer, Department of Dermatology, Medical University of Graz, Graz, Austria (werner.aberer@klinikum-graz.at). Germany: Ulrike Beiteke, Department of Dermatology, Dortmund, Germany (ulrike.beiteke@klinikumdo.de); Peter Frosch, Department of Dermatology, Dortmund and University of Witten/Herdecke, Dortmund, Germany (froschdo@yahoo.de); Thomas Werfel, Medizinische Hochschule Hannover, Department of Immunodermatology and experimental Allergy, Hannover, Germany (werfel.thomas@mh-hannover.de); Peter Elsner, Department of Dermatology and Allergology, University Hospital Jena, Jena, Germany (elsner@derma-jena.de); Detlef Becker, Department of Dermatology, University of Mainz, Mainz, Germany (detlef.becker@unimedizin- mainz.de). Lithuania: Gondinga Sliuziaviciene, Department of Skin and Venereal Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania (gondinga.pabrinkyte@gmail.com). Poland: Marta Kiec-Świerczynska, Department of Dermatology, Nofer Institute of Occupational Medicine, Łódź, Poland (marswier@imp.lodz.pl). Spain: Juan F. Silvestre, Department of Dermatology, Hospital General Universitario de Alicante, Alicante, Spain (silvestre_jfr@gva.es). Inmaculada Ruiz, Department of Dermatology, Complejo Asistencial de León, C/Altos de Nava s/n, León, Spain (iruizgon@saludcastillayleon.es); Pedro Mercader, Dermatology Department, Hospital General Universitario Morales Meseguer, Murcia, Spain (pedromercader@hotmail.com); Virginia Fernández- Redondo, Department of Dermatology, University Hospital Complex, Faculty of Medicine, A Coruña, Santiago de Compostela, Spain (); Juan García-Gavín, Department of Dermatology, University Hospital Complex, Faculty of Medicine, A Coruña, Santiago de Compostela, Spain (juangavin@gmail.com). Switzerland: Jürgen Grabbe, Department of Dermatology, Kantonsspital Aarau, Aarau, Switzerland (juergen.grabbe@ksa.ch); Alexander Navarini, Department of Dermatology, University Hospital Zürich, Zürich, Switzerland (alexander.navarini@usz.ch). This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2021 The Authors. Contact Dermatitis published by John Wiley & Sons Ltd. 186 wileyonlinelibrary.com/journal/cod Contact Dermatitis. 2021;85:186–197. 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LOMAN ET AL. 187 15 Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria 16 Faculty of Medicine and Health Science, Institute of Medical Science, Jan Kochanowski University, Kielce, Poland 17 Department of Dermatology, Nofer Institute of Occupational Medicine, Łódź, Poland 18 Department of Dermatology, University Hospital of Erlangen, University of Erlangen-Nuremberg (FAU), Erlangen, Germany 19 Division of Allergology, Paul-Ehrlich-Institut, Langen, Germany 20 Department of Dermatology-Allergology and Occupational Dermatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands 21 Department of Dermatology, Hospital Universitario la Princesa, Madrid, Spain 22 Department of Dermatology and Allergology, Cantonal Hospital Aarau, Aarau, Switzerland 23 Department of Dermatology and Allergology, University Hospital Jena, Jena, Germany 24 Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland 25 Department of Experimental Dermatology and Cosmetology, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland 26 Dermatologie et vénéréologie FMH, Center Médical d'Epalinges, Epalinges, Switzerland 27 Department of Skin and Venereal Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania 28 Department of Dermatology, Occupational Dermatology, University Hospital Heidelberg, Heidelberg, Germany 29 Division Occupational Medicine, Finnish Institute of Occupational Health, Helsinki, Finland Correspondence Dr. Marie L. A. Schuttelaar, Department of Abstract Dermatology, University Medical Centre, Background: Irritant contact dermatitis (ICD) is caused by the acute locally toxic Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands. effect of a strong irritant, or the cumulative exposure to various weaker physical Email: m.l.a.schuttelaar@umcg.nl and/or chemical irritants. Objectives: To describe the characteristics of patients with ICD in the population patch tested in the European Surveillance System on Contact Allergies (ESSCA; www.essca-dc.org) database. Methods: Data collected by the ESSCA in consecutively patch tested patients from January 2009 to December 2018 were analyzed. Results: Of the 68 072 patients, 8702 were diagnosed with ICD (without concomi- tant allergic contact dermatitis [ACD]). Hand and face were the most reported ana- tomical sites, and 45.7% of the ICD was occupational ICD (OICD). The highest proportions of OICD were found in metal turners, bakers, pastry cooks, and confec- tionery makers. Among patients diagnosed with ICD, 45% were found sensitized with no relevance for the current disease. Conclusions: The hands were mainly involved in OICD also in the subgroup of patients with contact dermatitis, in whom relevant contact sensitization had been ruled out, emphasizing the need for limiting irritant exposures. However, in difficult- to-treat contact dermatitis, unrecognized contact allergy, or unrecognized clinical rel- evance of identified allergies owing to incomplete or wrong product ingredient infor- mation must always be considered. KEYWORDS body site, eczema, epidemiology, irritant contact dermatitis, occupational contact dermatitis, patch testing, RRID:SCR_001905, sensitization 1 | I N T RO DU CT I O N and sensitization profiles of various body parts.1-7 However, results on patients eventually diagnosed with irritant contact dermatitis (ICD) Authors reporting results from the European Surveillance System on from the ESSCA database have not yet been reported. Contact Allergies (ESSCA) database have focused on specific allergens Contact dermatitis is a frequent problem and can negatively or allergen groups, occupational contact dermatitis, polysensitization, affect quality of life.8,9 The two main types are ICD and allergic 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 188 LOMAN ET AL. contact dermatitis (ACD). ICD is caused by the toxic effect of various attributed to the ICD diagnoses stratified for country, where Italy and physical and/or chemical irritants on the skin and includes both acute Lithuania were excluded because of missing data regarding anatomical and chronic manifestations. Acute ICD is often caused by a singular sites (respectively, 87.3% and 69.5% of missing data). In case of multi- toxic event, usually with a strong irritant, whereas chronic ICD is cau- ple consultations during the study period, occurring in a minority of sed by the cumulative exposure to weaker irritants.9 patients, one random consultation per patient was chosen. The exact pathophysiology of ICD is not yet fully elucidated. For the purpose of the present analysis, different patch test prep- There is increasing evidence that tissue damage, followed by an arations of one allergen, such as different concentrations, or TRUE immunological response resulting in the release of pro-inflammatory Test vs pet.