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 CCP reactions, nonreacting persons (those without a history of allergy or irritative reactions) can handle CCP without risk.

Jeansson et al. 1983, 1984. During patient followup visits, the authors investigated patients who had complaints related to any type of paper and who had been referred to an occupational dermatitis clinic in Sweden from January 1974 to December 1980. Their complaints included irritation of the eyes, nose, throat, arms, face, and scalp; cold symptoms; hoarseness; sores; itching, dryness, redness, or eczema of the hands; unpleasant odor or taste; fatigue; headache; nausea; joint pains; and a feeling of paralysis.

Jeansson et al. [1983] appraised the chemical contents of the papers by skin tests (patch and scratch) and by other examinations of 148 patients. No controls were included in this study. Three of the original 151 complainants were lost to followup. The focus of the study was to find the triggering chemical factor by (1) examining the chemical content and the toxicological effects of the paper, (2) examining the distribution of patients according to the suspected cause of problems, and (3) investigating the relative prevalence of contact allergies. The complaints involved multiple brands of CCP. Manufacturers submitted lists of the composition of 13 brands of CCP on the Swedish market along with samples of the chemicals from the production process. The authors applied a series of patch tests using a standard panel of 30 known antigens as well as samples of paper (CCP, data paper, carbon paper, and photocopying paper) and CCP components. The tests were performed on 134 patients (those with CCP-related complaints) using the CCP with which they worked. Of these patients, about 50 were also tested with approximately 60 chemicals from the paper production process. The authors tested the following CCP components: those in the CB and CF surfaces in both wet and dry preparations, saline extracts of CCP, 62 chemical components (representing about 95% of the components on the Swedish market), 7 desensitizing chemicals, and 3 adhesive products.

Specific antibodies (IgE, RAST) against dust and molds were identified in 4 of 35 cases, none of whom were among the patients with CCP complaints. The authors noted that this number was not an overrepresentation for a group such as this. The only positive reactions that occurred from any of the test materials other than the standard ones were from two types of carbon paper (not CCP). Slight irritation occurred when testing 50% kerosene (1 of 59) and 50% isoparaffins (1 of 59). Slight redness (1 of 1) occurred with 100% alkylated benzene, but no reaction occurred at repeat testing with a 50% concentration in 54 test subjects. Two of five D-inks produced primary irritation at 5% concentration: the first ink resulted in a slight redness in 43% of patients (19 of 44); and at 1% concentration, the second caused slight redness in 59% of those tested (26 of 44). "Itch" tests assessing skin response to a nonantigenic stimulus (histamine) were performed. Responses were measured as the duration of the sensation of itch and the size of the reddened area after administration of 3 concentrations of histamine below the epidermis. Twenty patients having CCP-related complaints were compared with 17 patients having previous complaints about non-CCP paper. The CCP patients suffered a significantly longer duration of itch (0.05>P>0.01 [Göthe et al. 1981]) than the matched comparisons; however, the area of redness did not differ between the two groups. The authors commented that the longer-lasting itch correlated with the higher prevalence of mucous membrane irritation on exposure to CCP (65% versus 50%).

Among the patients examined with possible CCP-related symptoms, no allergic or single irritant mechanism was found to explain how the handling of CCP directly resulted in