Abstract

Occupational skin diseases comprise a wide spectrum of conditions. Under epidemiological aspects, occupational contact dermatitis that is usually manifested on the hands is the most frequent occupational skin disease with an estimated average incidence rate of 0.7-1.5 cases per 1,000 workers per year. Irritant dermatitis is due to individual susceptibility and the exposure to irritants such as wet work combined with detergents or other hydrophilic irritants or solvents at the workplace. Chronic...

Acknowledgements

The present study was supported by the USAMRMC Cooperative Agreement No. DAMD17-03-2-0013 and the Binational Science Foundation Research Project 2001186. The authors thank Dr. Michal Raphael for reporting case study No. 2. Wormser U, Sintov A, Brodsky B, Amitai Y, Nyska A Protective effect of topical iodine preparations upon heat-induced and hydrofluoric acid-induced skin lesions. Toxicol Pathol 2002 30 552-558. Somani SM, Babu SR Toxicodynamics of sulfur mustard. Int J Clin Pharmacol Ther...

Barrier Creams

A BC, in theory, is designed to prevent or reduce the penetration of harmful agents 6-13, 19-21 . BCs are also called 'skin-protective creams' or 'protective creams' as well as 'protective ointments', 'invisible glove', 'barrier', 'protective'or 'pre-work' creams and or gels (lotions), 'antisolvent' gels and so on 19, 21-25 . Frosch et al. 19 consider 'skin-protective creams' a more appropriate terminology since most creams do not provide a real barrier, at least not comparable to the stratum...

Biogenic Amines

Regarding the irritative and barrier-disrupting properties of the biogenic amines 8 ammonium hydroxide, dimethylamine and trimethylamine in single and combined application with SLS, all 3 tested biogenic amines induced a barrier disruption and a pH increase paralleled with a 1-day-delayed onset of inflammatory signs. These effects were further enhanced and accelerated by a sequential application of SLS together with the biogenic amines, and inflammation occurred earlier than with the single...

Elimination Replacement of Harmful Exposures

Elimination or replacement of known sensitizing allergens can be a useful method to prevent ACD. Successful identification of a common allergen, chro-mate, and replacement with another nonsensitizing agent is well described in Denmark. In 1981, at manufacture, the chromate content of cement in Denmark was lowered to less than 2 parts per million of water-soluble chromate. This was accomplished by replacing chromate with ferrous sulfate at an added cost of approximately 1 . By this substitution,...

Evidence Based Medicine and Skin Protection

Although barrier creams are one of the most commonly recommended measures to prevent occupational dermatoses such as irritant contact dermatitis and allergic contact dermatitis, their actual benefit at the workplace is still lively debated 13 . Nevertheless, there is a lack of placebo-controlled, randomized clinical studies, evaluating the benefit of skin protection products in the prevention of occupational diseases under real workplace conditions. Moreover, the literature data are...

Exposures at the Workplace

Measures of skin protection depend on the one hand on exposures at the workplace and on the other hand on individual skin 'sensitivity' and history of hand eczema in the past. Relevant allergens in the metal industry are e.g. epoxy resins, acrylics, polyurethane, polyester and phenol-formaldehyde resin systems, colophony and p-phenylenediamine 2 . Preservatives and biocides in metalworking fluids may generally be discussed as relevant allergens, whereas metals like chromate and nickel seem to...

Glove Protection from Epoxy Resins

Epoxy resins are two-part adhesives used commonly in industry allergy to epoxy resins can be a significant dermatological problem. The bisphenol A type resins are low-molecular-weight oligomers that are frequent contact sensitizers 21 . Workers exposed to epoxy resins in a wind turbine factory were more likely to be epoxy sensitive with longer durations of work. In these workers, 3 layers of protective gloves were mandatory (cotton on the skin, thin nitrile gloves and thick black rubber gloves...

Gloves as Barrier Protection

Many workers use gloves, believing that they are protecting themselves from allergy-provoking chemicals and skin irritation. However, protection from gloves is not always the case. Skin irritation can be a significant problem from occlusion, sweating and maceration that occurs with prolonged glove use. Gloves themselves can produce ICD from bacterial endotoxins from gamma radiation used in sterilization and due to ethylene oxide 28, 29 . Surprisingly, allergens can penetrate many types of...

