[Work-related diseases of the skin]

Work-related diseases of the skin are aetiologically completely different diseases. The common denominator is that they are all triggered by occupational activity. Allergic and cumulative irritant contact eczema occur the most frequently. Early reporting of occupational dermatosis to the accident insurance carrier should first and foremost lead to adequate preventive measures at the workplace. Early recognition, systematic therapy and rapidly implemented prevention should enable the affected person to continue to work in his or her occupation. To implement appropriate preventive measures, the collaboration of the family physician, dermatologists, company doctor and accident insurance carrier is desired.

A 7-step consultation plan for health care workers and hairdressers

BACKGROUND

Skin diseases are among the most common occupational disorders in health care workers and hairdressers. Optimal prevention methods make it possible for more individuals to remain active in their profession. We devised a 7-step consultation plan which was employed in a standard fashion and then evaluated.

PATIENTS AND METHODS

264 employees were evaluated in the Education and Support Center of the German Accident Prevention and Insurance Association in the Health and Welfare Services (BGW schu.ber.z Berlin) from 2003 to 2005 in a standardized manner. Included were detailed history, physical examination, skin physiology measurements (transepidermal water loss, corneometry, sebumetry) and then making a diagnosis and therapeutic recommendations.

RESULTS

Within the study group of 264 employees the most frequent diagnosis were toxic-irritant hand eczema (28.4%), allergic contact eczema (19.7%), atopic eczema (15.5%) and irritant contact eczema with atopic diathesis (13.6%). The frequency of contact sensitivity was high in the study group (80.7%). The skin physiological parameters were not remarkably altered and did not differ between individuals with an atopic diathesis versus without an atopic diathesis.

CONCLUSION

This standardized protocol for a "7-step consultation plan"when applied in a standardized manner offers quality-controlled but also individually-adapted support considering dermatological, educational and occupational aspects. Skin physiology parameters did not provide any further information indicating the need of the development of novel techniques to measure skin barrier function.

Self-reported hand eczema in a hospital population

Occupational skin diseases are frequent in the healthcare sector. The objective of this study was to obtain baseline data on hand eczema and risk factors for hand eczema in an unselected hospital population. A questionnaire study on hand eczema and risk factors for hand eczema was performed among hospital employees at a middle-size Danish hospital. A total of 1909 employees from all job groups and all departments were included. Response rate was 65.3%. The overall frequency of self-reported hand eczema within the past 12 months was 23%. Divided into job groups, the frequencies varied from 8% to 32% and were significantly higher among assistant nurses (32%), nurses (30%), and nursing aids (27%). For the individual departments, the hand eczema frequencies varied from 7% to 50%, with the highest frequencies reported at medical and surgical wards. Occupational risk factors for hand eczema such as use of protective gloves and hand washing were significantly more frequent among respondents with hand eczema within the past year, which suggests a potential for prevention through workplace interventions. In conclusion, high frequencies of hand eczema were observed among assistant nurses, nurses, and nursing aids. Hand eczema was more frequent among women and in the younger age groups.

Effect of aloe-vera impregnated gloves on hand hygiene attitudes of health care workers

Following standard precautions and hand hygiene guidelines is important to health care workers and the patients they serve. The purpose of this study was to determine the effect of aloe-vera impregnated gloves on attitudes about hand hygiene among many health care workers and perceived sense of skin condition.

Occupational skin diseases in cleaning and kitchen employees: Course and quality of life after measures of secondary individual prevention

BACKGROUND

Cleaning and kitchen employees have an increased risk of suffering from occupational dermatoses. Prevention including improving individual skin care and skin protection behavior, health education, optimizing diagnostics and therapy as well as avoidance of occupational skin disease (BK 5101) is important.

PATIENTS AND METHODS

Participants in the courses were patients suspected of having an occupational skin disease. Besides socio-demographic and disease-related data, health-related quality of life (QL) was measured using the SF-36 and Skindex-29. One year later all participants were interviewed by telephone about the course of their skin disease.

