Diver's hand: a skin disorder common in occupational saturation diving

The Dermatology of Recreational Scuba Diving: A Narrative Review

Scuba diving is a popular watersport in the United States, with over 9 million certified divers. This activity uses specialized equipment that enables swimmers to explore deeper into the ocean for a more extended period than free diving. This popularity has led to the development of diving medicine, a multidisciplinary field that includes dermatologic management. An extensive literature review was conducted on PubMed and Google Scholar, using key search terms related to diving and dermatology to compile relevant peer-reviewed articles. This review examines the dermatological impacts of recreational and commercial diving. We explore hyperbaric oxygen therapy, its effects on the skin, and its potential benefits in wound healing. Furthermore, we present how environmental factors such as ultraviolet (UV) exposure and marine water toxins may increase skin cancer risk. We also discuss the risk of direct injury and envenomation from marine organisms and the risk of bacterial wound infections from different pathogens in marine water. We also reviewed the cutaneous manifestations of decompression sickness. As more people engage in recreational and commercial diving for extended periods, further research on potential dermatological implications is needed. Dermatologists could provide counseling on the use of sun-protective clothing and sunscreen to minimize cancer risk from UV exposure, on self-cleaning wounds to minimize infection risk from marine pathogens and identifying cutaneous infections, signs of decompression sickness, and methods of treating and preventing marine envenomation and bites.

Marine and Other Aquatic Dermatoses

Occupational and recreational aquatic activity predisposes our population to a wide variety of dermatoses. Sunburn, urticaria, jellyfish stings, and contact dermatitis to rubber equipment are common allergies that are encountered in the aquatic environment. Among the infections, tinea versicolor, intertrigo, and verruca vulgaris are widespread. Swimmer's itch may occur due to skin penetration by schistosome cercariae, while free-floating nematocysts of marine coelenterates may precipitate seabather's eruption. "Suit squeeze" due to cutaneous barotrauma and lymphoedematous peau d'orange due to decompression are rare, described entities. This review serves as a ready reckoner for Indian dermatologists and medical practitioners to identify and manage these conditions.

Up-Regulation of Antioxidant Proteins in the Plasma Proteome during Saturation Diving: Unique Coincidence under Hypobaric Hypoxia

Saturation diving (SD) is one of the safest techniques for tolerating hyperbaric conditions for long durations. However, the changes in the human plasma protein profile that occur during SD are unknown. To identify differential protein expression during or after SD, 65 blood samples from 15 healthy Japanese men trained in SD were analyzed by two-dimensional fluorescence difference gel electrophoresis. The expression of two proteins, one 32.4 kDa with an isoelectric point (pI) of 5.8 and the other 44.8 kDa with pI 4.0, were elevated during SD to 60, 100, and 200 meters sea water (msw). The expression of these proteins returned to pre-diving level when the SD training was completed. The two proteins were identified using in-gel digestion and mass spectrometric analysis; the 32.4 kDa protein was transthyretin and the 44.8 kDa protein was alpha-1-acid glycoprotein 1. Oxidation was detected at methionine 13 of transthyretin and at methionine 129 of alpha-1-acid glycoprotein 1 by tandem mass spectrometry. Moreover, haptoglobin was up-regulated during the decompression phase of 200 msw. These plasma proteins up-regulated during SD have a common function as anti-oxidants. This suggests that by coordinating their biological effects, these proteins activate a defense mechanism to counteract the effects of hyperbaric-hyperoxic conditions during SD.

Saturation diving; physiology and pathophysiology

In saturation diving, divers stay under pressure until most of their tissues are saturated with breathing gas. Divers spend a long time in isolation exposed to increased partial pressure of oxygen, potentially toxic gases, bacteria, and bubble formation during decompression combined with shift work and long periods of relative inactivity. Hyperoxia may lead to the production of reactive oxygen species (ROS) that interact with cell structures, causing damage to proteins, lipids, and nucleic acid. Vascular gas-bubble formation and hyperoxia may lead to dysfunction of the endothelium. The antioxidant status of the diver is an important mechanism in the protection against injury and is influenced both by diet and genetic factors. The factors mentioned above may lead to production of heat shock proteins (HSP) that also may have a negative effect on endothelial function. On the other hand, there is a great deal of evidence that HSPs may also have a "conditioning" effect, thus protecting against injury. As people age, their ability to produce antioxidants decreases. We do not currently know the capacity for antioxidant defense, but it is reasonable to assume that it has a limit. Many studies have linked ROS to disease states such as cancer, insulin resistance, diabetes mellitus, cardiovascular diseases, and atherosclerosis as well as to old age. However, ROS are also involved in a number of protective mechanisms, for instance immune defense, antibacterial action, vascular tone, and signal transduction. Low-grade oxidative stress can increase antioxidant production. While under pressure, divers change depth frequently. After such changes and at the end of the dive, divers must follow procedures to decompress safely. Decompression sickness (DCS) used to be one of the major causes of injury in saturation diving. Improved decompression procedures have significantly reduced the number of reported incidents; however, data indicate considerable underreporting of injuries. Furthermore, divers who are required to return to the surface quickly are under higher risk of serious injury as no adequate decompression procedures for such situations are available. Decompression also leads to the production of endothelial microparticles that may reduce endothelial function. As good endothelial function is a documented indicator of health that can be influenced by regular exercise, regular physical exercise is recommended for saturation divers. Nowadays, saturation diving is a reasonably safe and well controlled method for working under water. Until now, no long-term impact on health due to diving has been documented. However, we still have limited knowledge about the pathophysiologic mechanisms involved. In particular we know little about the effect of long exposure to hyperoxia and microparticles on the endothelium.

