!
I
Dermatoses among floral shop workers Diane M. Thiboutot, MD, a Bruce H. Hamory, IV[D,b and James G. Marks, Jr., M D a
Hershey, Pennsylvania Concern about the increasing incidence of hand dermatitis in floral shop workers in the United States and its possible association to the plant Alstroemeria, a flower that has become popular since its introduction in 1981, prompted investigation of the prevalence and cause of hand dermatitis in a sample of floral workers. Fifty-seven floral workers were surveyed, and 15 (26%) reported hand dermatitis within the previous 12 months. Sixteen floral workers (eight with dermatitis) volunteered to be patch tested to the North American Contact Dermatitis Group Standard and Perfume Trays, a series of eight pesticides and 20 plant allergens. Of four of seven floral designers and arrangers who reported hand dermatitis, three reacted positively to patch tests to tuliposide A, the allergen in Alstroemeria. Patch test readings for all other plant extracts were negative. A positive reading for a test to one pesticide, difolatan (Captafol), was noted, the relevance of which is unknown. (J AM ACADDERMATOL 1990;22:54-8.) Occupational dermatitis is well known in the European floral industry. 112 Concern about this problem is growing within the domestic floral industry and prompted the Society of American Florists to appoint a task force to determine its prevalence and cause. 13 The dermatitis generally affects the hands but may involve the forearms, face, and neck. In some cases, it is severe enough to require workers to change jobs. The Baltimore-Washington Allied Florists' Associations recently sent 1500 surveys by mail to 9member floral shops of the Mid-Atlantic Florists' Association to determine the prevalence of dermatitis in this group. 14 Surveys returned from 462 floral shops were reviewed by members of the Office of Occupational Medicine at the Occupational Safety and Health Administration. Approximately one in three retail shops reported at least one employee with dermatitis. I n those shops that reported a problem, approximately one in four employees (mostly floral designers) were affected. In this survey, workers were able to associate a resolution of their dermatitis with periods away from the designing bench. 13 W e reported 15 two cases of hand dermatitis in
From the Division of Dermatologya and the Division of Infectious Diseases and Epidemiology, b Department of Medicine, The Milton S. Hershey Medical Center of The Pennsylvania State University College of Medicine. Accepted for publication Feb. 21, 1989. No reprints available.
54
floral workers who reacted positively to a patch test to tuliposide A, the allergen found in the Alstroerneria plant. Orl the basis of these preliminary data, we presumed that the rise in dermatitis among floral workers might parallel the recent (since 198l) emergence of the sensitizing plant Alstroemeria as a popular cut flower in the United States. We therefore studied a sample of floral workers to determine the prevalence and cause of dermatitis in this group. SUBJECTS AND METHODS The study was conducted at a large central Pennsylvania floral company that employs 260 workers (101 floral designers in 13 floral shops). Cut flowers and plants are received in the wholesale unit where they are trimmed and treated with preservatives, such as Floralife 1I, Silfor 50, and Crysol, and then either used in the main facility or repackaged for distribution to branch shops. In central design, workers produce fresh or artificial floral arrangements in bulk for distribution, particularly during holiday seasons. Greenhouse workers are responsible for watering, trimming, and repotting plants. In sales, clerks take orders for flowers and make sales to the public. The designers and arrangers cut, clip, or break flowers and greenery and place them in a foam "oasis" that contains preservative. A pocket knife is manipulated between the thumb and forefinger to cut most stems (Fig. 1). Frequency of exposure to trauma, "wet work," and plant saps is highest among designers. A questionnaire was distributed randomly to approximately 65 workers throughout the company who handle flowers to determine the prevalence of dermatitis in this population. Workers were asked to report a history of hand dermatitis within the past year and any history of
I
Volume 22 Number 1 January 1990
Dermatoses among floral shop workers 55
Table I. Plant allergens and extracts (in petrolatum)
Tuliposide A (Alstroemeria, tulip, lilies) 0.1% Alantolactone (sneezeweed) 0.1% Parthenolide (feverfew) 0.1% Primin (primrose) 0.01% Chrysanthemum indicum hybrid 3% (chrysanthemum) 2,6-Dimethoxy- 1,4-benzoquinone 10% (mahogany and other woods) Thymoquinone (cedar) 0.1% Anthemis cotula (stinking dog-fennel) I% Achillea millefolium (yarrow) 1% Centaurea cyanus (cornflower) 10% Dianthus sp. hybrid (carnation) 1% Leucanthemum vulgate (marguerite) 1% Zinnia elegart~ (zinnia) 1% Laurus nobilis (laurel oil) 2% Tanacetum parthenium (feverfew) 1% Calendula officinalis (pot marigold) 10% Dahlia sp. hybrid (dahlia) 1% Gaillardia sp. hybrid (gaillardia) 1% D-Usnic acid (lichen) 1% Frullania (liverwort) Whole plant
asthma; hay fever; or allergy to foods, drugs, topical preparations, or plants. The cause of hand dermatitis was investigated in 16 volunteer workers from the main facility. These sixteen employees included seven designers and arrangers (one who was previously described in another studylS), three central designers, four wholesale workers, one greenhouse worker, and one sales worker. Each subject provided an occupational history and underwent examination of exposed skin and fungal scraping of any scaling dermatitis. After informed consent was obtained, subjects were patch tested to the North American Contact Dermatitis Group Standard and Perfume Trays; plant allergens (selected on the basis of extract availability from Dr. B. M. Hausen, Universitat Hamburg, Martinistrasse 52, 0-2000 Hamburg 20, West Germany, and frequency of the plant's use) and plant parts (Table I); and a series of pesticides (Hermal Kurt Hermann, P.O. Box 1228, D-2057 Reinbek/Hamburg, West Germany) in petrolatum, including captan 0.1%, zineb 1%, captafol (Difolatan) 0. 1%, maneb 1%, folpet (Phaltan), pyrethrum 2%, benomyl (Bcnlate) 0.1%, and ziram 1%. Finn Chambers (Hermal Pharmaceutical Inc., Oakhill, N.Y.), which contained the allergens, were secured on the subjects' backs for 48 hours. Readings were done at 48 and 96 hours from the time of placement. Reactions were graded in accordance with the North American Contact Dermatitis Research Group. The study was approved by the Institutional Review Board of The Milton S. Hershey Medical Center.