Identification of Allergens

An awareness and understanding of the chemicals that a worker is exposed to in the workplace are of the utmost importance for protecting the worker from exposures to substances that may induce ACD. Predictive tests such as the Draize test and the open epicutaneous test use animal models to help predict allergenic compounds. Other tests available use adjuncts, such as Freund's complete adjuvant test, the optimization test, the split adjuvant test and the guinea pig optimization test 13 ....

Incidence and Prevalence of Occupational Skin Diseases

High-quality epidemiological data on the incidence of occupational skin diseases are rare. Occupational hand dermatitis is the most frequent condition, and an incidence of 0.7-1.5 cases per 1,000 per year as a gross average is estimated (table 2) 11 . The incidence rates are very different between trades (table 3) 12 . Hairdressers are most frequently affected by occupational hand dermatitis. In a questionnaire study in the UK, 38.6 of responding hairdressers reported prevalent hand dermatitis...

Interaction of Irritants

However, this approach was limited, since only the cumulative effect of single irritants was tested. In contrast, in many professions the contact with hazardous substances can be very complex and manifold. For instance, workers in the metal industry are repetitively exposed to water-based metal working fluids, neat oils, detergents and organic solvents. The interaction between irritant chemicals at the workplace may have significant practical consequences. We therefore studied the effects of an...

Irritant Reaction

ICD is the result of an unspecific damage due to contact to chemical substances that cause an inflammatory skin reaction 1-3, 5 . Exposure of human beings to irritants such as solvents, detergents and even water 18 , at home and in work environments, leads to damage to the stratum corneum and hence skin barrier impairment 14 . The exact mechanisms of irritant action are incompletely understood, but it seems likely that there is an 'immunologic-like' component to the irritant response 3 . The...

Materials and Methods

The ingredients of the formulations are listed according to the declaration of the International Nomenclature of Cosmetic Ingredients. Water-in-oil emulsion aqua, paraffinum liquidum, panthenol, cera microcristallina, ceresin, glycerin, polyglyceryl-3-diisostearate, isopropyl palmitate, tocopheryl acetate, lanolin alcohol, magnesium sulfate, phenoxyethanol, diammonium citrate, aluminum stearates, citric acid, sodium citrate, potassium sorbate, magnesium stearate, perfume. Multiple (water oil...

Other Chemical Irritants

Commercial PI ointment was also effective against mustard derivatives such as the difunctional nitrogen mustard mechlorethamine 6 which is used as anticancer drug. A significant degree of protection was observed when the skin was treated with PI within 20 min after mechlorethamine exposure. Longer intervals of 60 and 180 min between nitrogen mustard exposure and PI application were also effective but to a lesser extent 6 . Skin toxicity of nonmustard alkylators, such as iodoacetate and...

Prevention and Protection

The prognosis for PICD reactions is generally poor, especially if the individual remains in the same working environment 1 . Therefore, PICD may be best resolved by preventing it. The aim should be to reduce all kinds of exposure to irritants. A single approach is not enough. Prevention and protection should include multiple approaches, including education of employers and employees, drawing their attention to potential hazards. If barrier disruption is indeed one of the primary pathogenic...

Proof of Efficacy Test and Evaluation Methods

The number of workplace substances is uncountable and technical progress enforces the adaptation of substances such as cutting fluids to the new demands. For that reason every new substance can hardly be tested in in vivo studies. Thus, testing of the efficacy of skin protection products, by both in vitro and in vivo models, is limited to a certain number of model irritants such as SLS as a hydrophilic model irritant. However, for some substance classes like lipophilic irritants, model...

Protection against Infectious Agents

In the healthcare setting, disinfection and hand hygiene are indispensable with regard to prevention of cross-infections. Easy access to hand hygiene and skin protection appears necessary for a satisfactory hand hygiene behaviour. Alcohol-based hand rubs may be superior to traditional hand washing as they require less time, act faster, irritate the hands less often and have recently been shown to significantly contribute to a sustained improvement in compliance associated with decreased...