- or aq.-based allergens, were regarded as one, as the cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF)-α, mostly slight differences noted between such preparations as activation of dendritic cells and T cells, which stimulate further cyto- reported previously both from the study period3,7 and elsewhere, kine and chemokine production, and eventually cutaneous inflamma- were not considered as possible confounders in this analysis. tion, are involved in ICD.10 For the total of patients patch tested in the study period, the ICD Most irritants that cause ICD are mild to moderate irritants (for case group, and patients who were occupationally active and in whom example water or soap), where repeated and/or prolonged exposure their dermatitis was considered work-related (OICD), the Male, Occu- is needed to cause tissue damage and ICD. However, the threshold pational dermatitis, Atopic dermatitis, Hand dermatitis, Leg dermatitis, concentration or duration may vary significantly from person to per- Face dermatitis, Age ≥40 years (MOAHLFA) index17 and ‘P’ measure son. Whereby, atopic dermatitis (AD), atopic skin diathesis, and (the proportion of patients with at least one positive reaction to the filaggrin gene (FLG) mutations are the most important endogenous risk baseline series) are given.18 11,12 factors for occupational ICD (OICD). A key information analyzed was the anatomical site affected by Although several other papers report results of ICD and, mostly dermatitis. “Primary site”, that is the skin region that is most affected their occupational relation, not much attention is giving to affected or where the current dermatitis started, is used for the “HLF” part of body sites and sensitization profiles in ICD. Furthermore, ICD in such the MOAHLFA index. In patients in whom this was not documented large numbers as the ESSCA database has never been studied before. (n = 20 234), the first site to the first diagnosis was conventionally This study aimed to evaluate the characteristics of patients diagnosed plugged-in; this was the case in n = 18 421 patients. For all other site- with ICD, without concomitant ACD, but with a possible other co- related analyses, in patients with ICD, site information strictly related diagnosis, in the population patch tested at the departments of the to the diagnosis of ICD was utilized. Thereby, figures based on the pri- ESSCA network from 2009 to 2018. mary site used for Table 1 and “site to diagnosis” as used in the remaining tables are not comparable. The anatomical sites strictly related to the diagnosis of ICD in the 2 | METHODS ESSCA were aggregated into 10 body sites. This resulted in the fol- lowing categories: head, face, arm, hand, trunk, anogenital, leg, foot, 2.1 | Study design and population generalized, and other (see Table S2 for the details of this process). As the WINALLDAT/ESSCA software allows documentation of up to three The analysis is based on data collected by the ESSCA network as described anatomical sites to one diagnosis, patients could be classified into sev- previously.13,14 Briefly, clinical and demographic data of all patients who eral different anatomical site categories. The group with generalized were patch tested in the participating departments are documented elec- ICD represents patients with widespread eczema with more than tronically using different data-capture software and partly, the multilingual three major body sites affected. software WINALLDAT/ESSCA provided by the ESSCA.15 Patch testing is done To evaluate OICD, all patients in the case group 16–68 years of 16 according to international recommendations. age, representing persons potentially engaged in working life, with a The case group includes all patients in whom ICD had been diag- documented current occupation were classified into occupational nosed as a first or second diagnosis, excluding patients with an addi- groups (on the 2- or 3-digit level of the International Standard Classifi- tional diagnosis of ACD, whereas AD and other, non-dermatitis co- cation of Occupations version 1988 (ISCO-88)) and in full detail level diagnoses were not an exclusion criterion. Moreover, patients had of occupational classification (mostly on the 4-digit level of the ISCO- been patch tested with a baseline series (European, national, or 88 classification and partly on the 5-digit extensions introduced by departmental). The study period was 2009 to 2018, inclusive ESSCA). In the ESSCA data, the relationship between occupational (10 years). Because the above case definition relies on a certain struc- exposure and contact dermatitis is documented as “yes,” “partial,” ture of the clinical documentation system, with two diagnoses and “no,” and “unknown.” For the present analysis patients with clear or three sites to each of these, only departments using the WINALLDAT/ partial occupational causation (relationship between occupational ESSCA software or the WINALLDAT/IVDK sister software could be exposure and contact dermatitis documented as “yes” or “partial”) included in the present analysis. Thereby, this study included data were defined as cases of OICD. Because the transition from the ISCO from 32 departments in eight European countries: Austria, Germany, version 1988 to version 2008 was only partly made even at the end Italy, Lithuania, Poland, Spain, Switzerland, and The Netherlands of the study period, the coding of the one department using (Table S1), except for the sub analysis about anatomical sites WINALLDAT/ESSCA software having converted to ISCO-08 (Krakow, 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LOMAN ET AL. 189 T A B L E 1 MOAHLFA index and “P” measure for all patients patched tested with a baseline series (European, national, or departmental) from 2009–2018 (overall, n = 68 072), patients with a diagnosis of irritant contact dermatitis (excluding an additional diagnosis of allergic contact dermatitis) (ICD, n = 8702), and the subgroup of patients with irritant contact dermatitis who are occupationally active in whom dermatitis was considered work-related (OICD, n = 3521) n(overall) n = 68 072 % (overall) n(ICD) n = 8702 % (ICD) n(OICD) n = 3521 % (OICD) Male 23 382 34.35 3572 41.05 1698 48.22 Occupational dermatitis 13 563 19.92 3975 45.68 3521 100 Atopic dermatitis 16 170 23.75 2058 23.65 1152 32.72 Site: Hand 19 539 28.70 5509 63.31 3025 85.91 Site: Leg 4010 5.89 302 3.47 36 1.02 Site: Face 9664 14.20 927 10.65 112 3.18 Age 40+ 43 479 63.87 5104 58.65 1912 54.30 “P’ measure 40 285 59.18 3918 45.02 