1. INDUSTRIJSKA OBOLJENJA KOŽE I BRIGA O KOŽI

2. Ciljevi prodajnog sastanka
Budite informirani o industrijskim oboljenjima kože i brizi o koži, a da bi mogli koristiti te elemente tijekom prodajnog procesa sa medicinskom sestrom, doktorom koji radi u industrijskom okruženju ili osobom koja je odgovorna za zdravlje i sigurnost radnika.
This presentation has been created to support you to promote our Plus Range but also to complete your general knowledge about the skin, its diseases and its care.

3. Plan rada Koža : sastav kože, brojnost oboljenja u inustriji, ...
Oboljenja kože
Dermatitis izazvan iritirajućim kontaktom
Dermatitis izazvan alergijom
Urticaria kontakt
Pogoršavajući faktori
Reakcije kože na rukavice
Latex : bez pudera, niski udio proteina, premazane
Nitrile
PVC i Neoprene
Proizvodi za zaštitu kože

4. Koža Epidermis Dermis Adipozno tkivo Ruke = 2.5 % površine tijela
Rožnati vanjski sloj
Granularni sloj
Osnovni sloj
Dermis
Adipozno tkivo
The skin surface is 1.85 m². The skin is vulnerable to cutting impact, penetration objects, radiation, all types of dirt, bacteria and fungi. Total thickness : 0.5 to 4 mm
1 cm² of skin contains :
12 sensory apparatuses for heat 15 sebaceous gland cells
2 yard of blood vessels 100 sweat gland 10 hairs,
3000 sensory cells at the end of nerve fibers 4 yards of nerves -25 pressure sensor
200 nerve endings to record pain 2 sensory apparatuses for cold
Adipous tissue : layer of fatty tissue which serves as an energy reserve and an insulation.
Dermis :1 to 4 mm. Collagen fibers and elastin => strength and elasticity
Cells, Small Blood vessels, Fine sensory nerves termination, perspiration cells, ...
Sebaceous glands that surround each hair roots --> water resistant lipid film (sebum) : keep hair flexible and form an oily film on the skin’s outer surface.
The outermost layer is termed the Epidermis, and provides our primary protection. The epidermial skin is only 0.06 to 1 mm thick.
Epidermis is also made up of several layers :
- the horny outer layer or stratum corneum. This layer protects our bodies against wear and tear. If contact with liquid chemicals would occur, the lipid film will rapidly be removed and allow substances to start penetrating the skin. Excessive hand washing or working with wet hands will also remove its protection.
- the granular layer, which is our primary defence against substances that would have penetrated the outer layer.
- the basal layer in which new skin cells are formed and travel upward to become the granular layer.
Only sweat ducts and hair follicles go right through to the epidermis layers.
Skin main functions :
- Protective membrane to protect the body, - absorbs some medicine
- contain the sensory captors - produce perspiration
Ruke = 2.5 % površine tijela

5. Reakcije kože
Ne reagiraju svi tipovi kože na isti način ili do istog stupnja na kemijske, fizičke i biologijske stresove.
Uključeni su razni faktori:
priroda kože (masnoća, dlakavost, pigmentacija),
godine,
spol,
godišnje doba i temperatura,
povijest kožnih oboljenja,
alergije i osobna higijena.
There are a lot of predisposing factors:
Nature of the skin : Our skin’s elasticity is dependant on its moisture content being kept between 10 % to 22 % max
Oily one : less susceptible when exposed to fat solvents, but more susceptible to substances that dissolve oil and so penetrate the skin
Dry : crack easily after exposure to alkalis and solvents -> infection more likely.
Age and experience: young and inexperienced people suffer more of occupational dermatitis (don’t wear glove easily); Allergies more present with older people => sensitization (cumulative exposure and altered percutaneous absorption)
Sex : women are more sensitive to occupational dermatitis because their skin is less oily but more likely to early treatment;
Temperature: occupational dermatitis are more frequent in warm weather (less clothed) because of perspiration . In winter temperature, the skin is dry and chapped => more occupational dermatitis.
History of skin disease : Type IV allergy can help to develop Type I allergy
Cleanliness : lack of cleanliness  greatest predisposition factor in Occupational dermatitis
To cause a skin disease, one of these 3 conditions must be fulfilled :
Damage the horny layer
Impair the horny layer that will facilitate irritant product penetration
Damage the “alive” dermis tissue
If the skin’s sweat pores become blocked, by contaminants such as dirt, engine grease, insoluble powders, etc… pressure on the ducts beneath will cause toxic substances in sweat to leak into surrounding tissue. This can cause uncomfortable skin eruptions that also provide openings for other substances or bacteria to enter the body.

6. Industrijska oboljenja - brojnost -
15 % svih industrijskih oboljenja povezana su sa kožom.
5 % svih industrijskih oboljenja je tzv. urticaria izazvana kontaktom (alergije).
Riskantnije aktivnosti :
- čišćenje, domarski poslovi i catering (deterdženti, dezinficirajuća sredstva, voda),
- građevinarstvo, tesarstvo (cement, bojanja, organski razrjeđivači, smole),
- industrija metala i mehanike (podmazivači, razrjeđivači, kiselina, tekućine za rad sa metalom),
- kemijska industrija (formol, isocijanati, …),
- industrija plastike (epoxy-smola, poliesteri, …),
- farmeri, vrtlari (fitosanitarni proizvodi),
- zdravstvo i zubari,
- frizeri (šamponi, boje, …),
Statistics demonstrate the skin diseases are more and more numerous because of the higher level of recognition by the social system…
Diseases related to chemical products are more and more numerous.
Before Skin diseases were considered like “Occupational risks” ... It is no longer necessary to get your hands dirty to “show that you are doing the job !”.
Skin diseases cause :
- alteration of efficiency - increase absenteeism
- may cause a downgrading of the employee - may cause a permanent incapacity (e.g. hair-dresser)
Others diseases than Urticaria or Dermatitis :
- Photosensitizers (coal tar, certain dyes, crude petroleum ) --> sunbrun, hives and blisters
- Insoluble oils, greases, tars, waxes, certain chlorinated hydrocarbons => folliculitis and acniform dermatitis --> skin cancer can result from repeated contact or prolonged contact.
- Arsenic, Coke oven, soots and tars --> skin cancer.
Example : Study on the hands among female cleaners (1107 people)- Denmark 1989
Wet hands at workplace and at home :
< 1 hour : 19 % ; 1-10 hours : 25 % ; hours : 33 % ; hours : 16 % ; hours : 6 % ; > 40 hours : 1 %.
- 2/3 of all cleaners worked less than 30 hours/ week.
- Wet hands occurred more than 25 % of the working hours amongst 81 % of the cleaners.
- 20 % of the cleaners indicated problems with cleaning agents.
Use of PPE :
Often : 26 % (Work) 8 % (Home)
Sometimes : 16 % (Work) 16 % (Home)
Seldom : 58 % (Work) 76 % (Home)
- 46 % of the cleaner reported at least 1 out of 4 skin symptoms during one year (red and rough skin, itching, cracks, vesicles).
- Dose response association between skin symptoms and number of hours cleaning with wet hands.
- Use of gloves was also associated with the occurrence of skin symptoms.

