Eczema Journal

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/265172684

Hand eczema in The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS): Prevalence, incidence and risk factors from adolescence to adulthood ARTICLE in BRITISH JOURNAL OF DERMATOLOGY · AUGUST 2014 Impact Factor: 4.28 · DOI: 10.1111/bjd.12963

CITATIONS

READS

13

51

3 AUTHORS: Charlotte G Mortz

Carsten Bindslev-Jensen

Odense University Hospital

Odense University Hospital

61 PUBLICATIONS 1,395 CITATIONS

313 PUBLICATIONS 9,723 CITATIONS

SEE PROFILE

SEE PROFILE

Klaus Ejner Andersen University of Southern Denmark 478 PUBLICATIONS 9,947 CITATIONS SEE PROFILE

Available from: Klaus Ejner Andersen Retrieved on: 03 April 2016

BJD

British Journal of Dermatology

E P ID EMIOL O GY AN D HE AL TH S ER VI CE S R ESEA RCH

Hand eczema in The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS): prevalence, incidence and risk factors from adolescence to adulthood* C.G. Mortz, C. Bindslev-Jensen and K.E. Andersen Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, DK-5000 Odense C, Denmark

Summary Correspondence Charlotte G. Mortz. E-mail: [email protected]

Accepted for publication 9 March 2014

Funding sources This work was supported by Aage Bang’s Foundation and Odense University Hospital Research Council.

Conflicts of interest K.E.A. is an advisor to and C.G.M. is an investigator for SmartPractice, Hillerød, Denmark. *Plain language summary available online. DOI 10.1111/bjd.12963

Background Several studies have evaluated the incidence and prevalence of hand eczema in unselected adults. However, no studies have followed unselected adolescents from primary school into adult life to evaluate the course and risk factors for hand eczema. Objectives To estimate the incidence of hand eczema from adolescence to adulthood and the prevalence of hand eczema in young adults, together with risk factors for hand eczema. Methods A cohort of 1501 unselected eighth-grade schoolchildren (mean age 14 years) was established in 1995. In 2010, 1206 young adults from the cohort were asked to complete a questionnaire and participate in a clinical examination, including patch testing. Results The incidence of hand eczema was 8
8 per 1000 person-years. The 1-yearperiod prevalence of hand eczema in the young adults was 14
3% (127 of 891) and the point prevalence 7
1% (63 of 891), with significantly higher prevalence in females. At the clinical examination 6
4% (30 of 469) had hand eczema. Factors in childhood of importance for adult hand eczema were atopic dermatitis and hand eczema. Wet work in adulthood was a risk factor, as was taking care of small children at home. Interestingly, hand eczema among unselected young adults was associated with sick leave/pension/rehabilitation, indicating possible severe social consequences. Only 39
0% of patients participated in the clinical examination, while 75
0% answered the questionnaire. Conclusions A high incidence and prevalence of hand eczema were found in 28– 30-year-old adults, and were highly associated with childhood hand eczema and atopic dermatitis, along with wet work and taking care of small children in adulthood. There was no association with smoking, education level or nickel allergy in childhood.

What’s already known about this topic?

•

Studies including the adult population have investigated the incidence and prevalence of hand eczema.

What does this study add?

• • • © 2014 British Association of Dermatologists

This is the first follow-up study of hand eczema in unselected young adults followed from primary school. The incidence rate of hand eczema was 8
8 per 1000 person-years. Factors significant for adult hand eczema were childhood atopic dermatitis and hand eczema, and exposure to wet work in adulthood. Hand eczema was associated with sick leave/pension/rehabilitation, indicating possible severe social consequences.

British Journal of Dermatology (2014) 171, pp313–323

313

314 Hand eczema in the TOACS cohort, C.G. Mortz et al.

Hand eczema is a frequent, long-lasting disease having both personal and work-related consequences resulting in sick leave, job change and, in the worst case, disability retirement. Population-based studies have confirmed that hand eczema occurs with a point prevalence of around 4%, a 1-year-period prevalence of approximately 10% and a lifetime prevalence of 15–20%.1–3 The median incidence rate of hand eczema in the adult general population has been calculated as 5
5 per 1000 person-years (women 9
6, men 4
0).1,4–6 Early onset of hand eczema is frequent, and in about onethird of cases it occurs before the age of 20 years.5 In a Swedish study of 10 950 adults, the self-reported 1-year prevalence of hand eczema was 12% in 19–29-year-old women compared with < 6% among women aged 70–80 years.7 The occurrence and work-related consequences of hand eczema in young adults have been poorly investigated, and it is important to study the incidence of hand eczema from adolescence to adulthood to determine the effect of occupational exposure; taking atopic dermatitis and nickel allergy into account, how many people will develop hand eczema when working in various occupations with different exposure to allergens and irritants? Atopic dermatitis is one of the most important risk factors for hand eczema,8–11 whereas a possible association between hand eczema and nickel allergy has been debated.12–15 Furthermore, occupational exposure to water and detergents is associated with hand eczema. However, although wet work has been associated with hand eczema,7,16 some studies have also rejected an association.17 Recently, it has been shown that high water exposure over the entire day was considerably more frequent than exposure at work, suggesting that a significant proportion of water exposure occurs outside work.18 Lifestyle factors such as smoking and alcohol, and also socioeconomic factors, are reported as risk factors for hand eczema.4,19–21 Most follow-up studies in adults are based on questionnaires without concomitant clinical examination by a dermatologist, and the information is given in adulthood, causing a considerable recall bias about information from childhood. Furthermore, questionnaire data do not always exclude other dermatoses such as psoriasis. Most studies have used one question, ‘Have you ever had hand eczema?’ to estimate the prevalence of hand eczema.1 Self-reported eczema has been validated in several studies.22–24 The Nordic Occupational Skin Questionnaire (NOSQ)-2002 was developed for studies on hand eczema and relevant exposure in order to obtain more standardized data, which can be compared between studies and countries.25 The hand eczema questionnaire was published in 1996, and alongside the question, ‘Have you ever had hand eczema?’ it included questions on location and duration.26 This questionnaire was used to describe the prevalence of hand eczema among unselected eighth-grade schoolchildren in Odense, Denmark 15 years ago.10 Since then, several other cohort studies have used the questionnaire in occupational studies on hand eczema.4,27,28 British Journal of Dermatology (2014) 171, pp313–323

This investigation is a follow-up study of the schoolchildren’s cohort evaluated in 1995–96 (mean age 14 years) and now reinvestigated after 15 years using the same questionnaire supplemented with questions about relevant exposure and occupation. As in 1995, a complete clinical examination was performed by the same dermatologist to determine the prevalence and extent of atopic dermatitis and hand eczema, as well as the subtype of hand eczema, also taking into account other skin diseases such as psoriasis.

