Evaluation of Contact 

Dermatitis Among Ink 

Ribbon Manufacturing 

Employees – New York

Loren C. Tapp, MD, MS

Srinivas Durgam, MSPH, MSChE, CIH

Charles Mueller, MS

Health Hazard Evaluation Report

HETA 2007-0261-3122

March 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific 

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2007-0261-3122 Page i

Appendix A

Report Abbreviations.......................................................................ii

Highlights of the NIOSH Health Hazard Evaluation............ iii

Summary .............................................................................v

Introduction..........................................................................1

Assessment.........................................................................3

Results.................................................................................5

Discussion .........................................................................23

Conclusions.......................................................................25

Recommendations.............................................................25

References ........................................................................28

Contents

Skin Patch Testing .............................................................40

Methods.............................................................................30

Occupational Exposure Limits and Health Effects.............32

Acknowledgments

Appendix B

Appendix C

Appendix D Tables ................................................................................42

Acknowledgments and Availability of Report.....................46
Page ii Health Hazard Evaluation Report 2007-0261-3122

ACGIH® American Conference of Governmental Industrial Hygienists

AIHA American Industrial Hygiene Association

CFR Code of Federal Regulations

CP1 Coating area Plant 1

CP2 Coating area Plant 2

CT Charcoal tube

fpm Feet per minute

GA General area

GC-MS Gas chromatography-mass spectrometry

HHE Health hazard evaluation

HVAC Heating, ventilating, and air-conditioning

LEV Local exhaust ventilation

LLNA Local lymph node assay

MDC Minimum detectable concentration

MEK Methyl ethyl ketone

mL Milliliter

MQC Minimum quantifiable concentration

MSDS Material safety data sheet

NAICS North American Industry Classification System

NIOSH National Institute for Occupational Safety and Health

OEL Occupational exposure limit

OSHA Occupational Safety and Health Administration

PEL Permissible exposure limit

PGMEA Propylene glycol methyl ethyl ether acetate

PPE Personal protective equipment

ppm Parts per million

PR Prevalence ratio

REL Recommended exposure limit

SMM Solvent mixture making

STEL Short-term exposure limit

TD Thermal desorption

TLV® Threshold limit value

TWA Time-weighted average

WEEL Workplace environmental exposure level

VOC Volatile organic compound

Abbreviations
Health Hazard Evaluation Report 2007-0261-3122 Page iii

What NIOSH Did

● We evaluated the facility in August 2007, March 2008, and 

September 2009.

● We looked at work practices and personal protective 

equipment use.

● We took air samples for volatile organic compounds in 

production areas.

● We spoke privately to employees about skin symptoms.

● We reviewed material safety data sheets, training programs, 

and medical records.

● We tested ink ingredient and ink mixture samples to see if 

they could cause an allergic skin reaction.

● We gave the entire workforce a written health survey.

● We noted workplace changes made by the company on the 

basis of our recommendations.

● We tested employees who had a history of dermatitis for skin 

allergies. Common skin allergens and workplace agents were 

used for testing.

What NIOSH Found

● Employees in the production areas had skin exposures to 

chemicals.

● Chemicals and ink dust were seen on work surfaces.

● Some employees were using gloves that did not protect them 

from certain solvents.

● Air sampling found very low levels of chemicals in the air.

● One ink ingredient, one ink mixture, and one brand of hand 

wipes were found to be skin allergens.

● Eighteen of 22 interviewed employees had dermatitis during 

the August 2007 site visit.

● Employees who worked in the production areas had more 

dermatitis than employees who worked in nonproduction 

areas.

● None of the employees who were tested had allergic skin 

reactions to workplace substances.

The National Institute for 

Occupational Safety and 

Health (NIOSH) received 

a request for a health 

hazard evaluation at an 

ink ribbon manufacturing 

plant in New York. The 

employer submitted the 

request because several 

production employees 

had dermatitis possibly 

from exposure to ink 

ingredients or ink 

mixtures.

Highlights of the

NIOSH Health

Hazard Evaluation
Page iv Health Hazard Evaluation Report 2007-0261-3122

Highlights of the

NIOSH Health

Hazard Evalution

(continued)

What Managers Can Do

● Replace work chemicals found to cause skin allergy with ones 

that do not.

● Require good housekeeping practices and continue Best 

Practices training to reduce skin exposure to inks.

● Continue to provide soaps and skin moisturizers that are less 

irritating.

● Continue to provide annual training on how to maintain 

healthy skin.

● Provide employees who are allergic to gloves with gloves that 

do not contain allergens.

● Refer employees with continual dermatitis to a dermatologist.

What Employees Can Do

● Avoid getting chemicals on your skin.

● Promptly clean up chemicals that spill onto work surfaces.

● Use work practices shown in the Best Practices training 

video.

● Use the correct gloves for the work you are doing and wear 

them as directed.

● Use good skin cleaning and moisturizing practices to keep 

skin healthy.

● Promptly report skin problems to your supervisor.
Health Hazard Evaluation Report 2007-0261-3122 Page v

In May 2007, NIOSH received a management request for an HHE 

to look at dermatitis in production employees. In August 2007, we 

toured the plant, interviewed employees, and examined their skin 

for irritation. We took air samples for volatile organic compounds, 

reviewed MSDSs and medical records, and tested workplace 

substances to see if they could cause skin allergy. Our evaluation 

found that airborne solvent exposures were low; however, 

production employees had the potential for skin contact with 

chemicals. The predominant location of dermatitis in employees 

was the hands and fingers, suggesting that the most likely cause of 

dermatitis was direct skin exposure to chemicals. Some ingredients 

in workplace inks, hand wipes, and hand cleaners were known 

sensitizers or were found to be sensitizers by our testing.

In March 2008, we asked employees to fill out health 

questionnaires and observed workplace improvements made by 

the company. The analysis of questionnaire data revealed that 

reporting work-related dermatitis was related to being exposed to 

ink production work and having a predisposition to allergic disease 

(defined as asthma, atopic eczema, or allergic rhinitis/hay fever).

Our initial findings suggested that the cause of the employees’ 

dermatitis was skin allergies, so we returned to do skin patch 

testing in September 2009. We tested 13 employees with a 

history of dermatitis to newly identified workplace allergens and 

to common allergens. No skin patch test participants reacted 

to any of the workplace substances; seven reacted to common 

allergens. A dermatologist under contract to NIOSH diagnosed 

eight participants with irritant contact dermatitis. Employees 

were exposed to several irritants at work including solvents, dusts, 

and irritating soaps and/or hand wipes. In addition, employees 

with dermatitis reported worsening of symptoms when exposed 

to cold, dry weather. Because the company made improvements 

in ventilation, work practices, and housekeeping; introduced 

appropriately protective gloves; introduced less irritating hand 

products; and began healthy skin program training, the dermatitis 

of most skin patch test study participants improved or resolved.

Although no participants reacted to workplace materials, we 

recommended taking precautions in handling sensitizing 

substances, because prolonged and/or large exposures to those 

substances may cause a skin sensitizing reaction in allergy-prone 

employees.

NIOSH evaluated skin 

exposures to workplace 

chemicals and contact 

dermatitis among ink 

ribbon manufacturing 

employees. We found 

that work-related contact 

dermatitis was associated 

with being exposed to 

ink production work and 

with having a history 

of allergic disease. 

We found that some 

workplace chemicals 

were skin sensitizers. 

Skin patch testing results 

indicated an irritant 

cause for the dermatitis. 

We recommended 

substitutions, 

improvements in 

ventilation and work 

practices, better hand 

hygiene to control skin 

exposure to chemicals, 

and early dermatologic 

referral for employees 

with persistent contact 

dermatitis.

Summary
Page vi Health Hazard Evaluation Report 2007-0261-3122

Summary (continued) Keywords: NAICS 339944 (Carbon Paper and Inked Ribbon 

Manufacturing), skin exposure, inks, PPE, gloves, chemicals, 

solvents, contact dermatitis, skin patch testing
Health Hazard Evaluation Report 2007-0261-3122 Page 1

Introduction

In May 2007, NIOSH received a request for an HHE from the 

management of an ink ribbon manufacturing plant in New York. 

The request indicated that several production employees had 

reported dermatitis over the few years prior to the request, possibly 

caused by working with ink and solvent mixtures. We visited the 

plant in August 2007 to meet with management and employee 

representatives, learn more about the manufacturing process, 

observe work practices, evaluate PPE use, interview employees, 

conduct an environmental evaluation, and review pertinent 

records. We returned in March 2008 to administer health 

questionnaires and document process and work practice changes. 

In September 2008, we sent an interim report and then met with 

managers and employees to explain the results of our evaluation. In 

September 2009, we performed skin patch testing to assess whether 

employees with dermatitis had skin allergy to the workplace skin 

allergens we identified or to common allergens. We sent letters 

summarizing the patch testing results to managers and personal 

results to patch test study participants in November 2009. This 

report includes the final results and conclusions of our evaluation, 

and recommends ways to prevent work-related dermatitis using the 

hierarchy of controls as a guide.

Background and Process Description 

This company manufactured wax, wax resin, and resin-based ink 

ribbons, which were packaged and shipped throughout the world. 

The ink ribbons consisted of a sturdy plastic film on which single 

or multiple coatings of ink mixtures were applied to one or both 

sides of the film. Company managers requested our assistance to 

evaluate dermatitis in employees exposed to inks and solvents used 

to make ink ribbon products and to the dust created when ribbons 

were cut. According to managers, production employees began 

reporting dermatitis in 2005. Inkmakers and coaters had reported 

most of the rashes. Twenty-seven employees reported having a 

rash at some time between the summer of 2005 and our first site 

visit in August of 2007; some employees had seen a dermatologist, 

and a few had undergone skin patch testing. A new product, “Ink 

Ribbon A,” was introduced into production in a limited amount 

in late 2003 and into full production in 2004. Some managers and 

production employees felt that exposure to this product might have 

been responsible for the new cases of dermatitis.
Page 2 Health Hazard Evaluation Report 2007-0261-3122

Introduction 

(continued) The production process occurred in two plants. Plant 1 contained 

the kitting room, wax ink area, solvent ink area (which included 

the solvent ink room, SMM center, and backing room), coating 

area, and slitting area. Plant 2 contained an additional coating area 

and the parts washing room. The CP1 used a different coating 

technology than CP2. The main solvents used at this facility were 

toluene, MEK, and isopropyl alcohol.

Dry chemical ingredients were weighed and placed into bags in a 

batch process in the kitting room. In the solvent ink area, solvent 

was weighed and added to large heated stainless steel vessels along 

with the dry ingredients from the kitting room. Some coating 

mixtures that needed agitation and mixing were created in mixing 

vessels in the solvent ink area. The wax ink area contained mixing 

vessels to which waxes were added along with dispersing agents and 

color pigments. These coating mixtures were used in the coating 

machines in CP1 and CP2 where they were then coated onto the 

plastic film.

On the basis of the product configuration, the coating machines 

in CP1 and CP2 could coat the plastic film with coating mixtures 

on one or both sides and, if needed, apply multiple coats on the 

same side. The coated film passed by a drying lamp and was then 

wound onto wide rolls called “jumbo rolls” as the finished product. 

Slitting machines cut these rolls to the required width. The 

finished ribbon product was wound on cores and packaged with 

shrink wrap.

The plant operated 24 hours a day, 7 days a week. Hourly 

production employees worked seven 12-hour shifts in a 2-week 

period. Shift changeover occurred at 7 a.m. and 7 p.m. About 

30 hourly employees in the distribution center a few blocks away 

worked five 8-hour shifts per week. At the time of our initial 

evaluation, approximately 400 employees worked at the plant. 

