Allergies at work: causes and consequences. Industrial allergies

Occurrence and properties of metals

We have to interact with metals every day: door handles, coins, cutlery, dishes and jewelry. Metals are mostly toxic rather than allergenic. Take at least one of the most striking examples - mercury. Everyone knows that if you break a thermometer, the mercury balls instantly scatter, get stuck in the cracks, in the pile of the carpet and begin to release toxic fumes. Since mercury is a cumulative poison, that is, it tends to accumulate in the body, its toxic fumes are deadly. However, the danger occurrence of allergies in the form of, in the worst case, bronchial asthma, with direct contact with one or another metal, also exists (4.5).

— simple substances, characterized by high thermal and electrical conductivity, plasticity, they are characterized by a peculiar metallic luster and opacity.

More than a half chemical elements— metals: iron, copper, aluminum, tin, lead, chromium, molybdenum and others. However, metals are not usually used in their pure form, except rare cases: when making copper wires or aluminum cookware. Most metals are soft, easily deformed and quickly oxidize in air, so they are almost always used in the form of alloys - mixtures of various metals with each other and with non-metals.

Metal alloys- A common cause of allergic contact dermatitis. Alloys causing allergies, most often contain nickel, chromium or cobalt - the most popular metal allergens.

Metal	Special purpose
	Paints, decorative cosmetics, in the manufacture of insulin
	Coins, accessories for clothing, furniture and interior items, jewelry, medical products: orthopedic and, needles, suture staples, as well as in the production of batteries
	Leather tanning compounds, pigments and paints, chrome plating of other metal products to give them decorative and anti-corrosion properties
	Filling material, cement mixtures (zinc phosphate cement)
	Dental amalgams, vaccines, eye drops, ear drops and other medicines, thermometers
	Jewelry, accessories
Platinum group metals (platinum group metals)	Dental and other medical alloys, jewelry, accessories
Aluminum	Antiperspirants, vaccines, dishes
Beryllium	Dental implants
	Coins, household items, medical and jewelry alloys, wires

And these are not all examples of the use of metals in Everyday life.

Allergic diseases caused by metals

When nickel is ingested as part of food products, a systemic systemic contact dermatitis , the manifestations of which are described as “baboon syndrome”: the occurrence of the buttock area.

Nickel in significant amount found in cocoa, tea, coffee, milk,, , peas, , herring, potatoes, asparagus, , beer, nuts, mushrooms, orange juice, and a number of other products. By eliminating these foods from the diet, healing occurs faster, but nickel is vital essential microelement, which is part of a number of enzyme proteins, so it complete removal not recommended from the diet (2).

Allergic reaction to nickel occurs more often than, for example, cobalt, but they are often combined with each other: 25% of those suffering from nickel dermatitis have a history of allergy to cobalt. When these two allergies coincide, contact dermatitis (eczema) is much more severe.

The European Union has developed recommendations that take into account the needs of those suffering contact allergy for nickel. They prescribe both a reduction in the nickel content in various household products and its exclusion from decorative products, as well as dietary recommendations.

Cobalt

A microelement necessary for the body, as it is part of B12 (cyanocobalamin), which ensures the formation of new red blood cells in the bone marrow. Deficiency of this vitamin leads to the development of megaloblatic anemia. A person receives it with food in the form of salts and compounds with organic substances.

Of the products in which cobalt is present, eye shadow should be especially noted, since in the area of the folds of the eyelids, sweating is higher, and accordingly, it is created favorable conditions for the absorption of cobalt into the skin and the development of contact dermatitis.

Other sources of cobalt in everyday life are stainless alloys, paints, and cement. Back in the 40s of the last century, Italian dermatologist Fabio Meneghini pointed out the possibility skin sensitization masons to cobalt and chromium, the occurrence of allergic contact dermatitis, later called cement eczema (1,2,5).

Allergy to cobalt can manifest itself both locally - with direct contact with metal and its alloys, and systemically - by inhaling metal dust or eating foods rich in cobalt: legumes (peas, beans), garlic, liver (1).

Chromium

In the human body, chromium is involved in glucose metabolism, lipid metabolism, and nucleic acid metabolism. At chromium deficiency There is a decrease in immunity, an increase in blood glucose levels. Acute chromium deficiency develops only with long-term parenteral nutrition. Chronic failure, according to some data, is present in no less than 20% of the population.

Liver, cheese, brewer's yeast, pomegranates, potatoes, tomatoes, and spinach are rich in chromium. It is a component of chromium picolinate, a substance used in dietary supplements.

In the human intestine, chromium can only be absorbed in the form of its salts with nicotinic acid and in the form of picolinate. Because a nicotinic acid- a very unstable compound, then long-term storage of products rich in it reduces its content. Chromium absorption is also reduced with frequent consumption of fatty foods.

Among everyday items, chromium is found in anti-corrosion and chrome-plated coatings, paints and cement, stainless alloys, and leather tanning compounds. Regular use of the above or constant contact with these substances at work leads to the development of allergic contact dermatitis.

A systemic contact allergy to chromium compounds ingested with food will only appear if there has previously been direct contact with chromium, and therefore hypersensitivity to this allergen has developed. The same can be said about other metals.

System contact allergy to chromium can develop when working with it (at work), in the presence of chromium-containing implants in the body (rarely), when using dietary supplements containing chromium against the background of contact dermatitis to it (1.5).

Zinc

Zinc is part of many enzyme proteins that ensure the most important biochemical processes in the body. Corn and are the foods richest in it; in addition, it is found in egg whites, beef liver, and oatmeal.

Contact zinc dermatitis most often develops when it enters the body from compounds. There are known cases of the appearance of eczematous dermatitis around the mouth, maculopapular rash, palmoplantar pustulosis (formation of numerous blisters) and other skin rashes after the installation of a dental filling based on zinc compounds. The inflammation disappeared after replacement with fillings made of zinc-free material (1,4,5).

Mercury

Mercury is a strong allergen and is also extremely toxic.

In its pure form, mercury is found, perhaps, only in a thermometer. Much more often, its mixtures with other substances (amalgams) or organic compounds are used.

Sources of inorganic mercury are amalgams used in dentistry, and organic mercury comes from some preservatives, in particular thiomersal (merthiolate). Skin rashes with mercury contact allergic dermatitis caused by dental materials, they are located in the mouth, face, and neck. The affected areas are swollen and are characterized by severe itching. Eczema-like lesions can also occur in the oral cavity, where, in fact, mercury is absorbed from filling materials.

