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doi:10.1136/oem.2005.026211
published online 19 Oct 2006; Occup. Environ. Med.
Meding
Lillienberg, Zoli Mikoczy, Jörn Nielsen, Lars Rylander, Kjell Torén and Birgitta
Marie-Louise Lind, Maria Albin, Jonas Brisman, Kerstin Kronholm Diab, Linnéa
hairdressers
Incidence of hand eczema in female Swedish
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Incidence of hand eczema in female Swedish hairdressers
Marie-Louise Lind1,2, Maria Albin3, Jonas Brisman4, Kerstin Kronholm Diab3, Linnéa
Lillienberg4, Zoli Mikoczy3, Jörn Nielsen3, Lars Rylander3, Kjell Torén4,5, Birgitta
Meding1
1National Institute for Working Life, SE-113 91, Stockholm, and Occupational and
Environmental Dermatology, Department of Medicine, Karolinska Institutet, Stockholm,
Sweden
2Occupational and Environmental Health, Centre for Public Health, Stockholm, Sweden
3Department of Occupational and Environmental Medicine, Lund
University Hospital, SE-221 85 Lund, Sweden
4Occupational and Environmental Medicine, Sahlgrenska Academy and University Hospital,
SE-40530 Göteborg, Sweden
5Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, SE-
413 45 Göteborg, Sweden
Key words: atopy, attributable fraction (AF), hand dermatitis, occupational skin disease,
skin exposure
Word count = 2 791 words
Correspondence to:
Marie-Louise Lind
National Institute for Working Life
SE-113 91 Stockholm
Sweden
Tel: +46 8 619 69 95; Fax: +46 8 619 68 96; E-mail: marie-louise.lind@niwl.se
OEM Online First, published on October 19, 2006 as 10.1136/oem.2005.026211
Copyright Article author (or their employer) 2006. Produced by BMJ Publishing Group Ltd under licence.
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ABSTRACT
Objective: To estimate the occurrence of hand eczema in hairdressers.
Methods: The occurrence of hand eczema was estimated in a Swedish longitudinal
retrospective cohort study including all female graduates from vocational schools for
hairdressers from 1970 to 1995. A stratified sample from the general population acted as
controls. A self-administered questionnaire including questions on occurrence of hand
eczema, skin atopy, working periods, and number of hair treatments performed per week
was sent to the participants. Incidence rate ratios (IRRs) of hand eczema were estimated.
Results: The incidence rate (IR) of hand eczema in hairdressers was 23.8 cases/1 000
person-years, while in hairdressers younger than 25 years it was 37.1/1 000 person-years.
The corresponding IRR for hairdressers compared with controls was 2.5 (95% confidence
interval (CI) 2.2–2.8), and 3.1 (95% CI 2.6–3.5) for the younger hairdressers. The mean age
at onset of hand eczema was 21.6 years for hairdressers and 21.2 years for controls. The
1-year prevalence of hand eczema was 18.0% for hairdressers and 12.1% for controls. A
large number of hair treatments involving exposure to skin irritants and sensitizers were
reported. The IR of hand eczema was higher among individuals with a history of childhood
eczema, both for hairdressers and for controls, giving an (age-adjusted) IRR of 1.9 and 2.2,
respectively. The attributable fraction (AF) of hand eczema from skin atopy was 9.6%. A
synergistic effect between skin atopy and hairdressing was found on the occurrence of
hand eczema. The relative excess risk due to interaction (RERI) was 1.21 (95% CI 0.21–
2.21; p=0.01).
Conclusion: Hairdressers are highly exposed to skin-damaging substances. The self-
reported incidence of hand eczema in female hairdressers was substantially higher than in
controls from the general population and higher also than previously found in register-based
studies. For many individuals, onset of hand eczema occurs early in life. Only about 10% of
the hand eczema cases among hairdressers would be prevented if no skin atopics entered
the trade.