1659 47.12 Abbreviations: EBS, European Baseline Series; ICD, irritant contact dermatitis; MOAHLFA, Male, Occupational dermatitis, Atopic dermatitis, Hand dermatitis, Leg dermatitis, Face dermatitis, Age ≥ 40 years; OICD, occupational irritant contact dermatitis. Note: “P’ measure: the proportion of patients with at least one positive reaction to the baseline series. Poland) were back-transformed to ISCO-88. The catalogue of occupa- the ICD case group included more males, more OICD, and a lower tions used by ESSCA is shown in Table S3. proportion of patients with at least one positive reaction to the base- line series compared to the overall group of patch tested patients. Similarly, lower percentages for previous or current diagnosis of AD 2.2 | Statistical analysis were seen for the ICD case group compared with the overall group (23.7% and 23.8%, respectively), whereas for OICD, a higher percent- For data management, the statistical software R (version 3.6, , RRID:SCR_001905) was used. Beyond descriptive ana- (32.7%). Hand as the primary site of dermatitis was more often reported lyses, log-binomial regression analyses were performed for each of for the ICD group compared to the overall group (respectively, 63.3% the allergens of the European baseline series, with the dichotomous vs 28.7%). In addition, for OICD, the hand was the primary site in 85.9% outcome positive (+, ++, and +++ on day 3 to day 5 inclusive) vs non- of the cases. When looking at the MOAHLFA index stratified for coun- positive patch test reaction. As explanatory factor of interest a diag- try (see Table S4), the highest proportion of males were observed in nosis of ICD vs all other diagnoses was examined in terms of quantify- Germany and The Netherlands (49.4% and 44.7%, respectively) and the ing the risk of a positive patch test reaction by the prevalence ratio lowest proportion of males in Lithuania and Austria (28.8% and 30.4%, (PR) accompanied by a corresponding 95% confidence interval (CI). As respectively). The highest proportion of patients ≥40 years were further adjustment factors, sex, age (dichotomized into <40 vs ≥40) observed in Spain and Germany (63.8% and 63.0%, respectively) and and contributing department were employed. the lowest in Italy (40.5%). In addition, Germany had the highest per- centage (68.5%) of OICD compared with the other countries. 3 | RESULTS 3.2 | Anatomical sites The ESSCA network reported data of 68 072 patients who were patch tested between 2009 and 2018. Altogether, 8702 (12.8%) A more detailed presentation of aggregated anatomical sites involved patients diagnosed with ICD without concomitant ACD, but with a in ICD, stratified for country, is presented in Table 2 (see Table S2 for possible other co-diagnosis, were identified. Furthermore, 20 236 details of this aggregating process). Of note, the overall share of a patients (29.7%) were diagnosed with ACD, without concomitant ICD. missing primary site information, after substitution as described in (See online supplemental figure S6 for the proportion of patients diag- Methods, was n = 1813 (2.7%) and in the ICD case group it was nosed with ICD among all patch tested patients per year). n = 28 (0.3%). In all countries, the hand was clearly the most reported anatomical site that ICD was attributed to, ranging from 36.5% in Spain to 84.7% in Germany. The face was, with 10.6%, the second 3.1 | Clinical and demographic characteristics ranking anatomical site that ICD was attributed to. The most striking differences between countries were between Poland and Germany, In Table 1, the clinical and demographic characteristics of the ICD with the face, trunk, and leg being reported as the most affected sites case group (n = 8702), the overall group of patients (n = 68 072), and in patients with ICD in Poland compared to the other countries the subgroup of ICD patients with OICD (n = 3521) are shown (respectively, 17.9%, 19.6%, and 17.6%), whereas the opposite was according to the MOAHLFA index, including the ‘P’ measure. Overall, seen in Germany (respectively, 5.4%, 2.2%, and 2.4%). When looking 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 190 LOMAN ET AL. at aggregated anatomical sites in patients with a valid occupation and (respectively, 87.3% and 69.5% of missing data). An identical analysis restricted to the patients with irritant contact dermatitis, a valid current occupation, age 16–68, and occupational irritant contact dermatitis T A B L E 2 Aggregated anatomical sites in patients diagnosed with irritant contact dermatitis (excluding an additional diagnosis of allergic contact dermatitis) (ICD), and the proportion of patients Generalized 3 (1.4%) 18 (0.6%) 46 (2.4%) 17 (3.5%) 111 (8.9%) 302 (3.6%) OICD, the hand and arm were the most reported anatomical sites 107 (7%) Note: Note that up to three sites may have been documented and thus there are multiple occurrences of patients. Numbers of “other” sites not shown. Note that because the detailed anatomical sites are recoded to aggregated anatomical sites, the total number of cases is smaller for the aggregated anatomical site than for the detailed anatomical sites (see also Table S2). The group with generalized irritant were OICD was attributed to (respectively, 85.8% and 9.9%) (see Table S5). contact dermatitis represents patients with widespread eczema with more than three major body sites affected. Italy and Lithuania were excluded because of missing data regarding anatomical sites Abbreviations: AT, Austria; CH, Switzerland; DE, Germany; ES, Spain; ICD, irritant contact dermatitis; n, number; NL, The Netherlands; OICD, occupational irritant contact dermatitis; PL, Poland. 152 (12.1%) 4 (1.9%) 105 (6.8%) 45 (2.3%) 26 (5.3%) 422 (5.0%) 90 (3%) 3.3 | Occupational irritant contact dermatitis Foot Further focusing on occupation-related aspects, the ICD case group with irritant contact dermatitis who are occupationally active and in whom irritant contact dermatitis was considered occupation-related (OICD), stratified for country 221 (17.6%) 7 (3.4%) 66 (4.3%) 70 (2.4%) 65 (3.4%) 17 (3.5%) 446 (5.3%) was narrowed to those between 16 and 68 years of age (inclusive) with an actual occupation documented, that is excluding non-formal Leg activities like housewife/−husband. This yielded a subsample size of 6224 individuals, of whom 3521 had OICD. The number of persons Anogenital 3 (1.4%) 118 (7.7%) 41 (1.4%) 26 (1.3%) 6 (1.2%) 35 (2.8%) 229 (2.7%) with ICD per occupational group (ISCO-88 2 or 3-digit level) is shown in Table 3, along with the proportion of OICD. Only occupational groups with >75 cases of OICD were considered for analyses. The highest percentage of OICD was found in the occupations classified 246 (19.6%) 8 (3.9%) 85 (5.5%) 64 (2.2%) 122 (6.3%) 38 (7.8%) 563 (6.7%) as blacksmiths, tool-makers, and related trades workers (84.8%) and Trunk machinery mechanics (82.0%). The lowest percentage of OICD was found in occupations classified as office clerks (9.7%) and teaching professionals (8.6%). Among nursing and midwifery associate profes- 132 (63.8%) 895 (58.4%) 2519 (84.7%) 704 (36.5%) 324 (66.7%) 612 (48.8%) 5186 (61.9%) sionals we found more individuals diagnosed with ICD compared to nursing and midwifery professionals (respectively, 26.4% vs 9.7%). By Hand contrast, when comparing OICD, the proportions were similar (71.7% vs 69.2%). 