The rates varied according to different body sites in men (A) and women (B).
Naldi L, Cazzaniga S, Gonçalo M, Diepgen T, Bruze M, Elsner P, Coenraads PJ, Svensson Å, Bertuccio P, Ofenloch R, for the EDEN Fragrance Study Group. Prevalence of Self-reported Skin Complaints and Avoidance of Common Daily Life Consumer Products in Selected European Regions. JAMA Dermatol. 2014;150(2):154-163. doi:10.1001/jamadermatol.2013.7932
Skin disorders are common in the general population, and they may be associated with significant disability. The use of daily skin products may affect the appearance and severity of skin conditions.
To assess the prevalence of reported itchy rash lasting longer than 3 days among the general population and to evaluate lifetime avoidance of different types of consumer products because of skin problems.
Design, Setting, and Participants
The European Dermato-Epidemiology Network (EDEN) Fragrance Study comprised a large descriptive epidemiological survey of the general population conducted in 6 European regions from August 20, 2008, to October 10, 2011. Participants were a random sample of individuals aged 18 to 74 years, based on electoral precincts. The participants were interviewed using a standardized questionnaire.
Lifetime exposure to products of common use was considered, including toiletry items that remained on the skin or were rinsed off and household and functional items.
Main Outcomes and Measures
The 1-month, 1-year, and lifetime age-standardized prevalence rates of itchy rash that lasted longer than 3 days.
In total, 12 377 individuals (53.9% female; median age, 43 years) were interviewed. The overall prevalences of itchy rash were 19.3% (95% CI, 18.6%-20.0%) during the month preceding the interview, 31.8% (95% CI, 31.0%-32.6%) during the preceding year, and 51.7% (95% CI, 50.8%-52.6%) over a lifetime. In addition, the percentage of individuals who reported avoidance of any product varied from 37.0% for products intended to be left on the skin to 17.7% for household or functional products.
Conclusions and Relevance
Our findings confirmed the magnitude of skin problems among the general population reported in other surveys. Although itchy rash is a nonspecific manifestation, it may be considered in epidemiological surveys to reflect a constellation of skin conditions and to summarize the burden of these conditions on general health.
Skin disorders are common in the general population.1- 3 They may range from mild, transient ailments to stable, chronic conditions and may be associated with significant disability, comparable to that observed in diseases of other functionally important organs.4 The use of daily skin products may affect the appearance and severity of skin conditions.5,6
A a large European survey to evaluate the frequency of contact allergies in the general population was conducted. The survey collected standardized data on a respondent’s history of localized, itchy rash that lasted longer than 3 days. The survey also asked about the skin area involved and any medical procedures implemented to treat the rash, as well as whether the rash might be related to a dry or sensitive skin condition7,8 and any specific dermatological diagnoses. We also explored whether the respondent used any of several daily life products and whether those products were avoided because of the appearance of a skin problem.
The main objective of this study was to assess the prevalence of reported itchy rash lasting longer than 3 days among the general population. Secondary objectives were to evaluate lifetime avoidance of different types of consumer products because of skin problems and to identify associations of skin conditions and avoidance behavior with rash occurrence. The present article is the first in a series on this large prevalence study that was conducted in Europe.
The study was approved by the ethics committee of each participating center. All participants gave written informed consent before starting the interview. The European Dermato-Epidemiology Network (EDEN) Fragrance Study comprised a large descriptive epidemiological survey of the general population conducted in 6 European regions. These included the metropolitan areas of Malmö (Sweden), Jena and Thüringen (Germany), and Heidelberg and Baden-Württemberg (Germany), as well as the provinces of Groningen (the Netherlands), Bergamo (Italy), and Coimbra (Portugal).
The study methods were previously published.9 Briefly, a random sample (age range, 18-74 years) was selected from the general population, based on electoral precincts. The study followed a stratified, proportional, sampling-with-replacement design. The participants were interviewed using a standardized questionnaire and were offered patch testing to investigate sensitization to various fragrances. Herein, we present only the interview data. The full phase of the study was from August 20, 2008, to October 10, 2011.
