Elimination or replacement of known sensitizing allergens can be a useful method to prevent ACD. Successful identification of a common allergen, chro-mate, and replacement with another nonsensitizing agent is well described in Denmark. In 1981, at manufacture, the chromate content of cement in Denmark was lowered to less than 2 parts per million of water-soluble chromate. This was accomplished by replacing chromate with ferrous sulfate at an added cost of approximately 1%. By this substitution, hand eczema decreased from 11.7 to 4.4% of workers . Chromate allergy also decreased from 10.5 to 2.6% of workers examined. Irritant dermatitis rates did not change . In a separate study, Avnstorp  compared the workers sensitized to chromate prior to the change in 1981 with younger workers who were employed after the decrease in cement chromate concentration. The older workers with chromate allergy appeared to show no improvement after 6 years, despite the reduction of chromate in the cement. Older workers also required more medical services and topical corticosteroids and took retirement at a younger age than non-chromate-sensitized workers. Workers with concomitant allergy to cobalt and rubber chemicals had a worse prognosis. The younger workers were able to continue working, and their employment status was not influenced by their skin problems . A change as seemingly simple as the substitution of one nonallergenic metal for an allergenic metal was enough to decrease the rate of ACD by 7.9% over the course of 6 years! The benefit of this change has recently been confirmed by Bock et al. , who examined the rates of ACD in the construction industry, finding potassium dichromate (chromium VI) to be the most prevalent allergen in cement workers in Germany, where the chromium VI content of the cement has not been decreased. The rate of sensitization was unchanged during the 1990s using the cement products with a higher chromium VI content .
This example of elimination of a known allergen illustrates the concept of primary prevention with excellent results for workers. Decreasing the rate of sensitization makes for better outcomes for workers and potentially reduces costs associated with worker compensation insurance and healthcare expenses for affected workers.
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