18 Dermatological Conditions JAMES E. LESSENGER Key words: predisposing factors, patch testing, wood’s light, urticarian, dermatitis Skin problems in worldwide agricultural workers are very common. Among California grape and tomato harvesters, pustular eruptions such as acne and fol- liculitis were present in 30% of studied workers. Irritant or allergic contact der- matitis was present in 2%. In Iowa, 9.6% of male farmers and 14.4% of wives of farmers reported dermatitis during the previous 12-month period. In Washington State, researchers studied 7445 claims for occupational skin disorders filed over a 5-year period. Medical bills totaled $1.22 million, and lost time payments were $1.23 million. The highest rates of occupational skin disorder claims were seen in agriculture with 2.8 claims per 10,000 full-time equivalent employee years. Most of these skin disorders were due to chemical and vegetation exposures (1–4). Among northern Ecuadorian potato farm workers, high rates of dermatitis and pigmentation disorders were attributable to the use of pesticides and fungi- cides. Among California farm workers, skin disease rates were found in tomato workers (6.2%), citrus (10.8%), and vineyard workers (21.0%). Factors found to contribute to dermatitis in farm workers included the specific type of crop cul- tivated, specific job activity, use of personal protective measures, field and home sanitation, environmental conditions of heat and humidity, personal hygiene, allergic history (including atopy), and ethnicity. Several pesticides were shown to cause irritant and allergic contact dermatitis. Causes were found to include pes- ticides, naturally occurring plant substances, heat, sunlight and humidity, atopy, and infectious fungal and bacterial agents (5,6). In Maryland, a study of watermen, people who harvest crabs, oysters and fish, demonstrated elevated rates of basal cell carcinoma, squamous cell car- cinoma, and actinic keratoses (7). Prevention Strategies Preplacement Physical Examination Preplacement examinations are useful in two ways: (1) making an inventory of the skin problems the worker has before beginning a task, and (2) 207 208 J.E. Lessenger identifying conditions that may preclude working at a specific job task. It may be impossible to exclude a given employee from a task due to legal or political restrictions. Therefore, the preplacement physical examination can identify the problems a prospective employee has and recommend specific control measures designed to keep from making it worse. An example of a condition that may preclude working at a specific job task is chronic eczema in a person applying to work with garlic and other crops that produce aller- gic responses (8,9). Training Educating the worker in proper handling methods for agricultural products and operation of equipment is essential in preventing occupational illness and injury. The proper operation of equipment can prevent exposures to toxic substances of all kinds. For example, teaching a pesticide applicator the proper way to mix chemicals can prevent spills and lessen the possibility of exposure (10,11). Safety Equipment Equipment designed to provide safety barriers can significantly reduce occu- pational illness and injury. Examples include air-conditioned, sealed cabins in pesticide application machines, automatic spice-packing machines that require no human contact, and sun shades for field workers to protect against the sun (11). Personal Protective Equipment and Clothing Hats, long-sleeved shirts, long trousers, and gloves protect against plants, chemicals, and insects that can cause rashes and other skin lesions. Protective clothing can also protect against sun damage. Protective ensembles, often made of advanced fibers and with vapor barriers, are used to protect against chemical exposures. The trade-off is that these ensembles expose the worker to heat injuries. Constant air-cooling devices can sometimes mitigate the risk of heat injury, but many times the employees must work at night. Unfortu- nately, away from the supervisors and designers of the equipment, workers simply remove the equipment rather than risk heat exhaustion or a decrease in production (11,12). Hygiene The following hygiene guidelines have been suggested: 1. Provision of effective, nonirritating, nonallergenic skin cleansers 2. Use of emollients, hand lotions, and creams after hand washing 18. Dermatological Conditions 209 3. Frequent clothing changes, when possible 4. Daily showering 5. Rapid removal of oil and chemical soaked clothing 6. Use of company laundering facilities or separate laundering facilities in the house 7. Prohibition of eating, drinking, or smoking in the work area 8. Use of sun block (8,9,11,13) Hand cleansing with organic solvents such