Module 1 - Dermatology

Skin disorders and the occupational physician
In the US alone, occupational skin diseases:
...account for approximately 50% of occupational illnesses.
...are responsible for an estimated 25% of all lost workdays.
...have been estimated as costing up to $1 billion each year.
[Source: Peate; Baxter et al.]
Occupational skin diseases are also among the top three registered occupational diseases in Europe. In the UK,
reports between 2002 and 2005 suggest overall rates of 406 per million workers. However, with most cases going
unreported, these figures probably represent only the tip of the iceberg.
Due to the prevalence of occupational exposures that can cause or exacerbate skin disorders, it is advisable to
screen all employees with skin disease for a work-related cause.
[Source: European Agency for Safety and Health at Work; Baxter et al.]
There is no universally accepted definition for occupational skin disease. These disorders tend to be broadly
defined as dermatoses (skin diseases) that are due wholly or partially to the person's occupation.
In stricter definitions, occupation must be a major contributing factor; and in the strictest ones, work must be
essential to causation.
Workers of all ages in a wide variety of settings are affected.
Which occupations do you think are most prone to work-related dermatoses?
The following areas account for 80% of reported occupational skin diseases in Europe:
• Hairdressing/beauty therapy
• Food industry
• Healthcare (including dentists and vets)
• Laboratory work (including scientists and laboratory technicians)
• Cleaning
• Painting and decorating
• Motor vehicle repair
• Construction
• Printing
• Homemaking
[Source: Ford]
Learning outcomes
On successful completion of this week, you will be able to:
• define the incidence, prevalence, and significance of occupational skin disorders and how these present in
the context of occupational medicine
• identify the main clinical features of work-related skin conditions
• apply basic concepts relating to the skin’s anatomy, physiology, and functions to occupational
dermatology issues
• carry out appropriate history taking, examination, and investigations to diagnose and make accurate
prognoses of work-related skin conditions
• clarify the occupational physician’s role at every stage of skin disorder management
• identify how the hierarchy of control is applied to prevent work-related skin disorders and manage their
associated risks
• evaluate fitness for work, defining adjustments and accommodations to prevent work-related skin
conditions and support employees with existing dermatological problems
The fundamentals of occupational dermatology
The basic physiology of the skin
The skin is comprised of the epidermis, dermis, and subcutis (or subcutaneous layer). It acts as a protective barrier
against a number of hazards within our environment, and is immunologically active through defense mechanisms
in the upper two layers. Having an appreciation of the skin's physiology aids understanding of the mechanism of
occupational skin disorders.
Select the icons to learn more about the three layers.

Epidermis
This constantly-renewing surface layer of the skin is comprised of

cells called keratinocytes, which:
• are stacked on top of each other to form sub-layers
• develop at the bottom and rise to the top, where they are
shed from the surface as dead cells
The epidermis’ most superficial layer, also known as the barrier

layer or horny layer:
• is a paper-thin lipoprotein membrane that is remarkably

resistant to penetration, although vulnerable to substances
of molecular weight < 1,000
• hinders water loss from deeper layers
• protects from UV radiation, mechanical damage, foreign chemicals, bacteria, and viruses
Dermis
This layer consists mostly of connective tissue and is much thicker than the epidermis. The dermis:
• is responsible for the skin’s pliability and mechanical resistance
• is involved in the regulation of body temperature
• supplies the avascular epidermis with nutrients via its vascular network
Subcutaneous layer
Sitting below the dermis, the subcutaneous layer:
• consists of loose connective tissue and fat
• acts as a protective cushion
• helps to insulate the body by monitoring heat gain and heat loss
• impacts the appearance of the skin
[Source: dermis.net]
Sub-features of the epidermis
• Basal cell carcinoma is believed to arise from the non-differentiated cells at the base of this layer.
• Squamous cell carcinoma is believed to arise from the cells in this layer.
• Hair follicles are downward growths into the dermis of epidermal tissue that produce hair. They are found
all over the body, except on the palms of hands, soles of feet, and lips.
• Melanocytes produce melanin, a dark pigment that contributes to skin color and provides UV protection.
• Dendritic (Langerhans) cells are involved in the epidermal immune system; they engulf foreign material
invading the epidermis and migrate out of the skin to stimulate an immune response.
Sub-features of the dermis
• Sebaceous glands, or oil glands, are small sacculated organs that secrete sebum (an oily substance that
acts as a natural moisturizer that conditions the hair and skin). These glands are found all over the body,
but they are more numerous in the scalp area and around the forehead, chin, cheeks, and nose.
• Sweat glands consist of a single tube, a coiled body, and a superficial duct; they are involved in
thermoregulation as they cool the skin by sweating.
• Nerve fibers forward information.
• Blood vessels are tiny pipes that supply

the skin with fresh blood (containing
nutrients and oxygen) and carry away waste
products.
• Arrector pili muscles are attached to the

bases of hair follicles; when they are
stimulated (e.g., by cold), they cause the
hairs to stand upright.
• Pacinian corpuscules function as

receptors for deep pressure and vibration.
• Meissner’s corpuscules are touch

receptors, especially effective in detecting
light touch and soft, fleeting movements.
• Free nerve endings are susceptible to pain, temperature changes, and itchiness.
Info: With a surface area of 1.5 to 2 m² and comprising roughly a sixth of the body's weight, the skin is the biggest
and functionally most versatile sense organ of the human body.
[Source: European Agency for Safety and Health at Work]
Types of exposure
Aside from the respiratory tract, a worker’s first line of contact with their environment is the skin. Disease can arise
from exposure to chemical, biological, or physical agents.
Select each heading to learn more about each kind.
Chemical exposure
Exposure to chemical substances is a leading cause of occupational skin disease. As most work involves manual
activities, the skin of the hands is very likely to be involved.
Numerous substances can trigger a response, including:
• acids and alkalis

