Occupational Dermatoses Program for Physicians

Occupational Dermatoses Program for Physicians

114 slides and narrative with an additional 26 slides on case studies

Endorsed by The American Academy of Dermatology and The American Academy of Occupational Medicine

Prepared originally in 1981 by:
Edward Shmunes, M.D.
Marcus M. Key, M.D.
James B. Lucas, M.D.
James S. Taylor, M.D.

Technical review:
Robert M. Adams, M.D.
Donald J. Birmingham, M.D.
Loren L. Hatch, D.O., Ph.D.

Statistical Slides and Script were Updated by:
Boris D. Lushniak, M.D., MPH in 1998, 2000, and 2001
Supplemental slides on Occupational Dermatology Case Studies were added in February, 2000 (Courtesy of Capt. James W. Steger, M.D., USN and Dirk M. Elston, MC, USA) and April 2001 (Courtesy of Susan Nedorost, M.D., Lakewood, OH.)

Please submit new case studies to: Boris D. Lushniak, M.D., MPH (NIOSH)

A Program for Physicians

Slides 1 to 5A

Slide 1 – NIOSH Introduction

Slide 2 – Occupational Dermatoses Title

Slide 3 – Statistics

Specific national occupational disease and illness data are available from the U.S. Bureau of Labor Statistics (BLS). The BLS conducts annual surveys of approximately 174,000 employers, selected to represent all private industries in the U.S. The goal is to ascertain the total numbers and incidence rates of occupational injuries and illnesses. The survey results are then projected to estimate the numbers and incidence rates of injuries and illnesses in the American working population. All occupational skin diseases or disorders, including occupational contact dermatitis (OCD), are tabulated in this survey. Information about OCD in particular can be extrapolated from the BLS tabulations (e.g., OCD constitutes 90-95% of all occupational skin diseases; irritant contact dermatitis constitutes approximately 80% of OCD). BLS data are limited in that they exclude self-employed individuals, small farms, and government agencies; depend on misinterpretable definitions of reportable occupational injuries and illnesses; rely to a large extent on employees reporting conditions to the employer; and do not provide information on the etiology of the skin disease. BLS data show that skin diseases accounted for a consistent 30-45% of all cases of occupational illnesses through the mid 1980’s. A decline in this rate since 1986 may be partially related to an increase in the diagnosis of disorders associated with repeated trauma. In 1999, of over 372,000 occupational illnesses reported, 12% were skin diseases/disorders, making skin diseases the most common non-trauma related occupational illness.

Slide 4 – Total Cases

In 1993, BLS data estimated 60,200 cases of occupational skin diseases or disorders in the U.S. workforce. However, because of BLS survey limitations, it has been estimated that the number of actual occupational skin diseases may be on the order of 10-50 times higher than reported by the BLS. This would potentially raise the number of occupational skin disease cases to between one-half and 3 million per year.

Slide 5 – Incidence

BLS data showed an annual incidence rate of 76 cases per 100,000 workers in 1993. Over the years there have been changes in the number of cases and incidence of occupational skin diseases. The downtrend seen into the mid-1980’s may be attributable to several factors: changes in industry and industrial practices, increased awareness and preventive measures, possible under-reporting, under-recognition, and misclassification.

Slide 5A – Changes in Incidence (1993 – 1999)

From 1993 to 1999 there have been further changes in the number of cases, incidence and proportion of occupational skin diseases. In 1999 BLS data showed 44,600 total cases of occupational skin diseases/disorders, or an incidence of 49 cases per 100,000. In 1999, 12% of all occupational illnesses reported were skin diseases/disorders.

Slides 6 to 10

Slide 6 – High Risk Industries

Total numbers and incidence rates of occupational dermatologic conditions by major industry division are shown for 1999. The greatest number of cases of occupational skin diseases is seen in manufacturing but the highest incidence rate is seen in agriculture / forestry / fishing.

Slide 7 – Work Time Lost

In 1993, 21% of all occupational skin diseases registered in the BLS survey resulted in days away from work (DAFW) with a median 3 DAFW. Over 17% of cases had over 11 DAFW.

Slide 8 – Costs

The economic impact of a disease can be measured by the direct costs of medical care and workers’ compensation (WC) or disability payments, and the indirect costs associated with lost workdays and loss of productivity. An analysis of 1984 U.S. occupational skin disease data estimated annual medical costs of over $4.7 million ($67 per case) and WC claim awards of over $6.3 million ($1590 per case). Based upon this data, the estimated annual indirect cost of lost productivity due to occupational skin diseases in 1984 was $11 million ($700 per case). In 1984 the estimated annual direct and indirect costs exceeded $22 million. However, considering that the actual annual incidence figures may be 10-50 times greater than reported in the BLS data, the total annual cost of occupational skin diseases may range from $222 million to $1 billion. These estimates do not include costs of occupational retraining or costs attributable to the effects on the quality of life.

Slide 9 – Large Plant

It is interesting to note that only 1/3 of America’s work force is employed in large plants like this one where there is greater likelihood of a comprehensive occupational health program. Some of these programs, however, are more safety oriented and may not be designed to include prevention of skin disease.

Slide 10 – Small Plant

The remaining 2/3 of the workers are employed in small plants that usually have fewer than 500 workers. It is here that the occupational skin disease rate tends to be highest because they lack comprehensive health care programs.

