Occupational Skin Diseases Dr. Alireza Safaiean Occupationala
Medicine Specialist
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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
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CAUSES OF SKIN DISORDERS CONTACT DERMATITIS FOLLICULITIS AND
ACNE PIGMENTARY DISTURBANCE NEOPLASMS, ULCERATION GRANULOMA
CHEMICAL X XXX MECHANICAL X PHYSICAL XX BIOLOGICAL X
APPROACH TO THE WORKER WITH SKIN DISEASE History Physical
examination Diagnostic techniques Supplemental information
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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
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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
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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
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Physical examination Lesion type Secondary changes Distribution
Other skin disease Photographic documentation
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Diagnostic techniques Skin scrapings Fungus Fibers Culture Skin
biopsy Patch test Contact urticaria test Photopatch test
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Supplemental information Material safety data sheets Medical
records Workplace Other physician
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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?
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CAUSES OF OCCUPATIONAL SKIN DISEASE
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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
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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)
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CAUSES OF OCCUPATIONAL SKIN DISEASE Predisposing Factors Age
& experience Skin type Sweating Gender Seasons and humidity
Hereditary allergy Personal hygiene Preexisting skin disease
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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
).
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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
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.
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Prognosis Of Occupational Dermatitis After Treatment 25%
complete recovery 25% refractory 50% remitting / relapsing
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Irritant Contact Dermatitis ICD
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Classification of ICD Acute Chronic
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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
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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.
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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
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Predisposing Factors Endogenous factors: Dryness vs. wetness
Sweating Age Atopic predisposition Hx of skin diseases
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.
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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
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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
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Allergic Contact Dermatitis ACD
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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
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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
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Classification of ACD Acute chronic
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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.
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Acute Allergic Contact Dermatitis Showing Erythema, Edema, and
Vesiculobullae
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Clinical Features ( Chronic Form ) Thickened, fissured,
lichenified skin with scaling The most common sites: Dorsal aspect
of hands Eyelids periorbital
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Subacute Eczema Showing Erythema, Oozing, Crusting,
Lichenification, and Scale
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Chronic Eczema: Showing Lichenification, Fissuring, and
Scale
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Diagnosis Complete history Occupational Non-occupational
Physical examination Patch test
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Patch Test Confirm delayed hypersensitivity Material&
technique: Medium Adhesive Marking of the test Occlusion for 48 h
Read in after 72-96 h
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Angry back
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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
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Doubtful reaction (?) Faint macular or homogeneous Erythema, no
infiltration Weak positive reaction (+) Erythema, Infiltration
Discrete papules
Management & Prevention Removal from exposure ( lifelong)
Drug treatment Topical steroid Emollients Prevention Like ICDs
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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
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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.
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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
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)
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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
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Diagnoses Distribution (on sun-exposed surfaces) of the
reaction Photopatch test
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treatment Avoidance of contact Other are the same as CD
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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
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Contact Urticaria Nonimmunologic: Caused by chemicals Direct
pharmacologic action on skin cells No sensitization necessary More
common than suspected
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Occupational Causes Latex allergy ( m/c ) Formaldehyde Food
industry Plants Vegetables Animal products Pharmaceutical industry
Streptomycin
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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)
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Management & Prevention Removal from exposure Treatment of
active disease Preventive measures
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Occupational Skin Cancers The second m/c form of occupational
skin diseases About 17% of all cases of occupational skin
diseases
