Occupational and Environmental Lung Diseases

Diseases from Work, Home, Outdoor and Other Exposures

Susan Tarlo, Paul Cullinan, Benoit B. Nemery, Susan Tarlo, Paul Cullinan, Benoit Nemery

• Publisher: Wiley
• Year: 2011
• ISBN:
  9781119957225
• Edition: 1
• Topic: Medicine
• Subtopic: Pulmonary & Thoracic Medicine

Documents both environmental and work-related causes of lung disease

Unlike other books on the subject, this new volume approaches occupational and environmental lung disease from the starting point of the patient who comes to the physician with respiratory symptoms. The authors recognize that potentially harmful exposures occur not only in the work environment, but also as a result of hobbies or other leisure activities, or from outdoor air pollution, and it is up the physician to identify whether a particular job or hobby is the cause of the patient's respiratory symptoms.
To help you arrive at a differential diagnosis, chapters in the book are arranged by job or exposure, and are divided into 5 sections:

• Personal environment
• Home environment
• Other indoor environments
• Work environment
• General environment

Each is written by an expert in the specific topic and provides pragmatic information for the practicing physician. This practical book is an invaluable resource that belongs close at hand for all physicians dealing with patients experiencing respiratory symptoms.

Part I

The personal environment

1

Cosmetics and personal care products in lung diseases

Howard M. Kipen

UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ, USA

1.1 Introduction: historical context of cosmetics and respiratory illness

Cosmetics may be associated with respiratory illness through two different but overlapping mechanisms. One is via causation of pathological disease, most prominently related to allergen-mediated mucosal and airway responses. The second mechanism is through symptoms and illness behavior associated with odors from the cosmetics. The extent to which these symptoms may also interact with mucosal irritant properties of the agents makes differentiation between airway pathology and symptoms unrelated to airway pathology at times problematic. This chapter will describe the data supporting different disease mechanisms and appropriate clinical and preventive responses.

A wide range of individuals, rather than typically ‘healthy workers’, regularly come into contact with personal care products such as soaps, perfumes and hair products. Many of these products are designed to announce their presence to those nearby (perfume odors), and they encompass a diverse array of chemical substances. Odordriven responses may be from the essential product, such as a perfume essence, or added material contained in a mix, such as fragrances added to a hairspray or after-shave. While behavioral effects of agents such as perfumes are intentional and legendary, the association of physical pulmonary conditions with cosmetic products was not reported until the late 1950s. Around 1960 a series of cases reporting a ‘storage disease’ (thesaurosis) or pneumonitis (‘hairspray lung’) were published. However a prevalent condition of the pulmonary parenchyma was never established (possibly due to various changes in hairspray formulations) and all subsequent concern with respiratory effects of cosmetic and personal care agents has centered on the airways, particularly asthma. The first report of allergic occupational asthma in hairdressers is attributed to Jack Pepys [1] in 1976. The remainder of this chapter will consider both allergic airway disease from cosmetics and personal products and the more complex nonallergic responses to odors.

1.2 Epidemiological context

1.2.1 Occupational exposure to cosmetics and personal care products

Data from the USA reveal the substantial size of the workforce involved in cosmetology. According to the US Bureau of Labor Statistics, barbers, cosmetologists and other personal appearance workers held about 790,000 US jobs in 2004. Of these, barbers, hairdressers, hairstylists and cosmetologists held 670,000 jobs; manicurists and pedicurists 60,000; skin care specialists 30,000; and shampooers 27,000. Because most of the relevant scientific literature pertains specifically to hairdressers, this term will be used for the remainder of the chapter. There is no available data on the number of individuals involved in the perfume industry.

Although methods for ascertainment differ greatly between countries, the burden of airway disease in hairdressers has been quantitiated in many different nations. Methodologies of varying rigor, including some that are population-based, have documented apparent excesses of asthma and respiratory symptoms relative to the general population among hairdressers working in Sweden, France, Germany, Belgium, Norway, Turkey and Italy.