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Main messages
Female hairdressers are at high risk for hand eczema
The number of hair treatments involving skin-damaging exposure is high
A synergistic effect exists between skin atopy and hairdressing on the development of
hand eczema
In the present study the attributable risk of hand eczema from skin atopy in hairdressers
was 9.6%
For about half of the females with hand eczema onset occurs before 20 years of age
Policy implications
Hairdressing is a high-risk occupation for hand eczema
To prevent hand eczema in hairdressers, reduction of skin-damaging exposure is
essential
A history of childhood eczema increases the individual risk of hand eczema, but is not a
major risk factor for hand eczema among hairdressers
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BACKGROUND
There are about 19 000 hairdressers in Sweden, 80–90% of whom are women and the majority of
whom are self-employed, working in small salons. Hand eczema is a well-known problem in
occupations that involve largely manual work, particularly in combination with long periods of wet
exposure and skin contact with chemicals. Hairdressing includes extensive wet work, which can
cause irritant contact dermatitis. Many hair cosmetic products such as hair colourings, permanent
wave solutions and bleaches can also cause contact allergy. Previous studies on the occurrence of
hand eczema in hairdressers give a cumulative prevalence of 17–42% (1, 2). A high prevalence (24–
70%) and incidence rate (IR) (152–328 cases per 1 000 person-years) of hand eczema have been
found among apprentice hairdressers (3–5). The only studies presenting IRs of hand eczema in active
hairdressers are based upon registers of industrial injuries, which report incidences of 5.6–9.7/1 000
person-years (6, 7). Registers of occupational skin diseases probably underestimate the actual
occurrence of disease owing to underreporting (8).
The objective of this study was to estimate the incidence of hand eczema and occupational skin
exposure in female hairdressers using a self-administered questionnaire.
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METHODS
The design was a longitudinal retrospective cohort study with a self-administered postal
questionnaire.
The study was approved by the Ethics Committee at Lund University, Lund, Sweden.
Subjects
Study population
The study population consisted of women born after 1945 who had graduated from vocational
schools for hairdressers in Sweden during the years 1970–1995. The hairdresser’s programme in
Sweden comprises 3 years. Altogether 7 203 trained hairdressers were identified. A questionnaire
was mailed to them in December 1996. After two reminders answers were obtained from 4 061
(56%). Of these, 396 (10%) had never worked as hairdressers after their initial training, leaving
3 665 for the analysis. The age distribution is shown in Table 1. In the latest period of employment
most hairdressers (80%) had worked more than 30 hours a week.
Controls
A total of 7 355 women, stratified by age and randomly selected from the Swedish population
register, constituted a population-based control group referred to as ‘population controls’. After two
reminders 5 034 (68%) returned the questionnaire. Their age distribution is shown in Table 1.
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Table 1. Descriptive and self-reported data for the female hairdressers and the population controls.
Variable Hairdressers
n=3 665 Population controls
n=5 034
Median year of birth (range)
1967 (1946–1977)
1965 (1946–1978)
Median age, yrs
(range)
29 (19–50)
31 (18–50)
Ever smokers
1 805/3 646 (49.5%)
2 289/4 978 (46.0%) (p<0.01)1
Childhood eczema
581/3 649 (15.9%)
1 050/5 004 (21.0%) (p<0.001)1
Hand location
106/559 (19.0%)
294/992 (29.6%) (p<0.001)1
Hand eczema
Cumulative lifetime
prevalence
1-year prevalence
1 068/3 665 (29.1%)
660/3 665 (18.0%)
967/5 034 (19.2%) (p<0.001)1
607/5 034 (12.1%) (p<0.001)1
Change of job due to hand
eczema
197/3 559 (5.5%)
97/4 814 (2.0%) (p<0.001)1
1Comparison between hairdressers and population controls
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Questionnaire
Hairdressers and controls were given questions about hand eczema and atopy history (see Appendix).
The questionnaire also contained items on respiratory symptoms, information that has been
published elsewhere (9, 10). The hairdressers were asked to state the calendar year of all periods of
employment as a hairdresser from the time they had graduated. They were also asked to state if there
had been periods of more than 1 year during which they had not worked as hairdressers. For each
employment, the hairdressers were asked about the number of hair treatments they performed per
week. The different treatments asked for were permanent waving, different hair colourings, hair
bleaching, shampoos and use of hair spray. A question on glove use during hair treatments was also
asked.