Each potential participant was contacted by letter. Nonresponses were followed up with a second letter and a telephone call. If no contact was achieved, another individual was randomly selected in the same age and sex strata. The initial contact participation rates ranged from 20.3% to 50.7% depending on the region considered.
The interview was conducted face-to-face with a trained interviewer (R.O.). It took place at the interviewer’s home or at a hospital, based on the preference of the interviewee. The interview consisted of 3 parts. The first part recorded demographic and personal characteristics, including age, sex, racial/ethnic group, skin phenotype, body weight, height, personal habits (eg, smoking), education, occupation, marital status, and family size. The second part recorded any history of skin problems such as localized erythema or itchy rashes that lasted more than 3 days during the month preceding the interview or during the preceding year (including the past month) or that occurred constantly over a lifetime (including the past month and the past year). The location of the erythema was indicated on a body diagram presented to the interviewees, who were asked whether they thought they had sensitive skin, defined as reactive or intolerant, with transient erythema or prickling, burning, or tingling sensations, due to various factors. Participants were also asked whether they had dry skin (ie, skin that lacked moisture and exhibited fine lines, scaling, or itching). They were asked to describe previous diagnoses of any skin disease made by a physician, as well as the treatment received, allergy tests, and any symptoms present at the time of the interview. The third part comprised a detailed history of exposure to consumer products of common use, including the following: (1) toiletry items that remained on the skin or were rinsed off, (2) household and other functional items (eg, cleaning and freshener products) (in perfumery, a functional product is any perfumed product other than alcoholic fragrances10), (3) adornments (eg, metals, leather, piercing and jewelry, and temporary and permanent tattoos), and (4) protective products (eg, plastics and rubber products, bandages, or tapes). They were also asked to list any topical medication used and any history of adverse reactions. For each product, they reported the frequency of use and history of avoidance because of skin problems.
The questionnaire reliability was assessed on a subsample of 96 individuals who were interviewed twice, with a 1-week interval. The weighted Cohen κ statistics were 0.85 to 1.00 for demographic data and approximately 0.70 for the questions regarding skin problems, allergy tests, dry skin, and sensitive skin. The weighted κ statistics for the questions concerning exposure frequencies to selected products ranged from 0.54 (shampoos) to 0.91 (lipsticks and lip balms); most items yielded κ statistics exceeding 0.70.
A web-based, electronic form was used to collect questionnaire data. Cross-referenced checks in the electronic form enabled reduction of input errors, missing data, and inconsistencies.
We aimed to obtain confidence estimates of rates exceeding 0.5%. Using the Clopper-Pearson CI method,11 we estimated that a sample size of 12 000 individuals would produce a 95% CI, with a width equal to 0.003 and a relative SE of 13% when the sample prevalence was 0.5%. Therefore, we interviewed 2000 individuals per center for a total of 12 000 participants. To assess the representativeness of the sample, we compared selected demographic variables of the sample with those of Eurostat 2010 data.12
Descriptive information is presented as numbers (percentages) of individuals. The prevalence of localized, itchy rash that lasted longer than 3 days is expressed as age-standardized estimates (95% CIs). Age standardization was performed according to the direct method.13 This method applies the observed age-specific rates to an age distribution from a standard reference population. For the purpose of our analysis, the chosen reference population was the European standard population.13 The association between the prevalence of itchy rash and selected factors was expressed in terms of odds ratios (ORs) (95% CIs). The OR estimates were obtained with multiple logistic regressions to control for potential confounders.
Table 1 gives the sociodemographic characteristics of 12 377 individuals in 6 European regions. As expected, women outnumbered men in all countries (53.9% female overall); this was consistent with the general population data obtained from Eurostat 2010 (difference, 2.8%; 95% CI, 1.9%-3.7%).
