Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):

Acta Dermatovenerol Croat 2007;15(3):191-198 REVIEW

Occupational Skin Diseases Caused by UV Radiation

Franjo Gruber, Vesna Peharda, Marija Kaštelan, Ines Brajac

University Department of and Venereology, Rijeka University Hospital Center, Rijeka, Croatia

Corresponding author: SUMMARY This overview highlights the risk of skin diseases arising Prof. Franjo Gruber, MD, PhD in workers exposed to radiation (UVR) at their workplace. There is a plethora of skin manifestations in outdoor workers such University Department of Dermatology and as seamen, fishermen, farmers after acute intense or long-term Venereology exposure to solar UVR, but some cutaneous diseases may also Rijeka University Hospital Center develop in indoor workers exposed to artificial sources. In recent years, investigations of the biological effects and damage caused Krešimirova 42 by UVB and UVA on the skin have improved our understanding of HR-51000 Rijeka the cellular and molecular mechanisms of , Croatia and other skin diseases caused by UVR exposure. The necessity of [email protected] primary prevention in workers exposed to UVR is emphasized.

Key words: ultraviolet radiation, outdoor work, indoor work Received: January 15, 2007 Accepted: June 14, 2007

INTRODUCTION Ultraviolet radiation (UVR) is a form of non- UVB rays make about 5% of all UVR reach- ionizing rays as part of the broad electromagnetic ing the earth as solar UVR of highest energy, and spectrum. UVR has greatest energy of all types of are mostly absorbed in the . Window optical radiation, and these rays can be reflected, glass filters out the major part of UVB. Biologi- scattered, transmitted or absorbed. These rays cally, they are most active in damaging the skin can be subdivided into three main bands: 320- and eyes. UVB exposure provokes vasodilatation 400 nm band designated as UVA or long-wave, with and , probably due to 290-320 nm band designated as UVB or medium the release of mediators such as prostaglandins, wave, and 200-290 nm band designated as UVC histamine and cytokines, e.g., IL-1, IL-6 and IL- or short-wave (1,2). Wavelengths below 200 nm 8 (5,6). Causing damage to nuclear DNA, they called vacuum UV are absorbed by the air, thus are mutagenic, immunosuppressive, and can in- being of no biological significance. The energy of duce premalignant lesions, non-melanoma skin each part of the radiation is inversely related to cancer, and have also been suggested to play a the wavelength. UVR makes up approximately role in causing melanoma. In the last decades, 5% of all rays emitted from the sun to the earth, ozone depletion in the stratosphere has led to an nevertheless, they have a large amount of energy increase in UVB at the ground level (7). UVA is and can affect the skin, eyes and immune system the predominant component of solar UVR (about considerably (3,4). 95%) that reaches the earth’s surface. The energy

ACTA DERMATOVENEROLOGICA CROATICA 191 Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):191-198

