9-Sep-2002

Glove reactions

Abstract

Are your cleanroom gloves safe? Nick Gardner of Kimberly Clark explains the facts on managing glove-associated reactions

Within the cleanroom environment, disposable gloves are widely worn in the electronic and healthcare industries. Not only are these gloves used for personal protection, but they fulfill the vital role of protecting the finished product from contamination. Glove usage in the cleanroom sector has undoubtedly grown reflecting the expansion of the high technology and healthcare industries, but precise data is lacking. Overall usage of gloves in the US has dramatically increased from less than a billion in 1986 to over 20 billion in 1996 . With escalating glove usage, variability in manufacturing processes, frequent glove changes and the use of powder, there has been an increase in reported glove-associated reactions. Thus, it is necessary to understand, manage and reduce the risk of developing reactions. The three glove-associated reactions are irritation, which is a non-allergic condition, and two allergic reactions: a Type IV hypersensitivity related to chemicals and a Type I hypersensitivity related to natural rubber latex protein allergens.

Irritation Irritation is a non-allergic inflammation of the skin and may be caused by either non-glove related or glove-associated irritants. Irritation can potentially affect everyone and with 40-60% of glove wearers experiencing this condition , it is the most common form of reaction . Irritation is often caused by non-glove related irritants such as detergents, disinfectants and chemicals used in hand soaps . Work conditions that include frequent hand washing often contribute to irritation. The problem may be compounded by the fact that the moist, warm, occlusive environment under a glove supports microbial growth and can exacerbate the risk of infection. Conversely, irritation can reduce the effectiveness of hand washing, as it is difficult to scrub hands that have open cracks and sores. Irritants can build up below or around jewellery if there is inadequate rinsing. Glove associated irritation may occur when wearing either natural rubber latex or synthetic gloves. Glove associated irritation may be caused by residual chemicals, endotoxin, powder, friction and air occlusion. Symptoms Burning, itching, redness, inflammation, swelling, excessive dryness, cracks or horizontal fissures, sores, blisters, papules (small, hard bumps) and thickened skin with crusting and peeling. The accumulation of sweat next to the skin in long term occlusive conditions can lead to dyshidrosis with vesicular eruptions on the hand that can eventually burst and lead to dermatitis. The onset of symptoms is usually rapid. It is important to note that if the irritation is associated solely with the gloves , the irritant symptoms are normally confined to the area of glove contact. Suggestions for Management of Irritation:

  • Consult your supervisor
  • Wear a larger glove to increase air circulation until hands heal
  • Change gloves more frequently to allow air to get to the hands if gloves are worn for long periods
  • Wear powder-free gloves
  • Wear gloves low in residual chemicals
  • Consider anti-inflammatory creams, but avoid petroleum-based creams when wearing latex gloves
  • Wear glove liners, but be sure to replace them every time gloves are changed.

Type IV A Type IV reaction is a T-cell mediated [4,5,8] allergic response to specific chemicals referred to as contact sensitizers. Like all allergies Type IV is dose and rate dependent, whilst only those individuals with a genetic predisposition to being sensitized by a specific chemical will develop a reaction. Again there is the potential for both non-glove associated and glove associated Type IV. With more than 2,800 non-glove substances having the potential for causing a Type IV reaction , any investigation to the cause should include consideration of soaps, detergents, lotions, jewellery, nickel, fragrances, gluteraldehyde, quaternary ammonias, formaldehyde and many other substances in the work, home and outdoor environment. With glove-associated Type IV, the allergy is usually caused by the chemicals added during manufacturing which can be found in both natural rubber latex and synthetic gloves. More than 80% of Type IV reactions can be traced to chemical accelerators such as thiurams, benzothiazoles, thioureas, carbamates etc. Other contact sensitizers in gloves may be found in the plasitcizers, stabilisers, biocides, antioxidants, donning agents etc.