• solvents and detergents
• mineral oil and other oils
• natural and artificial resins
• additives, preservatives, flavorings, and optical brighteners
• proteins
• plants
• epoxyresins and acrylates
• tar derivatives and halogen-containing compounds
• catechols, phenols, and vinyl chlorides
• furocoumarins
Biological exposure
Infectious agents may be encountered from various sources during work and could be bacterial, viral, fungal, or
parasitic in nature. The diagnostic and treatment process is identical to non-occupational disease. Some
examples include:
• unsanitary or inherently dirty environments (e.g., sewers)
• animals (notably, horses, cattle, pigs, cats, and dogs)
• aquatic life
• insects
• plants
Physical exposure
Physical exposure ranges from direct stimuli to environmental conditions and includes:
• mechanical trauma—including recurring rubbing, vibration, or increased pressure
• environmental factors—including prolonged heat/cold or high/low humidity
• ionizing or non-ionizing radiation—from either superficial or natural sources
• physical irritants—such as particulates, rough surfaces, and fibers (e.g., in fiberglass)
[Source: Ford]
Examples of occupational skin disorders
Establishing the possible triggers or exacerbating factors when taking a worker's history is crucial in reaching an
accurate diagnosis.
Select each card to see some examples of occupational skin disorders with a chemical, biological and
physical origin.
Skin disorders of chemical origin include:

• contact dermatitis (irritant, allergic, phototoxic, airborne)
• urticaria
• occupational acne/folliculitis
• skin cancer
• scleroderma
• leukoderma
• chemical burn
Skin disorders of biological origin can be bacterial, viral, fungal, or parasitic.
Bacterial: Pyodermas (commonly caused by Staphylococcus/Streptococcus), MRSA, skin TB, erysipeloid (from
fish and poultry), erythema chronicum migrans (ECM)
Viral: Orf, Milker's nodules
Fungal: Tinea corporis/trichophytia profunda (ringworm), candida albicans
Parasitic: Scabies, head lice
Skin disorders of physical origin include:
• lichenification
• miliaria
• intertrigo, fissures, blisters, callosity
• progressive vasoconstriction, chilblains, thermal burns
• radiodermatitis (acute/chronic)
• erythema, sunburn
• photoaging
• solar keratosis/keratoacanthoma
• skin cancer
[Source: Ford; European Agency for Safety and Health at Work; Peate]
General principles of diagnosis and treatment
If occupational skin disease is suspected, an in-depth history should cover:
• the exact time relationship between the skin condition (i.e., onset, improvement, and recurrence) and work
exposure, including the effects of time off and return to work
• family or personal history of atopy
• any present systemic disease that may have skin manifestations (e.g., diabetes mellitus)
Here are some common questions you might expect an occupational physician to ask during history-taking:
• Do you work with any chemicals or other potentially hazardous substances/irritants? If so, are you aware of
the safety data sheets for these?
• Do you have any tasks that involve direct skin contact with particular substances? If so, which substances,
and how long does the contact last?
• What types of controls are present at work to minimize or prevent exposure in your daily role? E.g., is
access limited to any particular substances? Are you provided with any protective equipment, such as
gloves?
What other questions might an occupational physician ask to assess exposure?
• Can you tell me about your general work conditions—for instance, is it particularly hot/humid/dirty?
• Do you encounter exposure other than skin contact—perhaps through inhalation or ingestion while eating?
• Do you work closely with other people, animals, or plants?
• Does your job involve exposure to radiation?
• Do any of your fellow workers have skin disease or symptoms like yours?
• Do you follow any particular personal or occupational hygiene rules?
• Have you noticed any improvement in your skin after being away from the workplace?
• Are you exposed to potential irritants or allergens outside of the workplace?
• What kind of hobbies are you involved in?
• Have you traveled recently or done any renovations to your home?
• Do you have pets?
• Are you taking any medications, including topical ones?
• Do you think your skin issues are related to your work? Why?
Clinical tip: History-taking should be focused on identifying possible causes while taking into account the skin's
presentation. For instance, a presentation of miliaria (heat rash) should involve inquiry about:
• the work environment
• physical demands of the job
• use of personal protective equipment
• use of medication such as clonidine
As part of the clinical examination, the occupational physician should look for the following when assessing
morphological presentation:
• redness, dryness, swelling, cracking, fissures,
eczematous lesions
• unusual pigmentation
• hives and other allergic responses
• acne or oily skin
• miliaria (i.e., “prickly heat,” with many tiny

vesicles near openings of sweat and
sebaceous glands)
• evidence of infection
General principles of treatment
Treatment depends on the history and diagnosis of the condition presented. While therapeutic measures almost
always provide some relief, cure is usually dependent on identifying the offending agent and removing exposure to
it.
Popular treatments used to treat the symptoms of occupational skin disorders include:
• steroids, systemic antihistamines and wet dressing—for conditions that are weepy, edematous, vesicular
(and usually acute)
• emollients and topical steroids—for conditions that are dry, scaly, cracked (and often chronic)
Info: For bacterial infection, topical or systemic antibiotics are usually indicated; other disorders of biological
origin may require specific medication. Tumors require surgical excision and possibly further treatment if they are
malignant.
General principles of prevention and control
Encouragingly, most occupational skin disorders can be prevented. However, before you focus on the measures
that can be taken while on the job, there are certain considerations to bear in mind.
What is research waste?
Predisposing factors can contribute to skin disease from a particular job.
For instance, outdoor workers—such as construction workers—with a lighter skin complexion (as a predisposing
factor) may be more prone to sunburn and other conditions related to UV exposure.
Having a pre-existing skin disease puts workers at greater risk of developing occupational skin disease.
For instance, employees who have a history of irritant

contact dermatitis face the possibility of exacerbating
their condition if they pursue a career that involves a lot of
wet working.
Info: The role of the occupational physician is to support

employees to remain in work wherever possible and
support their employers to help them do this.
Ordinary protective measures may not be sufficient for

some workers. However, with the right adjustments and
accommodations, they may still be able to continue in their chosen careers.
Each worker’s circumstances are unique, and recommendations should be made on a case-by-case basis.
However, many preventive measures have universal application.
Match each occupational exposure to the most suitable preventive measure.
[Source: Peate]
Preventive measure: Clothing made of tightly woven material
Select an answerLiquids/vapors/fumesDust/particulatesSunlight/UV lightTrauma
Answer: Dust/particulates
Preventive measure: Face shield, plastic or synthetic gloves and aprons, adequate ventilation
Answer: Liquids/vapors/fumes
Preventive measure: Leather gloves with smooth finish; steel tipped shoes
Answer: Trauma
Preventive measure: Protective clothing (hat, long-sleeved shirt), high SPF emollients
Answer: Sunlight/UV light
Submit
Incorrect.
Employers have a duty of care to ensure a stringent and holistic approach is taken to reducing workplace hazards
that put employees' skin at risk.
Like in other occupational safety and health programs, prevention measures should follow the hierarchy of control.
As such, suitable personal protective equipment (PPE) should be viewed as the least effective method of
protecting workers.
Hierarchy of controls
The hierarchy of controls is a step-by-step approach to eliminating