During our second and third site visits, employees numbered 

between 300 and 350.
Health Hazard Evaluation Report 2007-0261-3122 Page 3

Assessment

First Site Visit – August 2007

In August 2007, we held an opening conference with management 

and employee representatives and toured the facility to observe 

work processes and practices. 

We observed the weighing of dry raw materials in the kitting room 

and wax ink area and the dust bagging and disposal methods for 

dust collectors in the kitting room and slitting area. We collected 

spot slot air velocity measurements with a thermal anemometer 

(TSI Velocicalc® Model 8345, TSI, Shoreview, Minnesota) to 

determine whether the local exhaust hoods in the kitting room, 

wax ink area, solvent ink area, and parts washing room were 

functional. We used TD tubes to collect seven GA air samples to 

screen for VOCs in different areas of the plant. We also collected 

seven CT samples (side-by-side samples) to quantify VOCs 

identified from the screening. We confidentially interviewed 

production employees who had reported skin problems to 

management or who were chosen by job title and availability. 

Preliminary recommendations were given in a closing conference.

We requested bulk samples of certain workplace materials to test 

for potential skin sensitization using LLNA and chemical analysis. 

We reviewed documents including ink MSDSs and contents of 

hand products and gloves used by employees. We also reviewed 

medical records of employees with rash whom we had interviewed.

Details on our methods for measuring VOCs in air and to test 

workplace substances for the potential to cause skin sensitization 

are explained in Appendix A. The OELs and potential health 

effects for VOCs are discussed in Appendix B.

Second Site Visit – March 2008 

In March 2008, we administered health questionnaires to 

employees to evaluate possible associations between dermatitis and 

employee exposures, work practices, and PPE use. We asked about 

these topics in addition to demographic information, pertinent 

medical history, and nonwork exposures. Because the company 

had made changes in the workplace on the basis of our preliminary 

recommendations, we asked about PPE use, hygiene practices, 

work exposures, and dermatitis for two time periods: August 2007 

(time of the first NIOSH site visit) and March 2008 (time of the 
Page 4 Health Hazard Evaluation Report 2007-0261-3122

Assessment (continued) second NIOSH site visit and questionnaire). Questionnaire data 

were analyzed with SAS Version 9.2. (SAS Institute Inc., Cary, 

North Carolina). Details of the questionnaire analysis are described 

in Appendix A.

We classified our exposure groups on the basis of the reported 

current job title of the participant (i.e., our best indicator of ink 

exposure). All supervisors and managers of nonproduction staff 

and all administrative and office staff (with minimal or no ink 

production exposures) were classified as the “ink-unexposed” 

group, and all other reported current job titles were classified as the 

“ink-exposed” group (i.e., exposed to ink production work).

We defined work-related dermatitis by positive responses to both 

having dermatitis on hands, wrists, or forearms since being hired; 

and dermatitis improving away from work sometimes, usually, or 

always. A personal history of allergic disease, or atopy, was defined 

as ever having one of the following: asthma, a persistent itchy rash 

that affected skin creases (atopic dermatitis), or symptoms of allergy 

or hay fever. A family history of atopy was defined as having a 

blood relative (parents, brothers, or sisters) ever having one of the 

following: asthma, persistent rash, or allergy or hay fever.

During our second site visit, we documented substitutions of ink 

ingredients and hand products; changes in work processes and 

employee work practices; and improvements that had been put in 

place since our first site visit in engineering controls, housekeeping, 

employee training, and glove type provided for employees. We 

returned in September 2008 to present our preliminary findings to 

employees and managers and to answer questions.

Third Site Visit - September 2009 

In September 2009, we returned to conduct skin patch testing 

on employees with a history of dermatitis (study group) and 

employees without a dermatitis history (comparison group). We 

tested participants to specific workplace substances that were found 

to be skin allergens in mice and to other possible workplace skin 

allergens. Eligibility and procedures for participants in skin patch 

testing are explained in Appendix C. Because the preparations we 

used had not been used in skin patch testing on people before, 

employees with no dermatitis history were needed to make sure 

nonstandard preparations of workplace substances would not 
Health Hazard Evaluation Report 2007-0261-3122 Page 5

Assessment (continued) produce skin reactions due to irritation nor cause false positive 

reactions.

During our visit, we observed new engineering controls that 

we had recommended in our interim letter. These changes are 

discussed in the Results section.

First Site Visit – August 2007 

Environmental Evaluation

Our observations and the spot air velocity measurements identified 

a nonfunctioning local exhaust hood for the solvent ink area scale. 

The dust generated during the weighing of dry materials in the wax 

ink area was not fully captured by the LEV. Other local exhaust 

hoods we tested in the kitting room, wax ink area, and solvent ink 

area were functional. After our first site visit, we recommended 

improving general housekeeping within the plants and conducting 

a baseline survey to evaluate the LEV systems.

Analysis of the seven GA air samples collected with TD tubes 

indicated the presence of a multitude of chemicals. On the basis 

of their relative abundance in the screening samples, potential skin 

irritancy, and our review of MSDSs, we quantitatively analyzed 

the CTs for MEK, methyl isobutyl ketone, xylene, toluene, methyl 

vinyl ketone, PGMEA, trichloroethylene, limonene, and chemical 

constituents of “Chemical X,” an acrylic plastic powder. These 

results, the MDC and MQC for each analyte, and the applicable 

OELs are presented in Table D1 (Appendix D). Methyl isobutyl 

ketone, methyl vinyl ketone, trichloroethylene, and Chemical 

X constituents were not detected in our air samples. Toluene 

concentrations ranged from 0.34–11 ppm. All the air samples 

were analyzed for different isomers of xylene, and the highest air 

concentration of 0.11 ppm was observed in an air sample collected 

in the wax ink area. PGMEA concentrations ranged up to 0.55 

ppm. All the air sample concentrations were very low.

Results
Page 6 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) Document and Glove Review 

We reviewed the MSDSs of the four different types of hand hygiene 

products (two gritty-type hand cleaners, one lotion soap, and one 

hand lotion) and two types of hand wipes that were available to 

employees. In addition, the complete lists of ingredients for the 

blue and green hand wipes and one of the hand cleaners were 

obtained from their containers. At least two of the ingredients 

listed on the blue hand-wipes container were known sensitizers – 

d-limonene and triazine. The potentially irritating and sensitizing 

ingredients of each hand-wipe product are listed in Table D2 

(Appendix D), along with the MSDS statement concerning the 

products’ skin hazard potential. Both hand-wipe products contain 

a variety of sensitizing ingredients, however, only the green handwipe product states that use may cause sensitization by prolonged 

skin contact. Hand cleaners often contain compounds irritating to 

skin.

We reviewed the MSDSs for the chemicals used in formulating 

coating mixtures for Ink Ribbon A, which managers and employees 

identified as a potential cause of dermatitis. The MSDS for 

Chemical X, one component of Ink Ribbon A, indicated it is a 

resin copolymer. Upon our request, the manufacturer of Chemical 

X identified the proprietary chemical ingredients that make up the 

polymer; these ingredients are known skin sensitizers.

We also evaluated the gloves provided to employees: disposable 

nitrile gloves (Touch N Tuff, N Dex Nitehawk), arm-length nitrile 

gloves of two kinds (lined green Solvex, MAPA blue and yellow), 

Ansell Barrier® gloves, gloves for heat protection (yellow fuzzy 

duck), and cotton lining gloves (various types – thin, thick with 

rubber grip) for absorbing sweat. The nitrile gloves used at the 

facility were appropriate for working with isopropyl alcohol but 

not with toluene or MEK. We were informed that Ansell Barrier 

gloves were provided to employees working in the solvent ink area. 

However, we did not observe employees wearing these gloves.

Laboratory Evaluation 

Results of the LLNA testing of the blue hand wipes were positive 

for sensitization in both intact (without a pre-existing condition) 

and breached (slightly abraded) skin. The testing also evaluated the 

product for irritancy; results were negative for irritation.
Health Hazard Evaluation Report 2007-0261-3122 Page 7

Results (continued) The LLNA testing of the three coating mixtures of Ink Ribbon 

A revealed that the “Coating C” mixture was positive for skin 

irritancy and sensitization. Two potentially sensitizing ingredients 

in this coating mixture, “Chemical Y,” a polyvinyl butyral 

compound, and Chemical X, were further evaluated. Chemical 

Y tested positive for skin sensitization by LLNA. The suspect 

ingredient in Chemical Y, polyvinyl butyral, was tested and also 

found to be sensitizing. On the basis of an extensive literature 

search, we identified one study that found polyvinyl butyral 

to be nonirritating to the skin of rabbits [Knapczyk 1997]. No 

sensitization studies were located. The MSDS for Chemical Y does 

not list skin sensitization as a potential health hazard.

The second ingredient of the ink coating mixture, the resin 

copolymer Chemical X, was found to contain very small amounts 

of residual monomers known to be skin sensitizers. If the resin 

is in a 100% polymer form, it is not sensitizing. However, studies 

have shown that polymers often contain residual monomer 

[Bjorkner 1999; Pfeiffer and Rosenbauer 2004]. The results of our 

chemical analyses indicated that Chemical X contains residual 

“Monomers A and B” at estimated average concentrations of 

0.033% and 0.0035% by weight, respectively. The MSDS for 

Chemical X does not list skin sensitization as a potential health 

hazard.

Employee Interviews

Twenty-two production employees were interviewed; 19 were from 

a list of 27 who had reported skin problems to management (the 

other eight were unavailable) and three others were chosen by job 

title (i.e., high ink exposure potential) and availability. Among the 

22 employees interviewed, 18 reported a history of rash (one of the 

19 from the list reported no history of rash).

The eighteen employees with a history of rash included six 

inkmakers, three CP2 coaters, two slitters, and one each from 

the following areas: kitting room, CP1 coating, maintenance, 

utility operation, quality assurance, warehouse, and supervision. 

Seventeen reported that their rash began during or after 2004. 

Thirteen consulted a physician because of their rash. Seven 

employees with rash reported that they thought Ink Ribbon A was 

responsible; three of these specified Coating C, a coating from 

Ink Ribbon A, as the problem. Six employees reported that use of 
Page 8 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) the blue hand wipes, but not the green hand wipes, irritated their 

skin and/or caused a rash. One reported Rasol5000, and another 

reported 25B pigment (both are ink ingredients) as the cause of 

their rash. Some employees with rash stopped using the blue hand 

wipes and reported that the rash resolved. On examination, 17 

employees had dermatitis on their hands, wrists, and/or forearms 

with two of the 17 also having dermatitis on the face and/or 

lower extremities. One employee had dermatitis on the legs only. 

Characteristics of employee dermatitis included red, slightly raised, 

dry patches, some with flaking and/or cracking of the skin, some 

with tiny red papules and/or vesicles.

Medical Record Review 

We obtained medical records of ten employees who had 

experienced rash while working at this company and had seen a 

medical provider for the rash. Of these ten employees, six were 

diagnosed with work-related contact dermatitis; these six included 

two with work-related allergic contact dermatitis and four for whom 

the type (allergic vs. irritant) was not identified. The two employees 

diagnosed with allergic contact dermatitis were skin patch tested 

by their personal physicians but were not patch tested to specific 

products used in the workplace. One had also been diagnosed 

with work-related occupational asthma. Both had improvement of 

symptoms after being transferred to work areas without wet process 

exposure. Of the remaining four employees, three were diagnosed 

with dyshidrotic eczema (i.e., recurrent, small itchy blisters on 

hands and feet), and one had not been given a clear diagnosis.