RESULTS

Out of 212 participants, 84.0 % were female. The mean age was 41.6 (SD = 10.8) years.168 patients (79.2 %) suffered from hand dermatitis,with irritant contact dermatitis being the predominant diagnosis (46.2 %,n = 98). One year later 65.4 % (n = 85) of the patients interviewed still suffered from hand dermatitis.9.2 % (n = 12) had meanwhile quit their job due to the skin disease. QL was impaired in all age groups being lower with increasing age of the patients.

CONCLUSIONS

The follow-up confirmed the positive impact of the skin protection courses on patients' skin disease and well-being. Occupational skin diseases impair health-related quality of life in these professions but disease severity does not seem to play a key role.

How irritant is alcohol?

BACKGROUND

Alcohol-based hand rubs are used worldwide to prevent transmission of nosocomial pathogens.

OBJECTIVES

To investigate skin irritation caused by alcohols alone and in combination with detergent washing.

METHODS

Single and repetitive patch testing with 60-100% alcohols [ethanol, 1-propanol, 2-propanol (synonyms: isopropyl alcohol, isopropanol)], a positive control [0.5% sodium lauryl sulphate (SLS)] and negative controls (empty chamber and water) were performed. Wash tests were performed with 80% ethanol and 0.5% SLS on the forearms with each agent alone and with both agents in a tandem design. Skin hydration, erythema and barrier disruption [measured as transepidermal water loss (TEWL)] were evaluated (always 15 volunteers).

RESULTS

We found no significant change in skin barrier or erythema induced by the alcohols in the patch tests, whereas skin hydration decreased significantly. Application of alcohols to previously irritated skin did not show a stronger skin barrier disruption than application of SLS alone. Wash tests demonstrated that alcohol application caused significantly less skin irritation than washing with a detergent (TEWL, P < 0.001; skin hydration, P < 0.05; erythema, P < 0.05). Even on previously irritated skin, ethanol did not enhance irritation. By contrast, a protective effect of ethanol used after skin washing was observed (TEWL, P < 0.05; skin hydration, P < 0.05; erythema, P < 0.05).

CONCLUSIONS

Alcohol-based hand rubs cause less skin irritation than hand washing and are therefore preferred for hand hygiene from the dermatological point of view. An alcohol-based hand rub may even decrease rather than increase skin irritation after a hand wash due to a mechanical partial elimination of the detergent.

Health education about occupational allergies and dermatoses for adolescents

BACKGROUND

Occupational dermatoses and allergies are frequent and often affect individuals with atopic dermatitis. Our aim was to inform adolescents about potentially dangerous occupations, risk groups and preventive measures before they started apprenticeships in order to minimize the risk of occupational allergies or skin diseases.

METHODS

1015 high-school students were instructed by two dermatologists/ allergists (Heidelberg) and a teacher (Potsdam) in a 90-minute instructional unit. This included the exemplification of occupational skin hazards and allergies, the identification of at-risk persons, and application of preventive measures. A questionnaire was filled in by the students prior to and at least two weeks after the training.

RESULTS

In both regions, the students showed an increase in knowledge after the training, which was statistically significant higher in the Heidelberg region (6.6 points on average vs.4.4 points). 76% of students termed the subject matter as "important", and 67% rated the teaching unit as "very good" or "good".

CONCLUSIONS

We demonstrate that students who have not yet chosen a career are highly interested in this subject, that the developed instructional unit is widely accepted, and that it leads to an increase in knowledge. Therefore we suggest nation-wide implementation of this primary prevention measure in high-schools.

Contact allergy to propolis in beekeepers

BACKGROUND

Some toothpastes, cosmetics and ointments contain propolis, a bee product, and it is increasingly popular as a dietary supplement. Although propolis is known to cause contact allergy, there have been no studies of the prevalence of this.

OBJECTIVES

This study aimed to determine the prevalence of contact allergy to propolis in beekeepers and any relationship between propolis allergy and environmental and physical and mental health characteristics in this group.

SUBJECTS AND METHODS

A specially developed instrument which included a validated questionnaire on emotional stability was included in the issues of three German beekeeping journals sent to subscribers in a number of regions (potential readership 35,000). A reference group also completed questionnaire.