The age distribution was uniform among all countries except Sweden, which tended to have an older population. Moreover, the overall median age of 43 years was comparable to that of the general population in Eurostat 2010 (difference, −0.1 year; 95% CI, −1.1 to −0.1 years).
The race/ethnicity of 97.1% (range, 93.1% in Groningen to 99.5% in Coimbra) of individuals was white. Only 110 individuals (0.9%) represented mixed racial/ethnic groups, with the largest group (2.1%) in Groningen. Sixty-four individuals (0.5%) were Asian, with the largest group (1.1%) in Groningen. Twenty-six individuals were African European, and 96 individuals represented other racial/ethnic groups.
Table 2 gives the prevalence of reported localized, itchy rash that lasted longer than 3 days and had occurred during the month or year preceding the interview or constantly over a lifetime. The prevalence is reported for the overall population and according to sex, age, geographic region, and skin area involved. The overall prevalences of itchy rash were 19.3% (95% CI, 18.6%-20.0%) during the month preceding the interview, 31.8% (95% CI, 31.0%-32.6%) during the preceding year, and 51.7% (95% CI, 50.8%-52.6%) over a lifetime. The prevalence was always higher among women than among men, with relative increases in the prevalence among women of 31.2% for the lifetime prevalence, 34.8% for the 1-year prevalence, and 37.5% for the 1-month prevalence. There were some slight variations among different age groups for the 1-month prevalence rates, but the 1-year and lifetime prevalence rates were not remarkably different among the 4 age groups analyzed. The prevalence rates were lower in southern European centers compared with northern centers. The relative increases in prevalence among the northern region of Malmö compared with the southern region of Coimbra were 58.2% for the 1-month prevalence, 49.1% for the 1-year prevalence, and 60.8% for the lifetime prevalence.
The prevalence rates also varied depending on the skin area involved. The highest rates were reported for the lower limbs, hands, upper limbs, face, and ears. The lowest rates were reported for the buttocks, genital areas, and axillae. As shown in the Figure, the lifetime prevalences of itchy rash in various skin areas differed among men and women. In particular, the face was affected more frequently in women than in men. A similar sex difference was observed in the prevalence of rashes that occurred during the month or the year preceding the interview (data not shown).
A total of 1351 individuals (10.9%; 95% CI, 10.5%-11.6%) reported itchy rash that occurred at every consecutive time point analyzed, including the month before the interview, during the year (but not during the month before the interview), and over a lifetime (but not during the month or the year before the interview). This group seemed to exhibit a chronic condition.
The itchy rash prompted physician consultation in 43.2% (95% CI, 41.2%-45.3%) of individuals who reported a rash during the past month, in 48.3% (95% CI, 46.7%-49.9%) of individuals who reported a rash during the past year, and in 59.4% (95% CI, 58.1%-60.6%) of individuals who reported a rash that occurred over a lifetime. More women than men consulted a physician for their rash; in particular, for a rash that occurred over a lifetime, a relative excess of 9.6% of women compared with men consulted a physician. The proportion of consultations also varied for the different skin areas involved. Rashes that most frequently prompted a consultation over a lifetime were on the inguinal areas, buttocks, genital areas, and scalp.
Among individuals who consulted a physician, 51.3% (95% CI, 48.3%-54.7%) received a diagnosis of contact dermatitis or eczema for a rash that occurred during the previous month, 46.3% (95% CI, 43.8%-48.8%) for a rash that occurred during the previous year, and 47.0% (95% CI, 45.1%-48.8%) for a rash that occurred over a lifetime. Overall, slightly more women than men received a diagnosis of contact dermatitis or eczema for their rash. The proportions of contact dermatitis or eczema diagnoses also varied for different rash locations. These diagnoses most frequently applied to rashes on the hands, face, scalp, and lower limbs. They infrequently applied to rashes on the genital areas, buttocks, inguinal areas, and abdomen.