Materials and methods Population and study design Phase 1 of The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS) was conducted in 1995–96 as a cross-sectional study among 1501 eighth-grade schoolchildren (mean age 14 years) in the municipality of Odense. This cross-sectional study included questionnaires, interviews and clinical examinations, blood samples for IgE measurement and patch tests. Phase 2 was conducted in 1996–97 as a case–control study in selected groups of schoolchildren. The population and study design of phases 1 and 2 have been published.10 Phase 3 is a 15-year follow-up study in the same population (28–30 years of age). From the original cohort, 1271 had given consent to be contacted again and had given their personal identification number to be traced. An invitation to the follow-up study was sent in 2010 together with a code to an online questionnaire with 147 questions. After two reminders the questionnaire was also sent twice in paper version. Furthermore, the participants were offered a clinical examination, blood samples for IgE measurement, skin prick test, pulmonary function test and patch tests. The examination and testing took place in Odense, Copenhagen and Aarhus by the same investigator (C.G.M.) who performed the phase 1 and 2 studies, assisted by two experienced dermatological nurses and a laboratory technician. Pregnant women were not allowed to participate in patch tests and skin prick tests. Details about the follow-up study have been reported.29,30 The Regional Ethical Committee for Southern Denmark approved the study (S-VF-19950022). Questionnaire The responders completed the questionnaire with questions on atopic dermatitis, asthma, allergic rhinoconjunctivitis, hand eczema, urticaria/angio-oedema, and type I and IV allergy. The questionnaire included the same questions as in phase 1, supplemented with new questions including occupational aspects.10,25,26,29,31 The lifetime prevalence, 1-year-period prevalence and point prevalence of hand eczema were determined using the NOSQ2002 questionnaire.25,26 The criteria for a history of hand © 2014 British Association of Dermatologists

Hand eczema in the TOACS cohort, C.G. Mortz et al. 315

eczema were eczema (rash) on the fingers, finger webs, palms or back of hands, which had appeared once and continued for at least 2 weeks or had appeared several times or had been persistent.10 Furthermore, questions on hand eczema and skin exposure from NOSQ-2002 were used (C1–3, D1–12, E1–8, F1–4, G2–3, G6–8, H1–2, T1–3),25 together with questions on symptoms, frequency of hand eczema eruption, changes of occupation or work functions, skin care, hand disinfection, smoking and other diseases. Questions about education, occupation and managerial responsibilities were adopted from the NFA (National Research Centre for the Working Environment; www.arbejdsmiljoforskning.dk/da). Occupation was classified according to DISCO-08 (www.dst.dk/disco), the danish version of the ISCO-08 (International Standard Classification of Occupations; www.ilo.org/public/english/bureau/stat/isco/ isco08). Risk occupations were defined according to Skoet et al.32 Wet work was defined as exposure to wet work > 2 h per day, use of occlusive gloves > 2 h per day or very frequent hand washing (> 20 times per day) according to Diepgen and Coenraads.33 The severity of hand eczema was evaluated based on a selfadministered photographic guide,34 used with permission from Basilea Pharmaceutica (Basel, Switzerland). Furthermore, a visual analogue scale (VAS) was included. Data on quality of life were obtained using the Dermatology Life Quality Index (DLQI),35 with permission from Andrew Finlay. The lifetime prevalence of atopic dermatitis was defined by published questionnaire criteria.31 Clinical examination The point prevalence of hand eczema was evaluated clinically by the dermatologist (C.G.M.). Objective hand eczema was defined as inflammation with itching erythema, papules and/or vesicles and scaling localized to the fingers or finger webs, backs of hands or palms, and with a duration of at least 2 days.10 The severity of hand eczema was scored using the Hand Eczema Severity Index (HESCI).36 A clinical examination of the entire skin was performed in all participants. The 1-year-period and point prevalences of atopic dermatitis were calculated using the Hanifin and Rajka criteria.37 Severity was assessed by Scoring Atopic Dermatitis.38

Data handling and statistics The questionnaire was answered electronically by 743 respondents, and 156 answered a paper version. The responses were subsequently entered into a database by the first author (C.G.M.). All clinical data were entered twice; when differences were found, a comparison with raw input forms was made and corrections made accordingly. Statistical analysis was performed with Stata SE 11.0 (StataCorp, College Station, TX, U.S.A.). The results are given as prevalence proportions and 95% confidence intervals (CIs). Comparisons between sexes were made by v2-based table analysis. The incidence rate was calculated from 1995 to 2010 based on those without hand eczema in 1995. A logistic regression model was performed among those with current hand eczema (1-year-period prevalence in 2010) as the dependent variable and atopic dermatitis in childhood (0–14 years), nickel sensitization and wet work in eighth grade, and hand eczema during the last year in eighth grade as independent variables. Further independent variables, in adulthood, were wet work (exposure to wet work > 2 h per day, use of occlusive gloves > 2 h per day or very frequent hand washing, > 20 times per day), care for children aged < 4 years for > 2 h per day, being on sick leave/disability pension/rehabilitation, and smoking, education and sex. The strategy for statistitical analysis was decided in advance. Statistical significance was defined as P < 0
05.