of these rays is relatively small, but they are less ers may cause major trouble and concern (11). affected by altitude and atmospheric conditions, The quantity of solar UVR that reaches the can penetrate deeply into the skin, and can cross earth depends on the season, time of the day, window glass and fabrics. They cause quick tan- latitude, altitude, surface reflection, ozone layer, ning and premature skin aging, and are involved and cloud cover (7). It is estimated that 5% to 10% in phototoxic and photoallergic reactions. Today, it of the population in Europe are working outdoor is confirmed that these rays can also be carcino- (12). Occupational photodermatoses occur mostly genic (5,7). in outdoor workers with fair complexion, i.e. with Solar UVC rays are completely filtered out by phototype I and II according to Fitzpatrick (13). the ozone layer in the stratosphere, 15-50 km Exposure to solar UVR in workers engaged in above the sea level (7,8). Terrestrial UVC rays can outdoor work characteristically provokes lesions cause erythema, are mutagenic and germicidal. in sun exposed areas: face, neck, décolletage, Visible light can also cause photodermatoses, and extensor surface of the upper limbs, partic- while infrared rays can contribute to chronic skin ularly forearms, and hands (14,15). Both acute damage and aging from UVA rays (5). and chronic effects of exposure to solar UVR are The effect of solar radiation or artificial UVR linked to DNA damage. Already 0.1-0.3 MED can can be beneficial as in case of vitamin D3pho- activate p53 and p21, and cause immunosuppres- tosynthesis, influencing our mood maybe by af- sion and apoptosis of , i.e. fecting the endogenous opioid system, and in the cells (3). Acute exposure to causes sun- treatment of diseases, or can cause unwanted burn, immediate and delayed tanning, immune and deleterious effects such as skin diseases, alteration, and participates in phototoxic and pho- eye diseases (keratoconjunctivitis, cataract, pin- toallergic reactions, whereas chronic exposure guecula, pterygium and tumors), and local and causes actinic keratoses, , immu- systemic immunosuppression (9,10). So, intense nosuppression, premature aging of the skin, and acute or chronic exposure to UVR of solar origin or malignant tumors of the skin such as basal cell from artificial sources may overcome the natural cancer, keratoacanthoma, squamous cell cancer, cutaneous photoprotection mechanisms (stratum melanoma, and probably Merkel cell carcinoma corneum, , urocanic acid, antioxidants, (16). Some workers exposed to UVR can rarely DNA repair) and cause occupational skin diseases develop diseases such as or poly- (7,9,10). We therefore thought it worthwhile to give morphous light eruption. a survey of occupational skin diseases caused by Photoaging (premature skin aging or extrinsic exposure to solar or artificial UVR in outdoor or aging) and skin cancer are steadily increasing in indoor workers. the population. This is so because people live lon- ger and due to depletion of the ozone layer in the stratosphere caused by the use of chlorofluoro- SKIN DISEASES DUE TO SOLAR EXPO- carbons. Photoaging is characterized by the de- SURE velopment of xerosis, coarseness, wrinkling, deep Occupational health risks like environmental furrows, yellow discoloration (), hazards can be physical, chemical, biological and irregular pigmentation (actinic , guttate hy- psychosocial. Among physical ones, the most im- pomelanosis), senile purpura, and telangiectasias portant is UVR exposure, and the biological effects in the sun exposed areas (17,18). The described depend on the quality (spectrum) and intensity of changes (dermatoheliosis) are caused by cumula- exposure (8). Despite their biological differences, tive exposure to UVR, particularly UVA. UVA in- both UVB and UVA can cause occupational skin duces the formation of diseases. Acute or chronic exposure to solar UVR (ROS) like , hydrogen peroxide, hy- is of significance in outdoor workers, and exposure droxyl radical and others, and so indirectly damag- to UVR from a wide variety of artificial sources in es DNA. ROS also cause lipid peroxidation. UVA indoor workers (9). The UVB and UVA radiation causes changes not only in the epidermis (pig- can cause skin alterations alone, act synergisti- mentation) but even in the dermis (degeneration cally or in combination with endogenous or exog- of and elastic fibers). Studies in animals enous substances (11). Some occupational skin and humans have shown that exposure of the skin diseases are of minor medical significance, e.g., to UVR provokes activation of transcription factors pigmentations, telangiectasias or other stigmata, (AP-1, NF-kB), which results in an increase of ma- which do not affect working capacity, whereas oth- trix metalloproteinases (MMPs) produced by kera-

