Knowledge of Surgery-Related Allergic Contact Dermatitis among Florida Dermatological Surgeons: A Pilot Study

| November 5, 2009
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Panta Rouhani, PhD, MPH, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida;Department of Epidemiology and Public Health, Miller School of Medicine, University of Miami, Miami, Florida; Robert S. Kirsner, MD, PhD, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida; Department of Epidemiology and Public Health, Miller School of Medicine, University of Miami, Miami, Florida; Antoine Amado, MD, Department of Dermatology, Cleveland Clinic, Cleveland, Ohio; Lora E. Fleming, MD, PhD, Department of Epidemiology and Public Health, Miller School of Medicine, University of Miami, Miami, Florida; Keyvan Nouri, MD, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida; Sharon E. Jacob, MD, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida; Division of Dermatology, University of California, San Diego, San Diego, California

Disclosure: The authors report no relevant conflicts of interest.

Abstract
Objective. To assess knowledge base and practice habits of dermatological surgeons regarding surgery-related allergic contact dermatitis. Design. Cross-sectional study. Setting. The Florida Society of Dermatologic Surgery served as the study group. Participants. Cohort of dermatological surgeons. Measurements. An anonymous, close-ended survey instrument eliciting common surgical practices as well as allergic contact dermatitis knowledge. Results. Among the 45 respondents, 87 percent reported performing surgery more than 10 times per week and only 14 percent of respondents reported using latex-free gloves in their practice. Nearly two-thirds (66%) of respondents reported diagnosing allergic contact dermatitis either among themselves, their surgical staff, and/or patients. Surgeons were noted to use the TRUE Test® to screen for adhesive allergy. While colophony can be found both in adhesive products and on the TRUE Test, the main adhesives found in perisurgical products, acrylates, cannot. Similarly, the TRUE Test does not screen for antiseptics, yet this group of respondents suspected antiseptics nearly one-fourth of the time and used the TRUE Test to screen for them. Lastly, six dermatological surgeons used the TRUE Test to screen for suture allergy. While only two used chromated cat gut (the TRUE Test screens for chromium), the other surgical components are not screened. Conclusion. Education among dermatological surgeons is needed regarding exposure to a potential allergen in the surgical setting and risk of developing allergic contact dermatitis.  (J Clin Aesthetic Dermatol. 2009;2(11):33–36.)

With the growing number of dermatological surgeons comes an increased potential for exposure and sensitization to surgery-related antigens. While dermatological surgeons and medical staff have repetitive exposures to contact allergens, surgery-related allergic contact dermatitis (ACD) is not solely an occupational disease. Exposure to a potential allergen and risk of developing ACD are risks shared among patients, medical staff, and physicians. Cosmetic outcomes for patients after surgery may be negatively affected by the development of contact dermatitis. Dermatological surgeons and medical staff may be at an increased risk of developing allergies themselves because of the continued exposure to antigens, such as povidone-iodine, chlorhexidine gluconate, and rubber and additives in surgical gloves.[1] Opportunities for patient and physician exposures to potential contact allergens may occur preoperatively through skin preparation substances (e.g., iodine preparation), perioperatively (e.g., nickel-plated surgical instruments), and/or postoperatively (e.g., bacitracin, dressings).[2,4–5]

Reactions typically occur 48 to 96 hours after exposure. As a result, temporal association between reaction and allergen may become difficult to determine. Specialized testing (e.g., patch testing) may help establish the association.[1,2] While potential contact allergens that may be encountered in the surgical setting recently have been described, a specific standard screening panel for surgery-related allergens has not yet been developed.[3]

The cornerstone of treatment of ACD is avoidance. Knowledge, early detection, and diagnosis of ACD are important in the care of surgical patients and practitioners, alike. Inherent risk of developing ACD exists from exposure to surgery-related allergens. Decreasing contact is the best prevention, but this may only happen through knowledge of the issue and the risks. It is important that dermatological surgeons are aware of potential allergens that are related to surgery. If dermatological surgeons are unaware of allergens in commonly used products and practices, risk of developing ACD may be inadvertently increased for both patients and themselves. The purpose of this study was to assess ACD knowledge base and practice habits among Florida dermatological surgeons.