Results In total, 1206 of the 1271 original participants (95%) were retrieved in Denmark through the national Central Person Register; four had died, one person was missing and 60 had emigrated to other countries. After four reminders the response rate for answering the questionnaire was 74
5% (899 of 1206), and 38
9% (469 of 1206) of those invited (52
2% of those who responded by questionnaire) participated in the clinical examination (Fig. 1). The 899 answering the questionnaire in 2010 were a representative part of the 1995 population, except that more women than men participated in the follow-up questionnaire and more people with atopic dermatitis in childhood participated (Table 1). Questionnaire

Patch test

Prevalence and incidence of hand eczema

T.R.U.E. TEST panels (SmartPractice, Phoenix, AZ, U.S.A.) were used for patch testing. The prevalence, incidence and persistence of contact allergy and allergic contact dermatitis in the TOACS cohort have been reported elsewhere.29,30 Nickel sensitization was based on a patch test with T.R.U.E. TEST, supplemented with a nickel sulfate dilution series.14 The test results were scored according to the International Contact Dermatitis Research Group criteria and have been described in detail previously.10,14,29,30,39

The lifetime prevalence of hand eczema was 23
0% (205/ 891; 95% CI 20
3–25
9). The 1-year-period prevalence of hand eczema in the young adults was 14
3% (127/891; 95% CI 12
0–16
7) and the point prevalence 7
1% (63/891; 95% CI 5
5–9
0), with significantly higher prevalence in women than in men (Table 2). In 1995, 9
8% (87) of the 891 participants in phase 3 had ever had hand eczema (eight of the 899 did not answer the hand eczema questions). From 1995 to 2010, 14
7% (118 of

© 2014 British Association of Dermatologists

British Journal of Dermatology (2014) 171, pp313–323

316 Hand eczema in the TOACS cohort, C.G. Mortz et al.

Phase 1 (1995)

Phase 2 (1996)

Phase 3 (2010)

1501 eighth-grade school children invited

1206 adults invited

Questionnaaire 899 (74·5%)

Questionnaire 1438 (95·8%)

Further testing in cases and controls (563) including skin prick, skin barrier and pulmonary function tests

Clinical examination, interview 1340 (89·3%)

Patch test 1146 (76·3%)

Clinical examination, interview 469 (38·9%)

Patch test 442 (36·7%)

Blood sample 869 (57·9%)

Skin prick test 460 (38·1%)

Blood sample 466 (38·6%)

Fig 1. Flowchart and participation of the cohort in phases 1–3 (reproduced from Mortz et al.30).

Table 1 Comparison of baseline characteristics (1995) between participants and nonparticipants in the questionnaire in the follow-up study (2010) Participants in follow-up questionnaire Baseline characteristic Sex Female Male Present or past atopic dermatitis Present or past hand eczema Present or past allergic rhinitis Present or past asthma Contact allergya Positive specific IgEb a

Prevalence (%) 56
3 43
7 23
9 9
8 19
7 12
0 15
4 28
1

Nonparticipants in follow-up questionnaire

n/N 506/899 393/899 215/899 88/899 177/899 108/899 120/778 171/609

Prevalence (%) 38
4 61
6 16
9 8
3 16
9 11
3 14
7 33
1

n/N

P-value

207/539 332/539 91/539 45/539 91/539 61/539 54/368 86/260

< 0
05 < 0
01 0
36 0
19 0
69 0
74 0
14

In phase 1, 1146 of 1438 participated in patch testing; bin phase 1, 869 of 1438 gave blood samples for IgE measurement.

804) developed hand eczema, giving a calculated incidence rate of 8
8 per 1000 person-years. Among women the incidence rate was 11
0 per 1000 person-years and for men 6
0 per 1000 person-years. Description of current hand eczema (1-year-period prevalence) Further analysis was performed among the 127 individuals with current hand eczema (1-year-period prevalence); 93 had eczema on the fingers or finger webs (17 on the fingertips), 76 on the back of the hands and 34 on the palms. Of those with hand eczema during the last year, 40
2% (51 of 127) also reported eczema on the wrist and/or forearm (31 wrist, 25 forearm). The most commonly reported symptoms were itching (82
7%), erythema (81
9%) and dry skin with scaling (76
4%). Vesicles were reported by 36
2%. British Journal of Dermatology (2014) 171, pp313–323

The frequency of hand eczema eruption was reported to be less than once every third month among 36
2% (n = 46), more than once every third month among 29
1% (n = 37) and (nearly) all the time by 31
5% (n = 40). The severity of hand eczema in the questionnaire was evaluated both at present and when the eczema was worst, using a VAS and a photographic guide. At the time of the study the VAS score was 0 in 29
0%, 1–3 in 42
0% and 4–6 in 17
0%, while only 11
0% reported a VAS score ≥ 7. When the eczema was worst the VAS score was ≥ 7 in 38
0%, and 36
0% had a VAS score of 4–6, while only 26
0% had a score of ≤ 3. The photographic guide showed that 47
0% of patients were clear of disease at the time of the study, 32
0% were almost clear, 19
0% had moderate eczema, and 2
0% had severe and 0
8% very severe hand eczema. When the eczema was worst, 3
0% reported very severe eczema, 27
0% severe eczema, 46
0% moderate and 22
0% almost clear or clear. © 2014 British Association of Dermatologists

Hand eczema in the TOACS cohort, C.G. Mortz et al. 317 Table 2 Lifetime prevalence, one-year period prevalence and point prevalence of hand eczema based on questionnaire in the 891 adults participating both in phase 1 and 3, and point prevalence of hand eczema in the 469 interviewed and examined clinically in phase 3 Total population n = 891e % (n)

Questionnaire Ever hand eczema phase 1 (0–14 years) Ever hand eczema phase 1 and/or 3 (lifetime 0–29 years) Hand eczema during the last year phase 3 (1 year) Hand eczema at the moment phase 3 (point)

9
8 23
0 14
3 7
1

Women n = 502 % (n)

(87) (205) (127) (63)

12
6 29
1 17
9 9
0

Total population n = 469 %(n)

Clinical Hand eczema at the clinical examination (point)