When mercury-containing fillings are installed, those who are hypersensitive to mercury may develop lichen-like rashes around the mouth, orofacial granulomatosis.

Thiomersal is an organic mercury compound that is one of the five most common sources of contact allergens. It is widely used as a preservative in various pharmacological preparations (, external agents, ear and eye drops), and cosmetics.

In some eastern countries, cosmetics that whiten the skin, as well as mercury-based medicines that disinfect the skin, are popular. For example, cases of severe contact dermatitis in young women after regular use of such drugs. At the same time, elevated levels of mercury were found not only in the skin, but also in the blood.

Mercury may also be contained in some pigments used for mercury, and those who have pierced earlobes at the same time as a tattoo are more likely to develop contact dermatitis from mercury (1.5).

Gold

Gold can well be called one of the most common reasons occurrence of allergic contact dermatitis. Increased sensitivity to gold detected in some people with confirmed contact dermatitis. Moreover, during skin testing, sensitivity to gold salts is more often detected than to gold itself.

Despite the fact that gold dissolves very poorly, due to other metals in jewelry alloys, the release of gold ions occurs in sufficient quantity for occurrence . In this case, dermatitis can appear not only in places of direct contact with gold jewelry (earlobes, neck, fingers), but also, for example, on the skin of the eyelids. After some time, after stopping wearing gold jewelry, the dermatitis goes away.

Hypersensitivity to gold is more common in women than in men. This is understandable, since gold jewelry is worn mainly by women.

For golden contact dermatitis Eczema in the head and neck area is typical. If you take a biopsy of an area of skin that has been in frequent contact with gold jewelry, metallic gold may be found in it. Moreover, its absorption into the skin is possible even through an intact stratum corneum (1).

Platinum group metals (platinoids): platinum, palladium, rhodium, iridium

Platinum and related metals are rarely used in the manufacture of household items due to their high cost, but can be found in dental implants and jewelry. Cases of contact dermatitis have been described when wearing platinum wedding rings.

Following the release of the European Union directive to reduce the use of nickel in the manufacture of household and medical products to replace it, they began to increasingly resort to palladium, which led to an increase in the number of cases of contact allergic dermatitis to this metal.

Palladium present in dental implants can cause stomatitis, mucositis (inflammation of the mucous membrane), and oral scaly rashes.

Hypersensitivity to rhodium and iridium is extremely rare. It is usually discovered by chance in studies of large groups of people suffering from contact dermatitis on metals. In this case, an allergy to iridium and rhodium is combined with an allergy to other metals and is not found in isolated form (1).

Aluminum

Contact hypersensitivity to aluminum is very rare. The most common cause is regular use antiperspirant deodorants and the administration of vaccines or other pharmaceuticals containing aluminum compounds.

Aluminum contact dermatitis is characterized by relapsing eczema(for cutaneous application) and persistent granuloma at the site of drug administration. Cases of itchy dermatitis in the armpit due to abuse of antiperspirants and local treatment have been described. skin diseases paste containing aluminum compounds.

Aluminum can be found in pigments used in tattooing. When sensitization to this metal occurs in the tattoo area, granulomatous reaction- formation in the skin of small nodules consisting of lymphocytes (1).

Beryllium

Beryllium itself is poisonous and is used mainly in the aerospace industry and for the manufacture of special purpose alloys, such as springs that withstand increased amount load cycles. In everyday life, beryllium can only be found in dental alloys. Five different contact reactions to beryllium have been described: allergic contact dermatitis, toxic contact dermatitis, chemical burn, ulcerating granulomatosis and allergic cutaneous granulomatosis (1).

Copper is widely used in alloys for coins, jewelry, household products, fittings, dental and other medical products, and intrauterine devices. The most common causes of copper allergies are dentures and amalgams, intrauterine devices containing copper components.

In the first case, contact dermatitis to copper manifests itself as gingivitis, stomatitis, perioral allergic rashes . When installing intrauterine device with copper parts, dermatitis is systemic in nature and can be located in any area of the body in the form of urticarial rash, swelling of the eyelids, swelling of the labia majora and minora. Symptoms of contact dermatitis can appear cyclically, depending on the phase menstrual cycle (1).

Diagnosis of metal allergies

The most effective way to diagnose contact metal allergy is to perform a lymphocyte activation test.

There are attempts to assess the levels of various cytokines when stimulating blood cells with metals in vitro (1,2,6).

K. Wolf R. Johnson D. Surmond Dermatology according to Thomas Fitzpatrick atlas - reference book "Practice" Moscow 2007 pp. 58 - 73

Shuvatova E.V. Clinical and immunological characteristics of the personnel of the Mining and Chemical Combine of the Krasnoyarsk Territory and the population living near the production. dis. Ph.D. honey. Sciences State Scientific Center Russian Federation Institute of Immunology, Federal University “Medical, Biological and Extreme Problems” under the Ministry of Health of Russia, Moscow, 2004, pp. 11 - 28

Vasiliev A.A. Seasonal and age-related changes immune status staff of the Mining and Chemical Combine of the Krasnoyarsk Territory dis. Ph.D. honey. Sciences Federal State Budgetary Institution State Scientific Center of the Russian Federation Institute of Immunology of the Federal Medical and Biological Agency of Russia Moscow 2009. pp. 27 - 36

J. Bourke, I. Coulson, J. English “Guidelines for the Management of Contact Dermatitis: an Update” The British Journal of Dermatology. 2009;160(5):946 - 954

Food allergy means hypersensitivity immune system to certain foods. WHO has already called allergies “the disease of the century”, because... Today, the percentage of the population sensitive to one or more allergens is approaching 50%. Milknews found out how the presence of allergens in food products is regulated, what it means “may contain traces” and how manufacturers work with allergen-containing products.

How it works?

About 120 food allergens enter the human body every day.
The main food allergen is cow's milk; an allergy to it develops from the first year of life. Vera Revyakina, head of the allergology department of the Federal State Budgetary Institution of Science "Federal Research Center for Nutrition and Biotechnology" noted that among children under one year of age, milk remains the leading cause of allergic reactions - more than 80% of detections are associated with casein and whey proteins. Cheese allergy occurs in approximately 12% of people with food allergies - this is due to high histamine levels.

In general, the greatest allergenic activity comes from foods plant origin- cereals with gluten (rye, barley), nuts and their processed products cause up to 90% of all cases food allergies, in connection with which the Technical Regulations CU 022/2011 have a whole list of the main allergens.