Methods
A self-administered survey instrument eliciting common surgical practices, as well as inferred knowledge of ACD, was developed using close-ended questions. There were three key areas of interest assessed: physician demographics and daily practices, commonly used products and instruments, and knowledge and understanding of ACD. Questions regarding commonly used products and practices were inventory scales, allowing physicians to indicate any and all products that they use. The specific patch tests that were referenced on the questionnaire were the Thin-layer Rapid Use Epicutaneous (TRUE) Test® and comprehensive individualized testing in which the physician selects specific allergens for the patient for preparation in the Finn Chambers® or the IQ Chambers®. The Florida Society of Dermatologic Surgery (FSDS) was the study group.

Upon receipt of returned surveys, data was entered and stored in an Access database. Frequencies were calculated using SAS statistical software (version 9.1, SAS Institute Inc., Cary, NC). Institutional review board approval was obtained [IRB 2005-0243].

Results
A total of 221 surveys were sent to FSDS members. Forty-five of the 221 surveys were returned—a 20.4-percent response rate. The majority of respondents were male (82%). The mean age of the respondents was 52 years (range 27–75 years). The majority of respondents were in private practice (98%). The mean years in practice among the group were 20 years (range 2–45 years).

Practice behavior. Of the respondents, 87 percent reported performing surgery more than 10 times per week. Nearly 70 percent of the group reported washing their hands more than 20 times per day. When asked about glove type used in practice, 66 percent reported use of latex gloves, 20 percent were unaware of their glove type, and 14 percent of respondents reported using latex-free gloves. When asked what procedure the respondent would perform in a patient with “anesthetic allergy,” 63 percent reported saline infiltration. Less than one-tenth reported they would perform liquid nitrogen freeze (7%), refer for patch testing (5%), or perform TRUE Test (2%). Table 1 and Table 1 Continued lists the responses when asked about commonly used products and practices.

Knowledge of ACD. Nearly two-thirds (66%) of respondents reported diagnosing ACD either among themselves, their surgical staff, and/or their patients. Of these dermatological surgeons, three-fourths (75%) reported that they perform patch testing while one-fourth (25%) reported that they do not perform patch testing. Among those who reported patch testing, the majority (80%) reported use of the TRUE Test while smaller percentages reported use of the Finn Chamber (17%) or IQ Chamber (3%).

Table 2 lists the chemical exposures that were suspected among those dermatological surgeons who reported use of the TRUE Test.

Discussion
The purpose of this study was to assess ACD knowledge base and practice habits among Florida dermatological surgeons. In this study, among dermatological surgeons who reported use of the TRUE Test, adhesives were suspected 73 percent of the time, while nickel was suspected 63 percent of the time.

Surgical instruments may be potentially nickel or nickel-plated (e.g., scalpels, holders, curettes, skin hooks, and comedone extractors). Nickel is also included in many alloys used in the manufacturing of surgical instruments. Since nickel represents the top allergen found on screening in the United States and the biological response is of immense significance, the use of nickel-free surgical steel is recommended.6 Of clinical note, stainless steel, which usually contains eight-percent nickel and 18-percent chromium does not to have the same reactivity/ capacity to elicit contact dermatitis as alloys.[7,8]

In terms of the most suspected category of adhesives, colophony can be found both in adhesive products and on the TRUE Test. It is notable, however, that the main adhesives found in perisurgical products, acrylates, are not included on the commercially available screening panel.[9] In a recent case series, despite the use of a customized adhesive tray, Storrs et al[10] perceived the reactions to have been secondary to irritant contact dermatitis rather than ACD. Similarly, the TRUE Test does not screen for antiseptics, yet this group of respondents suspected antiseptics nearly one-fourth of the time and used the TRUE Test to screen for them.[9] Lastly, while the chromate in chromated cat gut is screened through use of the TRUE Test, other surgical sutures are not screened.[9] While six dermatological surgeons reported screening for suture, only two used chromated cat gut.

