To Örebro University

Hand eczema and facial skin problems are common occupational-related skin diseases. However, the data regarding care workers in community care settings are limited. To assess the prevalence and factors associated with hand eczema and facial skin problems among community care personnel, an online questionnaire link was sent to 10,194 personnel in Sweden, with questions regarding hygiene routines, skin problems, and demographics of the participants. Respondents were categorized into groups regarding their skin symptoms. In all, 1,923 (18.9%) responded (89.8% females; 75.9% assistant nurses and care assistants). The 1-year prevalence of hand eczema and facial skin problems was 34.7% and 45.5%, respectively. Dose-dependent associations were found between occupational exposure to soap and water and hand eczema, and duration of face mask use and facial problems. Also, a higher perceived level of stress, female sex, atopic dermatitis, and lower age group were associated with both hand eczema and facial skin problems. In conclusion, healthcare workers in community care have an increased risk of occupationally related skin symptoms, foremost hand eczema, but also facial symptoms related to the use of face masks. Thus, efforts to reduce the harmful effects from the risk factors should be the main concern.

BACKGROUND: Incontinence-associated dermatitis (IAD) is a prevalent and distressing form of irritant contact dermatitis caused by prolonged exposure to urine and/or faeces. Not all incontinent individuals develop IAD, suggesting that additional prognostic factors contribute to its onset. The quality of empirical evidence supporting risk factors for IAD development is moderate to very low. Therefore, it is necessary to systematically compile and analyse expert knowledge on this topic.

AIM: This study aimed to identify and prioritise key prognostic factors for IAD development through an international expert consultation.

MATERIALS AND METHODS: A cross-sectional expert survey was conducted among international experts using an electronic survey platform. Participants rated the importance of 26 pre-identified prognostic factors, ranked relevant factors and suggested additional factors. Data were analysed to determine expert consensus and factor rankings.

RESULTS: A total of 45 experts participated, with a response rate of 39 %. The highest-ranked prognostic factors included double incontinence, faecal incontinence, loose stools, stool frequency, urinary incontinence, and impaired mobility. Other important factors were advanced age, friction and shear forces, cognitive impairment, and poor nutrition. In addition, experts highlighted systemic factors such as caregiver knowledge gaps and staff shortages as potential contributors to IAD risk.

CONCLUSION: Study results support established risk factors for IAD development such as stool frequency and limited mobility. Experts also identified factors, such as higher age and the presence of loose or liquid stool, that are considered relevant by experts but are not yet fully supported by empirical evidence. Findings will inform a future large-scale cohort study.

Incontinence-associated dermatitis (IAD) is an irritant contact dermatitis from prolonged contact with urine or faeces, which can significantly impact patient comfort and quality of life. The identification of prognostic factors for the development of IAD has the potential to enhance management, support preventive measures and guide future research. The objective of this systematic review was to summarize the empirical evidence of prognostic factors for the development of IAD. This study included prospective and retrospective observational studies or clinical trials that described prognostic factors associated with IAD. There were no restrictions on setting, time, language, participants or geographical regions. Exclusion criteria included reviews, editorials, commentaries, methodological articles, letters to the editor, cross-sectional and case-control studies, and case reports. Searches were conducted from inception to April 2024 on MEDLINE, CINAHL, EMBASE and the Cochrane Library. The studies were assessed by two independent reviewers using the QUIPS and the CHARMS-PF for data extraction. A narrative synthesis approach was employed due to study heterogeneity and using the 'vote counting based on direction' method and the sign test. The overall certainty of evidence was assessed using adapted GRADE criteria. The review included 12 studies and identified 15 potential predictors. Moderate-quality evidence suggests that increased stool frequency, limited mobility and friction/shear problems are risk factors for IAD development. Female sex, older age, vasopressor use and loose/liquid stool are risk factors supported by low-quality evidence. Increased stool frequency, limited mobility and friction/shear problems seem to be risk factors for the development of IAD. There is insufficient evidence to support the predictive validity of female sex, older age, loose/liquid stool and vasopressor use. There is substantial methodological variability across studies, making it challenging to make comparisons. Large-scale cohort studies in different settings that incorporate our review findings should be conducted in the future.