People of all ages are susceptible to food allergies, starting from infancy; the body’s reaction can develop in a few minutes, over several hours or even every other day. Symptoms can also vary from completely unnoticeable external manifestations up to anaphylactic shock - a fatal reaction manifested in weakened breathing, decreased blood pressure and impaired heart rate with the possibility of death.

Allergens are divided into major, medium and minor. Main allergen binds about 50% of antibodies in the blood serum of a person who is sensitive to a given allergen, minor ones - about 10%.

IN Food Industry During processing of products, the antigenic properties change; heating, for example, leads to protein denaturation. At the same time, if some products may become less allergenic after heat treatment, others may become more dangerous. Thus, thermal denaturation cow's milk does not lead to the loss of the allergenic properties of proteins, but in some cases, if you have an allergy, it is better to boil the milk (this is recommended for those sensitive only to heat-labile protein fractions). The peanut allergen, for example, is almost not destroyed during any processing - allergy sufferers should remember this, especially considering wide application peanuts in the food industry. The allergenic properties of fish also change during processing, so if some patients are intolerant to freshly prepared fish, they may eat canned fish.

The only sure way to prevent food allergies is to completely eliminate allergens from the diet, but it’s not that simple either. If you think that if you are allergic to nuts, you can simply exclude them from your diet - then no, you will not protect yourself 100%. Even in products that do not contain any allergens, their residues (i.e. traces) may appear in them, simply because other products were packaged on the conveyor before.

There is no exact answer to the question of whether the consumer should be afraid of the specified data on traces of allergens - naturally, it all depends on individual sensitivity.

Manufacturer regulation

In accordance with Technical Regulation 022, today allergens include 15 types of components:

peanuts and their products;
aspartame and aspartame-acesulfame salt;
mustard and its processed products;
sulfur dioxide and sulfites, if their total content is more than 10 milligrams per kilogram or 10 milligrams per liter in terms of sulfur dioxide;
cereals containing gluten and their products;
sesame and its processed products;
lupine and products of its processing;
shellfish and their processed products;
milk and products of its processing (including lactose);
nuts and products of their processing;
crustaceans and their processed products;
fish and its processed products (except for fish gelatin used as a base in preparations containing vitamins and carotenoids);
celery and its processed products;
soybeans and products of its processing;
eggs and their products.

Manufacturers are required to indicate all of the above allergens on the label, regardless of how much of them is contained in the product formulation. Even if the recipe does not include an allergen, but it is impossible to exclude its presence in the composition, the manufacturer is obliged to indicate the possibility of containing the component and its traces. In the composition of the component, even if its mass fraction is 2 percent or less, the manufacturer must also indicate allergens and their processed products (from the above 15 groups: milk and its processed products (including lactose), etc.).
If the manufacturer does not indicate in the composition that the product may contain residues allergy medications, he is liable under Code of Administrative Offenses 14.43 part 1 (violation of the requirements of technical regulations) and part 2 (if the violation resulted in harm to life and health), which provide for a fine of 300 to 600 thousand rubles for legal entities, repeated violation entails a fine up to 1 million rubles. Also, the manufacturer may be subject to Article 238 of the Criminal Code of the Russian Federation “Production, storage, transportation or sale of goods and products that do not meet safety requirements” with possible restriction of freedom for up to two years, if the unsafe product caused serious harm to health or death of a person - up to six years, if two or more - up to ten years in prison.

Only technological aids, which are understood as substances or materials or their derivatives (with the exception of equipment, packaging materials, products and utensils), which, not being components of food products, are deliberately used in the processing and production of food products to perform certain technological goals and after achieving them are removed from such raw materials. Groups of technological aids are established in the technical regulation of the Customs Union 029/2012 “Safety requirements for food additives, flavorings and technological aids” (catalysts, solvents, etc.).

A conscientious manufacturer strives to ensure that allergens do not overlap in production, but sometimes it is not possible to exclude the presence of traces from other raw materials, even if a full range of measures is taken to clean and disinfect equipment.

On the assembly line

The problem of trace contamination most often occurs in the pharmaceutical and food industries. From the food industry, mainly in meat processing, because components such as soy, mustard, sesame and gluten-containing ones are often used in manufactured products. Technical Regulation 022/2011 establishes that components that can cause allergic reactions must be indicated in the composition, regardless of their quantity. Even if allergen-containing substances were not intentionally used in production, their presence cannot be completely excluded, information about their possible presence must also be placed on the packaging. This is necessary to promptly inform consumers that even in products that do not contain food allergens, their residues may remain.

To minimize the unintentional entry of allergens into food products, food enterprises are developing a whole range of measures within the framework of the so-called. allergen management programs. The implementation of such a system is included in the food safety management system.

To begin work in this direction, the manufacturer analyzes the total number of allergens that can cause a reaction in sensitive people, as well as identifying special groups population at particular risk, and only after determining the “target audience” among consumers is the allergens themselves studied.

The allergenicity of the components used is examined, as well as their “behavior” - for example, if the product has been processed, it may lack the corresponding protein, and therefore the product may not pose a danger due to the lack of risk of cross-contamination with the allergen.

After this, the probability of cross-contamination with allergens at each stage of food production is assessed; here it must be taken into account that it is different for liquids and powders. Powdered milk during weighing may get into the product by by air- through the ventilation system or through the clothing of personnel, but with liquid milk everything is simpler - if the distance is maintained and isolated by physical barriers, the likelihood of it getting into the product is close to zero.

If, nevertheless, the risk of contamination was assessed as unacceptable, the enterprise takes a number of measures aimed at reducing the unintentional release of allergens into products. Within the organization production process The GMP (Good Manufacturing Practice) standard is used - this is a set of rules that establish requirements for the organization of production and quality control.

The manufacturer must be aware of the presence of allergens in all raw materials used in production, as well as in raw materials obtained during work with the supplier and during incoming inspection. The manufacturer must request from suppliers all information about the content of food allergens in raw materials, whether this is one of the main components indicated in the composition (for example, soybean protein in a complex food additive), auxiliary component(a dietary supplement derived from an allergenic source), or undeclared ingredients that have entered the product due to manufacturing cross-contamination with allergens.

Suppliers, in turn, need to be aware of the risks of cross-contamination, they must fully describe all components in the labeling, and cannot use generic names of ingredients. After incoming control and placement in warehouses, it is necessary to identify all allergen-containing raw materials; it is advisable to store them separately.

