Abstract
Paint constituents have changed over time. Lead toxicity from lead in oil-based paints is less common today but may still be a lingering issue in older parts of early cities. Newer water-based paints are safer but more complex and may contain allergy-inducing ingredients including preservatives. Volatile preservatives of the isothiazolinone class are important causes of contact allergy for painters, with the most significant recent culprit being methylisothiazolinone (MI) and others including methylchloroisothiazolinone (MCI), octylisothiazolinone (OIT), benzisothiazolinone (BIT), and butylbenzisothiazolinone (BBIT). Many other paint components may also be allergenic. Epoxy resins including epoxy hardeners/curing agents may be sensitizers, with resins derived from diglycidyl ether of bisphenol A (DGEBA-R) having been considered the most important sensitizer. 1,3-Benzenedimethanamine (1,3-BDMA) – also known as m-xylenediamine (MXDA) – is currently considered a significant sensitizer in epoxy hardeners. Painters are at higher risk of developing allergies to paint components. Chronic exposure to paints by painters and consumers (e.g., residential dwellers) is an important cause of contact dermatitis including airborne contact dermatitis. Risk factors for allergy development in painters include environmental factors such as working conditions (room ventilation, room size, appropriate clothing/gloves), painting technique used (brush vs. roller vs. spray), and painter characteristics (hygiene, painting style, age). Worker education/health promotion and awareness of safety hazards are needed to reduce inadvertent skin/mucous membrane contact with paint components. Anatomical sites for painters with occupational contact dermatitis are most often the hands, followed by the face then the legs. Inhalation of airborne paint droplets can cause respiratory symptoms affecting the nose and lungs.
1 Core Messages
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Painters are at higher risk of developing allergic and/or irritant reactions to paint components. This can occur upon initial exposure but is more likely with chronic exposure.
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Chronic exposure to paints by painters and consumers (e.g., residential dwellers) is an important cause of contact dermatitis including airborne allergic contact dermatitis.
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Risk factors for allergy development include environmental factors such as working conditions (room ventilation, room size, appropriate clothing/gloves), painting technique used (brush vs. roller vs. spray), and painter characteristics (hygiene, painting style, age).
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Worker education/health promotion and awareness of safety hazards are needed to reduce inadvertent skin/mucous membrane contact with paint components.
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Anatomical sites for painters with occupational contact dermatitis are most often the hands, followed by the face then the legs.
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Inhalation of airborne paint droplets can cause respiratory symptoms affecting the nose and lungs.
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Paint components and formulations change over time.
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Water-based formulations require preservation and other additives which may be sensitizing.
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Preservatives of the isothiazolinone class are important causes of contact allergy for painters. The most significant recent culprit is methylisothiazolinone (MI). Others include methylchloroisothiazolinone (MCI), octylisothiazolinone (OIT), benzisothiazolinone (BIT), and butylbenzisothiazolinone (BBIT).
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Epoxy resins including epoxy hardeners/curing agents may be sensitizers. Resins derived from diglycidyl ether of bisphenol A (DGEBA-R) have been considered the most important sensitizer. 1,3-Benzenedimethanamine (1,3-BDMA) – also known as m-xylenediamine (MXDA) – is currently considered a significant sensitizer in epoxy hardeners.
2 Introduction
Constituents in paints have changed over time and are constantly changing as paint companies develop new formulations. Lead toxicity from lead in oil-based paints is much less common today but may still be a lingering issue in older parts of early cities such as St. John’s, NL, Canada, where at one point most house paints contained lead (Bell et al. 2010, 2011). Newer water-based paints are safer but more complex and may contain allergy-inducing ingredients including volatile preservatives such as the isothiazolinones methylisothiazolinone (MI) , methylchloroisothiazolinone (MCI) , and benzisothiazolinone (BIT) (Lundov et al. 2014). Many other paint components may also be allergenic. Painters in particular are at higher risk of developing allergies to paint components. Chronic exposure to paints by painters and consumers (e.g., residential dwellers) is an important cause of contact dermatitis including airborne contact dermatitis (Lundov et al. 2014). Risk factors for allergy development in painters may include environmental factors such as indoor versus outdoor work, climate, time of year, room ventilation and room size/size of the object to be painted, painting technique (brush painting vs. roller painting vs. spray painting, for example), and even the painter’s hygiene, painting style, and age.