Men n = 389 % (n)

(63)c (146)a (90)b (45)d

6
2 15
2 9
5 4
6

Women n = 286 % (n)

6
4 (30)

(24) (59) (37) (18)

Men n = 183 % (n)

7
7 (22)

4
4 (8)

P < 0
0001 for sex difference. P < 0
0005 for sex difference. P < 0
002 for sex difference. P < 0
02 for sex difference. In total, 899 answered the questionnaire, however only 891 had answered the questions on self-reported hand eczema. a

b

c

In 51 of the 127 patients with hand eczema during the last year, contact with certain materials, chemicals or anything else at work was reported to aggravate the eczema. The most common self-reported exacerbation factors at work were frequent hand washing or wet work (n = 16), protective gloves (n = 11), soap (n = 10), detergents (n = 6) and food or plants (n = 5). In 48 of 127, the eczema improved when away from normal work, as at weekends or during holidays. In total, 75 of 127 with current hand eczema reported onset of hand eczema at 18 years of age or later; 41 of these 75 (55
0%) had the same type of work as when the hand eczema started, and 36 of 75 (48
0%) had the same work function. Hand eczema was reported to affect daily occupational activities in 36
2% of this group (46 of 127). The most common statements were, ‘I have to use protective gloves’ (n = 27), ‘I have been sick listed or otherwise off work’ (n = 9) and ‘I have changed jobs’ (n = 7). None was on pension owing to hand eczema. In 55 of 127 patients with hand eczema during the last year, procedures outside the workplace were reported to worsen the hand eczema. The most common factors reported were exposure to detergents and other household cleaning and laundry products (n = 40), frequent hand washing or work with wet hands (n = 67), soap, shampoo and other personal hygiene products (n = 16), and handling of food (n = 16). Hand eczema was reported to have a negative influence on patients’ financial situation [medical and other linked expenses, lost workdays, work capacity and/or change of job] in 35
0% (44 of 127), with 6
0% having some to substantial financial loss, and 29
0% reporting that they had extra expenses. The NOSQ questions on how hand eczema affected life during the last 12 months showed that the most affected areas were daily activities at home (74 of 127), mood (55 of 127), occupational work (41 of 127) and sleep (36 of 127). The DLQI was between 0 and 18 (median 1) among those with hand eczema during the last year. Factors with the highest scores were itchy, sore, painful or stinging skin (68 of © 2014 British Association of Dermatologists

d

e

121), skin condition interfered with shopping or looking after home or garden (32 of 121) and eczema prevented the person from working or studying (26 of 121) (six did not answer the question on quality of life). Factors from childhood, educational level and smoking habits Atopic dermatitis in childhood occurred in 23
9% of those answering the questionnaire in phase 3, and hand eczema in adolescence (1-year-period prevalence in seventh–eighth grade) was found in 7
7%. Childhood atopic dermatitis was found in 41
7% of those with current hand eczema compared with 20
9% of those without, and 22
1% of those with current hand eczema had experienced hand eczema in adolescence compared with 5
4% of those without. In eighth grade, 8
5% of the population answering the hand eczema questionnaire in phase 3 were sensitized to nickel; 11
1% of those with current hand eczema as adults compared with 8
1% of those without hand eczema. Wet work in adolescence was reported by 34
3%, with no difference between the two groups. Middle (3–4 years) to long (> 4 years) vocational training was reported with the same frequency in those with or without current hand eczema (52
8% vs. 53
5%, respectively). The smoking history was approximately the same in those with hand eczema during the last year (54
0%) compared with those without (47
6%). Exposure and occupation The response to questions on selected exposure variables at work and home in relation to current hand eczema is shown in Table 3. There was no significant change in the results when dividing the group without current hand eczema into those with earlier hand eczema (> 1 year ago) and those who never had hand eczema. British Journal of Dermatology (2014) 171, pp313–323

318 Hand eczema in the TOACS cohort, C.G. Mortz et al. Table 3 Exposure at work and at home in relation to current hand eczema (1-year-period prevalence of hand eczema in 2010)

Factors at work Exposure to wet work, hours per day < 0
5 0
5–2 >2 Don’t know Glove use, hours per day 1 2 >2 Don’t know Hand washing, times per day 0–5 6–10 11–20 > 20 Hand disinfectant use, times per day 1–5 6–20 > 20 Moisturizer use (hands), times per day Not every day 1–2 >2 Factors at home Care for children aged < 4 years, hours per day < 0
5 0
5–2 >2

Total population, n = 889a

Hand eczema during the last year, n = 126

No hand eczema during the last year, n = 763

352 197 102 52 1 190 76 37 74 3 889 243 351 200 95 364 242 76 46 669 329 215 125

64 29 22 13 0 31 14 7 9 1 126 32 43 25 26 59 32 16 11 116 43 38 35

288 168 80 39 1 159 62 30 65 2 763 211 308 175 69 305 210 60 35 617 286 177 90

(39
6)

(5
8) (21
4)

(8
3) (100)

(10
7) (40
9)

(75
3)

321 (36
1) 17 17 287 (32
3)

(50
8)

(10
3) (24
6)

(7
1) (100)

(20
6) (46
8)

(92
1)

58 (46) 3 2 53 (42
1)

(37
7)

(5
1) (20
8)

(8
5) (100)

(9
0) (40
0)

(80
9)

263 (34
5) 14 15 234 (30
7)

Values are n or n (%). aIn total 899 patients answered the questionnaire, but only 891 had answered the questions on self-reported hand eczema, and 889 on exposure.