7. Što je dermatitis izazvan kontaktom?
Koža gubi mogućnost svoje revitalizacije.
Uzrokovan produženim kontaktom sa tvarima koje djeluju bezopasno, a ne može se vidjeti na vrijeme da će biti opasne po kožu.
Trebaju mjeseci ili čak godine da se razvije.
Contact dermatitis (Exogenous cause) = Contact Eczema (Endogenous cause)
Occupational dermatitis is an inflammation of the skin resulting form exposure to irritants in working environment. It is a non-allergic response to contact with an external agent that damages dermal cell (horny layer).
This phenomenon may vary from slight reddening with mild itching to a rash or a small eruption with intense itching.
Contact with a highly irritating substances will result in dermatitis of all exposed skin, including the dorsum of the hands.
Chemical acts as a primary skin irritants or cutaneous sensitizers : will damage or extract from the skin its essential components (strong acids, alkalis, corrosive salts, solvents, …)
* Most common category --> common to all people, due to the chemical product the skin is in contact with
* Skin is « damaged » during each exposure --> skin will be repared. If damaging > reparing => desease
* The only way to prevent :
- no exposition
- wear gloves
- change product
Irritant dermatitis of the hands is very common and can result from frequent hand washing.
Example :A janitor would not dream of using a powerful bleach without wearing gloves. But the same janitor will use a proprietary cleanser based on dilute bleach say after day without protection. He cannot see any damage to his skin; at worst, it may feel a little dry. But in fact the epidermis is being damage every time and the skin must supply new cells to repair it. Eventually, if the pratice continues, the skin’s repair mechanism gives up, and sensitive underlying dermal tissue will be exposed - visibly and very painfully.

8. Dermatitis izazvan kontaktom
ICD occurs as a result of damage to the skin ; this damage may not at once be apparent. The concept is proposed by Malten.
Every time the skin is exposed to an irritant, damage is done. When contact with irritant ceases, the skin will start to recover. The damage can be completely restored. However, if there is subsequent contact, there will be a cumulative effect.
If action is not taken and the damage continues to accumulate, we can eventually reach a point where the skin seems to lose its ability to repair itself (upper part of the curve).
Whereas the exposure in each may not be sufficient to initiate a skin disorder, the cumulative effect of exposure may do so.
As the “malten diagram” shows, the skin remains vulnerable for some time after it appeared to heal. Thus adequate time must be allowed before worker is permitted to be again in contact with irritants.

9. Što je alergija?
Imunološki sistem kontinuirano provjerava da li u organizmu ima stranih tijela i uništava ih i pretvara ih u bezopasne tvari.
Alergija je pretjerani odgovor na strano tijelo koje nema pravi potencijal da prouzroči štetu imunološkom sistemu.
Alergije kože u industriji imaju dvije različite forme:
kontaktni dermatitis
kontaktna urticaria
The immune system is designed to protect us from bacteria, viruses, chemicals and parasites.
Allergen (antigens)= substances, when recognized by the cells and antibodies, that can cause an allergic response (abnormal responses to normal substances
Allergens : major and minor ones (related to their frequency to cause allergy reactions).
Antibodies : element that will defence the body with the help of T-cells
Allergic reaction are not dosed-related - a single molecule can trigger the reaction as easily as many molecule.
Sensitivity differs from person to person, it is hard to know what type of allergen and how much is needed to trigger a reaction.
Each individual patient has distinct patterns of reactivity to multiple proteins and is depend on the route of exposure and the spectrum of proteins of the sensitized latex products.

10. Što je alergijski kontaktni dermatitis (tip IV) ?
Koža može pocrvenjeti, svrbjeti, osipati se ili nešto još gore, na mjestu koje je bilo izloženo utjecaju
Izazvan je kontaktom kože sa poznatim alergenom. Reakcija odgovara imunološkom sistemu svake osobe individualno.
U početku reakcija kože nije vidljiva
i potrebno je par epizodnih kontakata
da bi se uočio problem.
Contact dermatitis = Contact Eczema = Delayed Hypersensitivity
Type IV related to the Gell and Coombs classification
The group at highest risk are workers who are wearing regularly rubber gloves, such as in the medical profession, health care industry and rubber industry.
* When chemical product is in contact with the skin--> attacks lipids --> chemical product goes to the blood --> effect on the « immune system » :
1 contact : no reaction
2 contact : no reaction
3 contact : reaction
It is impossible to predict how much contact with an allergen is necessary before sensitisation begins. Many factors are involved :
- the nature of the allergen and its concentration (e.g. nickel, thiurams, …),
- the frequency and duration of contact
- the presence of the other skin damage
- the type of skin
The chemical product is to be considered as an « allergen » = foreign elements for the human body
The only way to prevent :
- no exposition
- wear gloves
- change product
Allergic Contact Dermatitis is seen frequently in the aged population because of cumulative exposure to potential allergens over time and because aged skin has altered percutaneous absorption of potential allergens.
Type IV allergy may assist in acquiring type I allergy
Type IV allergy can happen to everyone -> f(strength of the stimulus)

