Occupational Skin Disease C.J

Postgraduate Medical Journal (1989) 65, 374- 380 Postgrad Med J: first published as 10.1136/pgmj.65.764.374 on 1 June 1989. Downloaded from Occupational Medicine Occupational skin disease C.J. Stevenson Department ofOccupational Health and Hygiene, University ofNewcastle upon Tyne, Newcastle upon Tyne, UK. Introduction Diagnosis ofoccupational skin disease It is opportune to discuss occupational skin disorders Early diagnosis depends upon awareness of the pos- since recently a 'Save your Skin' Campaign has been sibility that a presenting dermatosis can be occupa- undertaken in the United Kingdom by the Employ- tional in origin. Sometimes the dermatosis is quite ment Advisory Service of the Health and Safety specific for exposure to a chemical, for example the Executive to increase the awareness of employers and lichenoid dermatosis seen in persons working with employees of the need to prevent skin problems in colour developers.3 Sometimes the dermatosis is a industry.' This was justified because skin disorders lookalike of a non-occupational disorder, such as caused by substances at work are the most common vitiligo, and sometimes we are faced with contact occupational health problem. dermatitis which could equally well be due to an Contact dermatitis (eczematous dermatitis of offending substance in the domestic environment. It is predominantly exogenous aetiology) is the com- important to realise that the environment is constantly monest form of occupational skin disease. However, changing and new processes are being introduced. For other occupational skin disorders occur, often presen- example, grass cutting by strimmers is now known to ting to physicians of different disciplines, for example cause a distinctive phytophotodermatosis in some infectious conditions, occupational skin cancer, individuals.4 copyright. occupational vitiligo, vibration white finger. The pur- A high index ofsuspicion arises when multiple cases pose ofthis article is to outline the major occupational of similar dermatoses occur amongst workers. How- skin disorders and to give references to sources of ever, it is important to realise that once a process is information in greater depth. suspected as a cause of dermatitis individuals may Since 1986 certain skin diseases linked to specified present with their non-industrial skin complaints such types of work must be reported in the United King- as rosacea, acne, psoriasis and other common dom.2 These include chrome ulceration of the nose or disorders in the belief that they are work-related. throat, or of the skin of the hands or forearms, in http://pmj.bmj.com/ persons in work involving exposure to chromic acid or to any other chromium compound; folliculitis, acne, Sources ofinformation and skin cancer, in those whose work involves exposure to mineral oil, tar, pitch or arsenic; When a dermatosis occurs, information can usually be inflammation, ulceration or malignant disease of the obtained from the employers through health and skin is also reportable in those working with ionizing safety leaflets concerning their products. Further radiation. In addition to these listed skin diseases, information may be obtained by reference to the on September 24, 2021 by guest. Protected anthrax is reportable whatever the person's occupa- Employment Medical Advisory Service of the Health tion and vibration white finger is reportable in those and Safety Executive. A general textbook such as exposed to a specified list oftools or processes in which Hunter's Diseases ofOccupations5can be helpful but in vibration or percussive features occur. It is of interest greater depth, Occupational Skin Disease by Robert that the most common dermatosis, contact dermatitis, Adams,6 Contact Dermatitis by Alexander Fisher7 and is not a reportable disease under the present regula- Contact Dermatitis by Etain Cronin8 are firmly esta- tions. blished sources of reference. The journal Contact Dermatitis9 is a valuable source of current contribu- tions to the literature. In the majority ofcases referral to Correspondence: C.J. Stevenson, M.D., F.R.C.P., a consultant dermatologist is advisable. Firstly, non- M.F.O.M., 16 Kingsland, Jesmond, Newcastle upon Tyne, occupational dermatoses can be excluded and UK. secondly, in the case of contact dermatitis, investiga- Accepted: 15 November 1988 tion by patch testing is likely to be required and can A) The Fellowship of Postgraduate Medicine, 1989 OCCUPATIONAL SKIN DISEASE 375 Postgrad Med J: first published as 10.1136/pgmj.65.764.374 on 1 June 1989. Downloaded from only be done efficiently in a clinic organized for this butchers, 4 different types ofHPV virus were involved. purpose. The dermatologist will probably need in Bacterial infection of the skin with haemolytic many cases to visit the workplace to see the process for streptococcus occurs in the slaughterhouse industry. It himself. is also important to realise that anthrax still occurs, although very rarely in Europe, in those handling imported meat, hides or wool. Presentation is with Non-eczematous dermatitis multiple pustules on the exposed parts of the skin followed