Symptoms A Type IV glove-associated reaction has a delayed response where the time from exposure to maximum expression of symptoms is 6-48 hours [11,12]. Symptoms include redness, swelling, small blisters, clustered vesicles, itching, pain, crusting, scabbing, sores, peeling, scaling, papules, open lesions and dry, thickened skin. Visually distinguishing between irritation and Type IV is difficult. Identification is aided by remembering that the symptoms of chronic Type IV glove-associated reactions may extend beyond glove border and the symptoms are delayed .

Suggestions for management of Type IV

  • Consult occupational health professional and a dermatologist if symptoms persist
  • Switch to gloves documented to be low in residual chemicals and low in chemical contact sensitizers
  • Select powder-free gloves only
  • Wear glove liners, but be sure to replace them every time gloves are changed. Please note glove liners do not replace hand washing.
  • Consider allergen contact avenues other than the gloves. For example, the accelerator thiuram is also present in fungicides, pesticides and a number of other materials.

Type I Type I is potentially the most severe of the three glove-associated reactions and is an Immunoglobulin E (IgE) antibody mediated allergy [8, 13] to the naturally occurring proteins found in natural rubber latex or cross-reactive plant allergens. Ten to twelve of the approximately 240 protein peptides in raw latex have been reported to be the major allergens, capable of inducing the production of IgE antibodies . Genetically prone individuals are those whose DNA have the instructions for making IgE to the specific allergen. Successive challenges by that specific latex protein allergen amplifies the production of IgE antibodies specific to the allergen. These IgE antibodies attach to increasing numbers of circulating mast and basophil cells . Once an individual's threshold level is reached, subsequent contact with the protein allergen triggers the sensitized cells to release immunological mediators such as histamine. Exposure can occur through direct skin or mucosal contact, invasive procedures, inhalation or aerosolised allergens (e.g. carried by powder). Those who have the genetic make-up to develop many different allergies (e.g. allergies to ragweed, grasses, pollens, peanuts and foods) are referred to as atopic individuals. Because atopic individuals have a greater probability for developing any allergy, they are also at a higher risk for having the genetic make-up for developing an allergy to natural rubber latex proteins . If no Type I glove associated allergy is thought to exist, you may choose either latex or synthetic depending on the task in hand. If latex gloves are selected, they should be low in natural rubber latex protein allergens. Powder-free gloves should be considered to further reduce the potential for powder associated aerosolization. Latex gloves that are classified according to the Council Directive 93/42/EEC for the Medical Device Directive (MDD) would qualify for being low in latex protein content in so far as the protein content must not exceed 50mm of total water extractable protein.

Symptoms Onset of symptoms is rapid and may appear locally at the point of contact or may spread throughout the body. Symptoms include hives, swelling, watery eyes, runny nose, breathing difficulties, asthma, abdominal cramps, dizziness, low blood pressure, rapid heart rate and anaphylactic shock. It is important to note that response levels are extremely individual and depend on a person's genetic make-up and the circumstances of their exposure. Also of interest is that the sensitization process may be accelerated by exposure to cross-reactive allergens . The latter include many common foodstuffs such as apple, bananas, melons, avocados, peaches, pears etc.

Suggested Management of Type I

  • Immediate care is required
  • Notify your occupational health professional and supervisor
  • Consult with an allergist
  • Avoid the use of latex products and wear only synthetic gloves
  • Notify your colleagues, personal physician and dentist of this allergy wear a medic alert bracelet
  • Request that individuals wearing gloves in the area use only powder-free latex or synthetic gloves
  • Be observant of any symptoms that may develop after contact with cross-reactive allergens
Conclusion The increase in glove-associated reactions correlates closely with the increase in glove use. Each reaction has specific causes, symptoms and management criteria. Irritation and Type IV, associated with both latex and synthetic gloves, share similar causes. Type I is unique in its association with latex proteins, in the systemic nature of several symptoms, in the potential severity of symptoms and in the effects of cross reactive allergens. Prudent glove selection is critical to reduce the risk of developing glove-associated reactions and respiratory complications. Choosing low protein (for latex gloves), low chemical, powder-free gloves is the first step to managing glove reactions.

For further information contact Nick Gardner on tel: +44(0)208 669 3839

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