Slides 11 to 15

Slide 11 – Skin Cross Section

As the skin meets the occupational environment, special anatomic and biochemical characteristics determine its vulnerabilities and consequent pathologic patterns of response. This cross-section illustrates the complex anatomy of the skin. The three main areas are the epidermis, the dermis and the subcutaneous tissue.

Slide 12 – Skin Cross-section, epidermis

The epidermis consists of three important layers: the outer keratin or stratum corneum composed of fibrous nonviable cells; a layer of living epidermal cells or stratum spinosum; and the basal or germinative layer. The reproductive or basal layer gives rise to living epidermal cells by division of the cells within the basal layer. Located also within the basal layer are the dendritic cells (melanocytes) which manufacture the protective pigment, melanin. The epidermal cells possess a high metabolic rate and gradually move upward to transform into anuclear keratinized cells which are flat, compact and dehydrated. This tough stratum corneum imparts the major barrier function to skin. If it is removed, damaged or becomes overhydrated, permeability is increased.

There are no blood vessels in the epidermis; nutrition diffuses outward from the rich blood supply of the dermis. The epidermis contains the orifices of three main types of skin appendages: the pilosebaceous units, the eccrine sweat glands and the apocrine sweat glands. The secretory portion and most of the ducts of these appendages are in the dermis.

Slide 13 – Skin cross-section, dermis

The dermis is much thicker than the epidermis, much less cellular and consequently has a lower metabolic rate. It is richly supplied with specialized nerve endings, blood and lymphatic vessels, and adnexal structures. The fibroblasts of the dermis produce ground substance, collagen and elastic fibers. The histiocytes or macrophages of the dermis are the scavengers of the skin.

Slide 14 – Skin cross-section, subcutaneous tissue

The subcutaneous tissue lies beneath the dermis. It is mainly composed of lobules of fat separated by collagen bundles and traversed by larger blood and lymphatic vessels and nerves.

Slide 15 – Routes of entry

External substances can interact with the skin in three ways:
(1) They can interact with the cells directly;
(2) they can penetrate the interstices of the cells;
(3) or they can gain entrance through the pilosebaceous and sweat gland orifices.
A number of chemical agents can be absorbed percutaneously to contribute to systemic toxicity with or without direct effect on the skin, such as organophosphates, carbon disulfide and methyl butyl ketone

Slides 16 to 20

Slide 16 – Pilosebaceous Unit

The pilosebaceous unit can be responsible for early penetration of substances through the skin before diffusion via the transepidermal route reaches its peak. The sebaceous glands are particularly vulnerable to external contactants that have a lipid affinity.

Slide 17 – Morphologic Correlations

There are a number of common clinical patterns which arise when certain target areas of the skin are affected by various environmental chemicals and physical agents. These morphologic patterns sometimes provide a clue to the etiologic agents involved.

Slide 18 – Contact Dermatitis, Acute

This arm shows a painful, acute contact dermatitis form exposure to the strong irritant, ethylene oxide. The arm is markedly swollen and shows an acute vesiculo-bullous dermatitis. A similar pattern may be seen on the basis of contact allergy.

Slide 19 – Contact Dermatitis, Subacute

This patient developed a bilateral and symmetric sub-acute dermatitis from the rubber accelerator, mercaptoben zothiazole, which was leached from the rubber portion of his work shoe as a result of sweating. In this case there is some edema and erythema with an eczematous eruption.

Slide 20 – Contact Dermatitis, Chronic

The hands, wrists and forearms are the most frequent sites of involvement in cases of industrial contact dermatitis. The hands and wrists of this worker with a chronic dermatitis show the effect of long term exposure to a solvent, in this case kerosene, which was used for cleaning the skin. The skin markedly thickened, hyperpigmented, dry and fissured, itching is usually a major symptom.

Slides 21 to 25

Slide 21 – Occupational Acne. Acute, Oil Folliculitis

Occupational acne is most commonly seen in workers exposed to insoluble cutting oils in the machine tool trades or in mechanics exposed to grease and lubricating oils. This worker developed folliculitis, sometimes called oil boils or acne, with multiple comedones and pustules on his arms and other covered areas of his body as a result of prolonged contact with oil. The lesions almost never develop from bacteria present in the oils.

Slide 22 – Oil Folliculitis Chronic, Chloracne

Chlordane is an extremely refractory type of acne caused by certain halogenated aromatic chemicals and can be certain halogenated aromatic chemicals and can be accompanied by systemic toxicity. It represents one of the most sensitive indicators of biologic response to these chemicals. Chloracne in this herbicide production worker involved almost every follicular orifice on his face and neck with comedones, papules and cyst like lesions.

Slide 23 – Depigmentation

The hands of this hospital maintenance worker are depigmented form contact with a phenolic germicidal detergent. Irritation or sensitization to the chemical is not a prerequisite for the pigment loss to occur. This loss of pigment may be permanent.

Slide 24 – Granuloma

Granulomas represent a focal, chronic inflammatory reaction. These granulomas were produced by beryllium and are considered to be on a allergic basis. Non-allergic granulomas are more common and represent the skin’s response to inoculated or implanted foreign materials such as wooden splinters, plant spines and silica.

Slide 25 – Eccrine

Miliaria represents blockage of the eccrine sweat ducts and may occur in workers who perspire excessively. In this case of miliaria rubra of prickly heat, the blockage site is the granular cell layer of the epidermis. When more than 30% of the skin surface is affected, an individual may develop thermoregulatory disorders such as heat exhaustion.