Use of gloves at present was common (n = 190), the most commonly used types being natural rubber/latex (n = 146) and synthetic rubber (e.g. nitrile, neoprene; n = 85). Other types were plastic (e.g. vinyl, polyvinylchloride, polythene; n = 45), cloth (n = 44), leather (n = 16) and other/unknown type (n = 16). Cotton gloves beneath rubber or plastic gloves were used by 23 respondents. Skin complaints from glove use were common and occurred in 16
2% (70 of 433) of those who had ever used gloves, particularly in those with hand eczema during the last year (48
0%, 34 of 71) but only 9
9% (36 of 362) of those without hand eczema during the last year. Natural rubber/latex gloves were the most common culprit (41/70), and 33% (23/70) had changed glove type or stopped using gloves. The occupational status of the cohort is shown in Table 4. In total, 13
1% worked in a risk occupation, 17
3% of those with current hand eczema and 12
4% of those without current hand eczema. Focusing on the occupations where more than 20 people were placed, the highest prevalence of hand eczema occurred in those on disability pension/rehabilitation (10 of 28, 36
0%), on sick leave (seven of 23, 30
0%), in healthcare work (15 of 77, 19
0%) and in those British Journal of Dermatology (2014) 171, pp313–323

unemployed/on leave (17 of 99, 17
0%). In typical dry work, such as office work, the prevalence was 12
4%. Very few cleaners, hairdressers, laboratory technicians or doctors/ dentists/midwives participated in the study, nor did people in the food and plants industry. In the group with hand eczema during the last year and on sick leave (n = 7), three answered that they had been on sick leave due to hand eczema, and all three had lost a job due to hand eczema. In the group on disability pension or rehabilitation (n = 10) none reported pension due to hand eczema. However, one had been on sick leave owing to hand eczema and lost a job owing to hand eczema. Predictive factors for current hand eczema in adults A logistic regression analysis with hand eczema during the last year as the binary outcome is shown in Table 5. The regression analysis include factors from childhood (phase 1), and exposures (phase 3), including wet work, taking care of small children, sick leave/disability pension/rehabilitation, education, smoking and sex. The number inluded in the analysis was 771 because not all questionnaire respondents in 2010 © 2014 British Association of Dermatologists

Hand eczema in the TOACS cohort, C.G. Mortz et al. 319 Table 4 Occupational status in relation to current hand eczema (1-year-period prevalence of hand eczema in 2010) Total population, n = 891a Wet work occupations Healthcare worker Cleaner Hairdresser Doctor, dentist, midwife Laboratory technician Food and plants occupations Butcher, cook, kitchen worker Greenhouse worker, florist Risk occupations in total (wet/food/plants) Other occupations Office worker, level 1–5b Tradesman, level 7 Other, level 6, 8, 9c Education theoretical Education practical Unemployed, on leave Sick leave Disability pension, rehabilitation

77 4 5 10 5

(8
6) (0
5) (0
6) (1
1) (0
6)

Hand eczema during the last year, n = 127

No hand eczema during the last year, n = 764

15 (11
8) 0 0 1 (0
8) 1 (0
8)

62 4 5 9 4

13 (1
5) 3 (0
3) 117 (13
1)

3 (2
4) 2 (1
6) 22 (17
3)

10 (1
3) 1 (0
1) 95 (12
4)

380 50 29 137 28 99 23 28

47 2 3 17 2 17 7 10

(42
6) (5
6) (3
3) (15
4) (3
2) (11
1) (2
6) (3
1)

(37
0) (1
6) (2
4) (13
4) (1
6) (13
4) (5
5) (7
9)

333 48 26 120 26 82 16 18

(8
2) (0
5) (0
6) (1
2) (0
5)

(43
6) (6
3) (3
4) (15
7) (3
4) (10
7) (2
1) (2
4)

Values are n (%). aIn total, 899 participants answered the questionnaire regarding occupation, but only 891 answered the questions on selfreported hand eczema. The occupations of the other eight were one healthcare worker, four office workers, one tradesman, one in education and one on disability pension/rehabilitation. bOffice worker, level 1–5, refers to DISCO-08, the Danish version of the International Standard Classification of Occupations. In this version, level 1 referes to leadership, level 2 high educational level, level 3 medium educational level, and level 4–5 officework and sales at lower level. cOther levels (6, 8, 9) refer to work in farms, fishing, hunting and factory work, transportation and other.

had been patch tested in 1995. Including all patients in phase 3, and using the question on self-reported nickel dermatitis as a marker of nickel sensitization instead of a positive nickel patch test in 1995 did not change the outcome (data not shown). The model shows that factors in childhood important for adult hand eczema were childhood atopic dermatitis and hand eczema already in adolescence. Wet work as an adult is also a risk factor, as is taking care of small children at home. Interestingly, sick leave/disability pension/rehabilitation, already at the age of 29 years, is associated with current hand eczema. Clinical examination: point prevalence of hand eczema In total, 6
4% of respondents (30 of 469) had hand eczema at clinical examination (Table 2). It appeared on the fingers or finger webs in 25 adults (four on the fingertips); 12 had eczema on the back of the hands and six on the palms. The severity score (HESCI) was mild in 22 of 30, moderate in seven and severe in one. The diagnosis of hand eczema was irritant contact dermatitis (ICD) and atopic dermatitis (n = 16), ICD (n = 5), vesicular hand eczema (n = 3), and one each with atopic hand eczema; allergic contact dermatitis and atopic hand eczema; atopic hand eczema and vesicular hand eczema; ICD and vesicular hand eczema; ICD, atopic hand eczema and vesicular hand eczema; and unspecific fungus-infected eczema. None had © 2014 British Association of Dermatologists

hyperkeratotic hand eczema. In 10 cases the eczema was judged to be work related. Only one had contact allergic hand eczema. The treatment reported was topical steroids in 19 of 30. None used topical immunomodulators or systemic treatment. In 28 of 30 moisturizers were used, in 14 twice or more a day. In 20 of these 30 the hand eczema had started after 18 years of age. All patients were interviewed about trigger factors, and 19 reported wet work, 16 soap, six cleaning agents, three food stuffs and three gloves. In addition to the patients with hand eczema (n = 30), the most common diagnoses were atopic dermatitis (n = 29), acne/rosacea (n = 13), psoriasis (n = 8), seborrhoeic dermatitis (n = 6) and vitiligo (n = 5).