or minimizing workplace hazards. Controls are ranked from the
most effective level of protection (elimination) to the least effective
level (PPE), so employers should take a top-down approach to the
inverted pyramid. For each layer, the employer evaluates the
feasibility of controls in relation to the hazard, before moving to the
next layer. When they reach the bottom of the pyramid, they will
have identified as many controls as needed to adequately protect
workers from the hazard in question.
Carrie's hair straightening treatment
In what follows, an example for each stage of the hierarchy of control will be provided in relation to Carrie's hair
salon.
Carrie has learned that one member of her team—Jez—is sensitive to a particular chemical in a popular hair-
straightening treatment the salon offers.
Elimination
The most effective way of controlling a hazard is to eliminate it,

which involves removing it entirely from the workplace.
Elimination should be used whenever possible.
Example: Carrie stops offering the hair straightening treatment

altogether.
Substitution
This involves replacing the hazard with a less hazardous

alternative. Care must be taken to ensure that the new hazard
poses a lower risk and not one that is potentially equally (or more) harmful.
Example: Carrie continues to offer the hair straightening treatment, but switches to a different brand that has
gentler ingredients.
Engineering controls
These involve preventing people from coming into contact with the hazard.
Engineering controls can be built into the design of a location,

equipment, or process and are a reliable way to control exposure—
provided they are designed, applied, and maintained properly. The
most common types of engineering controls are:
• process controls, which involve changing the way a job activity

or process is done
• enclosure and isolation controls, which aim to keep the hazard

"in" and the worker "out"
• ventilation controls, which add or remove air in the work environment to dilute or remove an air
contaminant
Example: Carrie keeps offering the existing hair straightening treatment, but keeps the sensitizing product in a
locked cupboard. She only books clients in for the treatment on Jez’s day off.
Administrative controls
Administrative controls establish work practices that reduce

the duration, frequency, or intensity of exposure and should be
applied in combination with other control measures.
Note: the hazard itself is not necessarily reduced or removed

from the workplace.
These include:
• work practice controls, which enforce safe procedures

when working with a hazard, e.g., completing risk
assessments, checking relevant safety data sheets,
limiting access to the hazard, etc.
• education and training controls, which empower workers to understand how to do their jobs safely in light
of the associated risks and protective measures
Example: Carrie keeps offering the existing hair straightening treatment, but does not allow Jez to carry it out on his
clients—she offers them an alternative stylist instead.
Personal protective equipment (PPE)
PPE refers to anything workers wear to help protect them from

a workplace hazard, e.g., gloves, coveralls, and aprons.
Using PPE as a main method to control exposures should be

limited to situations where:
• other control methods are not practicable
• additional protection is required or the hazard is a

result of a temporary/emergency situation
Considerations around PPE:
• PPE can be effective, but only when workers use it

correctly and consistently.
• PPE may appear to be an inexpensive option, but it can be costly over time.
Example: Carrie allows Jez to keep carrying out the straightening treatment, but always ensures he has adequate
PPE—gloves, apron, etc.
Alert: Administrative controls and PPE require significant and ongoing effort by workers and their supervisors.
Occupational physicians must bear this in mind when making recommendations and be realistic about human
error and possible shortcomings in terms of adherence. This is why elimination, substitution, and engineering
controls should always be prioritized wherever possible.
Summary for skin disorders and the occupational physician
Key learning points
You have completed this section. Review each key learning point before you progress.
• Occupational skin disorders are a widespread and commonplace form of occupational illness; because of
their high prevalence, all employees with skin disease should be screened for a work-related cause.
• There are certain occupations that make workers more prone to occupational skin disorders, and
occupational physicians should be mindful of these.
• Having an awareness of the features of the skin’s epidermis, dermis, and subcutis helps occupational
physicians understand the mechanism of occupational skin disorders.
• Occupational skin disorders can arise from chemical, biological, and physical exposure; knowing the type
of exposure can assist the occupational physician in reaching diagnosis.
• As well as clinical examination, taking an in-depth history is key to accurate diagnosis; this should cover
the time relationship between exposure and onset of disease, along with any existing atopy and systemic
disease.
• Treatments reliably provide relief from symptoms, but cure is usually dependent on identifying and
eliminating exposure to the offending agent.
• Prevention measures should follow the hierarchy of control, with elimination being the first measure to
consider, and PPE the last.
An overview of occupational dermatitis
Occupational contact dermatitis (OCD)

accounts for about 90% of skin disorders in
the workplace, and can broadly be categorized
as either:
• irritant contact dermatitis (ICD)
• allergic contact dermatitis (ACD)
• another occupational skin disease
Because it tends to develop at the site of

occupational contact, the hands are involved
in as many as 90% of cases of occupational
contact dermatitis.
[Source: Ford; Peate]

Distinguishing OCD
Dermatitis can be further categorized in the following ways:
• endogenous (i.e., with an internal or systemic cause), also known as atopic dermatitis, a common skin
disorder that is based on genetic disposition of decreased barrier function and impaired repair
• exogenous (i.e., through contact)
While the predominant focus of the occupational physician is the latter,

often a worker presents with a mixture of both. This is because atopic
dermatitis is a strong risk factor for developing OCD.
The two types can only be distinguished from each other on the basis of
etiology (as opposed to morphology or histopathology). The occupational
physician must also distinguish OCD from clinically similar dermatoses,
such as psoriasis and tinea.
Info: The term dermatitis is sometimes mistakenly used synonymously with

the term eczema. However, eczema might best be reserved for endogenous
or constitutional dermatitis, i.e., not caused by occupational or other
exposure.
The physiology of OCD
To cause contact dermatitis, a substance must first be capable of penetrating the barrier layer of the epidermis to
the living tissues beneath.
There, it can cause contact dermatitis by one of two mechanisms:
• contact irritation—which may result in irritant contact dermatitis
• contact sensitization (or contact allergy)—which may result in allergic contact dermatitis
Both forms of contact dermatitis may be morphologically and histologically indistinguishable from each other.
[Source: European Agency for Safety and Health at Work; Baxter et al.]
Diagnostic testing
As well as taking a comprehensive history and performing a clinical

examination, there are diagnostic tests that aid in the diagnosis of OCD.
Patch testing is usually used to verify allergic contact dermatitis. This

involves applying a minute and diluted dose of the potentially offending
substance to the skin, which is then observed periodically.
For irritant contact dermatitis, diagnosis is more reliant on the history-

taking and elimination of suspected triggers.
[Source: European Agency for Safety and Health at Work; NHS]
Clinical tip: Mixed form (allergic plus irritant) contact dermatitis also occurs frequently. There may be a number of
reasons for this:
• A substance may have both irritant and sensitizing properties.