Interviewees attributed their rash to exposure to a product they used daily for 25.0% (95% CI, 23.2%-26.8%) of rashes that occurred during the previous month, for 28.1% (95% CI, 26.7%-29.6%) of rashes that occurred during the previous year, and for 34.2% (95% CI, 33.0%-35.4%) of rashes that occurred over a lifetime. The attribution to products used in daily life varied for rashes among different skin areas. The association was highest for lesions on the axillae, genitalia, hands, abdomen, and neck, in that order. The association was lowest for lesions on the feet.
Approximately 42.5% of individuals with a rash over their lifetime and 46.1% with a rash during the past year were treated with a prescription drug. Approximately 32.2% were treated with a nonprescription drug.
Table 3 gives the proportion of individuals with a rash over their lifetime who consulted a physician and, of these, the proportion who received a diagnosis of contact dermatitis or eczema, as well as the proportions treated with prescription drugs or nonprescription drugs. In addition, the proportion of individuals who attributed their rash to exposure to a daily use product is reported.
The percentage of individuals who avoided any product varied among products intended to be left on the skin (37.0%), metals (29.3%), products intended to be rinsed off (21.0%, excluding hair dyes), and household or functional products (17.7%). Overall, the reported lifetime avoidance was markedly higher among women (68.3%) than among men (38.9%).
As summarized in Table 4, a total of 6421 individuals reported they had dry skin (age-standardized prevalence, 51.7%; 95% CI, 50.8%-52.6%) and 4861 individuals reported they had sensitive skin (age-standardized prevalence, 39.7%; 95% CI, 38.8%-40.5%). The prevalences of dry skin and sensitive skin were higher among women (59.1% and 49.5%, respectively) compared with men (42.8% and 28.1%, respectively).
A lifetime history of skin disease that had been diagnosed by a physician was reported by 6382 individuals (age-standardized prevalence, 51.5%; 95% CI, 50.7%-52.4%). Of those, 46.9% (95% CI, 45.6%-48.2%) were men and 55.4% (95% CI, 54.2%-56.6%) were women. In total, 67.8% (95% CI, 66.6%-68.9%) of participants with an itchy rash that occurred over their lifetime reported a lifetime history of a confirmed skin disease. Only 1351 individuals reported itchy rash that occurred exclusively at only 1 of 3 different time points (ie, during the month before the interview, during the year before, or over a lifetime). Of those, 1022 individuals (age-standardized prevalence, 76.1%; 95% CI, 73.8%-78.4%) had received a lifetime diagnosis of a skin disease by a physician. Based on age-standardized prevalences, the most common skin disease diagnoses were warts (26.3%; 95% CI, 25.7%-26.9%), eczema not better defined (13.4%; 95% CI. 12.9%-13.9%), acne (11.0%; 95% CI, 10.6%-11.4%), contact dermatitis (8.4%; 95% CI, 8.0%-8.8%), atopic dermatitis (7.0%; 95% CI, 6.7%-7.3%), urticaria (6.0%; 95% CI, 5.7%-6.3%), and psoriasis (4.1%; 95% CI, 3.8%-4.4%).
In Table 4, the duration of itchy rash over a lifetime is given relative to skin conditions (dry skin, sensitive skin, or lifetime skin diseases diagnosed by a physician) and avoidance history (avoidance of consumer products and metals). We performed a multiple logistic regression analysis that included terms for sex, age, country, occupation, and marital status to determine associations between skin conditions and avoidance behavior with rashes. During a lifetime, the ORs for developing itchy rashes were as follows for the different variables: 1.93 (95% CI, 1.78-2.08) for individuals with dry skin, 2.45 (95% CI, 2.26-2.65) for individuals with sensitive skin, 3.14 (95% CI, 2.89-3.40) for individuals with a lifetime skin disease diagnosis confirmed by a physician, 2.74 (95% CI, 2.52-2.98) for individuals who avoided products intended to be left on the skin, 2.67 (95% CI, 2.41-2.95) for individuals who avoided products to be rinsed off the skin, 3.22 (95% CI, 2.88-3.60) for individuals who avoided household and functional products, and 2.46 (95% CI, 2.24-2.70) for individuals who avoided metals.