Discussion This study confirms the high prevalence of hand eczema in young adults (28–30 years old), with a lifetime prevalence of 23
0%, a 1-year-period prevalence of 14
3% and a point prevalence of 7
1% evaluated by questionnaire, and a point prevalence of 6
4% evaluated by clinical examination (Table 2). Significantly more women than men had hand eczema. Compared with other population-based studies, our prevalence figures are higher, reflecting the different age group in this investigation (28–30 years) compared with other studies pooling data from different age groups, including older British Journal of Dermatology (2014) 171, pp313–323

320 Hand eczema in the TOACS cohort, C.G. Mortz et al. Table 5 Results of logistic regression on current hand eczema in adults (1-year-period prevalence of hand eczema in 2010) Hand eczema during the last year, phase 3 (2010), n = 116 Phase 1 (1995) Atopic dermatitis (age 0–14 years) No 66 Yes 50 (43
1) Nickel sensitization (age 14 years) No 103 Yes 13 (11
2) Wet work after school (age 14 years) No 76 Yes 40 (34
5) Hand eczema (age 13–14 years) No 88 Yes 28 (24
1) Phase 3 (2010) Wet worka No 83 Yes 33 (28
4) Taking care of children aged < 4 years for > 2 h per day No 66 Yes 50 (43
1) Sick leave/disability pension/rehabilitation No 101 Yes 15 (12
9) Smoking No 53 Yes 63 (54
3) Educational level None/short 55 Middle/long 61 (52
6) Sex Female 85 Male 31 (26
7)

No hand eczema during the last year, phase 3 (2010), n = 655

OR (95% CI)

P-value

503 152 (23
2)

1
9 (1
2–3
0)

< 0
01

602 53 (8
1)

1
0 (0
5–2
1)

0
93

420 235 (35
9)

1
0 (0
6–1
5)

0
89

617 38 (5
8)

4
2 (2
3–7
5)

< 0
01

535 120 (18
3)

1
7 (1
1–2
8)

0
03

460 195 (29
8)

1
7 (1
1–2
7)

0
02

626 29 (4
4)

2
7 (1
3–5
7)

< 0
01

349 306 (46
7)

1
4 (0
9–2
1)

0
13

295 360 (55
0)

1
0 (0
7–1
6)

0
91

372 283 (43
2)

0
66 (0
4–1
1)

0
09

OR, odds ratio; CI, confidence interval. Statistically significant results are in bold. The regression model is based on 771 adults participating in the questionnaire in both phases 1 and 3 and the patch test in phase 1, and thus excludes the 118 not patch tested in phase 1. aWet work was defined as exposure to wet work > 2 h per day, use of occlusive gloves > 2 h per day or very frequent hand washing (> 20 times per day).

people.1 Although they looked at different age groups, the other studies also showed a peak among young women.7,40,41 The incidence from adolescence to adulthood was 8
8 per 1000 person-years (11
0 in women, 6
0 in men). Incidence data based on prospective studies of hand eczema from adolescence to young adulthood have not been reported before. In the general adult population the incidence was reported in a retrospective study to be 3
3 per 1000 person-years in 24 –77-year-old unselected adults from Sweden.5 Meding and Jarvholm also found that the incidence was highest among 20–29-year-old women (11
4 per 1000 person-years),5 which is similar to our value. A Danish twin study among adults (aged 19–52 years) followed prospectively for 9 years also found an incidence of 8
8 per 1000 person-years.4 Furthermore, in a cohort of car industry workers followed for a mean of 13
3 years, about 30% had hand eczema at least once during the study period,42 showing the burden of hand eczema in the car industry. British Journal of Dermatology (2014) 171, pp313–323

The power of this study is that the participants were questioned and clinically examined prospectively over 15 years by the same investigative team, giving the best obtainable information about incidence together with risk factors in childhood, and also including information on education and occupation. Recall bias is eliminated. The limitations include only 39
0% participating in the clinical examination, while 75
0% answered the questionnaire. Comparing baseline characteristics in 1995 and 2010, the participants constitute a representative sample (Table 1), except that more with atopic dermatitis in childhood participated in the follow-up. The severity of hand eczema at the time of examination was moderate to very severe in 22
0%, as judged by the photographic guide, and 76
0% reported moderate-to-very-severe hand eczema when they were asked how severe the hand eczema was when it was worst during the last year. This is important and points to the fact that when chronic intermittent diseases are evaluated it is useful to evaluate the range of © 2014 British Association of Dermatologists

Hand eczema in the TOACS cohort, C.G. Mortz et al. 321

severity both from the day of investigation and when the disease is worst. One-third of participants reported chronic hand eczema. At the clinical examination 30 patients had hand eczema. Most cases were mild as evaluated by HESCI score, and only half had used topical corticosteroids, while none had used more potent treatments. One-third of the cases were judged be work related. Allergic contact dermatitis was found in only one case, and most cases were ICD and atopic dermatitis. Owing to a time interval between answering the questionnaire and performing the clinical examination of up to 6 months, the point prevalence in the questionnaire and at the clinical examination could not be compared directly. However, the prevalence found in the questionnaire (7
1%) and at the clinical examination (6
4%) was nearly the same. Childhood atopic dermatitis and hand eczema in adolescence were significantly associated with adult hand eczema, in agreement with several other studies, both in retrospective and prospective designs.4,11,28,43 We found no relationship between nickel sensitization or wet work in adolescence and development of adult hand eczema (Table 5). It has been suggested that nickel sensitization is associated with development of hand eczema,12 but in 2006 Josefson et al. showed that a positive nickel patch test in childhood did not indicate increased risk of hand eczema 20 years later in life,13 in agreement with this study. The importance of wet work, frequent hand washing and use of protective gloves as trigger factors for hand eczema is in agreement with present knowledge. Also, taking care of small children for > 2 h daily at home was important (Table 5), as shown previously.44 In the questionnaire, 40
2% of those with current hand eczema reported exacerbation at work and 37
8% reported improvement during time off. However, 43
3% also reported exacerbation factors outside work. Lifestyle factors such as smoking and educational level have been suggested as risk factors for hand eczema,19–21 but no correlation was found in this study. Many of the 29-year-old adults are still in education or have been working in trade for only a few years (Table 4). Categorizing the work into risk occupations according to Skoet et al.,32 there was a tendency that more people with hand eczema during the last year worked in wet occupations. However, the numbers in the different groups were small, and in total only 117 worked in risk occupations: 17
0% among those with hand eczema and 12
0% without. Therefore, further analysis could not be performed. Those with jobs as healthcare workers are at high risk, as recently shown in another Danish study.28 The high frequency of pension/ rehabilitation/sick leave among young adults with current hand eczema emphasizes the social impact of chronic hand eczema for the individual, as well as for society. It is alarming that hand eczema in young adults is associated with sick leave/disability pension/rehabilitation, as 13
4% of those with hand eczema belong to this group compared with 4
5% without hand eczema. In a 15-year follow-up in Sweden it © 2014 British Association of Dermatologists