Fig. 1. Allergic contact dermatitis of hands from cutting Alstroemeria. RESULTS
Of the 65 questionnaires distributed, 57 (87.7%; 11 from the main facility, 46 from branch shops) were returned. Fifteen employees (26.3% of respondents) reported a history of hand dermatitis within the past year. Of these, eight were at the main facility (prevalence 8 of 11 [72.7%]) and seven were from branch shops (prevalence 7 of 46 [ 15.2% ]). Twentyeight employees (49.1% of respondents) reported a history of hay fever; asthma; or allergy to foods, drugs, topical preparations, or plants. Four of these respondents were from the main facility, and 24 were from branch shops. Two respondents from the main facility voluntarily indicated a specific allergy to poison ivy. Among the sixteen workers who were patch tested (the study group), eight (50%) (four designers and arrangers, one central designer, two wholesale workers, and one greenhouse worker) reported a history of hand or facial dermatitis that they related to their work (Table II). Four designers and arrangers (subjects I to 4) reported pruritus, erythema, fissuring, scaling, and oozing of their hands related to work with Alstroemeria. Each reported improvement of their symptoms with weekends, vacation, and periods of reduced exposure to Alstroemeria. One worker from centraI design (subject 5) reported erythema, edema, and pruritus of the face after exposure to chrysanthemums during holiday seasons. Azalea was suspected as a cause of hand dermatitis by subjects 6 and 7. A wholesale worker (subject 8) noted erythema and fissuring of the hands associated with constant exposure to water in transferring flowers between water buckets. In the patch test
Journal of the American Academy of Dermatology
56 Thiboutot et al. Table II. Findings in floral shop workers who reported dermatitis , (yr)
Job
Atopy
affected
] observed
1 2
F/39 F/26
DA DA
---
Hand Yes Hand, arms Yes
3 4 5 6
F/35 F/42 F/40t F/33
DA DA CD WH
--+ +
Hand Hand Face Hand, arm
Yes No No No
7 8
F/18 M/24
GH WH
-+
Hand Hand
Yes Yes
Suspected cause
Positive* patch test readings
Tuliposide A Tuliposide A, formaldehyde diazolidinyl urea, quaternium-15 Alstroemeria Tuliposide A Alstroemeria None Chrysanthemum Captafol (Difolatan) Azalea; bulbs of tulip, Cinnarnie alcohol, nickel hyacinth, daffodil Azalea Benzoyl peroxide Wet work None Alstroemeria Alstroemeria
DA, Designerand arranger; CD, central design; W/if, wholesale; GH, greenhouse. *Definedas North American Contact Dermatitis Group grades 1, 2, or 3. ]'Worker experienceddyspneaand removed patches after 24 hours.
