Hair.html

Work-Related Respiratory Symptoms and Airway Disease in Hairdressers

GI Skoufi1, E Nena2, K Kostikas1, GA Lialios3, TC Constantinidis2, Z Daniil1, K Gourgoulianis1

1Department of Respiratory Medicine, Medical School, University of Thessaly, University Hospital of Larissa, Larissa, Biopolis 41110, Greece

2Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Alexandroupolis, Greece

3University Hospital of Larisa, Larissa, Biopolis 41110, Greece

Correspondence to

Georgia I Skoufi, MD, Terpsithea, 41500 Larisa, Greece

Tel: +30-694-686-1349

Fax: +30-241-061-1297

E-mail: georgiaskoufi@yahoo.gr

Received: Jan 20, 2013

Accepted: Feb 26, 2013

Abstract

Background: Hairdressers are occupationally exposed to a number of agents in their workplace that result in respiratory symptoms and changes in pulmonary function.

Objective: To evaluate associations between occupational exposure and respiratory function and reported symptoms in a group of hairdressers compared to a control group.

Methods: A questionnaire on respiratory symptoms and workplace characteristics was completed by 94 hairdressers and 39 age- and sex-matched controls. Spirometry and exhaled nitric oxide (FeNO) measurements were also performed.

Results: Hairdressers reported more severe dyspnea (p=0.03) and eye (p=0.001) and throat (p=0.007) irritation, compared to the control group, at the workplace; no differences were noted at home. Lower FEV1/FVC (p<0.001) and higher FeNO values (p=0.012) were observed in hairdressers. A larger working area and presence of window ventilation were associated with better pulmonary function.

Conclusion: Worsening of symptoms and pulmonary function at workplace, and alleviating the symptoms at home, indicate that they may be related to occupational exposure.

Keywords: Barbering; Occupational exposure; Respiratory tract diseases; Spirometry; Nitric oxide; Environmental exposure; Inhalation exposure

Introduction

Hairdressers are occupationally exposed to a number of agents in their workplace that would result in respiratory and ocular symptoms and changes in pulmonary function. There is a need to investigate whether potential occupational exposure of hairdressers to aerosol chemicals is associated with airway disease, including asthma.

Previous studies indicate that asthma and respiratory symptoms are common in hairdressers.1, 2 This has been attributed to their exposure to a number of toxic elements used in the coiffures, including sprays, hair colors,3 and, more importantly, bleaching agents, specifically persulfate salts, although the mechanism of inducing occupational asthma has not definitely been demonstrated.4 In addition, other risk factors such as smoking, may confound the effect of these toxins on the development of respiratory symptoms.5

According to the Observatoire National des Asthmes Professionnels (ONAP) data, hairdressing represented the fourth most frequent occupation in both sexes, and the second most frequent occupation in women, among people with occupational asthma.6 The high rates of occupational asthma are present not only in professional hairdressers, but also in their apprentices, who have been demonstrated to have poorer lung function than respective office apprentices, and who develop bronchial hyper-responsiveness and deterioration of lung function over a 3-year follow-up.7-9

The primary objective of this study was to determine self-reported ocular and respiratory symptoms as well as pulmonary function and airway inflammation, as measured by exhaled nitric oxide (FeNO) level among hairdressers and to compare it with a group of office workers. The secondary objective of this study was to determine whether these differences in respiratory symptoms and pulmonary function are affected by characteristics of hairdressers' working area, such as availability of natural ventilation (window) in their work environment, work duration and whether respiratory symptoms are modified at home.

Materials and Methods

All hairdressers (n=127) from the city of Larissa, central Greece, were invited to participate in this study. Of 127 invitees, 94 hairdressers agreed to participate (response rate of 74%). The hairdressers were matched with office employees for gender, age and smoking habit. Subjects with a previous diagnosis of asthma or other chronic respiratory conditions were excluded from the study. Answers to the distributed questionnaire, spirometry and FeNO measurements were obtained within their workplace during working hours. The study was approved by the Ethics Committee of the University Hospital of Larissa; all participants provided written informed consent.