References

1 de Boer EM, van Ketel WG, Bruynzeel DP Dermatoses in metal workers. I. Irritant contact dermatitis. Contact Dermatitis 1989 20 212-218. 2 Goh CL, Yuen R A study of occupational skin disease in the metal industry (1986-1990). Ann Acad Med Singapore 1994 23 639-644. 3 Berndt U, et al Hand eczema in metalworker trainees - An analysis of risk factors. Contact Dermatitis 2000 43 327-332. 4 Drexler H Skin protection and percutaneous absorption of chemical hazards. Int Arch Occup Environ Health 2003...

Results and Discussion

In the ROIT, all 3 test formulations significantly reduced skin irritation (visual score data not shown) and the transepidermal water loss increase caused by 0.5 SDS. The best protection was offered by the multiple emulsion (water oil water), followed by petrolatum and the water-in-oil formulation (fig. 1). In theory the protective effect of an emulsion or ointment can be based on a purely physical effect. That means the compounds of the formulations are building up a protecting film on the...

Safety Testing General Aspects

Safety testing of topically applied products is recommended by health authorities. It is assumed that all chemical substances, when coming into contact with the skin surface, have the potential to be absorbed at least in small amounts, thus exerting biological or even toxic effects. It is essential that all the products applied to the skin are clinically tested in order to verify their propensity for causing cutaneous reactions. As outlined above, for a new dermatological or cosmetic product to...

Solvents

Repeated applications of 4 SLS, an anionic detergent, and TOL, a model solvent, induced an irritant reaction, as indicated by an increase in TEWL and skin redness. In contrast to SLS alone, the application of TOL alone induced only a moderate increase in TEWL, confirming previous results. Concurrent application of SLS TOL and TOL SLS induced significantly stronger reactions than those caused by a twice daily application of each irritant on its own. Our results demonstrate that a mixed...

Specific Effects of Topical Formulations

Dermatological creams and PCs exert a number of effects, in and on the skin, including skin hydration, skin cooling and barrier effect 10 . The relative cooling effect of a PC can be attributed to the amount of water and or alcohol in the emulsion system(s) and to water 'activity', more precisely the amount of freely evaporating water that is liberated in the early phase after topical application. Moreover, the emulsion structure (e.g. liquid crystals) and the presence of hydrotopes determine...

Sulfur Mustard Toxicity

In order to improve its efficacy, iodine replaced PI and was formulated with tetraglycol (TG). Topical treatment with this preparation significantly protected the skin at an interval of 30min between SM exposure and iodine treatment (fig. 2, 3) 4 . The histopathological findings 4 are quantified in figure 4. At the interval of 15 min between exposure and treatment, a significant reduction was observed in dermal parameters indicative of acute tissue damage such as acute inflammation, hemorrhage...

The Vehicle Effect

In classical dermatological treatment, the ideal vehicle is believed to be inert in the therapeutic process of drug delivery. However, both clinicians and consumers expect that the topical product should provide appealing sensory effects in addition to drug delivery. These sensory properties are provided by the vehicle constituents. In skin protection strategies, the topical vehicle often occupies a position of even greater importance in terms of the 'protective' effect that it must afford the...

Theoretical Basis

Skin protection training courses are by their nature primarily intervention measures at the level of health-related behavioural prevention. In the sphere of primary prevention this would involve the training required under the legislation discussed above for employees whose skin was at risk, to be provided either at work or as lessons at vocational training colleges. The spheres of secondary and tertiary prevention primarily involve patient training in the sense of a 'high-risk strategy' aimed...

Untoward Effects

Some ingredients of skin protection products, though principally hardly indispensable for stability and or acceptance reasons, such as preservatives and fragrances, can induce contact sensitization 4, 14 . Therefore, fragrance ingredients should be used with caution and be limited to substances with a proven low sensitizing potential, in particular because these products will also be used on already impaired skin in many cases. Chemical ultraviolet filters are also potentially capable of...