Non-responders
Altogether 584 of the hairdressers and 217 of the women from the population controls (about one-
fifth and one-tenth, respectively) who had not returned the questionnaire were randomly selected for
a telephone interview by a nurse. Interviews were performed with 392 hairdressers (67%) and 134
from the population controls (62%). Altogether 368 (94%) of the hairdressers had been
professionally active after vocational school. All interviewees answered questions about hand
eczema, asthma, childhood eczema and any change of job. The wording of the questions was the
same as in the postal questionnaire. Lack of time was the most common reason given for not
returning the questionnaire.
Statistics
For statistical analysis, SAS Software, release 8.2 (SAS Institute Inc., Cary, NC, USA), was used.
Age was stratified into the categories of <25, 25–34 and >34 years. For the hairdressers, only periods
as active hairdressers are included in the calculations. The IRs were calculated as the number of new
cases of hand eczema per person-year of observation. Hairdressers without previous hand eczema
were followed from the year of certification, usually the age of 18, and during active years as
hairdressers. The population controls were followed from 18 years of age. Onset of hand eczema or
1996 (end of follow-up) were regarded as individual endpoints. Incidence rate ratios (IRRs) of hand
eczema, with 95% confidence intervals (95% CIs), were estimated by Poisson regression using
EGRET software (Statistics and Epidemiology Research Corporation, Seattle, WA, USA). For
comparison of proportions, chi2 test was used, and for comparison of means, Student’s t-test.
To establish whether there exists a biological interaction (synergism) between childhood eczema and
hairdressing the relative excess risk due to interaction (RERI) was calculated. A model with two
dichotomous risk factors was used giving four possible combinations (exposure categories), the
fourth serving as a reference category (11). Accordingly, if i=1 when the first risk factor is present
and 0 otherwise and if j=1 when the second risk factor is present and 0 otherwise; furthermore, if
RRij is the age-adjusted relative risk in exposure category i,j, and thus RR11, RR10, RR01 and RR00 are
the age-adjusted relative risks for each of the four categories (i.e. RR11 = hairdressers with childhood
eczema; RR10 = hairdressers without childhood eczema; RR01 = population controls with childhood
eczema; and RR00 = the reference category (i.e. population controls without childhood eczema = 1),
then RERI = RR11 – RR10 – RR01 + 1 (12). The CI was calculated according to Hosmer and
Lemeshow (13).
The AF (attributable fraction) of hand eczema from skin atopy, i.e. the proportion of hand eczema
cases attributable to childhood eczema, was calculated as follows:
AF = pc * (IRR – 1)/IRR,
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where pc is the prevalence of childhood eczema among the cases of hand eczema and IRR is the age-
adjusted IRR of hand eczema for hairdressers with childhood eczema compared with those without.
The CI was established for ln(1-AF), where ln is the natural logarithm (14).
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RESULTS
Occurrence of hand eczema
The IR of self-reported hand eczema is presented in Table 2. The IR observed for the hairdressers
was 23.8 cases/1 000 person-years compared with 9.6 for the controls. For hairdressers who at the
time of the study were younger than 25 years, the IR of hand eczema was even higher. IRRs are
shown in Table 2. A comparison between hairdressers and population controls gives an IRR of 2.5
(95% CI 2.2–2.8). The IRR for hairdressers under 25 years was significantly higher than that for
older hairdressers.
The mean age at onset of hand eczema was 21.6 years (median = 20.0) for hairdressers, and 21.2
years (median = 21.0) for the population controls. The onset of hand eczema among the hairdressers
is given in Figure 1. Forty per cent of the hairdressers reported that their hand eczema had started
during time for vocational school.
Cumulative lifetime prevalence and 1-year prevalence of self-reported hand eczema among
hairdressers and controls are shown in Table 1. Prevalences were significantly higher among the
hairdressers. The 1-year prevalence in hairdressers was 18%. Among both hairdressers and controls
with hand eczema during the previous 12 months, 54% stated that a physician had diagnosed the
disease. 31% of the hairdressers that were or had been smokers had ever suffered from hand eczema,
compared to 27% of those that had never smoked (p=0.017). Among the controls the corresponding
figures were 20% vs. 18% (p=0.054).