group, the highest prevalence of hand dermatitis (four of seven subjects, or 57.1%) occurred among designers and arrangers. Patch test results are recorded in Table II. Tests to azalea were not performed because of lack of an available extract. Three designers and arrangers (subjects 1 to 3) reacted positively to patch tests to tuliposide A. Active contact dermatitis was observed in subject 1. In subjects 2 and 3 the dermatitis appeared to be resolving. Topical steroids had been used in subjects 1 and 2, whereas subject 3 had used a barrier cream (Kerodex; Ayerst Laboratories, New York) without improvement. No history of exposure to the pesticide, Difolatan (captafol) was elicited in subject 5 despite the subject's positive reaction to the patch test to this chemical. Positive patch test readings for nickel in subject 6 and for benzoyl peroxide in subject 7 could not be related directly to the subject's work. Of interest is the positive reaction to the patch test to cinnamic alcohol in subject 6 because this chemical is found naturally in the hyacinth and in many commercial perfumed products. 16 Among the eight subjects without a history of hand or facial dermatitis patch test readings to the following substances were positive (North American Contact Dermatitis Group grades 1, 2, or 3): nickel (three subjects), cinnamic alcohol (three subjects), eugenol (two subjects), cinnamic aldehyde (one subject), balsam of Peru (two subjects), neomycin suffate (one subject), and thimerosal (one subject). DISCUSSION Our finding of a 26% prevalence of hand dermatitis among employees in a large floral company is
comparable to the 25% prevalence found within some individual shops in the Baltimore-Washington survey but is greater than that reported from South Carolina (12%). 17 The association between hand dermatitis and history of atopy or allergy to food, drugs, topical preparations, or plants is difficult to define. In our survey, 11 of 15 workers (73%) with hand dermatitis reported atopy or allergy to these materials, whereas 17 of 42 (40.5%) (X 2 -- 3.55,p = NS) without dermatitis reported this phenomenon. The cause of dermatitis in floral workers has been linked to exposure to soaps, detergents, water, fertilizers, herbicides, parasites, and irritating plants and plant parts. 18 Plants can cause mechanically induced dermatoses, contact urticaria, irritant contact dermatitis, photodermatitis, and allergic contact dermatitis) Patch tests with plant allergens or actual plant parts have been particularly helpful in diagnosis of allergic contact dermatitis. Caution must be used, however, because injudicious use of plant materials can cause severe bullous reactions. We have tested more than 24 control subjects to tuliposide A and found it to be nonirritating. Cut and slightly crusted parts of Alstroemeria also appeared to be nonirritating. 15 The presence of allergens is not uniform within sensitizing floral species. A particular species may have hundreds of varieties of cultivars that do not possess the same amounts of allergens. Even within a single plant, the amount of allergen varies among the bulb, leaf, petal, and stem, 1~ as well as according to the plant's phase of growth.19 These variables may contribute to the exacerbations and remissions of dermatitis reported by some of the study subjects.
Volume 22 Number 1 January 1990
van KetaI et al., 1 in reviewing patch test results of 64 patients with probable plant contact dermatitis, found Chrysanthemum, Codiaeum variegatum, and Alstroemeria to be the top three sensitizers. Codiaeum (also known as croton) is an ornamental plant that is sold in greenhouses and generally not used in floral arrangements. An extract for patch test was not available for our subjects. W e identified tuliposide A as the allergen in three of eight floral workers with hand dermatitis and of the four, three (75%) reacted positively to patch tests to tuliposide A. Verspyck-Mijnssen 2 identified amethylene-3,-butyrolactone, the hydrolysis product of tuliposide A, as the causative agent of dermatitis in tulip workers. The term tulip fingers is used to describe an erythematous, pruritic, scaling dermatitis that affects the forefinger and thumb of tulip bulb workers. Domestic floral workers, particular designers and arrangers, report a similar dermatitis, although they usually do not handle tulips or bulbs in their work. In 1973 Slob 3 identified the presence of large quantities of tuliposide A in Alstroemeria. Early reports of combined sensitivity to tulips and Alstroemeria3.5, lo,20 were followed by several case reports of nursery workers and florists who exhibited positive patch test readings to Alstroemeria plant parts or extracts, tuliposide A, or a-methylene3,-butyrolactone. 5-10Santucci et al. 11 studied 50 floriculture workers exposed to Alstroemeria and found 10 with eczema of the hands and feet. Patch tests were done on all workers, and 3 of 10 (30%) with eczema had positive reactions to Alstroemeria plant parts and extracts. This finding compares to that in our study in which three of eight (37.5%) workers with hand dermatitis reacted positively to patch tests to tuliposide A. Allergic contact dermatitis to Alstroemeria appears to have a latent onset. Hausen et al. 1~reported a delay of 19 months to 3 years between first exposure to the plant and development of dermatitis; a similar phenomenon was noted in this study. No dermatitis was reported in three of seven designers and arrangers whose mean duration of employment was less than 3 years. Four of seven designers and arrangers who reported hand dermatitis associated with Alstroemeria noted onset of their dermatitis approximately 3 to 6 years after the first introduction of Alstroemeria into the United States in 1981. This is a somewhat longer latency period than observed by Hausen et al. and may be due to more intense exposure among their subjects who cultivated only A lstroemeria and one other plant species.
Dermatoses among floral shop workers 57 In contrast to the results of van Ketel et al. 1 no positive readings to patch tests to Chrysanthemum were observed. Subject 5, who reported facial erythema, edema, and pruritus when working with chrysanthemums in bulk, had a negative reaction to a patch test to an extract from Chrysanthemum indicum. The four varieties of Chrysanthemum used by this worker were subsequently identified as Chrysanthemum morifolium, the most common species used in this country, recently reclassified as Dendranthema grandiflora.21 The description given for subject 5 correlates with Chrysanthemum sensitivity, which is noted 22 to produce a pattern of dermatitis suggestive of an airborne allergen, ascribed to windborne, dry trichomes from stems and leaves of the plant. Patch tests to the particular varieties used in this work are needed to document Chrysanthemum allergy in this case. Rook 4 noted similar difficulties when 12 of 16 varieties of Chrysanthemum tested produced negative patch test readings in a sensitive person. The role of pesticides as a cause of allergic contact dermatitis in floral workers should be addressed. Dermatitis that results from pesticides, traditionally reported as rare in the agricultural industry, appears to be increasing in incidence. 23 Lisi et al. 23 recently patch tested 652 subjects (both agricultural and nonagricultural workers) to a series of 36 pesticides. Allergic reactions were found in 46 subjects (7%). Most positive reactions were to a group of thiophthalamides (captan, folpet, and Difolatan). A comparable result was obtained in our study in which one of 16 (6.25%) workers tested reacted positively to a patch test to the pesticide Difolatan. The relevance of this reaction in subject 5 is unknown. It is difficult to document pesticide use on flowers, particularly imported varieties, which comprised a large percentage of the flowers used by the workers in this study. Because pesticides are sprayed on the external surface of plants, dermatitis would be expected in wholesale workers, greenhouse workers, and workers in other areas where plants are handled in bulk. Results of this study showed a concentration of dermatitis among designers and arrangers who contact plant saps intensely. Efforts are under way by the Society of American Florists, in conjunction with the Occupational Safety and Health Administration, to establish guidelines for the use of Alstroemeria in the domestic floral industry. 13 Gloves may offer protection. Marks, 15 however, noted the allergen tuliposide A penetrated vinyl, but not nitrile, gloves. Barrier creams have
58
Thiboutot et al.
