Occupational and Environmental Medicine 1994;51:689-692

Occupational hand dermatoses of hairdressers inTainan City

Yueliang Leon Guo, Bour-Jr Wang, J Yu-Yun Lee, Shu-Yuan Chou

AbstractObjectives-To determine the preva-lence, clinical features, and patterns ofhand dermatosis in hairdressers inTainan, Taiwan, and to examine theassociations between patterns of der-matosis and risk factors such as jobdescription, work exposure, and sensiti-sation to common allergens.Methods-Interviews, examinations, andpatch tests of the hairdressers from ninehairdressing stores randomly selectedfrom Tainan City. Patch test agentsincluded 41 substances with commonallergens, shampoo preservatives, hairdyes, permanent waving and bleachingagents.Results-98 hairdressers finished theexamination, 83% of them had occupa-tional dermatosis and 32% had scissorinduced scars or wounds. Most of thedermatoses belonged to either dry meta-carpophalangeal dermatitis or eczema ofthe fingers. 44% of the hairdressersshowed positive skin reaction to one ormore patch test agents. The patch testresults were different from previousreports in that the most common aller-gens were nickel, thimerosal, Captan,Kathon CG, and fragrance mix, and thatthe sensitivity to hair dye and permanentwave ingredients were low. The drymetacarpophalangeal dermatitis wasassociated with exposure to shampoo,and the eczema of the fingers with skinsensitivity to patch test agents.Conclusion-Hairdressers in Tainan Cityhad a high prevalence of dermatosesincluding traumatic wounds, and allergicand irritant contact dermatitis. The ratesof sensitivity to some of the commonsensitising agents were different fromprevious reports.

(Occup Environ Med 1994;51:689-692)

Keywords: occupational dermatitis, hairdressers, patchtests

Occupational hand dermatosis among hair-dressers has been recognised as a significanthealth concern.1-3 The dominant occupationalskin disorder for hairdressers is contact der-matitis of both irritant and allergic types.Irritant dermatitis is mostly attributed to wetwork and exposure to shampoos. Nickel,formaldehyde, fragrance, rubber additives,

ammonium thioglycolate, and p-phenylene-diamine and its related agents have been iden-tified as the common allergens in thisoccupation.45 Cronin reported two main pat-terns of hand dermatitis in hairdressers: thedry irritant metacarpophalangeal (MP) jointpattern, and eczema of the fingers.6 The asso-ciation between these dermatoses and sensi-tivity to common allergens is not understood,although it has been suggested that the MPtype was likely to be associated with wet workand contact with shampoo.2

In Taiwan, the hairdressers usually worklonger hours than in western countries. Onewould expect hand dermatosis to be a signifi-cant health problem among Taiwan's hair-dressers, but the actual statistics are lacking.In this study, we examined the prevalence,clinical features, and patterns of hand der-matoses in hairdressers in Tainan city,Taiwan. Associations between patterns of der-matosis and risk factors such as job descrip-tion, work exposure, and sensitisation tocommon allergens were investigated.

Subjects and methodsWe visited nine randomly selected hairdress-ing shops with at least 10 workers in TainanCity. After obtaining their informed consent,the hairdressers were interviewed for theircurrent job description, work exposure, workhistory, medical history, and factors associ-ated with skin problems-for example,pierced ears. Skin examination was performedby a dermatologist and photographs of handswere taken. Severity of dermatological signswere graded according to the following crite-ria: mild if there was any presence of thicken-ing or scaling of the skin; moderate if therewas erythema, itching, or hyperpigmentationassociated with thickening: and severe if therewas oedema, vesicles, fissures, or notable ery-thema. The photographs were later reviewedblind for skin manifestations and patterns ofdermatitis. The dermatitis was categorisedinto two types: dry irritant dermatitis of theMP joint areas with lichenification or scaling(MP type); and eczematous dermatitisespecially that involved the fingers, but sparedthe MP areas. Most of the MP type dermatitisinvolved the dorsal more than the palmarsurface.

Allergens from the standard tray and hair-dressers tray including shampoo preservatives,hair dyes, and their related agents, and per-manent waving and bleaching agents(Chemotechnique Diagnostic AB, Sweden)

Department ofEnvironmental andOccupational HealthY L GuoDepartment ofDermatologyB-J WangJ Y-Y LeeCenter forOccupational Health,National Cheng-KungUniversity MedicalCenterY L GuoB-J WangS-Y ChouDepartment ofDermatology,Provincial Chia-YiHospitalB-J WangCorrespondence to:Dr Y L Guo,Department of Occupationaland Environmental Health,National Cheng-KungUniversity Medical College,61 Shiao Tong Roed,Tainan 70428, Taiwan,Republic of China.Accepted 22 June 1994