11. Senzitivacija kod alergijskog kontaktnog dermatitisa1
Prvi kontakt
Bez prepoznavanja -
Nema napada
Senzitivacija
Tvar je “progutana”
od strane
langerhans stanica 2
Drugi kontakt
Tvar je uhvaćena od strane langerhans stanica
Reakcija
Memorijske
T stanice se proizvode da bi pripremile idući kontakt
This reaction is related to an hypersensitivity of cells (without antibodies production).
An antigen must penetrate the horny layer of the skin to reach the epidermis. There will make contact with a Langerhans cell. A fraction of the antigen adheres to the outer surface of the Langerhans cell.
Sensibilisation phase (cell-mediated)
- Substances are extracted from the glove and infiltrate into skin. The first time this happens, these are not immediately recognised as “foreign” and therefore they are not attacked (the necessary information is missing)
- Special bodycells absorb the substances and perform an “identity control”.
- The information gained are transferred to special defence cells, called T-Lymphocytes.
- Now the sensibilization for this particular substance has taken place, although the person has not noticed it 4 3

12. Alergijski kontaktni dermatitis početna faza
Novi kontakt
T-stanice su prisutne, spremne da se povežu na supstancu
Reakcija
Tvar je uhvaćena od strane T-stanica 1 2
Trigger Phase
- When the contact with this “allergen” is repeated, the specific T-cells do their job : they attach to the allergen
- Lymphokine is extracted by the cell and these activate other cells to produce “mediators”
- Inflammation occurs, hence first allergic reaction 3
Alergijska reakcija
T-stanice oslobađaju limfokin koji će aktivirati druge obrambene stanice
Histamine

13. Industrijski proizvodi koji mogu prouzročiti alergijski kontaktni dermatitis
Nickel allergy may induce hand dermatitis, which may be confused with glove dermatitis, since most metal items are made of alloys which contains nickel.
Others products : Anyline dyes, Organic mercury compounds and plastic organic solvents, uncured epoxy resins, …
Chromium Allergy : If a bricklayer (mason) is already allergic to chromium and if he wear some leather glove, he will once again have some redness and others manifestation.
Principal Occupation Sensitizers :
- Antimicrobial agents
- Antioxydants
- Perfumes
- Colophony
- Metals
- Medicines
- Organic dyes
- Pesticides and Fungicides
- Photographic chemicals
- Plants and Woods
- Plastics
- Rubber compounds
- Tars
- Turpentine
- Wood preservative
- Alcohols
- Benzoyl peroxyde
- Food
- Organic silicones
- Glues, adhesives and sealants
- Lanolin
- Metal working Fluids.
Jedini način, kada se radi sa alergenom, je da se spriječi kontakt sa kožom, odnosno da se nose odgovarajuće rukavice cijelo vrijeme.

14. Alergijski kontaktni dermatitis uzrokovan rukavicama
Neki kontaktni dermatitisi se šire putem akceleratora
i antioksidanata koji se nalaze u sintetičkoj gumenoj rukavici (nitrile, neoprene).
Thiuramidi : Tetramethylene thiuram disulfide (TMTD),
Dithiocarbamati : Zinc diethyldithio carbamate (ZDEC),
Benzothiazoleidi : 2-mercaptobenzothiazole (MBT),
Thioureaidi : diphenylthiourea
isopropylparaphenylenediamine (IPPD)
Products listed by importance : 1 Thiurams and 4 Thioureas
Accelerators : Thiuram, Carbamate and Benzothiazoles, Thioureas
Some others products can cause sensitization :
- Anti-oxydants : IPPD : isopropylparaphenylenediamine
- Colorants
Thiuram : sulphur donors in order to help vulcanization process
- Dipentamethylene thiuram tetrasulphide
Carbamate : Zinc dimethyldithiocarbamate (ZDMC), Zinc dibutyldithiocarbamate (ZDBC), Zinc pentamethylene dithiocarbamate (ZPED)

15. Što je kontaktna urticaria (tip I) ?
Imunološki sustav pretjerano reagira na neke alergente. Reakcija ovisi o imunološkom sustavu pojedinca.
Izazvan kontaktom s prividno bezopasnim tvarima: prirodni latex proteini, elementi hrane, ...
Nakon nekoliko izlaganja (senzitivacija),
traje par sekundi do par minuta
da se razvije
Immediate Allergy.
* Indeed, this is an expression of an immune system disease : when an allergen (natural latex protein) is in contact with the immune system, an over reaction occurs immediately
* The only way to prevent --> limit exposure to most common allergens (to limit the sensibilization phase) then avoid contact.

16. Kontaktna urticaria Senzitivacija
proizvodnja IgE povezanog sa alergenom
Trenutak “okidanja”
alergeni su povezani sa IgE
Priprema imunološkog sistema
IgE su povezani sa stanicama ili su slobodni u serumu
Alergijska reakcija
Histamin se otpušta. Dan je znak za uzbunu. 2 1
Exposure to latex proteins : sensitization and subsequent production of Immunoglobuline E (IgE) to latex proteins (polypeptides) necessitates exposure to the latex proteins => occurs by direct contact with the skin (through the skin layer, via the hair follicules, through the sweat duts) or mucous membranes and by inhalation of aerosolized latex proteins.
Wetting of the skin increases the likelihood of penetration by allergens because wet skin tends to be more permeable.
Allergic reaction : Immediate : induction of formation of IgE antibodies -> bind to receptors on various cells (mast celles, basophiles) => degranulation (Release of Histamine ) to alert the defender cells => redness, eczema and asthma.
Mast cells will carry on their surface a large number of proteins, known as immunoglobulin Ig. When antigen penetrate the skin and is detected by IgE molecules, they will lock on antigen. The mast cell then absorbs calcium and starts the process known as Degranulation (release the mediator : histamine that will act as a messenger for the defence cells).
In case of allergy : mast cells will react to the substance to an excessive degree, releasing far more of messengers, resulting in the typical burning sensations, redness and blistering of the skin.
With every contact with the allergen, the number of antibodies increases and hence also sensibilization.
Histamine 3 4