Second Site Visit – March 2008

Health Questionnaire 

Description of Participants and Exposure Groups 

On the day scheduled for administering the health questionnaire 

in March 2008, 291 of 349 (83%) available employees completed 

the questionnaire. Information obtained from employee rosters 

and employee sign-in sheets at the time of the questionnaire 

was used to calculate participation rates. Of 207 employees 

working A, B, C, and D shifts, 203 (98%) participated; of 113 

office employees, 63 (56%) participated; and of 29 distribution 
Health Hazard Evaluation Report 2007-0261-3122 Page 9

Results (continued)

Dermatitis Among Employees 

Of 291 participants, 60 (21%) reported having dermatitis on 

their hands, wrists, or forearms since they began working at the 

company; none of the 10 employees hired since August 2007 

reported dermatitis. Among these 60 employees, 44 reported 

that the dermatitis improved away from work sometimes, usually, 

or always, and 27 reported that they had seen a doctor for their 

dermatitis. Twenty-four of 60 employees reported that their 

dermatitis was worse in winter; 29 reported that season made no 

difference, and 3 reported worsening dermatitis in summer. Fiftythree of the 60 employees with dermatitis since hire reported the 

year in which their dermatitis began; 35 (66%) reported that their 

dermatitis began in 2005 or later; 7 reported that their dermatitis 

began in 2005; 16 in 2006; and 11 in 2007. The year of dermatitis 

onset was of interest because Ink Ribbon A had been suggested as a 

possible cause and was introduced into production in early 2004.

center employees, 25 (86%) participated. On the basis of the 

questionnaire responses, we found 10 of the respondents in March 

2008 were not employed by the company in August 2007.

From August 2007 to March 2008, one employee changed from 

an ink-unexposed to an ink-exposed job, and another employee 

changed from an ink-exposed to an ink-unexposed job. Because the 

movement of employees between exposed and unexposed jobs was 

rare, we used the job exposure classifications from March 2008 as 

representative of both time periods when looking at demographic 

data (Table 1).)

Table 1. Demographic characteristics among ink-exposed and ink-unexposed employees

Characteristic

Ink-exposed

(N = 251–254)*

Number (%) 

Ink-unexposed

(N = 37)

Number (%) 

Male 203 (80) 16 (43)

Personal history of atopy 143 (56) 28 (76)

Family atopy 119 (47) 25 (68)

Age in years – Average 44.9 43.5

Total years at company – Average 12.2 10.6

*Range of denominators (i.e., the number of employees answering each question differed)
Page 10 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) Employees reporting dermatitis since hire also reported the jobs 

they held when their dermatitis began. The most common jobs 

were slitting (20), coater (8), and inkmaker (6). When asked what 

they thought caused their rash, the most commonly reported 

causes were blue hand wipes (12), cold or dry weather (7), and Ink 

Ribbon A or a component of Ink Ribbon A (6). Among employees 

with dermatitis since hire, dermatitis reported in August 2007 and 

March 2008 most often occurred on the back of the hands 

(60%–63%) and the back of the fingers (51%).

We looked at the prevalence (%) of dermatitis and work-related 

dermatitis since hire. As measured by the prevalence ratio, the inkexposed group was nearly three times as likely to report dermatitis 

of the hands, wrists, and forearms since hire as the unexposed 

group. When work-relatedness was taken into account, they were 

six times as likely to report work-related dermatitis since hire. 

Both of these relationships were statistically significant (Table 2). 

Because our survey did not include questions about the workrelatedness of dermatitis reported for August 2007 and March 

2008, we were unable to estimate the prevalence of work-related 

dermatitis for those periods. Among ink-exposed employees, the 

prevalence of dermatitis was slightly lower (3%) in March 2008 

than in August 2007.

Table 2. Self-reported dermatitis among ink-exposed and ink-unexposed employees

Ink-exposed 

(N = 244–254)*

Number (%)

Ink-unexposed 

(N = 37)

Number (%)

Prevalence 

Ratio†

(P value)

Dermatitis of hands, wrists, or forearms since being 

hired 

57 (22) 3 (8) 2.8 (0.04)‡

Work-related dermatitis of hands, wrists, or forearms 

since being hired§ 

43 (17) 1 (3) 6.3 (0.02)‡

Dermatitis in March 2008 (“current”) 32 (13) 3 (8) 1.6 (0.59)

Dermatitis in August 2007¶ 40 (16) 3 (8) 2.0 (0.19)

*Range of denominators (i.e., the number of employees answering each question differed)

†The percent in the exposed group divided by the percent in the unexposed group

‡Statistically significant

§Work-related dermatitis defined by positive responses to both having dermatitis on hands, wrists, or 

forearms since being hired, and dermatitis improving off work sometimes, usually, or always

¶Exposure groups based on reported job in August 2007
Health Hazard Evaluation Report 2007-0261-3122 Page 11

Results (continued) Differences Between Ink-exposed Employees With 

and Without Dermatitis in August 2007 

To determine factors that may be associated with dermatitis, we 

looked at ink-exposed employees working in August 2007 and 

compared characteristics, behaviors, and PPE use among those 

with and without dermatitis in August 2007 (Table 3). We used the 

August 2007 period because this is when the concern was greatest, 

and no changes or interventions had been implemented at that 

point.

Table 3. Characteristics, behaviors, and PPE use among ink-exposed employees with and without dermatitis in 

August 2007

Characteristics Ink-exposed employees* P value

With dermatitis in 

August 2007

(N = 36–40)†

Without dermatitis in 

August 2007

(N = 180–204)†

Average Average

Age 46.6 45.2 0.31

Total years at the company 13.3 12.6 0.43

# times applied lotion 1.5 1.3 0.49

# times wash hands in 24 hours 6.2 6.8 0.47

Number (%) Number (%)

Males 32 (80) 163 (80) 0.99

Atopic history 34 (85) 102 (50) <0.01‡

Family history of atopy 19 (48) 94 (46) 0.89

Worked with wet hands ≥ 2hrs a day 3 (8) 15 (7) >0.99

Used gloves 28 (70) 108 (53) 0.051

Usually reused gloves

(among glove users)

10 of 27

 (37)

 64 of 105

 (61) 0.03‡

Used Tyvek® sleeves 10 (26) 41 (21) 0.53

Used cotton sleeves 12 (31) 67 (35) 0.65

Used blue hand wipes 28 (78) 121 (65) 0.15

Used green hand wipes 12 (32) 99 (52) 0.02‡

*Exposure groups based on reported August 2007 job

†Range of denominators (i.e., the number of employees answering each question differed)

‡Statistically significant
Page 12 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) Dermatitis among exposed workers was significantly associated 

with a personal history of atopy (P < 0.01). The use of gloves was 

greater in those employees with dermatitis, but was not statistically 

significant (P = 0.051). Among glove users, reusing gloves was 

more common in employees without dermatitis (P = 0.03). The 

use of green hand wipes was statistically greater among exposed 

workers without dermatitis than among those with dermatitis (P 

= 0.02). We compared exposures that were not work related for 

the two groups (e.g., preparing food, cleaning the household or 

car, caring for children under the age of 4 years, handling soil or 

plants, handling oil, handling solvents or paints, handling glue, 

and handling cement or drywall). The comparison showed no 

meaningful differences in these exposures between workers with 

dermatitis and those without dermatitis.

The Use of Hand Wipes and Dermatitis 

Our LLNA testing showed that the blue hand wipes can produce 

skin sensitization. For this reason, we recommended that the 

company eliminate these hand wipes from the workplace. The 

company removed the blue hand wipes from the workplace prior 

to January 2008. Among the 40 ink-exposed employees with 

dermatitis in August 2007, 33 (83%) reported that they were using 

blue hand wipes when their dermatitis began. Twenty (61%) of the 

33 reported that their dermatitis improved or resolved after they 

stopped using these wipes. Of ink-exposed employees working in 

August 2007, 59 (24%) reported they did not use hand wipes, and 

36 (15%) had missing information. Of those reporting complete 

information on blue and green hand-wipe use, 81 (33%) used 

both, 55 (23%) used only blue, and 13 (5%) used only green hand 

wipes. Ink-exposed employees who used green hand wipes were half 

as likely to report dermatitis as those not using green hand wipes 

(PR = 0.48; P = 0.02). Those using blue hand wipes were more 

likely to report dermatitis, but this relationship was not statistically 

significant (PR = 1.69; P = 0.15). Employees in the ink-exposed 

group who used blue hand wipes exclusively were nearly three 

times as likely to report dermatitis in August 2007 

(PR = 2.93; P < 0.01) compared to those who did not use hand 

wipes or used green hand wipes at least some of the time.
Health Hazard Evaluation Report 2007-0261-3122 Page 13

Results (continued) Use of Personal Protective Equipment and Hygiene 

Practices in August 2007 and March 2008 

We looked at hygiene practices and PPE use for ink-exposed 

employees in August 2007 and March 2008 (Table 4). From 

August 2007 to March 2008, we found small increases in glove use, 

number of hours gloves were worn per day, and number of times 

gloves were changed per day. The practice of reusing gloves among 

glove wearers and the use of cotton and Tyvek® sleeves stayed 

about the same. The number of times moisturizing hand lotion 

was applied on a typical workday increased between August 2007 

and March 2008. Of the 60 employees with dermatitis since hire at 

the company, 26 reported that their dermatitis had improved since 

the company management had made changes in gloves, soaps, and 

training programs; 20 reported their dermatitis did not improve; 

and 11 had improved before the workplace changes.

Table 4. Reported PPE use and hygiene practices among ink-exposed employees in August 2007 and 

March 2008

Reported PPE use and hygiene practices August 2007

(N = 227–244)*

March 2008

(N = 247–254)*

Average Average

# times lotion applied over 24 hours 1.3 2.1

# times hands washed in 24 hours 6.7 6.7

# hours per day gloves used (among glove 

users)

4.9

(N = 126)

5.4

(N = 154)

# times per day gloves changed to new pair 

(among glove users)

4.1

(N = 122)

4.7

(N = 146)

Number (%) Number (%)

Green hand-wipe use 111 (49) 173 (70)

Used Tyvek sleeves 51 (22) 51 (20)

Used cotton sleeves 79 (34) 81 (33)

Used gloves at work 136 (56) 156 (61)

Reused gloves (among glove users) 74 (56)

(N = 132)

 78 (51)

 (N = 152)

*Range of denominators (i.e., the number of employees answering each question differed)
Page 14 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) Hygiene and Personal Protective Equipment 

Practices Among Higher Risk Employees in March 

2008

To see how well employees in the ink-exposed jobs with higher 

potential for exposure were using PPE and practicing good 

hygiene, we looked at the same hygiene and PPE practices as 

Table 4 for specific job groups. We combined kitters, inkmakers, 

coaters, solvent recovery, and utility operators into the wet ink 

mixture-exposed group and all slitters into the finished product 

dust-exposed group. Employees of both groups reported applying 

moisturizing lotion about twice a day. Of wet ink mixture-exposed 

employees, 94% reported using gloves during work, using gloves an 

average of about 6 hours per day, and changing to a clean pair of 

gloves over six times per day. Of dust-exposed employees, 

34% reported using gloves during work, using gloves an average of 

4 hours a day, and changing to a clean pair of gloves fewer than two 

times per day. Results are presented in Table D3, Appendix D.