been suggested but did not protect against dermatitis in subject 3. Verspyck Mijnssen, as reported by Hjorth and Wilkinson, t2 noted that a mixture of cysteine and c~-methylene-3,-butyrolactone gave negative patch test reactions in sensitive subjects. A barrier cream that contained cysteine was suggested in that study. Because the amount of allergen can vary among plant varieties, perhaps horticulturists can select and breed less allergenic varieties. At present, treatment should be based on avoidance of Alstroemeria in affected persons. In summary, we believe that hand dermatitis represents a significant problem in the floral industry, with approximately 45,000 workers at risk in the United States. Pesticides seem an unlikely cause of this problem. Alstroemeria, containing tuliposide A, appears to be the leading cause of sensitization, although the role of the commonly used Chrysanthemum should still be considered. Future tests should include Chrysanthemum plant parts or species-specific extracts in addition to tuliposide A to place Alstroemeria sensitization in proper perspective. REFERENCES 1. van Ketel WG, Bruynzeel DP. Contact dermatitis due to plants in Amsterdam. In: Bolletino di. Dermatologica allergologica e professionale. Vol 2. Italy: Bari, 1987:1328. 2. Verspyck Mijnssen GAW. Pathogenesis and causative agent of"tulip finger." Br J Dermatol 1969;81:737-45. 3. Slob A. Tulip allergens in Alstroemeria and some other lilliflorae. Phytochemistry 1973; 12:81 i-5. 4. Rook A. Alstroemeria causing contact dermatitis in a florist also allergic to tulips. Contact Dermatitis Newsletter 1970;7:166.
Journal of the American Academy of Dermatology
5. Cronin E. Sensitivity to Tulip and Alstroemeria. Contact Dermatitis Newsletter 1972;11:286. 6. van Ketel WG, Verspyck Mijnssen GAW, Neering H. Contact eczema from Alstroemeria. Contact Dermatitis 1975;1:323-4. 7. Rycroft RJG, Calnan CD. Alstroemeria dermatitis. Contact Dermatitis 1981;7:284. 8. Rook A. Dermatitis from Alstroemeria: altered clinical pattern and probable increasing incidence. Contact Dermatitis 1981;7:355-6. 9. Bjorkner B. Contact allergy and depigmentation from AIstroerneria. Contact Dermatitis 1982;8:178-84. 10. Hausen BM, Prater E, Schubert H. The sensitizing capacity of Alstroemeria cultivars in man and guinea pig. Contact Dermatitis 1983;9:46-54. 11. Santucci B, Picardo M, Iavorone C, et al. Contact dermatitis to Alstroemeria. Contact Dermatitis 1985;12: 215-9. 12. HjorthN, Wilkinson DS. Contact dermatitis IV. Br J Dermatol 1968;80:696-8. 13. Hoogasian C. Dermatitis concerns spark industry study. Florist 1988;21:95-9. 14. Kuach DL. Field focus: handle with care. Greenhouse Grower 1987;5:86-90. 15. Marks JG. Allergic contact dermatitis to Alstroemeria. Arch Dermatol 1988;124:914-6. t6. Opdyke DLJ. Fragrance raw materials monographs: cinnamic alcohol. Food Cosmet Toxicol 1974;12:855-6. 17. Bethea LK, Schuman SH, Smith-Phillips SE, et al. South Carolina florists dermatitis: case report and survey results. J SC Med Assoc 1988;84:446-8. 18. Adams RM. Occupational skin disease. New York: Grune & Stratton, 1983:41. 19. Shelmire B. Contact dermatitis from vegetation. South Med J 1940;33:337-46. 20. Rook A. Plant dermatitis. Br J Derrnatol 1961;73:283-7. 2 I. Anderson NO. Reclassification of the genus Chrysanthemum L. Hortscience 1987;22:313. 22. Benezra C, Maibach H, Foussereau J, eds. Occupational contact dermatitis. Philadelphia: WB Saunders, 1982:114. 23. Lisi P, Caroffmi S, Assalve D. Irritation and sensitization potential of pesticides. Contact Dermatitis 1987; 17:212-8.