as mineral oils or paint thinners, or the hand cleaners that contain them, should be discouraged. The repeated use of organic solvents can desiccate the skin of the hands and cause a chronic irritant dermatitis. When using soap and water to clean the hands, care must be taken to remove as much grease and oil as possible from the creases and pores. Small pieces of metal or organic material left in the creases can cause a foreign-body reaction and lead to chronic irritant dermatitis (11,13). Elimination of Hazards Solvents that cause dermatitis may be eliminated with a switch to a less irri- tating substance. The use of pesticides that lead to chloracne may be reduced with modern equipment using laser sensors that turn off spray noz- zles when passing between trees or turning corners. A packing or produc- tion process in the open air can be moved into a shed to provide sun protection (11). Approach to the Diagnosis The History Predisposing Factors Not every worker exposed to an agricultural environment will develop an occupational skin disease. Factors that place the worker in greater or lesser jeopardy are age, the work environment, a history of atopy and other allergic conditions, the presence of concomitant skin disease such as psoriasis, plant or field cleanliness, worker cleanliness, and the gender of the worker. Younger workers may be inexperienced or not follow safety regulations. There is also the phenomenon of “hardening” seen in older workers who have been work- ing in the particular agriculture environment for a long time. On the other hand, younger workers may heal faster (Table 18.1) (9,14). Temperature and relative humidity are also important factors in the devel- opment of skin disorders. Cool, dry environments favor xerosis and xerotic eczema. Warm, humid environment favors the development of miliaria and folliculitis. Sun exposure leads to skin tumors, increasing in severity and number with the extent of exposure and with certain skin types. Poor hygiene 210 J.E. Lessenger TABLE 18.1. Predisposing factors of skin disease in agriculture. Age Relative humidity Younger workers Wind Positive Sun exposure Heal faster Presence of concomitant skin disease More resilient Psoriasis Negative Atopy Fail to follow safety regulations Irritant contact dermatitis potentiating Inexperienced in job tasks allergic contact dermatitis Older workers Work-site cleanliness Positive Worker cleanliness Hardening phenomenon Availability of wash stations Follow safety regulations Gender of the worker Experienced in job task Men are more prone to acneiform Negative eruptions Less resilient and heal slower Women tend to be more fastidious Environment in cleanliness Temperature Use of safety equipment and procedures Source: Data from Peate (9) and Wollenberg et al. (14). and lack of bathing facilities may extend the time the offending substance is on the skin and exacerbate the illness (8–11,15). Having a skin disorder can predispose a worker to other skin disorders. Workers with atopic dermatitis are more prone to allergic contact dermatitis. Psoriasis (through the Koebner phenomenon) worsens on exposure to heat, irritating chemicals, or extreme cold. Workers with preexisting irritant con- tact dermatitis or xerosis are more likely to develop secondary allergic sensi- tization (9). Gender also makes a difference. Hairiness, sebum and sweat production, and the pH of the skin make male workers more prone to acneiform erup- tions. Women seem to be more fastidious in removing dirt from skin and clothing and are thus more protected (8,9). History of the Illness It is important to accurately record the worker’s personal data and history of the illness as summarized in Table 18.2 (8,9,16–19). Physical Examination Objective findings should be described in detail, beginning with where on the body the problem started. Objective information is listed in Table 18.3. Dia- grams of the distribution of the lesions can be extremely helpful, especially when used in conjunction with photos. Photos may be important to docu- ment the lesions for insurance claims and to demonstrate improvement over time (Table 18.3) (16–18). TABLE 18.2. Dermatological history. Worker identifying data Work description Age History of what the employee came Gender in contact with on the job Skin color What protective equipment was used? Job title Other jobs the employee might have Actual job task Use of deodorants, cosmetics, perfumes, Insurance information or other hygiene products Exposure information A complete employment and exposure Date and time of onset of skin history may be necessary lesion Past history Previous similar lesion from same job Prior skin exposures and lesions Job task at time of onset Systemic illness Where on the body it started Allergies Whether