SwedAD, a Swedish nationwide registry for patients with atopic dermatitis receiving systemic pharmacotherapy, was launched on 1 September 2019. We describe here the establishment of a user-friendly registry to the benefit of patients with atopic dermatitis. By 5 November 2022, 38 clinics had recorded 931 treatment episodes in 850 patients with an approximate national coverage rate of 40%. Characteristics at enrolment included median Eczema Area and Severity Index (EASI) 10.2 (interquartile range 4.0, 19.4), Patient-Oriented Eczema Measure (POEM) 18.0 (10.0, 24.0), Dermatology Life Quality Index (DLQI) 11.0 (5.0, 19.0) and Peak Itch Numerical Rating Scale-11 (NRS-11) 6.0 (3.0, 8.0). At 3 months, median EASI was 3.2 (1.0, 7.3) and POEM, DLQI, and NRS-11 were improved. Regional coverage varied, reflecting the distribution of dermatologists, the ratio of public to private healthcare, and difficulties in recruiting certain clinics. This study highlights the importance of a nationwide registry when managing systemic pharmacotherapy of atopic dermatitis.

INTRODUCTION: Incontinence-associated dermatitis (IAD) is irritant contact dermatitis and skin damage associated with prolonged skin contact with urine and/or faeces. Identifying prognostic factors for the development of IAD may improve management, facilitate prevention and inform future research.

METHODS AND ANALYSIS: This protocol follows the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Prospective and retrospective observational studies or clinical trials in which prognostic factors associated with the development of IAD are described are eligible. There are no restrictions on study setting, time, language, participant characteristics or geographical regions. Reviews, editorials, commentaries, methodological articles, letters to the editor, cross-sectional and case-control studies, and case reports are excluded. MEDLINE, CINAHL, EMBASE and The Cochrane Library will be searched from inception until May 2023. Two independent reviewers will independently evaluate studies. The Quality in Prognostic Studies tool will be used to assess the risk of bias, and the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies-Prognostic Factors checklist will be used for data extraction of the included studies. Separate analyses will be conducted for each identified prognostic factor, with adjusted and unadjusted estimated measures analysed separately. Evidence will be summarised with a meta-analysis when possible, and narratively otherwise. The Q and I2 statistics will be calculated in order to quantify heterogeneity. The quality of the evidence obtained will be evaluated according to the Grades of Recommendation Assessment, Development and Evaluation guidance.

ETHICS AND DISSEMINATION: No ethical approval is needed since all data is already publicly accessible. The results of this work will be published in a peer-reviewed scientific journal.

Hand eczema is a chronic disease that results in economic and psychosocial burdens. The aim of this study was to systematically review and assess the magnitude of the association between exposure related to occupations and the incidence rate of hand eczema. A systematic search in PubMed, EMBASE, CINAHL and Cochrane databases, from inception to September 2017, of full-text observational studies reporting incident cases of hand eczema during employment, and a supplementary search in PubMed to September 2020, were conducted. Among 2,417 screened abstracts, 15 studies fulfilled the inclusion criteria. Incidence rates were reported per 100 person-years. Based on the Newcastle-Ottawa Scale, 9 studies were good quality, 2 fair quality, and 4 poor quality. Hairdressers had a high incidence of hand eczema of 21.4 (95% confidence interval [CI] 15.3-27.4), as did nurses, 16.9 (95% CI 11.2-22.7), and metal workers, 12.4 (95% CI 3.5-21.3). Hairdressers were predominantly women, and metal worker were predominantly men. Office occupations had an incidence rate of hand eczema of 4.9 (95% CI 1.2-9.6). The high risk of hand eczema for hairdressers, nurses, and metal workers, should be considered by healthcare policymakers. Even occupations with low irritant profile, such as office workers, were at risk of developing hand eczema, and more occupations should be investigated regarding the related risk of developing hand eczema.

Background: Valid epidemiological tools are required for surveillance of the prevalence of contact allergy. Population based studies including patch testing is the most reliable method, but implies heavy expenses and logistical problems. Clinical data are not representative for the general population and questionnaires concerning contact allergy have a low validity. Self-testing might be a useful method but it has to be validated and evaluated.