192 ACTA DERMATOVENEROLOGICA CROATICA Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):191-198

tinocytes and fibroblasts, like collagenase (MMP- also on the time of the day, possible shade during 1), gelatinase (MMP-9) and stromelysin (MMP-3) the work, and clothing habits (24). (18,19). Recent in vitro and in vivo studies have Outdoor workers can develop photodamage demonstrated that UVR induces ROS, which also by contact with plants, coal tar derivatives, drugs, damage mitochondrial DNA. It is known that mito- dyes and exposure to sunlight; these interactions chondrial DNA has a reduced repair capacity, and are phototoxic and cause photoallergic reactions. so alteration in the mitochondria may contribute to Phototoxic reactions () are photoaging (20). more common and occur without involvement of Colloid pseudomilium, of Civatte, immune mechanisms (11,25). They are mostly and Favre-Racouchot syndrome characterized by caused by contact with plants that contain pho- the presence of brown-black papules and open tosensitizers such as furocoumarins. Furocou- comedones in periorbital region may also develop marins are tricyclic compounds that plants syn- occasionally in workers exposed to sunlight, most- thesize in defense from fungi, and can be linear ly in men. So, Cellini and Offidani found dermato- () or angular (angelicin and pimpinellin). sis in 2.5% of agricultural workers but not in the Their photoactivation leads to the formation of ad- control group (21). ducts with pyrimidine bases and consequential Frequently, photoaging, actinic keratoses and DNA damage and cross strand links. This leads skin cancers can be observed in outdoor workers to erythema, vesiculobullous lesions, burning, and such as seamen, fishermen, farmers, asphalters, can occur in farmers, florists, gardeners, horticul- roofers, horticultural workers, construction work- turists, botanists, grocery store workers, food han- ers, and others (8,9) (see Table 1). In some profes- dlers, and others (26). Most of the plants causing sions such as fishermen and seamen the quantity phototoxic reactions belong to the family Umbel- of UVR reaching the skin is increased not only by liferae () like (Apium graveolens), direct exposure to solar UVR but also by the rays (Pastinaca sativa), (Petroselinum reflected (5%-20%) from the sea (15). In addition, crispum), false bishop’s weed (), cow some reports point to the importance of sun expo- parsnip ( sphondylium) that causes sure as a health risk in professional cyclists, moun- trimmer , and angelica (27-29). Plants tain guides and policemen (22,23). So, Moehrle of other families can also cause phytophotoder- et al. demonstrated in mountain guides carrying matitis, e.g., figs ( carica), garden rue (Ruta dosimeters that the daily dose of UV exceeded the graveolens), and others (30). It is important to limits sixfold or more, which is suggestive of an differentiate this reaction from pseudophytopho- increased risk of skin tumors (23). Recent stud- todermatitis caused by contact with plant insecti- ies in gardeners demonstrated the dose of UVR cides and herbicides (31). In workers, the use of received to depend not only on sun exposure but certain drugs (sulphonamides, antidiabetics, thia-

Table 1. Outdoor workers potentially exposed to UV radiation

Fishermen Farmers Seamen Gardeners Watermen Green-keepers Lifeguards Horticultural workers Construction workers Oilfield workers Road workers Pipeline workers Brick masons Military personnel Postal carriers Ski instructors Railroad track workers Professional cyclists Policemen Surfers Outdoor maintenance workers Landscapers

Modified from Epstein JHet al. Occupational skin cancer. In: Adams RM, ed. Occupational skin diseases, 3rd ed. Philadelphia: Saunders; 1998.

ACTA DERMATOVENEROLOGICA CROATICA 193 Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):191-198