I
Dermatoses among floral shop workers Diane M. Thiboutot, MD, a Bruce H. Hamory, IV[D,b and James G. Marks, Jr., M D a
Hershey, Pennsylvania Concern about the increasing incidence of hand dermatitis in floral shop workers in the United States and its possible association to the plant Alstroemeria, a flower that has become popular since its introduction in 1981, prompted investigation of the prevalence and cause of hand dermatitis in a sample of floral workers. Fifty-seven floral workers were surveyed, and 15 (26%) reported hand dermatitis within the previous 12 months. Sixteen floral workers (eight with dermatitis) volunteered to be patch tested to the North American Contact Dermatitis Group Standard and Perfume Trays, a series of eight pesticides and 20 plant allergens. Of four of seven floral designers and arrangers who reported hand dermatitis, three reacted positively to patch tests to tuliposide A, the allergen in Alstroemeria. Patch test readings for all other plant extracts were negative. A positive reading for a test to one pesticide, difolatan (Captafol), was noted, the relevance of which is unknown. (J AM ACADDERMATOL 1990;22:54-8.) Occupational dermatitis is well known in the European floral industry. 112 Concern about this problem is growing within the domestic floral industry and prompted the Society of American Florists to appoint a task force to determine its prevalence and cause. 13 The dermatitis generally affects the hands but may involve the forearms, face, and neck. In some cases, it is severe enough to require workers to change jobs. The Baltimore-Washington Allied Florists' Associations recently sent 1500 surveys by mail to 9member floral shops of the Mid-Atlantic Florists' Association to determine the prevalence of dermatitis in this group. 14 Surveys returned from 462 floral shops were reviewed by members of the Office of Occupational Medicine at the Occupational Safety and Health Administration. Approximately one in three retail shops reported at least one employee with dermatitis. I n those shops that reported a problem, approximately one in four employees (mostly floral designers) were affected. In this survey, workers were able to associate a resolution of their dermatitis with periods away from the designing bench. 13 W e reported 15 two cases of hand dermatitis in
From the Division of Dermatologya and the Division of Infectious Diseases and Epidemiology, b Department of Medicine, The Milton S. Hershey Medical Center of The Pennsylvania State University College of Medicine. Accepted for publication Feb. 21, 1989. No reprints available.
54
floral workers who reacted positively to a patch test to tuliposide A, the allergen found in the Alstroerneria plant. Orl the basis of these preliminary data, we presumed that the rise in dermatitis among floral workers might parallel the recent (since 198l) emergence of the sensitizing plant Alstroemeria as a popular cut flower in the United States. We therefore studied a sample of floral workers to determine the prevalence and cause of dermatitis in this group. SUBJECTS AND METHODS The study was conducted at a large central Pennsylvania floral company that employs 260 workers (101 floral designers in 13 floral shops). Cut flowers and plants are received in the wholesale unit where they are trimmed and treated with preservatives, such as Floralife 1I, Silfor 50, and Crysol, and then either used in the main facility or repackaged for distribution to branch shops. In central design, workers produce fresh or artificial floral arrangements in bulk for distribution, particularly during holiday seasons. Greenhouse workers are responsible for watering, trimming, and repotting plants. In sales, clerks take orders for flowers and make sales to the public. The designers and arrangers cut, clip, or break flowers and greenery and place them in a foam "oasis" that contains preservative. A pocket knife is manipulated between the thumb and forefinger to cut most stems (Fig. 1). Frequency of exposure to trauma, "wet work," and plant saps is highest among designers. A questionnaire was distributed randomly to approximately 65 workers throughout the company who handle flowers to determine the prevalence of dermatitis in this population. Workers were asked to report a history of hand dermatitis within the past year and any history of
I
Volume 22 Number 1 January 1990
Dermatoses among floral shop workers 55
Table I. Plant allergens and extracts (in petrolatum)
Tuliposide A (Alstroemeria, tulip, lilies) 0.1% Alantolactone (sneezeweed) 0.1% Parthenolide (feverfew) 0.1% Primin (primrose) 0.01% Chrysanthemum indicum hybrid 3% (chrysanthemum) 2,6-Dimethoxy- 1,4-benzoquinone 10% (mahogany and other woods) Thymoquinone (cedar) 0.1% Anthemis cotula (stinking dog-fennel) I% Achillea millefolium (yarrow) 1% Centaurea cyanus (cornflower) 10% Dianthus sp. hybrid (carnation) 1% Leucanthemum vulgate (marguerite) 1% Zinnia elegart~ (zinnia) 1% Laurus nobilis (laurel oil) 2% Tanacetum parthenium (feverfew) 1% Calendula officinalis (pot marigold) 10% Dahlia sp. hybrid (dahlia) 1% Gaillardia sp. hybrid (gaillardia) 1% D-Usnic acid (lichen) 1% Frullania (liverwort) Whole plant
asthma; hay fever; or allergy to foods, drugs, topical preparations, or plants. The cause of hand dermatitis was investigated in 16 volunteer workers from the main facility. These sixteen employees included seven designers and arrangers (one who was previously described in another studylS), three central designers, four wholesale workers, one greenhouse worker, and one sales worker. Each subject provided an occupational history and underwent examination of exposed skin and fungal scraping of any scaling dermatitis. After informed consent was obtained, subjects were patch tested to the North American Contact Dermatitis Group Standard and Perfume Trays; plant allergens (selected on the basis of extract availability from Dr. B. M. Hausen, Universitat Hamburg, Martinistrasse 52, 0-2000 Hamburg 20, West Germany, and frequency of the plant's use) and plant parts (Table I); and a series of pesticides (Hermal Kurt Hermann, P.O. Box 1228, D-2057 Reinbek/Hamburg, West Germany) in petrolatum, including captan 0.1%, zineb 1%, captafol (Difolatan) 0. 1%, maneb 1%, folpet (Phaltan), pyrethrum 2%, benomyl (Bcnlate) 0.1%, and ziram 1%. Finn Chambers (Hermal Pharmaceutical Inc., Oakhill, N.Y.), which contained the allergens, were secured on the subjects' backs for 48 hours. Readings were done at 48 and 96 hours from the time of placement. Reactions were graded in accordance with the North American Contact Dermatitis Research Group. The study was approved by the Institutional Review Board of The Milton S. Hershey Medical Center.
