No matter how effective a skin management system in a workplace may be, we can never completely eliminate the potential for a skin problem to arise. Everyone’s skin is unique, so there is always the possibility that one person’s skin will react to something that does not affect others. Furthermore, we have to bear in mind what has been termed the ’24:8 rule’ – that is that we have our skin for 24 hours a day, for which on average for most people, only eight will be spent at work.
Detection
What is important is that any damage to the skin is detected and dealt with as early as possible. With irritant contact dermatitis, the most common form of occupational skin disease, it is now possible, using what are termed skin bio-engineering techniques, to detect damage at a sub-clinical stage.
A skin health surveillance system, a legal requirement for most employers, can then implement pre-emptive measures, thus preventing the contact dermatitis from developing. With allergic reactions, the first indication will be a skin reaction. However, even here, early detection and intervention is important, as the longer the exposure is allowed to continue, the lower the threshold at which a reaction will occur, and the more difficult it will be to keep that person at work.
Once a skin condition has been detected, it is essential that a full investigation is conducted to ascertain the true cause. Assumptions as to the cause can result in inappropriate treatment, making the problem worse and, ultimately, more difficult to resolve.
Our aims should therefore be to:
identify the true cause of the skin problem
ensure the correct treatment to resolve the problem
take action to eliminate the cause and keep the employee in their original job without any further problem
take action to make sure other employees are not also affected.
This article will consider primarily determining what has caused the skin problem. This is not as simple as many assume. In the first place, there are several hundred clinically recognisable skin diseases, many of which will look similar. Many of these will be endogenous – the result of some internal disorder manifesting itself as a visible skin reaction. Since this can look identical to an exogenous skin problem, ie, one caused by skin exposure to one or more causative substances, it is easy to reach an inappropriate conclusion unless the relevant information and tests have been conducted.
Bio-psychosocial model
We need to keep in mind that the skin is affected both by external and internal influences. In fact, when investigating a suspected occupational skin problem, we would do well to keep in mind the bio-psychosocial approach proposed by professor Gieler.1, 2 This suggests that we need to include in our considerations:
Is there a predisposition in the affected individual towards a skin problem? For example, has that person been diagnosed as atopic – someone with a predisposition to developing an allergic skin reaction or more susceptible to skin damage from exposure to irritant chemicals? Is there a history of skin problems in the past?
What exposures occur in their life, both at work and at home? Bear in mind that the most common form of contact dermatitis, the irritant form, is almost always the result of repeated exposures to many different substances, often over an extended period, perhaps of many years. Since even water can be an irritant to the skin, the picture can be complex.
Are there other factors that can influence the skin? For example, there is ample evidence that stress can result in a skin reaction? Furthermore, psychosomatic factors can also lead to a skin problem. For example, Hashizume and his co-workers could show that anxiety accelerates T-helper 2-tilted immune responses in patients with atopic dermatitis, resulting in a worsening of the skin disease.3 At a conference in 2004, professor Marks commented: “Interestingly, the integrity of the stratum corneum barrier appears to be influenced by emotional stimuli because in one study, subjects who had marital problems repaired damaged stratum corneum barrier more slowly than did matched controls.”4
Seasonal effects
One element that is frequently overlooked is the season in which the skin problem occurred. Our skin needs to retain a certain moisture content in the stratum corneum to function effectively as a barrier. This is controlled by a microscopically thin layer of an emulsion in the outer layers of skin cells. An essential component of this is sebum, produced by sebaceous glands in the skin. Due to the effect of cold, wind, etc in the winter, we need more of this at this time than, for example, in the summer. Unfortunately, studies have shown that the sebaceous glands actually produce up to 30% less in the winter months.
Thus, since as a result the skin may be much more vulnerable, it is not uncommon to find that dermatitis often occurs during the winter. Of 111 healthcare workers, 58% developed hand dermatitis to soaps. All of the severe cases occurred between November and April, and 79% of the milder cases occurred during the winter months.5
Complications
Are you dealing with a simple cause, or is more than one type of skin reaction involved? Take the case of a construction worker who develops dermatitis. Patch testing by a dermatologist reveals that he has an allergic reaction to chromates, which may still be found in some cement. However, cement is also a potent irritant, as are many other chemicals found on construction sites. Thus we may well be dealing with a combination of irritant and allergic contact dermatitis, the irritant element perhaps exacerbated by exposure to irritant substances commonly found in the home and in hobbies. What might we be exposing him to?