Documentation of Workplace Changes 

Occurring Between August 2007 and March 

2008

Between our August 2007 and March 2008 site visits, we sent 

company managers information on educational programs targeting 

skin health and methods to prevent dermatitis. We recommended 

additional employee education, evaluation of hand cleaners for 

sensitizing agents, use of moisturizing lotion, and elimination 

of the blue hand wipes while our lab evaluated the blue hand 

wipes, ink ingredients, and mixtures. We recommended use of the 

Ansell Barrier gloves as they are protective against all three major 

solvents that the company uses [Forsberg and Mansdorf 2007]. We 

also suggested the use of a better fitting glove over these gloves to 

improve dexterity.

During our second site visit in March 2008, we found that the 

company had implemented our initial recommendations and 

made a variety of modifications to work processes and practices. 

These changes are described below, grouped according to the 

occupational safety and health hierarchy of controls for controlling 

exposure:
Health Hazard Evaluation Report 2007-0261-3122 Page 15

Results (continued) Substitution 

● Hyperdispersants, used in the manufacturing process in 

a fine dry powder form, were mentioned by employees as 

a concern because these materials got on their skin and 

clothes and were hard to clean up. We observed that the 

material became airborne when dispensed in the powder 

form. This material was found on the floors of the wax 

ink area and near the scale. During our second site visit, 

we found that the powder form had been replaced with a 

waxy solid kept in liquid phase by heating the material to 

around 95°F. Employees used a hand pump to dispense the 

required quantity of material as needed (Figure 1). Review of 

the MSDS of this material indicated that the melting point 

was 95°F, and hence would be nonvolatile at typical storage 

temperatures.

Figure 1. Hand pump used to dispense the waxy solid.
Page 16 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) ● The company removed several of the original hand hygiene 

products and the blue hand wipes and introduced less 

irritating hand care products for employees. One of the 

original hand cleaners and the green hand wipes were still 

used.

Engineering Controls

● In the kitting room, the seal on the dust collector drum was 

modified to ensure complete enclosure.

● A ventilation survey of each area was being conducted to 

establish a baseline for performance of the system.

● Automated slitting machines were modified to handle a 

variety of different products. These machines have built-in 

dust collection systems that help capture dust generated 

during the slitting process.

Administrative Controls

● Cleaning of the supply air diffusers throughout Plant 1, the 

dust collector, and HVAC system serving the wax ink area 

had begun.

● Simple ventilation checks using a streamer attached to a pole 

were being done by employees to ensure the local exhaust 

hoods were functioning and drawing air inwards.

● A housekeeping checklist was generated for locations in the 

ink making area (i.e., kitting room, solvent ink area, and wax 

ink area). The checklist was to be completed at the end of 

each shift and made available to employees on the next shift. 

The supervisor conducted housekeeping audits before the 

start of each shift.

● Videos were developed showcasing the best practices when 

conducting specific tasks such as transferring materials to 

drums or totes, and weighing materials. The training videos 

were used to educate employees performing these operations 

(e.g., kitters and inkmakers). The videos were also being 

integrated into the training of new employees hired for these 

jobs or when employees are cross-trained.

● The final product was shrink-wrapped before sending to the 

distribution center.
Health Hazard Evaluation Report 2007-0261-3122 Page 17

Results (continued) ● The “Healthy Skin Program,” initiated in January 2008, 

explained the importance of good skin care and dermatitis 

prevention methods.

Personal Protective Equipment

● Between our August 2007 visit and March 2008 visit, the 

company discontinued use of the synthetic gloves and 

introduced the following gloves into the workplace: blue 

Stanzoil®/NK-22, yellow and black Kevlar® K1450, purple 

Trilites®/994, and blue and black Temp-Tec® NL-56 

Neoprene. The Stanzoil/NK-22 and Temp-Tec NL-56 gloves 

are made of neoprene, and Trilites/994 is made from a blend 

of neoprene, nitrile, and natural rubber. We reviewed the 

manufacturers’ product specification sheets, which indicated 

that these gloves are designed for brief use when working 

with solvents such as MEK and toluene, but not for extended 

use.

● Employees had been provided with personal PPE totes 

(Figure 2). This ensures that they have a clean and safe 

location for storage of their PPE such as unused gloves and 

filtering-facepiece respirators.

Figure 2. Personal PPE tote.
Page 18 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) ● Charts containing information on the appropriate glove 

for the jobs being conducted in a given area were posted 

throughout the plant (Figure 3). Employees were provided 

the appropriate type of gloves and educated on donning and 

doffing procedures.

Figure 3. Glove use chart posted at locations throughout the 

 production areas.

Third Site Visit – September 2009 

Skin Patch Testing 

Skin patch testing was performed on 13 of the 40 eligible study 

participants (the “study group”). Of the remaining 27 who did 

not participate, 10 did not return phone messages, eight refused, 

eight were unable to be contacted (wrong or missing phone 

number, no answering machine/service), and one was no longer 

employed at the company. Seven of 230 comparison employees (the 

“comparison group”) were chosen by convenience and skin patch 

tested to only the workplace substances. Of the 13 with dermatitis 

history, nine had active skin irritation on their hands, wrists, 

and/or forearms; the remaining four did not have active skin 

problems. None of the comparison employees had active skin 

problems.
Health Hazard Evaluation Report 2007-0261-3122 Page 19

Results (continued) Eight of the nine study participants with active skin rash were 

diagnosed with irritant contact dermatitis by the dermatologist 

contracted by NIOSH; five of the eight also had additional skin 

diagnoses (i.e., dyshidrotic dermatitis, lichen simplex chronicus, 

seborrheic dermatitis, and psoriasiform dermatitis). One of these 

nine study participants was unable to continue the testing because 

of skin discomfort and could not be evaluated. In addition, three 

of the 13 study participants had irregular skin lesions that were 

not related to work; we recommended further evaluation by their 

dermatologist.

No study group (13) or comparison group (7) participants had 

a skin reaction to the workplace-specific materials. Seven study 

participants had positive skin patch test reactions to one or more 

of the 50 common North American allergens, including:

● Thiuram mix and mixed dialkyl thiourea (additives used to 

make protective gloves)

● 4-tert-butylphenolformaldehyde resin (glue used in leather 

products)

● Potassium dichromate (chemical used in leather tanning and 

also an ingredient in cement)

● Nickel (most common allergen found in North America 

– used to make costume jewelry, belt buckles, metal wrist 

bands, etc.)

● Amerchol L101 (also known as lanolin, or sheep oil, used in 

many emollients)

● Bacitracin and neomycin sulfate (topical antibiotics)

● 4-phenylenediamine base (chemical used in hair dyes)

● Cinnamic aldehyde

● Balsam of Peru

● Fragrance mix (found in many personal hygiene products 

such as lotions, shampoos, shower gels)

● Disperse blue mix 106/124 (chemical used to dye poly-blend 

clothing)

● Composite mix (mixture of Tanacetum vulgare [ragweed], 

Arnica montana [arnica], Parthenolide [feverfew], 

Chamomilla romana [chamomile], and Achillea millefolium 

[yarrow])
Page 20 Health Hazard Evaluation Report 2007-0261-3122

Results (continued) Employees with positive skin reactions were counseled to avoid 

allergens they reacted to in order to prevent allergic contact 

dermatitis. Employees with a dermatitis history (past or current) 

were advised to protect their skin from irritants by using 

appropriate gloves, cleaning the skin appropriately with gentle skin 

cleansers, and using skin moisturizing products frequently.

Study participants received a letter informing them of their 

individual skin patch test results, what the results mean, and, in the 

case of positive reactions, which chemicals, materials, or items they 

should avoid. They were also given information on ways to prevent 

or alleviate irritant contact dermatitis symptoms. Participants were 

asked to share this information with their personal healthcare 

providers.

Documentation of Workplace Changes 

Occurring Between September 2008 and 

September 2009 

During our last site visit, we observed a few additional engineering 

controls that had been instituted based on recommendations we 

made in our interim letter. These changes were:

● In August 2007, the company was using an enclosed hood in 

the kitting room to weigh dry and powdery ink ingredients 

(Figure 4). As can be seen in Figure 4, ink ingredient 

materials spilled when transferred from larger 55-gallon 

containers to smaller drums. This was a possible source 

of employee exposure to sensitizing ink ingredients. We 

recommended installing semi-downdraft ventilation booths 

as described in an earlier NIOSH publication titled “Control 

of Dust from Powder Dye Handling Operations” [NIOSH 

1997]. This was implemented as shown in Figure 5.
Health Hazard Evaluation Report 2007-0261-3122 Page 21

Results (continued)

Figure 4. Enclosed hood to weigh dry powders in the kitting room – 

 August 2007.

Figure 5. Semiventilated downdraft booth installed in the kitting room –

 September 2009.
Page 22 Health Hazard Evaluation Report 2007-0261-3122

Results (continued)

Figure 6. Ventilated solvent weighing booth in the SMM center – 

 August 2007.

● In August 2007, we recommended keeping the empty drums 

close to the LEV hood slots when transferring solids or 

liquids (Figure 6). The solvent weighing booth in the SMM 

center was modified by adding an additional slotted hood to 

increase exhaust ventilation (Figure 7). We did not evaluate 

the modified exhaust hood.

Figure 7. Modified solvent weight booth in the SMM center – 

 September 2009.
Health Hazard Evaluation Report 2007-0261-3122 Page 23

Our evaluation found that airborne solvent exposures were low; 

however, production employees had the potential for chemicals to 

contact their skin. Because the predominant location of dermatitis 

in employees was the hands and fingers, the most likely cause of 

dermatitis is direct skin exposure to chemicals. Many workplace 

substances are skin irritants, and some are known skin sensitizers. 

We found some ink ingredients and one brand of hand wipes to be 

skin sensitizers by LLNA testing.

Health questionnaire data revealed that exposure to ink 

production work and a personal history of atopy were associated 

with work-related dermatitis. Exposure to inks is a well-known 

cause of dermatitis [Nethercott and Holness 1999]. The association 

between a history of atopy and work-related dermatitis is consistent 

with other studies that found individuals with a predisposition 

to developing allergies appear to have a greater likelihood of 

developing work-related dermatitis under certain conditions 

[Klas et al. 1996; Belsito 2005]. Production employees with 

dermatitis wore gloves more often and reused gloves less often than 

those without dermatitis. Because we collected information at one 

point in time (i.e., cross-sectional study), we cannot determine if 

those with dermatitis tend to wear gloves more often or if those 

who wear gloves more often tend to develop dermatitis. We did 

see a small increase in the use of gloves and skin moisturizer, and a 

small decrease in the prevalence of dermatitis among ink-exposed 

employees, from August 2007 to March 2008, suggesting that the 

employee training has had a positive impact.

 

The results from exposure assessments, laboratory analyses of 

workplace chemicals, record reviews, and questionnaire responses 

led us to assess whether employee dermatitis had an allergic 

component. Because no skin patch test participants reacted to any 

of the workplace substances on patch testing, and eight of nine 

were diagnosed with irritant contact dermatitis by the NIOSHcontracted dermatologist, we believe the majority of cases of 

dermatitis were from irritant causes. Irritants that employees are 

potentially exposed to at work include solvents, dusts, soaps,

and/or hand wipes. In addition, several employees reported 

worse skin symptoms during winter, which is consistent with 

skin irritation from cold, dry weather. Information on contact 

dermatitis found in Appendix B may be helpful in recognizing, 

understanding, and preventing the disease.

Discussion
Page 24 Health Hazard Evaluation Report 2007-0261-3122

Discussion (continued) No participants reacted to the workplace-specific ingredients that 

were skin sensitizers in mice studies. It is unclear if this was due 

to lack of sufficient numbers of study participants, the specific 

concentrations of the workplace ingredients used for patch testing, 

the mouse model not being a good surrogate for sensitization in 

humans, or other factors not yet understood. It is possible that 

some current or former employees with dermatitis who did not 

participate may have reacted to these allergens.