Slides 26 to 30

Slide 26 – Tumors

Skin tumors, such as this ulcerating squamous cell carcinoma most frequently arise after years of occupational exposure. Malignant tumors may represent to occupational carcinogens such as coal tar and physical agents such as sunlight. Skin cancer is the commonest form of cancer. The role played by occupational factors is frequently difficult to determine.

Slide 27 – Causes of occupational dermatoses

There are four direct causes of occupational dermatoses. In order of their importance and frequency they are: chemical, mechanical, physical and biological.

Slide 28 – Chemical

Many new chemicals capable of injuring the skin are introduced each year. Organic and inorganic chemicals encountered in industry, including tose in natural products, constitute a never-ending list of potential hazards. These chemicals may act as primary irritants or as allergic sensitizers.

Slide 29 – Primary skin irritant

A primary skin irritant is a substance that causes damage at the site of contact because of direct chemical or physical action on the skin. No antecedent immunologic sensitization is required. Some primary skin irritants are also allergens. Only about 20% of all occupational contact dermatitis results form sensitization, while about 80% is attributable to primary irritants.

Slide 30 – Absolute irritants

Absolute irritants include an extensive list of strong acids and basis, and reactive chemical compounds. Their potential hazard is usually recognized and skin problems arise most often as accidents or as a result of basic unfamiliarity or ignorance. These agents produce severe inflammation on the first exposure. The response may vary from redness to necrosis.

Slides 31 to 35

Slide 31 – Absolute irritant, buttocks

After this gardener accidently sprayed an insecticide-solvent mixture on his overalls, he failed to change immediately. It resulted in first and second degree chemical burns due to the strength of the irritant.

Slide 32 – Irritant alkali

This patient demonstrates the acute responses of the skin to another strong alkaline irritant. Many vesicles are present on the fingers.

Slide 33 – Marginal irritants

Marginal irritants require repeated contact to produce irritation. This man cleaned the rollers of an offset press with a sponge containing a solvent solution of potassium dichromate. Although he was not allergic to this chemical, it served as an irritant producing this degree of clinical dermatitis.

Slide 34 – Sources of Dermatitis

A study of the occupational contact dermatitis cases reported to workers’ compensation in Ohio from 1988-1992 shows chemical agents, as a group, to be the most frequent cause. Where available, reports from other states verify this conclusion. Extensive lists of irritants and allergens are available in reference books. The most frequent causes of irritant contact dermatitis include soaps/detergents, fiberglass and particulate dusts, food products, cleaning agents, solvents, plastics and resins, petroleum products and lubricants, metals, and machine oils and coolants. Causes of allergic contact dermatitis include metallic salts, organic dyes, plants, plastic resins, rubber additives, and germicides.

Slide 35 – Alkalies

Strong alkalies, such as sodium or potassium hydroxide, are potent keratin solvents and in high concentrations produce the type of caustic burns illustrated here. In lesser concentrations alkalies may produce less severe forms of skin damage. Weak alkaline solutions are particularly insidious marginal irritants and frequent repeated contact may compromise the skin’s barrier function resulting in excessive water loss and eczematous dermatitis.

Slides 36 to 40

Slide 36 – Solvent, poor work practice

Workers often acquire the bad habit of washing their hands in the same solvent used to clean tools and brushes contaminated with a resin and catalyst. This not only exposes the skin to the irritant action of the solvent, but also to the additive effects of the dissolved chemicals.

Slide 37 – Solvent, nummular eczema

Organic solvents are among the most frequently used substance in industry. Repeated skin contact leads to excessive dehydration of surface keratin and eczema. In this worker, who habitually used an organic solvent for cleansing purposes, the dermatitis appears as scattered, coin shaped concentrated patches, commonly referred to as “nummular” eczema.

Slide 38 – Chrome hole, fingers

Chromic acid and alkaline chromate are agents commonly encountered in the tanning and electroplating industries. These substances have a corrosive action when they enter the skin through a minor nick or break in the integument. This results in the formation of chronic, ulcerative lesions known as “chrome holes”. Typically, the lesions are found on fingers, hands or forearms. “Chrome holes” also occur on the dorsal surfaces of the feet when chrome salts have been allowed to permeate boots or shoes. The lesions are usually painless and persist for many months before spontaneously healing with permanent atrophic scar. Identical lesions can also be produced by arsenic or zinc salts but these are less frequently encountered.

Slide 39 – Chrome hole, nasal

When chrome containing materials are present as aerosols, painless ulceration of the nasal mucosa and septum may occur. With continues exposure permanent septal perforation eventually results, as in this young woman who was employed in chrome plating small appliance parts.

Slide 40 – Cutting fluids

Cutting fluids used in machine shops and metal working operations are common marginal or low grade irritants. Many operations require cutting fluids to cool the metal, to flush away cuttings and to prevent rust.

Slides 41 to 45

Slide 41 – Cutting fluids, eczematous

Since these fluids are generally alkaline, machinists whose hands and forearms undergo prolonged exposure to them, frequently develop dermatitis. While impermeable gloves might prevent this, they may interfere with dexterity and pose a safety hazard around moving machinery.