Fig. 1. Allergic contact dermatitis of hands from cutting Alstroemeria. RESULTS
Of the 65 questionnaires distributed, 57 (87.7%; 11 from the main facility, 46 from branch shops) were returned. Fifteen employees (26.3% of respondents) reported a history of hand dermatitis within the past year. Of these, eight were at the main facility (prevalence 8 of 11 [72.7%]) and seven were from branch shops (prevalence 7 of 46 [ 15.2% ]). Twentyeight employees (49.1% of respondents) reported a history of hay fever; asthma; or allergy to foods, drugs, topical preparations, or plants. Four of these respondents were from the main facility, and 24 were from branch shops. Two respondents from the main facility voluntarily indicated a specific allergy to poison ivy. Among the sixteen workers who were patch tested (the study group), eight (50%) (four designers and arrangers, one central designer, two wholesale workers, and one greenhouse worker) reported a history of hand or facial dermatitis that they related to their work (Table II). Four designers and arrangers (subjects I to 4) reported pruritus, erythema, fissuring, scaling, and oozing of their hands related to work with Alstroemeria. Each reported improvement of their symptoms with weekends, vacation, and periods of reduced exposure to Alstroemeria. One worker from centraI design (subject 5) reported erythema, edema, and pruritus of the face after exposure to chrysanthemums during holiday seasons. Azalea was suspected as a cause of hand dermatitis by subjects 6 and 7. A wholesale worker (subject 8) noted erythema and fissuring of the hands associated with constant exposure to water in transferring flowers between water buckets. In the patch test
Journal of the American Academy of Dermatology
56 Thiboutot et al. Table II. Findings in floral shop workers who reported dermatitis , (yr)
Job
Atopy
affected
] observed
1 2
F/39 F/26
DA DA
---
Hand Yes Hand, arms Yes
3 4 5 6
F/35 F/42 F/40t F/33
DA DA CD WH
--+ +
Hand Hand Face Hand, arm
Yes No No No
7 8
F/18 M/24
GH WH
-+
Hand Hand
Yes Yes
Suspected cause
Positive* patch test readings
Tuliposide A Tuliposide A, formaldehyde diazolidinyl urea, quaternium-15 Alstroemeria Tuliposide A Alstroemeria None Chrysanthemum Captafol (Difolatan) Azalea; bulbs of tulip, Cinnarnie alcohol, nickel hyacinth, daffodil Azalea Benzoyl peroxide Wet work None Alstroemeria Alstroemeria
DA, Designerand arranger; CD, central design; W/if, wholesale; GH, greenhouse. *Definedas North American Contact Dermatitis Group grades 1, 2, or 3. ]'Worker experienceddyspneaand removed patches after 24 hours.