zides, nonsteroidal anti-inflammatory drugs, phen- electricians, sculptors, and others, who are not otiazines) or contact with oils and tars can also aware of all problems associated with this process induce sensitization to solar UVR (11,32). Photo- and so can be injured by UVR. toxic and photoallergic dermatitis can be induced UVR is used in sterilization of operating rooms, by airborne allergens and irritant substances in dermatologists use it in diagnosing and treatment the form of solid particles, gases or droplets (33). of numerous skin diseases, and pediatricians use Sun exposure probably also causes chronic phototherapy for neonatal hyperbilirubinemia. actinic dermatitis (actinic reticuloid), which devel- UVR is used in lighting offices too. Indoor UVR ops mostly on the face in older men working out- can cause lesions in dentists who use UVA for po- door while photoprotected sites as upper eyelids, lymerization of resins (42,43). UVR is used for cur- submental region and behind the ears are spared ing of printing inks, curing of paints, curing of met- (34). Exposure to sunlight in workers can also al decorating in packaging industry, inspection of worsen a pre-existing skin disease such as lupus printed circuit board in electronics industry, and by erythematosus, dermatomyositis, pityriasis rubra the staff of tanning pools (42) (Table 2). UVR lamps pilaris, Darier’s disease and rosacea (35). and transilluminators are used by many research laboratories for studies of photobiology (animal INDOOR WORK AND PHOTODAMAGE experiments), in photochemistry, genetics (visual- There are numerous sources that emit different ization of DNA and RNA) and molecular biology types of UVR, which are used for a wide range (visualization of subcellular structures), where re- of application at workplace. The potential risk of searchers or students are engaged (44,45). UVR indoor exposure to UVR is very high in welders, is used for identification of substances, analytical depending on the material being welded, and and diagnostic processes, or for polymerization of particularly when using electric arc welding. The chemicals in biochemical laboratories. In microbi- risk is diminished in workers using oxyacetylene ological laboratories UVC rays (germicidal lamps welding, laser welding, and electron beam welding with a peak around 260 nm) are employed for (36-38). In electric arc welding temperature can be sterilization of surfaces, liquids and spaces (42). very high (2000 °C and more), and according to Similar lamps are used to kill fly (electric fly kill- Wien's law the radiation peaks to short waves if ers) and for disinfection of water, milk, wine, beer, temperature increases. juices, and pools. Recently, 26 medical students suffered skin and eye injuries due to exposure to Non-welders in the vicinity of welding are also a malfunctioning germicidal lamp (46). From the exposed to high doses of UVR (39). The effects of above one can conclude that there is a necessity welding on the skin include erythema, small scars to prevent UVR exposure in workers. and keratoconjunctivitis on the eyes (arc eye); some studies have demonstrated an increase of Although numerous skin diseases can occur in eye cancer and melanoma in welders (40). In our workers exposed to UVR during outdoor or indoor region as in other maritime regions welding can work, as described above, the primary long-term pose a problem in ship building industry (41). risk of exposure to solar or artificial UV light, par- Sometimes welding is also used by mechanics, ticularly in fair-skinned people (melanocompro-

Table 2. Indoor workers potentially exposed to UV radiation Welders Printers Physicians Lithographes Nurses Painters Dentists Wood curers Cosmetologists Plastic workers Laboratory workers Food irradiation Plasma torch operators Kitchen workers Maintenance workers Pipecutters

Modified from Epstein JHet al. Occupational skin cancer. In: Adams RM, ed. Occupational skin diseases, 3rd ed. Philadelphia: Saunders, 1998.

