1. Occupational Skin Diseases Dr. Alireza Safaiyan Occupational Medicine Specialist

2. Introduction l The second cause of occupational diseases ( 23-25% of all occ.diseases ) l A skin disease that is caused by physical, biological or chemical factor in work l Also a worsening of pre-existing skin disease can be termed as occupational skin disease

3. Classifications of work-induced skin diseases l Occupational dermatitis l Occupational photosensitivity reactions l Occupational phototoxicity reaction l Occupational skin cancers l Occupational contact urticaria l Occupational acne l Occupational skin infections l Occupational pigmentary disorders l Miscellaneous

4. Work-aggravated Skin Diseases l Psoriasis l Acne

5. Diagnosis Of Occupational Skin Diseases l Patient history: Does skin disease relate to work? l Exposure: Are there causative agents (allergens, irritants) in the work-place? l Clinical symptoms: Are they in accordance to clinical disease?

6. Questions l When did disease start? l In which skin area was the first symptom? l What is work technique? l Free time, other works l Cleaning measures l Protection l Vacation, holidays

7. Contact Dermatitis l Occupational dermatitis is an inflammation of the skin causing itching, pain, redness, swelling and small blisters. l Contact dermatitis is an eczematous eruption caused by external agents, which can be broadly divided into: Irritant substances that have a direct toxic effect on the skin (irritant contact dermatitis, ICD) Allergic chemicals where immune delayed hypersensitivity reactions occur (allergic contact dermatitis, ACD).

8. What Types? Irritant Contact 80% of all dermatitis is caused by direct contact with a substance It may occur randomly Allergic Contact Once sensitised, the problem is life long and any exposure to the substance will result in an attack

9. What Causes it? Irritants l Detergents l Solvents l Engine oils l Cutting fluid l Lubricants l Fibreglass Allergens l Salts l Nickel l Epoxy resins l Dyes l Rubber

10. Common site of involvement l Skin disease starts on the area of contact. l Dorsal aspects of hands and fingers, volar aspects of arms, interdigital webs, medial aspect of thighs, dorsal aspects of feet.

11. Prognosis Of Occupational Dermatitis After Treatment l 25% complete recovery l 25% refractory l 50% remitting / relapsing

12. Irritant Contact Dermatitis ICD

13. Classification of ICD l Acute l Chronic

14. Acute ICD This is often the result of a single overwhelming exposure or a few brief exposures to strong irritants or caustic agents. Common work chemicals: – Concentrated acids (sulfuric, nitric, chromic, hydrochloric, hydrofluoric acids) – Strong alkali(CaOH,NaOH,KOH),wet concrete, sodium and potassium cyanide – Organic and inorganic salts, e.g. dichromates, arsenic salts – Solvents/gases, e.g. acrylonitrile, ethylene oxide, CS2

15. Clinical Presentation l Stinging, burning, painful, erythematous eruption occur after brief contact with strong irritant chemicals. l Erosion and skin ulceration may occur. l May result in permanent scar.

17. Chronic (cumulative) ICD l Repetitive exposure to weaker irritants -Wet : detergents, organic solvents, soaps, weak acids, and alkalis -Dry : low humidity air, heat,dusts, and powders l Disease of the stratum corneum l Is due to a stepwise progression of damage to the barrier function of the skin

18. Predisposing Factors l Endogenous factors: Dryness vs wetness Sweating Age Atopic predisposition Hx of skin diseases

19. Causes of Chronic ICD l Water/wet work l Detergents l Antiseptics l Disinfectants l Soap/cleansing agents l Weak Acids & alkali l Wet cement l Solvents l Low humidity l friction l Fiberglass fibers l Cutting oil l Food l Pesticides l Plants & vegetation l Rubber products l Acrylic resins l Soldering flux l Dusts l Degreasing agents

20. l 35% Washing l 10% Solvents l 6% Plastics and adhesives l 6% Foodstuff l 5% Dirty, wet work l 5% Mineral oils At risk occupations: l Bartenders l Caterers l Cleaners l Hairdressers l Metalworkers l Nurses l Solderers l Fisherman l construction workers.

21. Clinical Presentations l Usually presents with dry, scaly fissuring, lichenified and eczematous lesions on the fingers and hands. l Vesicular lesions do occur but are less common than in ACD. l May in face ( forehead, eyelids, ears, neck) and arms due to airborne irritant dusts and volatile irritant chemicals

25. Management l Removal from exposure in active lesion l Treating the active case Topical corticosteroids Soap substitutes Emollients l Second line ( for steroid resistant cases): Topical PUVA Azathioprine Cyclosporin

27. Allergic Contact Dermatitis ACD

28. Allergic Contact Dermatitis l Caused by low-molecular weight haptens l Hapten is “incomplete allergen” l Binds to carrier protein for immunogenicity l Low molecule weight enables penetration of hapten

29. l Hapten penetrates through stratum corneum of a sensitized individual l A classical Type IV reaction

30. Occupational Skin Allergens l Poison oak/ivy l Metals: Chromium Nickel Gold Mercury Cobalt l Rubber industry Accelerators Antioxidants l Plastic resins Epoxy resins PU resins Phenolic resins Formaldehyde resins Acrylic resins l Rosin ( colophony ) Soft soldering l Organic dyes ( azo dyes ) l Methyl metacrylate l Plants l Latex and its powder l Germicides and biocides e.g. lanolin l Some pesticides l Some solvents Formaldehyde Turpentine Aliphatic amines l Nitrates l Ethylene oxide

31. Classification of ACD l Acute l chronic

32. Clinical Features ( Acute Form ) l Rash appears in areas exposed to the sensitizing agent, usually asymmetric or unilat. l Sensitizing agent on the hands or clothes is often transferred to other body parts. l The rash is characterized by erythema, vesicles and sever edema. l Pruritus is the overriding symp.