Objectives: To investigate the validity of self-patch testing for nickel allergy. Methods: Patients from three dermatology clinics were included consecutively when referred to patch testing. In total, 191 patients participated and they were provided with a self-test package including written instructions. The self-test was applied on the arm by the patient, on the same day as the patch test was applied on the back, in the clinic. The patient evaluated the self-test before the patch test reading at the clinic.

Results: Patch test at dermatology clinic (‘gold standard’) gave 46/191 (24%) nickel-positive individuals. The sensitivity of the self-test was 72% (95% CI 57–84), the specificity was 91% (95% CI 85–95) and the proportion of agreement was 86% (95% CI 81–91).Conclusions: The validity of self-testing for nickel allergy was adequate in the studied population. To determine whether self-testing is a useful tool for measuring the prevalence of nickel allergy in the general population further studies will be needed.

Nickel allergy is the most prevalent contact allergy and has been discussed as a possible riskfactor for hand eczema. However, hand eczema is one of the most frequently occurring skindiseases and has multifactorial origin. The aim of this thesis was to study the association between nickel allergy and hand eczema in the general population. There are only a fewpopulation-based studies previously published, that include patch testing. In addition, this thesis aimed to evaluate methods to follow the prevalence of nickel allergy.The study cohort consisted of 908 women who had been patch tested for the occurrence of nickel allergy as schoolgirls. Twenty years later, they were invited to participate in a follow-up questionnaire study. The response rate was 81%. In total, 17.6% of respondents reported handeczema after the age of 15 years and there was no statistically significant difference in the occurrence of hand eczema between those who were nickel-positive and those who were nickel negativeas schoolgirls. To further investigate possible links, another study was performed,which included a second questionnaire, a clinical investigation and patch testing. All schoolgirls from the baseline study who were still living in the area as adults were invited to participate and the participation rate was 77%. Patch test showed 30.1% nickel-positive individuals.When all participants were included in the analysis, there was no statistically significant difference between nickel-positive and nickel-negative women regarding occurrence of hand eczema. The most important risk factor for hand eczema was childhood eczema. Adjusted prevalence proportion ratio (PPR) for hand eczema after age 15 in relation to nickel patch testresults was 1.03 (95% CI 0.71--1.50) and in relation to childhood eczema 3.68 (95% CI 2.45--5.54). When women with and without history of childhood eczema were analyzed separately, the hand eczema risk was doubled in nickel-positive women without history of childhood eczema. In conclusion, the risk of hand eczema in nickel-positive women may previously havebeen overestimated. Next, the validity of self-reported nickel allergy was investigated. In the established cohort; two questions regarding nickel allergy were compared with patch test results. The validity of self-reported nickel allergy was low, and the questions regarding nickel allergy overestimated the true prevalence of nickel allergy. The positive predictive values were 59% and 60%. Another method for estimating the prevalence of nickel allergy, namely self-patch testing, was validated in the last study. In total, 191 patients from three different dermatology departments participated. The validity of self-testing for nickel allergy was adequate, with sensitivity 72%and proportion of agreement 86%.