194 ACTA DERMATOVENEROLOGICA CROATICA Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):191-198

mised, types I and II according to Fitzpatrick), is that 96% of skin cancers were caused by UV ex- the development of precancerous lesions, non- posure, so that outdoor work represents an impor- melanoma skin cancer and melanoma. As early tant factor in the development of skin tumors (61), as 1894, Unna described degenerative changes whereas in Finland and Sweden there was no as- in the epidermis and dermis, found in the sun sociation of outdoor work in agricultural workers, exposed area of the skin in seamen, and linked forestry workers and construction workers with these alterations with the development of cancer increased skin cancers (62,63). An explanation (47). In the same year, Enziere described cancer could be that in these countries cumulative expo- of the lower lip in peasants working outdoor, while sure is low because of the high latitude. Different being rare among town people (48). In 1928, Find- health systems and legislation across European lay first proved experimentally the development countries may also make the data difficult to com- of skin cancer in mice irradiated with UVR from pare (12). Data from Japan also show that cancer mercury arc (49). It was confirmed by the Argen- is increased in outdoor workers (64). tinian Roffo, who demonstrated that sunlight and Jakac, a pioneer in the study of professional UVR from artificial sources can induce skin cancer skin diseases in Croatia, clearly demonstrated the in rodents. He also demonstrated that the major relevance of solar exposure in the development carcinogen was UVB (50,51). Later investigations of skin cancer in sailors and fishermen, but also demonstrated that UVR induced mutation of the in construction workers, agricultural workers, and genetic material, i.e. DNA, directly on pyrimidine shipworkers. On their skin, he often observed cu- bases (thymine and cytosine) in particular forming tis nautae and cutis agricolae on their skin, which photoproducts that led to C-T or CC-TT transitions are not atrophia cutis senilis but degeneratio cutis (52), or indirectly by ROS, i.e. oxidation of the pu- climatica according to Kogoj (65). His study on the rine guanine (53). Most of these DNA damages epidemiology of skin cancer in Rijeka region from are quickly enzymatically corrected (nucleotide 1955 to 1959 showed that nearly 90% of male excision repair). These "signature mutations" are patients were outdoor workers, mostly fishermen present particularly in the suppressor genes such and sailors (32.9%), then farmers (29.2%), dock as p53 or PTCH. If not corrected, their protein workers (9.6%), building and construction work- product cannot control cell cycle properly, thus fa- ers (9.3%) and other outdoor workers (7.5%). In voring cell growth, proliferation and survival. More women, skin cancer developed most frequently in recently, Kripke and Fisher (54) and Kripke and peasants (34.4%) and housewives working in their Morison (55) demonstrated experimentally that vegetable gardens (23.1%). He had also found UV irradiation of rodents significantly depressed that cancer mostly developed in fair skinned work- their immune defense, thus allowing for carcino- ers, and proposed skin cancer as a professional genesis. These studies confirmed the clinical and disease (15,66,67). In more recent years, the epidemiological data that skin cancer develops af- prevalence of skin cancer in fishermen and sailors ter intensive and prolonged exposure to UVR, and is dropping (68,69); these recent data are proba- permitted better understanding of the cellular and bly associated with the lower number of workers in molecular mechanisms in photocarcinogenesis. these professions, and their later engagement in Numerous epidemiological, clinical, and exper- this kind of work. Fishermen now work mostly dur- imental studies assessed the importance of UVR ing the night, do not use tars to impregnate their exposure in the development of skin cancers and nets, and perhaps use . The high rate melanoma (56-58). Basal cell cancer seems to be of skin cancer in housewives can be explained by connected with cumulative sun exposure and also the fact that women frequently work outdoor in to intermittent exposure (on the trunk), while the their vegetable gardens or truck farms. Particular more aggressive squamous cell carcinoma cor- caution is needed in workers treated with immuno- relates better with lifelong cumulative exposure. suppressive drugs because they are at a high risk Melanoma seems to be associated with intense of cancer development (70). episodic, intermittent UVR exposure (56). Epide- In conclusion, UVR exposure at workplace can miological studies from Australia and USA suggest induce numerous different skin diseases and also the relevance of outdoor work for the development leads to precancerous lesions and malignant tu- of basalioma, squamous skin cancer and melano- mors. It is not easy to obtain verification that skin ma, and most of the workers also have evidence cancer is occupational because there is a long pe- of chronic actinic damage (56,59,60). Data from riod between the exposure and its development, Europe are variable; so, Cherry et al. found in UK and sometimes because the individuals had previ-

ACTA DERMATOVENEROLOGICA CROATICA 195 Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):191-198