It should be clarified that painters as discussed in this chapter refer to house painters and not artists who produce paintings and other works of art. Artistic paints have entirely different formulations. Issues relating to paints and varnishes as used by artists are not specifically discussed here.
The following is a listing of contact irritants (Table 1) and contact allergens (Table 2) relevant for painters, varnishers, and lacquerers.
3 Specific Aspects
3.1 Significant Issues for Painters
What allergic issues do paint substances cause in painters and of what significance is this as an occupational hazard? A PubMed search of painters using the MeSH headings irritant dermatitis, irritation, photoirritant dermatitis, photoirritation, allergic contact dermatitis, photoallergic contact dermatitis, photosensitivity, and contact urticaria yielded 49 results from 1983 to 2017, with 13 from 2012 to 2017. Similar searches for lacquerers and varnishers did not yield any new results. Some of the more recent findings are highlighted here and older findings are briefly discussed and tabled.
In 2013, a review of 1,000 consecutive new cases of severe occupational contact dermatitis at a specialist center in the capital region of Denmark showed that male painters had the fourth highest incidence (after cooks, mechanics, and machine operators), with an incidence rate of 16.5 per 10,000 workers per year. Female painters were ranked 15th (with nursing, hairdressing, cleaning, cooking, and many other occupations ranking higher). Although the distribution of occupations was different, the incidence rate for female painters was equally significant at 22.7 per 10,000 workers per year, due to a female predominance in the 1,000 cases (618F:382M) and an underlying higher prevalence of atopic dermatitis among female patients. On the basis of the prevalence, females more often had allergic contact dermatitis as their main diagnosis compared to males (p < 0.01). In absolute numbers, among the 1,000 new cases were 20 male painters and 6 female painters (Schwensen et al. 2013).
From 2005 to 2010, the Danish National Board of Industrial Injuries registered 126 cases of occupational skin diseases among Danish painters (Mose et al. 2012). A closer scrutiny (based on patch test analysis) by the Danish Contact Dermatitis Group of all painters registered in the National Database for Contact Allergy (NDCA) from 2001 to 2010 was reported in 2012. (In 2012, the NDCA was at the Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Denmark, and the Danish Contact Dermatitis Group consisted of a network of private practice dermatologists and three hospital dermatology departments.) Patch testing of 36,147 patients between 2001 and 2010 identified 219 patients registered as painters of which 155 were male and 64 were female. Anatomical sites of dermatitis were most commonly the hands (58%), followed by the face (16%) and legs (4%). Positive patch test allergens included those preselected from the European baseline series and additional ones, in particular some preservatives. The most common allergens among the preservatives were MI , octylisothiazolinone (OIT), and BIT (Mose et al. 2012).
Methylisothiazolinone (MI), methylchloroisothiazolinone (MCI), octylisothiazolinone (OIT), and benzisothiazolinone (BIT) are all isothiazolinones. These are compounds which provide the needed preservation in water-based paints. MCI has been a known contact allergen for years and is part of the 50 allergens in the baseline panel for patch testing identified by the North American Contact Dermatitis Group (Lachapelle and Maibach 2012). The European baseline series used by the Danish Contact Dermatitis Group also includes MCI/MI (Mose et al. 2012).
Whether alone or in combination, MI and MCI are high on the list for causing preservative contact allergy. A retrospective epidemiological observational study of consecutively patch tested contact dermatitis patients at Copenhagen University Hospital Gentofte between 1 January 2009 ad 31 December 2013 showed that MI was the second most frequently registered preservative (n = 830 with n = 446 in paints and varnishes), MCI/MI was the third (n = 630 with n = 354 in paints and varnishes), and MCI was the fourth (n = 407 with n = 252 in paints and varnishes). (Formaldehyde was the preservative most frequently registered (n = 894 with n = 401 in paints and varnishes) (Schwensen et al. 2017).)