28 (13.5%) 173 (13.8%) In addition to the large subset of patients analyzed in Table 3, the 243 (8.2%) 109 (5.6%) 38 (7.8%) 699(8.3%) 108 (7%) following special groups were analyzed regarding the share of ICD Arm within each of the groups: (a) retired (defined as age >68, 546 of a total of 8098 in that age group, ie, 6.7%); patients without docu- mented current occupation, being 16–68 years of age (128 of 1839 32 (15.5%) 192 (12.5%) 206 (10.7%) 70 (14.4%) 224 (17.9%) 886(10.6%) 162 (5.4%) without occupation, ie, 7%); unemployed patients (270 of 2027 unem- Face ployed, ie, 13.3%); and patients 15 years of age and younger (120 of 2033 within that age group, ie, 5.9%). A similar analysis focusing on the full detail level of occupational 137 (10.9%) 12 (5.8%) 84 (4.4%) 30 (6.2%) 371 (4.4%) 61 (4%) 59 (2%) classification, that is, the 4-digit level and 5-digit extensions partly Head introduced by ESSCA was done; results are shown in Table 4. The highest proportion of OICD, of all workers with ICD working in this occupation, were found in “Turners (metal)” (89.8%) and “Bakers, 3472 (41.4%) 79 (38.2) 287 (18.7) 2036 (68.5) 444 (23.0) 225 (46.3) 401 (32.0) pastry-cooks, and confectionery makers” (72.4%). The lowest percent- age of OICD was observed in “Building structure cleaners” (34.4%). OICD However, the occupations with the lowest percentage of OICD in this table, have only the lowest percentage among the occupation with at 671 (34.7%) 50 (3.3%) 19 (0.6%) 7 (1.4%) 810(9.7%) least 75 cases of OICD. 0 (0%) 63 (5%) Missing 3.4 | Patch test results 8384(100%) Patch test reactions to the 32 allergens of the European baseline n(ICD) is found in Table S5. 207 486 1533 2974 1931 1253 series (EBS) and prevalence ratios for the subgroup of patients with ICD and for the whole group minus the ICD case group are shown in Country Table 5. Total Patch test positivity to allergens in the EBS among patients with CH DE NL AT ES PL ICD varied from 14.9% (95%CI: 14.13–15.68) for nickel sulfate to 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LOMAN ET AL. 191 T A B L E 3 The absolute and relative proportion of irritant contact dermatitis in the detailed occupational groups (classified on the 2- and 3-digit level of the ISCO-88 classification), and the percentage of occupational irritant contact dermatitis cases among the irritant contact dermatitis ISCO-88 Occupational group n(total) n(ICD) %(ICD) n(OICD) %(OICD) 7220 Blacksmiths, tool-makers, and related trades workers 747 244 32.7 207 84.8 7230 Machinery mechanics and fitters 1006 305 30.3 250 82.0 7310 Precision workers in metal and related materials 292 75 25.7 59 78.7 7120 Building frame and related trades workers 644 147 22.8 112 76.2 7410 Food-processing and related trades workers 601 131 21.8 98 74.8 8210 Metal- and mineral-product machine operators 311 85 27.3 62 72.9 3230 Nursing and midwifery associate professionals 1958 516 26.4 370 71.7 5140 Other personal services workers 1094 179 16.4 125 69 .8 2230 Nursing and midwifery professionals 802 78 9.7 54 69.2 7130 Building finishers and related trades workers 625 126 20.2 87 69.0 6110 Market gardeners and crop growers 437 84 19.2 58 69.0 3220 Modern health associate professionals (except nursing) 1164 243 20.9 160 65.8 9130 Domestic and related helpers, cleaners and launderers 1152 274 23.8 171 62.4 5120 Housekeeping and restaurant services workers 1994 427 21.4 257 60.2 3110 Physical and engineering science technicians 810 137 16.9 79 57.7 2220 Health professionals (except nursing) 1159 187 16.1 101 54.0 7140 Painters, building structure cleaners, and related trades 931 207 22.2 92 44.4 workers 5220 Shop salespersons and demonstrators 1029 126 12.2 50 39.7 5200 Models, salespersons, and demonstrators 657 78 11.9 26 33.3 4200 Customer services clerks 977 207 21.2 24 11.6 4100 Office clerks 6365 444 7.0 43 9.7 2300 Teaching professionals 1051 81 7.7 7 8.6 Note: Only occupations with at least 75 cases of irritant contact dermatitis are shown in the table, ordered by decreasing proportion of occupational irritant contact dermatitis among the workers with irritant contact dermatitis in that group. Workers are defined as patients between 16 and 68 years of age with a documented current occupation. N(total), number of workers in the occupational group patch tested between 2009 and 2018; n(ICD), number of workers diagnosed with irritant contact dermatitis, %(ICD), % of workers diagnosed with irritant contact dermatitis among all the workers tested in the specific occupational group; n(OICD), number of workers diagnosed with occupational irritant contact dermatitis; %(OICD), % of occupational irritant contact dermatitis among all irritant contact dermatitis cases in that group. Abbreviations: ICD, irritant contact dermatitis; ISCO-88, International Standard Classification of Occupations version 1988; n, number; OICD, occupational irritant contact dermatitis. 0.0% (95%CI: 0–0.12) for primin. For the whole group patch tested persons with dermatitis from 32 departments in eight European coun- with EBS minus the ICD case group, positive patch test reactions tries between 2009 and 2018 were diagnosed with ICD, without hav- ranged from 20.7% (95%CI: 20.37–21.03) for nickel sulfate to 0.4% ing concomitant ACD. The frequency of ICD of this study is a little (95%CI: 0.35–0.53) for clioquinol. Overall, as expected, patients diag- higher compared to a smaller single center study, which included nosed with ICD had a lower risk of a positive patch test reaction for patients who were referred for patch testing and reported 215/2321 all the EBS allergens compared to patients with (all) other diagnoses, (9.3%) patients diagnosed with ICD.19 We included ICD with all possi- the PR ranging from 0.1 (95%CI: 0.03–0.50) for mercapto mix to 0.7 ble combinations of other co-diagnoses (except for ACD), whereas (95%CI: 0.69–0.77) for nickel sulfate. the study of Turcic et al. included only solitary ICD. This might explain the higher frequency of ICD in our study. However, generally, the per- centage of ICD in patch tested patients is assumed to be lower com- 4 | DISCUSSION pared to the whole clinical population, the latter including varying