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were used for patch testing. The test agentswere applied to Finn chambers (Epitest,Helsinki, Finland) which were fixed to theupper back with Scanpor tape and secured by3M tape. The patches were removed after 48 hand the sites were examined for evidence of areaction at 48 and 72 h after initial applica-tion.7 The reading at 72 h was consideredpositive if the reaction was equal to or

Table I Work description of the 98 hairdressers

Stylists Apprentices

Work duration (h/week):Full time 73 67 (1-26) (n = 33) 73-56 (1-37) (n = 57)Part time 11-50 (0 50) (n = 3) 8-80 (3-35) (n = 5)

Full time workers (h/week):Shampooing 0 01 (0 01) (n = 33) 15-07 (1-10) (n = 57)Waving 6-86 (1 91) 12-56 (3 26)Dyeing 0-14 (0-07) 0-43 (0 11)Cutting 8-85 (1-66) 0Cosmetic work 0-15 (0-15) 0Blow drying 21-93 (2-47) 7-61 (1-32)

Reported time wearing gloves at work (%):Shampooing 0 3-7 (1 9)Waving 2-9 (1-7) 1-6 (1-6)Dyeing 17-1 (6 5) 30-6 (5 9)Cutting 0 NACosmetic work 0 NABlow drying 0 0

Results are expressed as means (SEM).NA = not applicable because apprentices were not involved in dyeing or cutting.

Table 2 Severity of dermatitis and presence ofscars instylists and apprentices

Apprentces Stylists Total(n (%)) (n (%)) (n (%))

Dermatitis*:Absent 1 (1-6) 15 (41-7) 16 (16-3)Mild 18 (29 0) 11 (30 6) 29 (29 6)Moderate 42 (67 7) 9 (25 0) 51 (52 0)Severe 1 (1-6) 1 (2-8) 2 (2-0)

Web scarst:(-) 60 (96 8) 7 (19-4) 67 (68 4)(+) 2 (3 2) 29 (80 6) 31 (31-6)

Total 62 36 98

*P < 0 0001 apprentices had more severe dermatitis, by x2 test.t P < 0-0001 stylists had more scars in the web between theindex and middle fingers, by X 2 test.

Figure 1 Scissor induced wounds.

stronger than a palpable erythema. The datawere analysed by descriptive statistics, analy-sis of variance, and X2 test with the SASpackage.

ResultsThere were 108 hairdressers enrolled in thisstudy. Among them, 10 did not return forexamination either at 48 or 72 h and wereexcluded from the final analysis. This resultedin 98 subjects in the complete data analysis.The 98 subjects consisted of 15 men and 83women. The median age was 19 years,median duration of work was 24 months, andmean duration of work was 39 months.Among the 98 subjects, 36 were stylists and62 were apprentices. The mean (range) dura-tion for an apprentice to become a stylist was27 (9-64) months. Table 1 shows theirwork descriptions. Full time hairdressersworked long hours, on average 73-7 h forstylists and 74-4 h for apprentices perweek. The main duties of the stylists were cut-ting, blow drying, and waving whereas theapprentices do shampooing, waving, blowdrying, and dyeing. Hairdressers used glovesinfrequently.Hand dermatitis was seen in 82 subjects.

The duration of the skin lesions persisted for>1 year in 60% and <1 year in 40% of thecases. Dermatitis seemed to be more severe inthe apprentices than in the stylists (table 2). Aunique manifestation was trauma inducedwounds or scars over the web between theindex and middle fingers of the non-dominanthand (fig 1) due to cuts from scissors duringhair cutting (fig 2). The stylists had signifi-cantly more web scars than did the appren-tices (table 2).

Table 3 shows the results of patch testsfor the 98 subjects. None of the 98 subjectshad skin sensitivity to hydrogen peroxide,hydroquinone, chloroacetamide, 2-bromo-2-nitropropane-1,3-diol, 4-chloro-3-cresol, imi-dazolidinyl urea, quaternium 15, zincpyrithione, lanolin, benzocaine, p-amino-benzoic acid, p-tert-butylphenol formalde-hyde resin, and toluenesulphonamideformaldehyde resin. Forty three hairdressersreacted to at least one allergen tested, and 27reacted to at least one non-nickel allergen.The prevalence of positive skin tests was notdifferent between stylists and apprentices.Previously pierced ears seemed to be a majorrisk factor for developing nickel sensitivity(table 4).Among the 82 hairdressers with dermatitis,

cleaning agents were reported by 51 individu-als as the aggravating factor for their symp-toms. Fifty seven of the 82 individuals withdermatitis reported worst symptoms duringthe winter. Seventy seven of the 98 subjectsthought that the skin problems were relatedto work exposure. Shampooing (42/62) wasconsidered by most apprentices to be thecause of skin diseases, then perm (10/62), hotwater burns (3/62), and a scissor cut (1/62).Scissor cuts were considered to be the mostimportant cause of skin problems by 12/36

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Occupational hand dermatoses of hairdressers in Tainan City

stylists, then shampooing (7/36), and perm(3136).Among the 82 subjects with hand dermati-

tis, MP type eruption was identified in 56subjects and eczema of the fingers in 20. Noclear pattern was identified in the remainingsix cases. Apprentices had more dermatitis ofboth MP type and eczema of the fingers than

Figure 2 Position of the non-dominant hand during hair cutting.