Participants were interviewed by one of the researchers, using a questionnaire which included demographic data, smoking history, family and past medical history of asthma and atopy, chronic respiratory symptoms (cough, sputum production, dyspnea, wheezing, and eye-nose-throat irritation), and temporal changes in symptoms (worse at work or improved during weekends or holidays).10 Smoking status was measured in pack-years (PYS). Respiratory and ocular symptoms at work and home were measured using response items containing 10 ordinal responses calibrated from 0 (indicating “the worst outcome,” i.e., “frequent or intense symptoms”) to 10 (“the best outcome,” i.e., “no symptoms”). Separately, these items included cough, sputum production, dyspnea, wheezing, and eye, nose, and throat irritation. Additionally, in order to evaluate modifiable risk factors for occupational asthma, occupational history data, work duration (total years of work, hours per day and hours per week) and intensity, work area size and ventilation in the workplace (window, ventilation exhaust hood, fan or other ventilation), were included in the questionnaire. Work intensity was estimated using a validated measure which included the average number of bleaching, dye and permanent wave applications per week.11 Work area size was calculated as working area per person in square meter. We also assessed the presence of ventilation, its type and frequency of use during the work hours.

Spirometry was performed using a dry spirometer (KoKo Legend, Ferraris, UK), according to the American Thoracic Society recommendations.12 The spirometric reference values used were those proposed by the European Respiratory Society (ERS).13 Forced expiratory maneuvers were repeated until three acceptable tests were obtained and the best forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and FEV1/FVC values were recorded. FeNO was measured using a portable nitric oxide analyzer (NIOX MINO airway inflammation monitor, Aerocrine, Solna, Sweden) that provided FeNO measurements at 50 mL/s exhalation flow rate; the values were reported in parts per billion (ppb).14 Measurements with this device are in clinically acceptable agreement to measurements provided by a stationary analyzer (NIOX; Aerocrine) according to the American Thoracic Society guidelines.15-17 The accuracy of the NIOX MINO device is ±5 ppb for measured values of <50 ppb and ±10% for values ≥50 ppb. All subjects were asked not to consume food or beverages or smoke at least for two hours before the measurement of FeNO.

Normality of distribution was assessed for all continuous variables prior to any statistical analyses. For normally distributed measures, Student's t test for unpaired data was used. For ordinal measures of respiratory and ocular symptoms, Wilcoxon signed-rank test was used to assess differences between hairdressers and the control group, stratified by smoking history, while current smoking was used to define smokers. Spearman's rho was used to assess the correlation between the hairdresser's work area and measures of pulmonary function and FeNO. All analyses were performed by SPSS® for Windows® ver 19.0. A two-tailed p value <0.05 was considered statistically significant.

Results

Ninety-four hairdressers and 39 office workers participated in this study. The majority of the participants were female (88% of hairdressers, and 85% of office workers) and current smokers (60% of hairdressers, and 72% of office workers) (Table 1).

Table 1: Comparison between anthropometric characteristics, spirometric results and FeNO values between two studied groups. Values are mean±SD or frequency (%).

Parameter

Hairdressers (n=94)

Office workers (n=39)

p value

Age (yrs)

34.7±11.4

36.9±9.1

0.298

Female gender

83 (88%)

33 (85%)

0.563

Smokers

56 (60%)

28 (72%)

0.183

Amount of smoking (pack year)

12.4±1.4

16.5±2.4

0.129

FEV1 (L)

3.18±0.65

3.22±0.62

0.768

FEV1 (% Pred)

99.3±1.5

98.7±1.8

0.825

FVC (L)

3.73±0.80

3.79±0.72

0.691

FVC (% Pred)

100.7±19.2

100.3±11.2

0.906

FEV1/FVC (% Pred)

92.0±10.3

103.5±6.1

<0.001

FeNO (ppb)

13.8±10.2

9.6±3.7

0.012

No significant differences were noted in age, gender, and smoking habit between hairdressers and office workers (Table 1). Hairdressers had a significantly lower FEV1/FVC (%) (p<0.001) and a higher FeNO values (p=0.012) compared to the office workers. During working hours, hairdressers reported more severe dyspnea (p=0.03), and irritation of eye (p=0.001) and throat (p=0.007) as compared to the controls (Table 2). This effect appeared to be driven by the subgroup of smoking hairdressers who, in comparison to smoking office workers, had significantly more severe self-reported intensity of dyspnea, eye, nose, and throat irritation (Table 3). No significant differences in self-reported symptoms were demonstrated between the two groups when they were away from work; 17 (18%) of hairdressers reported worsening of their respiratory symptoms at work in contrast to no office workers.

Table 2: Comparison between self-reported evaluation of symptoms at work between hairdressers and office workers. Data are presented as mean±SD. Lower values indicate a worse outcome, i.e., frequent or severe symptoms.