• The worker may be exposed to multiple substances.
• Irritant exposure harms the barrier function of the skin, which promotes sensitization by enabling increased
absorption of allergens.
Irritant contact dermatitis
Accounting for up to 80% of cases, irritant contact dermatitis (ICD) is the most
common occupational skin disease. It is around five times more frequent than
allergic contact dermatitis (ACD).
ICD occurs when contact with the offending agent injures the skin’s surface
faster than the skin can repair the damage. This non-immunologic response
often develops slowly over days to months.
It may be a single episode, repeated relapsing episodes, or chronic due to repetitive injury. Previous damage may
render the skin more susceptible to future exposure.
Select each section to find out the answers to some commonly asked questions about ICD.
How does ICD usually present?
The rash appears in the exposed or contact areas, and often where the skin is thinner (e.g., the dorsum of hands
rather than the palms). Lesions assume a clearly demarcated pattern; they tend to be asymmetric and can be
unilateral.
Why is wet work a leading cause?
ICD can be caused or exacerbated by prolonged exposure to weaker irritants (such as water, solvents, or soaps).
This disrupts the natural barrier of the skin, also increasing the risk of allergy because sensitizing agents can more
easily penetrate.
Note: The more frequent wearing of occlusive gloves results in increased sweating of the hands, which in itself can
be a cause of irritation.
Why are strong irritants becoming a less common cause?
This is largely due to the increasing use of effective PPE (such as protective) gloves.
Consequently, the prevalence of acute ICD (which results in more extreme and often immediate symptoms) has
also decreased. Chemical burns are included in this category, but because of their severity, these are not often
reported in the first instance to the occupational physician.
How and why does the age of onset vary?
Age of onset varies from one occupation to another, with those at both ends of working life seeming to be at higher
risk than those in mid-career.
One example of early onset could be a susceptible apprentice hairdresser who presents with ICD due to more
frequent wet work (hair washing) involved in the personal care of clients.
Conversely, an example of later occupational onset could be a motor mechanic who, after 20–30 years of exposure
to irritants (solvents and friction), presents with chronic hand eczema.
The degree of damage following exposure depends on:
• the potency of the irritant
• duration of application
• frequency of exposure
• occlusion of the irritating agent (e.g., by gloves, jewelry, or wristwatch)
• temperature
• anatomical site
• individual susceptibility (in atopic individuals, the skin has a lower capacity to resist against irritants)
Agents that can cause ICD
The most common irritants involved are:
• soaps
• detergents
• strong acids and alkalis
• heavy metals
• solvents
• synthetic oils
• fiberglass
• wood preservatives
• hair dyes
• wet work
• friction
• multifunctional acrylates
• adhesive
• metalworking fluids
Workers affected
Types of workers commonly affected include:
• factory workers
• medical workers
• waiters
• butchers
• bartenders
• kitchen staff
• cleaners
• construction workers
• florists
• metalworkers
• printers
• vets
Irritant contact dermatitis: Key facts
Select each icon to learn more about this condition.
Symptoms
Mild to moderate (often chronic) symptoms include: xerosis (dryness); redness; erythema; cracking; lichenous
lesions; hardening or adaptation; fissures; edema (swelling); burning; and bleeding.
Severe (often acute) symptoms include: painful lesions, which may be weepy, bullas, and vesicular; broken skin,
which leads to a risk of infection; erosion; desquamation; and necrosis.
[Source: Peate; Ford; Baxter et al.]
Differential diagnosis
The differential diagnoses for irritant contact dermatitis include:
• chronic inflammatory joint diseases
• connective tissue disorders
• rheumatoid arthritis
• psoriatic arthritis
• infection
• mechanical stress
History
Ask about:
• onset and symptoms