Of course, the only way to avoid cross-contamination is to use different production sites - separate for each product, which is most often impossible, but there are ways to minimize the possibility of contamination, for example - dividing production into zones, using separate equipment and planning production cycles. Care must be taken to thoroughly clean equipment between cycles, provide a separate air supply if possible, and work with staff - people are also potential carriers of food allergens.

If produced New Product or a new ingredient is introduced, the manufacturer must be aware that this may introduce allergens into all existing products, so a complete full risk assessment of contamination must be carried out before doing so.

A decade and a half ago, the Federal Archival Service of Russia acquired its own holiday - Archive Day, which has since traditionally been celebrated on March 10. Archival service workers are people who are familiar with allergies to archival dust firsthand. It’s not for nothing that from the 1970s to the 1990s they were even given milk “for being harmful.”

However, not only archivists suffer from “paper allergy”. Paper is present in our lives in huge quantities and in a wide variety of forms. And if you have an allergy, but the cause is unknown, you should take a closer look at the world around you - maybe it’s all about paper sources of allergens. MedAboutMe understands the allergy risks and dangers of plain paper.

Where does paper allergy come from?

An allergy is the body's excessive sensitivity to certain substances. The immune system of an allergy sufferer sees them as a threat. When first meeting a substance that the body considers an allergen, this reaction is not yet noticeable. At this stage, sensitization to this substance occurs: antibodies are produced or lymphocytes activated to specific antigens are formed. From this moment the body is “ready” to meet the allergen. As soon as this happens, a whole series of events are triggered - enzymes are activated, histamine, serotonin, prostaglandins and other allergy mediator substances are released, and specific cells of the immune system are formed. A person sneezes, breaks out in a rash, and in worst cases begins to choke and may even die if he is not helped in time.

Of course, the paper itself is not an allergen, as such. Allergies develop to proteins, to glycoproteins (compounds of proteins with carbohydrates) and, less often, to certain substances (for example, to certain metals). Paper consists of cellulose, and there is no allergy to cellulose - just as there is no allergy to poplar fluff (which is, in fact, cotton, that is, the same cellulose). But there is an allergy to various proteins that settle on paper (and poplar fluff). These proteins most often do not float in the air by themselves, but are part of, for example, plant pollen - and here is the answer to “fluff allergy”, or are components of the feces of dust mites - miniature creatures ranging in size from 0.1 to 0.25 mm. It is in the proteins contained in their bodies and in waste products that the secret of allergy to dust, including archival dust, lies.

Book runny nose

Old books that have been kept in unventilated areas for decades are out of sunlight and often with high humidity - an ideal environment for dust mites living on them. Feces and particles from the bodies of the dead inhabitants of the books, along with dust, enter the human respiratory system, which leads to the development of an allergic reaction.

Most often it manifests itself in the form of a runny nose with watery eyes, frequent sneezing and increased production mucus in the nasal cavity. If such symptoms appear, you should leave the room with old books and minimize such contacts in the future. Continuing to work in such conditions can cause the development of chronic bronchial asthma.

For bibliophiles who keep old books at home, librarians whose work is related to archives, and other people who are forced to come into contact with archival dust, doctors recommend using respirators and disposable gloves. If possible, rooms where books are stored should be regularly dusted and ventilated. The lower the dust concentration, the lower the risk of allergies.

Allergy to new books and documents

For most book lovers, the smell of printing ink is an exciting aroma that speaks of the anticipation of reading a freshly purchased publication. But there are people who love to read, but are in no hurry to inhale the smell of a new book. The reason is an allergy to printing ink. Employees of printing houses themselves are in the high-risk group. Microscopic particles of paint penetrate the respiratory tract and trigger a chain of reactions that result in an allergy. That is, in this case, we are not talking about the paper as such, but about what is applied to it.

In the same way, there is no allergy to office paper - there is nowhere for dust to come from, a freshly opened pack in a large office “flies away” within a few days. The paper itself, if it is not impregnated with flavors and dyes, does not contain any allergenic components. But printers and copiers that require paper to operate can actually cause an allergic reaction.

It's the toner. Like printing ink, its microscopic (3-4 microns) particles can cause allergies in some people, as they contain:

heavy metals (nickel, chromium, copper, aluminum, etc.), volatile compounds (benzene, phenol, toluene, etc.), tin compounds dangerous to the body, etc.

Substances such as nickel are allergens, and organotin compounds have a depressant effect on the immune system.

Hypoallergenic paper

The word “hypoallergenic” can often be found on toilet paper packaging - this is how manufacturers assure customers that their paper will definitely not cause allergies even when used in the most intimate way. What does this mean? Only that it is just paper - without dyes, without fragrances or fragrances. When purchasing, you just need to check the integrity of the packaging. There is nothing more special about hypoallergenic paper, as we indicated above - the paper itself, as such, cannot cause allergies.

Allergy to money

This is perhaps the most annoying allergy for a working person. Moreover, it manifests itself upon contact with both paper money and coins. This means that the problem is in the metal particles that are used in the production of both types of money - most often it is nickel. Its particles are so small that they can penetrate the upper layers of the skin upon contact with banknotes and change the configuration of some skin proteins. And these altered proteins are perceived by the body as foreign, that is, they become allergens. As a result, an allergic skin reaction develops - a rash on the hands, irritation, redness of the skin. People who are allergic to money have to use plastic cards.

What to do?

First, you need to accurately determine that this is an allergy, and not a random runny nose. You should monitor yourself and the symptoms of the disease. So, an allergic person only needs to spend half an hour in a potentially dangerous room and the symptoms will begin to appear. But as soon as you leave the room, the condition will improve within a short time. With a normal runny nose, changing the room will do nothing. You can also give the suffering person an antihistamine. If it's an allergy, the improvement will come instantly.

If a person suffers from an allergy, but cannot understand where it came from, the allergens - the cause of the disease - should be determined. To do this, you need to contact an allergist and undergo skin tests or a blood test to identify the allergen.

And then it is possible that you will have to make a choice: change jobs and maintain health, or stay in the same place, fighting invisible enemies. Few people agree to wear a respirator, gloves and fight with colleagues for regular ventilation of the room. But as a result of constant exposure to allergens on an organism sensitized to them, even while taking antihistamines, the situation will worsen over time. So you still have to make a choice - and it’s better to take care of it before the body’s condition worsens.