group, the highest prevalence of hand dermatitis (four of seven subjects, or 57.1%) occurred among designers and arrangers. Patch test results are recorded in Table II. Tests to azalea were not performed because of lack of an available extract. Three designers and arrangers (subjects 1 to 3) reacted positively to patch tests to tuliposide A. Active contact dermatitis was observed in subject 1. In subjects 2 and 3 the dermatitis appeared to be resolving. Topical steroids had been used in subjects 1 and 2, whereas subject 3 had used a barrier cream (Kerodex; Ayerst Laboratories, New York) without improvement. No history of exposure to the pesticide, Difolatan (captafol) was elicited in subject 5 despite the subject's positive reaction to the patch test to this chemical. Positive patch test readings for nickel in subject 6 and for benzoyl peroxide in subject 7 could not be related directly to the subject's work. Of interest is the positive reaction to the patch test to cinnamic alcohol in subject 6 because this chemical is found naturally in the hyacinth and in many commercial perfumed products. 16 Among the eight subjects without a history of hand or facial dermatitis patch test readings to the following substances were positive (North American Contact Dermatitis Group grades 1, 2, or 3): nickel (three subjects), cinnamic alcohol (three subjects), eugenol (two subjects), cinnamic aldehyde (one subject), balsam of Peru (two subjects), neomycin suffate (one subject), and thimerosal (one subject). DISCUSSION Our finding of a 26% prevalence of hand dermatitis among employees in a large floral company is
comparable to the 25% prevalence found within some individual shops in the Baltimore-Washington survey but is greater than that reported from South Carolina (12%). 17 The association between hand dermatitis and history of atopy or allergy to food, drugs, topical preparations, or plants is difficult to define. In our survey, 11 of 15 workers (73%) with hand dermatitis reported atopy or allergy to these materials, whereas 17 of 42 (40.5%) (X 2 -- 3.55,p = NS) without dermatitis reported this phenomenon. The cause of dermatitis in floral workers has been linked to exposure to soaps, detergents, water, fertilizers, herbicides, parasites, and irritating plants and plant parts. 18 Plants can cause mechanically induced dermatoses, contact urticaria, irritant contact dermatitis, photodermatitis, and allergic contact dermatitis) Patch tests with plant allergens or actual plant parts have been particularly helpful in diagnosis of allergic contact dermatitis. Caution must be used, however, because injudicious use of plant materials can cause severe bullous reactions. We have tested more than 24 control subjects to tuliposide A and found it to be nonirritating. Cut and slightly crusted parts of Alstroemeria also appeared to be nonirritating. 15 The presence of allergens is not uniform within sensitizing floral species. A particular species may have hundreds of varieties of cultivars that do not possess the same amounts of allergens. Even within a single plant, the amount of allergen varies among the bulb, leaf, petal, and stem, 1~ as well as according to the plant's phase of growth.19 These variables may contribute to the exacerbations and remissions of dermatitis reported by some of the study subjects.
Volume 22 Number 1 January 1990
van KetaI et al., 1 in reviewing patch test results of 64 patients with probable plant contact dermatitis, found Chrysanthemum, Codiaeum variegatum, and Alstroemeria to be the top three sensitizers. Codiaeum (also known as croton) is an ornamental plant that is sold in greenhouses and generally not used in floral arrangements. An extract for patch test was not available for our subjects. W e identified tuliposide A as the allergen in three of eight floral workers with hand dermatitis and of the four, three (75%) reacted positively to patch tests to tuliposide A. Verspyck-Mijnssen 2 identified amethylene-3,-butyrolactone, the hydrolysis product of tuliposide A, as the causative agent of dermatitis in tulip workers. The term tulip fingers is used to describe an erythematous, pruritic, scaling dermatitis that affects the forefinger and thumb of tulip bulb workers. Domestic floral workers, particular designers and arrangers, report a similar dermatitis, although they usually do not handle tulips or bulbs in their work. In 1973 Slob 3 identified the presence of large quantities of tuliposide A in Alstroemeria. Early reports of combined sensitivity to tulips and Alstroemeria3.5, lo,20 were followed by several case reports of nursery workers and florists who exhibited positive patch test readings to Alstroemeria plant parts or extracts, tuliposide A, or a-methylene3,-butyrolactone. 5-10Santucci et al. 11 studied 50 floriculture workers exposed to Alstroemeria and found 10 with eczema of the hands and feet. Patch tests were done on all workers, and 3 of 10 (30%) with eczema had positive reactions to Alstroemeria plant parts and extracts. This finding compares to that in our study in which three of eight (37.5%) workers with hand dermatitis reacted positively to patch tests to tuliposide A. Allergic contact dermatitis to Alstroemeria appears to have a latent onset. Hausen et al. 1~reported a delay of 19 months to 3 years between first exposure to the plant and development of dermatitis; a similar phenomenon was noted in this study. No dermatitis was reported in three of seven designers and arrangers whose mean duration of employment was less than 3 years. Four of seven designers and arrangers who reported hand dermatitis associated with Alstroemeria noted onset of their dermatitis approximately 3 to 6 years after the first introduction of Alstroemeria into the United States in 1981. This is a somewhat longer latency period than observed by Hausen et al. and may be due to more intense exposure among their subjects who cultivated only A lstroemeria and one other plant species.
Dermatoses among floral shop workers 57 In contrast to the results of van Ketel et al. 1 no positive readings to patch tests to Chrysanthemum were observed. Subject 5, who reported facial erythema, edema, and pruritus when working with chrysanthemums in bulk, had a negative reaction to a patch test to an extract from Chrysanthemum indicum. The four varieties of Chrysanthemum used by this worker were subsequently identified as Chrysanthemum morifolium, the most common species used in this country, recently reclassified as Dendranthema grandiflora.21 The description given for subject 5 correlates with Chrysanthemum sensitivity, which is noted 22 to produce a pattern of dermatitis suggestive of an airborne allergen, ascribed to windborne, dry trichomes from stems and leaves of the plant. Patch tests to the particular varieties used in this work are needed to document Chrysanthemum allergy in this case. Rook 4 noted similar difficulties when 12 of 16 varieties of Chrysanthemum tested produced negative patch test readings in a sensitive person. The role of pesticides as a cause of allergic contact dermatitis in floral workers should be addressed. Dermatitis that results from pesticides, traditionally reported as rare in the agricultural industry, appears to be increasing in incidence. 23 Lisi et al. 23 recently patch tested 652 subjects (both agricultural and nonagricultural workers) to a series of 36 pesticides. Allergic reactions were found in 46 subjects (7%). Most positive reactions were to a group of thiophthalamides (captan, folpet, and Difolatan). A comparable result was obtained in our study in which one of 16 (6.25%) workers tested reacted positively to a patch test to the pesticide Difolatan. The relevance of this reaction in subject 5 is unknown. It is difficult to document pesticide use on flowers, particularly imported varieties, which comprised a large percentage of the flowers used by the workers in this study. Because pesticides are sprayed on the external surface of plants, dermatitis would be expected in wholesale workers, greenhouse workers, and workers in other areas where plants are handled in bulk. Results of this study showed a concentration of dermatitis among designers and arrangers who contact plant saps intensely. Efforts are under way by the Society of American Florists, in conjunction with the Occupational Safety and Health Administration, to establish guidelines for the use of Alstroemeria in the domestic floral industry. 13 Gloves may offer protection. Marks, 15 however, noted the allergen tuliposide A penetrated vinyl, but not nitrile, gloves. Barrier creams have
58
Thiboutot et al.