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Table 2. Incidence rates (IRs) (cases/1 000 person-years) of hand eczema in hairdressers and population
controls in relation to age. Number of incident cases in parenthesis. Incidence rate ratio (IRR) of hand
eczema, with 95% confidence intervals (95% CIs).
Table 3. Incidence rates (IRs) (cases/1 000 person-years) of hand eczema in hairdressers and population
controls in relation to history of childhood eczema. Number of incident cases in parenthesis. Incidence rate
ratio (IRR) of hand eczema, with 95% confidence intervals (95% CIs).
History of atopy
Anamnestic data on childhood eczema are shown in Table 1. A significantly lower proportion of
hairdressers than of controls reported childhood eczema. Both for hairdressers and for controls, the
IR of hand eczema was higher among individuals with a history of childhood eczema giving an (age-
adjusted) IRR of 1.9 and 2.2, respectively (Table 3). The RERI was calculated to be 1.21 (95% CI
0.21–2.21; p=0.01). The attributable fraction (AF) of hand eczema from skin atopy was 9.6% (95%
CI 5.7–13.4).
For hairdressers reporting childhood eczema, the mean age at onset of hand eczema was 18.8 years,
while it was 15.8 years for controls who had had eczema during childhood (p<0.001). For 66% of the
hairdressers reporting childhood eczema, the hand eczema had started before 21 years of age,
compared with 46% among those without childhood eczema (p<0.001). For the controls, the
corresponding figures were 67% v. 29% (p<0.001). A total of 28% among those with onset of hand
eczema during time for vocational school reported childhood eczema.
Exposure and skin protection
The self-reported number of hair treatments per week and use of protective gloves during current
employment are presented in Table 4. For alkaline permanent waving, hair colouring and bleaching,
between two and seven treatments/week was most common. Fifty-eight per cent of hairdressers
stated that they performed shampooing more than 30 times a week. During colouring and bleaching
glove use was most frequent but during permanent waving and shampooing, gloves were used more
IR
(cases/1 000 person-years) IRR and 95% CI
Age Hairdressers
Population
controls Hairdressers v. population controls
All
<25 yrs
25–34 yrs
>34 yrs
23.8 (549)
37.1 (397)
13.8 (135)
6.6 (17)
9.6 (614)
12.2 (348)
8.8 (214)
4.8 (52)
2.5 (2.2–2.8)
3.1 (2.6–3.5)
1.6 (1.3–2.0)
1.4 (0.8–2.4)
IR
(cases/1 000 person-years)
IRR and 95% CI
Childhood
eczema No childhood
eczema Childhood eczema
v. no childhood
eczema
Childhood eczema
v. no childhood
eczema
(age-adjusted)
Hairdressers
Population
controls
43.9 (112)
19.0 (164)
21.3 (437)
8.1 (445) 2.1 (1.7–2.5)
2.3 (2.0–2.8) 1.9 (1.5–2.3)
2.2 (1.9–2.7)
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rarely. Of the glove users 64% reported using polyvinyl chloride (PVC) gloves, 50% used natural
rubber latex (NRL) gloves and 4% did not know the glove material (more than one answer possible).
As many as 65% reported discoloration of the hands as reason for using gloves, while 72% gave
prevention and 19% gave alleviation of skin problems as the reason (more than one answer possible).
Whereas 64% reported use of hand cream one to three times a day, 18% used cream more than four
times a day and 18% never used hand cream. Seventy-three per cent stated that they wore rings or
bracelets while working.
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Table 4. Self-reported number of hair treatments per week and glove use during current employment.