Table 3 Patch test results (n = 98)

Concentration(%/w/w)

4-Phenylenediamine dihydrochloridep-Toluenediamine sulphatep-AminodiphenylamineResorcinol3-Aminophenol4-AminophenolAmmonium thioglycolateGlyceryl monothioglycolateAmmonium persulphateNickel sulphateFormaldehydeKathon CGCaptanHexachlorpheneParabensBalsam of PeruFragrance mixColophonyBlack rubber mixMercapto mixThiuram mixCarba mix

0 51.01-01-01-01-02-51-02-55-01-00-020*51-0

15-025-08-0

20-00-62-01-03 0

PositiveSolvent reactions

pet 3pet 0pet 0pet 1pet 2pet 0aq 2aq 2pet 1

pet 22aq 3aq 5pet 6pet 1

pet 2pet 1

pet 5pet 1

pet 1

pet 1

pet 0pet 0

Solvent was petroleum (pet) or water (aq).

Table 4 Association between job type, pierced ears, and patch test results

Job type (n (%O))* Pierced ears (n (0o))tApprentices Stylists - + Total

Sensitivity to nickel:_ 48 (77 4) 28 (77 8) 49 (89 1) 27 (62 8) 76+ 14 (22-6) 8 (22 2) 6 (10 9) 16 (37 2) 22

Sensitive to non-nickel allergen:- 45 (72-6) 26 (72 2) 39 (70 9) 32 (74 4) 71+ 17 (27 4) 10 (27-8) 16 (29-1) 11 (25-6) 27

Total 62 36 55 43 98

*Apprentices and stylists had essentially the same results in sensitivity to nickel (P - 097) andsensitivity to non-nickel allergen (P = 0-93).tThose with pierced ears had a higher prevalence of sensitivity to nickel (P = 0-002) but not tonon-nickel test agents (P = 0 70).

stylists (P < 0-0001). The prevalence of skinsensitivity to the patch agents was similar inhairdressers with MP type dermatitis andthose with no dermatitis. All of those witheczema of the fingers, however, had skin sensi-tivity to at least one test agent. The MP typeskin lesions were associated with time perweek spent shampooing, but eczema of thefingers was not.Of the 98 cases, 13 had either atopic der-

matitis, allergic rhinitis or asthma, and wereconsidered to be atopic. Of the 13 atopic hair-dressers, 10 (76-9%) had MP type dermatitisand two (15-4%) had eczema of the fingers.Of the non-atopic hairdressers, 58-2% hadMP dermatitis and 22-8% had eczema of thefingers. Severity of dermatitis, MP dermatitis,and eczema were not significantly differentbetween atopic and non-atopic hairdressers.

DiscussionIn this cross sectional study we found a highprevalence of hand dermatoses in hairdressersin Tainan City. The prevalence was higheramong apprentices than stylists. When der-matitis was categorised into the MP jointpattern and eczema of the fingers, moreapprentices (69 4%) than stylists (36- 1 %) hadMP type dermatitis (P = 0 0007); but similarproportions of apprentices (22 6%) and styl-ists (16-7%) had eczema of fingers (P = 0-46).The MP type dermatitis was associated withlonger hours of shampooing and might havebeen caused by chronic irritation to the skin ofthe MP area and infrequent use of protectivegloves (table 1). An allergic aetiology wasstrongly implicated in the hairdressers witheczema of the fingers because positive patchtests were consistently found, although sub-jects with skin sensitivity to the patch testagents also presented with no skin problemsor MP type dermatitis. Whether MP typedermatitis could be caused by contact withskin allergens remains unknown. It was con-ceivable, however, that some subjects withboth MP type dermatitis and positive skintests were caused by irritation rather thansensitisation.