ously worked in a tropical country (12). For this 14. Wolf A. Fotodermatoze (aktiničke dermatoze). reason, it is of paramount importance to recom- In: Jakac D, editor. Dermatologija i venerologi- mend effective primary prevention measures like ja. Beograd-Zagreb: Medicinska knjiga; 1981. legislation measures, education of the workers to p. 301. undertake appropriate protection measures, wear- 15. Jakac D. Importanza dei fattori climatici nella ing appropriate protective clothing, broad brimmed manifestazione degli epiteliomi cutanei nei ma- hats, eye protectors, and seek to work in shade. rinai e nei pescatori. Chron Derm 1971;2:43- The use of sunscreens may pose a problem be- 57. cause they frequently are not used appropriately 16. Honigsmann H, Diepgen TL. UV induced skin and sometimes can prolong the exposure. cancer. JDDG 2005;3(Suppl 2):26-31. 17. Matsamura Y, Ananthaswamy HN. Toxic effec- References ts of ultraviolet radiation on the skin. Toxicol 1. Coblentz WW, Stair R, Hogue JM. The spec- Appl Pharmacol 2004;195:298-308. tral erythemic reaction of the to 18. Berneburg M, Plettenberg H, Krutmann J. ultraviolet radiation. Proc Natl Acad Sci USA Photoaging of human skin. Photodermatol 1931;17:401-5. Photoimmunol Photomed 2000;16:239-44. 2. Matts PJ. Solar ultraviolet radiation: definition 19. Fisher GJ, Wang ZQ, Datta S, Varani J, Kang and terminology. Dermatol Clin 2006;24:1-8. S, Voorhees JJ. Pathophysiology of premature 3. ICNIRP. Guidelines on limits of exposure to skin aging induced by ultraviolet light. N Engl J ultraviolet radiation of wavelengths between Med 1997;337:1419-28. 180 nm and 400 nm (incoherent optical radia- 20. Berneburg M, Kamenisch Y, Krutmann J. tion ). Health Phys 2004;87:171-86. Repair of mitochondrial DNA in aging and 4. Longstreth J, de Gruijl FK, Kripke ML, Abseck carcinogenesis. Photochem Photobiol Sci S, Arnold F, Slaper HL, et al. Health risks. J 2006;5:190. Photochem Photobiol 1998;46:20-5. 21. Cellini A, Offidani A. An epidemiologic study 5. Gruber F, Peharda V, Brajac I. Influence of cli- on cutaneous diseases of agricultural workers matic factors on the skin. Labin 1999; Procee- authorized to use pesticides. Dermatology dings. pp. 234-40. 1994;189:129-32. 6. Clysdale GJ, Dandie GW, Muller HK. Ul- 22. Moehrle M, Heinrich L, Schmid A, Garbe C. traviolet light induced injury: immunologic Extreme UV exposure of professional cyclists. and imflammatory effects. Immunol Cell Biol Dermatologica 2000;201:44-5. 2001;79:547-68. 23. Moehrle M, Dennenmoser B, Garbe C. Con- 7. Guarrera M. Fotoprotezione: come, quando e tinuous long-term monitoring of UV radiation perché. G Ital Dermatol Venereol 2001;136:21- in professional mountain guides reveals extre- 38. mely high exposure. Int J Cancer 2003;103: 8. Diffey BL. Human exposure to solar ultravio- 775-8. let. J Cosmet Dermatol 2002;1:124-30. 24. Thieden E, Collins SM, Philipsen PA, Murphy 9. Škreb Y, Šarić M. The effects of ultraviolet ra- GM, Wulf HC. Ultraviolet exposure patterns of diation on occupationally exposed workers. Irish and Danish gardeners during work and Arh Hig Rada Toksikol 1983;34:275-86. leisure. Br J Dermatol 2005;153:795-801. 10. Nola I, Kotrulja L. Skin photodamage and life- 25. Kiec-Swierczynska M, Krecisz B. Photosen- time protection. Acta Dermatovenereol Croat sitivity induced skin disease. Med Pol 2001; 2003;11:32-40. 52:3-7. 11. Jakac D. Profesionalne dermatoze. In: Jakac 26. Berkley SE, Hightower AW, Beier RC, Fleming D, editor. Dermatologija i venerologija. Beo- DW, Brokopp CD, Ivie GW, et al. Dermatitis in grad-Zagreb: Medicinska knjiga; 1981. p. 198. grocery workers associated with high natural 12. Diepgen TL, Drexler H. Hautkrebs und Beruf- concentration of furocoumarins in celery. Ann serkrankungen. Hautarzt 2004;55:22-7. Intern Med 1986;105:351-5. 13. Fitzpatrick TB. The validity and practicality of 27. Maso MJ, Ruszkowski AM, Bauerle J, DeLeo sun reactive skin type I through VI. Arch Der- VA, Gasparoo FP. Celery phytophotodermati- matol 1988;124:869-71. tis in a chef. Arch Dermatol 1991;127:912-3.