19–12% hydrogen peroxide
26–9% hydrogen peroxide
3Low percentage of hydrogen peroxide
40–2% hydrogen peroxide
5Persulphates
Change of job
Change of job due to hand eczema was reported almost three times more often by the hairdressers
than by the controls (Table 1). Twenty per cent of the hairdressers who reported ever having had
hand eczema stated that they had changed jobs due to hand eczema (not shown in the Table). Among
the 396 hairdressers who had never worked in the occupation after completing their training 74
(19%) reported hand eczema as the reason. Therefore, 2% of all 4 061 individuals never started to
Number of treatments/week Glove use
0–1 2–7 8–14 15– Never Seldom
Often/
always
Hair treatment % % % % % % %
Alkaline permanent
waving
22 64 13 2 72 15 12
Acid permanent waving
65
33
2
1
59
18 23
Colouring to make the
hair appear lighter1
69 29 2
0.3
6
6
87
Oxidative hair colouring2
44 52 3
0.3
5
5
90
Direct, reactive colouring
(supertones)3
38 55 7
0.6
7
7
85
Direct, non-reactive
colouring (mousse/tones)4
59 36 4
0.3
9
11
80
Bleaching5
36 58 5
0.5
6
8
85
Number of treatments/week Glove use
0–30 31–50 51–70 71+ Never Seldom
Often/
always
Hair treatment % % % % % % %
Shampooing
43 39 14 5
89
6
5
Spray
28 42 20 10 – – –
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work as hairdressers after school because of skin problems (74/4 061). Twenty-seven per cent
(20/73) of these had a history of childhood eczema.
Non-responders
No statistically significant differences were found between responders to the mail questionnaire and
participants in the telephone interview with regard to prevalence of hand eczema, childhood eczema
and change of job for hairdressers and population controls.
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DISCUSSION
A remarkably high IR of hand eczema among hairdressers was found in this retrospective cohort
study in which about every fifth hairdresser in Sweden participated. The results confirm that
hairdressing is a high-risk occupation for hand eczema, with extensive exposure to skin irritants and
sensitizers.
An interesting observation is that the age of onset of hand eczema was 20 years or younger for about
half of the hairdressers, and also for the controls. For 40% of the hairdressers, onset of hand eczema
occurred during the time for vocational training (Fig. 1). In other studies a high prevalence and a
high IR of hand eczema were found among apprentice hairdressers (3–5). In two German studies the
risk was highest in the youngest age group (15, 16). The explanation for early onset of hand eczema
is probably that individuals with increased susceptibility, atopics as well as non-atopics, develop
hand eczema at an early stage when exposed to skin irritants and contact allergens (17).
Many cases of occupational skin disease are probably not reported to the register of industrial
injuries. In Sweden only 5-10% of the hand eczema cases in hairdressers are reported. There is
probably some underreporting also to the registers in Germany and Denmark as the reported
incidence in these countries is considerably lower than what we found in this study (6, 7).
The high risk for hand eczema in hairdressers is in accordance with clinical experience. There are
several studies showing that hairdressers have a high risk of developing occupational allergic contact
dermatitis (18–21). In our study we have no data on the occurrence of contact allergy in the
hairdressers. It was not feasible to perform patch testing because the hairdressers were scattered all
over Sweden.
Childhood eczema results in a highly increased risk of developing hand eczema as an adult (17, 22–
26). Brisman et al. found that skin atopy increased the incidence of hand eczema among bakers about
threefold and a synergistic effect of atopy and exposure was indicated (27). In our study we found a
twofold risk for hand eczema in skin atopics among hairdressers and controls. A statistically
significant RERI was found, indicating a biological interaction between hairdressing and childhood
eczema. Consequently the sensitive skin among the atopics in combination with the extensive
exposure in hairdressing seems to have a synergistic effect on the occurrence of hand eczema.
The AF of hand eczema cases from atopy was 9.6%, indicating that only one out of ten hand eczema
cases in hairdressers could be ascribed to atopy, and that the majority of cases are due to other
factors. In a German study 19% of occupational skin diseases among hairdressers could be ascribed
to atopy (26). In our study the prevalence of childhood eczema in hairdressers was lower than in the
general population. This implies a selection away from the hairdressing profession for skin atopics in
agreement with another German study reporting lower prevalence of childhood eczema among
hairdressers (16). The relative risk of developing hand eczema for hairdressers would therefore have
been even higher if the IRs had been adjusted for atopy.
