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OTHER DERMATOSESR:ROSENSTOCK

By M.H.Davari MD

Shahid Sadoughi University of medical sciences

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Work-related health problems as reported by UK occupational physicians during 1996

Problem

Musculoskeletal

Dermatological

Respiratory

Hearing loss

Other

P.M

Percentage

45.3

23.4

9.2

8.7

13.9

Thirty percent of occupational injury and 40% of occupational disease are dermatologic

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OCCUPATIONAL ACNE

1. Oil acne (folliculitis) Pathogenesis: hair follicle is particularly

susceptible to irritation from lipids plugging of the follicle (comedo formation) or induce an inflammatory reaction by rupture of the

follicular wall (folliculitis) Petroleum distillates, cutting oils, pitch, and tar

Clinical course: dorsae of the hands and forearms

Diagnosis: area of involvement history

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Age: any age Prevention:

Protective clothing Mandatory daily laundering of work clothes

Treatment: similar to those for routine acne Oral antibiotics (tetracycline and erythromycin) Topical antibiotics (clindamycin; erythromycin) Refractory Comedones long-term topical retinoids

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ACNE VULGARIS

Persons at risk: workers in fast food restaurants,

actors, actresses, models, and cosmeticians

Age: peak 11-20 yrs

Pathogenesis: in addition to oil, Friction, heat, and

sweating

Clinical course: face, neck, upper chest and back

Diagnosis: history of exposure

Treatment and prognosis: like oil acnea

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Viktor Yushchenko, the Ukranian President who was supposedly assassinated by the KGB with dioxin poisoning.

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CHLORACNE

Sensitive indicator of systemic exposure to specific polyaromatic hydrocarbons

Persons at risk include workers: hydrocarbonbased pesticides and herbicides, electrical workers exposed to older polychlorinated biphenyl (PCB)

Pathogenesis: follicular level of the agent may be of greatest importance

Clinical course: pale yellow (straw) cyst + comedo inflammatory papules and pustules of acne vulgaris are

not evident postauricular folds, the malar crescent, and the

genitalia. The nose typically is spared onset within 2w–2m regress over a 4–6m (1-2 yr)

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Non-cutaneous findings: Hepatomegaly, Hepatic porphyria, Peripheral neuropathy

TCDD causing chloracne at the lowest concentrations

Diagnosis: history of exposure (suggest) Serum levels of suspect compounds and

metabolites should be obtained (confirmation of exposure) (GC/MS)

Biopsy cause loss of follicular sebaceous glands (DDX: actinic elastotic comedones)

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Treatment: Difficult Oral antibiotics, topical retinoic acid, and oral

isotretinoin Cyst formation prevent by early retinoid therapy

Prevention: Even minute exposures must be avoided shower facilities Use disposable clothing for workers Routinely monitor for plant contamination using

wipe samples Routinely educate and monitor workers.

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PIGMENTARY DISORDERS

1. Hyperpigmentation Types:

1. Exogenous pigment deposition2. Deposition in skin systemically3. Photoeruptions (more common)4. PIH (more common)Or by wood lamp examination:5. Epidermal?6. Dermal7. Mix

Workers at risk: heavy metals, organic nitrogen compounds and dyes

17 Hyperpigmentation: nitro compounds and dyes that stain skin

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Hyperpigmentation: metals that may be systemically or locally deposited in skin

Clinical course: The most striking form of dyspigmentation is

argyria due to systemic deposition of silver. Pigmentation from heavy metal toxicity

exacerbated by exposure to the sun PIH occurs at the sites of skin injury

Diagnosis:1. History & examination2. Wood lamp examination3. Biopsy

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Prevention: Sun screen Protective clothes (exposure to organic dye-like

component) Treatment:

Tattoos and systemic heavy metal toxicity may be irreversible

PIH: may persist for months (dark skin)1. Retinoic acid2. Hydroquinone

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2. Hypopigmentation:1. PIH

Cutaneous injury, from inflammation or trauma

2. Leukodermia Hydroquinone or derivatives of alkyl phenols and

catechols Workers at risk: rubber workers, photographic

developers, hospital housekeepers, printers, and workers in the oil, paint and plastics industries

Pathogenesis: direct cytotoxic effect on melanocytes formation of antigens, which activate

lymphocytes Diagnosis : wood lamp Treatment:

1. long-term PUVA2. allograft

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Picture of a phototoxic drug reaction

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PHOTODERMATOSES

UVA: aging, occupational dermatosis UVB: sun burn UVA,B,C: carcinogen

Outdoor occupationsPhototoxic: Nonimmunologic, reactive O2, improve immediately with avoidancePhoto allergic: type IV imune reaction, substance convert to hapten, Not improve immediately with avoidance

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PHOTOTOXIC AGENTS

Some common plants containing furocoumarins

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Picture of photoallergic and phototoxic dermatides

29 Contact photodermatitis

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Diagnosis: History of sun exposure Typical photodistribution Exposure to photoactive substances biopsy may be helpful to exclude other causes of

photosensitivity (lupus erythematosus, medications)

Prevention: Sunscreens: (SPF) rating of #15 or better ,(which

is less effective in preventing UVA) Use of protective clothing EPA (enviromental protection agency)

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http://www2.epa.gov/sunwise/uv-index-scale

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Treatment: open-wet dressings bland emollients Rarely systemic steroids for severe cases.