Despite the negative skin patch test results for workplace 

substances, the results of the LLNA animal study should not be 

disregarded. The LLNA has been supported in the international 

scientific literature as a good predictor of human skin sensitization 

[Kimber et al. 2001; EPA 2003]. The positive animal test results 

provide further reason for taking precautions in handling those 

substances because prolonged and/or heavy exposures could result 

in future skin sensitization in employees who are prone to allergies.

Since the company instituted improvements in ventilation, work 

practices, and housekeeping, and began its healthy skin training 

program, the occurrence of dermatitis among ink-exposed 

employees has decreased modestly, on the basis of questionnaire 

responses. In addition, the skin patch testing found that the 

dermatitis of most study participants has improved or resolved. 

It is important to note, however, that one fourth to one third 

of persons diagnosed with hand dermatitis will have chronic 

and persistent dermatitis symptoms, and this is not affected by 

whether the dermatitis is irritant or allergic [Jungbauer et al. 2004; 

Cvetkovski et al. 2006]. Studies on the prognosis of occupational 

contact dermatitis stress the importance of primary prevention. 

The company management has made important workplace 

changes to date. Following the additional recommendations in this 

report will further protect employees from potentially hazardous 

workplace exposures.
Health Hazard Evaluation Report 2007-0261-3122 Page 25

We found that production employees had the potential for skin 

exposure to chemicals, that some workplace chemicals were 

skin sensitizers, and that work-related dermatitis was associated 

with exposure to inks and to having an allergic predisposition. 

Skin patch testing found that no employees had skin allergy to 

workplace chemicals, and that all skin patch test participants with 

active dermatitis were diagnosed with irritant contact dermatitis.

The company has made several improvements in the workplace to 

reduce ink exposures among employees and to provide appropriate 

PPE and training to employees. It appears that these improvements 

have contributed to the decrease in employee cases of dermatitis.

On the basis of our findings, we recommend the actions listed 

below to create a more healthful workplace. We encourage the 

company to continue to use the labor-management health and 

safety committee or working group to discuss the recommendations 

in this report and develop an action plan. Those involved in 

the work can best set priorities and assess the feasibility of our 

recommendations for the specific situation at the company. Our 

recommendations are based on the hierarchy of controls approach 

(refer to Appendix B: Occupational Exposure Limits and Health 

Effects). This approach groups actions by their likely effectiveness 

in reducing or removing hazards. In most cases, the preferred 

approach is to eliminate hazardous materials or processes and 

install engineering controls to reduce exposure or shield employees. 

Until such controls are in place, or if they are not effective or 

feasible, administrative measures and/or personal protective 

equipment may be needed.

Elimination and Substitution 

Elimination or substitution of a toxic/hazardous process material 

is a highly effective means for reducing hazards. Incorporating 

this strategy into the design or development phase of a project, 

commonly referred to, as “prevention through design,” is most 

effective because it reduces the need for additional controls in the 

future.

● Investigate options for substituting nonsensitizing ink 

ingredients for those ingredients we found to be sensitizing.

Recommendations

Conclusions
Page 26 Health Hazard Evaluation Report 2007-0261-3122

Recommendations

(continued) Engineering Controls 

Engineering controls reduce exposures to employees by removing 

the hazard from the process or placing a barrier between the 

hazard and the employee. Engineering controls are very effective 

at protecting employees without placing primary responsibility of 

implementation on the employee.

● Maintain the exhaust ventilation in the wax ink area 

and solvent ink area according to the manufacturer’s 

recommendation. For drum filling operations, we 

recommend following the guidelines in “Industrial 

Ventilation – A Manual of Recommended Practice for 

Design,” which requires a minimum duct velocity of 3500 

fpm and an air flow rate of 100 cubic feet per minute per 

square foot of drum surface area [ACGIH 2007].

Administrative Controls 

Administrative controls are management-dictated work practices 

and policies to reduce or prevent exposures to workplace hazards. 

The effectiveness of administrative changes in work practices 

for controlling workplace hazards is dependent on management 

commitment and employee acceptance. Regular monitoring and 

reinforcement are necessary to ensure that control policies and 

procedures are not circumvented in the name of convenience or 

production.

● Refer employees with recurrent or persistent skin symptoms 

in a timely manner to a dermatologist knowledgeable about 

occupational diseases and skin patch testing. Allergic contact 

dermatitis can be diagnosed definitively only with skin patch 

allergy testing. Skin patch testing allows these employees 

to know if they have skin allergy to certain workplace 

substances, as well as to other common skin allergens. The 

results can be used to counsel employees individually on 

what substances to avoid to prevent dermatitis recurrence. If 

employees are allergic to ink ingredients that they are unlikely 

to have contact with outside of work, it may be possible to 

avoid the ink ingredients by additional or more protective 

PPE and careful work practices. If these protective methods 

fail to relieve the dermatitis symptoms, then removal from 

exposure may be necessary. In some cases of allergic skin 
Health Hazard Evaluation Report 2007-0261-3122 Page 27

Recommendations

(continued) disease, employees may have to be reassigned with retention 

of pay and employment status to areas where exposure is 

minimal or nonexistent.

● Provide annual healthy skin program training in the fall to 

help employees remember preventive measures they can take 

to protect their skin from drying out in winter. Employees 

with a history of allergic disease should be informed that 

they are at increased risk for developing contact dermatitis 

and need to take extra precautions to keep their skin healthy. 

See Appendix B, Occupational Exposure Limits and Health 

Effects, Contact Dermatitis, for tips on preventing dermatitis. 

A healthy skin barrier is one of the best protections against 

irritant and allergic contact dermatitis.

Personal Protective Equipment 

PPE is the least effective means for controlling employee exposures. 

Proper use of PPE requires a comprehensive program and calls 

for a high level of employee involvement and commitment to be 

effective. The use of PPE requires the choice of the appropriate 

equipment to reduce the hazard and the development of 

supporting programs such as training, change-out schedules, and 

medical assessment if needed. PPE should not be relied upon as 

the sole method for limiting employee exposures. Rather, PPE 

should be used until engineering and administrative controls can 

be demonstrated to be effective in limiting exposures to acceptable 

levels.

● Provide the appropriate gloves for the nature of the exposure. 

Neoprene gloves are protective against MEK and toluene 

splashes and are recommended for short duration use. 

Chemical resistant gloves made of materials such as butyl 

rubber are protective against MEK for longer time periods. 

Gloves made of polyvinyl alcohol are protective against 

toluene, but may degrade if in direct contact with water or 

water-containing mixtures. These gloves are recommended 

for extended use and should be made available to the 

employees working in the solvent ink area.

● Provide gloves without sensitizing additives (i.e., thiurams 

and thioureas) to employees who continue to have hand 

dermatitis after using currently provided gloves.
Page 28 Health Hazard Evaluation Report 2007-0261-3122

References

ACGIH [2007]. Industrial ventilation: A manual of recommended 

practice for design. 26th ed. Cincinnati, OH: American 

Conference of Governmental Industrial Hygienists, pp.13–14.

Belsito DV [2005]. Occupational contact dermatitis: etiology, 

prevalence, and resultant impairment/disability. J Am Acad 

Dermatol 53(2):303–313.

Bjorkner B [1999]. Plastic materials. In: Adams RM, ed. 

Occupational skin disease. 3rd ed. Philadelphia, PA: W.B. 

Saunders, pp. 434–462.

Cvetkovski RS, Zachariae R, Jensen H, Olsen J, Johansen JD, 

Agner T [2006]. Prognosis of occupational hand eczema: a followup study. Arch Dermatol 142(3):305–311.

EPA [2003]. Health Effects Test Guidelines: OPPTS 870.2600 

Skin Sensitization. The Office of Prevention, Pesticides and Toxic 

Substances, U.S. Environmental Protection Agency, EPA 712–C–

03–197. [http://www.epa.gov/ocspp/pubs/frs/publications/Test_

Guidelines/series870.htm]. Date accessed: November 2010.

Forsberg K, Mansdorf SZ [2007]. Quick selection guide to chemical 

protective clothing. 5th ed. Hoboken, NJ: John Wiley and Sons, 

Inc.

Jungbauer FH, van der Harst JJ, Groothoff JW, Coenraads PJ 

[2004]. Skin protection in nursing work: promoting the use of 

gloves and hand alcohol. Contact Dermatitis 51(3):135–140.

Kimber I, Basketter DA, Berthold K, Butler M, Garrigue JL, Lea 

L, Newsome C, Roggeband R, Steiling W, Stropp G, Waterman S, 

Wiemann C [2001]. Skin sensitization testing in potency and risk 

assessment. Toxicol Sci 59(2):198–208.

Klas PA, Corey G, Storrs FJ, Chan SC, Hanifin JM [1996]. Allergic 

and irritant patch test reactions and atopic disease. Contact 

Dermatitis 34(2):121–124.

Knapczyk JW [2000]. Vinyl acetal polymers. Kirk-Othmer 

encyclopedia of chemical technology. Wiley Online Library. 

[http://onlinelibrary.wiley.com/doi/10.1002/0471238961.2209142

511140116.a01/pdf]. Date accessed: October 2010.
Health Hazard Evaluation Report 2007-0261-3122 Page 29

References (continued) Nethercott JR, Holness DL [1999]. Industrial processes commonly 

associated with skin disease. In: Adams RM, ed. Occupational skin 

disease. 3rd ed. Philadelphia, PA: W.B. Saunders, pp. 336–351.

NIOSH [1997]. Control of dust from powder dye handling 

operations. Cincinnati, OH: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, 

National Institute for Occupational Safety and Health, DHHS 

(NIOSH) Publication 97–107.

Pfeiffer P, Rosenbauer EU [2004]. Residual methyl methacrylate 

monomer, water sorption, and water solubility of hypoallergenic 

denture base materials. J Prosthet Dent 92(1):72–78.
Page 30 Health Hazard Evaluation Report 2007-0261-3122

Volatile Organic Compounds

SKC Pocket Pump® air sampling pumps calibrated at a flow rate of 50 cubic centimeters per minute 

were used for sampling airborne VOCs. All air sampling pumps were calibrated before and after use. We 

collected 14 GA air samples to evaluate airborne VOC concentrations using both thermal TD tubes and 

CTs. TD tubes were used to screen for various VOCs, and CTs were used to quantify chemicals identified 

from the chromatogram. Five samples each of TD tubes and CTs were collected from the wax ink area, 

the solvent ink area, and CP1 of Plant 1. Two samples each of TD tubes and CTs were collected from CP2 

and the parts washing room of Plant 2. The GA air samples were placed near an employee’s work station 

or location. The TD tubes were analyzed by a GC-MS per NIOSH Method 2549 [NIOSH 2010]. The CTs 

were also analyzed by GC-MS per modified NIOSH Method 1501 [NIOSH 2010].

Local Lymph Node Assay

Bulk samples of Chemical Y, three ink coatings used to make Ink Ribbon A, and blue hand wipes were 

analyzed by LLNA to test their potential to cause skin sensitization.

The LLNA evaluates the ability of a substance to induce lymphocyte proliferation as a result of chemical 

sensitization in mice. LLNA has been accepted as a stand-alone alternative to the Guinea Pig Maximization 

Test and the Buehler Assay by regulatory authorities for assessing the allergic contact dermatitis potential 

of chemicals [Kimber et al. 2001; EPA 2003]. The basic principle underlying the LLNA is that sensitizers 

induce proliferation of lymphocytes in the lymph nodes, draining the site of chemical application. 