Research Needs Regarding Protection from Combined Irritants

So far, the reported study has been the only one that assessed the efficacy of a skin protection product in a TRIT. Since combination exposures are the rule, not the exception in the workplace, further work in this area is dearly needed before skin protection products can be proposed in combination exposure situations. Especially the combined exposure to detergents on one side and solvents, mechanical stress and hot air on the other side seems to potentiate epidermal barrier damage and is...

Prevention of Skin Barrier Breakdown Postexposure Skin Care

Postexposure skin care is especially important for workers chronically exposed to irritating substances, but is also important for workers known to be allergic to substances with which they come into contact. ICD is the most common cause of occupational skin disease and can play a role in the development and perpetuation of allergic skin reactions. Skin barrier breakdown allows greater penetration of allergenic substances, thus increasing the opportunity for sensitization. Good skin care such...

Practical Applications in the Occupational Setting

Basel Freiburg Paris London New York Bangalore Bangkok Singapore Tokyo Sydney Library of Congress Cataloging-in-Publication Data Skin protection practical applications in the occupational setting volume editors, S. Schliemann, P. Elsner. p. cm. - (Current problems in dermatology, ISSN 1421-5721 v. 34) Includes bibliographical references and indexes. ISBN-13 978-3-8055-8218-6 (hard cover alk. paper) ISBN-10 3-8055-8218-8 (hard cover alk. paper) 1. Occupational dermatitis. 2. Skin-Safety...

Future Perspectives in Skin Protection

In contrast to many other occupational diseases, occupational skin diseases are not hidden. As they are visible for the subject and his environment with signs on the hands forearms, the necessity, success, but also the failure of preventive measures will be obvious for all participants. Therefore, teaching the company management and the workers about existing dermatological risks at the workplace and their consequences is reasonable. It is also easy to convince both groups that there are good...

Mechanical Irritation

In this study, we found the following rank of irritancy 9 occlusion with SLS and mechanical irritation > occlusion with SLS > occlusion with water and mechanical irritation > mechanical irritation and occlusion with water > occlusion with a glove and mechanical irritation > mechanical irritation > occlusion with water. Barrier disruption caused by occlusion or mechanical irritation was enhanced by the tandem application. The choice of irritant under occlusion, time of occlusion and...

Spectrum of Occupational Skin Diseases

Skin diseases are among the most frequent occupational diseases in many countries. In Germany, 40 of all notified and acknowledged occupational Others 1,747 Vertebral column disorders 308 Chronic Bronchitis Emphysema 336 Others 1,747 Vertebral column disorders 308 Chronic Bronchitis Emphysema 336 Occupational hearing impairments 5,478 Fig. 1. Notified and acknowledged occupational diseases in Germany 2005 1 . Occupational hearing impairments 5,478 Fig. 1. Notified and acknowledged occupational...

Fields of Combined Application

Application of skin protection cannot be regarded as equivalent to usage of protective gloves 6 . While gloves are indispensable in exposure settings with toxic or mutagenic materials, dangerous microbes, as well as when dealing with strong irritants, skin-protective products are primarily intended to diminish the barrier-impairing effects of repeated exposure to mild irritants and a high wet-work load in order to prevent irritant contact dermatitis of the cumulative type. In contrast to skin...

Practical Determinants of the Use of Barrier Creams

Even if a proper logistics of barrier creams is assured and workers are provided with adequate medical advice on dermal exposures at the workplace and skin protection (plan), one must not automatically expect that they will use barrier creams properly Figure 2 shows that subjects with a very high risk of hand eczema on the one hand ( group 1 in instructions for special periodical medical examinations for the prevention of occupational skin diseases 8 but only non-relevant dermal exposures at...

Tandem Repeated Irritation Test

As the model seemed to have potential for testing protective creams (PCs), the sequential application of 2 irritants in the TRIT was investigated in a study to evaluate the benefit of a commercially available PC compared to non-pretreated control sites 12 . Twenty healthy non-preselected Caucasian volunteers without any skin diseases were included. Informed consent was obtained from all participants, and the study passed the local ethical committee. Subjects were allowed to bathe as usual but...