Take the testIs your child prone to allergic diseasesIs your child prone to allergic diseases and what is the allergen? Take the test and find out what your child should avoid and what measures to take.

Allergens- these are antigens causing allergies. Under certain conditions, the properties of allergens can be acquired by factors of various natures, primarily all high- and low-molecular substances of organic and inorganic origin. The list of industrial allergens exceeds a hundred items and includes haptens(formaldehyde, epichlorohydrin, furan, diisocyanate, aromatic nitrobenzenes, ursol, salts of chromium, nickel, cobalt, manganese, platinum, etc.) and full antigens(synthetic polymer materials, components of varnishes, resins, adhesives, elastomers, cements, compounds, etc.).

In industry, workers also encounter allergens. natural composition: dust of grain, flour, tobacco, cotton, wool and animal dander, plant pollen. The latter, being household allergens, can also cause occupational diseases.

The mechanisms of formation of allergies to industrial allergens depend on the properties of the allergen itself and its combination with other factors. Allergic reactions to full(high-molecular-weight) allergens according to the mechanism of development correspond to non-occupational allergies: hypersensitivity, manifested in immediate-type reactions, delayed-type reactions, antibody-dependent cytotoxicity, immunocomplex cytotoxicity, granulomatous reaction.

Allergy to haptens(low molecular weight allergens) is formed due to the formation of the so-called “complex antigen”, i.e. compounds of hapten with protein molecules.

The route of entry of the allergen into the body, as a rule, determines the form of occupational allergic disease. When inhaled, they develop allergic diseases respiratory organs, when entering through the skin - skin diseases. Long-term exposure to these substances disrupts the barrier function of the mucous membranes and skin, which increases their permeability to the allergen, resulting in the formation of professional

sional allergic disease in the form of rhinitis, sinusitis, rhinosinusitis, pharyngitis, rhinopharyngitis, bronchial asthma, asthmatic bronchitis, exogenous allergic alveolitis, epidermitis, dermatitis, eczema and toxicoderma. These forms of diseases are most often observed in the chemical industry (among operators at chemical-pharmaceutical and chemical plants), workers in the woodworking and electronics industries, in construction industry, production of polymer materials, biotechnology, medicine, etc.

The risk of developing occupational allergic diseases largely depends on the conditions of exposure and the entire complex of occupational factors. In this case, the routes of entry and concentration of allergens, exposure modes and dose loads play a particularly important role. Under production conditions, there is an unfavorable course (hypersensitivity) of allergic reactions with complex exposure to allergens. Finally, an important place is occupied by the increased individual sensitivity of the body.

The effects of irritation of the mucous membranes of the respiratory tract and

skin. As a result of their mechanical trauma (quartz dust), maceration of the skin associated with high humidity with increased sweating in a heating microclimate, an increase in allergenic effect is observed when the skin is exposed to a chemical product.

The phenotype of allergic diseases is fundamentally different from the forms of response healthy body on industrial allergens and, first of all, the fact that the sensitization reaction develops against the background of the functional activity of the T- or T- and B-immune systems.

It should be noted that in modern production conditions, in combination with or without allergens, the body of workers can be exposed to substances that cause clinically similar reactions to those of a true allergy. This applies to compounds with immunomodulating and immunotoxic effects. Moreover, depending on the characteristics of the immune and biochemical status of the worker, the reactions are dominated by allergic or toxic-allergic responses or non-immune direct degranulation of tissue basophils with hyperproduction of inflammatory mediators and bronchospasm.

In this regard, as a rule, it is carried out comprehensive assessment the state of cells of the immune system and other inflammatory cells, their mediators, cytotoxins, antibodies for the purpose of diagnosis, examination and prognosis. Using this approach, such forms of occupational diseases as berylliosis, bronchial asthma (when exposed to solvents), metalloconiosis, byssinosis and

etc.

Main way prevention of occupational allergic diseases- hygienic standardization allergens in the air working area and contamination of the skin, taking into account their specific sensitizing effect.

An important place in the system of prevention of occupational allergic diseases is occupied by the diagnosis of their early signs with subsequent treatment, identification of individuals with a genetic or acquired predisposition to allergic reactions and the formation of risk groups.

Currently, specialized allergological examinations of industrial workers are carried out by research institutions. In accordance with the long-term program of medical examination of workers, work on

training of allergists, immunologists and occupational pathologists and the introduction into the practice of health care at enterprises of express and microvariants of immunological tests for quantitative and functional assessment of the immune system. The effectiveness of the prevention of occupational allergic diseases depends on a set of measures, including socio-economic, sanitary and hygienic, therapeutic and preventive elements and sanitary educational work.

It is known that about 30% of doctors and 40% of pharmacists and pharmacists are sensitized to the main groups of drugs (antibacterial, anti-inflammatory, local anesthetics).

In addition to drugs that are full-fledged allergens and haptens, immunopathological processes can cause

chemical reagents used in laboratory practice;
substances for anesthesia, disinfection, detergents used in medical institutions;
medicinal plant materials and epidermal allergens of laboratory animals in vivariums;
biological products (enzymes, vaccines, serums and other blood products that are produced at blood transfusion stations).

It was noted that doctors in last years The number of immediate allergic reactions has increased dramatically, which is to some extent associated with the use of latex gloves. In this case, not only contact urticaria is observed, but also respiratory (even shock) reactions.

Anaphylactic shock

Characterized by rapidly developing predominantly general manifestations: decreased blood pressure. body temperature, blood clotting, central nervous system disorder, increased vascular permeability and spasm of smooth muscle organs. It develops due to repeated introduction of the allergen, regardless of the route of entry and the dose of the allergen (it can be minimal).

Anaphylactic shock is the most severe manifestation of occupational immunopathology. Many chemicals used in medical practice, as well as almost all medications or preventive medications, can sensitize the body and cause a shock reaction.

The frequency of development of such reactions depends on the properties of the occupational allergen, the frequency and intensity of contact. With external contact with the allergen, anaphylactic shock develops later, after 1-3 hours, as it is absorbed.

In medical and pharmaceutical workers suffering from cardiovascular diseases, the mortality rate from anaphylactic shock is significantly increased. With age, anaphylactic shock becomes more severe, as the body's compensatory capabilities decrease, resulting in the formation of chronic diseases.

Full-fledged allergens that most often cause anaphylactic shock are heterologous and homologous protein and polypeptide drugs (antitoxic serums, allogeneic globulins, blood plasma proteins, polypeptide hormones - ACTH, insulin).