This proliferation is generally proportional to the dose applied, and provides a means of obtaining a 

quantitative measurement of sensitization potential.

Chemical Analysis of Chemical X 

We evaluated Chemical X for residual monomer compounds. A 1 gram portion of the bulk material was 

weighed into a 10 mL headspace vial. Six separate aliquots of the sample were weighed for analysis, and 

each sample was capped and allowed to sit at ambient temperature for 16 hours to equilibrate before 

analysis. The headspace was analyzed by GC-flame ionization detector. A working standard was prepared 

by placing 5 microliter of Monomer A and 5 microliter of Monomer B into 10 mL of hexadecane. A sixpoint calibration curve was prepared from the working standard. Two assumptions were made during the 

analysis:

● Hexadecane solvent and the bulk material will yield equivalent amount of Monomer A and 

Monomer B in the headspace.

● Equilibrium was reached between headspace and the sample after 16 hours at ambient temperatures.

The values are reported as an estimate because of the nonstandard analytical procedure.

Appendix A: Methods
Health Hazard Evaluation Report 2007-0261-3122 Page 31

Appendix A: Methods (continued)

Statistical Analyses 

Descriptive statistics including means, frequencies, and percents were provided to summarize the data 

from the questionnaires. To compare prevalence of dermatitis for those in the ink-exposed and inkunexposed job categories, either the chi-square test or the Fisher’s exact test was used, and the PR was 

reported. The PR is defined as the prevalence of dermatitis reported by ink-exposed employees divided 

by the prevalence of dermatitis reported by ink-unexposed employees. Therefore, a PR > 1 would indicate 

that an ink-exposed employee was more likely to report dermatitis. Similarly, we compared the prevalence 

of dermatitis for those using and not using certain types of hand wipes. To compare characteristics, 

behaviors, and PPE use among ink-exposed employees with and without dermatitis in August 2007, 

we used t-tests, chi-square tests, or Fishers exact tests, as appropriate. Results with P values ≤ 0.05 were 

considered statistically significant.

References 

EPA [2003]. Health Effects Test Guidelines: OPPTS 870.2600 Skin Sensitization. The Office of 

Prevention, Pesticides and Toxic Substances, U.S. Environmental Protection Agency, EPA 712–C–03–197. 

[http://www.epa.gov/ocspp/pubs/frs/publications/Test_Guidelines/series870.htm]. Date accessed: 

November 2010.

NIOSH [2010]. NIOSH manual of analytical methods (NMAM®), 4th ed. Schlecht PC, O’Connor PF, 

eds. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 

94–113 (August, 1994); 1st Supplement Publication 96–135, 2nd Supplement Publication 98–119; 3rd 

Supplement 2003–154. [http://www.cdc.gov/niosh/docs/2003-154/]. Date accessed: November 2010.

Kimber I, Basketter DA, Berthold K, Butler M, Garrigue JL, Lea L, Newsome C, Roggeband R, Steiling 

W, Stropp G, Waterman S, Wiemann C [2001]. Skin sensitization testing in potency and risk assessment. 

Toxicol Sci 59(2):198–208.
Page 32 Health Hazard Evaluation Report 2007-0261-3122

In evaluating the hazards posed by workplace exposures, NIOSH investigators use both mandatory (legally 

enforceable) and recommended OELs for chemical, physical, and biological agents as a guide for making 

recommendations. OELs have been developed by Federal agencies and safety and health organizations to 

prevent the occurrence of adverse health effects from workplace exposures. Generally, OELs suggest levels 

of exposure that most employees may be exposed up to 10 hours per day, 40 hours per week for a working 

lifetime without experiencing adverse health effects. However, not all employees will be protected from 

adverse health effects even if their exposures are maintained below these levels. A small percentage may 

experience adverse health effects because of individual susceptibility, a preexisting medical condition, 

and/or a hypersensitivity (allergy). In addition, some hazardous substances may act in combination with 

other workplace exposures, the general environment, or with medications or personal habits of the 

employee to produce health effects even if the occupational exposures are controlled at the level set by 

the exposure limit. Also, some substances can be absorbed by direct contact with the skin and mucous 

membranes in addition to being inhaled, which contributes to the individual’s overall exposure.

Most OELs are expressed as a TWA exposure. A TWA refers to the average exposure during a normal 

8- to 10-hour workday. Some chemical substances and physical agents have recommended STEL or ceiling 

values where health effects are caused by exposures over a short period. Unless otherwise noted, the STEL 

is a 15-minute TWA exposure that should not be exceeded at any time during a workday, and the ceiling 

limit is an exposure that should not be exceeded at any time.

In the United States, OELs have been established by Federal agencies, professional organizations, state 

and local governments, and other entities. Some OELs are legally enforceable limits, while others are 

recommendations. The U.S. Department of Labor OSHA PELs (29 CFR 1910 [general industry]; 

29 CFR 1926 [construction industry]; and 29 CFR 1917 [maritime industry]) are legal limits enforceable in 

workplaces covered under the Occupational Safety and Health Act. NIOSH RELs are recommendations 

based on a critical review of the scientific and technical information available on a given hazard and the 

adequacy of methods to identify and control the hazard. NIOSH RELs can be found in the NIOSH Pocket 

Guide to Chemical Hazards [NIOSH 2005]. NIOSH also recommends different types of risk management 

practices (e.g., engineering controls, safe work practices, employee education/training, personal protective 

equipment, and exposure and medical monitoring) to minimize the risk of exposure and adverse health 

effects from these hazards. Other OELs that are commonly used and cited in the United States include 

the TLVs recommended by ACGIH, a professional organization, and the WEELs recommended by the 

American Industrial Hygiene Association, another professional organization. The TLVs and WEELs are 

developed by committee members of these associations from a review of the published, peer-reviewed 

literature. They are not consensus standards. ACGIH TLVs are considered voluntary exposure guidelines 

for use by industrial hygienists and others trained in this discipline “to assist in the control of health 

hazards” [ACGIH 2010]. WEELs have been established for some chemicals “when no other legal or 

authoritative limits exist” [AIHA 2010].

Outside the United States, OELs have been established by various agencies and organizations and include 

both legal and recommended limits. Since 2006, the Berufsgenossenschaftliches Institut für Arbeitsschutz 

(German Institute for Occupational Safety and Health) has maintained a database of international 

Appendix B: Occupational Exposure Limits and Health Effects
Health Hazard Evaluation Report 2007-0261-3122 Page 33

Appendix B: Occupational Exposure Limits and Health Effects (continued)

OELs from European Union member states, Canada (Québec), Japan, Switzerland, and the United 

States available at http://www.dguv.de/bgia/en/gestis/limit_values/index.jsp. The database contains 

international limits for over 1250 hazardous substances and is updated annually.

Employers should understand that not all hazardous chemicals have specific OSHA PELs, and for some 

agents the legally enforceable and recommended limits may not reflect current health-based information. 

However, an employer is still required by OSHA to protect its employees from hazards even in the absence 

of a specific OSHA PEL. OSHA requires an employer to furnish employees a place of employment free 

from recognized hazards that cause or are likely to cause death or serious physical harm [Occupational 

Safety and Health Act of 1970 (Public Law 91–596, sec. 5(a)(1))]. Thus, NIOSH investigators encourage 

employers to make use of other OELs when making risk assessment and risk management decisions to 

best protect the health of their employees. NIOSH investigators also encourage the use of the traditional 

hierarchy of controls approach to eliminate or minimize identified workplace hazards. This includes, in 

order of preference, the use of: (1) substitution or elimination of the hazardous agent, (2) engineering 

controls (e.g., local exhaust ventilation, process enclosure, dilution ventilation), (3) administrative controls 

(e.g., limiting time of exposure, employee training, work practice changes, medical surveillance), and (4) 

personal protective equipment (e.g., respiratory protection, gloves, eye protection, hearing protection). 

Control banding, a qualitative risk assessment and risk management tool, is a complementary approach 

to protecting employee health that focuses resources on exposure controls by describing how a risk 

needs to be managed. Information on control banding is available at http://www.cdc.gov/niosh/topics/

ctrlbanding/. This approach can be applied in situations where OELs have not been established or can be 

used to supplement the OELs, when available.

Volatile Organic Compounds 

VOCs are a large class of low molecular weight chemicals that are organic (i.e., containing carbon) and 

have a sufficiently high vapor pressure to allow some of the compounds to exist in the gaseous state 

at room temperature. The health effects associated with VOCs depend on the toxicity of the specific 

VOC, the level of exposure, and the duration of the exposure [EPA 2009]. Symptoms experienced from 

exposure to VOCs may include eye and respiratory tract irritation, headaches, dizziness, visual disorders, 

and memory impairment [NIOSH 2005]. The most common route of exposure to VOCs is through 

inhalation, but some solvents may contribute to systemic health effects through skin absorption [LaDou 

2004; Klaassen 2008]. The rate of systemic elimination of solvents depends on how volatile and lipophilic 

the chemicals are. Some subpopulations may be more susceptible to health effects from solvents based on 

age, sex, and genetics [Klaassen 2008]. Heating, burning, or chemical reactions may cause materials to emit 

VOCs. The most common work practice leading to solvent-related dermatitis is washing the hands with a 

solvent. Because solvents tend to combine with lipids, they can dry out the skin. NIOSH and ACGIH have 

recommended OELs for many VOCs [NIOSH 2005; ACGIH 2010]. OSHA also has standards and/or 

PELs for many VOCs [29 CFR 1910.1000].
Page 34 Health Hazard Evaluation Report 2007-0261-3122

Appendix B: Occupational Exposure Limits and Health Effects (continued)

Contact Dermatitis 

Contact dermatitis makes up 90% to 95% of all occupational skin diseases [Ingber and Merims 2004; 

Lushniak 2004]. Contact dermatitis, both irritant and allergic, is an inflammatory skin condition caused 

by skin contact with agents such as chemical irritants (irritant contact dermatitis) or allergens (allergic 

contact dermatitis). Irritant contact dermatitis is skin inflammation due to direct cell damage from a 

chemical or physical agent, while allergic contact dermatitis is a delayed immune reaction. Over 57,000 

chemicals are reported to cause skin irritation, but only 3,700 chemicals are known skin allergens [Belsito 

2005]. Usually only a small percentage of people are susceptible to skin allergens.

In contact dermatitis, the skin initially turns red and can develop bumps and small, oozing blisters. After 

several days, crusts and scales form. Stinging, burning, and itching often occur. With no further contact 

with the agent, the dermatitis usually disappears in 1 to 3 weeks. With chronic exposure, deep fissures, 

scaling, and darkening of the skin can occur. Exposed areas of the skin, such as hands and forearms, have 

the greatest contact with irritants or allergens and are most commonly affected. Over 80% of occupational 

contact dermatitis involves the hands. [Warshaw et al. 2003; Belsito 2005; Flyvholm et al. 2007]. If the 

agent gets on clothing, it can bring on dermatitis at areas of greatest contact, such as thighs, upper back, 

armpits, and feet. Dusts can produce dermatitis at areas where the dust accumulates and is held in contact 

with the skin, such as under the collar and belt line, at the tops of socks or shoes, and in skin creases, 

such as inside elbows and behind knees. Mists can produce dermatitis on the face and neck. Irritants and 

allergens can be transferred to distant areas of the body, such as the trunk or genitalia, by unwashed hands 

or from areas of accumulation, such as under rings or in finger webs. It is often impossible to clinically 

distinguish irritant contact from allergic contact dermatitis, as both can have a similar appearance and 

both can result in an acute, subacute, or chronic condition.