Epidemiology

In Finland PICD was noted in 139 of 4,320 cases of occupational skin disease during a 7-year observation period 4 . However, the actual number is probably higher, because mechanical forces are accepted as natural occurrences by most employees and are not reported. Thirty-two percent of individuals presenting with PICD are atopic and 6 suffer from psoriasis 5 . PICD is aggravated occupationally in 84 of cases, in 6 related to hobbies and in 6 due to medical devices. Body sites most likely...

Allergens in the Workplace

So-called universal precautions resulted in the marked increase in use of latex gloves as personal protective equipment. Since then, the rate of NRL allergy, especially type I allergy, has increased. While approximately 1 of the general population is sensitized to latex, it is now believed that 10-17 of healthcare workers have a type I allergy to NRL allergenic proteins 6, 7 . However, these numbers may be inflated by self-reported allergy assessments. In a study by Allmers 8 , it was found...

Combination of Iodine and Anti Inflammatory Agents

The evolution of a chemical burn involves a variety of inflammatory processes including production of inflammatory mediators 4, 13-19 and dermal infiltration of polymorphonuclear cells 4 . This was supported by the beneficial effect of anti-inflammatory agents such as olvanil and indomethacin against SM in the mouse ear edema model 14 . A combination of iodine with steroidal (clobetasol) and nonsteroidal (piroxicam) anti-inflammatory agents led to improved therapeutic activity in the guinea pig...

Risk Factors for Occupational Skin Diseases Examples

Skin protection products are designed to protect the skin against exogenous risk factors occurring at the workplace. Among the most frequent non-toxic, non-cancerogenous and non-sensitizing low-grade hazards in the occupational field, water, wet work, detergents, solvents and cutting fluids seem to play an important role 3 . Regular skin cleansing with washing substances is one of the probable potential ways by which skin irritation might be induced 4 . The surfactants in modern cleansing...

Pathological Aspects of Skin Irritation

Exposure to skin irritants such as heat and ultraviolet light causes an inflammatory response initiated by erythema (local vasodilation) followed by blister formation and or dermal and epidermal ulceration and necrosis. In general, this is a feature common to the pathology of skin irritants however, they differ from each other by the kinetics of the evolution of the tissue response. For instance, heat burns develop rapidly there is an immediate burning sensation, and the appearance of erythema...

Avoidance of Photosensitizing Drugs

Intake of phototoxic drugs (whose action spectrum almost always involves the UVA range) and exposure to UV radiation cause erythema and edema or even vesiculobullous lesions on sun-exposed skin within hours in susceptible patients. In contrast, a photoallergic reaction is a delayed-type hypersensitivity response in which patients do not have clinical manifestations upon the first exposure to the photoallergic drugs. Sensitized individuals may develop pruritic eczematous eruptions. Photoinduced...

Background

Sunlight is indispensable for organisms living on earth and there is no doubt about the beneficial effects of sunrays on human beings. On the other hand, sunlight is biologically harmful. Numerous epidemiological investigations have shown that sunlight is carcinogenic to humans, and the IARC classifies sunlight within group 1, which includes human carcinogens 1 . Practical steps to achieve optimal sun protection include avoidance of the sun during the peak hours of radiation, avoidance of...

Fruit Acids

Twice daily application of either citric or malic acid alone did not induce a significant irritant reaction. Combined exposure to one of the fruit acids 6, 7 and SLS caused marked barrier disturbance, but the latter irritant effect was smaller than that obtained by a combined exposure to SLS and water. Thus, the combined exposure to the above-mentioned fruit acids and SLS did not enhance cumulative skin irritation. In a second study, we assessed the irritant effects and barrier disruption...

Methods

The study started in September 2000 and was terminated in February 2001. Ninety-four healthy apprentices of the occupational school for food-processing trades, Gera, Germany, were included in this controlled intervention study after providing their and their parents' written informed consent. The study was approved by the ethical committee of the Friedrich Schiller University of Jena. Fifty-eight apprentices were assigned to the UV hardening group (UV), and the remaining 49 apprentices were...

