Occupational Skin Diseases

Dr. Alireza SafaiyanOccupational Medicine

Specialist

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

Classifications of work-induced 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

Work-aggravated Skin Diseases

Psoriasis Acne

Diagnosis Of Occupational Skin Diseases

Patient history: Does skin disease relate to work?

Exposure: Are there causative agents (allergens, irritants) in the work-place?

Clinical symptoms: Are they in accordance to clinical disease?

Questions

When did disease start? In which skin area was the first

symptom? What is work technique? Free time, other works Cleaning measures Protection Vacation, holidays

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).

What Types?

Irritant Contact

80% of all dermatitis is

caused by direct contact with a

substanceIt may occur

randomly

Allergic Contact

Once sensitised, the problem is life

long and any exposure to the substance will

result in an attack

What Causes it?

Irritants Detergents Solvents Engine oils Cutting fluid Lubricants Fibreglass

Allergens Salts Nickel Epoxy resins Dyes Rubber

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.

Prognosis Of Occupational Dermatitis After Treatment

25% complete recovery 25% refractory 50% remitting / relapsing

Irritant Contact Dermatitis

ICD

Classification of ICD

Acute

Chronic

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

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.

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

Predisposing Factors

Endogenous factors:• Dryness vs wetness• Sweating• Age• Atopic predisposition• Hx of skin diseases

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

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.

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

Management

Removal from exposure in active lesion Treating the active case

• Topical corticosteroids• Soap substitutes• Emollients

Second line (for steroid resistant cases):

• Topical PUVA• Azathioprine• Cyclosporin

Allergic Contact Dermatitis

ACD

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

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

Classification of ACD

Acute

chronic

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.

Clinical Features ( Chronic Form )

Thickened , fissured, lichenified skin with scaling

The most common sites:• Dorsal aspect of hands• Eyelids• periorbital

Diagnosis

Complete history• Occupational• Non-occupational

Physical examination Patch test

Patch Test

Confirm delayed hypersensitivity Material& technique:

• Medium• Adhesive• Marking of the test• Occlusion for 48 h• Read in after 72-96 h

Angry back

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

•Doubtful reaction ( )?

Faint macular or homogeneous

Erythema, no infiltration

Weak positive reaction )+(

Erythema , InfiltrationDiscrete papules

•Strong positive reaction( )++

ErythemaInfiltration

PapulesDiscrete vesicles

•Extreme positive reaction( +++)

Coalescing vesicles/bullous reaction

Interpretation codes (Ladou 2004)

Management & Prevention

Removal from exposure ( lifelong)

Drug treatment• Topical steroid• Emollients

Prevention• Like ICDs

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

Mathias criteria for occupational contact

dermatitis (4 of 7) Clinical appearance Workplace exposures Anatomic distribution Temporal relationship Non-occupational exposure Improvement Patch test

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

Phototoxic Photoallergic

Coal-tar derivative Dyes (Eosin) Drug -phenothiazines -sulfonamides Plants&derivative -psoralen -lemon

Antifungal agents Fragrances Halogenated

salicylanilide Phenothiazines Sunscreens Whiteners Agricultural

Clinical course

Phototoxcic: - painful , exaggerated sunburn that may

develop bullae and pigmentation -by avoiding the agent, dermatitis usually

disappears promptly Photo-ACD: - many of the features of ACD ( itching ,

vesiculation)

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

DX

Distribution (on sun-exposed surfaces) of the reaction

Photopatch test

treatment

Avoidance of contact Other are the same as CD

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

Contact Urticaria

Nonimmunologic:• Caused by chemicals• Direct pharmacologic action on skin

cells• No sensitization necessary• More common than suspected

Occupational Causes

Latex allergy ( m/c ) Formaldehyde Food industry

• Plants• Vegetables• Animal products

Pharmaceutical industry• Streptomycin

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)

Contact Urticaria

Nonimmunologic:• Caused by chemicals• Direct pharmacologic action on skin

cells• No sensitization necessary• More common than suspected

Management & Prevention

Removal from exposure Treatment of active disease Preventive measures

Occupational Skin Cancers

The second m/c form of occupational skin diseases

About 17% of all cases of occupational skin diseases

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 (Bowen’s disease)

• Lentigo maligna

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