Symptom

Hairdressers (n=94)

Office workers (n=39)

p value

Cough

8.9±2.0

9.2±1.6

NS*

Sputum production

9.1±2.2

8.9±2.2

NS

Dyspnea

9.0±2.2

9.5±1.9

0.026

Wheezing

9.9±1.1

9.9±0.3

NS

Eye irritation

7.7±3.2

9.4±1.7

0.001

Nose irritation

8.9±2.4

9.3±2.3

NS

Throat irritation

8.9±2.3

9.8±1.1

0.009

Table 3: Comparison between self-reported symptoms at work between smokers of the two studied groups. Data are presented as mean±SD. Lower values indicate a worse outcome, i.e., frequent or severe symptoms.

Symptom

Hairdressers (n=94)

Office workers (n=39)

p value

Cough

8.7±2.1

9.0±1.8

NS*

Sputum production

8.8±2.4

8.9±2.1

NS

Dyspnea

8.8±2.4

9.6±1.7

0.027

Wheezing

9.8±1.3

9.9±0.3

NS

Eye irritation

7.6±3.1

9.5±1.7

0.001

Nose irritation

8.9±2.2

9.6±1.5

0.022

Throat irritation

8.9±2.1

9.9±0.3

0.007

 

Within the hairdressers group, a significant positive correlation was found between spirometric values and the work area size per person (Spearman's ρ = 0.54) (Table 4). While the presence of a ventilation system did not affect the reported symptoms and the spirometry and FeNO measures, the presence of window, as a mode of ventilation in the workplace, was associated with better spirometric values (Table 5). However, neither a large working area, nor the type of chemical exposure or ventilation was associated with self-reported respiratory or ocular symptoms. No significant correlation was observed between work duration, work intensity and either spirometric or FeNO results.

Table 4: Correlation between work area (m2) and spirometric and FeNO values in 94 hairdressers

Parameter

Spearman's ρ

p value

FEV1 (%)

0.323

0.002

FVC (%)

0.394

<0.001

FEV1/FVC (%)

0.539

<0.001

FeNO

-0.107

0.311

Table 5: Comparison of the spirometric values of hairdressers working with vs without window (natural ventilation). Values are mean±SD.

Parameter

Window

No window

p value

FEV1 (%)

108.3±16.3

97.8±13.4

0.021

FVC (%)

119.9±34.1

97.6±13.3

<0.001

FEV1/FVC (%)

97.2±13.5

91.2±9.5

<0.001

Discussion

In the present study, hairdressers reported worse respiratory symptoms than office workers. This finding was also demonstrated in previous studies that also reported improvement of symptoms away from work.19 We also found that the working environment plays a key role in the severity of respiratory symptoms reported by the participants—hairdressers at work, had a significantly higher intensity of dyspnea, eye and throat irritation as compared to a group of office workers. Moreover, the temporal nature of their symptoms, which were not significantly different from those of the office workers when both were not at work, suggest that occupationally-related exposures are responsible for these symptoms. Although the presence of natural ventilation in the form of a window, work duration, and the intensity of exposure—as measured by the number of chemical applications per week—did not appear to be associated with self-reported ocular and respiratory symptoms, a larger working area and the presence of natural ventilation were significantly associated with improved spirometric measures. The outcome of the survey agrees with similar surveys and is further supported by our spirometric and airway inflammation data.7, 18

Exposure to pollutants in the air of hairdressing salons can cause irritation and sensitization. Workplace health surveillance aims to identify possible causes of irritation to prevent progression of the condition to a permanent disease.20 Self-reported symptom questionnaires and spirometry are commonly used in surveillance programs, however, questions have been raised regarding their validity and reliability.20-23 Therefore, there remains a need for other non-invasive tests that can be used in addition to questionnaires and spirometry.

The mechanism of inducing asthma in hairdressers is still not well-understood. Some studies suggest an immunological mechanism, immunoglobulin (Ig)E dependent24, 25 or non-IgE dependent26, while others report a non-immunological mechanism27. An underlying immunological mechanism is strongly suggested but not definitively demonstrated.24, 28, 29

The fact that FeNO and spirometric results, as well as the reported symptoms are not significantly correlated with work duration and severity of symptoms can be attributed to the fact that similar duration of exposure does not necessarily mean similar total dose of exposure.4 Spirometry is the most common pulmonary function test and is an important means for assessing conditions such as asthma. According to our analysis, hairdressers had lower FEV1/FVC values compared to the age- and smoking-matched office workers—a result suggestive of impaired airway function in hairdressers that may be related to occupational exposure. The fact that a larger work area and natural ventilation were associated with better spirometric data in the hairdressers further supports a possible association of pulmonary function with working environment.