The same Copenhagen study also found that, of the 4,487 patients with contact dermatitis patch tested, more than 20% (n = 995) were diagnosed with occupational contact dermatitis. Similar to the 2012 NDCA registry report, anatomical sites of dermatitis for the patients with occupational preservative contact allergy were most commonly the hands (82.3%), followed by the face (19.9%) and legs (0.7%). Risk factors included atopic dermatitis and age > 40. In particular, age > 40 appeared to be the most significant risk factor especially for cases of occupational contact allergy to at least one preservative (71.6%) in comparison to those cases not associated with preservatives (45.8%), and the difference between groups was significant (p < 0.001) (Schwensen et al. 2017). A more specific German study assessing risk factors associated with MI contact sensitization again identified age > 40 as a significant risk factor, atopic dermatitis as a small but significant risk factor; and anatomically, both hand and face dermatitis but particularly ano-genital dermatitis (hygiene wipe use) were significantly associated with MI sensitization. Analyses of the association between occupation and MI sensitization identified painters as being of highest significance (Uter et al. 2013).
A 2015 retrospective study of all patients presenting to the Finnish Institute of Occupational Health (FIOH) from 2002 to 2013 with suspected occupational contact allergy found that 4.1% (72/1745) showed an allergic reaction to MCI/MI and/or MI. Patch-test results were positive to MCI/MI in 45 patients (2.6%), to both MCI/MI and MI in 24 patients (1.4%), and 3 patients (0.2%) tested positive to MI alone, which is significant as MI was not a standard test allergen in the baseline series. The contact allergy was considered to be occupational in 36/72 cases (50%) for those testing positive to MCI/MI and/or MI, among these were 6 people working in painting or painting-related jobs. The six cases were a painter using several paints with MCI/MI and MI; a coating worker using an anti-condensation paint with MI and OIT ; a paint factory worker handling/making paints with MI and OIT; a vehicle painter using a hand cleaner that contained MCI and MI; a tile layer using a water-proofing material that contained MI, BIT, and MCI; and a visual artisan who used acrylic colors containing MCI/MI and gouache colors containing MCI/MI and OIT (Vauhkala et al. 2015).
It is important to keep in mind that these preservatives are not only used in paints and varnishes but also in liquid soaps, industrial hand cleansers, and other products such as hygiene wipes. Thus, the above 2015 FIOH study of occupational contact allergy to MCI/MI and MI alone found that the most significant occupational groups were hairdressers and beauticians, mechanics and repairmen, and machinists, followed by painters and paint factory workers, and café and restaurant workers (Vauhkala et al. 2015). A second study of MCI /MI, MI, and BIT identified painters as the occupation with the highest number of reactions to MI or BIT, but cosmetologists were higher than painters with respect to MCI/MI. Blacksmiths (MCI/MI) and tile setters/terrazzo workers (MI) also had high incidences (Schwensen et al. 2014a). A third study in blue-collar workers (which by the International Standard Classification of Occupation includes painters, blacksmiths, and tile setters/terrazzo workers) corroborated the above – that MCI/MI contact allergy was occupationally related, with painters often affected (odds ratio 5.52; 95% CI 2.16–14.13) (Schwensen et al. 2014b).
In addition, this third study also identified other types of contact allergens, namely epoxy resin, 2-bromo-2-nitropropane-1,3-diol, potassium dichromate, and methyldibromo glutaronitrile. Painters were also associated with 2-bromo-2-nitropropane-1,3-diol (OR 4.09; 95% CI 1.18–14.21). However, in this study it was construction workers and tile setters/terrazzo workers who were associated with epoxy resins, and the latter was also associated with potassium dichromate (Schwensen et al. 2014b).
Other studies have identified epoxy resins as a culprit for contact allergy in painters. In a study of 209 cases of occupational contact allergy to epoxy chemicals, the largest occupational group was painters (n = 41) (Aalto-Korte et al. 2015). Resins derived from diglycidyl ether of bisphenol A (DGEBA-R) are considered the most important sensitizer in epoxy systems (Aalto-Korte et al. 2015). Epoxy hardeners/curing agents and reactive diluents may also be sensitizers. 1,3-Benzenedimethanamine (1,3-BDMA), also known as m-xylylenediamine (MXDA) , is a commonly used epoxy curing agent currently considered the most significant sensitizer in epoxy hardeners. The first six cases of contact allergy to derivatives of 1-3-BDMA were reported in June 2016 by FIOH. Of the six cases, four were painters and a fifth worked in a paint factory. The other case was a floor layer (Pesonen et al. 2016). Refer to the Paint chapter for further discussion. N-(2-phenylethyl) derivatives, also used as a curing agent in epoxy paints and coatings, resemble MXDA and may be sensitizing as well (Pesonen et al. 2016).