This limited study allowed for a glimpse of the practice habits of our local dermatological surgeons. We found that nearly three-fourths of the respondents (70%) reported washing their hands more than 20 times per day. With frequent handwashing, a risk factor for irritant contact dermatitis (ICD), it is important that dermatological surgeons are aware of their increased risk for ICD. Knowledge of glove type was particularly interesting among this study population. One-fifth (20%) were unaware of the types of gloves they use in practice, while two-thirds (66%) acknowledged use of latex gloves. Previous studies have demonstrated the medical and economic merits of latex glove allergy awareness among dermatological surgeons.[11–13] The observed lack of  knowledge about glove type use among our respondents highlights the need for increased awareness of glove type and the potential allergens found in gloves. Additionally, the need for knowledge regarding allergy to rubber accelerators is also needed. Although the amount of protein in latex gloves has dramatically decreased over recent years, rubber accelerators in latex as well as latex-free gloves are a significant source of exposure for ACD.[14,15]

Although limited by a low response rate (20.4%), the results of this preliminary study indicate the need for further analysis of ACD in the surgical setting. It is probable that low knowledge among dermatological surgeons may have indirectly contributed to the low response rate by deterring respondents from participating. A future study utilizing a more refined survey to capture knowledge is needed. Additionally, administration of any survey through numerous mailings, contacts, and any involvement of other larger dermatological surgery organizations should yield higher response rates to capture larger groups.

Conclusion
Based on incongruities between suspected allergens and allergens screened for, we determined that education among dermatological surgeons is needed regarding the limitations and utility of the standard screening tool. With this increased knowledge, the efficacy of the TRUE Test could be optimized as correct use would yield higher detection rates and eliminate improper and incomplete testing (e.g., screening for allergens not included on the screen).

Furthermore, since prevention of surgery-related ACD requires identification of harmful exposures to irritants and allergens, the authors encourage subsequent efforts be focused on reduction, replacement, elimination and avoidance of exposures to identified agents. Further epidemiological studies on the prevention of ACD in the surgical setting are needed to prove the effectiveness of preventive measures.

References
1.    Jacob SE, Amado A, Cohen DE. Dermatologic surgical implications of allergic contact dermatitis: a review. Dermatol Surg. 2005;31(9 Part 1):1116–1123.
2.    Jacob SE, James WD. From road rash to top allergen in a flash: bacitracin. Dermatol Surg. 2004;30(4):521–524.
3.    Messingham MJ, Arpey CJ. Update on the use of antibiotics in cutaneous surgery. Dermatol Surg. 2005;31(8):1068–1078.
4.    Cohen DE, Kaufmann JE. Hypersensitivity reactions to products and devices in plastic surgery. Facial Plast Surg Clin North Am. 2003;11(2):253–265.
5.    Jacob SE, Amini S, Cohen DE. Contact dermatitis in dermatologic surgery. In: Nouri K, ed. Complications in Dermatologic Surgery. New York: Elsevier; in press.
6.    Pratt MD, Belsito DV, DeLeo VA, et al. North American Contact Dermatitis Group patch-test results, 2001–2002 study period. Dermatitis. 2004;15(4):176–183.
7.    Jensen CS, Lisby S, Baadsgaard O, et al. Release of nickel ions from stainless steel alloys used in dental braces and their patch test reactivity in nickel-sensitive individuals. Contact Dermatitis. 2003;48(6):300–304.
8.    Reclaru L, Ziegenhagen R, Eschler PY, Blatter A, Lemaître J. Comparative corrosion study of “Ni-free” austenitic stainless steels in view of medical applications. Acta Biomater. 2006;2(4):433–434.
9.    Allerderm. TRUE Test. http://www.truetest.com/Patient
PDF/Patient1_TRUE%20TEST%20QandA.pdf. Accessed August 24, 2007.
10.    Widman TJ, Oostman H, Storrs FJ. Allergic contact dermatitis from medical adhesive bandages in patients who report having a reaction to medical bandages. Contact Dermatitis. 2008;19(1):32–37.
11.    Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis. 1987;17;270–275.
12.    Wyss M, Elsner P, Wuthrich P, et al. Allergic contact dermatitis from natural latex without contact urticaria. Contact Dermatitis. 1993;28:154–156.
13.    Sussman GL, Beezhold DH. Allergy to latex rubber. Ann Intern Med. 1995;122(1):43–46.
14.    Depree GJ, Bledsoe TA, Siegel PD. Survey of sulfur-containing rubber accelerator levels in latex and nitrile exam gloves. Contact Dermatitis. 2005;53(2):107–113.
15.    Anaveskar NS, Nixon R. Occupational allergic contact dermatitis to cobalt octoate included as an accelerator in a polyester resin. Australas J Dermatol. 2006;47(2): 143–144.

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Category: 11-2009 (November 2009), Allergic Contact Dermatitis, Original Research

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