Measurement of FeNO is a non-invasive, potentially useful test for respiratory surveillance, which was initially proposed as an index of airway inflammation in asthma.30 FeNO was found to be useful as a marker of exposure to dusts, gases and organic solvents31, 32 and as an early marker of asthma in workers exposed to potroom pollutants and concentrations of exhaled NO have been positively associated with the level of exposure to dust, but it was not significantly associated with either duration of employment or routine measurements of dust and fluorides.33 Measuring FeNO may be a useful way to screen airway inflammation in occupational epidemiology.8 It has been proposed that FeNO is so useful in occupational setting that it must be add to the information obtained by questionnaires and spirometry.20 In the present study, the mean FeNO for hairdressers was higher than that for the control group; higher variability of FeNO was observed in hairdressers as compared to the office workers. FeNO was however not significantly associated with either duration of employment or ventilation in the workplace. The presence of elevated FeNO levels in the hairdressers provides evidence for the presence of increased eosinophilic airway inflammation in them that may be suggestive for an increased risk of asthma. The latter suggestion however needs to be confirmed in longitudinal studies.

The present study was limited by the validity and reliability of the self-reported questionnaire in accurately reflecting the true symptoms of the study subjects. Equally objective changes in pulmonary function may be variably reported between subjects. Moreover, although the self-reported ocular and respiratory symptom questionnaire does capture some disease specific information, we did not capture global measures of health related quality of life such as the SF-36 or EuroQol questionnaires. Moreover, the actual surface area of natural ventilation and strength of mechanical ventilation systems were not precisely measured. Finally, we could not elucidate which of the multiple chemical exposures most affected respiratory symptoms, as we did not capture each type of chemical and amount or duration of exposure in our study.

In conclusion, we found that the nature of work of hairdressers, which involves use of various chemicals, is associated with more frequent ocular and respiratory symptoms compared to office workers. The symptoms are associated with spirometric evidence of airflow obstruction and increased levels of airway inflammation, as reflected by increased FeNO level. However, further studies are needed to find out the actual chemicals which produce symptoms and declines in pulmonary function, the long-term consequences of these exposures in terms of symptoms, spirometric function and health-related quality of life.

Conflicts of interest: None declared.