Slide 42 – Allergy mechanisms

Allergic contact dermatitis is an example of cell mediated immune response. The main cells responsible for the reaction in sensitized individuals are T-lymphocytes. The chemicals that sensitize easily are usually of low molecular weight, fat soluble and reactive with tissue proteins. The chemicals themselves are haptens, or incomplete antigens, forming conjugates with tissue proteins. The hapten-protein conjugates are the complete antigens.

For allergic contact dermatitis to occur, a period of 5-7 days of more is required for incubation. Thereafter, the sensitized lymphocytes react to further encounters with the sensitizing antigen within a period of 24 hours after contact.

Slide 43 – Major chemical allergens

In industry the most common causes of allergic contact dermatitis include epoxy resins, Rhus genus of plants, chromates, nickel and rubber chemicals.

Slide 44 – Epoxy resins

Although completely cured resins are inert, the production and application of epoxy resin system, with modifiers and hardeners that are frequently sensitizers, carry the risk of both primary irritant and allergic reactions. This dermatitis on the eyelids – a typical site for dermatitis from airborne substances – was caused by the vapor of an amine hardener used in curing epoxy resins.

Slide 45 – Other Resin System

This photo was removed due to privacy concerns.

This severe allergic contact dermatitis was due to a phenol-formaldehyde resin. These resins are used as bonding agents for foundry sand, electrical devices and in molded and cast plastic articles. They may also produce irritant reactions.

Slides 46 to 50

Slide 46 – Polyester

Allergic contact dermatitis can result from the process of mixing polyester resin and catalyst in body-fender work. The article being glued is fibrous glass.

Slide 47 – Chromium

In the United States, all cement contains chromium. Allergic sensitivity to dichromate is often associated with a cement dermatitis. In such cases the primary irritant action of the alkali plus the abrasive and hygroscopic properties of cement precede and favor sensitization by the chrome salts.

Slide 48 – Chemical Accelerators in Rubber

Allergic contact dermatitis due to rubber chmicals is fairly common in industry. Chemial accelerators that speed up the vulcanization raction and antixidants are the more frequent allergens. They present a potential hazard in finishing goods as well.

Slide 49 – Poison ivy

The Rhus genus of plants include poison ivy, poison oak and poison sumac. These plants pose a significant occupational problem to a diverse group of workers in highway maintenance, construction, utilities, agriculture and other occupations with outdoor exposures. Poison ivy dermatitis may even be acquired from the smoke burning plants.

Slide 50 – Airborne chrysanthemum

This photo was removed due to privacy concerns.

Repeated exposure to relatively small amounts of airborne allergens can cause dermatitis at points of contact, as shown in this example of dermatitis in a florist due to chrysanthemums. Airborne patterns tend to involve the wrinkles and folds of the exposed body areas. Many of the common allergens are pollens and dusts.

Slides 51 to 55

Slide 51 – Ultraviolet cured processes

The technology of using ultraviolet light sensitive chemicals is relatively new in creating templates for printing. It is also being used in the manufacture of certain printing inks and in dentistry. Various acrylates have been the sensitizers in this process.

Slide 52 – Photosensitivity

Many chemicals need light to activate and produce the complete phototoxin or photoallergen. The furocoumarins in limes produced this vesicular phototoxic dermatitis in a bartender who squeezed limes all afternoon in direct sun.

Slide 53 – Contact urticaria – Latex Rubber

Contact urticaria is an important manifestation of natural rubber latex allergy. Workers exposed to latex gloves and other products containing natural rubber latex may develop allergic reactions such as skin rashes; hives (contact urticaria); nasal eye or sinus symptoms; asthma; and (rarely) shock.

Slide 54 – Contact urticaria – Raw Fish

A person who developed immediate clinical contact urticaria demonstrates a positive provocative open epicutaneous patch test to fish. The observation time to read the test is shortly after application, as opposed to the two to four day interval between testing and reading in delayed hypersensitivity contact dermatitis.

Slide 55 – Tar and sunlight hyperpigmentation

This photo was removed due to privacy concerns.

Chronic exposure to tar and sunlight caused the marked hyperpigmentation in this Caucasian pipeline worker. The occupational photosensitizing chemicals most well the action spectrum lies in the long wave ultraviolet and visible light. Such derivatives include anthracene, phenanthrene, creosote and certain dyes. Coal tar products are used in roofing, pipeline and road construction, wood preservation and may other processes.

Slides 56 to 60

Slide 56 – Stained hands in foundry worker

Foundry workers using a no-bake sand binder with an oil base may develop an exogenous discoloration which is very difficult to remove. The binder not only binds sand to sand, but also binds dirt to skin.

Slide 57 – Pitch warts

Pitch warts represent a type of skin reaction to several chemicals that cause epidermal hyperplasia, which may be associated with tumor or cancer formation. Certain petroleum intermediates and products, retorted shale oil, coal liquification intermediates, a number of coal tar derivatives and arsenic can stimulate the epidermal cells to produce these effects.

Slide 58 – Mechanical

Second to chemicals in order of frequency and importance are the mechanical causes of occupational dermatoses. Friction produces calluses, blisters, abrasions and lichenification. Pressure causes bullae, skin atrophy and necrosis. Other trauma brings about the Koebner phenomenon in which a dermatosis localizes itself at the site of trauma.

Slide 59 – Callosities

Here you see calluses and fissures produced by repetitive hand motion and by the use of certain types of tools.

