Occupational Skin Diseases Dr. Alireza Safaiean Occupationala Medicine Specialist
Preview:
Citation preview
- Slide 1
- Occupational Skin Diseases Dr. Alireza Safaiean Occupationala
Medicine Specialist
- Slide 2
- Introduction The second cause of occupational diseases ( 23-25%
of all occ.diseases ) A skin disease that is caused by physical,
biological or chemical factor in work Also a worsening of
pre-existing skin disease can be termed as occupational skin
disease
- Slide 3
- CAUSES OF SKIN DISORDERS CONTACT DERMATITIS FOLLICULITIS AND
ACNE PIGMENTARY DISTURBANCE NEOPLASMS, ULCERATION GRANULOMA
CHEMICAL X XXX MECHANICAL X PHYSICAL XX BIOLOGICAL X
- Slide 4
- Classifications of skin diseases Occupational dermatitis
Occupational photosensitivity reactions Occupational phototoxicity
reaction Occupational skin cancers Occupational contact urticaria
Occupational acne Occupational skin infections Occupational
pigmentary disorders Miscellaneous
- Slide 5
- Work-aggravated Skin Diseases Psoriasis Acne
- Slide 6
- APPROACH TO THE WORKER WITH SKIN DISEASE History Physical
examination Diagnostic techniques Supplemental information
- Slide 7
- History A. Present illness Date of onset Body site at onset
Patient description Onset abrupt or gradual Appearance, spread
Frequency Effect of treatment Course of disease Effect of weekend,
vacation Work procedure change Treatment and effect on
dermatitis
- Slide 8
- History B. Occupational information Current employer Employment
dates Job title (At time of onset, Description of job tasks,
Materials contacted, Protection, Water exposure, Hand washing)
Clothing/equipment: (Protective creams/cleansers, Skin cleaning,
Method and frequency) Other workers affected Job since dermatitis
Previous job tasks or jobs Episodes of dermatitis Second job Dates
of disability Date of job changes
- Slide 9
- History C. Personal history Other exposures (Animals, Foods,
Plants, Clothing, Personal care products, Hobbies) Past history of
skin disease (Plant dermatitis, Hand dermatitis, Psoriasis,
Athletes foot) History of atopy Personal/family (Atopic dermatitis,
Hay fever, Asthma) Medical problems Medications
- Slide 10
- Physical examination Lesion type Secondary changes Distribution
Other skin disease Photographic documentation
- Slide 11
- Diagnostic techniques Skin scrapings Fungus Fibers Culture Skin
biopsy Patch test Contact urticaria test Photopatch test
- Slide 12
- Slide 13
- Supplemental information Material safety data sheets Medical
records Workplace Other physician
- Slide 14
- Diagnosis Of Occupational Skin Diseases Clinical symptoms: Are
they in accordance to clinical disease? Patient history: Does skin
disease relate to work? Exposure: Are there causative agents
(allergens, irritants) in the work-place?
- Slide 15
- CAUSES OF OCCUPATIONAL SKIN DISEASE
- Slide 16
- Chemical agents The main cause of occupational skin diseases
and disorders. These agents are divided into two types: Primary
irritants: Primary or direct irritants act directly on the skin
though chemical reactions. Sensitizers: may not cause immediate
skin reactions, but repeated exposure can result in allergic
reactions. A workers skin may be exposed to hazardous chemicals
through: direct contact with contaminated surfaces, deposition of
aerosols, immersion, splashes
- Slide 17
- Other Causes Physical agents such as extreme temperatures (hot
or cold) and radiation (UV/solar radiation). Mechanical trauma
includes friction, pressure, abrasions, lacerations and contusions
(scrapes, cuts and bruises). Biological agents include parasites,
microorganisms, plants and other animal materials. ( Animal
breeders, vets, horticulturists, bakers, tanners, bricklayers, etc.
are all possible victims of biological)
- Slide 18
- CAUSES OF OCCUPATIONAL SKIN DISEASE Predisposing Factors Age
& experience Skin type Sweating Gender Seasons and humidity
Hereditary allergy Personal hygiene Preexisting skin disease
- Slide 19
- Contact Dermatitis Occupational dermatitis is an inflammation
of the skin causing itching, pain, redness, swelling and small
blisters. Contact dermatitis is an eczematous eruption caused by
external agents, which can be broadly divided into: Irritant
substances that have a direct toxic effect on the skin (irritant
contact dermatitis, ICD ) Allergic chemicals where immune delayed
hypersensitivity reactions occur (allergic contact dermatitis, ACD
).
- Slide 20
- Types of contact dermatitis Irritant Contact 80% of all
dermatitis is caused by direct contact with a substance It may
occur randomly Allergic Contact Once sensitised, the problem is
life long and any exposure to the substance will result in an
attack
- Slide 21
- The Causes Irritants Detergents Solvents Engine oils Cutting
fluid Lubricants Fibreglass Allergens Salts Nickel Epoxy resins
Dyes Rubber
- Slide 22
- Common site of involvement Skin disease starts on the area of
contact. Dorsal aspects of hands and fingers, volar aspects of
arms, interdigital webs, medial aspect of thighs, dorsal aspects of
feet.