Isocyanates are polyurethane resins which may be airborne and are known health hazards even at low air concentrations (Frick et al. 2003). In addition to respiratory issues, contamination of the skin resulting in contact allergy can also occur. An outbreak of dermatitis related to an isocyanate lacquer being sprayed onto the tongue and groove laminate boards for flooring has been reported. The spraying was done automatically; however, the boards were then picked up by hand and further manipulated. Of 20 machine operators working with this procedure, 5 developed work-related skin lesions that were suspected to be cause by the lacquer. The isocyanate lacquer was based on diphenylmethane-diisocyanate (MDI) monomer. The authors cautioned that, when working with isocyanates, attention should be focused not only on respiratory hazards but also on contact hazards. It is important to also avoid skin contamination by using good hand protection and maintaining hygienic conditions (Frick et al. 2003).
3.1.1 Irritant Contact Dermatitis
Although the focus of this chapter has been on allergic contact dermatitis in painters/varnishers/lacquerers, prolonged skin irritation resulting solely in an irritant dermatitis also occurs as is illustrated in this study (Fischer et al. 1995). The authors investigated 202 construction painters (200 M, 2 F) working for 8 companies that predominantly used water-based paints. The painting companies (each with more than 20 employees) were identified in cooperation with the Regional Construction Industry’s Organization for Working Environment, Safety and Health in Sweden. Of the 202 painters, 87% had started as construction painters before age 20 and had remained in the same occupation. Twenty-four percent painters (48/202) had a history of eczema and 31 painters had current problems. Twenty-five painters had a history of hand eczema of which 16 had ongoing disease. Fourteen painters who reported that their eczema deteriorated with work were primarily diagnosed with atopic, dyshidrotic, or tylotic eczema.
Irritant reactions were defined as erythema, itching, and dryness of the skin which disappears after a few days of skin rest. This was observed in 18/202 painters. However, the painters were asked their opinion as to whether work operations caused these types of skin irritation and the numbers were much higher. Skin dryness was the most common complaint in the 202 painters: 42 while painting, 91 while puttying and grinding fly-ash putty by hand, 29 while hanging wallpaper. Itching was next with 8 while painting, 19 while puttying, and 7 while hanging normal wallpaper but 100 while hanging glass fiber fabric. Erythema was least common (7 while painting, 4 while puttying) except while hanging glass fiber fabric (40 painters). (Glass fiber fabric, painted waterproof, was a common wallcover in bathrooms and other wet areas.) Eight painters had pronounced dry fissuring of knuckles, and sides and tips of fingers. (Allergic contact dermatitis was investigated through patch testing by an occupational dermatologist. Thirty-one of 202 painters tested positive and 8 of these 31 cases (i.e., 8/202 or 4%) were probably related to work: 4 reacted to isothiazolinones, 2 to p-tert-butylphenol-formaldehyde resin, 1 to nickel and cobalt, and 1 to colophony) (Fischer et al. 1995).)
A study in the United Kingdom and in China identified nasal, eye, and skin irritation in dockyard painters. For details refer to the Paints, Varnishes, and Lacquers chapter (Chen et al. 2001).
There are other contact allergens and contact irritants that may be of concern for painters, lacquerers, and varnishers which may not have been discussed but are noted in the preceding tables (Tables 1 and 2).
3.2 Issues Related to Painting Procedures, Techniques, and Painting Styles
A separate concern from substances in paint or painter demographics is the painter’s environment. As mentioned earlier, environmental factors such as indoor versus outdoor work, climate, time of year, room ventilation and room size/the size of the object to be painted, painting techniques, and even the painter’s hygiene and painting style may all affect the painter’s exposure to sensitizers and irritants in paints. A few issues are highlighted here.
Confined environments. One study explored the degree of skin and clothing contamination using an airless spray painting technique of a container as the test environment. Workers all wore appropriate overalls but no gloves and were divided into those who painted the outside of the container versus the inside. The results showed that even though they were using similar spraying techniques on the same subject, those who sprayed the inside of the container had overalls with three times higher contamination than those who sprayed the outside, but skin contamination (hands, wrists, and face) were similar (Brouwer et al. 2000).