196 ACTA DERMATOVENEROLOGICA CROATICA Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):191-198

28. Ippen H. Phytophotodermatitis caused by plant 45. Akbar-Khanzadeh F, Jahangir-Blourchian M. trimming (edger’s rash). Derm Beruf Umwelt Ultraviolet radiation exposure from UV-tran- 1989;38:190-2. silluminators. J Occup Environ Hyg 2005;2: 29. Milavec-Puretić V, Zečević J. Kontaktni alergij- 493-6. ski i nealergijski dermatitisi uzrokovanim bilj- 46. Trevisan A, Piovesan S, Leonardi A, Bertocco kama. Acta Dermatovenerol Iug 1983;10:25- M, Nocolosi P, Pellizzo MG, et al. Unusual 30. high exposure to ultraviolet-C radiation. Pho- 30. McGowern TW. Botanical briefs: The Fig-Fi- tochem Photobiol 2006;82:1077-9. cus carica. Cutis 2002;69:339-40. 47. Unna P. Histopathologie der Hautkrankheiten. 31. Stoner JG, Rasmussen JE. Plant dermatitis. J Berlin: Hirschwald, 1894. Am Acad Dermatol 1983;9:1-15. 48. Enziere JP. Du cancer des levres. Thesis. 32. Jeanmougin M. Exogenous Montpellier, 1894. reactions. 1993;30:9-13. 49. Findlay GM. Ultraviolet light and skin cancer. 33. Goosens A. Airborne dermatosis. Acta Derma- Lancet 1928;215:10715. tovenerol Croat 2006;14:153-5. 50. Roffo AH. Cancer et soleil. Carcinomes et sar- 34. Ferguson J, Ibbotson S. The idiopathic pho- comes provoques par l’action du soleil in toto. todermatoses. Semin Cutan Med Surg Bull Cancer 1934;23:590-616. 1999;18:257-73. 51. Roffo AH. Über die physikalische Aetiologie 35. Morison WL,Towne LE, Honig B. The photo- der Krebskrankheit. Strahlenther1939;66:328- aggravated dermatoses. In: Hawk JLM, editor. 50. Photodermatology. London: Arnold,1999:219- 52. Beukers R, Berends W. Isolation and identi- 60. fication of the irradiation product of thymine. 36. Tenkate TD. Optical hazards of welding arcs. Biochim Biophys Acta 1960;41:550-1. Rev Environ Health 1998;13:131-46. 53. Kvam E, Tyrrell RM. Induction of oxidative 37. Garcia-Guinea J, Carrecher V, Lambardero DNA base damage in human skin cells by UV M, Gonzales-Martin R. Study of the ultraviolet and near visible irradiation. Carcinogenesis emission of the electrode coating of arc wel- 1997;18:2379-84. ding. Int J Environ Health Res 2004;14:285- 54. Kripke ML, Fisher MS. Immunologic parame- 94. ters of ultraviolet carcinogen. J Natl Cancer 38. Emmett EA, Horstman SW. Factors influen- Inst 1976;57:211-5. cing the output of ultraviolet radiation during 55. Kripke ML, Morison WL. Studies on the me- welding. J Occup Med 1976;18:41-4. chanism of systemic suppression of contact 39. Okuno T, Ojima J, Saito H. Ultraviolet radiation hypersensitivity by ultraviolet B radiation. Pho- emitted by CO2 arc welding. Ann Occup Hyg todermatology 1986;3:4-14. 2001;45:597-60. 56. Armstrong BK, Kricker A. The epidemiology of 40. Currie CL, Monk BE. Welding and non-me- UV induced skin cancer. J Photochem Photo- lanoma skin cancer. Clin Exp Dermatol biol B 2001;63:8-18. 2000;25:28-9. 57. de Gruijl FR, Sterenborg HJCM, Forbes PD, 41. Szarmach H, Synoradzka-Nakonieczna H. Davies RE, Cole C, Kelfkens G, et al. Wavel- Evaluation of the effect of welding on the oc- ength dependence of skin cancer induction by currence of dermatoses in ship industry. Pr- ultraviolet irradiation of albino hairless mice. zegl Dermatol 1970;57:195-202. Cancer Res 1993;52:53-60. 42. Diffey BL. Human exposure to ultraviolet ra- 58. Wikonkal NM, Brash DE. Ultraviolet radiation diation. Semin Dermatol 1990;9:2-10. induced signature mutations in photocarci- nogenesis. J Invest Dermatol Symp Proc 43. Bruzell-Roll EM, Jacobsen N, Hensten-Pet- 1999;4:6-10. tersen A. Health hazards associated with cu- ring light in the dental clinic. Clin Oral Invest 59. Vitasa BC, Taylor HR, Strickland PT, Rosenthal 2004;8:113-7. FS, West S, Abbey H, et al. Association of non- melanoma skin cancer and actinic keratoses 44. Cazzuli O, Giroletti E. Rischio di esposizione a with cumulative solar ultraviolet exposure in radiazione UV nei laboratori biochimici. G Ital Maryland watermen. Cancer 1990;65:2811-7. Lav Erg 2002;24:56-65.