Change of jobs due to hand eczema was reported almost three times as often by the hairdressers as
by the controls. One out of five hairdressers who had ever had hand eczema had left the occupation
because of the eczema. Half of the hairdressers and controls with hand eczema stated that a physician
had diagnosed the disease. This implies that the burden to society in terms of medical costs and
possible compensation for income losses to the individual is of considerable proportions. In a Finnish
self-administered questionnaire-based study the risk of hairdressers having to leave their profession
because of asthma or hand eczema was 3.5 times as great as that found among the control group (28).
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Our results show that hairdressers perform a large number of different hair treatments; and that most
of them are performed several times a week. To use protective gloves can be difficult during certain
work tasks, e.g. during hair cutting. Glove use was reported to be low during permanent waving and
shampooing, but higher during hair colouring and bleaching. Several studies show that dermatitis on
the hands is correlated with extensive daily exposure to occupational skin irritant factors (29). In one
study on apprentice hairdressers, unprotected wet work in combination with less than 2 hours/day of
glove use gave a high risk for developing skin disorders (15).
Smokers had a slightly higher prevalence of hand eczema, both among the hairdressers and among
the controls. There is little previous knowledge about whether there exists an association between
smoking and hand eczema. Few studies have been published, with contradictory results (30–32).
In the present study the postal questionnaire was sent to about one-fifth of all active hairdressers in
Sweden. Results from the analysis of non-responders showed that there was no difference between
responders and non-responders regarding occurrence of hand eczema and childhood eczema, and that
the results can therefore be considered representative. The question asking for the 1-year prevalence
of hand eczema has been previously validated, and has shown to lead to some underestimation (33).
However, using IRs gives a better understanding of the risk of developing hand eczema considering
the long duration of the disease (34). The question about childhood eczema has previously been
validated (35).
In conclusion, hairdressers are highly exposed to skin-damaging substances. The self-reported
incidence of hand eczema in female hairdressers was substantially higher than previously found in
register-based studies and also, higher than in control persons from the general population. Onset of
hand eczema often occurs early in life. Although the risk for hand eczema is increased in relation to
history of childhood eczema, the AF from atopy is only about 10%. Measures to prevent the
development of hand eczema among hairdressers should be given high priority.
ACKNOWLEDGEMENTS
This study was funded by the Swedish Council for Work Life Research, the Vardal Foundation for
Health Care Sciences and Allergy Research (2000-0074), the Swedish Council for Working Life and
Social Research (2001-2399) and the Medical Faculty of Lund University. Gunborg Lindahl assisted
with collection of the cohort data and the data analysis. Karin Amilon and Ingrid Lindqvist
interviewed the non-participants. Anders Holmén assisted in editing the questionnaire for scanning.
Gudrun Persson, Gunnel Nilsson, Monica Hansi, Helena Brönmark and Ulrika Wallin handled the
questionnaires. Jonas Björk assisted in the calculations of the RERI and AF.
The Corresponding Author has the right to grant on behalf of all authors and does
grant on behalf of all authors, an exclusive licence (or non exclusive for
government employees) on a worldwide basis to the BMJ Publishing Group Ltd and
its Licensees to permit this article (if accepted) to be published in
Occupational and Environmental Medicine editions and any other BMJPGL products
to exploit all subsidiary rights, as set out in our licence.
(http://oem.bmjjournals.com/misc/ifora/licenceform.shtml).
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Appendix
Questionnaire items regarding hand eczema and skin atopy
Hand eczema:
Have you ever had hand eczema?1) Yes No
If yes:
What year did the hand eczema start? 19…….
Have you had hand eczema on any occasion during
the past 12 months?2) Yes No
Was your hand eczema diagnosed by a physician? Yes No
Have you ever changed job because of hand eczema? Yes No
Skin atopy:
Have you had childhood eczema? Yes No
If yes:
Was this eczema sometimes on your hands? Yes No
_______________________________________________________________________________
1) Gives cumulative life time prevalence of hand eczema.
2) Gives 1-year prevalence of hand eczema.
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