A 2002 questionnaire study of all active Swedish hairdressers showed an asthma incidence rate ratio of 1.6 in never smokers, comparable to the effect of smoking alone in the same group. There was also a nonsignificant excess risk of asthma for self-reports of more frequent exposure to bleaching agents or hairsprays. Interestingly, there was no effect modification by reported atopy and no dose-response relationships for use of persulfates, at variance with much of the clinical data cited below that emphasize the role of persulfate exposure.

Iwatsubo and colleagues [2] found no increased respiratory symptoms among hairdressing apprentices compared with office apprentices, but there was a significant decline in FEV₁ and FEF_25-75 (forced expratory flow), not linked to any specific hairdressing activities. Other studies from France are based on the voluntary national physician reporting program for occupational asthma (Observatoire National des Asthmes Professionels). French asthma incidence rates for hairdressers are 308/million, placing hairdressers at the third highest risk for occupational asthma after bakers and pastry makers (683/million) and car painters (326/million).

In Belgium questionnaires completed by hairdressing students showed that 14.1% had already had asthma and 26.7% reported wheezing over the past 12 months. A 1996 study estimated that the burden of work-related asthma in Turkish hairdressers was 14.6%. In Italy about half of a group of hairdressers referred for work-related respiratory symptoms were found to have occupational asthma by specific inhalation challenge, along with a strong association with occupational rhinitis.

1.2.2 Non-occupational exposure to cosmetics and personal care products

In a Danish nonoccupational population-based study that included methacholine challenge and skin prick testing it was found that there was no relationship between perfume-associated significant symptoms and atopy, serum ECP or FEV1. However, 42% of subjects reported ocular or airway symptoms from exposure to fragrance, and these 42% were 2.3 times as likely to have bronchial hyperreactivity (BHR) as those without symptoms, suggesting a link between fragrance responses and this defined physiological vulnerability. The fact that 30-40% of those who reported respiratory symptoms in this population-based study had a positive BHR test suggests the possible import of fragrance-induced symptoms, although physiological studies in vulnerable or symptomatic individuals, discussed below, suggest that these relationships are quite complex.

Reported provocation of symptoms by environmental chemicals, prominently including perfumes and cosmetics, typically detected by odor, has been shown to be common, averaging about 10-20% of random samples with a range of 10-60% of more specific subpopulations, asthmatics being a prominent subgroup. A more extreme form of such reported sensitivity to chemicals is multiple chemical sensitivities (MCS) or idiopathic environmental intolerance (IEI). In this case the sensitivity to odors affects behavior and social interactions, becoming potentially disabling. No clear physiological abnormalities or explanations have been discovered. Although many clinicians and researchers favor psychological mechanisms for such odor-induced symptoms, there is substantial disagreement.

Of particular interest to pulmonologists, individuals fitting the description of MCS seem to have a high rate of pulmonary symptoms. Although data come from clinical series, when compared with age- and sex-matched controls, MCS individuals reported on questionnaires from 1.5 to over 10 times the rate of upper and lower respiratory symptoms, and as suggested above, individuals with asthma report higher rates of provocation by cosmetics and personal care products.

1.3 Description of exposures

1.3.1 Major work processes

Hairdressers, besides cutting and shampooing hair, are involved in permanent wave applications and rinsing, in applications of neutralizing agent, in preparing, applying and rinsing hair color, and in preparing, applying and rinsing hair bleaches. Mixing of bleaching powder takes 2-5 minutes per treatment, and it is thought that most exposure to persulfates occurs in this phase, often done in a back room of the salon, rather than during application in the salon per se.

1.3.2 Occupational exposures

Hair dressers have three main classes of workplace exposures:

1. para-phenylamine diamine based dyes, generally associated with delayed hyper-sensitivity contact dermatitis;

2. henna (vegetable dye), a rare cause of occupational asthma; and

3. lacquers and bleaching agents with persulfate salts, known to cause dermatitis, rhinitis and asthma.

