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First Published in the New England Journal of Medicine, January 26, 1933.

Dermatitis From Rubber Gloves

By John G. Downing, M..D.*

In these days of aseptic surgery, the use of rubber gloves is so essential that the utmost care in their manufacture is necessary, for any disturbance in the skin of a surgeon prevents him from scrubbing and, therefore, lessens his chances of having thorough asepsis. Occasionally cases of dermatitis are seen among surgeons. In the past six months I have had occasion to see two such cases. In view of this fact, and also because I have been unable to find any cases in literature where rubber gloves were definitely proved to be a cause of dermatitis of the hands, I am reporting the following cases:

On January 14, 1932, A. H. S., a lineman employed by one of the public utilities companies, complained of itching and swelling of his hands. The condition began two weeks previously with a few red pimples on the skin, between the fingers of both hands. He used a solution to relieve the itching, and then, after wearing rubber gloves all day, his hands began to swell.

On investigation, it was found that in this work the men wear rubber gloves practically all day; in fact, it is a rule of the company that no man should climb a pole without having his hands protected by rubber gloves. The men are instructed to first put on a pair of white cotton gloves, and then the rubber gloves over these. The rubber globes are made of a heavy material and extend about six inches above the wrists. Over these gloves are worn leather casings, or heavy leather gloves. It was noted that the cotton gloves, after being washed, generally shrank considerably and did not extend beyond the upper part of the palmar surface, so that the rubber came in direct contact with the anterior surface of the wrist.

Both hands were considerably swollen and there were many fine vesicles scattered throughout. The dermatitis was most marked on the dorsum of the hands. This case was considered to be a combination of a slight hypersensitivity and the use of an external irritant.

On February 24, 1932, however, two men, doing the same work but in a different district, reported. The first man gave a history of having had a dermatitis in August, 1931, exactly the same as that from which he was suffering at this time. Just previous to that attack he wore a pair of chocolate-colored gloves for the first time. At that time his condition was diagnosed as poison oak dermatitis and it quieted down in a short time. From then until two weeks ago, he had worn a different type of rubber glove and had no disturbance. Two weeks ago he was again given a pair of chocolate-colored gloves, and several days later his hands began to itch and burn and he had a recurrence of the condition from which he had suffered in August.

On March 4, 1932, another lineman working in an entirely different district from the previous cases, reported, stating that on February 25 he was given a new pair of chocolate-colored gloves which he wore for three days. Then his wrist became very itchy.

These three cases all presented the same type of eruption. The condition was most marked on the anterior surface of the wrists, where the rubber came in direct contact with the skin, and consisted of marked redness with numerous fine papules and vesicles scattered throughout. From this area, the redness shaded and became less marked, involving the backs of the hands to a slight degree.

The men have all worked for this company for years, wearing rubber gloves, sometimes for eight hours a day. Up to the present time, with the exception of one of them, they have never had any disturbance of their skin.

On March 14, 1932, a man who had worked for the above company for twenty-eight years and whose work now consists of emergency work, stated that he had not worn a pair of rubber gloves for a month. A week before he tried on his bare hands a pair which were very tight. He kept them on only about five minutes. The following day both hands began to itch and burn, and by night they were swollen considerably. He presented marked redness and swelling, with numerous vesicles on the dorsum of both hands. This case, like the first one, showed marked reaction which, in my opinion, was due to marked susceptibility to the offending agent.

Further investigation revealed the fact that a short time before, namely on November 19, 1931, and January 30, 1932, two cases of dermatitis in men doing the same type of work and wearing the same brand of gloves, were treated for a dermatitis, the description of which was similar to case two.

It was now felt that there was a definite relationship between the rubber gloves and these dermatoses. A patch test was performed on three different persons. The medical director of the company applied a square inch of the chocolate-colored rubber gloves to the dorsum of his shaved wrist. He wore this for twenty-four hours and showed marked reaction. He later applied pieces of cellophane and two other types of rubber gloves. He found absolutely no reaction after wearing them for twenty-four hours. Further investigation showed that, although the company purchases gloves from several different firms, the chocolate-colored gloves, which were thought to be the cause, were all purchased from the same rubber company.