Slide 60 – Fibrous glass

Contact with fibrous glass, particularly of large fiber diameter, can produce itching, but lesions are seldom visible expect for secondary effects from rubbing or scratching. Commonly affected sites are flexural areas and where clothing is restrictive. In some individuals, especially those with dermographism, small erythematous papules may occur where the spicules have penetrated, as shown here.

Slides 61 to 65

Slide 61 – Leather buffer

Occupational marks or professional stigmata, such as these knuckle pads in a leather buffer, provide distinctive clues as to occupation, but seldom result in disability. Other examples are coal miner’s tattoos and violinist’s or fiddler’s neck.

Slide 62 – Chipper

High frequency pneumatic tools such as chippers, electrical tools, chain saws and grinders can produce Raynaud’s phenomenon or “vibration white fingers” among users. Redesign of these tools utilizing vibration dampers has been of some help in prevention.

Slide 63 – Painful white fingers

The hands are affected by paroxysmal attacks of numbness and blanching and pain of the fingers. This phenomenon may also be precipitated by exposure to cold. The initial pallor is succeeded by a slight hyperemia and in some cases by cyanosis. Gangrene and other degenerative bone changes may result.

Slide 64 – Physical Agents

Physical agents – heat, cold and radiation – are a third direct cause of occupational dermatoses. Heat accounts for burns, sweating, erythema and telangiectasia. Cold can bring on Raynaud’s disease, trench foot and frostbite. Radiation causes keratoses, sunburn, radiodermatitis, photosensitivites and skin cancers.

Slide 65 – Hot water burn

Hot water produced these first and second degree burns on the forearm of a kitchen worker. Immediate ice water immersion would have reduced the depth and extent of the burn.

Slides 66 to 70

Slide 66 – Electrical burn

Electrical burns may show erythema and bullae from the heat of arcing current or may be non-descript with severe internal damage between the points of contact and exit of the current.

Slide 67 – Frostbite

Frostbite, especially of the extremities, can be severe, with destruction of the skin and deeper tissues. Degrees of injury are graded according to the depth of tissue damage, similar to thermal burns.

Slide 68 – Immersion foot

Macerated skin of immersion foot, common among troops in Viet Nam, is also seen among workers wearing water soaked boots for extended periods of time. This variety of immersion foot caused by a species of Corynebacterium produces pitted keratolysis.

Slide 69 – Radiodermatitis

Numerous sources of ionizing radiation are encountered in industry. Gamma radiation and x-rays produce acute and chronic radiodermatitis as well as radiation sickness. Typical sequelae of radiation include atrophy, depigmentation, hyperpigmentation and telagiectasia – all visible here.

Slide 70 – Squamous cell epithelioma

Squamous cell skin cancer and basal cell skin cancers are common complications of chronic radiodermatitis. Occupations at risk include dentists, industrial radiographers, and x-ray diffraction technicians. These same tumors result from long term solar radiation.

Slides 71 to 75

Slide 71 – Biological

Biological agents act as the fourth direct cause of occupational dermatoses. Not only plants, insects and animals, but also microbiologic viruses, rickettsia, bacteria, fungi, protoza and other parasites attack the skin and sometimes produce systemic disease as well. All necessary precautions must be exercised whenever occupational exposure to these agents can occur.

Slide 72 – Anthrax

Cutaneous anthrax can be found in workers who handle animal products. In the United States, the most common cause is imported animal hair and raw wool contaminated with anthrax spores.

Slide 73 – Sporotrichosis

Fungi whose natural home is in the soil or in vegetation cause infections that may be occupational in origin. Sporotrichisis often develop after trauma break the skin, for example, when handling mine timbers, rose bushes, straw, sphagnum moss and other natural products. This florist represents a classic example of sporotrichosis, with nodules along the lymphatic vessels.

Slide 74 – Mycetoma

Other fungi causing mycetoma and chromoblastomycosis become implanted when workers lack proper shoes and other protective clothing. This mycetoma in an agricultural worker was caused by an actinomycete.

Slide 75 – T. Verrucosum

Zoophilic fungi characteristically produce inflammatory infections in man. This cattle rancher’s tinea corporis was due to Trichophyton verrucosum

Slides 76 to 80

Slide 76 – Herpetic fingers

Dentists, physicians and other health personnel may develop herpes simplex on their hands.

Slide 77 – M. marinum

This granulomatous infection in an employee of a tropical fish store was due to Mycobacterium marinum, which is usually acquired from an inoculation injury. It is also referred to as swimming pool granuloma.

Slide 78 – Milker’s nodule

Milker’s nodule is due to a viral infection which occurs on the udders of cows and can be transmitted to man. The lesions are nodular rather than vesicular and run a self-limiting course in several months.

Slide 79 – Orf

Orf, a viral dermatosis, is acquired from contact with infected sheep. While the hand are most often affected, the virus can be carried to other skin sites.

Slide 80 – Tick bite

Ticks present a considerable problem for outdoor workers in wooded areas. Because the initial bite is painless, the first sign may be itching at the site of the bite several days after.

Slides 81 to 85

Slide 81 – Tick bite reaction

This reaction is fairly typical and may persist for 1 to 2 weeks before subsiding. In addition some ticks are vectors for Rocky Mountain spotted fever and other rickettsial diseases.

Slide 82 – Nail disorder, traumatic

The spectrum of occupational dermatoses also includes work-related disorders of the hair and nails. Frequently these are the result of trauma, but may also include infections, inflammatory reactions and discoloration.

