Reviewing OH dermatitis and urticaria best practice

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Guidelines to a standard of care on occupational dermatitis and urticaria will be published in full in a future issue of Occupational Health. OH nurse adviser Diane Romano-Woodward provides a guide to reviewing the service.

In 2006, the House of Lords Science and Technology Committee appointed a subcommittee to discuss the impact of allergy on the population. This included patients, society and the economy. The scope was wide reaching, covering allergies to substances commonly found in the community, in workplaces and in the general environment.

The report, “Allergy”, was part of the 6th Report of Session 2006/07. This is an informative document with an excellent description of the nature of allergies, both IgE-mediated (atopy) and non-IgE-mediated (House of Lords, 2007).

The report also contains specific information on occupational allergies. Mention was made of asthma, rhinitis and extrinsic allergic alveolitis, as well as allergic contact dermatitis. The committee recognised a lack of consistency in the diagnosis and care of those with allergies in both primary and secondary care. It made recommendations to the Health and Safety Executive (HSE) for further action (see box 1).

As a result of this report, the HSE supported the British Occupational Health Research Foundation (BOHRF) in assembling stakeholders from the fields of occupational health, dermatology, general practice, trade unions and patients’ groups. In 2010, they produced evidence-based guidance on occupational dermatitis and urticaria (Romano-Woodward, 2010).

The HSE then formed a standards of care working group to develop standards, including a representative from the Association of Occupational Health Nurse Practitioners. The 10 standards have been published (see box 2) and cover the whole of the “patient’s journey”, dealing with the responsibilities of employers and also of the healthcare professionals with whom the employee will come into contact.

Many employees do not have access to OH services and the initial diagnosis and onward referral may be made by a GP.

If there is an OH service, it may be nurse led, so that the initial history taking and advice about health and control of hazards will be from an OH professional who is not a physician.

However, all health surveillance programmes should be overseen by a physician with expertise in OH, to whom the nurse can refer those affected.

These guidelines are aimed at all professionals who come into contact with those with dermatitis and urticaria, encouraging them to consider if occupation may be a contributing factor.

A list of occupations where dermatitis is common, as well as resources such as posters and case studies, can be found on the HSE website.

The standard of care and the associated appendices, which are flow charts of health surveillance and the patient’s journey, are available online as an advanced publication, and there may be some alterations before they are published in full in this journal. They will also be available on the HSE website.

Their publication does give the OH professional the opportunity to reflect on and improve practice in this area.


Practical action for OH


Outlined below is a guide to reviewing the service provided to ensure that it is based on current best practice.

The workplace



  • Read the risk assessments that relate to known skin irritants and sensitisers.
  • Check that the health record held by management contains all the required information.
  • Check accident and absence records for evidence of skin problems.
  • If there are known skin hazards, schedule a workplace visit to gain an understanding of the control measures already in place. Explore the procedures to see whether the substances are being handled as expected or if poor practice has slipped in. Look for warning and advice notices on display.




    quotemarksMake sure that employees know to report skin rashes promptly and not to wait until the next scheduled health surveillance.”


  • Identify what information and training are being given to staff, and at what intervals. This should occur at the start of employment and at regular intervals afterwards.
  • Make sure that employees know to report skin rashes promptly and not to wait until the next scheduled health surveillance.
  • If barrier creams have been provided, advise management of the current advice not to promote these and to provide moisturisers instead. Help the employer to identify appropriate sources.
  • Check that handwashing areas are clean and functioning and that skin-conditioning creams are available.
  • If personal protective equipment is used as a control measure, ensure that it is available in various sizes. If not disposable, check how it is kept clean, how it is stored and the systems in place to monitor the condition and provide replacements. Check that this process is documented for future reference.

The OH service



  • Review guidance note MS24 (2004) Medical aspects of occupational skin disease.
  • Review health surveillance arrangements to ensure that they are of suitable format (questionnaire/examination) and frequency.
  • Ensure that there is an arrangement in place with an OH physician for overall supervision of the health surveillance programme and also for referral of cases of occupational dermatitis or urticaria.
  • If the nature of the work means that skin problems are likely, consider setting up a system for rapid referral to a dermatologist.
  • Ensure that the pre-employment health questionnaire includes appropriate questions on previous dermatitis and/or history of atopy. This may involve extra questions specifically for those at risk. Remember others who may not undertake the main work process but who may be exposed, such as cleaners and maintenance staff.
  • Document the condition of the skin on commencement and, if appropriate, advise the individual that they are at increased risk of skin disease and include the fact in the OH record. Written information may help to reinforce the advice.
  • Identify suppliers of appropriate cotton liners that can be provided if there are problems with gloves.
  • Consider using a camera with reasonable resolution and having appropriate software installed on the computer before skin problems arise to enable skin condition and the progress of healing to be documented.