The safety engineer also applied a piece of the rubber glove to his arm and had a marked reaction. It was also applied to the forearm of patient number four and worn for twenty-four hours. At the end of twenty-four hours no reaction appeared, but at the end of seventy-two hours, there was a marked reaction with intense itching. This reaction persisted longer than the original dermatitis, lasting almost three weeks.

The delayed reaction is interesting. Its importance is illustrated by the standardized patch test for rubber which was developed by Dr. S. H. Katz of the Edgewood Arsenal, working in cooperation with the United States Public Health Service. A letter from the commanding officer of the Edgewood Arsenal gives the United States standardized patch test as follows:

"U. S. Army Specification 20-75A, Face Blank, Face Piece, Gas Mask, includes a test for toxicity of the rubber. In amplification of the test method; this test is made by applying a piece of the rubber one inch square to the inner arm of each subject, about 3 inches below the axilla for 24 hours. Sometimes the application has been extended to 72 hours. The test piece is held with adhesive tape and covered with a cloth bandage which is moistened from time to time to simulate perspiration.

"It is found advisable to examine the site of the application over a period of three weeks because in some cases the appearances of physiological effects have been delayed."

It was, therefore, definitely proved that all these cases of dermatitis arose from the same cause; that is, rubber gloves manufactured by one rubber company. This company admitted the claim, and this brand of gloves was remove from use. Since then, there has been no case of dermatitis.

Letters were sent to various rubber companies to determine whether they knew of other cases of dermatitis resulting from rubber gloves. All replied negatively, with the exception of one company, whose chief chemist made the following statement:

"In the last twenty years we have had reports of perhaps twenty cases of dermatitis caused from rubber gloves. There has probably been a considerable number of cases of which we had no complaint. This experience is about the same as we have had in other lines of rubber goods in which the rubber was used in direct contact with the skin. As might be expected, there seems to be no one particular substance in the rubber to account for every case. We do know, however, that some individuals are so hypersensitive that they will get a marked reaction from the protein materials in the rubber as it comes direct for the tree. With other individuals there is no reaction except with certain of the vulcanizing agents used in the manufacturing processes. We have found in some cases that persons who showed a marked reaction to rubber vulcanized by the acid process would not be affected by rubber vulcanized by the heat process, and conversely, we have found individuals who could use no rubber except that made by the acid process.

"We have done considerable work on this subject, having in our own organization one individual who is highly hypersensitive. However, our conclusions amount to very little because of the apparent wide variation in the quality and degree of hypersensitivity in various individuals."
 
 

It has been known for a long time that contact with rubber will produce a dermatitis, especially in manufacturers, and considerable study has been made to eliminate possible irritants. Research has found that these various substances used in rubber manufacture can bee classified as follows:

Highly Toxic or Irritant

Aniline
Hexamethyline-tetramine
Ortho-toluidine
Para-Phenylinediamine
Para-toluidine
Slightly Toxic or Irritant Alpha-naphthylamine
Beta
Methyline aniline
No Hazards with Proper Handling Aldehydeammonia
Diortho-tolyl-thiourea
Heptaldehydeaniline
Methyline diphenyl diamine
Thiocarbanilide
No Hazards Dimethylammonium-dimethyl-dimethyl-dithiocarbonate
Diortho-tolyl-guanidine
Diphenyl-guanidine
Ethylidine aniline
Mercapto-benzo-thiozole (Captax)
Piperidonium penta methyline dithiocarbonate
While this list is not a complete one, it contains most of the ordinary accelerators used.

Summary

  1. Seven cases of dermatitis due to a particular type of rubber glove are reported.
  2. The same type of dermatitis was reproduced in two controls and in one of the patients by application of the rubber to the skin.
  3. The irritants involved in the manufacture of rubber are described briefly.

 
 




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