Risk Factors of Occupational Contact Dermatitis

The development of occupational contact dermatitis depends on a combination of endogenous (individual susceptibility) and exogenous factors (exposure). Except for an exposure to strong sensitizing substances, occupational contact dermatitis usually develops in steps, frequently starting with atopic hand dermatitis, followed by irritant dermatitis leading to sensitization and eventually allergic contact dermatitis (multistep eczema). Therefore, susceptibility to irritant dermatitis is of high...

Biological Effects and Side Effects of Suncare Products

In the past years, the safety and usefulness of sunscreens had been controversially and critically discussed on the basis of the following objections the use of a sunscreen may convey a misleading impression of security to the consumer, which may result in longer sun exposure and, therefore, greater skin damage 12 and, therefore, UV erythema should serve as a warning signal to discontinue sun exposure instead of being suppressed by sunscreen use 13 . Ingredients of sunscreen products may also...

Climatic Conditions

Environmental humidity has been shown to contribute to the appearance of the outermost surface of the skin. Employing a mouse model, the effects of the humidity on the skin's pathology have been studied 7 a dry environment leads to a drastic decrease in amino acids, i.e. filaggrin generation, and consecutively to stratum corneum imbalance and skin surface dryness. A decreased amino acid content has been found in dry skin 5 . In dry compared to normal skin, the expression of the...

Personal Protective Equipment

Barrier creams are used as both primary and secondary prevention from exposure to allergens in the workplace. Their functional intent is to provide a nonpermeable barrier, separating the skin from potential irritating, noxious and or allergenic substances to which a worker may be exposed. There are three types of nonspecific barrier creams, water repellant, oil repellant and silicone based. Water-repellant barrier creams contain hydrophobic substances. They are used in wet work professions and...

Electromagnetic Radiation

Electromagnetic radiation may irritate the skin. The effects of short-wave ultraviolet irradiation present a good example of this type of irritation. Details on UV protection are presented in the chapter by Kutting and Drexler (pp. 87-97). Changes in small cutaneous vessels, particularly capillaries, represent the earliest damage induced in the skin by ionizing radiation in those individuals administering X-rays. Later the caliber of the vessels increases, accompanied by a reduced blood flow....

Physical Irritant Contact Dermatitis

Physical irritant contact dermatitis (PICD) is a common occupational dermatosis with multiple types and many mechanisms involved in its development 1 . The diagnosis is primarily based on a history of exposure to a known irritant and negative patch test results to exclude contact allergy. The basic concept of PICD is physical skin damage without preceding or concomitant chemical irritation and sensitization, respectively. Initial PICD is characterized by a local inflammatory reaction, i.e....

Conclusion

The use of skin protection products such as BCs and moisturizers may help people to avoid or reduce the intensity of skin irritations caused by irritants at home and at the workplace. We should clearly educate people that BCs should be not used as a primary protection against high-risk substances as well as corrosive agents. It is recommended to provide the protection against low-grade irritants. However, wet workers utilizing water, soaps and detergents daily may benefit by applying BCs...

Protection against Irritants

Wet work and irritant exposure (table 2) in the healthcare setting are frequent due to hand hygiene which is indispensable with regard to prevention of cross-infections. Alcohol-based hand rubs may be superior to traditional hand washing and irritate the hands less often 2, 3 . Besides easy access to hand hygiene, skin protection has been introduced as a necessary prerequisite for a satisfactory hand hygiene behaviour 2 . In the healthcare setting, frequently protection gloves are used...

Suncare Products

The biological activity and efficacy of a suncare product, as represented by the SPF, is evaluated by its ability to protect human skin from erythema and edema. It is measured by determination of the dose which is required to induce a just perceptible redness (MED minimal erythema dose) on untreated and on sunscreen-treated skin. The SPF is defined as the ratio of the dose of UV radiation required to produce a minimal erythematic response 24 h after exposure on protected skin after application...

Mechanical Influences

Mechanical traumas to the skin can affect all levels from the stratum corneum to subcutaneous tissue. Excessive friction can result in the formation of various dermatoses. Hyperkeratosis, lichenification and calluses may be induced. However, sudden friction may induce blisters. Under experimental settings, tape strippings have been employed to induce PICD and to collect the intercellular composition of ceramides, sterols and fatty acids, i.e. stratum corneum lipids that maintain the water...