RESULTS

1051 questionnaires were returned and 37 cases of allergic reactions to propolis were reported (3.6%). Only 10 of the 37 (27%) beekeepers had recognised the allergy before participating in this study. Propolis contact allergy was significantly associated with lung diseases and other allergic reactions. Only some affected beekeepers protected their hands more while working with bees and showed significantly greater emotional instability than those not sensitised to propolis.

CONCLUSIONS

Contact allergy to propolis is common among beekeepers, but they do not seem to recognise the problem or protect themselves properly.

Protection from physical noxae

Protection from physical noxae must include multiple approaches; physical irritant contact dermatitis develops most likely when the cumulative exposure to several physical factors, such as climatic environmental conditions and friction, pressure or occlusion is given. The additive effect of these conditions, frequently found in modern working environments, not only provokes barrier disturbances, but also inflammatory reactions of the deeper layers of the skin. This review reflects on some examples of occupational physical irritant contact dermatitis (PICD) and the current understanding of its possible pathomechanism. On the one hand, the literature reveals epidemiological studies and case reports and on the other hand murine studies. The combination of both views may permit new insights into the pathogenic mechanisms of PICD and its prevention.

Protection from combination exposure

In the workplace, repeated skin exposure to a combination of irritants either simultaneously or one after the other is frequent. Therefore, assessing the efficacy of skin protection products only against single irritants is far from the daily life situation. We studied the interaction of irritants in a tandem repeated irritation test (TRIT). Shortly, healthy volunteers are exposed repeatedly to different irritants, and the skin reactions are assessed by visual scoring, transepidermal water loss, chromametry and skin capacitance. Using this model, a potentiation of irritation could be shown for several combinations of irritants, such as sodium lauryl sulfate (SLS) and toluene, SLS and mechanical stress, and SLS and hot airflow. The TRIT has been successfully used to prove the efficacy of a protective cream against a tandem application of 0.5% SLS and undiluted toluene. This test has great potential for the evaluation of skin care products to prevent irritant contact dermatitis.

OEESC-2005--summing up on the theme irritants and wet work

The aim of this paper was to summarize the presentations and discussions on the theme Irritants and Wet Work at the second conference on Occupational and Environmental Exposures of Skin to Chemicals held in Stockholm June 2005 (OEESC-2005) to bring the focus points to a broader group of professionals and stimulate further discussions. Occupational skin diseases are common diseases with a huge potential for prevention. The risk factors are mostly well known, and the ongoing high occurrence of occupational skin diseases may be seen as a paradox problem. Although all mechanisms involved in occupational skin diseases are not shown throughout, much is known. The existing knowledge justifies the relevance of reducing exposure and introducing prevention programmes. The questions identified for further research included an internationally agreed-upon definition of wet work; better methods to assess the exposure to wet work; the effect of combined exposure to water and water-soluble irritants; the importance of wet work with frequent/short wet-dry cycles versus working longer periods with wet hands; testing skin protection and skin care products; long-term skin effects from alcohol-based hand disinfectants; workplace testing of evidence-based prevention programmes in prospective randomized, controlled intervention studies.

Disabling work-related persistent photosensitivity following photoallergic contact dermatitis from chlorpromazine and olaquindox in a pig breeder

The use of veterinary medicines and medicated feed has a potential for the exposure of agricultural workers to pharmaceuticals with phototoxic and photoallergic side-effects. We present a 67-year-old self-employed farmer and pig breeder with a 22-year history of severe persistent photosensitivity following photoallergic contact dermatitis due to direct occupational dermal and airborne contact to chlorpromazine (sedative) and olaquindox (antibiotic and animal growth promoter, AGP). His first dermatitis symptoms appeared at the age of 45 when the pig breeding was intensified. He showed erythematous, scaly, and pruritic plaques localized symmetrically on the sun-exposed backs of his hands, fingers, and forearms, spreading to his face and other sun-exposed body sites. Without protective measures, he injected the animals with chlorpromazine. Besides, for several years he mixed by hand a powder containing olaquindox into the pigs' dry food. Epicutaneous and photo-patch tests showed positive reactions to promethazine, chlorpromazine, and olaquindox. In spite of the complete avoidance of the identified photoallergens for several years, his life is still extremely disabled due to the persistent photosensitivity. Our case report stresses the observation that olaquindox and chlorpromazine as phototoxic agents and photoallergens are capable of inducing a persistent and severe photosensitivity for many years, even after termination of exposure. Although the use of phenothiazine derivates and APGs for animals has meanwhile been banned in the European Union (EU), AGPs are still widely used in Asia. Physicians, especially occupational physicians, should be still aware of these phototoxic and photoallergic agents to reduce the burden of skin disease at work.