Prognosis: Workers with clinical signs of chronic sun

exposure are at risk for cutaneous malignancies and should be followed closely

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ERYTHEMA AB IGNE

The area usually is regional corresponding to the site of repeated applications of heat

Workers exposed to furnaces, such as cooks, stokers, glass blowers, and kiln operators

Clinical course: Early:

vasodilation (livedo reticularis)Later:

Poikiloderma(epidermal atrophy, telangiectasia, and pigment alteration)

SCC and Merkel cell carcinomas occur in the poikilodermatous area

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Diagnosis: The local nature of the condition, along

with a history of exposure to heat, is suggestive

Biopsy: exclude other conditions associated with livedo reticularis

Prevention: Repeated exposure avoidedEducation of workers at risk is the key to

prevention. Treatment

Cessation of exposure in early changes.permanent change: monitored for future

development of skin carcinoma

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MILIARIA

Bakers, foundry workers, cooks, coke oven operators, and workers with similar exposure to excessive heat that causes sweating

blockage of the sweat ducts Trunk: most commonly affected location, especially the

chest, back, submammary, and axillary areas Clinical lesions are on a spectrum encompasssing clear vesicles 1. if the blockage is in the superficial epidermis (miliaria

crystallina)2. macules or papules if the blockage is in the lower

epidermis (miliaria rubra) or3. flesh-colored to pale white papules if the obstruction is

in the dermis (miliaria profunda).

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Symptoms usually are absent with miliaria crystallina, while miliaria rubra and miliaria profunda may be pruritic or painful

May lead to inadequate body thermoregulation with accompanying heat exhaustion

Pathogenesis: Sweating and maceration cause plugging of

the eccrine sweat duct with ductal keratin. Microbial organisms may invade the macerated keratin and cause further plugging of the duct

Diagnosis: clinical picture, symptoms, and the history of onset

after excessive heat exposure and sweating.

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Prevention: exposures should be avoided Hexachlorophene soap decrease bacterial population. Maceration of the skin should be avoided by frequent

clothing changes when sweating is profuse. Treatment and prognosis

Removal A period of a week or more should elapse before re-

exposure of the individual to the hot environment is attempted, particularly if the eruption is severe enough to cause a decrease in systemic heat tolerance.

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Cleaners of vinyl chloride polymerization reactor tanks1. Raynaud’s phenomenon 2. Osteolytic bone changes3. sclerodermia

Silica dust have been reported to be at risk for developing:1. Raynaud’s phenomenon2. Scleroderma

organic solvents has also been associated with: systemic sclerosis

OCCUPATIONAL ACRO-OSTEOLYSIS AND SCLERODERMA

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Diagnosis: Patients presenting with Raynaud’s phenomenon

without a history of vibration exposure should be questioned regarding exposure to vinyl chloride, silica, organic solvents, and epoxy resins

Prevention Workers cleaning polymerization reactor tanks of vinyl

chloride need complete skin and respiratory protection.

Respiratory protection also is critical in those workers exposed to silica.

All workers with Raynaud’s phenomenon, whether or not the condition is job related, should have protection of their hands from cold weather

Treatment and prognosis Acro-osteolysis stabilize after withdrawal from vinyl

chloride monomer exposure Scleroderma of any cause, however, tends to be

progressive.

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FOREIGN BODY REACTIONS

Workers in construction, electronics, metal working, and mining1. Fiberglass (extremely pruritic)2. Beryllium3. Sillica 4. unusual form clam diggers as a result of exposure

to avian schistosomes5. Hairdressers

Acute reactions resemble irritant dermatitis. Chronic reactions typically are more

papulonodular Secondary bacterial infection may

complicate the clinical picture

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Pathogenesis: A granulomatous respons is typically a non-

allergic response Beryllium is due to delayed hypersensitivity

Treatment and prognosis Localized granulomas of any cause may be

treated surgically. Topical therapies including open wet

dressings and topical steroids are useful in the treatment of acute foreign body reactions.

Fiberglass may be removed by using tape stripping of the skin.

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BIOLOGIC CAUSES OF OCCUPATIONAL DISEASESBACTERIAL DISEASES:

work with animals and those in the construction trades

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FUNGAL DISEASES

workers at greatest risk are thosein the agricultural trades

Candida and dermatophyte infections are the most common superficial fungal infections

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An unusual variant of tinea pedis (one hand–two feet tinea) needs to be considered in the differential diagnosis of hand dermatitis

Diagnosis: potassium hydroxide examination of scale fungal culture

Treatment: Topical antifungal agents usually are adequate

for treatment, although occasionally administration of oral antifungals (griseofulvin, ketoconazole, itraconazole, terbinafine) is necessary

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VIRAL DISEASES

HSV1/2 infection of the finger (herpetic whitlow) 1. Healthcare workers.2. Farm workers 3. Meat handlers

Untreated infections last for 1 to 2 weeks Athough therapy with oral antivirals is helpful in

shortening the course. Diagnosis:

Tzanck smear, showing multinucleated giant cells viral culture

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PARASITIC DISEASES

Parasites are unusual causes of occupational disease in temperate climates

However, workers in developing countries are at particular risk.

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