37. Clinical Features ( Chronic Form ) l Thickened, fissured, lichenified skin with scaling l The most common sites: Dorsal aspect of hands Eyelids periorbital

44. Diagnosis l Complete history Occupational Non-occupational l Physical examination l Patch test

46. Patch Test l Confirm delayed hypersensitivity l Material& technique: Medium Adhesive Marking of the test Occlusion for 48 h Read in after 72-96 h

47. Angry back

48. Interpretation of patch test result l Nothing: negative reaction l Erythema, papules, infiltration, no vesicle: weak reaction l Erythema, vesicular eruption, edema: strong reaction l Bulla, ulceration: extreme reaction l Erythema to eczematous: irritant reaction

49. Doubtful reaction (?) Faint macular or homogeneous Erythema, no infiltration Weak positive reaction (+) Erythema, Infiltration Discrete papules

50. Strong positive reaction (++) Erythema Infiltration Papules Discrete vesicles Extreme positive reaction (+++ ) Coalescing vesicles/bullous reaction

51. Interpretation codes (Ladou 2004)

54. Management & Prevention l Removal from exposure ( lifelong) l Drug treatment Topical steroid Emollients l Prevention Like ICDs

56. Irritant versus Allergic dermatitis l ICD Hx. Of contact with known irritant Acute onset Stinging, Burning Neg. patch test Localized Many people Improved with long vacation (3 weeks) l ACD Hx. Of contact with known allergen Delay onset (1-3d) Itching, Vesicle Positive patch test Spreads Few people May improved even on weekends

57. Mathias criteria for occupational contact dermatitis (4 of 7) l Clinical appearance l Workplace exposures l Anatomic distribution l Temporal relationship l Non-occupational exposure l Improvement l Patch test

58. Contact photodermatitis l Some chemicals may cause CD only in the presence of light l Sunlight or artificial light sources that emit specific wavelengths l 2 categories: -phototoxic -photoallergic

59. Phototoxic Photoallergic l Coal-tar derivative l Dyes (Eosin) l Drug -phenothiazines -sulfonamides l Plants&derivative -psoralen -lemon l Antifungal agents l Fragrances l Halogenated salicylanilide l Phenothiazines l Sunscreens l Whiteners l Agricultural

60. Clinical course l Phototoxcic: - painful, exaggerated sunburn that may develop bullae and pigmentation -by avoiding the agent, dermatitis usually disappears promptly l Photo-ACD: - many of the features of ACD ( itching, vesiculation)

61. Where involved ? l Exposed areas: face, ant. V of the neck, back of the hand, uncovered sites on the arm&leg l Hairy areas, upper eyelids, and below the chin may be spared

62. DX l Distribution (on sun-exposed surfaces) of the reaction l Photopatch test

63. treatment l Avoidance of contact l Other are the same as CD

64. Contact Urticaria l Immunologic : Caused by proteins that act as allergens Proteins penetrate through skin ⇝ bind to IgE on the surface of mast cell ⇝ release of histamine and other mediators (type-1 reaction) Sometimes generalized reactions occur Latex allergy

65. Contact Urticaria l Nonimmunologic: Caused by chemicals Direct pharmacologic action on skin cells No sensitization necessary More common than suspected

66. Occupational Causes l Latex allergy ( m/c ) l Formaldehyde l Food industry Plants Vegetables Animal products l Pharmaceutical industry Streptomycin

67. Clinical Features Of Contact Urticaria l Hives (edema) appear on sites of contact within minutes l The hives disappear within 1-4 hours l Mild: Only itching l Severe: Systemic symptoms (anaphylaxis)

69. Contact Urticaria l Nonimmunologic: Caused by chemicals Direct pharmacologic action on skin cells No sensitization necessary More common than suspected

70. Management & Prevention l Removal from exposure l Treatment of active disease l Preventive measures

71. Occupational Skin Cancers l The second m/c form of occupational skin diseases l About 17% of all cases of occupational skin diseases

72. What Cancers? l Malignant lesions: Basal cell carcinoma Squamous cell carcinoma Malignant melanoma l Pre-malignant lesions: Actinic (solar) keratoses Tar keratoses (‘warts’) Arsenical keratoses Keratoacanthoma Intra-epidermal carcinoma ( Bowen’s disease) Lentigo maligna

78. زلال باش.... ، ‌ زلال باش.... ، فرقی نمی كند كه گودال كوچك آبی باشی ، یا دریای بیكران ، زلال كه باشی ، آسمان در توست