Irritant contact dermatitis can be caused by many factors. The most common skin irritant at work is 

wet work, defined as exposure of skin to liquid for more than 2 hours per day, use of occlusive gloves 

for more than 2 hours per day, or frequent hand washing [Chew and Maibach 2003; Slodownik et 

al. 2008]. Other common causes of irritant contact dermatitis include soaps and detergents, solvents, 

food products, cleaning agents, plastics and resins, petroleum products and lubricants, metals, and 

machine oils and coolants [Chew and Maibach 2003; Slodownik et al. 2008]. Frictional irritant contact 

dermatitis can be caused by low humidity, heat, paper, tools, metals, fabrics, plastics, fibrous glass and 

other particulate dusts, and cardboard, among other causes [Morris-Jones et al. 2002; McMullen and 

Gawkrodger 2006]. Causes of allergic contact dermatitis include plants (e.g., poison ivy), metallic salts, 

germicides, plastic resins, rubber additives, and fragrances [Mathias 1990]. In patients with occupational 

contact dermatitis who were skin-patch tested, the most common relevant allergens included thiuram 

mix, carba mix, bacitracin, methyldibromo glutaronitrile/phenoxyethanol, formaldehyde, glutaraldehyde, 

methylmethacrylate, nickel, cobalt, and chromium [Warshaw et al. 2007, 2008].

Studies on the prognosis of occupational contact dermatitis stress the importance of primary prevention. 

One study found that 32% of 124 surveyed patients had severe hand dermatitis 5 years after they were 

initially diagnosed with irritant hand dermatitis. Severity was measured by self-reported frequency of 
Health Hazard Evaluation Report 2007-0261-3122 Page 35

Appendix B: Occupational Exposure Limits and Health Effects (continued)

relapses, frequency of dermatologist visits, and use of topical corticosteroids [Jungbauer et al. 2004]. 

Another study found that 25% of 540 surveyed patients had persistently severe or aggravated symptoms 

1 year after initial diagnosis of occupational hand dermatitis. Poor prognosis was associated with the 

presence of atopic dermatitis and being 25 years of age or older. Prognosis was not affected by whether the 

dermatitis was irritant or allergic. Those with severe occupational hand dermatitis at baseline had a higher 

risk of taking sick leave and job loss in the following year than those with mild cases. The study found no 

significant improvement in the disease after the change of job [Cvetkovski et al. 2006]. Widespread hand 

dermatitis on initial examination was found to be the greatest factor for a poor long-term prognosis in a 

third study [Meding et al. 2005]. In addition, many skin disorders, including contact dermatitis, have been 

shown to have a significant impact on quality of life [Kadyk et al. 2003; Cvetkovski et al. 2005; Fowler et 

al. 2006; Lan et al. 2008].

Prevention of Contact Dermatitis 

Avoiding irritants and allergens, in addition to wet work, is the first step in dermatitis prevention. Liberal 

use of skin moisturizers helps to prevent contact dermatitis by maintaining a healthy skin barrier, and also 

helps to repair this barrier if it has been compromised [Chew and Maibach 2003].

The following list provides strategies in the prevention of occupational contact dermatitis:

● Identifying irritants and allergens

● Substituting chemicals that are less irritating or allergenic

● Establishing engineering controls to reduce exposure

● Emphasizing personal and occupational hygiene

● Establishing educational programs to increase awareness in the workplace

● Utilizing PPE, such as gloves and special clothing [NIOSH 1988]

Chemical changes in industrial materials have been beneficial. For example, the addition of ferrous 

sulfate to cement to reduce the hexavalent chromium content has been effective in reducing occupational 

allergic contact dermatitis in Europe. Protective gloves can reduce or eliminate skin exposure to hazardous 

substances if used correctly, but may actually cause or worsen hand dermatitis (by permeation and 

penetration) if selected poorly and used improperly (by contamination) [Foo et al. 2006]. The use of 

PPE may occlude irritants or allergens next to the skin, and PPE components may directly irritate the 

skin, so the correct use of PPE is at least as important as the correct selection of materials [Kwon et al. 

2006]. Similarly, the excessive pursuit of personal hygiene in the workplace may actually lead to misuse of 

soaps and detergents and cause irritant contact dermatitis. Proper hand washing methods and adequate 

moisturizing are valuable in preventing contact dermatitis [Warshaw 2003]. The effectiveness of barrier 

creams is controversial because data on the protective nature of these topical products during actual 
Page 36 Health Hazard Evaluation Report 2007-0261-3122

Appendix B: Occupational Exposure Limits and Health Effects (continued)

working conditions involving high-risk exposures are limited. Educating the workforce about skin care, 

exposures, and PPE use is an especially important measure in the prevention of occupational contact 

dermatitis [Schwanitz et al. 2003; Loffler et al. 2006; Weisshaar et al. 2006].

The following list provides tips on proper hand washing [Warshaw et al. 2003]:

● Avoid hot water; use lukewarm or cool water instead.

● Use mild cleansers without perfume, coloring, or antibacterial agents.

● Pat hands dry, especially between fingers.

● Apply skin moisturizer generously after hand washing and repeat throughout the day.

● Avoid rubbing, scrubbing, the use of washcloths, and the overuse of soap and water.

The following list provides tips for the workplace [Warshaw et al. 2003]:

● Remove rings before work.

● Wear protective gloves in cold weather and for dusty work.

● Wear tight-fitting leather gloves for frictional exposures.

● When performing “wet work,” wear cotton gloves under vinyl or other nonlatex gloves.

● Avoid immersing hands; use running water if possible.

References

ACGIH [2010]. 2010 TLVs® and BEIs®: threshold limit values for chemical substances and physical 

agents and biological exposure indices. Cincinnati, OH: American Conference of Governmental 

Industrial Hygienists.

AIHA [2010]. AIHA 2010 Emergency response planning guidelines (ERPG) & workplace environmental 

exposure levels (WEEL) handbook. Fairfax, VA: American Industrial Hygiene Association.

Belsito DV [2005]. Occupational contact dermatitis: etiology, prevalence, and resultant impairment/

disability. J Am Acad Dermatol 53(2):303–313.

Chew AI, Maibach HI [2003]. Occupational issues of irritant contact dermatitis. Int Arch Occup Environ 

Health 76(5):339–346.

CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Office of the 

Federal Register.
Health Hazard Evaluation Report 2007-0261-3122 Page 37

Appendix B: Occupational Exposure Limits and Health Effects (continued)

Cvetkovski RS, Rothman KJ, Olsen J, Mathiesen B, Iversen L, Johansen JD, Agner T [2005]. Relation 

between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema. 

Br J Dermatol 152(1):93–98.

Cvetkovski RS, Zachariae R, Jensen H, Olsen J, Johansen JD, Agner T [2006]. Prognosis of occupational 

hand eczema: a follow-up study. Arch Dermatol 142(3):305–311.

EPA [2009]. An introduction to indoor air quality: organic gases (volatile organic compounds – VOCs). 

[http://www.epa.gov/iaq/voc.html]. Date accessed: November 2010.

Flyvholm MA, Bach B, Rose M, Jepsen KF [2007]. Self-reported hand eczema in a hospital population. 

Contact Dermatitis 57(2):110–115.

Foo CC, Goon AT, Leow YH, Goh CL [2006]. Adverse skin reactions to personal protective equipment 

against severe acute respiratory syndrome--a descriptive study in Singapore. Contact Dermatitis 55(5):291–

294.

Fowler JF, Ghosh A, Sung J, Emani S, Chang J, Den E, Thorn D, Person J, Duh MS [2006]. Impact of 

chronic hand dermatitis on quality of life, work productivity, activity impairment, and medical costs. J Am 

Acad Dermatol 54(3):448–457.

Ingber A, Merims S [2004]. The validity of the Mathias criteria for establishing occupational causation and 

aggravation of contact dermatitis. Contact Dermatitis 51(1):9–12.

Jungbauer FH, van der Harst JJ, Groothoff JW, Coenraads PJ [2004]. Skin protection in nursing work: 

promoting the use of gloves and hand alcohol. Contact Dermatitis 51(3):135–140.

Kadyk DL, McCarter K, Achen F, Belsito DV [2003]. Quality of life in patients with allergic contact 

dermatitis. J Am Acad Dermatol 49(6):1037–1048.

Klaassen CD, ed. [2008]. Casarett and Doull’s toxicology: the basic science of poisons. 7th ed. New York: 

McGraw-Hill Companies, Inc. pp. 931–997.

Kwon S, Campbell LS, Zirwas MJ [2006]. Role of protective gloves in the causation and treatment of 

occupational irritant contact dermatitis. J Am Acad Dermatol 55(5):891–896.

LaDou J [2004]. Current cccupational and environmental medicine. 3rd ed. Norwalk, CT: McGraw-Hill 

Companies, Inc., pp. 503–536.

Lan CC, Feng WW, Lu YW, Wu CS, Hung ST, Hsu HY, Yu HS, Ko YC, Lee CH, Yang YH, Chen GS 

[2008]. Hand eczema among University Hospital nursing staff: identification of high-risk sector and 

impact on quality of life. Contact Dermatitis 59(5):301–306.
Page 38 Health Hazard Evaluation Report 2007-0261-3122

Appendix B: Occupational Exposure Limits and Health Effects (continued)

Loffler H, Bruckner T, Diepgen T, Effendy I [2006]. Primary prevention in health care employees: a 

prospective intervention study with a 3-year training period. Contact Dermatitis 54(4):202–209.

Lushniak BD [2004]. Occupational contact dermatitis. Dermatol Ther 17(3):272–277.

Mathias CGT [1990]. Prevention of occupational contact dermatitis. J Am Acad Dermatol 23(4 Pt 1):742–

748.

McMullen E, Gawkrodger DJ [2006]. Physical friction is under-recognized as an irritant that can cause or 

contribute to contact dermatitis. Br J Dermatol 154(1):154–156.

Meding B, Wrangsjo K, Jarvholm B [2005]. Fifteen-year follow-up of hand eczema: predictive factors. J 

Invest Dermatol 124(5):893–897.

Morris-Jones R, Robertson SJ, Ross JS, White IR, McFadden JP, Rycroft RJ [2002]. Dermatitis caused by 

physical irritants. Br J Dermatol 147(2):270–275.

NIOSH [1988]. Proposed national strategy for the prevention of leading work-related diseases and injuries: 

Dermatological conditions. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for 

Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 

89–136.

NIOSH [2005]. NIOSH pocket guide to chemical hazards. Cincinnati, OH: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational 

Safety and Health, DHHS (NIOSH) Publication No. 2005–149. [http://www.cdc.gov/niosh/npg/]. Date 

accessed: November 2010.

Schwanitz HJ, Riehl U, Schlesinger T, Bock M, Skudlik C, Wulfhorst B [2003]. Skin care management: 

educational aspects. Int Arch Occup Environ Health 76(5):374–381.

Slodownik D, Lee A, Nixon R [2008]. Irritant contact dermatitis: a review. Australas J Dermatol 49(1):1–9.

Warshaw E, Lee G, Storrs FJ [2003]. Hand dermatitis: a review of clinical features, therapeutic options, 

and long-term outcomes. Am J Contact Dermat 14(3):119–137.