• presence of rash in areas that are exposed/in contact
• clinical improvement of the rash on removal of the offending agent
• underlying atopy or systemic illness that affects general immunity
Investigations
Investigations for irritant contact dermatitis include clinical examination and patch test (negative).
Treatment
Treatment for irritant contact dermatitis includes:
• emollients
• topical steroids
• antibiotics (for secondary infection)
Preventive measures include:
• avoiding contact with the substance and using alternative
• using PPE, barrier creams, special clothing (e.g., gloves, apron)
• practicing good hygiene (wash contaminated skin or clothing immediately if contact occurs)
Allergic contact dermatitis
Allergic contact dermatitis (ACD) is an immunologic response to exposure to an antigenic substance. It accounts
for more than 10% of occupational skin disease—a figure that appears to be rising.
Sensitization may be induced after only one contact or after many contacts over a prolonged period (during which
time it had been tolerated). However, once sensitized, the reaction may occur with minimal exposure to the
allergen.
Info: The percentage of people who react to a particular substance varies widely, but only people who are allergic
will display symptoms. Sensitization to one agent may induce sensitivity to related substances, but susceptibility
to one allergen does not necessarily imply any general susceptibility to contact sensitization.
The mechanism of ACD
After penetrating the barrier layer of the skin, a contact allergen is chemically reactive enough to provoke a type IV
allergy (also known as a delayed or cell-mediated response). As such, ACD depends primarily on the activation of
specifically sensitized T cells, which is an untoward side effect of a well-functioning immune system.
Select each step for more information about the stages of the development of a type IV allergy.
1- Stage 1: Induction
• Step 1: The allergen binds to major histocompatibility complex (MHC) class II molecules on the surface of
allergen-presenting cells—which are present on Langerhans’ cells within the epidermis.
• Step 2: These cells migrate via the lymphatics to the paracortical areas of the regional lymph nodes.
• Step 3: T cells specifically recognize the allergen-class II molecule complexes and are activated to
proliferate within the node.
• Step 4: These T cells are released into the circulation and enter the skin.
Once initiated, induction takes around 7 days to be completed. After such time, further skin contact with that
particular allergen results in Stage 2 of the process.
2- Stage 2: Elicitation
• Step 1: Allergen-presenting cells and specific T cells meet in the skin, leading to cytokine production.
• Step 2: Release of these mediators results in the arrival of more T cells, which further amplifies local
mediator release.
• Step 3: A dermatitic reaction is produced—this is within a few hours to 1 or 2 days of the re-exposure,
depending on both degree of contact and degree of sensitivity.
Hypersensitivity to a given chemical may last for life, although avoiding further contact with the chemical agent
may lower the level of reaction.
[Source: Peate; Baxter et al.]
Select each section to find out the answers to some commonly asked questions about ACD.
How does ACD usually present?
The rash appears in areas that have been exposed to the sensitizing agent, and it tends to have an asymmetric or
unilateral distribution. It may appear elsewhere on the body if the sensitizing agent has been transferred via the
hands or clothes.
How can I tell the difference between ICD and ACD?
In appearance, ACD can be indistinguishable from ICD—which is one reason that taking a detailed history is
crucial to diagnosis. However, workers with ACD cite itching as predominant over burning. Furthermore, with ACD,
skin lesions are more likely to develop at unexposed parts too (whereas with ICD, they tend to be more limited to
places of contact).
ACD is often less amenable to subsequent prevention, because of the much smaller quantities of allergen that
may cause a response in a sensitized individual (compared with the quantities required of irritants to trigger ICD).
Consequently, unless the allergen can be identified and removed from the workplace, it can be much more difficult
to manage.
Is latex allergy relevant to ACD?
Yes, it can be. People can react to latex in one of two ways:
• Type I reaction (urticaria)—primarily caused by the latex protein in the gloves
• Type IV reaction (ACD)—usually caused by the non-latex chemicals used in glove production
Note: Between 10 and 17% of health workers react to latex—a considerable proportion of a workforce that is
almost universally required to wear protective gloves routinely.
Common irritants include:
• hair dyes
• metals (chromium, nickel, cobalt, and mercury)
• rubber
• accelerators
• epoxy resins
• rhys genus (e.g., poison oak, poison ivy)
• acrylates
• p-phenylenediamine (PPD)
• natural and artificial resins
• biocides
• preservatives
• animal feeds
• plants
• pharmaceuticals
Types of workers commonly affected include:
• firefighters
• maintenance and utility workers
• landscapers
• workers in high-tech industries (e.g., computers, chemicals, electronics)
• wire and cable workers
• floor layers
• pipe workers
• cashiers
• grinders
• jewelers; battery makers; electroplaters
• miners; refiners; textile workers

• nail technicians, hairdressers, and beauticians
• healthcare workers and dental technicians
• cleaners
• painters
• florists
Allergic contact dermatitis: Key facts
Symptoms
Pruritus is the overriding symptom; the rash—depending on severity— is characterized by erythema, vesicles,
edema, xerosis, redness, and cracking. Secondary infection is common if left untreated.
The differential diagnoses for allergic contact dermatitis include:
• irritant contact dermatitis
• psoriasis
• dyshidrotic eczema
• lichen simplex chronicus
• tinea corporis
• atopic dermatitis
[Source: European Agency for Safety and Health at Work; Ford]
History
Ask about:
• onset (time between exposure and response can indicate the agent responsible)
• symptoms;
Investigations
Investigations for allergic contact dermatitis include clinical examination and patch test.
Treatment
Treatment for allergic contact dermatitis includes:
• emollients
Tunde's sore hands
Tunde has arrived in clinic because of the progressive discomfort he has been in with his sore hands.
Select each tab to review Tunde's record.
• Employee
o Name: Tunde
o Age: 35
o Occupation: Trainee chef
• Presenting complaint
o Dryness
o Stinging sensation and mild pruritis
o Mild edema on the skin of both hands, extending up to wrist—no secondary areas
• Medical history
o In general, Tunde is in good health

o No records relating to atopy or skin disorders in the past
o Not on any medications
• Known allergies
• Penicillin
Clinical examination
Note: The subtle redness that develops from contact dermatitis can be more difficult to detect in people with
darker skin tones.
To get further clarification on what might be causing Tunde's rash, the occupational physician takes a detailed
history.
Occupational physician
Tunde, please can you tell me a bit about what your work as a trainee chef involves?
Tunde
Aside from actually cooking, I do a lot of food preparation. I also help with cleaning at the end of the day—including
the stove.
And how long have you been doing this job?
Tunde
Not long, actually. I left my previous job as an accountant to follow my dream of becoming a chef. I started my
training about 3 months ago.
And has anything changed in your life outside of work?
Tunde
No, everything else is the same. I've never had any issues like this since I was a child, when I had very mild eczema.
When did you first notice symptoms?
Tunde
About 2 weeks after I started in the kitchen, my hands became dry and a bit sore. They've got progressively worse
since then.
Does anything seem to make your symptoms better or worse?
Tunde
I haven't tried anything yet. Some people in the kitchen wear gloves, but I find it easier to handle the food without
them. I try not to get the detergents on my skin, because that seems to dry them out more. Handling very hot or
cold things also makes them sore.
Clinical tip: Patients tend to underestimate the length of their history, remembering the exacerbation that finally
led them to seek medical advice rather than the original onset of the earliest signs. Furthermore, many patients do
not seek medical advice until they have had milder degrees of contact dermatitis for considerable periods.
Visiting the workplace to look at the work being done can increase understanding.
[Source: Baxter et al.]