A positive relationship was found between the location of itchy rash on specific body areas and avoidance of specific products typically applied to those areas. For example, the rate of avoiding deodorants or antiperspirants was 43.8% among individuals with itchy rash on the axillae that occurred over a lifetime; in contrast, the avoidance rate was only 15.2% among those without a rash in that location (adjusted OR, 3.59; 95% CI, 3.04-4.23). Similarly, the rate of avoiding shampoos or other hair products was 23.8% among individuals with itchy rash on the face or scalp that occurred over a lifetime compared with 9.4% among those without a rash in those locations (adjusted OR, 2.45; 95% CI, 2.16-2.78).
This study showed that 51.7% of the general population from different geographic European regions reported the occurrence over a lifetime of a localized, itchy rash that lasted longer than 3 days. Furthermore, 46.9% reported that because of skin irritations they avoided daily use products, including cosmetics, soaps, shampoos, and functional or household products. These proportions were consistently higher among women than among men and showed some variation across different geographic regions, with northern regions showing on average higher rates of a history of itchy rash compared with southern regions. No substantial differences in 1-month, 1-year, or lifetime itchy rash prevalence rates were found across various age categories. In addition, our survey documented that self-perception of having dry skin or sensitive skin was related to the occurrence of itchy rash. The frequency of rash varied according to the skin area affected. The highest rates occurred on the limbs and, in women, on the face. Approximately 59.4% of individuals with a rash that occurred over a lifetime consulted a physician. The consultation rate was higher among women than among men, and it varied with the location of the rash. The highest consultation rates were for lesions on the inguinal areas, buttocks, genital areas, and scalp. In addition, a north-south geographic gradient was detected, with higher rates reported in northern countries than in southern countries. This observation indicates that climatic or cultural factors may contribute to the prevalence.
As defined in our study, itchy rash is a nonspecific manifestation, and it could reflect a wide variety of mild to serious conditions. However, almost half of the individuals who consulted a physician for their rash received a diagnosis of contact dermatitis or eczema. The proportion diagnosed was higher among women than among men, and it was highest for lesions on the hands and lowest for lesions on genital skin. Approximately 55.8% of individuals with a rash that occurred over a lifetime received a prescription drug, and 33.6% received a nonprescription drug for treatment. More than one-third of the study participants with a rash attributed it to exposure to a daily use product.
Our findings are relevant to public health issues. They confirm the magnitude of skin problems among the general population reported in other surveys, and the results improve our understanding of factors that influence consultations for skin problems.1- 16 Our study shows that consultation rates differ between the sexes and for various skin areas involved. Therefore, when restricted to individuals who consult a physician, epidemiological profiling of skin diseases characterized by a localized rash and itching may provide misleading information. Our data allow us to make some estimates of the health costs associated with the history of an itchy rash. Assuming a 1-year prevalence estimate of 31.8%, the costs involved may be relevant. With reference to the 2012 European population of 503.9 million, the approximate expense may range from 2.72 to 15.52 billion € (US $3.37-19.23 billion) for physician consultation (48.3% of individuals who reported itchy rash consulted a physician), assuming a cost for consultation ranging from 35 to 200 € (US $43.40-247.90) per visit.17 The approximate expense may range from 0.52 to 3.70 billion € (US $0.64-4.59 billion) for prescription drugs (46.1% of individuals who reported itchy rash were given a prescription drug), assuming a cost ranging from 7 to 50 € (US $8.70-62.00) per prescription.17 These are rough estimates and may vary according to the country considered and the year.