The safety data sheets are frequently inadequate to inform us of this, since they generally only refer to those substances that have risk phrases and are incorporated into the product as supplied. This can be very different to what is actually present when the product is used.
Consider the following example. A young lady working with nickel-plated components (the nickel being shown on the safety data sheet) developed a hand dermatitis. This disappeared when she was on holiday, reappearing shortly after she returned to work. Patch testing at the local dermatology clinic revealed that she was allergic to nickel. The obvious conclusion was that this was a case of occupational contact dermatitis due to exposure to the nickel.
However, in a subsequent investigation to identify what measures needed to be taken to prevent other workers from developing the same problem, it was found that no nickel was being released from the components that she handled. Thus nickel allergy could be excluded as a cause of her skin problem. In fact, in her spare time, she worked as a hair stylist. Her dermatitis was an irritant contact dermatitis caused by exposure to shampoos and hair styling products.
Investigations
What does this mean for the employer seeking to identify the cause of a skin problem in an employee? Simply that investigation is not always as simple as many assume. Almost certainly it will require collaboration between the employee, those responsible for risk assessment and risk management within a workplace, the occupational health team, should there be one, and a consultant dermatologist whose speciality is contact dermatitis and who, preferably, has a particular interest in occupational skin diseases.
The first step will be to interview the employee, and to gain as much information about their condition, its history, and whether there are any other factors that might be relevant. Next, a full review of their workplace and the work they do is essential to establish what they are being exposed to in the workplace. The next step is usually referral to the dermatologist for a clinical examination and diagnosis. It is important that the dermatologist is properly briefed, so that any tests are relevant to what that employee might be exposed to.
An example of the importance of this is a case of two employees in an engineering works. Both had been diagnosed with irritant contact dermatitis to the oil used in the particular machine on which they worked. Patch testing with the oil in both new and used condition had been negative, hence the diagnosis of irritant contact dermatitis. In fact, the used oil contained several contaminants, one in sufficient strength to elicit an allergic reaction. Since patch testing is usually carried out with the product diluted to what is termed the “highest non-irritant concentration” (in this case 1%), insufficient exposure to this contaminant occurred during patch testing, resulting in no response being detected. Our investigation showed both workers highly sensitised to the contaminant, so that in reality, what we were dealing with was an allergic contact dermatitis, requiring a totally different approach to that for an irritant contact dermatitis.
Once a diagnosis has been made, this needs to be checked to ensure that it is relevant to the situation we are dealing with, as is demonstrated by the examples already given. A strategy can then be developed, hopefully to allow the employee to continue at their work without any further skin complaint.
Conclusion
It should be apparent that investigating a skin problem where there is suspicion that it may be occupational in origin is not simple. In fact, in many cases, even with the most careful investigation, it may not be possible to determine with any accuracy the relative significance of occupational and non-occupational factors. However, unless a full investigation is carried out, assumptions can easily be made that will result in action, and possibly treatment, that can actually make the problem worse. Certainly, in almost all cases, the investigation will require the involvement of a medical specialist properly trained in dealing with contact dermatitis.
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By Chris Packham, partner, EnviroDerm Services
References
Harth W, Gieler U, Psychosomatische Dermatologie, Springer Verlag (pubs.), ISBN 3-540-24890-0
Gieler U, Die Haut als Spiegel der Seele (The skin as mirror of the soul), Th. Knaur Nachf. (pubs), ISBN 978-3-426-87346-5
H.Hashizume, T.Horibe, A. Ohshima, T.Ito, H.Yagi, M.Takgawa, Anxiety worsens skin symptoms in patients with atopic dermatitis. – Br. J. Dermatol, 2005, 152(6)
Marks, R, The Stratum Corneum Barrier: The Final Frontier, American Society for Nutritional Science, 2004
“Frequent hand washing by healthcare workers may be counterproductive if performed too frequently.”, Study by University Hospitals Case Medical Center, Cleveland, USA – presented at 66th meeting of American Academy of Dermatology.