Based on what you know about Tunde's sore hands, what do you think is the likely primary diagnosis?
Select all correct options.
• Irritant contact dermatitis
• Allergic contact dermatitis
• Bacterial infection
Correct.
It is likely that Tunde's primary reaction was irritant in nature. Prolonged and constant contact with water,
detergents, and wet foodstuffs, along with potentially irritant ingredients (such as seasoning), could certainly
trigger a response.
The products Tunde works with may also contain potential allergens, and—because of the weakening of his skin's
natural barrier—there is an increased chance of these penetrating the upper layers. These may have had a
sensitizing effect that they might not have had if Tunde's skin were not already damaged. However, from Tunde's
history and clinical diagnosis, if ACD is involved, it is likely to be secondary to ICD.
There is currently no indication of bacterial infection (e.g., discharge).
Which of the following would be suitable next steps in Tunde's treatment?
Select the correct option.
• Patch testing
• A prescription for emolients
• A prescription for topical antibiotics
• A prescription for antihistamines
• A prescription for topical steroids
Correct.
Although allergic contact dermatitis is a possibility, at this stage a patch test would be unnecessary. In due
course—if Tunde's condition does not improve with the rest of his treatment plan—patch testing for the detergents
and ingredients Tunde uses might be indicated, as might antihistamines and topical steroids.
Regular application of emollients should be prescribed (by the nurse practitioner or GP). These will create an
occlusive film to protect Tunde's inflamed skin and reduce fissuring and evaporation.
Prevention of future recurrence
The occupational physician's role involves educating the employee and employer about the nature of the diagnosis
and the likely exacerbating factors.
Select each heading to see advice the occupational physician could give.
Advice for Tunde
• Avoid strong chemicals wherever possible.
• Use only mild detergents when necessary (containing no irritants/chemicals that cause allergies).
• If using potential irritants is unavoidable, ensure no direct contact with the skin.
• Use PPE when handling cleaning agents and food items, and suitable gloves when cleaning the stove.
• Continue to use emollients on a regular basis, especially directly after handwashing.
Advice for Tunde's employer
• Allow Tunde a period of temporary redeployment to facilitate recovery.
• Ensure all staff receive appropriate skincare advice.
• Provide suitable products for hand washing.
• Depending on outcome of risk assessments and the legislative requirements of the context of work, notify
the relevant authorities about a case of disease under the accident and dangerous occurrence reporting
regulations.
Read this article to learn more about both types of occupational contact dermatitis.
Summary for occupational dermatitis
Key learning points
• Occupational contact dermatitis (OCD) accounts for 90% of workplace skin disorders.
• Establishing the occupational cause of contact dermatitis can be far from straightforward; it requires a
thorough dermatological and occupational history, coupled with clinical examination and—where
appropriate—diagnostic testing.
• OCD is caused by one of two mechanisms: irritation or sensitization. Irritant contact dermatitis (ICD) is the
leading subtype, but allergic contact dermatitis (ACD) is becoming increasingly commonplace. Mixed form
OCD is also frequent.
• OCD tends to affect the hands more than any other body part, and the occupational physician must
distinguish it from endogenous dermatitis and other clinically similar dermatoses.
• Clinical presentation of ICD and ACD can be very similar; diagnosis lies primarily in etiology.
• Pruritis is a differentiating factor for ACD (whereas burning tends to be more common with ICD). For both,
onset could be triggered by a single exposure, or the condition may have become chronic due to repetitive
injury.
• The underlying mechanism for ACD is Type IV allergy—therefore, patch testing is the most prevalent (and
appropriate) form of testing.
Further subtypes of contact dermatosis
You have already covered the foundations of occupational skin disorders, including:
• the fundamentals of occupational dermatology
• general principles of diagnosis, treatment, prevention and control
You have also explored the work-related skin disorder most commonly encountered by occupational physicians:
occupational dermatitis.
In this week's elearning, the focus will be on other other occupational skin disorders that employees may present
with. While these are less prevalent than occupational dermatitis, it is crucial for occupational physicians to have
an understanding of them to support the well-being of employees.
Throughout, you will draw on the information presented last week to consolidate what you have already learned
about work-related skin disorders and extend your knowledge further.
Learning outcomes
On successful completion of this module, you will be able to:
• define the incidence, prevalence, and significance of occupational skin disorders and how these present in
the context of occupational medicine
• identify the main clinical features of work-related skin conditions
• apply basic concepts relating to the skin’s anatomy, physiology, and functions to occupational
dermatology issues
• carry out appropriate history taking, examination, and investigations to diagnose and make accurate
prognoses of work-related skin conditions
• clarify the occupational physician’s role at every stage of skin disorder management
• identify how the hierarchy of control is applied to prevent work-related skin disorders and manage their
associated risks
• evaluate fitness for work, defining adjustments and accommodations to prevent work-related skin
conditions and support employees with existing dermatological problems
Airborne contact dermatitis and protein contact dermatitis
Airborne contact dermatitis (ABCD)
ABCD is a morphological diagnosis that encompasses all acute or chronic dermatoses (predominantly of exposed
parts of body), which are caused by substances that, when released into the air, settle on the exposed skin. It may
be acute or chronic and have an underlying pathology of either irritation or allergy. It is caused by:
• environmental dust particles (e.g., wood dust or fiberglass)
• other chemical compounds suspended in the air as gas, vapor, or fumes (e.g., epoxy resins or acrylates)
[Source: Handa et al.]

ABCD is characterized by symmetrical skin inflammation, primarily located on or around the face, eyes, and neck;
however, it may be present on the hands or even cloth-covered areas (due to the accumulation of airborne
particles under the occlusion).
It is common for the eye to be involved, and this can be the only affected site.
Clinical tip: The importance of ABCD is that it needs to be distinguished from photosensitivity, which can occur in
the same parts of the body with the same localization. The differentiating factor for photosensitivity is that it spares
"shadow areas" such as the eyelids and retroauricular folds.
Photoxic and photoallergenic versions of ABCD can also occur.
The following substances can cause ABCD:
• wood dust
• textile fibers
• cement, sand, glass, and fiber
• epoxy resins
• acrylates
• vegetable dust (e.g., from the Compositae/Asteraceae family)
• pollens and propolis
Workers commonly affected include:
• painters and paint manufacturers
• hairdressers; beauticians
• construction workers and carpenters
• workers in the surface coatings industry
• furniture manufacturers
• timber industry workers
• pharmaceutical workers
• healthcare workers
• agriculture workers
Airborne contact dermatitis: Key facts
Symptoms
Symptoms of ABCD include:
• itching, burning, and stinging