Among medications, cases of anaphylactic shock have been reported following the administration of radiocontrast agents, muscle relaxants, local anesthetics, vitamins and other medications.

A whole range of medicinal, diagnostic and prophylactic drugs(iodine-containing radiocontrast agents, muscle relaxants, blood substitutes, globulins) can cause pseudoallergic reactions. These drugs either cause the direct release of histamine and some other mediators from mast cells and basophils, or include an alternative pathway of complement activation with the formation of its active fragments, some of which also stimulate the release of mediators from mast cells. These mechanisms can operate simultaneously.

In protein preparations, aggregation of molecules can occur, and aggregated complexes can cause an immunocomplex type of damage, leading to the activation of complement along the classical pathway. In contrast to anaphylactic shock, this immunopathological condition is called anaphylactoid shock.

Anaphylactic shock is characterized by rapid development, violent manifestations, extreme severity of the course and consequences. The type of allergen does not affect the clinical picture and severity of anaphylactic shock.

Clinical picture anaphylactic shock is varied. The less time has passed since the allergen entered the body, the more severe the clinical picture shock. Highest percentage Anaphylactic shock produces lethal outcomes when it develops 3-10 minutes after the allergen enters the body.

After suffering a shock, doctors and pharmacists may develop complications in the form of allergic myocarditis, hepatitis, glomerulonephritis, neuritis and diffuse damage nervous system, vestibulopathy. In some cases, anaphylactic shock is like a trigger for latent diseases of allergic and non-allergic origin.

Diagnosis is usually not difficult, since a clear temporal relationship between the development of shock and exposure to the allergen is easily established. True, drug reactions are sometimes difficult to distinguish from non-immune reactions. side effect drugs (for example, penicillin, radiocontrast agents), but this is not important for carrying out symptomatic treatment in the acute period.

Clarification of pathogenesis similar conditions necessary to prevent such reactions in the future. As a rule, the development of anaphylactic shock in the anamnesis is preceded by milder manifestations of an allergic reaction to some medication or chemical substance.

Prevention anaphylactic shock in medical and pharmaceutical workers depends on a carefully collected anamnesis, if they have already experienced sensitization phenomena. In each case of professional immunopathology, recommendations are given for the rational employment of doctors and pharmacists, excluding contact with allergens, as well as irritants. chemicals, capable of causing pseudoallergic reactions.

The development of anaphylactic shock, as a rule, is preceded by any mild or moderate manifestations of an allergic reaction that previously occurred upon contact with this allergen during work. This may be an increase in temperature - allergic fever, skin itching or rash, rhinorrhea, abdominal pain, bronchospasm and others. The occurrence of such symptoms in doctors, pharmacists, and pharmaceutical workers requires urgent medical attention and consultation with an immunologist-allergist.

If the immunopathological nature of clinical manifestations is suspected, a full allergological examination is recommended, including leukocytolysis tests for a possible allergen (drug, herbal raw materials, chemical reagents) and removal from work of those in contact with allergens until the results of allergy and immunodiagnostics are obtained.

If an allergological examination of an employee is not possible, it is recommended to refer him to an occupational disease clinic (in this case, it is necessary to report all allergens and chemicals with which contact was noted at the workplace).

Pharmacotherapy should also be carried out very carefully in patients with already diagnosed immunopathological processes of professional etiology (especially with drug allergies). Particular attention should be paid when prescribing medications to a patient with drug allergies cross-reactions within a group of drugs that have common determinants.

In patients with drug allergies, one should not indulge in polypharmacy without proper reasons, prescribing intravenous injections medications, if it can be administered intramuscularly or subcutaneously, especially for patients with an allergic constitution. Such patients in mandatory must remain in the medical facility for at least 30 minutes after administration of the drug.

Patients who have previously suffered anaphylactic shock should have with them a card indicating the cause-significant allergens, as well as an anaphylactic set of medications that should be used if necessary.

Occupational bronchial asthma

Occupational bronchial asthma (OBA) should be defined as a disease etiologically caused by substances affecting the respiratory tract in the workplace of a medical worker or pharmacist.

PBA has some clinical features: determination of the allergen is especially important both from the point of view of its elimination (change of profession), and for legal and financial reasons when transferring a patient to another job or when determining the disability group.

PBA has been known since the beginning of the 18th century, when pharmacists' asthma (ipecac asthma) was described.

Some epidemiological studies have shown that up to 14% of all asthma patients suffer from PBA. Recent studies have established that the incidence of PBA in Russia is about 2%. Of these, a significant proportion of patients

doctors (cause asthma latex, psyllium, disinfectants - sulfathiazole, chloramine, formaldehyde, glutaraldehyde; in anesthesiology - enflurane),
pharmacists (antibiotics, herbal medicinal raw materials),
laboratory assistants (chemical components of diagnostic kits, antibiotics, disinfectants),
Vivarium workers (due to exposure to dander, animal saliva, and high molecular weight animal urine proteins)
workers in pharmaceutical production (antibiotics, methyldopa, cimetidine, salbutamol, piperazine).

Drug-induced PBA is one of the most common types of asthma in people involved in the production of medicinal products, less often in medical workers and pharmacists.

IgE-induced asthma is caused by enzymes (trypsin, pancreatin, streptokinase) and groups of cephalosporins. penicillin. In the latter case, scratch and intradermal tests with native drugs can be negative, but positive with penicilloylpolylysine, a special conjugate for testing consisting of a compound of the active metabolite of penicillin with polylysine. A positive reaction is also detected in the radioallergosorbent test.

PBA has also been described under the influence of many other drugs - streptomycin, piperazine, phenothiazine derivatives. The mechanism of disease development in these cases remains unclear.

Studies have shown that airborne powder from latex gloves can cause the development of PBA in nurses and surgeons.

In general, all professional sensitizers. causing PBAs are classified according to their molecular weight. Molecules of substances with high molecular weight sensitize people and cause asthma by the same mechanism as allergens. The mechanism of action of sensitizers with small molecular weight molecules remains largely unknown and continues to be studied.

Diagnostics. Only an integrated approach, including the study of professional and allergic history, documentation data, on the basis of which one can get an idea of the dynamics of the disease and the working conditions of doctors, pharmacists, pharmaceutical workers, the results of determining the immune status and allergological examination, allows one to establish the professional genesis, etiology of asthma and resolve issues of medical labor examination.