Slide 83 – Wet work, nails

Jobs that require repeated exposure to wet work frequently result in paronychial infections. These painful fingernail folds often harbor both

Slide 84 – Kerion

This farm worker developed a kerion of the scalp due to infection with Trichophyton verrucosum. The involved scalp has become boggy and edematous.

Slide 85 – Traumatic alopecia

Long hair presents a special hazard among machine tool operators; entanglement can result in avulsion and traumatic alopecia.

Slides 86 to 90

Slide 86 – Acroosteolysis, clinical

Acroosteolysis or shortening of the terminal digits, as the left thumb and right forefinger show here, has been observed among polyvinyl chloride reactor workers who enter vessels to chip away hardened resin. In addition to the acroosteolysis, Raynaud’s pnenomenon and scleroderma-like skin may occur as components of a triad.

Slide 87 – Acroosteolysis, x-rays

Early changes of acroosteolysis can be detected by x-ray. In this radiograph there is dissolution and fragmentation of the bone in several of the terminal phalanges.

Slide 88/89 – Drug interaction/Degreasers’ flush

This photo was removed due to privacy concerns.

Degreasers’ flush can occur in workers imbibing alcohol following industrial exposure to trichloroethylene (TCE) vapor. The subject shows the appearance of normal facial skin after exposure to trichloroethylene, and shortly after beginning to drink beer. Forty-four minutes later, the flush is very apparent. The dermal response of flush reaches maximum intensity 30 minutes after onset and fades within 60 minutes.

Slide 90 – Predisposing factors

In recognizing the clinical pattern of skin disease, it is always important to consider possible occupational etiology. This includes the employee, as well as the occupational setting. These factors include: race, sex, age, skin type, presence of other skin problems, history of allergies, cleanliness and seasonal variations.

Slides 91 to 95

Slide 91 – Women in industry

This photo was removed due to privacy concerns.

More than half of American women between the ages of 18 and 65 are now employed outside the home on a full or part-time basis. This trend continues to increase. Physiologically women tend to have drier skin and slightly higher pH than men which may result in a somewhat heightened susceptibility to skin irritants. In addition, women usually have a greater exposure to irritants within the home such as cleaners, soaps, detergents and waxes which may lower the threshold of skin irritation. The reported incidence of industrial dermatitis is slightly higher in women then men.

Slide 92 – Acne prone

Acne prone workers placed in environments in which there is contact with oils frequently have poral occlusion problems. Hot humid environments may also cause sufficient hydration and swelling of the skin to predispose to acne. This worker’s head was positioned in such a way as to constantly crease on side of his neck, causing recurrent deep lesions in that one location.

Slide 93 – Poor hygiene

Additional predisposing factors include poor hygiene, soiled clothing and lack of adequate washing facilities at the work site. Wearing soiled clothing in contact with the skin increases the likelihood of dermatoses.

Slide 94 – Copper smelter

Many workers, like this copper smelter, are exposed to intense heat, dust and fumes. They often develop intertriginous eruptions because of the prolonged sweating of body folds and creases.

Slide 95 – Axillary intertrigo

Axillary intertrigo is just one of the resulting changes that occur in workers who perpsire excessively and have hot work environments. A wet warm axilla can support the growth of many pathogenic bacteria, yeasts and fungi.

Slides 96 to 100

Slide 96 – Epoxy resin mixing, poor work practice

This photo was removed due to privacy concerns.

Poor work practices can be an overriding factor in causing occupational skin disease. Mixing epoxy resin paints in a closed space creates a potential hazard for vapor inhalation as well as skin contact.

Slide 97 – Atopic

Atopic individuals are predisposed to develop dermatitis from marginal irritants. These individuals usually have a personal or family history of hay fever, sinusitis, asthma or childhood eczema. Flares of atopic dermatitis are common in industrial environments that cause individual skin irritation. However, the atopic individual is not predisposed to allergic contact dermatitis.

Slide 98 – Work History

This photo was removed due to privacy concerns.

Obtaining a detailed history of work exposures as part of a medical record is essential in making a dignosis of occupational skin disease. Following a careful medical examination, there are a number of studies which may need to be done depending on the diagnosis in question.

Slide 99 – Diagnostic Studies

The studies may include:
(1) Microscopic scrapings of skin to detect yeasts, fungi, parasites and fibrous glass;
(2) Cultures;
(3) Patch tests to detect contact allergy;
(4) Skin biopsy.

Slide 100 – Patch test

A patch test is a bioassay for the definitive diagnosis of delayed hypersensitivity of the allergic contact type. The test is performed by applying a non-irritation concentration of the substance to unaffected skin for 48 hours. The test should not be performed unless one has had sufficient experience with this procedure as there are a number of possibilities for both false positive and false negative reactions. Diagnostic patch testing is not used for testing direct irritants. The key to interpreting patch test reactions is to determine the relevance of the reaction to the patient’s environment. Routine pre-placement patch testing is not recommended.

Slides 101 to 105

Slide 101 – Patch test, read

This illustration shows a positive patch test. When the patches are removed, at least 30 minutes should elapse before the test is read. Readings should be made at 48 and 72 hours and even later to detect delayed responses.

Slide 102 – Walk-through survey

This photo was removed due to privacy concerns.

