Occupational Skin Disease W.F. PEATE, M.D., M.P.H., University of Arizona College of Medicine, Tucson, Arizona Contact dermatitis, the most common occupational skin disease, is characterized by clearly demarcated areas of rash at sites of exposure. The rash improves on removal of O A patient informa- the offending agent. In allergic contact dermatitis, even minute exposures to antigenic tion handout on work-related skin substances can lead to a skin rash. Common sensitizing agents include nickel and mem- problems, written by bers of the Rhus genus (e.g., poison ivy, poison oak). Severe skin irritants tend to cause the author of this immediate red blisters or burns, whereas weaker irritants produce eczematous skin article, is provided on changes over time. An occupational cause should be suspected when rash occurs in page 1039. areas that are in contact with oil, grease, or other substances. Direct skin testing (patch or scratch) or radioallergosorbent testing may help to identify a specific trigger. Skin cancer can have an occupational link in workers with prolonged exposure to sunlight and certain chemicals, although it can take decades for lesions to develop. In workers with occupational skin disease, workplace changes and protective measures are impor- tant to prevent future exposure. (Am Fam Physician 2002;66:1025-32,1039-40. Copy- right© 2002 American Academy of Family Physicians.) ork-related skin diseases relationship between the skin condition (i.e., account for approximately onset, improvement, and recurrence) and the 50 percent of occupa- work exposure, including the effects of time off tional illnesses and are and return to work. An in-depth occupational responsible for an esti- history should cover the following points: Wmated 25 percent of all lost workdays. These 1. General work conditions (e.g., heat, dermatoses are often underreported because humidity) and specific activities in the their association with the workplace is not patient’s present job that involve skin contact recognized.1 with potential hazards. Note that Material Occupational skin diseases affect workers of Safety Data Sheets are more informative for all ages in a wide variety of work settings. large acute exposures than for the low-level Industries in which workers are at highest risk chronic exposures that are so common with include manufacturing, food production, skin conditions. construction, machine tool operation, print- 2. Physical, chemical, and biologic agents ing, metal plating, leather work, engine ser- (chemical and trade names) to which the vice, and forestry.2,3 patient is or may be exposed. 3. Presence of skin diseases in fellow workers. General Principles of Diagnosis 4. Control measures to minimize or prevent Because of the prevalence of occupational exposure in the workplace, including personal exposures that can cause or exacerbate skin and occupational hygiene (e.g., handwashing disorders, it is advisable to screen all patients instructions and facilities, showers, laundry with skin disease for a work-related cause. If service) and the availability of gloves, aprons, occupational skin disease is suspected, ques- shields, and enclosures. tions should be asked about the exact time 5. Compensation the patient received for skin disease in a previous job. 6. Other exposures, including soaps, deter- Work-related skin diseases account for approximately gents, household cleaning agents, materials used in hobbies (e.g., resins, paints, solvents), 50 percent of occupational illnesses and are responsible and topical medications, especially those con- for an estimated 25 percent of all lost workdays. taining sensitizing agents such as neomycin (e.g., Neosporin). SEPTEMBER 15, 2002 / VOLUME 66, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1025 The depth of questioning should reflect sures can almost always provide some relief, the morphologic presentation of the skin but cure depends on identification of the disorder. The physician should look for offending agent and cessation of exposure. eczema, hives, asthma, hay fever, clothing or food allergy, psoriasis, acne, oily skin, mil- ACUTE DERMATITIS iaria (i.e., “prickly heat,”with many tiny vesi- Wet Dressings. Absorbent material (e.g., cot- cles near openings of sweat and sebaceous ton dressings) moistened with cool water or glands), contact allergies (e.g., reactions to Burow’s solution (aluminum acetate diluted metal objects, cosmetics, home cleansers), 1:40 in water) should be applied to the fungal infections (e.g., athlete’s foot, ring- affected area four to six times a day. The effects worm), family history of atopy or psoriasis, of this treatment include bacteriostasis, gentle and systematic diseases that may have skin debridement, debris removal, and evaporative