Uninformed workers/lack of awareness of safety hazards. Triglycidyl isocyanurate (TGIC) is a known respiratory and skin sensitizer. A study on skin exposure to dry powder spray showed high TGIC values in the dust, with glove surface loading rates ten times higher than overall rates. However, many of the workers did not know whether they had used a paint with TGIC or not (Roff et al. 2004). Health promotion and education are important considerations.
Isocyanates are synthetic resins (Table 2). Workers in the auto body repair and refinishing industry may be exposed to aliphatic polyisocyanates. Unbound isocyanate on recently painted surfaces poses a skin exposure risk for workers who handle them gloveless to sand, buff, or polish them. Workers may be less conscious of avoiding skin exposure since there is no spraying or mixing task (Estlander et al. 2000; Bello et al. 2007, 2008). As mentioned earlier, workers handling laminate floor boards coated with an isocyanate lacquer developed allergic dermatitis on their forearms and hands (Frick et al. 2003). Thus, in addition to respiratory precautions, avoidance of skin contamination is important, such as good hand protection with the use of protective gloves (Boman et al. 2005).
Inadvertent skin/mucous membrane contact. Accidental spilling, splashes, paint droplets in the air, sloppy painting style, use of contaminated or dirty containers/brushes/drop cloths/clothing/shoes, etc. are all likely to increase the skin/mucous membrane exposure potential (Estlander et al. 2000; Delgado et al. 2004; Estlander and Kanerva 2006).
Using special painting techniques. To create special paint effects, painters may use special decorative wall painting techniques such as sponging, marbling, rag rolling, stenciling. This may increase the risk of skin contact since some of these techniques are best done with bare rather than gloved hands (Fischer and Adams 1999; BHG-1). Furniture painting to create decorative effects such as distressing may also pose a skin exposure risk (BHG-2) (Surakka et al. 2000).
Miscellaneous other potential allergens/irritants and safety hazards. Painters may encounter other environmental allergens and irritants in the course of their work day. For example, in preparing walls for painting, there may be allergens in sandpaper, putty or spackling compound (powdered or paste forms), and masking tape. In removing grease or dirt and preparing surfaces for painting, there may be allergens and irritants in paint strippers, varnish removers, solvents (turpentine, limonene), soaps, or detergents (Estlander and Kanerva 2006). Construction painters have an increased risk of hand dermatitis associated with water-based plasters and putties (Kaukiainen 2005). Fillers, putties, and plasters may contain limestone, cement, aluminum cement, gypsum, solvents, and epoxy resin. Their alkaline pH nature may cause irritation or skin corrosion and their sticky nature may mean that the worker will need to use strong skin cleansers/solvents and strong mechanical rubbing for their removal, potentially further contributing to skin irritation. Painters may occasionally be tasked to hang wallpaper thus encounter additional irritants and allergens. Special fabric wallpaper may contain fiberglass, an irritant that may also cause skin abrasions. Wallpaper paste/glues on the backs of wallpaper sheets may contain allergens or irritants (Estlander et al. 2000). Other miscellaneous allergens/irritants include inks, blueprints, and stencils. Doing outdoor work, painters may develop dermatitis from exposure to light, plants, or both, e.g., from accidental contact with poison oak or poison ivy. In cold weather, exposure to cold may aggravate dermal symptoms.
Refer to the “Paints, Lacquers, and Varnishes” chapter for additional information.
4 Summary
People with anticipated frequent exposures to paints, varnishes, and lacquers such as painters should take protective measures (e.g., gloving and masking as needed), follow recommended procedures, and use careful rather than sloppy techniques, in order to reduce the possibility of an allergic or irritant dermatologic reaction.
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Law, R.M., Maibach, H.I. (2018). Painters, Lacquerers, and Varnishers in Occupational Dermatology. In: John, S., Johansen, J., Rustemeyer, T., Elsner, P., Maibach, H. (eds) Kanerva’s Occupational Dermatology. Springer, Cham. https://doi.org/10.1007/978-3-319-40221-5_178-2
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