Nothing can replace the first hand opportunity to examine the task and work environment. A walk-through survey may be the first step in understanding the overall picture by identifying potential hazards in the affected employee’s tasks or surroundings.

Slide 103 – Prevention

Prevention of occupational dermatoses can be accomplished by engineering controls, personal protective measures, proper work practices and administrative controls. These methods can be applied individually or minimize skin contact with potential irritants.

Slide 104 – Closed systems

Environmental controls and safety devices that require engineering can be introduced most easily when the plant is being built. Where possible, all potentially hazardous operations should be conducted in systems that are entirely closed. This oil refinery represents an industry using numerous closed systems.

Slide 105 – Ventilation

When processing cannot be entirely enclosed, it is usually possible to install local exhaust systems that collect irritant dust, vapors, fumes and mists. But extensive ventilation systems like this on can be very costly.

Slides 106 to 110

Slide 106 – Hood

Less elaborate devices can be used to control the workers’ environment. A hood can draw airborne contaminants away from the worker minimizing potential hazards.

Slide 107 – Proportional pump dispenser

An automatic proportional dispenser can be used to avoid contact with a primary irritant. Experience shows that small plants usually depend more upon less expensive personal hygiene measures than extensive environmental controls.

Slide 108 – Wash Basin

This photo was removed due to privacy concerns.

Workers should be furnished means of keeping clean at work if they are to reduce the amount of contact with harmful agents. Inconveniently located wash areas invite undesirable practices as washing with solvents, mineral oils or industrial detergents.

Slide 109 – Worker washing hands

This photo was removed due to privacy concerns.

Providing the right cleansers is also important. Powdered soap and waterless cleansers are popular because they remove greases, tars, paints and some plastics quite easily. But if such cleansers contain an excess of alkali or solvents, they can damage the skin.

Slide 110 – Protective gear

Personal protective equipment should be carefully matched to the job requirements. In a particularly hazardous environment, such as this chemical dump site, elaborate personal protective devices are necessary.

Slides 111 to 113

Slide 111 – Personal protective

Protective gear generally includes aprons, coveralls, caps and hairnets, smocks, sleeves, shoes and gloves. Synthetic rubber protects the hands against acids and alkalies; neoprene dipped cotton materials protect against most other liquid irritants.

Slide 112 – Barrier creams

Barrier creams designed for specific hazards also offer a certain amount of protection, but they should never be sustituted for special gear.

Slide 113 – Credits

Skin diseases of occupational origin outnumber all other work-incurred illnesses. Early all other work-incurred illnesses. Early recognition and preventive measures can effectively reduce the incidence of occupational dermatoses in the United States.

The following individuals and organizations have participated in the preparation of this program.

Kenneth Arndt, M..D.
Steven R. Cohen, M..D.
William L. Epstein, M.D.
Gerald A. Gellin, M.D.
Leon Goldman, M.D.
Jon M. Hanifin, M.D.
Stanford I. Lamberg, M.D.
William R. McWilliams, M.D.
Robert D. Pittekow, M.D.
Rufus C. Rucker, M.D.
Richard K. Scher, M.D.
Richard D. Stewart M.D.
Raymond R. Suskind, M.D.
Donald E. Wasserman, MSEE
Rex H. Wilson, M.D.
The Cleveland Clinic Foundation
New York University

Slides 114 to 118

Slide 114 and 115 – NBC Warfare Agent (Lewisite?)

SLIDE 114 - NBC Warfare Agent (Lewisite?)

SLIDE 115 - NBC Warfare Agent (Lewisite?)

This patient was seen several months after the Gulf War with recurrent blisters with minor rubbing and friction and spontaneously as well on the right wrist in a very localized area. During Desert Storm he was assigned as an NBC warfare specialist, and after finding some Iraqi chemical agents, he spilled them on himself while examining them. Although he was wearing full MOP gear, because of the heat, he had rolled up his sleeves while still wearing gloves. He decontaminated the chemical injury very quickly, but has continued to have recurrent blistering in the areas of original injury. This represents a case of dermatitis in loco minoris resistensia (dermatitis in an area of decreased local resistance due to previous injury to the skin). It was felt that the original chemical was Lewisite, or a Lewisite like agent.

Slide 116 – 118 – Irritant Contact Dermatitis from Fiber Glass

SLIDE 116 - Irritant Contact Dermatitis from Fiber Glass

SLIDE 117 - Irritant Contact Dermatitis from Fiber Glass

SLIDE 118 - Irritant Contact Dermatitis from Fiber Glass

These 3 slides of fiber glass dermatitis were from a young sailor who was removing fiber glass insulation from a USN ship (irritant contact dermatitis).

Slides 119 to 123

Slide 119 – Rhus Dermatitis

Recognition of basic morphologic patterns of skin eruptions is critical for accurate diagnosis of occupational skin disease. Acute allergic contact dermatitis is characterized by microvesicles. (Rhus Dermatitis)

Slide 120 – Positive Patch Test

A positive patch test reaction demonstrates the characteristic microvesicular morphology of acute contact dermatitis. Once an allergen has been identified, the patient must be provided with a list of possible sources of exposure to the allergen and alternatives that are free of the allergen. Many allergens have a complex array of cross reactions. The patient must be warned about these as well.