been suggested but did not protect against dermatitis in subject 3. Verspyck Mijnssen, as reported by Hjorth and Wilkinson, t2 noted that a mixture of cysteine and c~-methylene-3,-butyrolactone gave negative patch test reactions in sensitive subjects. A barrier cream that contained cysteine was suggested in that study. Because the amount of allergen can vary among plant varieties, perhaps horticulturists can select and breed less allergenic varieties. At present, treatment should be based on avoidance of Alstroemeria in affected persons. In summary, we believe that hand dermatitis represents a significant problem in the floral industry, with approximately 45,000 workers at risk in the United States. Pesticides seem an unlikely cause of this problem. Alstroemeria, containing tuliposide A, appears to be the leading cause of sensitization, although the role of the commonly used Chrysanthemum should still be considered. Future tests should include Chrysanthemum plant parts or species-specific extracts in addition to tuliposide A to place Alstroemeria sensitization in proper perspective. REFERENCES 1. van Ketel WG, Bruynzeel DP. Contact dermatitis due to plants in Amsterdam. In: Bolletino di. Dermatologica allergologica e professionale. Vol 2. Italy: Bari, 1987:1328. 2. Verspyck Mijnssen GAW. Pathogenesis and causative agent of"tulip finger." Br J Dermatol 1969;81:737-45. 3. Slob A. Tulip allergens in Alstroemeria and some other lilliflorae. Phytochemistry 1973; 12:81 i-5. 4. Rook A. Alstroemeria causing contact dermatitis in a florist also allergic to tulips. Contact Dermatitis Newsletter 1970;7:166.
Journal of the American Academy of Dermatology
5. Cronin E. Sensitivity to Tulip and Alstroemeria. Contact Dermatitis Newsletter 1972;11:286. 6. van Ketel WG, Verspyck Mijnssen GAW, Neering H. Contact eczema from Alstroemeria. Contact Dermatitis 1975;1:323-4. 7. Rycroft RJG, Calnan CD. Alstroemeria dermatitis. Contact Dermatitis 1981;7:284. 8. Rook A. Dermatitis from Alstroemeria: altered clinical pattern and probable increasing incidence. Contact Dermatitis 1981;7:355-6. 9. Bjorkner B. Contact allergy and depigmentation from AIstroerneria. Contact Dermatitis 1982;8:178-84. 10. Hausen BM, Prater E, Schubert H. The sensitizing capacity of Alstroemeria cultivars in man and guinea pig. Contact Dermatitis 1983;9:46-54. 11. Santucci B, Picardo M, Iavorone C, et al. Contact dermatitis to Alstroemeria. Contact Dermatitis 1985;12: 215-9. 12. HjorthN, Wilkinson DS. Contact dermatitis IV. Br J Dermatol 1968;80:696-8. 13. Hoogasian C. Dermatitis concerns spark industry study. Florist 1988;21:95-9. 14. Kuach DL. Field focus: handle with care. Greenhouse Grower 1987;5:86-90. 15. Marks JG. Allergic contact dermatitis to Alstroemeria. Arch Dermatol 1988;124:914-6. t6. Opdyke DLJ. Fragrance raw materials monographs: cinnamic alcohol. Food Cosmet Toxicol 1974;12:855-6. 17. Bethea LK, Schuman SH, Smith-Phillips SE, et al. South Carolina florists dermatitis: case report and survey results. J SC Med Assoc 1988;84:446-8. 18. Adams RM. Occupational skin disease. New York: Grune & Stratton, 1983:41. 19. Shelmire B. Contact dermatitis from vegetation. South Med J 1940;33:337-46. 20. Rook A. Plant dermatitis. Br J Derrnatol 1961;73:283-7. 2 I. Anderson NO. Reclassification of the genus Chrysanthemum L. Hortscience 1987;22:313. 22. Benezra C, Maibach H, Foussereau J, eds. Occupational contact dermatitis. Philadelphia: WB Saunders, 1982:114. 23. Lisi P, Caroffmi S, Assalve D. Irritation and sensitization potential of pesticides. Contact Dermatitis 1987; 17:212-8.