We focus on the latter for this respiratory disease text.

There are three categories of hair-dye formulation used respectively for temporary, semi-permanent and permanent hair coloring. The latter are also known as oxidative dyes and are resistant to shampooing. The permanent dyes almost invariably contain ammonium, potassium and sodium persulfates. Persulfate salts are reactive, low-molecular weight compounds widely used in many industries, but particularly cosmetics. The persulfates (H₂S₂O₈) are mixed with an oxidant (H₂O₂) immediately before use. Improved hair penetration is achieved with the addition of ammonia releasers such as ammonium chloride or ammonium phosphate. Permanent waving chemicals can be either alkaline or slightly acidic aqueous solutions. They contain thioglycolic acid or hydrogen peroxide, with ammonia added to enhance hair penetration. Thus, potent irritants/oxidants including ammonia, hydrogen peroxide (H₂O₂) and persulfates (H₂S₂O₈) are commonly found in the hairdressing environment.

Hair bleaching agents are generally felt to be the most common cause of occupational asthma in hairdressers; however not all studies report that duration of exposure was significantly greater in those who became sensitized. They are the leading causes implicated in specific occupational asthma reports from France and Italy.

1.3.3 Perfumes and nonoccupational exposures

Perfumes are blends of odiferous ingredients made from a diluent (commonly ethanol) and mixtures of up to 3000 natural and synthetic fragrance ingredients including volatile oils and aldehydes, potential irritants and sensitizers. Because many of the ingredients are volatile, exposure is widespread, either intentionally or incidentally in proximity to users. Cleaning agents for home or commercial use are associated with asthma, and also contain perfume agents as well as cleaning agents that may be respiratory irritants or sensitizers.

1.3.4 Quantitation of exposures in hair salons

In a Swedish study exposures to persulfates during mixing were associated with personal exposures of 35-150 μg persulfates/m³ and mixing area exposures ranged from 23-50 μg persulfates/m³. In a study of exposure in French salons, H₂O₂ showed mean personal exposure levels of 51 μg/m³, NH₃ was 900 μg/m³ and persulfate was 190 μg/m³. These values are below applicable workplace standards, although many deficiencies in ventilation were noted in this study and would seem to be common in the industry.

1.3.5 Exposure history: practical advice and pitfalls

It is important to understand the layout of a salon, including any separate rooms in which mixing of hair products takes place. Specific questions about windows or mechanical ventilation are important. Although ventilation in salons is often reported as substandard, in the rare instances when exposures have been measured, they have been typically less than applicable threshold limit values (TLV) (H₂O₂, NH₃ and H₂S₂O₈) on either side of the Atlantic. This may reflect that the salons studied were not completely representative of all salons. Of course, for individuals who have become sensitized, adherence to threshold limit values cannot be relied upon to prevent future reactions.

1.3.6 Documentation of exposure and biomonitoring

Exposure monitoring in salons is not commonly performed, and measures of persistent body burden do not exist and are probably not appropriate to the natural history of the relevant conditions. Moscato [3] reports that, although some hairdressers with asthma have positive skin tests to persulfate, it is not a reliable test of sensitization, because many individuals with disease and apparent exposure have negative tests. As with other prominent causes of occupational asthma, especially for low molecular weight antigens, the available skin test is not clearly immunologically (IgE) mediated. One caveat is that anaphylaxis to persulfate skin testing has been reported.

1.4 Respiratory diseases associated with exposure to cosmetics and personal care products

1.4.1 Occupational asthma

Occupational asthma in hairdressers is felt to arise most commonly from sensitization to pe...

Table of contents

• Cover
• Title
• Copyright
• Contributors
• Preface
• Introduction
• Part I: The personal environment
• Part II: Other indoor environments
• Part III: The work environment
• Part IV: The general environment
• Index