Slide 121 – Chromate Dermatitis

Chronic occupational contact dermatitis to chromates may remain microvesicular, or may evolve into a chronic lichenified dermatitis with accentuation of skin markings. This is true of many cases of chronic occupational contact dermatitis — microvesicles are still present histologically, but not apparent clinically.

Slide 122 – Phototoxic Reaction to Lime Juice

Phototoxic reactions appear as macular erythema. Phototoxic reactions to lime juice represent a common occupational hazard among bartenders.

Slide 123 – Ethylene Oxide Dermatitis

Irritant contact dermatitis (non-allergic) is characterized by erythema and unilocular bullae, resulting from epithelial necrosis. (Ethylene Oxide Dermatitis)

Slides 124 to 128

Slide 124 – Phytophotodermatitis

Plant dermatitis is common among landscapers, nurserymen and forestry workers. The morphologic pattern is helpful in determining the offending agent. Microvesicular dermatitis suggests allergic contact dermatitis, such as poison ivy dermatitis. Photodistributed or streaky macular erythema suggests a phytophotodermatitis, such as lime, fig or meadow parsnip dermatitis. Agave dermatitis is seen among landscapers who come in contact with the juice from the leaves of the agave plant. Agave dermatitis is an irritant contact dermatitis, resulting in varying degrees of epithelial and vascular necrosis. The vascular necrosis results in purpura.

Slide 125 – Allergic Plant Dermatitis

Patterns of distribution often predict the offending allergen in cases of allergic occupational dermatitis. Streaks of dermatitis suggest a point source of allergen. This is the typical pattern of allergic plant dermatitis.

Slide 126 – Poison Ivy Leaf

Many plants, such as poison ivy, do not release an allergen until the leaf is injured. The black resin visible on this poison ivy leaf results in a streak of dermatitis when an arm or leg moves past it.

Slide 127 – Allergic Shoe or Work Boot Dermatitis

Patches of dermatitis involving the dorsa of the feet generally represent allergic shoe or work boot den-natitis. Mercaptobenzothiazole is the most common allergen. The allergen is widely distributed in rubber and adhesives as well as cutting oils, antifreeze, detergents, flea powders and fungicides. The patient must be counseled about all sources of exposure.

Slide 128 – Work Boot Dermatitis on Ankles

Work boot dermatitis commonly involves the ankles. Other common sites of involvement are heel, toe and dorsum of foot. (Photo courtesy of MAJ Richard Vinson, MC USA).

Slides 129 to 135

Slide 129 – Shoe Dermatitis

Slide 130 – Clothing Dermatitis

Clothing dermatitis is commonly the result of permanent press finishes used in the manufacture of uniforms and other clothing items. Detergents and fabric softeners result in a similar pattern of dermatitis. The axillary vault is typically spared, with dermatitis involving the rim of the axilla.

Slide 131 – Elastic Dermatitis (allergy to bleached rubber)

Elastic dermatitis is commonly the result of allergy to bleached rubber. The offending allergen is formed by the interaction of chlorine bleach and a carba compound in the elastic. Non-chlorine bleach is safe, but all elastic garments bleached with chlorine bleach must be discarded.

Slide 132 – Contact Allergy to Computer Keyboard Wrist Rests

Contact allergy to computer keyboard wrist rests is generally an allergy to a thiuram accelerator used in manufacture of the synthetic neoprene rubber.

Slide 133 – Contact Urticaria Syndrome to Raw Fish

Most allergic contact dermatitis becomes evident 48 hours after contact with the offending allergen. Contact urticaria syndrome is an exception to this rule. Manifestations include immediate burning, itching, swelling or vesiculation. The reaction commonly occurs within minutes of exposure. Implicated allergens are generally proteins. This patient experienced immediate vesiculation when contacting proteins in raw fish.

Slide 134 – Raw Fish Reaction

Immediate reaction to epicutaneous patch test with raw fish. Cooking denatures the implicated proteins, therefore cooked fish did not evoke a reaction. Severe reactions may be associated with symptoms of anaphylaxis. Anaphylaxis may occur during testing, and the physician should be prepared to treat anaphylactic reactions.

Slide 135 – Cashew Nut

Cashew shell oil may contaminate processed cashew nuts and result in contact dermatitis. The oil is used to manufacture brake linings and clutch facings, and the finished products may remain allergenic.

Slides 136 to 139

Slide 136 – Dental Assistant (allergy to glutaraldehyde and neomycin)

Workers frequently develop a secondary contact allergy to topical products such as antibiotics that they use to treat their work-related dermatitis. This dental assistant with hand dermatitis was allergic to glutaraldehyde that she used to sterilize instruments, and to neomycin.

Slide 137 – Optician – non-dominant hand dermatitis (allergy to ethyl acrylate)

Dermatitis primarily on the non-dominant hand develops in workers who grip an object while performing a more delicate task, often with a tool, with the dominant hand. This right-handed optician recalled only after patch-testing positive to ethyl acrylate that he sometimes held heated acrylic frames in his left hand, which caused his dermatitis.

Slide 138 – Hair stylist (allergy to hair dye and permanent wave solution)

Slide 139 – Hair stylist (patch test sites)

SLIDE 139 - Hair stylist (allergy to hair dye and permanent wave solution)

This hair stylist with hand dermatitis was allergic to para-phenylenediamine (hair dye) and glyceryl monothioglycolate (permanent wave solution). The latter penetrates both vinyl and rubber gloves and allergy may be a cause of permanent disability.