was also found that 5% of patients with hand eczema had far-reaching consequences, including long sick-leave periods, sick pension and change of occupations.45 The long-term prognosis for hand eczema is poor,45 and hand eczema has a significant impact on quality of life.46,47 Although hand eczema in this population-based study was mild to moderate in the majority of cases, and the DLQI not as high as in studies including patients from dermatological departments,46 one-third of the young adults were affected in daily activities in their occupations. Most commonly, they reported that they had to use gloves, had been sick listed or had even changed job. Only 6% reported some or substantial financial loss in this age group. Recently, a Danish study evaluated the effect of a secondary prevention programme for hand eczema among healthcare workers. The programme reduced disease severity and improved quality of life and had a positive effect on self-evaluated severity and skin protective behaviour by hand washing and the wearing of protective gloves.48 Such programmes should be recommended to all people in at-risk occupations to improve the long-term prognosis for hand eczema and the quality of life for patients. It will be important to follow up the TOACS cohort again with respect to development of hand eczema when the young adults have been working for a longer time in their trade. Many were still in education. In conclusion, this prospective population-based cohort study of hand eczema from adolescence to adulthood showed a high incidence and prevalence of hand eczema both by questionnaire and by clinical examination, although most cases were mild to moderate. Childhood factors of significance for adult hand eczema were atopic dermatitis (at age 0– 14 years) and hand eczema in adolescence (age 14 years), while the factors of importance in adulthood were wet work and exposure to wet work at home (taking care of small children). Association with risk occupations in this unselected population of young adults could not be evaluated further due to the small numbers of people in the different occupations. Many were still in education or had worked only a few years in their particular jobs.

Acknowledgments We thank the adults from the TOACS cohort for their cooperation, and nurses Lis Lykkegaard and Marianne Hald, and laboratory technician Anni Larsen for skilful technical help. This work used the technical facilities of OPEN (Odense Patient data Exploratory Network), Odense University Hospital, Odense, Denmark.

References 1 Thyssen JP, Johansen JD, Linneberg A, Menn
e T. The epidemiology of hand eczema in the general population – prevalence and main findings. Contact Dermatitis 2010; 62:75–87. 2 Meding B, Swanbeck G. Prevalence of hand eczema in an industrial city. Br J Dermatol 1987; 116:627–34.

British Journal of Dermatology (2014) 171, pp313–323

322 Hand eczema in the TOACS cohort, C.G. Mortz et al. 3 Meding B. Epidemiology of hand eczema in an industrial city. Acta Derm Venereol Suppl Stockh 1990; 153:1–43. 4 Lerbaek A, Kyvik KO, Ravn H et al. Incidence of hand eczema in a population-based twin cohort: genetic and environmental risk factors. Br J Dermatol 2007; 157:552–7. 5 Meding B, Jarvholm B. Incidence of hand eczema – a populationbased retrospective study. J Invest Dermatol 2004; 122:873–7. 6 Lantinga H, Nater JP, Coenraads PJ. Prevalence, incidence and course of eczema on the hands and forearms in a sample of the general population. Contact Dermatitis 1984; 10:135–9. 7 Meding B, Liden C, Berglind N. Self-diagnosed dermatitis in adults. Results from a population survey in Stockholm. Contact Dermatitis 2001; 45:341–5. 8 Yngveson M, Svensson A, Johannisson A, Isacsson A. Hand dermatosis in upper secondary school pupils: 2-year comparison and follow-up. Br J Dermatol 2000; 142:485–9. 9 Meding B, Jarvholm B. Hand eczema in Swedish adults – changes in prevalence between 1983 and 1996. J Invest Dermatol 2002; 118:719–23. 10 Mortz CG, Lauritsen JM, Bindslev-Jensen C, Andersen KE. Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis. Br J Dermatol 2001; 144:523–32. 11 Meding B, Swanbeck G. Predictive factors for hand eczema. Contact Dermatitis 1990; 23:154–61. 12 Menn
e T, Borgan O, Green A. Nickel allergy and hand dermatitis in a stratified sample of the Danish female population: an epidemiological study including a statistic appendix. Acta Derm Venereol 1982; 62:35–41. 13 Josefson A, F€arm G, Stymne B, Meding B. Nickel allergy and hand eczema – a 20-year follow up. Contact Dermatitis 2006; 55:286–90. 14 Mortz CG, Lauritsen JM, Bindslev-Jensen C, Andersen KE. Nickel sensitization in adolescents and association with ear piercing, use of dental braces and hand eczema. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS). Acta Derm Venereol 2002; 82:359–64. 15 Thyssen JP, Linneberg A, Menn
e T et al. The association between hand eczema and nickel allergy has weakened among young women in the general population following the Danish nickel regulation: results from two cross-sectional studies. Contact Dermatitis 2009; 61:342–8. 16 Apfelbacher CJ, Funke U, Radulescu M, Diepgen TL. Determinants of current hand eczema: results from case–control studies nested in the PACO follow-up study (PACO II). Contact Dermatitis 2010; 62:363–70. 17 Bryld LE, Hindsberger C, Kyvik KO et al. Risk factors influencing the development of hand eczema in a population-based twin sample. Br J Dermatol 2003; 149:1214–20. 18 Meding B, Lindahl G, Alderling M et al. Is skin exposure to water mainly occupational or nonoccupational? A population-based study Br J Dermatol 2013; 168:1281–6. 19 Thyssen JP, Linneberg A, Menn
e T et al. The effect of tobacco smoking and alcohol consumption on the prevalence of selfreported hand eczema: a cross-sectional population-based study. Br J Dermatol 2010; 162:619–26. 20 Dalgard F, Svensson A, Holm JØ, Sundby J. Self-reported skin morbidity in Oslo. Associations with sociodemographic factors among adults in a cross-sectional study. Br J Dermatol 2004; 151:452–7. 21 Bingefors K, Lindberg M, Isacson D. Quality of life, use of topical medications and socio-economic data in hand eczema: a Swedish nationwide survey. Acta Derm Venereol 2011; 91:452–8.