Aquatic sports dematoses. Part 2 - in the water: saltwater dermatoses

The second part of this three-part series on water-related dermatoses will discuss dermatologic conditions seen in athletes exposed to saltwater. The vast majority of the following dermatoses result from contact with organisms that inhabit saltwater, including bacteria, cnidarians, and echinoderms. This review also will include other dermatoses affecting saltwater athletes and should serve as a guide for dermatologists, sports medicine physicians, and other medical practitioners in recognition and treatment of these dermatoses.

The impact of environmental Pseudomonas aeruginosa genotypes on skin infections in occupational saturation diving systems

Skin infection caused by Pseudomonas aeruginosa is the most frequent health problem associated with occupational saturation diving on the Norwegian continental shelf. In the course of 14-y surveillance of infection and environmental control in occupational offshore saturation diving systems, a collection of approximately 1000 P. aeruginosa isolates has been amassed. Retrospective genomic analyses using restriction enzyme fragmentation and pulsed-field gel electrophoresis have identified 24 of 76 environmental P. aeruginosa genotypes as being of significance for single infections, outbreaks of infections and recurrent skin infections in occupational diving systems. In addition, these genomic analyses have made it possible to separate outbreaks of infection into outbreaks with 1 single genotype and clusters of infections where different genotypes are involved. We conclude that the established, assumed diver-to-diver contagion vector ought to be replaced by a environmental contagion vector as the most likely vector within these specific occupational environments. Furthermore, consecutive presence of the frequent environmental/infectious genotypes demands specific improvement of infection prevention and control in these systems.

Survival of infectious Pseudomonas aeruginosa genotypes in occupational saturation diving environment and the significance of these genotypes for recurrent skin infections

BACKGROUND

Occupational saturation divers suffer from various skin disorders, of which skin infections are the most serious and frequent. Pseudomonas aeruginosa is the microbe most often isolated.

METHODS

P. aeruginosa isolates from 292 skin infections in operational saturation divers and about 800 isolates from occupational saturation diving systems have been collected during the period 1986 to 1998. Genotyping of the isolates has been performed by using restriction enzyme fragmentation and pulsed field gel electrophoresis.

RESULTS

Four hundred and seventy-two P. aeruginosa isolates have been analyzed, of which 181 originate from skin infections in divers. Ninety-seven significantly different P. aeruginosa genotypes have been defined. Some of these genotypes are solely found from skin infections, some solely from the saturation environment and about 25% were found both from infections and from the saturation environment. Eight frequent infectious genotypes have been identified, and these are shown to be present over several years, both in infections and in the saturation environment.

CONCLUSIONS

The study suggests that skin infections in occupational saturation divers are commonly caused by environmental strains.

Identification of infectious Pseudomonas aeruginosa strains in an occupational saturation diving environment

OBJECTIVES

Occupational saturation divers have various skin disorders, of which skin infections are the most serious and frequent. Pseudomonas aeruginosa is the microbe most often isolated from skin infections in divers. The purpose of the present work was (a) to report the occurrence of P aeruginosa in skin infections in operational saturation diving in the North Sea from 1987 to 1995; (b) to report the environmental occurrence of P aeruginosa in saturation diving systems, and finally (c) to identify possible relations between infection related to strains of P aeruginosa and environmental isolates of the microbe.

RESULTS

During the period 1987-95, P aeruginosa was isolated from 257 skin infections in operational saturation divers. Most of the isolates related to infection by P aeruginosa show a unique growth inhibition pattern towards the normal skin flora, and the serotype pattern of P aeruginosa from skin infections is limited compared with similar infections in non-divers. In a mini-epidemiological study on board one diving vessel during one operational diving period, five significantly different DNA fragment profiles were found among the 12 isolates related to infection by P aeruginosa obtained from the saturation system. In two cases the infectious genotypes were detected in the fresh water for the saturation chambers weeks before the arrival of the infected diver.

CONCLUSIONS

The most commonly used epidemiological marker for P aeruginosa world wide, also used in earlier studies, is serotyping, but with pulsed field gel electrophoresis (PFGE) miniepidemiology it was shown to be insufficient for epidemiological purposes in saturation environments. PFGE analyses were shown to be superior both to antibacterial factor and to serotyping in epidemiological analyses of P aeruginosa infections in saturation diving.