If a case of dermatitis or urticaria occurs:



  • Consider “same day” access to OH if an employee has a skin problem. This appointment can be to document the condition of the skin, give immediate advice and to get the individual to begin a written record of the aspects that will be discussed in the full consultation. The Royal College of Nursing’s Tools of the trade document on glove use has a list of information to be gathered.
  • Take a history of all past jobs and the associated substances that employees may have been exposed to, the medical history, details of all current work exposures and whether or not the rash is associated with work or improves when away from work. Discuss out-of-work exposures, such as housework and hobbies.
  • Describe the rash specifically – for example, tiny blisters, weeping, scaling, cracking, redness, white areas, thickening, dryness and itchiness.
  • If possible, take pictures of the rash showing the areas affected and the spread. If the hands are involved, take pictures of the palmar and dorsal surface with the fingers spread. It is useful to include a card with the individual’s name and date.
  • Consider whether a short period of time away from the workplace or in an alternative working area might be useful to allow healing.
  • Advise the employee to get a diagnosis and treatment from their GP. Provide a copy of BOHRF guidance for the GP.
  • Refer to the OH physician promptly if the rash does not resolve quickly with enhanced hand care.




    quotemarksEnsure that there is an arrangement in place with an OH physician for overall supervision of the health surveillance programme and also for referral of cases of occupational dermatitis or urticaria.”


  • If occupational dermatitis or urticaria is confirmed in writing by a physician, advise management to report under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) (RIDDOR). The requirements of RIDDOR do not overrule medical confidentiality and the case can be reported anonymously if the individual does not consent to management being informed.
  • If the condition is thought to be allergic or does not resolve within three months, refer to specialist for patch testing or ask the GP to consider doing so. Provide details of skin hazards to the specialist. Material safety data sheets may be useful. With the individual’s consent, provide photographs and history. If an employee is shown to have an allergy, help them to recognise, remove or reduce exposure to the allergen.
  • Continue to follow up with the employee until the condition resolves or to support job modification or redeployment, and document the advice given.
  • Give the employee information about Industrial Injuries Disablement Benefit (C30a Chrome D5 other substances) if appropriate.

Diane Romano-Woodward, RN RSCPHN-OH BSc M Med Sc. (Occ Health) is an OH nurse adviser at Sunny Blue Sky

References


Adisesh A, Robinson E, Nicholson PJ et al (2013). “UK standards of care for occupational contact dermatitis and occupational contact urticaria”. British Journal of Dermatology, published online 3 February.

House of Lords Science and Technology Committee inquiry (2007), 6th Report of Session 2006-07. Allergy Volume 1: Report. London; The Stationery Office Ltd.

Health and Safety Executive. HSE guidance on dermatitis, introduction and resources.

Health and Safety Executive. What are the high risk jobs and workplaces?

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) (RIDDOR).

Nicholson PJ, Llewellyn D (eds) (2010). Occupational contact dermatitis and urticaria. British Occupational Health Research Foundation. London.

Romano-Woodward D (2010). “Handle with care”. Occupational Health; vol.62, issue 8, pp.17-19.

Romano-Woodward D. “On-hand advice”. Occupational Health; vol.64, issue 8, pp.13-15.

Royal College of Nursing (2012). Tools of the trade: Guidance for health care staff on glove use and the prevention of contact dermatitis.








BOX 1: Recommendations to the Health and Safety Executive for further action


5.53 “We welcome the educational work of the Health and Safety Executive (HSE) to raise awareness and decrease the risk of occupational allergic disorder among employers and staff, and we would like to see this work developed. Once allergy centres have been developed we recommend that the HSE should liaise with occupational allergy specialists in each centre to inform its policies and to develop strategies to prevent occupational allergic disorders.”

9.9 “It is vital that the HSE works with the Department of Health to ensure that medical practitioners are adequately educated in the diagnosis and treatment of occupational allergic skin disorders. We support the work of the Group of Occupational Respiratory Disease Specialists convened by the HSE, which developed a standard-of-care document for the diagnosis of occupational asthma and recommended that the HSE should work with stakeholders to produce a similar document for occupational allergic skin disease.”








Box 2: Standards of care – employer


Employer



  1. There should be no use of pre-work creams labelled as “barrier creams”.
  2. Skin-conditioning creams should be available at handwashing areas and in other appropriate places. Training and guidance in the application of skin-conditioning creams should be provided.
  3. Arrangements for access to a physician who has expertise in occupational skin disease should be in place for initial diagnosis and recommendations regarding appropriate workplace adjustments together with subsequent investigations by patch/prick testing if appropriate.
  4. Employers have legal duties to assess the health risks from skin exposure to hazardous substances at work. They should prevent or, when this is not reasonably practicable, adequately control exposure to the hazards.
  5. Where adequate control of exposure cannot be achieved by other means, suitable personal protective equipment should be provided in combination with other measures. The use of gloves must take into account appropriate selection and training on glove use, including the provision of cotton liners.
  6. Information and training aimed at improving and maintaining skin health should be provided to employees who are at risk of developing occupational contact dermatitis or occupational contact urticaria at the time of appointment and regularly thereafter.

Health professional



  1. When someone of working age presents with a skin rash, the clinical record should contain a full clinical and occupational history about their job, the materials with which they work, the location of the rash and any temporal relationship with work.
  2. The diagnosis of suspected occupational skin disease (contact dermatitis or contact urticaria) should include objective patchtesting where: the condition has not improved three months after initial advice; and a contact allergy is suspected or there are implications for fitness to work such as altered employment, loss of job or a complete change of employment.
  3. Where a worker has been offered a job that will expose them to causes of occupational contact dermatitis, the clinical record should indicate whether or not they have a history of dermatitis, particularly in adulthood, and record advice given to them of their increased risk and how to care for and protect their skin.
  4. Where a worker has been offered a job that would expose them to causes of occupational contact urticaria, the clinical records should indicate whether or not they have a history of atopy and record advice given to them of their increased risk and how to care for and protect their skin.

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