17. Faktori koji nadražuju
Produženi kontakt kože sa vodom ili višim nivoom vlažnosti
Pretjerano pranje kože sa deterdžentima, razrjeđivačima, alkalnim proizvodima, … (uništavanje lipidnog sloja kože)
Znojenje : pretjerano (Glove’s “zatvarajući” efekt ili hiperhidroza) ili nedovoljno (kseroza)
Bakterijski endotoksini
Perspiration : Perspiration can be considered as an irritant product (f(people)). Sweat generally has a pH rank between 4 to 6.8. In addition, sweat will tend to leach chemicals out of the glove causing degradation of rubber, which may trigger an allergic reaction.
Contact with water : Water and Humidity are always aggraving factors or factors that can help to develop dermatitis => destruction of the skin lipidic layer.
“Dishpan” (bassine à vaisselle) hands generally show more involvement on the palmar surface than the dorsal surface of the hand : due to frequent washing or handling harsh chemicals (e.g. detergents, disinfectant, bleach, …).
Destruction of the skin lipidic layer => poly-sensibilization and contact urticaria.
Gloves can induce both irritant and allergic dermatitis (reactions).
Even when an individual is not allergic to rubber, gloves make existing hand dermatitis worse because of occlusive, maceration effect of enclosure, sweating.
Hygiene :
Endotoxins : Gloves sterilized with g radiations will have higher level of bacterial endotoxins. Fever, chills and hypotension can be developed in reaction to these bacterial endotoxins.
Sweating under the gloves may enhance entry into the skin with subsequent reaction as endotoxin in water soluble.
In the USA, the highest level of endotoxin authorized within medical devices is 0.1 ng/ml.
If Gram - bacterias are counted before sterilization, it gives a good idea of the level of endotoxins after sterilization.
Sterilization : Ethylen Oxyde residues can help to develop dermatitis

18. Faktori koji nadražuju
Loša higijena
Postojeći ekcemi (atopični)
Sastrugana koža :
Puder na rukavicama,
Iritirajući materijal na spojnim linijama unutar rukavice
Mehaničke akcije prouzročene alatima, pokretima
Porezana koža
Skin with Dermatitis increases skin colonization with bacterias and can act as a portal entry for blood borne infection :
- Bacterias in cutting oils.
- Parasites in food and grain handers, farmers, laborers, miners, fruit handlers, horiculturists, butchers, handle corpses.
Sometimes, Virus, Fungis and bacterias also cause Occupational Dermatitis.
A spectra glove contains fiber glass that can cause skin irritation when the broken fibers penetrate the skin pores.

19. “In Vivo” metode testiranja
Epicutaneous test (test sa flasterima)
Mala količina antigena se stavlja na površinu kože. Nakon 48 sati, testirana područja se pregledavaju i primjenjuje se sistem bodovanja.
Intradermalni test (test probadanja kože)
Ekstrakt antigena se ubacuje injekcijom ispod površine kože. Nakon 15 minuta, pregledavaju se ubodna mjesta i primjenjuje se sistem bodovanja.
Patch Test : This is the standard procedure for Type IV reactions.
A small amount of each of the suspected substances is is dissolved in petrolatum, water or ethanol and place in a small cup attached to a sticky tape. The tape is then placed on the skin and left here for 48 hours. On removal, the dermatologist will examine the skin for any reactions. If any dermatitis or itching is noticed that persists for a couple of days, it is suggested that the patient is sensitive to this ingredient.
Skin Prick Testing (SPT)
An extract of the test substance, diluted in saline, is dropped on the skin and pricked with a lancet. An allergic response after 10 to 60 minutes, suggest a Type I reaction and an allergic response after 4 to 6 hours suggests a Type IV reaction. This method provides quick results.
The Skin Prick Test can be used with known latex allergic patients. SPT is the most sensitive for comparing allergenicity of different products but requires NRL sensitized people who are willing to be retested. When only a slight or no reaction occurs on the group of patients tested, it is probable that the product will not sensitize and is therefore safe for general use.
The SPT results correlate will with the RAST Inhibition and ELISA Inhibition methods.
This method is dangerous due to its direct injection. This test is not recommendable as it can create anaphylactic shocks to sensitised people.
Back = large area and homogeneous
Test = 48 hours + scoring => sensitization to certain products…
- Use test : In this test; the patient dons a glove on one wetted finger and measurement ( i.e. itching ) is made after 30 minutes. If there is no reaction, an additional test - an entire glove on a wet hand for 30 minutes - is performed.