One of the reliable ways specific diagnostics PBA from chemical haptens is a provocative inhalation test with minimal concentrations aqueous solutions chemical allergens, eliminating the nonspecific effects of odor and irritating properties inherent in many sensitizers. The patient inhales the allergen solution using an aerosol spray, and then the pneumotachogram parameters are determined (20 minutes before the study, 20 minutes, 1 hour, 2 hours and 1 day after the diagnostic inhalation).

Often the appearance of cough, wheezing, or shortness of breath in the workplace is mistakenly regarded as an exacerbation of chronic bronchitis, although bronchial obstruction is completely reversible. In this case, early recognition of the disease (peak flowmetry at the workplace and at home), cessation of further contact with the allergen and timely initiation of treatment are very important.

If it is impossible to carry out provocative tests due to serious condition The patient is recommended to use the test of inhibition of natural migration of leukocytes (“rinse test”), the principle of which is based on a change in the migration of leukocytes into the oral cavity after rinsing weak solution allergen. This test is especially recommended if a drug allergy is suspected.

To confirm the occupational genesis of bronchial asthma, it is necessary to determine the serum level total IgE and allergen-specific IgE (skin testing, enzyme immunoassay - ELISA, RAST) for household, pollen, fungal, and occupational allergens.

IN general view The diagnostic algorithm for PBA, taking into account the recommendations of the European Respiratory Society, appears to be as follows:

Anamnesis collection. Detailed professional history. Use of special questionnaires.

Diagnosis of asthma:
- Diagnosis of reversibility of broncho-obstructive syndrome, study of speed function parameters external respiration and viscous respiratory resistance.
- Nonspecific bronchoprovocation tests.
- Dynamic peak flowmetry.

Confirmation of the occupational nature of asthma:
- Dynamic peak flowmetry at the workplace and after work.
- Dynamic study of nonspecific bronchial hyperreactivity.

Confirmation of sensitization by a professional agent:
- Skin testing.
- In vitro tests (determination of allergen-specific IgE or IgG by ELISA, RAST and others).

Confirmation of the causal role of a professional agent in the origin of PBA:
- Specific bronchial challenge tests with a suspected causative factor.
- Leukocytolysis reactions with suspected allergens. medicines.
- Basophil test.
- Inhibition test of natural leukocyte migration (“rinse test”),

In the diagnosis of pulmonary emphysema, pneumosclerosis. pulmonary heart For respiratory failure, X-ray, electro- and echocardiographic methods, computer pneumotachography with determination of viscous respiratory resistance are used.

Clinic. PBA often appears suddenly. PBA is characterized by

dependence of the occurrence of the disease on the intensity and duration of exposure to the causative factor,
the occurrence of symptoms during and after exposure to allergens and chemicals in the workplace,
absence of previous respiratory symptoms,
combination of asthma with other clinical manifestations of occupational allergies (skin, upper respiratory tract),
elimination effect (frequency of respiratory symptoms with improvement on weekends and during the holiday period),
reexposure effect (deterioration of the subjective state and increase in the severity of respiratory symptoms after returning to the workplace in contact with allergens),
reversible nature bronchial obstruction(cough, shortness of breath and wheezing difficulty breathing).

The development of PBA is possible when exposed to occupational allergens, the content of which in the work area did not exceed the maximum permissible concentrations.

The change in the course of PBA is currently associated with urbanization, increased environmental pressure on humans - pronounced antigenic saturation environment, changes in immunological homeostasis, high frequency of viral, mycoplasma infections of the respiratory tract, sensitization of the body during vaccination, pharmacotherapy with antibiotics, drugs household chemicals and other reasons.

To accurately assess the ongoing pharmacotherapy and increase its effectiveness, dynamic peak flowmetry with recording of the results in a special diary for subsequent analysis and the use of a spacer are recommended for patients with PBA. In this regard, the implementation of educational programs for patients with occupational asthma and occupational pathologists and pulmonologists is very important.

Allergic rhinitis

The incidence of allergic occupational rhinitis is quite high, and the prevalence of the disease is increasing. Many professional factors, with which medical and pharmaceutical workers have contact, are full-fledged allergens or have a strong irritant effect on the nasal mucosa and lung tissue.

These are medications (injection and aerosol forms, vaccines, enzymes, serums), chemicals used in laboratory practice and at blood transfusion stations; means for anesthesia, treatment and cleaning of premises medical institutions(operating rooms, treatment rooms, patient rooms), medicinal plant raw materials in pharmaceutical factories and pharmacies.

The true incidence of allergic rhinitis in medical workers is underestimated, since in some cases polyvalent sensitization may occur, which does not bother patients and they do not always consult a doctor. In addition, diagnosing occupational rhinitis in medical workers presents certain difficulties.

Previously, there was an opinion that small particles with low molecular weight were unable to provoke an immune response. But it turned out that these particles are haptens (for example, many drugs) and, thus, can be the cause of an allergic reaction.

According to the International Consensus on Diagnosis and Treatment, occupational rhinitis is defined as a disease caused by contact with harmful substance at work. Occupational rhinitis is identified as a separate form in international classification rhinitis.

Many researchers note that allergic rhinitis is often accompanied by occupational bronchial asthma. Clinical symptoms of damage to the nasal mucosa upon contact with occupational allergens are observed simultaneously with symptoms of bronchial hyperreactivity and have similar pathogenetic mechanisms.

Diagnosis of occupational rhinitis in medical and pharmaceutical workers includes

careful collection of anamnestic data using special questionnaires developed at the State Research Center - Institute of Immunology M3 of the Russian Federation and other researchers;
physical examination of the patient, since symptoms of allergic rhinitis may appear 6-8 hours after contact with the allergen (delayed hypersensitivity).

On weekends, symptoms of the disease usually decrease, but with prolonged contact with the allergen clinical symptoms continues on weekends, except in cases where patients do not work for 7 days or more. It is also important to have no symptoms before working in contact with occupational allergens.

Detection of allergen-specific IgE, carrying out provocative nasal tests with occupational allergens and skin testing form the basis for diagnosing allergic rhinitis of occupational etiology among physicians and pharmacists, allowing to exclude sensitization to epidermal, food, pollen, fungal and other groups of allergens.

Currently, kits have been developed for the diagnosis of allergen-specific IgE to drugs (penicillin, ampicillin, cephalosporins) and other occupational allergens.

Clinic. Clinical manifestations of allergic rhinitis are quite typical. The main symptoms of the disease are itching and irritation of the nasal cavity, sneezing and rhinorrhea, often accompanied by nasal congestion.