British Journal of Dermatology (2014) 171, pp313–323

22 Susitaival P, Husman L, Hollm
en A, Horsmanheimo M. Dermatoses determined in a population of farmers in a questionnaire-based clinical study including methodology validation. Scand J Work Environ Health 1995; 21:30–5. 23 Smit HA, Coenraads PJ, Lavrijsen AP, Nater JP. Evaluation of a selfadministered questionnaire on hand dermatitis. Contact Dermatitis 1992; 26:11–16. 24 Meding B, Barregard L. Validity of self-reports of hand eczema. Contact Dermatitis 2001; 45:99–103. 25 Susitaival P, Flyvholm MA, Meding B et al. Nordic Occupational Skin Questionnaire (NOSQ-2002): a new tool for surveying occupational skin diseases and exposure. Contact Dermatitis 2003; 49:70–6. 26 Susitaival P, Kanerva L, Hannuksela M et al. Tuohilampi questionnaire for epidemiological studies of contact dermatitis and atopy. People Work 1996; 10:1–26. 27 Lysdal SH, Søsted H, Andersen KE, Johansen JD. Hand eczema in hairdressers: a Danish register-based study of the prevalence of hand eczema and its career consequences. Contact Dermatitis 2011; 65:151–8. 28 Ibler KS, Jemec GB, Flyvholm MA et al. Hand eczema: prevalence and risk factors of hand eczema in a population of 2274 healthcare workers. Contact Dermatitis 2012; 67:200–7. 29 Mortz CG, Bindslev-Jensen C, Andersen KE. Prevalence, incidence rates and persistence of contact allergy and allergic contact dermatitis in The Odense Adolescence Cohort Study: a 15-year followup. Br J Dermatol 2013; 168:318–25. 30 Mortz CG, Bindslev-Jensen C, Andersen KE. Nickel allergy from adolescence to adulthood in the TOACS cohort. Contact Dermatitis 2013; 68:348–56. 31 Schultz Larsen F, Diepgen T, Svensson  A. The occurrence of atopic dermatitis in north Europe: an international questionnaire study. J Am Acad Dermatol 1996; 34:760–4. 32 Skoet R, Olsen J, Mathiesen B et al. A survey of occupational hand eczema in Denmark. Contact Dermatitis 2004; 51:159–66. 33 Diepgen TL, Coenraads PJ. The epidemiology of occupational contact dermatitis. Int Arch Occup Environ Health 1999; 72:496–506. 34 Hald M, Veien NK, Laurberg G, Johansen JD. Severity of hand eczema assessed by patients and dermatologist using a photographic guide. Br J Dermatol 2007; 156:77–80. 35 Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19:210–16. 36 Held E, Skoet R, Johansen JD, Agner T. The hand eczema severity index (HECSI): a scoring system for clinical assessment of hand eczema. A study of inter- and intraobserver reliability. Br J Dermatol 2005; 152:302–7. 37 Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol Suppl Stockh 1980; 92:44–7. 38 European Task Force on Atopic Dermatitis. Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the European Task Force on Atopic Dermatitis. Dermatology 1993; 186:23–31. 39 Mortz CG, Lauritsen JM, Bindslev-Jensen C, Andersen KE. Contact allergy and allergic contact dermatitis in adolescents: prevalence measures and associations. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS). Acta Derm Venereol 2002; 82:352–8. 40 Meding B, Swanbeck G. Epidemiology of different types of hand eczema in an industrial city. Acta Derm Venereol 1989; 69:227–33. 41 Kavli G, Førde OH. Hand dermatoses in Tromsø. Contact Dermatitis 1984; 10:174–7. 42 Apfelbacher CJ, Radulescu M, Diepgen TL, Funke U. Occurrence and prognosis of hand eczema in the car industry: results from the PACO follow-up study (PACO II). Contact Dermatitis 2008; 58:322–9.

© 2014 British Association of Dermatologists

Hand eczema in the TOACS cohort, C.G. Mortz et al. 323 43 Josefson A, F€arm G, Magnuson A, Meding B. Nickel allergy as risk factor for hand eczema: a population-based study. Br J Dermatol 2009; 160:828–34. 44 Nilsson E, Mikaelsson B, Andersson S. Atopy, occupation and domestic work as risk factors for hand eczema in hospital workers. Contact Dermatitis 1985; 13:216–23. 45 Meding B, Wrangsjo K, Jarvholm B. Fifteen-year follow-up of hand eczema: persistence and consequences. Br J Dermatol 2005; 152:975–80.

© 2014 British Association of Dermatologists

46 Agner T, Andersen KE, Brandao FM et al. Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. Contact Dermatitis 2008; 59:43–7. 47 Cvetkovski RS, Zachariae R, Jensen H et al. Quality of life and depression in a population of occupational hand eczema patients. Contact Dermatitis 2006; 54:106–11. 48 Ibler KS, Jemec GB, Diepgen TL et al. Skin care education and individual counselling versus treatment as usual in healthcare workers with hand eczema: randomised clinical trial. BMJ 2012; 345:e7822.

British Journal of Dermatology (2014) 171, pp313–323