20. Alergija na prirodni latex
Latex sadrži 2 do 3 % proteina prirodnog latex-a.
Prohevein, hevein, hevamin
i faktor produljivanja gume
Kontakt sa proteinima prirodnog latex-a izaziva senzitivaciju
Latex senzitivacija (1999)
Opća populacija : 1-6 %
Radnici u zdravstvu : 8-12 %
Križana reaktivnost
Alergije na hranu : avokado, banana, rajčica, kesteni, kivi, papaja, ...
Composition of latex from Hevea Brasiliensis :
34 % cis-1,4-polyisoprene (rubber) % proteins (1% after centrifugation)
1,5-3,5 % resins % sugars
0,1-0,5 % sterol glycosides - 0,5-1 % ash
% water
Natural Rubber Latex composition varies because latex comes from different clones of Hevea brasiliensis. NRL contents 240 different peptides and 57 bind IgE antibodies. The main ones are : proheveine, hevein (protect against fungal attack and coagulation of latex), hevamine and rubber elongation factor (REF adds cis-isoprene to rubber molecules; it is an enzyme). There is no consensus on which NRL proteins should be considered as major or clinically significant allergens.
Rubber glove intolerance is a complex clinical problem. Allergen(s) in NRL were characterized as being of protein nature, water soluble and with the allergenicity still remaining after manufacturing. The structure of allergen(s) is complex, seems to depend on the source of latex and can vary both quantitatively and qualitatively.
Latex sensitivity (1999)
hospital personnel : 3 % - operating room nurses : 12 %
dentist : 13 % - spina bifida child : %
Repeated exposure to latex both in medical devices (surgical and examination gloves, anesthesia masks) and in other consumer products may be part of the reason that prevalence of latex sensitivity appears to be increasing (AIDS + Obligation to wear appropriate PPE).
Cross Reactivity
Persons with a history of other allergic reaction are at even greater risk of become sensitized to latex (association with allergies to certain foods especially avocado, banana, tomato, chestnuts, kiwi, fruits and papaya). The food connection as resulting from proteins in certain foods being “structurally similar” to known natural latex allergens (wheat, gums, corn, soybean, hazelnut, melon, passion fruit, …).
--> 3 % of food allergic children are sensitive to NRL proteins.
Food allergy -> intact or partially digested antigens cross the intestinal mucosal barrier and encounter the intestine -> associated lymphoid tissue, an extremely advance immune network which protects against pathogens and prevents immune reactions directed against food antigens. E.g. eggs, cow milk
History / USA
Dermatitis to NRL gloves known for at least 60 years. In March 1991, due to the increase of allergy cases, FDA Medical Alert on latex allergy to health professionals. In 1991, Federal Drug Administration (FDA is advising health care professionals to identify their latex-sensitive patients and be prepared to treat allergic reactions promptly). Letter to manufacturers of latex devices requesting them to identify, measure and reduce content of latex proteins
In the USA, the legislation requires that latex products used in healthcare facility have low protein level to prevent or lessen the possibility of allergic reaction.

21. Rukavice od prirodnog latex-a
Zaraza : diektni ili indirektni kontakt
Simptomi (lokalizirani ili generalizirani) : koža, oči, pluća, usta i probavni sistem, tijelo
Nadražujući faktor : znojenje, atopični profil
Određivanje udjela alergensa u sastavu rukavica
Ne postoji standardizirana metoda za određivanje alergenskog potencijala latex materijala, većinom zato što relevantni latex alergensi nisu precizno identificirani.
Postoji razlika između “in vitro” i “in vivo” reakcija. Ukupni proteini ne pokazuju točno alergenski sastav rukavica.
“The more extensive the exposure, the more likely an individual will develop a latex allergy.”
Direct contact with latex results in the transfer of latex proteins allergens within a matter of seconds. The extend wearing of the gloves and inevitable sweating provides a vehicle (sweat) to mobilize the peptides. Furthermore, disruption of the intact skin barrier by contact dermatitis may enhance the passage of the allergens.
Contamination: proteins get absorbed into the body through direct contact of skin or mucosal surfaces with the rubber product.
The major route of occupational exposure : body sweat inside latex gloves may make latex proteins soluble  solubilized proteins are then absorb through skin  sensitizing the wearer to the protein.
Surprising fact : speed at which the latex proteins are solubilized : within one minute, it has been observed 50 % of the maximal protein levels in the glove extracts  latex proteins may be liberated in a very short period  allergic reaction may appear rapidly.
Immediate hypersensitivity reactions to latex proteins results from the culmination of a complex of interaction between proteins, allergens and specific IgE antibodies.
Latex allergy are IgE mediated
Specific IgE antibody is present in the serum and in the surface of the connective tissue mast cells of latex-allergic individuals.
Latex allergy symptoms
Latex + skin (mostly on the hands but also in the face) : dermatitis (reddened and inflamed skin)
Latex + lungs : respiratory problems like asthma, rhinitis
Latex + body : anaphylactic shock (drop in blood pressure, vascular collapse)
Latex + eyes : conjunctivitis
Latex + mouth, swallow and intestine : reaction !
Risk of allergy = f (genetic, environmental or indirect factors, …)

22. Metode testiranja za procjenu
ukupan nivo proteina koji se mogu izvući iz proizvoda prirodnog latex-a gume :
Svi proteini Alergenski proteini
- promijenjena dubina (EN 455-3), - test “skakanja”
- metoda kromatografije tekućinapod visokim pritiskom - RAST inhibicija
nivo senzitivacije proizvode od prirodnog latexa gume kod osoba:
- test probadanja kože (SPT),
- test “skakanja”, RAST inhibicija.
Total Protein Determination
In NRL, there are over 240 different proteins and polypeptides of which have so far been identified as allergens. In addition, other proteins such as casein may be added during manufacturing.
A preferred method for total protein measurement, and recommended by the FDA, is the modified Lowry. This is a chemical method which has some drawbacks such as lack of sensitivity, specificity and interference from accelerators and other additives used in glove manufacture. It has been shown that correlation between SPT and the modified Lowry is relatively good. Therefore, this method can be used as a primary … by manufacturers to determine the protein amounts of their products.
ELISA Inhibition (EI)
ELISA Inhibition is a well-known test methodology. This method is used to analyze the NRL allergens. The results obtained to date show this method to correlate very well with Skin Prick Test and Rast Test. This method uses human serum from NRL sensitized individuals which means it has the same limitation as Rast Test.
ELISA – based assay is a reproductible measure of the allergenic potential of gloves.