Allergic rhinitis of occupational etiology may be accompanied by tickling in the throat, itching in the eyes and ears, lacrimation and swelling eyeballs. Almost 20% of patients experience symptoms of bronchial asthma. In mild cases allergic rhinitis creates only minor inconveniences; in severe cases, it leads to complete loss of ability to work. It can be complicated by headache, fatigue, impaired concentration and significantly reduce the quality of life of patients. Over time, symptoms of the disease may decrease.

Allergic dermatitis

For medical workers and pharmacists, employees of pharmaceutical factories and production facilities allergic lesions skin lesions are a fairly common pathology.

The professional nature of allergic dermatitis in doctors and pharmacists is likely if the following features are present:

the occurrence of dermatitis during professional activity;
deterioration of clinical manifestations during work;
reduction in the activity of the process upon termination of labor activity;
contact with irritants of different nature or potential allergens during production activities.

In most cases, manifestations of occupational allergic dermatitis are localized on the hands and lower forearms, as well as in places of greatest thinning of the stratum corneum of the skin (dorsal surface of the skin, interdigital folds). Sometimes the site of primary localization is the skin of the face or some other parts of the body.

There are a number of chemical and physical irritants (solvents, detergents and others), the direct contact of which with the skin causes the development of allergic dermatitis. Susceptibility to the effects of irritants with sufficient intensity of contact is absolute. The manifestations are localized in places of greatest thinning of the stratum corneum of the skin (the dorsum of the hand, interdigital folds).

There are acute and chronic contact dermatitis. Acute dermatitis occurs early after contact with the irritant and spontaneously undergoes complete reverse development upon cessation of contact.

The chronic form of dermatitis develops after repeated contacts, continues for a long time and is characterized by exacerbations of the process when exposure to the irritant is resumed.

Allergic dermatitis is the result of a type 4 hypersensitivity reaction. The inflammatory process occurs in areas of the skin that come into contact with the allergen. It is also possible for skin lesions to spread through contaminated hands.

Allergens can be various substances (for example, formaldehyde and other chemicals used in laboratory practice; chromate, pharmacological preparations, plant allergens of medicinal raw materials). Experiments have shown that minimum period from first contact to the development of hypersensitivity is 10-14 days. Most potential allergens used in everyday life and at work have low sensitizing activity.

It is also important to note that in terms of localization and morphological features pathological changes With dermatitis, it is not always possible to accurately determine its etiology. Great importance in this regard, they have a detailed interview with the patient about the peculiarities of his work, a thorough analysis of the medical history and identification of possible etiological agents.

The sooner it is delivered correct diagnosis, the faster contact with irritating substances or allergens that adversely affect the prognosis of the disease in medical and social terms will be eliminated. It is necessary to refer patients to specialized dermatology departments and occupational pathology clinics as early as possible.

Clinic. Clinical manifestations of allergic dermatitis depend on the severity and duration of exposure to the allergen, as well as on the routes of entry into the body and its general condition. Protective properties skin levels are greatly reduced due to a decrease in immunological and nonspecific reactivity. Therefore it is possible to develop infectious complications, candidiasis.

The condition of the skin may also be significant for the development of some allergic dermatitis (inflammation develops faster on damp, sweaty skin). Medical workers note some features of the localization and characteristics of the skin rash. In nurses, for example, skin lesions more often occur in the interdigital folds of the hands due to the leakage of antibiotic solutions when they perform medical procedures, and the inflammation is characterized by pronounced exudative processes, often accompanied by weeping.

Histopathological changes in occupational allergic dermatitis develop predominantly in the deep layers of the epidermis. where intercellular edema occurs with the formation of vesicles, while in the skin itself there is perivascular mononuclear infiltration with inclusions of other cellular elements. In addition, hypertrophy and hyperplasia of the endothelial and perithelial elements of blood vessels and narrowing of their lumen are also detected.

If the action of the etiological factor ceases, then inflammatory phenomena under the influence of therapy they quickly resolve, leaving peeling and slight pigmentation. Allergic dermatoses caused by antibiotics. Clinical and morphological manifestations do not differ from similar skin diseases caused by the influence of other etiological factors.

Treatment allergic dermatitis involves eliminating the cause of the disease. With pronounced clinical manifestations prescribe hyposensitizing agents (calcium preparations, sodium thiosulfate, second-generation antihistamines), elimination agents (diuretics, activated carbon), vitamins ( ascorbic acid, calcium pantothenate, calcium pangamate, potassium orotate). Patients are recommended to eat a diet limited in sodium chloride, carbohydrates, and extractives.

In cases of severe inflammation, corticosteroids are prescribed. High efficiency with the rapid onset of positive clinical effect showed various shapes(ointment, cream, lotion) GCS for topical use. External treatment is carried out taking into account the stage of the disease and the severity of the inflammatory process.

For erythema, zinc oxide is prescribed, white clay in the form of powders, aqueous shaken mixtures, 2-3% zinc ointments, creams and ointments containing GCS. For exudation, lotions are indicated, as well as aniline dyes and indifferent pastes (Lassara or zinc in combination with 1-2% dermatol). At the stage of resolving the inflammatory process, ointments are used that have a resolving effect (2% sulfur-tar, 2% sulfur-salicylic, 1-2% ichthyol, glucocorticoid).

For prevention purposes, adequate information and protection of physicians, laboratory workers, pharmaceutical workers and vivarium workers is important. For example, in case of possible contact with irritants and allergens in laboratory practice, special creams are used to protect the skin.

Particularly relevant are the issues of proper selection of applicants for work in medical institutions, laboratories, vivariums, pharmaceutical production. Persons with allergic diseases of the skin, upper and lower respiratory tract are contraindicated from working in contact with allergens (including medicines different groups) and chemicals, since the disease can become mixed (polyvalent allergy).

So, S.Z. Batyn offers the following set of measures to prevent latex allergies:

replacing them with hypoallergenic gloves,
avoiding contact with latex products during an exacerbation period,
usage individual funds protection when in contact with latex products,
traditional basic therapy with immunological drugs wide range actions.

In case of occupational allergic dermatitis, recommendations are given on the patient’s employment without contact with allergens and substances toxic to the skin, treatment is prescribed by a dermatologist, immunologist-allergist at the place of residence, and a mandatory re-examination is prescribed after 1 year.

Kosarev V.V., Babanov S.A.