proportions of patients with perhaps apparently clear-cut irritant der- This study describes the characteristics, including demographics, ana- matitis who are not suspected to be contact allergic, and thus not tomical sites, occupation, and sensitization profile of patients who patch tested. Moreover, the characteristics of a department may play were patch tested and diagnosed with ICD in the ESSCA database. In a role: In a tertiary referral center, more patients with prolonged this study, we found that 12.8% (n = 8702) of the patch tested course, and perhaps an initial diagnosis of ICD, are patch tested with 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 192 LOMAN ET AL. T A B L E 4 The absolute and relative proportion of irritant contact dermatitis analyzed in occupations (on the 4-digit level of the ISCO-88 classification and 5-digit extensions partly introduced by ESSCA) with at least 75 cases of irritant contact dermatitis, ordered by decreasing proportion of occupational irritant contact dermatitis among all the workers with irritant contact dermatitis in that group ISCO-88 Occupation n(total) n(ICD) %(ICD) n(OICD) %(OICD) Mean age %(males) 72 231 Turners (metal) 254 88 34.6 79 89.8 45.3 88.6 7412 Bakers, pastry-cooks, and confectionery makers 335 76 22.7 55 72.4 31.9 36.8 5141 Hairdressers, barbers, beauticians, and related workers 954 165 17.3 116 70.3 32.8 4.2 3226 Physiotherapists and related associate professionals 367 89 24.3 62 69.7 37.9 14.6 5122 Cooks 744 179 24.1 122 68.2 34.6 40.8 7141 Painters and related workers 378 79 20.9 47 59.5 44.8 55.7 5121 Housekeepers and related workers 322 77 23.9 45 58.4 40.6 9.1 5123 Waiters, waitresses, and bartenders 619 145 23.4 78 53.8 37.7 19.3 2221 Medical doctors 462 88 19.0 42 47.7 36.0 17.0 7143 Building structure cleaners 496 125 25.2 43 34.4 45.3 4.8 Note: Workers are defined as patients between 16 and 68 years of age with a documented current occupation. N(total), number of workers in the occupational group patch tested between 2009 and 2018; n(ICD), number of workers diagnosed with irritant contact dermatitis, %(ICD), % of workers diagnosed with irritant contact dermatitis among all the workers tested in the specific occupational group; n(OICD), number of workers diagnosed with occupational irritant contact dermatitis, %(OICD), % of occupational irritant contact dermatitis among all irritant contact dermatitis cases in that group; mean age and %(males) refers to the patients with occupational irritant contact dermatitis in the respective occupation. Abbreviations: ESSCA, European Surveillance System on Contact Allergies; ICD, irritant contact dermatitis; ISCO-88, International Standard Classification of Occupations version 1988; n, number; OICD, occupational irritant contact dermatitis. T A B L E 5 Positive patch test results to allergens of the baseline series in patients with irritant contact dermatitis and patients with (all) other diagnoses (non-irritant contact dermatitis), on the right the prevalence ratio (PR) with 95% confidence intervals (95%CI) quantifying the in- or decreased risk of a positive patch test reaction in patients diagnosed with irritant contact dermatitis vs non-irritant contact dermatitis diagnoses; additionally adjusted for sex, age (dichotomized at 40 years) and contributing department ICD Non-ICD Risk (ICD) Allergen Tested n (pos.) % (pos.; 95% CI) Tested n (pos.) %(pos.; 95% CI) PR (95% CI) Potassium dichromate 8456 263 3.11 (2.75–3.5) 56 257 2949 5.24 (5.06–5.43) 0.54 (0.47–0.61) Cobalt (II)-chloride 8399 382 4.55 (4.11–5.02) 57 048 4215 7.39 (7.18–7.61) 0.58 (0.52–0.64) Nickel sulfate 8184 1219 14.89 (14.13–15.68) 57 502 11 901 20.7 (20.37–21.03) 0.73 (0.69–0.77) Fragrance mix I 8259 288 3.49 (3.1–3.91) 56 299 4786 8.5 (8.27–8.73) 0.48 (0.43–0.54) Fragrance mix II 8071 185 2.29 (1.98–2.64) 55 203 2771 5.02 (4.84–5.21) 0.53 (0.46–0.62) HICC 8288 86 1.04 (0.83–1.28) 56 284 1110 1.97 (1.86–2.09) 0.53 (0.42–0.67) Myroxolon pereirae (balsam of Peru) 8474 293 3.46 (3.08–3.87) 57 916 4087 7.06 (6.85–7.27) 0.56 (0.50–0.63) Colophonium 8488 142 1.67 (1.41–1.97) 56 467 2016 3.57 (3.42–3.73) 0.50 (0.42–0.59) Propolis 4690 107 2.28 (1.87–2.75) 31 675 1236 3.9 (3.69–4.12) 0.67 (0.54–0.81) Formaldehyde 8482 84 0.99 (0.79–1.22) 57 904 1300 2.25 (2.13–2.37) 0.46 (0.37–0.58) MCI/MI 8404 254 3.02 (2.67–3.41) 57 687 3698 6.41 (6.21–6.61) 0.44 (0.39–0.50) Methylisothiazolinone 4201 143 3.4 (2.88–4) 35 186 2650 7.53 (7.26–7.81) 0.39 (0.33–0.47) Paraben mix 8480 29 0.34 (0.23–0.49) 57 938 483 0.83 (0.76–0.91) 0.44 (0.30–0.65) Quaternium 15 3887 12 0.31 (0.16–0.54) 29 109 315 1.08 (0.97–1.21) 0.26 (0.14–0.46) Methyldibromo glutaronitrile 8541 130 1.52 (1.27–1.8) 57 968 2132 3.68 (3.53–3.83) 0.48 (0.40–0.57) p-Phenylenediamine 4996 73 1.46 (1.15–1.83) 38 448 1622 4.22 (4.02–4.42) 0.35 (0.28–0.45) Benzocaine 2662 7 0.26 (0.11–0.54) 18 926 197 1.04 (0.9–1.2) 0.25 (0.12–0.55) Clioquinol 2056 1 0.05 (0–0.27) 20 691 89 0.43 (0.35–0.53) 0.13 (0.02–0.97) Budesonide 4020 32 0.8 (0.55–1.12) 31 193 317 1.02 (0.91–1.13) 0.62 (0.42–0.90) Tixocortol-pivalate 3999 8 0.2 (0.09–0.39) 38 655 360 0.93 (0.84–1.03) 0.26 (0.13–0.53) Neomycin sulfate 4024 27 0.67 (0.44–0.97) 31 941 469 1.47 (1.34–1.61) 0.36 (0.24–0.53) Thiuram mix 8469 133 1.57 (1.32–1.86) 58 025 1325 2.28 (2.16–2.41) 0.58 (0.48–0.70) 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LOMAN ET AL. 193 TABLE 5 (Continued) ICD Non-ICD Risk (ICD) Allergen Tested n (pos.) % (pos.; 95% CI) Tested n (pos.) %(pos.; 95% CI) PR (95% CI) IPPD 7505 34 0.45 (0.31–0.63) 52 359 489 0.93 (0.85–1.02) 0.44 (0.31–0.63) Mercapto mix (MBT,CBS,MBTS,MOR) 2864 2 0.07 (0.01–0.25) 24 834 191 0.77 (0.66–0.89) 0.12 (0.03–0.50) Mercapto mix (CBS, MBTS, MOR) 6306 24 0.38 (0.24–0.57) 38 591 305 0.79 (0.7–0.88) 0.40 (0.26–0.62) Mercaptobenzothiazole 8495 26 0.31 (0.2–0.45) 58 062 416 0.72 (0.65–0.79) 0.44 (0.29–0.66) Sesquiterpenlactone mix 4074 6 0.15 (0.05–0.32) 30 457 273 0.9 (0.79–1.01) 0.24 (0.11–0.54) Primin 2962 0 0 (0–0.12) 23 613 111 0.47 (0.39–0.57) n.c. Lanolin (wool fat) alcohols 8359 73 0.87 (0.69–1.1) 54 599 1379 2.53 (2.4–2.66) 0.52 (0.41–0.66) Epoxy resin 8010 54 0.67 (0.51–0.88) 56 449 918 1.63 (1.52–1.73) 0.38 (0.29–0.51) PTBFR 6204 31 0.5 (0.34–0.71) 45 191 481 1.06 (0.97–1.16) 0.45 (0.31–0.66) Textile dye mix 479 6 1.25 (0.46–2.71) 4094 168 4.1 (3.52–4.76) 0.27 (0.12–0.60) Abbreviations: CBS, N-cyclohexyl-2-benzothiazyl sulfenamide; CI, confidence interval; HICC, hydroxyisohexyl 3-cyclohexene carboxaldehyde; ICD, irritant contact dermatitis; IPPD, N-isopropyl-N0 -phenyl-p-phenylenediamine; MBT, 2-mercaptobenzathiazole; MBTS, dibenzothiazyldisulfide; MCI/MI, methylchloroisothiazolinone/methylisothiazolinone; MOR, morpholinyl mercaptobenzothiazole; n, number; n.c., not