23. “In vitro” testovi … test promijenjene dubine
Vodeno razgradiva Buffer otopina se nalijeva u rukavicu (unutar proteina).
Razgradivi proteini se izvlače pomoću otopine.
Nakon raznih kemijskih reakcija, proteini se pobojaju sa bakrenim reagentom,a tada se mjeri njihova koncentracija metodom spektrofotometrije.
mg/ml otopine --> mg/g rukavice
Gloves : small fraction of proteins phase are residual extractable (or soluble) protein (EP) --> Sensitization and Type I allergy.
EP are measure by RRIM modified Lowry and SE-HPLC (sensitive and very reproductible)
Content of latex residual extractable proteins varies with processing conditions :
- Compounding
- Vulcanisation or drying
- Leaching (wet-gel stage, dry film stage)
- Chlorination
EP value : 1 mg/g : unleached / unchlorinated
0.03 mg/g : leached / chlorinated
Relation EP<--> Allergenicity : not established
Combination EP level and Skin Prick Test :
- gloves with high EP associated with higher degrees of positive allergic reactions or rather low level of negative reactions.
- gloves with low EP levels --> much higher % of negative response recorded.
The RRIM Lowry assay :
- simple, reproductible and easy to perform,
- not really sensitive, can be intefered by chemical that may be in the material because of aged.
The lower quantification limit is approximately 10 mg/g of glove

24. “In vitro” testovi … test “skakanja”
Dobro presvući u latex proteine (4 sata)
Inkubirati sa ljudskim sera antitijelima (IgE)
Blokirati
Oprati
Dodati ortofenilenediamin substrat i promatrati promjenu boje
Presvući dobro sa
zečjim sera antitijelima IgE
Evaluation of the potentially allergic patient
Total serum IgE Testing
- sandwich technique (imitation of immune system)
- not accurate, not relevant
Color change will be analysed with spectrophotometer --> give a concentration
ng/ml solution --> ng/g glove
Latex ELISA for Antigenic Proteins (LEAP) Assay
(ELISA = Enzyme linked immunosorbent assay)
The LEAP Assay relies on the use of antigens developed in rabbits against ammoniated latex proteins. Therefore, basically a total protein assay and is not allergen specific. For the time being, the LEAP assay has not been validated against allergen measuring methods, such as Skin Prick Test or RAST inhibition. This method is sensitive to measure not only total latex protein but also immunologically reactive latex protein.
Comparison Lowry / LEAP methods
> 50 mg/g correlation in between results are good
< 50 mg/g correlation in between results are not good => 50 mg/g will be the FDA’s cut off point for protein content labelling.
Oprati

25. “In vitro” testovi … RAST testiranje
Disk za testiranje sa Nerazgradivim antigenom latex-a
Latex antitijela u pacijentovom tijelu će se trajno prilijepiti na disk
Veže se sa bilo kojim IgE koji je ostao u pacijentovom tijelu
Evaluation of the potentially allergic patient
RAST = Radio-Allergo-Sorbent Test
Immunoabsorption “sandwich” techniques : support / human antigen IgE / detection
- Take several days
- Cost : x 2 minimum
- Less sensitive than skin testing
No risk for the patient versus allergens.
Give no idea of the allergenic potentiality
The advantage of this method in comparison to Skin Prick Test is that only sera from NRL sensitized humans is required.
The values used in this test are given in arbitrary units, which means everything is compared to the value set for NRL.
Stupanj radioaktivnosti određuje da li se pacijent koji je na promatranju smatra alergičnim na latex
Radioaktivno označeni anti IgE

26. Rukavice od prirodnog latex-a
Metode smanjenja izvlačivih proteina
Tretiranje latex-om
Proizvodni proces
Od 1991, NRL alergija se jako povećala. Postoji mnogo uzroka koji mogu sudjelovati u tom fenomenu:
povećana upotreba rukavica koja se nalaže po univerzalnim mjerama opreza,
promjene u obradi latex-a ili proizvodnji rukavica,
tržište je preplavljeno sa visokim udjelom alergena koje distribuiraju nove kompanije,
promjene u proteinima nastale od Hevea Brasiliensis,
...
NRL : unsurpassed for elasticity and tenacity : compared to plastic polymers and synthetic rubber. In 1992 : consumption in average : 7 kg/pers
The soluble proteins migrate towards the surface of a latex film during the manufacturing process of latex dipped products. Most of extractable protein is located on the inner surface of the glove.??
Methods to reduce Extractable proteins level :
Proteins in NRL play an important part in the stabilization of latex against coagulation.
Ammonia -> preservation against microbiological growth and subsequent destabilization of the latex leading to its coagulation.
- Latex treatment
- Centrifugation : double centrifugation --> less serum --> lost 10 % of latex --> proteins content is reduced by up to 50 %.
- Enzyme addition : proteins = smaller peptides -> destabilization => Surfactant +++
- Chemical addition : proteins modified -> destabilization => others chemicals +++
- Process treatment
- Leaching (efficient => water quality) extract processing chemicals and water soluble proteins
- Chlorination (Chlorinated gloves => extremely low LEP) : surface becomes harder
- Enzyme treatment
- Barriers layers or coating (delamination, imcomplete coverage !!!)
Curing Phase : ???
It is not possible to remove or to wash out the latex proteins from the gloves ????
2 voies de diminution du taux de proteines : dénaturation protéique et baisse du taux protéique

27. Rukavice od prirodnog latex-a sa puderom
Proteinski alergeni razgradivi u vodi iz NRL
rukavica se prenose na puder od kukuruznog škroba:
Puder služi kao vektor (odnosno, medij transporta) za proteine = kontaktna kontaminacija sa napudranom rukom (direktna ili indirektna)
Alergeni latex-a nošeni zrakom mogu se ponašati kao aeroalergeni uzrokujući rinitis i astmu = kontaminacija nošena zrakom .
Upotreba rukavica bez pudera od strane drugih radnika može omogućiti ljudima koji su alergični da nastave raditi u svojoj profesiji i može spriječiti mjerivu izloženost zrakom nošenom latex-u.
Talc (magnesium silicate): body can’t digest / destroy it -> human tissue develop fibrosis or granuloma  use of corn starch
Cornstarch composition : 97 % corn starch, 1,5 % magnesium oxide, 1,5 % tri-calcium phosphate.
The exposure to native corn starch powder  no asthmatic reactions
Cornstarch powder is used in some disposable latex gloves to make putting them on or taking them off easier. When the gloves are removed, the cornstarch containing allergic proteins is scattered into the air. The sensitized person does not even need to be wearing the gloves to be exposed – just being near someone who is removing gloves could cause a reaction.
Airborne contamination
The levels of latex allergens in the air can attain the same order of magnitude as many other allergens including grass and pollens.
Washing to remove lubricant powder  do not reduce the amount of protein that is transferred to any surface  surface proteins can be transferred directly by contact with latex alone.
Sometimes, NRL additives can also be found on the powder particulates.
Starch powder damages the skin and exacerbates irritant contact dermatitis by acting as an abrasive and a drying agent.