- Slide 23
- Prognosis Of Occupational Dermatitis After Treatment 25%
complete recovery 25% refractory 50% remitting / relapsing
- Slide 24
- Irritant Contact Dermatitis ICD
- Slide 25
- Classification of ICD Acute Chronic
- Slide 26
- Acute ICD This is often the result of a single overwhelming
exposure or a few brief exposures to strong irritants or caustic
agents. Common work chemicals: Concentrated acids (sulfuric,
nitric, chromic, hydrochloric, hydrofluoric acids) Strong
alkali(CaOH,NaOH,KOH),wet concrete, sodium and potassium cyanide
Organic and inorganic salts, e.g. dichromates, arsenic salts
Solvents/gases, e.g. acrylonitrile, ethylene oxide, CS2
- Slide 27
- Clinical Presentation Stinging, burning, painful, erythematous
eruption occur after brief contact with strong irritant chemicals.
Erosion and skin ulceration may occur. May result in permanent
scar.
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Chronic (cumulative) ICD Repetitive exposure to weaker
irritants -Wet : detergents, organic solvents, soaps, weak acids,
and alkalis -Dry : low humidity air, heat,dusts, and powders
Disease of the stratum corneum Is due to a stepwise progression of
damage to the barrier function of the skin
- Slide 33
- Predisposing Factors Endogenous factors: Dryness vs. wetness
Sweating Age Atopic predisposition Hx of skin diseases
- Slide 34
- Causes of Chronic ICD Water/wet work Detergents Antiseptics
Disinfectants Soap/cleansing agents Weak Acids & alkali Wet
cement Solvents Low humidity friction Fiberglass fibers Cutting oil
Food Pesticides Plants & vegetation Rubber products Acrylic
resins Soldering flux Dusts Degreasing agents
- Slide 35
- 35% Washing 10% Solvents 6% Plastics and adhesives 6% Foodstuff
5% Dirty, wet work 5% Mineral oils At risk occupations: Bartenders
Caterers Cleaners Hairdressers Metalworkers Nurses Solderers
Fisherman construction workers.
- Slide 36
- Clinical Presentations Usually presents with dry, scaly
fissuring, lichenified and eczematous lesions on the fingers and
hands. Vesicular lesions do occur but are less common than in ACD.
May in face ( forehead, eyelids, ears, neck) and arms due to
airborne irritant dusts and volatile irritant chemicals
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Management In workplace Removal from exposure in active lesion
Skin cleansing (water rinse without soap if possible) Barrier cream
Gloves Treating the active case Topical corticosteroids Soap
substitutes Emollients (either water- or oil-based) Second line
(for steroid resistant cases): Topical PUVA Azathioprine
Cyclosporin
- Slide 41
- Slide 42
- Allergic Contact Dermatitis ACD
- Slide 43
- Allergic Contact Dermatitis Caused by low-molecular weight
haptens Hapten is incomplete allergen Binds to carrier protein for
immunogenicity Low molecule weight enables penetration of hapten
Hapten penetrates through stratum corneum of a sensitized
individual A classical Type IV reaction
- Slide 44
- Occupational Skin Allergens Poison oak/ivy Metals: Chromium
Nickel Gold Mercury Cobalt Rubber industry Accelerators
Antioxidants Plastic resins Epoxy resins PU resins Phenolic resins
Formaldehyde resins Acrylic resins Rosin ( colophony ) Soft
soldering Organic dyes ( azo dyes ) Methyl metacrylate Plants Latex
and its powder Germicides and biocides e.g. lanolin Some pesticides
Some solvents Formaldehyde Turpentine Aliphatic amines Nitrates
Ethylene oxide
- Slide 45
- Classification of ACD Acute chronic
- Slide 46
- Clinical Features ( Acute Form ) Rash appears in areas exposed
to the sensitizing agent, usually asymmetric or unilat. Sensitizing
agent on the hands or clothes is often transferred to other body
parts. The rash is characterized by erythema, vesicles and sever
edema. Pruritus is the overriding symp.