We are unaware of any studies similar to ours that focused on itchy rash and related that to avoidance of daily-use products. In a population-based study2 conducted in Oslo, Norway, self-reported skin symptoms were associated with female sex. In a study5 among a random sample of the Danish population, rash was related to the use of scented products in 28.6% of the sample with occurrence over a lifetime, and women were significantly more likely than men to report a rash. An opinion poll conducted among a random sample of individuals 15 years or older in 8 European countries, including Belgium, France, Germany, Greece, Italy, Portugal, Spain, and Switzerland, documented that 38.4% reported sensitive skin or very sensitive skin.8 In addition, women reported sensitive skin more frequently than men. Furthermore, dermatological diseases were reported by 31.2% of individuals with very sensitive skin, by 17.6% of individuals with sensitive skin, and by only 3.7% of individuals without sensitive skin.
Although the term itchy rash is nonspecific, the metrics may have captured a large proportion of inflammatory skin conditions. In the present study, itchy rash was reported by 68.2% (95% CI, 67.1%-69.4%) of individuals who had a lifetime history of a confirmed skin disease; conversely, a lifetime history of a confirmed skin disease was reported by 67.8% (95% CI, 66.6%-68.9%) of individuals with itchy rash that occurred over their lifetime. While nonspecific, a history of itchy rash that lasted longer than 3 days may be considered in epidemiological surveys to reflect a constellation of skin conditions and to summarize the burden of these conditions on general health.
Group Information: The EDEN Fragrance Study Group investigators are listed at the end of this article.
Accepted for Publication: August 29, 2013.
Corresponding Author: Luigi Naldi, MD, Department of Dermatology, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Centro Studi Gruppo Italiano Studi Epidemiologici in Dermatologia–Fondazione per la Ricerca Ospedale Maggiore Presidio Ospedaliero Matteo Rota, Via Garibaldi 13/15, 24122 Bergamo, Italy (firstname.lastname@example.org).
Published Online: December 25, 2013. doi:10.1001/jamadermatol.2013.7932.
Author Contributions: Drs Cazzaniga and Bertuccio had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Naldi, Gonçalo, Diepgen, Bruze, Elsner, Coenraads, Svensson.
Acquisition of data: Ofenloch.
Analysis and interpretation of data: Naldi, Cazzaniga, Diepgen, Bertuccio, Ofenloch.
Drafting of the manuscript: Naldi, Cazzaniga, Diepgen.
Critical revision of the manuscript for important intellectual content: Naldi, Gonçalo, Diepgen, Bruze, Elsner, Coenraads, Svensson.
Statistical analysis: Cazzaniga, Bertuccio, Ofenloch.
Obtained funding: Naldi, Diepgen.
Administrative, technical, or material support: Bertuccio.
Study supervision: Naldi, Gonçalo, Diepgen, Bruze, Elsner, Coenraads, Svensson.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by the Research Institute for Fragrance Materials and in part by L’Oreal Research and Innovation, The Procter & Gamble Company, Henkel AG & Co KGaA, Kao Corporation, Hoyu Co Ltd, and Unilever NV.
Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Group Information: The EDEN Fragrance Study Group investigators were Luigi Naldi, MD, Margarida Gonçalo, MD, Thomas Diepgen, MD, Magnus Bruze, MD, Peter Elsner, MD, Peter J. Coenraads, MD, PhD, and Ake Svensson, MD.
Additional Contributions: The following contributed to the study: Luigina Vecchi (Bergamo, Italy); Geke Dijkstra (Groningen, the Netherlands); Nils Hamnerius, Sue Harden, and Ewa Wallin (Malmö, Sweden); and Fátima Ribeiro, Pedro Andrade, Ana Brinca, Neide Pereira, Sara Vaz, and Telma Seguro (Coimbra, Portugal). Eugenia Caggese provided administrative support. We thank the individuals who took part in the survey and the residents and nurses who contributed to the study in the participating centers. Special thanks to Marta Rossi, PhD, for her contribution to the study and to Eugenia Caggese, who provided administrative support.