Skin protection for hairdressers

The application of protective creams in the hairdressing trade forms part of a complex concept for the prevention of occupational skin disorders. To date, no comparative controlled intervention studies have been carried out using different skin-protective creams. Previously published skin protection plans concerning barrier creams for the hairdressing trade are fairly general or rudimentary, reflecting our still limited knowledge on the subject. Bioengineering studies have even demonstrated a paradoxical effect of a certain skin-protective foam designed for hairdressers. Regarding other barrier creams, a certain protective effect could however be shown in studies concerning exposure to wetness and detergents. Pre-exposition skin protection seems to be of particular relevance. Thus, in principle, the regular application of adequate skin protection creams can be recommended in the hairdressing trade, although the protective effect should not be overvalued.

Skin protection training. The route to practical applications

A skin protection cream can only provide effective protection at exposed workplaces if it is applied sufficiently and without gaps. This is sometimes difficult to achieve. Various studies have shown that success in the primary, secondary and tertiary prevention of occupational skin diseases is possible with intervention measures which include skin protection training. However, knowledge alone does not automatically lead to a change of attitudes, and this in turn may not automatically lead to a change of behaviour. The generation of health protection behaviour is in fact a very complex process. This complexity, together with the various intervention time points (primary, secondary or tertiary prevention) and the target groups should be taken into account when deciding the goals, contents and methods of skin protection training as well as the selection of the trainer. Typical goals, contents and methods are given for practical training which allow 'learning with head, heart and hand'.

[Contact dermatitis in Dakar]

Because of the widespread repartition of allergens, allergic contact dermatitis is the most common inflammatory skin disease. It's the best model of dilated hypersensibility mediated by T lymphocytes cells. Atopic dermatitis and irritative dermatitis are to be distinguished to contact dermatitis. The aetiological diagnosis is the most important step of management of patients with that disease because it's the best way to avoid recurrences. The identification of cause is based on aetiological interrogatory and epicutaneous tests with 23 allergens completed with personnel products and specialised tests. Contact dermatitis can be classified according to results of aetiological management. In occupational contact dermatitis, contact dermatitis due to drugs, to metals, cosmetics, clothes and accessory and proteins. Management of patients with contact dermatitis is based on individual eviction, protection, cosmetovigilance, declaration of occupational dermatosis and allergovigilance.

Protection from irritants

Contact dermatitis is a common skin disease in the workplace and at home. The theoretically optimal way to minimize this problem is to use skin protection products such as barrier creams and moisturizers. Numerous ingredients have been formulated into the skin protection products in the marketplace. However, the US Food and Drug Administration only issued 13 skin protectants for over-the-counter products. Definition, reasons, mechanism of action and duration, application methods as well as efficacy of using skin protection products are extensively reviewed in this article. We conclude that the use of skin protection products may help people to reduce the intensity of skin irritations caused by irritants at home and at the workplace. We should remind the public not to use them as a primary protection against high-risk substances such as corrosive agents. Additionally, careful selection of appropriate skin protection products in the specific situations/environments is suggested.

Intervention implementation research: an exploratory study of reduction strategies for occupational contact dermatitis in the printing industry

BACKGROUND

Occupational dermatitis is a problem in the printing industry but can be avoided through adequate protective measures. Research into intervention implementation is fundamental to the success of a formal intervention effectiveness trial.

OBJECTIVES

The preliminary testing of four risk reduction strategies for occupationally caused dermatitis, which represent a range of approaches and cost implications.