In this investigation, we did not find theinflamed interdigital papules in the fingerwebs of hairdressers secondary to handlinghair. Eighty one per cent of our stylists, how-ever, were found to have scissors inducedscars or wounds at the web between the indexand middle fingers of the non-dominant hand.This was a unique manifestation that had notbeen described previously, and was caused bythe common practice of holding the hair inthe non-dominant hand between the secondand third fingers and cutting it with the scis-sors in the dominant hand.The common allergens reported among

hairdressers include nickel,4 p-phenylene-diamine,5 8 glyceryl monothioglycolate,9 sham-poo preservatives such as formaldehyde,'ammonium thioglycolate,"° and rubber addi-tives.3 In this study, 43/98 hairdressers hadpositive reactions to one or more allergens.The prevalence of allergic reactions to the test

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Guo, Wang, Lee, Chou

agents was not different between the appren-tices and the stylists (table 4). The commonallergens in our subjects were nickel (22%),Captan (6%), Kathon CG (5%), and fra-grance mix (5%). The prevalence of sensitiv-ity to nickel in hairdressers varied much, from8-67% in different centers, and was depen-dent on the population studied." We foundthat similar to a previous finding pierced earswas a major risk factor for nickel sensitivity.'2

Kathon CG and Captan were also impor-tant allergens in our study. Little information isavailable about their sensitivity rates amonghairdressers. Captan was used in the past inshampoos. It was banned as a pesticidebecause of carcinogenicity. Its current use as ashampoo additive in Taiwan is unknown.Further investigation to elucidate the cause ofthis sensitivity is warranted. Kathon CG wasintroduced in 1977 as a biocide. It is used inindustry and also cosmetics. Studies from sev-eral contact dermatitis clinics in Europe3 "4showed a sensitivity rate ofKathon CG varyingfrom 1 1-6-1%. The highest of these ratesmight reflect large amounts of Kathon CGused in some countries.'5

Five of our hairdressers were reactive to fra-grance mix. These results were not differentfrom previous reports. The sensitivity rate toformaldehyde, a preservative in many sham-poos, was also similar to a previous report.'

Taiwanese people dye their hair less fre-quently, as reflected by a short exposure timein our subjects to hair dyes (8 min/week onaverage for stylists and 26 for apprentices).Only 3/98 in this group of hairdressers weresensitive to p-phenylenediamine, a primaryintermediate in hair dyes, and none wassensitive to either of the p-phenylenediaminederivatives (p-toluenediamine sulphate orp-aminodiphenylamine) compared with 15%,8%, and 4% in an European series.'6 The rateof sensitivity to another component of hairdyes, 3-aminophenol, was also low comparedwith 3F 1-25% in previous studies.'

Sensitivity rates to rubber additives, blackrubber mix (1/98), mercapto mix (1/98),carba mix (0/98), and thiuram mix (0/98)were very low. This could be attributed to theuncommon use of gloves at work in our sub-jects (table 2). Glyceryl monothioglycolateand ammonium thioglycolate, the permanentwaving ingredients, caused quite variable ratesof sensitivity among hairdressers.'41017 Oursubjects had low rates of sensitivity to thesetwo chemicals.

Atopic subjects are more prone to develop-ing irritant contact dermatitis.'8 In this investi-gation, atopic subjects had a non-significanthigher percentage ofMP type dermatitis.

It is possible that those workers who weremost sensitive to irritants or allergens in hair-dressing tended to leave the occupation ear-lier, and we only saw the healthierhairdressers. In those with more severe der-matitis, the average work duration wasshorter. There were few hairdressers withmoderate or severe dermatitis who worked for

>4 years in this group. We therefore mighthave underestimated the overall prevalenceand severity of skin diseases in hairdressers inthis investigation. Further investigation withprospective follow up is important to deter-mine the risk of developing dermatitis or sensi-tivity in hairdressers.

ConclusionThe present study of 98 hairdressers inTainan showed a high incidence (95%) ofoccupational hand dermatoses. Three- pat-terns of skin problems were found: MP pat-tern dermatitis, eczema of the fingers, andscissor induced trauma. MP pattern dermati-tis was found mainly -in the apprentices. Theyhad dry, lichenification, and scaling over themetacarpophalangeal joint associated withtime of shampooing. Eczema of the fingerswas found in the stylists and apprentices andwas associated with sensitivity to the commonallergens. The patch test results were differentfrom previous reports in that the most com-mon allergens were nickel, Captan, KathonCG, and fragrance mix, and that the rates ofsensitivity to hair dye and permanent waveingredients were low.

The Center for Occupational Health is sponsored jointly byNational Cheng-Kung University Medical College andDepartment of Health, Taiwan, Republic of China. Weexpress our sincere thanks to Dr Jenny Su for her assistance inproofreading this manuscript.

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hairdressers in Tainan City.Occupational hand dermatoses of

Y L Guo, B J Wang, J Y Lee and S Y Chou

doi: 10.1136/oem.51.10.6891994 51: 689-692 Occup Environ Med 

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