Nickelallergi är vanligt förekommande. Prevalensen i Skandinavien är 15--25% hos kvinnor och cirka 3% hos män. Sambandet mellan nickelallergi och uppkomst av handeksem har tidigare diskuterats och i vissa studier anges att 30--45% av alla individer med nickelallergi får handeksem. Det finns dock endast ett fåtal publicerade studier där personer ur normalbefolkningen har lapptestats för nickel. Handeksem ärvanligt och har ofta flera olika kombinerade orsaker. Det övergripande syftet med avhandlingen var att studera nickelallergins betydelse för uppkomst av handeksem. Detfinns ett intresse av att följa förekomsten av nickelallergi över tid, speciellt sedan det i början av 2000-talet infördes ett EU-direktiv som begränsar nickelinnehåll i klockor,smycken, metallknappar etc. Ytterligare ett syfte med avhandlingen var att utvärderaepidemiologiska metoder för att följa förekomsten av nickelallergi.Den första studien var en uppföljningsstudie av 908 flickor ur normalbefolkningen,vilka i skolåldern lapptestats med nickel. Tjugo år senare skickades en enkät till dessa kvinnor, svarsfrekvensen var hög (81%). Förekomsten av självrapporterat handeksemefter 15 års ålder var 17.6%. Det förelåg ingen signifikant skillnad i förekomst avhandeksem mellan de kvinnor som var nickelallergiska som barn jämfört med dem som inte var nickelallergiska. År 2006 utfördes ytterligare en studie, som inkluderade de kvinnor som fortfarande bodde i Örebro län. Studien omfattade en klinisk undersökning av händerna samt ett lapptest. 30% av kvinnorna var positiva för nickel.Det förelåg ingen signifikant skillnad i förekomst av handeksem mellan de som var positiva för nickel och de som var negativa. Vid separat analys av de kvinnor som angav tidigare barneksem jämfört med dem som aldrig hade haft barneksem visade det sig att risken för handeksem var dubbelt så stor hos nickelallergiker i den gruppen som aldrig hade haft barneksem. Båda studierna visade att barneksem var den största riskfaktorn för att få handeksem som vuxen, med en 3-4 gånger ökad risk. Den tredje studien var en validering av självrapporterad nickelallergi. Överensstämmelsen var låg mellan enkätfrågor gällande nickelallergi och lapptestverifierad nickelallergi. Av dem som själva bedömde sig vara nickelallergiska var endast 59% positiva enligt lapptest. För att följa förekomsten av nickelallergi i befolkningen behövs därför andra metoder. I den fjärde studien utvärderades ett självtest för nickelallergi. 191 patienter från tre olika hudkliniker i Sverige deltog i studien. Validiteten för metoden självtest var tillfredsställande, sensitiviteten var 72%och graden av överensstämmelse var 86%.

Background: To estimate the prevalence of nickel allergy, self-reports are sometimes used in epidemiological studies. Self-reports are practical and may facilitate estimation of prevalence provided that the questions are validated.Objectives: To investigate the validity of self-reported nickel allergy.Methods: Three hundred and sixty-nine women, aged 30–40 years, from the general population participated in the study. The participants answered a questionnaire before a clinical examination and patch testing. The two questions being validated were ‘Are you sensitive/hypersensitive/allergic to nickel?’ and ‘Do you get a rash from metal buttons, jewellery or other metal items that come in direct contact with your skin?’Results: Patch test showed nickel-positive reaction in 30% of the subjects. Self-reported prevalence of nickel allergy as indicated by the two respective questions was 40% and 35%. Positive predictive values for the two questions were 59% (95% CI 50–67) and 60% (95% CI 51–69). History of childhood eczema was over-represented among women with ‘false-positive’ self-reported nickel allergy (P = 0.008). Self-reported hand eczema or ‘high wet exposure’ did not influence the validity.Conclusions: The validity of self-reported nickel allergy is low. The questions regarding nickel allergy overestimate the true prevalence of nickel allergy.

BACKGROUND: In population-based studies using self-reported nickel allergy, a hand eczema prevalence of 30-43% has been reported in individuals with nickel allergy. In a previous Swedish study, 958 schoolgirls were patch tested for nickel. In a questionnaire follow up 20 years later no association was found between nickel allergy and hand eczema. OBJECTIVES: To investigate further the relation between nickel allergy and hand eczema. METHODS: Three hundred and sixty-nine women, still living in the same geographical area, now aged 30-40 years, were patch tested and clinically investigated regarding hand eczema. RESULTS: Patch testing showed 30.1% nickel-positive individuals. The adjusted prevalence proportion ratio (PPR) for hand eczema after age 15 years in relation to nickel patch test results was 1.03 (95% confidence interval, CI 0.71-1.50). A history of childhood eczema was reported by 35.9%, and the PPR for hand eczema in relation to childhood eczema was 3.68 (95% CI 2.45-5.54). When analysing the relation separately in women with and without a history of childhood eczema a statistical interaction was found. The hand eczema risk was doubled in nickel-positive women without a history of childhood eczema, with a PPR of 2.23 (95% CI 1.10-4.49) for hand eczema after age 15 years. CONCLUSIONS: A doubled risk for hand eczema was found in nickel-positive women without a history of childhood eczema. When analysing all participants, there was no statistically significant difference between nickel-positive and nickel-negative women regarding occurrence of hand eczema. The most important risk factor for hand eczema was childhood eczema. The risk for hand eczema in nickel-positive women may previously have been overestimated.