28. Hipoalergijske rukavice
“Hipoalergijske” jednostavno znači da je manje vjerojatno da će proizvod izazvati kontaktni dermatitis (tip IV), kao što je onaj prouzročen kemijskim akceleratorima u rukavicama. Latex rukavica nazvana “hipoalergijskom” ne garantira uvijek sprečavanje suprotnih reakcija.
Regulative za definiranje “hipoalergičnosti” nisu precizno definirane.
Etiketiranje
zbog tužbi => upozorenje:
“Ovaj proizvod sadrži prirodni latex gume koji može izazvati alergijske reakcije kod nekih osoba”.
The claim for “hypoallergenic” gloves refers to leached gloves that do not contain thiurams. Most hypoallergenic gloves use carbamates as the accelerator system because it appears to sensitize to a lesser degree than other agents.
In the past, FDA has allowed specific gloves, low in chemical additives, and which passed a modified Draize test to be labelled as “Hypoallergenic”. The emergence of latex protein has rendered this simple labelling process obsolete and misleading.

29. Kako spriječiti alergijske reakcije na NRL rukavice?
Selekcija rukavica
Normalne NRL
NRL bez pudera
NRL sa niskim nivoom prirodnog
latex proteina
presvučeni NRL
Rukavice bez latex-a.
Slijed
Od jednog koraka do drugog : promatranje simptoma i odluka koja se odnosi na nestanak ili povlačenje
Those who have latex sensitivity should be wearing synthetic glove without NRL and not rely on “hypoallergenic”; It is true that synthetic glove still can contain chemical accelerators. The only efficient way to prevent reaction is to eliminate contact between contaminants and the skin.
Use of latex gloves with low allergen content or powder free latex gloves by all workers seems to be the only way of ensuring a safer environment for NRL allergic persons (aeroallergens)
The choice of a glove
the glove must be an adequate barrier versus chemical products
the glove must not cause allergic reactions
It should be noted that NRL gloves labelled “hypoallergenic”, “powder-free” or with an integral lining coating are still unsuitable for use in the care of acutely latex sensitive patient.
Market should switch to - powder free, chlorinated, coated, low proteins content
- synthetic products
Some reported solutions :
PE or cotton gloves worn under the latex gloves
233 employees (Hospital and Dental care) --> Glove related skin complaints.
37 % reported skin symptoms : 2 % localised contact urticaria ; 10 % hand eczema; 24 % unclassifiable skin intolerance reaction ; 2 % facial irritation from gloves.
Sometimes subjects with skin symptoms had changed types of gloves which they could tolerate.

30. Niski nivo prirodnog latex proteina prirodne latex rukavice
Rukavice sa udjelom < 50 mg/g proteina latex-a (EN 455).
Smanjuje rizik stvaranja alergije kod ljudi koji prije nisu bili osjetljivi.
Nije garantirano da će se smanjiti alergijski potencijal proizvoda : ljudi koji imaju alergiju tip I na latex mogu reagirati na vrlo niski nivo antigenskih proteina.
To prevent allergy => make protein level as low as possible.
The use of low natural latex protein level gloves would be an effective means of reducing the risk of asthmatic reactions in health care workers with latex induced asthma when complete avoidance cannot be achieve.
Latex products with such low extractable protein levels (<100 mg/g) can be considered to be of low risk to users => minimal allergen content / activity. High degree of negative allergic reaction.
Extractable = Water soluble --> the only proteins that can be measure with the EN 455 test method.
The detection limit (minimal detectable differences from the background or “zero dose” that is measurable with a statistical significance of 95 %. For protein level (Lowry test) : 20 or 10 mg/g.
Low extractable protein levels tend to show weak or no positive response. The 2 parameters are correlated with high significance. Latex gloves with very low EP (0.1 mg/g) and less showing little or no allergenicity.
Lowry method is the FDA standard for measuring latex proteins in medical products : the one to use to claim “low in latex proteins”.
Interference : any substance which results in a false positive or negative measurement in the analytical test method.
Repeatability : variability or test error between independent test results obtained within a single lab
Reproductibility : within different laboratories.

31. Presvučena rukavica od prirodnog gumenog latex-a
LRC biogel rukavice imaju iznutra akrilat kao zaštitni sloj, ali akrilat se vrlo brzo troši  bez dugotrajnog utjecaja.

32. Nitrilne rukavice Kontaktna urtikaria
Većina proizvođača nitrilnih rukavica koriste latex (prirodni) u njihovoj izradi (do 30% latex /nitril). Ove vrijednosti su izmjerene tijekom intenzivnog (HPLC).
Alergijski kontaktni dermatitis
Akceleratori mogu izazvati alergijske reakcije.
Problem
Nitrilne rukavice su znatno skuplje nasuprot prirodnim latex rukavicama.

33. PVC i neoprenske rukavice
Alergijski kontaktni dermatitis
Feniltiurea je otkrivena u PVC i neoprenskim rukavicama, obzirom da je to nitrogensko-sulfurna mješavina, može prouzročiti alergiju.
Problem
PVC rukavice imaju nezadovoljavajuće mehaničke karakteristike nasuprot rukavica od prirodnog latex-a.
Neoprenske rukavice nisu dostupne u verziji za jednokratnu upotrebu.

