Glove-related hand urticaria: an increasing occupational problem among healthcare workers

Dear Editor, Reaction to gloves can be immediate or delayed and may be caused by irritancy, contact urticaria and/or allergic contact dermatitis.1 While contact urticaria to latex is commonly suspected when immediate and local urticarial reactions are described, it is also important to consider glove‐related hand urticaria.2 3 4 5 Glove‐related hand urticaria is a form of symptomatic dermographism thought to be caused by a combination of shearing forces associated with recurrent application and removal of gloves,3 and physical pressure exerted by the glove itself.4 As frequent glove users, healthcare workers are more likely to experience glove‐related hand urticaria, and based on recent trends seen in our practice, we believe it is becoming an increasing occupational problem. Between 2012 and 2015, 17 healthcare workers were diagnosed with glove‐related hand urticaria (Table 1). They included doctors, nurses, phlebotomists, radiographers, laboratory technicians, healthcare assistants, porters and medical and dental students. There were 13 women and four men, with a mean age of 39 years. Five patients were referred for a suspected latex allergy, seven for a nitrile allergy and five for a combination of the two. Each worker described an urticarial reaction occurring within minutes of glove application. All had evidence of dermographism when linear pressure was applied to the skin. Three workers had underlying chronic idiopathic urticaria, and 11 had concurrent hand dermatitis. Specific IgE and skin prick testing to latex were performed if they used latex gloves. A provocation test in the form of a modified glove challenge was also performed (Fig. 1). However, these tests were all negative. Eleven workers with concurrent dermatitis were also patch tested to the British Society of Cutaneous Allergy standard (47 allergens), rubber (nine allergens) and staff series (12 allergens). Readings were performed at 48 and 96 h. Five workers were positive to at least one allergen but only two had relevant reactions (Table 1). List of patients with glove‐related hand urticaria: demographics, causative glove types, underlying idiopathic urticaria, presence of dermatitis and patch test reactions Relevant allergen. List of patients with glove‐related hand urticaria: demographics, causative glove types, underlying idiopathic urticaria, presence of dermatitis and patch test reactions Relevant allergen. Modified glove challenge test. The term ‘glove‐related hand urticaria’ was first used in 1999 and refers to glove reaction caused by dermographism2 – the most common type of physical urticaria, affecting 4% of the population.6 It is different from delayed pressure urticaria, which although stimulated by pressure, is usually associated with a delayed skin reaction occurring 4–6 h after the pressure stimulus. Furthermore, delayed pressure urticaria is frequently accompanied by pain, burning and pruritus in the affected area, as well as systemic symptoms such as malaise, fever and headache, none of which is present in glove‐related hand urticaria.7 Patients with glove‐related hand urticaria typically present with a localized urticaria that occurs immediately upon application of the glove. Therefore, glove‐related hand urticaria can mimic symptoms of contact urticaria to latex,3 5 which is more common, affecting approximately 12% of healthcare workers.8 In addition to latex, contact urticaria can also be caused by corn starch powder, casein, antioxidants and rubber accelerators (Table 2).9 Causes of contact urticaria in gloves9 14 Causes of contact urticaria in gloves9 14 It is not unusual for patients with glove‐related hand urticaria to react to a variety of glove types such as nitrile,4 which are increasingly being used in hospitals to replace latex gloves. Nitrile gloves can be more troublesome for dermographic patients as they are usually more rigid and less flexible than latex, so the pressure exerted by the glove is greater. This was exemplified in part by our case series, where more patients described a reaction to nitrile than latex gloves. We believe that glove‐related hand urticaria is underdiagnosed, and many patients may be wrongfully labelled as latex allergic, especially if skin prick testing facilities are not available. Lowe et al. have shown previously how services for latex allergy investigations vary depending on who investigates and the facilities available.10 Being wrongly diagnosed as having latex allergy can cause an unnecessary and significant impact on patients’ quality of life,11 given the need for allergen avoidance, and may affect both their present occupation and future employment. Nevertheless, it is important to remember that there will be patients who have both glove‐related hand urticaria and latex allergy, thus emphasizing the importance of testing for both conditions. One difficulty when performing skin prick testing for dermographic individuals is that positive reactions (especially if weak) could be misinterpreted as true allergy.12 An additional test that can be used to facilitate diagnosis is a glove challenge test, which usually involves the application of a latex glove (if testing for latex allergy) onto a finger and subsequently the hand of a patient, using a nonlatex glove on the other hand as a control, with reading performed at 15–20 min.13 However, as with skin prick testing, dermographic patients will likely exhibit an urticarial response. We therefore suggest the use of a modified glove challenge, whereby a cut piece of the glove (approximately 5 × 5 cm) is placed onto the patient's forearm (Fig. 1). By eliminating the shearing force and pressure associated with wearing the glove, we believe this will remove the confounding dermographism effect and thus should be positive only in patients with true allergy or contact urticaria. The modified glove challenge should also be undertaken in patients reacting to nonlatex gloves such as nitrile (using vinyl glove as control instead) to ensure that other causes of contact urticaria are not missed. If the modified glove challenge is positive, then it will be essential to perform short‐contact open patch testing and/or skin prick testing to the relevant chemicals that can potentially cause contact urticaria, as listed in Table 2, with readings performed at 15–20 min. As the modified glove challenge was negative in all of our patients, this was not undertaken. For patients with suspected latex allergy, it is best to proceed with specific IgE and/or skin prick testing to latex first (as we have performed for our patients), as latex glove challenge carries a higher risk of causing anaphylaxis in latex‐allergic individuals. The presence of hand dermatitis should not exclude a diagnosis of contact urticaria or glove‐related hand urticaria, especially if immediate, urticarial symptoms are also described, as patients can have a combination of diagnoses. Eleven workers in our case series also had concurrent hand dermatitis and were patch tested. Five were positive to at least one allergen but only two had relevant reactions. Both of these workers were positive to limonene and were using a limonene‐containing hand wash. One of them was also positive to methylchloroisothiazolinone and was using a hand wash that contained both limonene and methylchloroisothiazolinone. Allergen avoidance resulted in significant resolution of their dermatitis. The relevance for the other three workers was unknown as they were not exposed to any products containing the allergens that they had reacted to, and their dermatitis persisted (although this may also have been due to irritancy from recurrent hand washing). In order to help guide clinicians in assessing patients presenting with immediate reactions to gloves, we have devised a simple flowchart (Fig. 2). Flow diagram for assessment of patients presenting with immediate reactions to gloves. Interestingly, 13 of the 17 workers with glove‐related hand urticaria were female. This higher prevalence in women is consistent with the literature,1 2 3 and is also observed for symptomatic dermographism in general in both adult and paediatric populations.15 16 Three workers in our series also had chronic idiopathic urticaria. This is not surprising, as other forms of urticaria can coexist with dermographism.17 The immediate urticarial symptoms in most of the workers in our series (including the ones with concurrent dermatitis) improved with simple measures such as using larger‐sized gloves and taking extra care when applying and removing gloves. Very few required antihistamines and none has needed phototherapy so far. In conclusion, as frequent glove users, healthcare workers are prone to glove‐related hand urticaria, and we believe this is an increasing occupational problem. We therefore encourage clinicians to consider this diagnosis in all workers who present with immediate, urticarial reaction to gloves, particularly if they have experienced the same symptoms to multiple glove types, irrespective of the presence of hand dermatitis. It is important to make the correct diagnosis, as misdiagnosis could have a profound impact on quality of life and occupation. Funding sources: none. Conflicts of interest: none declared.