References

  1. Pankow W, Hein H, Bittner K, et al. Persulphate asthma in hairdressers. Pneumologie 1989;43:173-5.
  2. Schwartz HJ. Effect of chronic chromolyn sodium therapy in a beautician with occupational asthma. J Occup Med 1989;31:112-4.
  3. Macchioni P, Kotopulos C, Talini D, et al. Asthma in hairdressers: a report of 5 cases. Med Lav 1999;90:776-85.
  4. Moscato G, Pignatti P, Yacoub MR, et al. Occupational asthma and occupational rhinitis in hairdressers. Chest 2005;128:3590-8.
  5. Parra FM, Igea JM, Quirce S, et al. Occupational asthma in a hairdresser caused by persulphate salts. Allergy 1992;47:656-60.
  6. Ameille J, Pauli G, Calastreng-Crinquand A, et al. Observatoire national des asthmes professionnels. Reported incidence of occupational asthma in France, 1996-99: the ONAP programme. Occup Environ Med 2003;60:136-41.
  7. Gülmez I, çetinkaya F, Oymak FS, et al. Occupational asthma among hairdressers apprentices [abstracts]. Eur Respir J 1998;28(Suppl):333-4.
  8. Tossa P, Paris C, Zmirou-Navier D, et al. Increase in exhaled nitric oxide is associated with bronchial hyperresponsiveness among apprentices. Am J Respir Crit Care Med 2010;182:738-44. Epub May 27, 2010.
  9. Iwatsubo Y, Matrat M, Brochard P, et al. Healthy worker effect and changes in respiratory symptoms and lung function in hairdressing apprentices. Occup Environ Med 2003;60:831-40.
  10. Malo JL, Ghezzo H, L’Archevêque J, et al. Is the clinical history a satisfactory means of diagnosing occupational asthma? Am Rev Respir Dis 1991;143:528-32.
  11. Akpinar-Elci M, Cimrin AH, Elci OC. Prevalence and risk factors of occupational asthma among hairdressers in Turkey. J Occup Environ Med 2002;44:585-90.
  12. American Thoracic Society. Standardization of spirometry:1994 update. Am J Respir Crit Care Med 1995;152:1107-36.
  13. Quanjer PH, Tammeling GJ, Cotes JE, et al. Lung volumes and forced ventilatory flows. Report working party standardization of lung function tests, European community for steel and coal. Official statement of the European respiratory Society. Eur Respir J 1993;6(Suppl 16):5-40.
  14. Gill M, Graff GR, Adler AJ, et al. Validation study of fractional exhaled nitric oxide measurements using a handheld monitoring device. J Asthma 2006;43:731-4.
  15. ATS/ERS recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide, 2005. Am J Respir Crit Care Med 2005;171:912-30.
  16. Alving K, Janson C, Nordvall L. Performance of a new hand-held device for exhaled nitric oxide measurement in adults and children. Respir Res 2006;7:67.
  17. Menzies D, Nair A, Lipworth BJ. Portable exhaled nitric oxide measurement: comparison with the “gold standard” technique. Chest 2007;131:410-4.
  18. Arcangeli G, Baldasseroni A, Palmi S, Bianchi A. Reversible pulmonary response to irritating substances: study on a population of apprentice hairdressers. Prevenzione Oggi 1999,11:3-33.
  19. Hollund BE, Moen BE, Lygre SH, et al. Prevalence of airway symptoms among hairdressers in Bergen, Norway. Occup Environ Med 2001;58:780-5.
  20. Bohadana AB, Hannhart B, Ghezzo H, et al. Exhaled nitric oxide and spirometry in respiratory health surveillance. Occup Med (Lond) 2011;61:108-14. Epub Jan 31, 2011.
  21. Allan KM, Murphy E, Ayres JG. Assessment of respiratory health surveillance for laboratory animal workers. Occup Med (Lond) 2010;60:458-63. Epub May 6, 2010.
  22. Gordon SB, Curran AD, Murphy J, et al. Screening questionnaires for bakers’ asthma- are they worth the effort? Occup Med (Lond) 1997;47:361-6.
  23. Kraw M, Tarlo SM. Isocyanate medical surveillance: respiratory referrals from a foam manufacturing plant over a five-year period. Am J Ind Med 1999;35:87-91.
  24. Munoz X, Cruz MJ, Orriols R, et al. Occupational asthma due to persulfate salts: diagnosis and follow-up. Chest 2003;123:2124-9.
  25. Wrbitzky R, Drexler H, Letzel S. Early reaction type allergies and diseases of the respiratory passages in employees from persulphate production. Int Arch Occup Environ Health 1995;67:413-7.
  26. Yawalkar N, Helbling A, Pichler CE, et al. T cell involvement in persulphate triggered occupational dermatitis and asthma. Ann Allergy Asthma Immunol 1999;82:401-4.
  27. Blainey AD, Ollier S, Cundell D, et al. Occupational asthma in a hairdressing salon. Thorax 1986;41:42-50.
  28. Babilas P, Landthaler M, Szeimies RM. [Anaphylactic reaction following hair bleaching]. Hautarzt 2005;56:1152-5. [in German]
  29. Perfetti L, Galdi E, Biale C, et al. Anaphylactoid reaction to patch testing with ammonium persulfate. Allergy 2000;55:94-5.
  30. Kharitonov SA, Barnes PJ. Exhaled markers of pulmonary disease. Am J Respir Crit Care Med 2001;163:1693-722.
  31. Ulvestad B, Lund MB, Bakke B, et al. Gas and dust exposure in underground construction is associated with signs of airway inflammation. Eur Respir J 2001;17:416-21.
  32. Maniscalco M, Grieco L, Galdi A, et al. Increase in exhaled nitric oxide in shoe and leather workers at the end of the work-shift. Occup Med (Lond) 2004;54:404-7.
  33. Lund MB, Oksne PI, Hamre R, Kongerud J. Increased nitric oxide in exhaled air: an early marker of asthma in non-smoking aluminium potroom workers? Occup Environ Med 2000;57:274-8.

TAKE-HOME MESSAGE

  • Hairdressers are occupationally exposed to a number of agents in their workplace that would result in respiratory symptoms and changes in pulmonary function.
  • Hairdressers reported more severe symptoms compared to office workers at the workplace.
  • Hairdressers had significantly lower spirometric and higher FeNO values than the controls.
  • Worsening of symptoms at workplace and alleviation of the symptoms at home, indicate that they may be related to occupational exposure.
  • A larger working area and presence of window were significantly associated with improved pulmonary function in hairdressers.

Cite this article as: Skoufi GI, Nena E, Kostikas K, et al. Work-related respiratory symptoms and airway disease in hairdressers. Int J Occup Environ Med 2013;4:53-60.




 pISSN: 2008-6520
 eISSN: 2008-6814

Creative Commons LicenseThis work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License