PATIENTS/METHODS

The strategies, the provision of (i) skin checks plus treatment advice; provision of (ii) gloves of the correct type/size plus use of an after-work cream; provision of (iii) information highlighting the problem of occupational dermatitis and (iv) development of a best practice skin care policy, were evaluated over 3 months in two non-randomly selected companies. A post-intervention evaluation into the effectiveness and efficacy of the intervention was also carried out.

RESULTS AND CONCLUSIONS

All interventions were found to be acceptable to some extent. No single intervention appeared to be completely effective. The most practical intervention appeared to be the regular use of gloves of the correct type and size. This preliminary intervention study has demonstrated an improvement in the skin condition of workers examined and points towards the need for further testing of risk reduction strategies for the prevention of dermatitis in the printing industry on a much larger scale.

Protection from occupational allergens

Occupational skin disease (OSD) is an important and costly problem within occupational medicine. Ten to 15% of all occupational illness is caused by skin disease with contact dermatitis being the cause of up to 95% of all OSD. While irritant contact dermatitis is the most frequent cause of OSD, allergic contact dermatitis (ACD) is an important cause of chronic skin disease. In this chapter, various methods of protecting a worker from work-related allergy, including immediate and delayed-type hypersensitivities, are considered and reviewed. Concepts such as elimination of harmful exposures and allergen identification are considered. Personal protective equipment is an important component of prevention, including barrier creams, gloves and protective clothing. Methods for preventing allergy are discussed including prevention of sensitization, prevention of skin barrier breakdown, postexposure skin care and the role of educational programs. Protecting a worker from initial sensitization is the primary goal in prevention, but this is challenging considering the small amounts of an allergen needed to initiate and potentiate dermatitis. Patients diagnosed as having ACD can have symptoms that are more persistent, despite accurate diagnosis and therapy. With the high prevalence of contact dermatitis in the occupational setting, prevention is a key to healthy skin.

Skin protection in the healthcare setting

Professions of the healthcare setting are at high risk for occupational skin diseases. Irritant and allergic contact dermatitis of the hands frequently occurs, whereas contact urticaria and hospital-acquired infections are less common. Wet work and irritant exposure are frequent due to hand hygiene which is indispensable with regard to prevention of crossinfections. In the healthcare setting, protection gloves are frequently used alternating with protection creams. Since the use of occlusive protection gloves has adversary effects on the skin barrier, use times have to be limited. Furthermore, a 3-step concept consisting of skin protection before work, cleaning and skin care after work is one of the generally recommended measures to prevent occupational contact dermatitis. Recently, educational programmes for skin protection as measure of primary, secondary and tertiary prevention of occupational skin diseases have been effectively introduced in the healthcare setting. The effectiveness of skin care programmes is based on 3 factors: the effectiveness of the products used, the frequency of the application and, finally, the effectiveness of the education (reduction of exposure to skin-damaging substances). For the identification of contact allergens in healthcare workers with hand dermatitis, supplementary work-specific series as well as substances used at work should be patch-tested in addition to the standard series.

[Evaluating efficiency of individual skin protective means in exposure to nickel compounds]

Evaluating efficiency of individual skin protective means, the author used complex of clinical and laboratory methods with consideration of etiopathogenetic mechanism underlying occupational allergic dermatosis.

Skin protection in the food industry

In food occupations, like in many other skin risk occupations, the regular use of personal protection equipment, i.e. of skin protection ointments and protective gloves, is recommended as well as regular skin care for the prevention of occupational hand dermatitis. We investigated the uptake and maintenance of different prevention strategies (instructions for skin protection and skin care, prevocational skin hardening with UV light) in food occupations and their efficacy in the primary prevention of vocationally caused hand dermatitis. We could show that the acceptance and regular use of skin protection and care measures could be significantly increased by theoretical and practical instructions in food industry trainees. The highest acceptance was seen with skin protection ointment (100%) and skin care (90%). Protective gloves (43.3%) were used to a lesser extent. The hand dermatitis point prevalence in the groups after 6 months was 13.3% (skin protection), 19.4% (UV hardening) and 29.1% (controls). These clinical trends were supported by statistically significant differences in the basal TEWL values. Adequate skin protection and regular skin care seem to be promising for the prevention of occupationally caused hand dermatitis. The experimental approach using UV hardening prevocationally did not fulfil the expectations.