by constitutional symptoms 3 or 4 days later. Animalparasites Erysipeloid due to infection with Erysipelothrix insidiosa is seen following scratches in fishermen and Animal parasites as a cause ofdermatoses in industry butchers. Typically about 3 days after infection a are frequently overlooked. Fleas can present with sharply demarcated purplish erythema develops, papular urticaria or even bullae in susceptible individ- usually on a finger, and spreads to the adjacent hand uals; mites typically occur in grain and may affect and can be associated with small vesicles. A minority poultry workers. Scabies is a particular hazard of patients have fever and feel unwell. Sometimes a amongst nurses and care attendants. In geriatric and chronic form can occur. The condition is responsive to psychiatric institutions some patients have a low penicillin. threshold to itching and develop an atypical crusted Folliculitis progressing to pustule formation can form of scabies which is not clinically recognized and occur from Pseudomonas aeruginosa amongst divers these highly infested individuals can transfer the and others wearing wet suits and can also afflict those acarus to the attendant staff. sharing whirlpools and swimming baths. Some occupations demand that the worker lives in Persons working with tropical fish can acquire an the tropics where infestations with parasites in the infection due to Mycobacterium marinum. Known as environment may be acquired, such as leishmaniasis swimming-pool granuloma or fish tank granuloma, seen in troops in South America and bizarre eruptions the histology is tuberculoid. The incubation period is such as larva migrans. ofthe order of 3 weeks and a typical lesion is a nodule present often on the back of the hands and gradually Dermatoses due to micro-organisms forming a superficial ulcer or pustule. The lesion can copyright. resemble an abscess. Regional adenitis is minimal. The Orfis caused by a pox virus which can be identified by condition responds to a combination ofcurettage and electron microscopy ofscrapings from the lesion. This treatment for 6 weeks with co-trimoxazole, or with appears about 5 days after exposure to the virus as a rifampicin if response to treatment is slow. The firm, reddish-blue papule later becoming a haemorr- infection is often misdiagnosed and the occupation of hagic pustule, with a depressed umbilicated centre. the individual is a pointer to the correct diagnosis. The lesion may be associated with lymphangitis and in Amongst farmers, infection with Trichophyton ver- some cases with the appearance of a widespread rash rucosum from cattle can give rise to severe ringworm http://pmj.bmj.com/ of the erytheme multiforme type. Orf particularly lesions or to a carbuncle-like lesion on the scalp known occurs at the lambing season, when the infection is as kerion. The source ofinfection is not normally from acquired from lambs particularly those requiring the animals themselves, but more commonly from hand-feeding or dosing. Treatment is to control posts, gates and other surfaces against which the -secondary infection. animals have rubbed. Cows suffer mild infections of the mouth and sometimes of the teats due to the parapox virus which Occupational vitiligo can cause milker's nodules on the hands of attendant on September 24, 2021 by guest. Protected 'workers. The lesions are less acute than those of orf, Depigmentation of the skin can result from exposure but may be followed after an interval ofabout 10 days to certain substituted phenols and catechols.'2 The 'by a papulovesicular eruption mainly on the upper depigmentation can be confined to the source of skin limbs. Electron microscopy of biopsy fragments is contact, for example in shoemakers handling an diagnostic. adhesive containing paratertiary-butyl-phenol, or the Virus warts, common in the population, are much condition may be symmetrical and clinically identical more prevalent amongst meat handlers'° and amongst with naturally occurring vitiligo and indistinguishable workers in modem poultry packing stations." Impor- both histologically and on electron microscopy. Such 'tant factors in the latter appear to be prolonged cases are due to the absorption of a chemical through exposure to cold and the occurrence ofminor trauma the skin or by inhalation. to the skin from scratches and maceration. The The condition is well recorded, but owing to its infecting virus is always ofthe human papilloma virus resemblance to natural vitiligo outbreaks of (HPV) type. In one investigation amongst a group of chemically-induced vitiligo have been missed on 376 C.J. STEVENSON Postgrad Med J: first published as 10.1136/pgmj.65.764.374 on 1 June 1989. Downloaded from several occasions.'3 If a person presents with vitiligo on the cheeks, forehead, neck and behind the ears, has and there are other cases in the working environment, been reported due to chlorinated naphthalenes and, it is necessary to screen the workforce with Wood's more recently, chlorinated biphenyls used in the lamp, since cases can be detected before they are electrical industry.

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