calculable; pos., positive; PR, prevalence ratio; PTBFR, p-tert-butylphenol formaldehyde resin. an extended range of allergens, which increases the likelihood of current population consists of patch tested individuals, and the cur- eventually correctly diagnosing ACD. By contrast, on the level of pri- rent recommendation of the working group of the European Society mary care—not well-represented in our network—the share of actual of Contact Dermatitis is to perform diagnostic patch testing in all ICD, and of patients not patch tested, or patch tested with just a lim- patients with hand eczema with a duration of more than 3 months ited scope of allergens, may be higher, and thus the possibly partly and/or relapse, this could partly explain the high percentage of hand erroneous diagnosis of ICD be made more often. involvement in ICD.23 The high prevalence of ICD of both the hands A variability in individual thresholds, and thereby the susceptibil- and face could be explained by the higher amount of exposure to irri- ity of developing ICD, is known to be an important endogenous fac- tants to these body regions, especially for the hands. In a population- tor. Some individuals develop ICD following exposure to relatively based study on exposure to irritants among 2128 patients with occu- low levels or short duration of exposure to irritants, whereas others pational skin disease (OSD), the most frequently mentioned irritant tolerate much higher or longer exposures without skin complaints. In was work-related exposure to detergents (52%, in a nonspecific distri- previous studies, sodium lauryl sulfate (SLS) was applied to the upper bution for all occupational groups), which are mostly used on the outer arm of volunteers at different concentrations, and a variability hands.24 In addition, wet work is known to be one of the most com- 20,21 in the threshold irritant response was seen. An important mon triggers of ICD and almost always involves the hands.25 For the predisposing factor of developing OICD is AD.11 The higher suscepti- face, exposure to cosmetic products and detergents could play a role bility of OICD in AD is attributed to an impaired skin barrier with in developing ICD. Recently, a 22-year retrospective cross-sectional higher transepidermal water loss and easier percutaneous penetration analysis including 1332 male patients with facial dermatitis identified with higher diffusivity of irritants, even in non-involved AD skin.22 In cosmetic products as the most common source of ICD, including both this study, similar percentages for a history or current diagnosis of AD rinse-off and leave-on products (27.2%).26 Factors possibly contribut- were seen for both the ICD case group and the overall patch tested ing to a higher susceptibility of the exposed skin are, among others, group (23.7% and 23.8%, respectively). The increased risk of OICD in the thickness of the stratum corneum and absorption ability of the patients with AD is confirmed in the current study.11 Higher percent- skin, which both vary considerably depending on anatomical site. This ages for a history or current diagnosis of AD in the OICD group com- might particularly play a role in facial skin, as facial skin has the pared to the overall and the ICD group were seen. This might be smallest number of cell layers of stratum corneum and the greatest explained by the greater exposure to irritants in an occupational set- absorption capacity compared to other anatomic sites such as the ting, perhaps with mandatory use of occlusive personal protective trunk, extremities, and palms and soles.27,28 As a result, a lower equipment and per-protocol hygiene measures, compared to non- threshold for developing ICD on the face induced by the same amount occupational settings. of exposure compared to other body regions can be assumed. Palmar skin has almost the largest number of cell layers of the stratum cor- neum, so that exogenous factors, like frequency of exposure, will play 4.1 | Anatomical sites a larger role in this anatomical site compared to the thickness of the stratum corneum. Previously, an ESSCA study was performed on body The hand and face, with respectively, 61.9% and 10.6%, were the sites in patients with ACD, which included cases with a minimum of most frequently reported anatomical sites for ICD. Because the one positive patch test reaction to the EBS and a final diagnosis of 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 194 LOMAN ET AL. ACD attributed to only one body site. The head (including the face) midwifery associate professionals on the other. The overall prevalence and hand were the most reported anatomical sites for ACD (respec- of ICD was much lower in the former group compared to the latter 5 tively, 30.5% and 29.6%). In a smaller retrospective study of group (respectively, 9.7% vs 26.4%). However, both occupational 353 patients with contact dermatitis (ACD or ICD), the face (25%) and groups had comparable results regarding the relative proportion of the hands (19%) were also the most frequently affected areas.29 OICD (respectively, 69.2% and 71.7%). This discrepancy could be Because exposure is the causative factor, and products applied to the explained by differences in job tasks, and thereby the level of occupa- face and hands contain either irritants or allergens, or both, these ana- tional exposure between these two occupational groups. It is possible tomic regions prevail in both ICD and ACD. When stratifying for that nurses and midwifery professionals are more often involved in country, the highest percentage of patients with ICD attributed to the administrational tasks compared with nurses and midwifery associate hand was seen in Germany (84.7%) and the lowest percentages were professionals who are more often involved in, for example, wet work. seen for Spain (36.5%) and Poland (48.8%). This difference might be If, however, the nursing professionals had developed ICD, it was as explained partly by the low percentages of OICD in Spain and Poland commonly OICD as in the associate professionals. (23.0% and 32.0%) in contrast to the highest percentage of OICD in Germany (73.5%), whereby in OICD the hands are more often involved compared with non-OICD. In addition, when looking at 4.3 | Sensitization pattern OICD, the hand was the most commonly reported anatomical site for OICD in Germany (95.4%) and the least reported anatomical site for When comparing patients diagnosed with ICD to the group containing OICD in Poland (55.1%). Another explanation for the high frequency all other diagnoses, the sensitization pattern is very similar and largely of OICD in Germany might be the billing system of patch testing in overlapping when looking at the most common contact allergies in Germany. In