Warshaw EM, Ahmed RL, Belsito DV, DeLeo VA, Fowler JF, Maibach HI, Marks JG, Mathias CG, Pratt 

MD, Rietschel RL, Sasseville D, Storrs FJ, Taylor JS, Zug KA [2007]. Contact dermatitis of the hands: 

cross-sectional analyses of North American Contact Dermatitis Group Data, 1994–2004. J Am Acad 

Dermatol 57(2):301–314.
Health Hazard Evaluation Report 2007-0261-3122 Page 39

Appendix B: Occupational Exposure Limits and Health Effects (continued)

Warshaw EM, Schram SE, Maibach HI, Belsito DV, Marks JG, Fowler JF, Rietschel RL, Taylor JS, Mathias 

CG, DeLeo VA, Zug KA, Sasseville D, Storrs FJ, Pratt MD [2008]. Occupation-related contact dermatitis 

in North American health care workers referred for patch testing: cross-sectional data, 1998–2004. 

Dermatitis 19(5):261–274.

Weisshaar E, Radulescu M, Bock M, Albrecht U, Diepgen TL [2006]. Educational and dermatological 

aspects of secondary individual prevention in healthcare workers. Contact Dermatitis 54(5):254–260.
Page 40 Health Hazard Evaluation Report 2007-0261-3122

Eligibility 

Eligible study participants were employees who completed the March 2008 health questionnaire and 

answered “yes” to either “Have you had dermatitis on your hands, wrists, or forearms (excluding fronts of 

elbows) in the past 4 weeks?” or “Did you have dermatitis on your hands, wrists, or forearms (excluding 

fronts of elbows) in the month before the NIOSH visit (August 7–9, 2007)?” Eligible comparison 

participants were employees who completed the March 2008 questionnaire and answered “no” to “Have 

you had dermatitis on your hands, wrists, or forearms (excluding fronts of elbows) since you began working 

at [this company]?”

What We Did

We patch tested participants with a history of dermatitis to the North American Standard Series of 50 

common environmental allergens found outside the workplace, and some allergens found both in the 

workplace and outside of work (e.g., glove additives and soap ingredients). We also tested these participants 

and participants with no dermatitis history, to specific workplace substances that we found to be allergens 

in mice (i.e., Coating C, Chemical X, Chemical Y, polyvinyl butyral, and blue hand wipes) and to possible 

workplace allergens (i.e., Ink Ribbon A top side, Ink Ribbon A back side, and green hand wipes).

Components of Skin Patch Test 

We used the Chemotechnique® North American Standard Series (NA-1000) patch test allergens to 

identify standard skin allergies. Chemotechnique Diagnostics® laboratory in Sweden performed feasibility 

studies and prepared skin patch test dilutions of nonstandard workplace substances identified by NIOSH 

as skin sensitizers in animal testing (LLNA).

Procedure 

On the first appointment, the participants underwent a brief medical history and skin examination.

On the second appointment, the participants had patches with chambers filled with the suspect allergens 

applied to their backs.

On the third appointment, 48 hours after the patches were applied, the patches were removed and the first 

skin reaction readings were performed, followed by photos of the participants’ backs.

On the fourth appointment, (2–3 days after the patches were removed), the second skin reaction readings 

were performed, followed by photos of the participants’ backs.

Appendix C: Skin Patch Testing
Health Hazard Evaluation Report 2007-0261-3122 Page 41

Appendix C: Skin Patch Testing (continued)

On the final appointment (5 days after the patches were removed), the NIOSH physician and Dr. David 

Cohen, board certified in dermatology and occupational medicine, performed the final skin reaction 

readings, and interpreted the final skin patch test results using standard clinical practice methods used in 

dermatology clinics [Li et al. 2003]. These results were explained to each participant.

Reference 

Li LF, Sujan A, Wang J [2003]. Detection of occupational allergic contact dermatitis by patch testing. 

Contact Dermatitis 49(4):189–193.
Page 42 Health Hazard Evaluation Report 2007-0261-3122

Appendix D: Tables Table D1. Charcoal tube air sampling results for VOCs (August 2007) Work Location Sampling Time (minutes) Air Concentration (ppm) MEK Methyl isobutyl ketone Xylene (meta and para) Xylene (ortho) Toluene Methyl vinyl ketone Trichloro ethylene PGMEA Solvent Ink Area 519 2.1 ND* (0.026)† ND 5.3 ND ND 0.049 SMM Center 516 3.8 ND (0.046) ND 9.0 ND ND ND Backing Room 334 3.8 ND (0.049) ND 3.8 ND ND 0.32

Coating Area CP1 (OTC 3) 331 3.1 ND ND ND 3.2 ND ND (0.039)

Wax Ink Area 460 0.12 ND 0.11 (0.0041) 0.34 ND ND ND

Coating Area CP2 (MSC 2) 471 8.5 ND ND ND 10 ND ND 0.55

Renzmann Room 274 7.7 ND ND ND 11 ND ND 0.46NIOSH REL 200 100 100 100 200 100

‡

OSHA PEL 200 50 100 100 100 25

ACGIH TLV 200 50 100 100 20 50

MDC§ 0.016 0.012 0.022 0.011 0.013 0.0089 0.013MQC¶ 0.054 0.039 0.074 0.037 0.043 0.029 0.043*Not Detected, concentration is below the MDC †Concentrations between the MDC and MQC are listed in the table but are contained within parentheses to acknowledge that there is more uncertainty surrounding concentrations below the MQC. ‡AIHA WEEL for PGMEA is 50 ppm.§MDC = Minimum detectable concentration calculated by dividing the method limit of detection by the average sample volume collected (0.021 cubic meter of air).MQC¶ = Minimum quantifiable concentration calculated by dividing the method limit of quantitation by the average sample volume collected (0.021 cubic meter of air).
Health Hazard Evaluation Report 2007-0261-3122 Page 43

Appendix D: Tables (continued)

Table D2. Potentially irritating and sensitizing ingredients in workplace hand-wipe products used in August 

2007

Product Potential sensitizing 

ingredients

Potential irritant 

ingredients

MSDS statement concerning 

skin hazard

Green Hand Wipes Methyldibromo 

glutaronitrile [Warshaw et 

al. 2007]; methylparaben 

[Shaw et al. 2010]; 

propylene glycol [Warshaw 

et al. 2007]; D-limonene 

[Karlberg and DoomsGoossens 1997]; 

DMDM Hydantoin (2,3-

Imidazolidinedione) 

[Warshaw et al. 2007]

Terpenes and terpenoids 

(solvents) [Slowdownik et 

al. 2008]

Prolonged skin contact 

may cause mild irritation in 

sensitive individuals. Patch 

testing does not indicate a 

potential for sensitization or a 

potential for dermal irritation 

in humans. May possibly 

aggravate dermatitis, 

psoriasis, and other skin 

conditions. European Union 

classifications: irritant, 

flammable, irritating to eyes, 

may cause sensitization by 

skin contact.

Blue Hand Wipes Hexahydro-1,3,5-tris 

(2-hydroxyethyl)-s-triazine 

[DeGroot et al. 2009]; 

D-limonene [Karlberg and 

Dooms-Goossens 1997]; 

propylene glycol [Warshaw 

et al. 2007]; fragrance 

[Warshaw et al. 2007]

Sodium lauryl sulfate 

[Slowdownik et al. 2008]; 

ethoxylated alcohols 

(C12-15 Pareth-7) [Bodin 

et al. 2000]

May cause mild eye or skin 

irritation, redness, burning, 

drying or cracking of skin. 

Pre-existing skin conditions 

such as dermatitis may be 

adversely affected by this 

and other oil and grease 

effective cleaners.
Page 44 Health Hazard Evaluation Report 2007-0261-3122

Appendix D: Tables (continued)

Table D3. Reported dermatitis, PPE use, and hygiene practices among two high risk groups: wet ink-exposed 

group and finished product dust-exposed group, March 2008

Wet ink-exposed*

(N = 68-72)‡

Number (%)

Finished product dustexposed†

(N = 42-44)‡

Number (%)

Dermatitis in August 2007 11 (16) 9 (21)

Dermatitis in March 2008 8 (11) 5 (11)

Average number of times lotion applied over 24 hours 1.8 2.0

Average number of times hands washed in 24 hours 6.2 6.9

Used green hand wipes 58 (82) 32 (73)

Used Tyvek sleeves 27 (38) 0 (0)

Used cotton sleeves 51 (72) 2 (5)

Used gloves during work 68 (94) 15 (34)

Of those who used gloves:

Average number of hours per day gloves were used 5.9

 N = 68

 3.9

 N = 14

Average number of times per day gloves changed to 

clean pair

 6.4

 N = 65

 1.5

 N = 12

Reused gloves 37 (55)

 N = 67

 10 (67)

 N = 15

*Wet-exposed employees include kitters, inkmakers, coaters, solvent recovery, and utility operators

†Finished product dust-exposed employees include slitters.

‡Range of denominators (i.e., the number of employees answering each question differed)

 
Health Hazard Evaluation Report 2007-0261-3122 Page 45

Appendix D: Tables (continued)

References 

Bodin A, Fischer T, Bergh M, Lars J, Nilsson G, Karlberg AT [2000]. Skin irritation from air-oxidized 

ethoxylated surfactants. Contact Dermatitis 43(2):82–89.

DeGroot AC, Flyvholm MA, Lensen G, Menne T, Coenraads PJ [2009]. Formaldehyde-releasers: 

relationship to formaldehyde contact allergy. Contact allergy to formaldehyde and inventory of 

formaldehyde-releasers. Contact Dermatitis 61:63–85.

Karlberg AT, Dooms-Goossens A [1997]. Contact allergy to oxidized d-limonene among dermatitis 

patients. Contact Dermatitis 36(4):201–206.

Shaw T, Simpson B, Wilson B, Oostman H, Rainey D, Storrs F [2010]. True photoallergy to sunscreens is 

rare despite popular belief. Dermatitis 21(4):185–198.

Slodownik D, Lee A, Nixon R [2008]. Irritant contact dermatitis: a review. Australas J Dermatol 49(1):1–9.

Warshaw EM, Ahmed RL, Belsito DV, DeLeo VA, Fowler JF, Maibach HI, Marks JG, Mathias CG, Pratt 

MD, Rietschel RL, Sasseville D, Storrs FJ, Taylor JS, Zug KA [2007]. Contact dermatitis of the hands: 

cross-sectional analyses of North American Contact Dermatitis Group Data, 1994–2004. J Am Acad 

Dermatol 57(2):301–314.
Page 46 Health Hazard Evaluation Report 2007-0261-3122

Acknowledgments and

Availability of Report

The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational Safety 

and Health Act of 1970, 29 U.S.C. 669(a)(6) which authorizes 

the Secretary of Health and Human Services, following a written 

request from any employer or authorized representative of 

employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

The findings and conclusions in this report are those of the 

authors and do not necessarily represent the views of NIOSH. 

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

websites. All Web addresses referenced in this document were 

accessible as of the publication date.

This report was prepared by Loren C. Tapp, Srinivas Durgam, 

and Charles Mueller of HETAB, Division of Surveillance, Hazard 

Evaluations and Field Studies. Dermatologic consultation was 

provided by David Cohen. Medical field assistance was provided 

by Ayodele Adebayo and Elena Page. Analytical support was 

provided by Stacey Anderson of Health Effects Laboratory 

Division. Statistical support was provided by Denise Giglio. 

Health communication assistance was provided by Stefanie Evans. 

Editorial assistance was provided by Ellen Galloway. Desktop 

publishing was performed by Robin Smith.

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and the Occupational Safety and Health Administration 

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Below is a recommended citation for this report:

NIOSH [2011]. Health hazard evaluation report: evaluation of contact dermatitis 

among ink ribbon manufacturing employees – New York. By Tapp L, Durgam 

S, Mueller C. Cincinnati, OH: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Institute for Occupational 

Safety and Health, NIOSH HETA No. 2007-0261-3122.

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