Occupational Asthma and Occupational Rhinitis in Hairdressers

Gianna Moscato, MD; Patrizia Pignatti, PhD; Mona-Rita Yacoub, MD; Canzio Romano, MD; Sandro Spezia; Luca Perfetti, MD


CHEST. 2005;128(5):3590-3598. 

In This Article


From 1996 to 2004, 47 hairdressers were referred to our center for suspected OA. All were enrolled in the study. The characteristics of the patients are shown in Table 1 . SICs induced a bronchial response in 24 patients (51.1%), who received a diagnosis of OA. The responsible agents were ammonium persulfate in 21 cases (87.5%), permanent hair dyes in 2 cases (8.3%), and latex in 1 case (4.2%). In 13 of these 24 patients (54.2%), a nasal response was also induced by the SIC. These patients also received a diagnosis of OA. The responsible agents were ammonium persulfate in 11 cases (84.6%) and paraphenylenediamine in 2 cases (15.4%). In the remaining 23 patients (patients without OA), SIC induced a nasal response in 2 patients, resulting in a diagnosis of OA to persulfate in 1 patient and to latex in the other patient (both patients also had non-OA). In addition, in the same group, three patients received a diagnosis of non-OA plus nonoccupational rhinitis and one patient had nonoccupational rhinitis. In the overall group (n = 47), 17 patients received a diagnosis of allergic occupational dermatitis, 7 patients in the group with OA, and 10 patients in the group without OA.

Since the number of patients with OA due to substances other than persulfate salts was small, a comparison was made only between the two groups of patients, respectively, with OA due to persulfate (patients with a positive SIC response to ammonium persulfate, n = 21) and patients without OA due to persulfate (patients with a negative SIC response to ammonium persulfate, n = 23).

The patients of this group were young (mean age, 25.6 ± 8.7 years) and mostly women (81%). Only a minority were current smokers (38.1%). The average overall duration of exposure was 7 years (range, 3 to 11 years), and the time elapsed between the beginning of exposure and the onset of symptoms (latency period) was 5.3 years (range, 1.8 to 9 years). Seven patients (33.3%) presented a family history of allergic disease. None of the patients reported previous occupations with possible risk factors for asthma, or symptoms of asthma, rhinitis, or dermatitis prior to the beginning of working as hairdressers. All 21 patients reported bronchial and/or nasal symptoms related to the workplace (positive stop/resume test result): 18 patients referred an association between bleaching and symptoms onset, while the remaining 3 patients were not able to relate symptoms to bleaching. In 11 patients, symptoms appeared almost 60 min after starting work, whereas in the other 10 patients the onset of symptoms varied from day to day. The time elapsed from the onset of respiratory symptoms and diagnosis was 1.5 years (range, 0.6 to 2 years). In addition to the diagnosis of OA, 8 patients (38.1%) also received a diagnosis of occupational dermatitis and 11 patients (52.4%) received a diagnosis of occupational rhinitis. Among hairdressers with both asthma and occupational rhinitis, seven patients reported a simultaneous onset of nasal and bronchial symptoms, whereas in the other four patients rhinitic symptoms had preceded the onset of bronchial symptoms. Eleven patients (52.4%) also reported skin symptoms (dermatitis or urticaria).

SPTs results for common inhalant allergens were positive in 10 patients (47.6%), who were considered atopics. SPT results with ammonium persulfate were negative in all patients tested (n = 14). Patch test results with ammonium persulfate were positive in six patients; five of which were also positive to other substances used at the workplace; in three patients, patch test results were positive only for other substances used at the workplace. In the nine patients with a positive patch test result to ammonium persulfate or to other substances used at the workplace, a diagnosis of occupational dermatitis was made in addition to the diagnosis of OA. Sixteen patients (76.2%) had high total IgE levels (>120 kilounits per liter); 11 patients (52.4%) had specific IgE for common inhalant allergens as well as 2 patients (9.5%) for latex.

The results of spirometry, methacholine tests, and bronchodilator tests are shown in Table 1 . All patients had normal spirometry findings at the time of diagnosis. The methacholine test result was positive in 12 patients (57.2%). The average time between last exposure and methacholine challenge was 4 days (range, 1.5 to 8 days). The bronchodilator test result was positive in only a third of patients (28.5%).

SIC with ammonium persulfate induced an early bronchial response in 4 patients (19.0%), an isolated late response in 14 patients (66.7%), and a dual response in 3 patients (14.3%). The details of the specific challenge tests are described in Table 2 and in Figure 1. The time onset of the late phase in late or dual responses negatively correlated with the overall duration of work exposure (r = – 0.69, p = 0.002). Eleven patients also had a positive nasal response to the SIC, as shown by symptom score, and a diagnosis of occupational rhinitis was made. The nasal response preceded the late bronchial response in all cases.

FEV1 maximal (Max) fall during SIC with persulphates in SIC-negative and SIC-positive patients.

The induced sputum cell count of patients with SIC positive to ammonium persulfate is reported in Table 3 . Seven of 10 of these patients (70.0%) in this group had eosinophilic airway inflammation. The frequency of patients with eosinophilic airway inflammation tended to be higher in the SIC-positive patients compared to SIC-negative patients (3 of 11 SIC-negative patients, 27.3%) [p = 0.05]. The total amount of neutrophils was low in both groups; nevertheless, SIC-positive hairdressers had a significantly lower amount of sputum neutrophils compared to SIC-negative patients. The average time elapsed between the last work exposure and the sputum induction was comparable in the two groups of patients (SIC-positive hairdressers, 4.5 days; range, 3 to 21 days; SIC-negative hairdressers, 4.0 days; range, 0 to 60 days). No correlation between sputum eosinophils and the last work exposure, PD20 values, disease duration, IgE levels, and FEV1 maximal fall after SIC was found.

The general characteristics of these patients are described in Table 1 . No significant difference was found between the two groups in age, sex, atopy, IgE levels, smoking habits, overall duration of exposure, latent period before onset of symptoms, duration of symptoms before diagnosis, and baseline FEV1 percentage. A significantly lower number of positive responses to the methacholine test was found in this group of patients (p = 0.0001), compared with patients with positive SIC responses to ammonium persulfate. Positive stop/resume test results were significantly more frequent in the SIC-positive group vs the SIC-negative group ( Table 1 ).

The time between the last exposure and methacholine challenge was 3 days (range, 1 to 45 days) without any significant difference with the other group. No significant response to the bronchodilator test was found in any patient of this group. The maximal percentage fall in FEV1 during the SIC with ammonium persulfate was 6% (range, 2 to 15%) [Fig 1].


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