Germany, patients with suspected OSD are more often both groups. The highest prevalence of positive patch test reactions patch tested, since remuneration for the patch test is by the state was seen to metals and fragrances, which have also often been seen accident insurance instead of the general health insurance covering in both the clinical population3 and the general population.32 30 non-OSD. Other frequently reported anatomical sites in both ICD Overall, the proportion of ICD patients with at least one positive and OICD in Poland included the face, trunk, and leg. Another possible reaction to the EBS was 45.0%. This is higher compared to the general explanation might be that farmers are still a relatively large occupa- population in Europe. A cross-sectional study of 3119 patch tested tional group in Poland. Farmers are more likely to develop airborne persons from the general population in Europe showed that 27.0% dermatitis, for example, during harvest activities, especially during had a positive reaction to at least one allergen of the EBS.32 Approxi- summer months when wearing less- protective clothing. mately two to six times higher percentages were seen for the 10 aller- gens with the highest prevalence in the ICD case group compared to the general population. Per definition, as an additional diagnosis of 4.2 | Occupation-related ICD ACD was excluded, all the positive reactions to the EBS in the ICD group had to be non-relevant for the current skin disease. These con- ICD is often mentioned as a frequent OSD.31 In the present study, tact allergies could have been relevant in the past for other skin dis- 45.7% of the ICD was OICD. A previous study using data of the eases at other body parts, or have become non-relevant for the ESSCA database, with a partial overlap to the current period of analy- current problem due to avoidance. sis of 2 years, only analyzing patients with occupational contact der- ICD is thought to predispose to the induction of skin sensitiza- matitis, included 10 617 patients between 16 and 68 years of age. Of tion.33 According to the available human evidence for the impact of these, 28.7% had ICD, 35.3% ACD, and 10.7% had both ACD and irritation on the elicitation of ACD, irritants lower the threshold elici- ICD. High percentages of OICD were found in waiters, waitresses, tation concentration for allergens.34 However, human evidence on and bartenders (47.6%), bakers, pastry cooks, and confectionery the impact of irritants on the induction phase of ACD is limited due to makers (40.5%) and nursing and midwifery professionals (34.9%).1 ethical considerations. In animal models it was demonstrated that the A population-based study, including data of 5285 workers' com- presence of 5% SLS approximately doubled the rate of induction of pensation claims reported to a register of OSD, identified occupa- sensitization from 38% to 78% to p-phenylenediamine in guinea tional groups at risk for ICD.24 The highest incidence rates for OICD pigs.35 One study assessing 25 human volunteers demonstrated that were found in hairdressers, bakers, and pastry cooks and ICD was the pre-treatment of the skin with SLS increased the frequency of induc- main diagnosis of OSD in pastry cooks (76%), cooks (69%), food- tion of sensitization from 8% to 54% compared to control skin.36 Irri- processing industry workers and butchers (63%), mechanics (60%), tants seem to lower the threshold for induction of sensitization by and locksmiths and automobile mechanics (59%). As the study did not inducing inflammation and increasing permeability of the horny layer. use the same occupational group classification, a direct comparison The predisposition to skin sensitization conveyed by irritants has been for all the occupational groups is not possible. However, overlap outlined previously as the “danger model,” in which an antigenic signal based on job title is certainly conceivable. will produce sensitization only in the presence of a danger signal In the current study, a remarkable difference in results was found (in ICD the activation of the innate immune system), and in the for nursing and midwifery professionals on one hand, and nursing and absence of a danger signal, tolerance will occur.34 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LOMAN ET AL. 195 4.4 | Limitations AUTHOR CONTRIBU TIONS Laura Loman: Conceptualization; data curation; investigation; meth- A limitation of our study is that the type and amount of exposure to odology; project administration; resources; validation; visualization; irritants is not systematically documented in the ESSCA database. An writing-original draft; writing-review & editing. Wolfgang Uter: Con- extended documentation on irritant exposure for hand dermatitis has ceptualization; formal analysis; methodology; project administration; been proposed previously to, partly, overcome this problem in the resources; software; visualization; writing-original draft; writing- 37 future. Another limitation is that the current and past relevance of review & editing. José Armario-Hita: Data curation; investigation; pro- individual positive patch test reactions to the current dermatitis was ject administration; resources; validation; visualization; writing- not documented. However, this would be a limitation for studies review & editing. Fabio Ayala: Data curation; investigation; project addressing ACD, whereas a lack of current clinical relevance to a diag- administration; resources; validation; visualization; writing-review & nosed contact allergen is in line with an exclusive diagnosis of ICD editing. Anna Balato: Data curation; investigation; project administra- defining our study sample. Furthermore, to date, no definite common tion; resources; validation; visualization; writing-review & editing. diagnostic criteria for ICD are available, thus a considerable country- Barbara Ballmer-Weber: Data curation; investigation; project adminis- to-country, center-to-center, and doctor-to-doctor variability has to tration; resources; validation; visualization; writing-review & editing. be taken in to account. Andrea Bauer: Data curation; investigation; project administration; In conclusion, the hand and face were the most reported anatomi- resources; validation; visualization; writing-review & editing. Andreas cal sites for ICD, and the hands were mainly involved in OICD. Almost Bircher: Data curation; investigation; project administration; half of the patients with ICD had OICD. Furthermore, almost half of resources; validation; visualization; writing-review & editing. Timo the patients diagnosed with ICD had at least one contact sensitization, Buhl: Data curation; investigation; project administration; resources; with a similar sensitization pattern compared to the