manifestations (e.g., diabetes mellitus, cooling (which lessens pruritus). peripheral vascular disease). Steroids. Topical steroids have no effect on The history of the illness and the occupa- acute vesicular reactions, but they may be tional history may reveal a close association applied once vesicles have resolved. Systematic between the skin condition and a specific steroid therapy is indicated when lesions are work exposure known to produce such skin widespread, vesicular, and edematous or bul- effects. The appearance of the condition may lous. Short courses of prednisone, in a dosage also suggest the cause. For example, a glove- of 40 to 60 mg per day for five to seven days, pattern distribution of vesicular lesions on the are usually satisfactory and do not require hands strongly indicates a contact dermatitis. tapering. Secondary infections should be It is not unusual to discover an underlying treated. Systemic steroids should be used cau- skin disease that is exacerbated by work tiously in patients with diabetes mellitus, psy- exposures. However, multiple occupational chotic disorders, uncontrolled hypertension, and nonoccupational exposures may be or infections such as tuberculosis or herpes. identified, no clear time relationship between Systemic Antihistamines. Diphenhydramine the skin lesions and the work history may be (e.g., Benadryl), in a dosage of 25 to 50 mg found, or the skin lesions may be difficult to three or four times daily, or hydroxyzine classify. hydrochloride (Atarax), in a dosage of 25 mg three or four times daily, provides an antipru- General Principles of Treatment ritic effect. Because of the sedating effects of For therapeutic purposes, contact dermati- these drugs, patients should be advised against tis can be classified as acute (weepy, edema- operating machinery or vehicles. Doxepin tous, vesicular, blistered) or chronic (dry, (Sinequan), in a dosage of one to three 10-mg cracked, scaly, thickened). Therapeutic mea- capsules taken at night as needed, is effective, but patients should be monitored for anti- cholinergic effects. A 5 percent doxepin cream (Zonalon) is also effective. Topical antihista- The Author mines should be avoided because of their W.F. PEATE, M.D., M.P.H., is associate professor of clinical family and community med- potential sensitizing action. icine and director of occupational health/campus health at the University of Arizona College of Medicine, Tucson. Dr. Peate graduated from Dartmouth Medical School, CHRONIC DERMATITIS Hanover, N.H., and completed a master of public health degree at Harvard University, Boston. Emollients. Topical agents such as petrola- tum (Vaseline) provide an occlusive film over Address correspondence to W.F. Peate, M.D., M.P.H., University of Arizona College of Medicine, Department of Family and Community Medicine, 1435 N. Fremont, Tucson, inflamed skin, decrease fissuring, and reduce AZ 85719 (e-mail: [email protected]). Reprints are not available from the author. evaporation. Emollients are most effective 1026 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 6 / SEPTEMBER 15, 2002 Occupational Skin Disease when they are applied after skin has been soaked or washed in water. In acute contact dermatitis, the skin is usually blistered Topical Steroids. These agents reduce inflam- and weepy. Chronic dermatitis typically leads to dry, scaly, mation and associated pruritus. Topical thickened skin. steroids should be applied no more than twice a day; more frequent use provides no advantage and may induce tachyphylaxis. Treatment with higher potency fluorinated steroids, such as CONTROL MEASURES 0.05 percent fluocinonide (Lidex), in contrast As long as proper protective measures are in to mid-potency 0.1 percent triamcinolone ace- place, workers with irritant or even allergic tonide (Kenalog), is indicated in patients with contact dermatitis often can remain on the job. more persistent dermatitis or chronic dermati- However, ordinary protective measures may be tis affecting the hands. Occlusion with plastic inadequate for some workers with allergic con- wrap or plastic gloves enhances absorption. tact dermatitis. It may be necessary to recom- Fluorinated steroids should not be used around mend that these persons be given a different the eyes, on the face, or in the groin area job or moved to another workstation. because of their long-term effects, which Many dermatoses can be prevented by include the development of striae. improved worker and workplace cleanliness. Workers should be counseled about personal General Principles of Prevention hygiene, and management personnel should and Control be advised about proper handwashing agents. Most occupational skin diseases can be Contact with organic solvents (e.g., mineral prevented.