- Slide 47
- Acute Allergic Contact Dermatitis Showing Erythema, Edema, and
Vesiculobullae
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Clinical Features ( Chronic Form ) Thickened, fissured,
lichenified skin with scaling The most common sites: Dorsal aspect
of hands Eyelids periorbital
- Slide 55
- Subacute Eczema Showing Erythema, Oozing, Crusting,
Lichenification, and Scale
- Slide 56
- Chronic Eczema: Showing Lichenification, Fissuring, and
Scale
- Slide 57
- Slide 58
- Slide 59
- Slide 60
- Slide 61
- Slide 62
- Slide 63
- Diagnosis Complete history Occupational Non-occupational
Physical examination Patch test
- Slide 64
- Slide 65
- Patch Test Confirm delayed hypersensitivity Material&
technique: Medium Adhesive Marking of the test Occlusion for 48 h
Read in after 72-96 h
- Slide 66
- Angry back
- Slide 67
- Interpretation of patch test result Nothing: negative reaction
Erythema, papules, infiltration, no vesicle: weak reaction
Erythema, vesicular eruption, edema: strong reaction Bulla,
ulceration: extreme reaction Erythema to eczematous: irritant
reaction
- Slide 68
- Doubtful reaction (?) Faint macular or homogeneous Erythema, no
infiltration Weak positive reaction (+) Erythema, Infiltration
Discrete papules
- Slide 69
- Strong positive reaction (++) Erythema Infiltration Papules
Discrete vesicles Extreme positive reaction (+++ ) Coalescing
vesicles/bullous reaction
- Slide 70
- Interpretation codes (Ladou 2004)
- Slide 71
- Slide 72
- Slide 73
- Management & Prevention Removal from exposure ( lifelong)
Drug treatment Topical steroid Emollients Prevention Like ICDs
- Slide 74
- Slide 75
- Irritant versus Allergic dermatitis ICD Hx. Of contact with
known irritant Acute onset Stinging, Burning Neg. patch test
Localized Many people Improved with long vacation (3 weeks) ACD Hx.
Of contact with known allergen Delay onset (1-3d) Itching, Vesicle
Positive patch test Spreads Few people May improved even on
weekends
- Slide 76
- Criteria to Determine Occupational Causation 1. The clinical
appearance is consistent with contact dermatitis. 2. There are
workplace exposures to potential cutaneous irritants or allergens.
3. The anatomic distribution of dermatitis is consistent with
cutaneous exposure in relation to the job task. 4. The temporal
relationship between exposure and onset is consistent with contact
dermatitis. 5. Non-occupational exposures are excluded as probable
causes. 6. The dermatitis improves if work exposure to the
suspected irritant or allergen ceases. 7. Patch or provocation
tests identify a probable causal agent. If four of the seven
statements in Table are true, the eczema is probably occupational
in origin.
- Slide 77
- Contact photodermatitis Some chemicals may cause CD only in the
presence of light Sunlight or artificial light sources that emit
specific wavelengths 2 categories: -phototoxic -photoallergic
- Slide 78
- Phototoxic Coal-tar derivative Dyes (Eosin) Drug
-phenothiazines -sulfonamides Plants&derivative -psoralen
-lemon Photoallergic Antifungal agents Fragrances Halogenated
salicylanilide Phenothiazines Sunscreens Whiteners
Agricultural
- Slide 79
- Clinical course Phototoxcic: - painful, exaggerated sunburn
that may develop bullae and pigmentation -by avoiding the agent,
dermatitis usually disappears promptly Photoallergic: - many of the
features of ACD ( itching, vesiculation)
- Slide 80
- Where involved ? Exposed areas : face, ant. V of the neck, back
of the hand, uncovered sites on the arm&leg Hairy areas, upper
eyelids, and below the chin may be spared
- Slide 81
- Diagnoses Distribution (on sun-exposed surfaces) of the
reaction Photopatch test
- Slide 82
- treatment Avoidance of contact Other are the same as CD
- Slide 83
- Contact Urticaria Immunologic : Caused by proteins that act as
allergens Proteins penetrate through skin bind to IgE on the
surface of mast cell release of histamine and other mediators
(type-1 reaction) Sometimes generalized reactions occur Latex
allergy
- Slide 84
- Contact Urticaria Nonimmunologic: Caused by chemicals Direct
pharmacologic action on skin cells No sensitization necessary More
common than suspected
- Slide 85
- Occupational Causes Latex allergy ( m/c ) Formaldehyde Food
industry Plants Vegetables Animal products Pharmaceutical industry
Streptomycin
- Slide 86
- Clinical Features Of Contact Urticaria Hives (edema) appear on
sites of contact within minutes The hives disappear within 1-4
hours Mild: Only itching Severe: Systemic symptoms
(anaphylaxis)
- Slide 87
- Slide 88
- Management & Prevention Removal from exposure Treatment of
active disease Preventive measures
- Slide 89
- Occupational Skin Cancers The second m/c form of occupational
skin diseases About 17% of all cases of occupational skin
diseases
- Slide 90
- What Cancers? Malignant lesions: Basal cell carcinoma Squamous
cell carcinoma Malignant melanoma Pre-malignant lesions: Actinic
(solar) keratoses Tar keratoses (warts) Arsenical keratoses
Keratoacanthoma Intra-epidermal carcinoma ( Bowens disease) Lentigo
maligna
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- .... ....