group containing validation; visualization; writing-review & editing. Magdalena all other diagnoses, albeit on a (much) lower level of relative fre- Czarnecka-Operacz: Data curation; investigation; project administra- quency, if PRs are considered. The focus of prevention of ICD should tion; resources; validation; visualization; writing-review & editing. include the identified high-risk occupations, with special attention Heinrich Dickel: Data curation; investigation; project administration; given to exposure to the hands. In addition, in difficult-to-treat con- resources; validation; visualization; writing-review & editing. Thomas tact dermatitis, unrecognized contact allergy, or unrecognized clinical Fuchs: Data curation; investigation; project administration; resources; relevance of identified allergies owing to incomplete or wrong prod- validation; visualization; writing-review & editing. Ana Giménez- uct, ingredient information must always be considered. Further Arnau: Data curation; investigation; project administration; resources; research should focus on the type and duration of exposure to differ- validation; visualization; writing-review & editing. Swen Malte John: ent kinds of irritants in individuals with ICD to gain more insight into Data curation; investigation; project administration; resources; valida- the exposure patterns and identify further leads in the prevention tion; visualization; writing-review & editing. Birger Kränke: Data of ICD. curation; investigation; project administration; resources; validation; visualization; writing-review & editing. Beata Krecisz: Data curation; CONF LICT OF IN TE RE ST S investigation; project administration; resources; validation; visualiza- There was no funding. W.U. has accepted a honorarium for a presen- tion; writing-review & editing. Vera Mahler: Data curation; investiga- tation from mixed dermatopharmaceutical sponsors. T.R. has accepted tion; project administration; resources; validation; visualization; honoraria for presentations from several pharmaceutical companies. writing-review & editing. Thomas Rustemeyer: Data curation; investi- The other authors have no conflicts of interest to report. gation; project administration; resources; validation; visualization; writing-review & editing. Anna Sadowska-Przytocka: Data curation; A U T H O R CON T RIB U T I O N ( CR ed i T ) investigation; project administration; resources; validation; visualiza- • Conceptualization: W.U., M.L.A.S., L.L.: (equal), M.P.(supporting) tion; writing-review & editing. Javier Sanchez-Perez: Data curation; • Data curation: all others except W.U.: (equal) investigation; project administration; resources; validation; visualiza- • Formal analysis: W.U. (lead) tion; writing-review & editing. Kathrin Scherer Hofmeier: Data • Funding acquisition: – curation; investigation; project administration; resources; validation; • Investigation: all others except W.U.: (equal) visualization; writing-review & editing. Sibylle Schliemann: Data • Methodology: W.U., M.L.A.S., L.L., M.P.: (equal) curation; investigation; project administration; resources; validation; • Project administration: all authors (equal) visualization; writing-review & editing. Dagmar Simon: Data curation; • Resources: all authors (equal) investigation; project administration; resources; validation; visualiza- • Software: W.U. (lead) tion; writing-review & editing. Radoslaw Spiewak: Data curation; • Supervision: – investigation; project administration; resources; validation; visualiza- • Validation: all others except W.U.: (equal) tion; writing-review & editing. Philipp Spring: Data curation; investiga- • Visualisation: all authors (equal) tion; project administration; resources; validation; visualization; • Writing – original draft: L.L. (lead), M.L.A.S, W.U, M.P (supporting) writing-review & editing. Skaidra Valiukeviciene: Data curation; • Writing – review & editing: all authors (supporting) investigation; project administration; resources; validation; 16000536, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cod.13833 by Readcube (Labtiva Inc.), Wiley Online Library on [10/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 196 LOMAN ET AL. visualization; writing-review & editing. Nicola Wagner: Data curation; 9. Bains SN, Nash P, Fonacier L. Irritant contact dermatitis. Clin Rev investigation; project administration; resources; validation; visualiza- Allergy Immunol. 2019;56(1):99-109. https://doi.org/10.1007/ s12016-018-8713-0 tion; writing-review & editing. Elke Weisshaar: Data curation; investi- 10. Lee HY, Stieger M, Yawalkar N, Kakeda M. Cytokines and chemokines gation; project administration; resources; validation; visualization; in irritant contact dermatitis. Mediators Inflamm. 2013;2013:916497. writing-review & editing. Maria Pesonen: Conceptualization; data https://doi.org/10.1155/2013/916497 curation; investigation; methodology; project administration; 11. Visser MJ, Landeck L, Campbell LE, et al. Impact of atopic dermatitis and loss-of-function mutations in the filaggrin gene on the develop- resources; validation; visualization; writing-original draft; writing- ment of occupational irritant contact dermatitis. Br J Dermatol. 2013; review & editing. Marie Schuttelaar: Conceptualization; data curation; 168(2):326-332. https://doi.org/10.1111/bjd.12083 investigation; methodology; project administration; resources; valida- 12. Dickel H, Bruckner TM, Schmidt A, Diepgen TL. Impact of atopic skin tion; visualization; writing-original draft; writing-review & editing. diathesis on occupational skin disease incidence in a working popula- tion. J Invest Dermatol. 2003;121(1):37-40. https://doi.org/10.1046/j. 1523-1747.2003.12323.x DATA AVAI LAB ILITY S TATEMENT 13. ESSCA Writing Group. The European surveillance system of contact The data that support the findings of this study are available from the allergies (ESSCA): results of patch testing the standard series, 2004. corresponding author upon reasonable request. J Eur Acad Dermatol Venereol. 2008;22(2):174-181. https://doi.org/ 10.1111/j.1468-3083.2007.02359.x 14. Uter W, Aberer W, Armario-Hita JC, et al. Current patch test results ORCID with the European baseline series and extensions to it from the Laura Loman https://orcid.org/0000-0003-2731-9284 “European surveillance system on contact allergy” network, Wolfgang Uter https://orcid.org/0000-0002-4498-3710 2007-2008. Contact Dermatitis. 2012;67(1):9-19. https://doi.org/10. Andrea Bauer https://orcid.org/0000-0002-4411-3088 1111/j.1600-0536.2012.02070.x 15. Uter W, Arnold R, Wilkinson J, et al. A multilingual European patch Andreas J. Bircher https://orcid.org/0000-0002-6683-3975 test software concept: WinAlldat/ESSCA. 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