34. Sinteza
Immune System

35. Učestalost kožnih alergija
Alergije kože od nošenja rukavica može biti postavljeno kako slijedi:
Iritirajuće reakcije zbog loše higijene, nošenja rukavica u predugom vremenskom periodu, kombinacija začepljenja/perspiracije, mehaničkog trenja,
Iritirajuće reakcije od nošenja neodgovarajućih rukavica,
Tip IV alergije,
Tip I alergije,
Wrong gloves : chemicals which permeate through the glove material.
Whether the occlusive effect of gloves could enhance allergen penetration from prior contamination of the skin and in this way mimic glove intolerance

36. Razlozi koji opravdavaju tretiranje kože
Etička odgovornost
Smanjivanje troškova uzrokovanih:
bolovanjem
medicinskim tretmanima
rahabilitacijom ili/i prekvalifikacijskim programom
Podizanjem morala zaposlenika
Human resource maintenance !!!
Employees are working in an age market by no relenting (?) rise in the incident of skin diseases => Prevent work related skin disease has assumed a top priority.

37. Tretman kože 1 Zaštita kože
Ciljevi:
Pomaže zaštititi kožu
protiv tvari baziranih na ulju i koji nisu razgradivi u vodi i organskih otapala poput ulja, boja, grafita, metalne prašine, karbonskog crnila, ...
protiv otapala na vodenoj bazi
Povećava upijajuća svojstva
Omogućava lakše čišćenje kože
Ostaje mogućnost dobrog hvata
Upotreba: prije početka posla i nakon svake pauze
Skin treatment should be selected specifically for the material being used (e.g. creams filter from UV radiations).
Warning : Skin protective products should be used only on healthy skin ; otherwise, some additional problems could occur.
These products has been called in the past “Barrier Cream”.

38. Proizvodi za zaštitu kože
Proizvodi za zaštitu kože teoretski smanjuju
prolazak do kože i upijanje kroz kožu opasnih
materijala.
Pomanjkanje odgovarajućih standardiziranih tehnika za procjenu njihovog zaštitnog djelovanja.
Nude nedokazanu stvarnu zaštitu i mogu stvoriti lažan osjećaj sigurnosti.
Površina primjene proizvoda
Kvaliteta premaza na proizvodu : početni i tijekom posla
Pravi odabir nasuprot opasnosti
Scientific proof :
Many claims are made by suppliers of these creams --> little scientific data has been produced to support these (most anecdotal type than anything else..) <=> reason that until recently, methods were not available for testing penetration of substances through the skin in vivo. Some suppliers show how the cream does not dissolve in the substance it is supposed to protect against (degradation =/ penetration <=> gloves).
- No scientific proofs (no EN Standard) regarding efficiency of the protection.
- demos exists but no possibility to compare efficiency of different brands of products.
Surface of application : flexural surfaces versus plan surfaces
The care with which a skin protection product is applied will vary widely and will affect its it s ability to provide the protection claimed.
Cannot check easily if workers wore it (extremely difficult to control for the employer and the employee)
Quality of the film : the way the cream is applied (certain areas may not be covered --> like wearing gloves with holes in them)
initial : related to experience and training of the workers
during use : action of abrasion, chemical products’ actions
wet environment
contact with solvents, detergents

39. Proizvodi za zaštitu kože
Ostavlja zaštitni premaz na površini kože -->
pomaže u sprečavanju iritirajućih sredstava
da dopru do kože ali ne sprječava alergijske reakcije.
Moguće povećanje dermatitisa
za sami proizvod za zaštitu kože,
za iritirajući proizvod,
za određene komponente rukavica, ako se nose.
Dobra nadopuna uz efikasni proizvod za zaštitu (rukavicu)
djelovati će kao druga barijera ako rukavica ne uspije --> bolja zaštita
In fact, their use has long been the subject of lively debate concerning the prevention of contact dermatitis (some reports are negative). SPP are recommended only for low-grade irritants (water, detergent, organic solvents, cutting oils).
Increase of dermatitis :
- irritant : penetration is indeed facilitate
- glove component : natural latex proteins
- cream composition : preservatives
Hand cream actually increases the amount of latex protein that is transferred from gloves to the hand of the wearer. Thus, if hands are not washed thoroughly after wearing NRL powdered gloves, the latex proteins that remains on the skin can be transferred by the hand to any other surface.
Should be used exceptionally alone when gloves can not be worn
Oil-based creams can deteriorate latex !!!

40. Tretman kože 2 Čišćenje kože
Ciljevi:
čistač ruku za jake nečistoće poput ulja, masti, karbonskog crnila, metalne prašine, podmazivala, boja, lakova, smola, ljepila, ...
sa strugalom ili bez strugala
Upotreba: sa čišćenje tijekom pauze ili nakon posla
Dangerous, potentially damaging chemicals are often (but, improperly= used for skin cleaning. Building workers are known to use sand and diesel fuel, painters use white spirit and garage mechanics use petrol, whilst some leather worker have been known to use dilute sulphuric acid to remove tanning from their hands.
In many industries, minute fragments of work material become embedded in hand skin. People are usually unaware of these metal “fines” entering their skin from machine coolants, or tiny glass fibers used in thermal insulation or glass reinforced polyester product manufacture. But gradually, they experience increasing discomfort and painful, eruptive skin infections
Examining the hands with a low-power magnifying glass will reveal literally hundreds of minute, embedded particles and skin punctures. The particles are seldom removed by skin cleansers, and punctures remain until closed by new skin growth. Until then, harmful and potentially allergenic substances and bacteria have direct entry.
===> Better to wear suitable gloves for the work and accepted by the worker.

41. Tretiranje kože 3 Briga o koži
Ciljevi:
Briga o koži koja je izložena industrijskim i drugim stresovima u okruženju
koža = lice, lice i podlaktice
koža = suha i normalna
Popravlja prirodni uljni premaz na koži
Upotreba: brine o koži i nakon kraja radne smjene
Skin treatment should be selected specifically for the material being used (e.g. creams filter from UV radiations).