ACTA DERMATOVENEROLOGICA CROATICA 197 Gruber et al. Acta Dermatovenerol Croat Occupational skin diseases and UV rays 2007;15(3):191-198

60. Geies P, Wright J. Measured solar ultravio- fishing island and in an inland agriculture area let radiation exposure of outdoor workers in of Japan. J Dermatol 2005;32:875-82. Queensland in the building and construction 65. Kogoj F. Cutis nautae – koža pomoraca. Po- industry. Photochem Photobiol 2003;78:342- morski zbornik 1966;4:625-42. 8. 66. Jakac D. Haufigkeit und berufliches Charakter 61. Cherry N, Meyer JD, Adisesh A, Brooke R, des Lichtkrebses in den Küstengebieten Jugo- Owen-Smith V, Swales C, et al. Surveillance slawiens. Berufsdermatosen 1961;9:1-14. of skin diseases: epiderma and OPRA. Br J 67. Jakac D. Actinic carcinoma in the coast region Dermatol 2000;142:1128-34. of the north-east Adria. Acta Fac Med Flumi- 62. Hakansson N, Floderus B, Gustavsson P, nensis 1973;1:85-92. Feychting M, Halln N. Occupational sun- 68. Mohar N. The frequency and importance of light exposure and cancer incidence among skin carcinoma in the region of Rijeka. Acta Swedish construction workers. Epidemiology Derm Iug 1976;3:19-31. 2001;12:552-7. 69. Stašić A, Lenković M, Gruber F, Grgurev Z. 63. Hannuxela-Svahn A, Pukkala E, Karvonen J. Frequency of skin cancer in seamen. Procee- Basal cell skin carcinoma and other non-me- dings, I Hrvatski kongres pomorske, podvodne lanoma skin cancers in Finland from 1956 th- i hiperbarične medicine, Split, 1998:106-12. rough 1995. Arch Dermatol 1999;135:781-6. 70. Periš Z. Skin malignancy – a side effect of 64. Anzai S, Anan T, Kay Y, Goto M, Arakawa S, continuous immunosuppressive therapy. Lijec Shimizu F, et al. Skin cancer screening on a Vjesn 1988;110:15-7.

By rain and bad weather use Nivea cream; year 1935. (from the collection of Mr. Zlatko Puntijar)

198 ACTA DERMATOVENEROLOGICA CROATICA