• scaly erythematous macules
• lichenoid eruption
• plaques
• a pustular rash (because of secondary infection
The differential diagnoses for ABCD include:
• irritant/allergic contact dermatitis
• psoriasis
• tinea corporis
• photocontact dermatitis
• lymphomatoid CD
[Source: DermNet; European Agency for Safety and Health at Work]
History
Ask about:
Investigations
Investigations for ABCD include clinical examination and patch test.
Treatment
Treatment for ABCD includes:
• emollients
• antihistamines (for allergic cause)
Protein contact dermatitis
This is an allergic reaction, induced principally by proteins of either plant or animal origin. Other offending agents
include flour and proteolytic enzymes.
Clinical presentation is that of chronic dermatitis, so it is often difficult to differentiate between ICD/ACD and other
eczematous dermatoses.
Workers typically affected by protein contact dermatitis include kitchen workers, food vendors, slaughterhouse
workers, butchers, commercial anglers, farmers, and veterinarians.
Info: Pathogenesis is unclear but likely involves a type I, and/or possibly a type IV hypersensitivity reaction, and is
often with superimposed ICD or ACD.
Protein contact dermatitis: Key facts
Symptoms
Symptoms of protein contact dermatitis include those of chronic dermatitis (which occurs recurrently at the site of
contact):
• acute flares of pruritis
• urticarial papules/plaques and/or edema/vesiculation with overlying fine scale (noted minutes after
contact with the substance)
• lichenification (if chronic)
[Source: Oakley; Levin, Warshaw]
The differential diagnoses for protein contact dermatitis include:
• irritant or allergic contact dermatitis
• urticaria
• psoriasis

• tinea corporis
History
Ask about:
• previous irritant contact dermatitis or anything causing a disruption to the skin’s barrier
Investigations
Investigations for protein contact dermatitis include a clinical examination, patch test, prick/scratch test, and
fungal testing (to exclude tinea corporis).
Treatment
Treatment for protein contact dermatitis includes:
• emollients
• antihistamines
Radiodermatitis
These days, occupational exposure to ionizing radiation is stringently monitored and limited. Therefore, it very
rarely affects those working in areas where it may be a concern, for instance, medical imaging/therapy.
Prevention is usually achieved through enclosure, segregation, and proper maintenance—accompanied by strict
protocols, shielding devices, and PPE.
Ionizing radiation exposure in the workplace can cause local skin signs, known as radiation dermatitis (or
radiodermatitis). X-ray and gamma radiation can penetrate deeper than beta radiation (which is absorbed
superficially) and harms inner layers.
Skin symptoms after a short high level exposure are termed acute radiodermatitis; the effects of long-term
exposure are termed chronic radiodermatitis.
Select each heading to learn more about the different kinds of radiodermatitis.
Acute radiodermatitis
Dose range to cause a reaction: Skin erythema: 2–5 grays; irreversible skin damage: 20–40 grays
Initial symptoms: Local erythema, edema and depigmentation; nausea/vomiting may also be present
Possible later symptoms (after days of latency): Livid inflammation with vesicles, bullas, and necrosis that heals
with a scar, atrophy, and loss of hair
Chronic radiodermatitis
Dose to cause a reaction: Repeated exposure to 3–8 grays with a total of 50–60 grays
Symptoms: Atrophic indurated plaques; spider veins or hyperkeratosis; poikiloderma
Note: Skin cancer can arise months or years later as a result of poikiloderma.
[Source: European Agency for Safety and Health at Work; Ranaweera]
Technology improvements and consistent health and safety standards have vastly reduced the risk to workers from
ionizing radiation. Yet, despite the rarity of radiodermatitis, it is important to be aware of it since human error or
delayed onset of symptoms might result in encountering a case.
Have you ever encountered a very rare occupational skin disorder such as this? How would you ensure best
practice if you did?
Note your thoughts for future reference.
Treatment
Treatment for protein contact dermatitis includes:
• emollients
• antihistamines
Urticaria
Urticaria is a much less common dermatosis than occupational contact dermatitis. Its key differentiating factor
lies in its response to exposure, which is:
• immediate (within minutes of contact)
• short-lived (usually lasts a few hours and rarely more than 24)
Etiology is understood to be primarily a type I allergy (immunoglobulin E-mediated). However, there remains some
uncertainty around the precise mechanism. A type IV response may be responsible, or it may further compound
the type I response against the sensitizing agent.
Clinical tip: A prick/scratch test is the most popular test for urticaria: a small lancet is used to (barely) penetrate
the skin’s surface with a potentially offending substance, to check for immediate allergic reaction to it.
The most common substances that cause urticaria are:
• latex
• some foods
• cold/heat
• proteins
• plants
• chromium; cobalt; additives; dyes; fruits; vegetables; cobalt
Workers typically affected by urticaria include:
• catering workers
• workers who have close contact with animals or vegetables
• healthcare workers
Urticaria: Key facts
Symptoms
Urticaria is characterized by a wheal and flare presentation (swelling and red mark)—usually localized to the site of
contact, but may spread across the body.
Symptoms include itching, tingling, and burning—sometimes accompanied by conjunctivitis, asthma, or (in severe
cases) anaphylaxis.
[Source: International Labour Organisation (ILO); Ford; Bourrain]
The differential diagnoses for urticaria include:
• irritant/allergic contact dermatitis
• psoriasis
• tinea corporis
• photocontact dermatitis
• lymphomatoid CD
History
Ask about:
• at least one previous exposure to the allergic substance and symptoms as a consequence of subsequent
exposures (sensitization period is usually 10–15 days)
• underlying atopy/systemic illness that affects general immunity
Investigations
Investigations for urticaria include:
• clinical examination
• prick/scratch test (or, alternatively, an intracutaneous test—a slightly more invasive procedure, which
involves injecting a small amount of the potential allergen into the skin)
• in vitro laboratory assays (including RAST) (less sensitive and specific)
Investigations
Investigations for urticaria include:
• prick/scratch test (or, alternatively, an intracutaneous test—a slightly more invasive procedure, which
involves injecting a small amount of the potential allergen into the skin)
• in vitro laboratory assays (including RAST) (less sensitive and specific)
Info: Urticaria is usually a result of exposure to a proteinaceous material or, less commonly, a chemical.
Latex gloves, which are derived from natural rubber and contain latex protein, are a common cause. Powdered
latex gloves can increase airborne exposure to latex, since the latex protein is not confined to the glove.
UV light exposure and photosensitive reactions
UV light exposure
Exposure to UV light is one of the most important health risks for workers, both outdoor workers (exposed to solar
UV) and indoor workers (exposed to artificial sources of UVR).
In the EU alone, the estimated number of workers exposed to artificial UV light is about 1.2 million, which
constitutes about 1% of total employment.
[Source: European Agency for Safety and Health at Work; European Agency for Safety and Health at Work]
Info: Artificial sources of UV light are used in many applications in the working environment—e.g., in material
inspection, photocuring, sterilization, research, insect traps, and for banknote/ID inspection.
The associated occupational health risks may be more significant than from solar radiation since the UV levels
emitted may be higher and include short wavelengths (which are normally filtered by the earth’s atmosphere).
Select each section to find out the answers to some commonly asked questions about UV exposure.
What are the general health effects?
While not undermining the serious risks associated with UV exposure, it is important to note its positive effects on
human health (depending on the conditions of exposure and wavelength of radiation). These include:
• treatment for medical conditions such as psoriasis
• vitamin D production
However, excessive UV exposure can cause a range of adverse effects (which may be acute or chronic), such as:
• photochemical reactions
• DNA lesions
• damage to the skin and the eyes
• immune system disruption
What are the associated skin conditions?
Skin conditions associated with UV light include:

• erythema (sun burn)
• tanning/thickening of the skin
• actinic keratoses
• actinic cheilitis
• immunosuppression
• premature aging of the skin
• malignancy and benign tumors
Who is particularly at risk?
• Outdoor workers, such as seamen, fishermen, farmers, asphalters, roofers, horticultural workers,
construction workers—especially if working outside around midday when UV levels are highest, or in
locations where UV is generally high (e.g., Australia)
• Those exposed to artificial UV radiation (as found in UV lamps and lasers), e.g., welders, nail technicians,
scientific and medical workers, staff in television and theatre studios, workers in the graphics industry
How can the risk be prevented/minimized?
• Effective use of PPE, such as shields, hats, UV-protective clothing (including extra measures for those with
photosensitivity)
• Engineering, administrative and other controls, e.g., enclosure of UV source, regular monitoring of
equipment to ensure UV output remains at a safe level, etc.
• Medical surveillance, e.g., for changes in moles
• Substituting day work with night work, or avoiding outdoor shifts during peak UV times
Info: Exposure to sunlight in workers can also worsen a pre-existing skin disease such as lupus erythematosus,
dermatomyositis, pityriasis rubra pilaris, Darier's disease, and rosacea.
Photosensitivity
Photosensitivity is caused by the interaction of light and an exogenously acquired chemical agent
(photosensitizer)—both the chemical and radiation are necessary for the response to be produced. The chemical
increases the sensitivity of human skin to UV light so that exposure produces a reaction.
Exposure to a photosensitizer can be topical or systemic; the mechanism can be irritant (phototoxicity) or allergic
(photoallergy type IV). The resulting conditions can be classified into four clinical entities:
1. Photo irritant contact dermatitis (PICD)
2. Photoallergic contact dermatitis (PACD)
3. Photoallergy to a systemic agent
4. Phototoxicity to a systemic agent
[Source: DeLeo]
Info: Some photosensitizers are not only responsible for photosensitivity, but also for an increased risk of
cutaneous malignancies, such as melanoma and non-melanoma skin cancer.
The vast majority of occupationally-related photosensitivity reactions are due to PACD and PICD. For topically
applied chemicals, the mechanism of action (allergic/toxic) is easy to discern on the basis of clinical features.
Photopatch testing (which is the same as regular patch

testing except the area the patch is applied to is exposed to
UV light) will produce:
• a positive response in sensitized individuals
• a negative response in unsensitized individuals
If the photosensitizer is systemic, distinction between the

two pathogenetic mechanisms can be difficult. Most
systemic sensitizers are drugs, so it is unlikely that
photosensitivity to systemic agents would occur in the
workplace as a function of chemical exposure. However:
• people with outdoor occupations may have reactions

due to drugs they take for personal medical reasons
• healthcare workers may have topical exposure to some

medications (that are systemic photosensitizers that
can cause photo-contact reactions) while delivering
them to patients (the same applies to farmers/vets
delivering them to animals)
Info: Photosensitivity due to solar radiation is often reported in

outdoor workers; however, this is not always the case. The
quantity of radiation needed to induce a reaction can be very
small (e.g., car journeys might suffice).
As part of the clinical examination, how might you distinguish between a phototoxic and photoallergic reaction?
Select each tab to find out about how photosensitivity can present differently, depending on etiology.
Phototoxic reactions
Phototoxic reactions caused by photosensitizers are localized. They show up on exposed areas of skin and do not
affect (or are less severe in) areas that are generally covered. Clues to phototoxicity include:
• summer exacerbation
• sharp cut-off between affected area and skin covered by clothing/jewelry
• sparing of skin folds (e.g., eyelids), scalp and skin shadowed by the ears/nose/chin
In most cases, the phototoxic reaction is proportional to the concentration of the photosensitizer and to the
magnitude of UV exposure.
• Photoallergic reactions
Photoallergic reactions caused by photosensitizers are not localized—the effect reaches far beyond the site of
exposure.
Furthermore, the magnitude of the photoallergic reaction is not proportional to the concentration of the
photosensitizer/the magnitude of UV exposure, but instead it depends on the amplitude of the immunologic
reaction.
Photosensitivity (photodermatosis, photodermatitis): Key facts
Symptoms
Symptoms of photosensitivity include:
• features compatible with those of contact dermatitis, showing eczematous eruption
• exaggerated sunburn
• erythema and edema, potentially together with itching and associated blisters, weeping, and peeling of the
skin
• pigmentation (phototoxicity)
• skin fragility leading to blisters
• milia, hypertrichosis
• porphyria/pseudoporphyria (rare)
[Source: Allen, Kaidbey; Lozzi et al.; Oakley]
The differential diagnoses for photosensitivity include:
• allergic contact dermatitis
• airborne contact dermatitis
• drug-Induced bullous disorders
• irritant contact dermatitis
History
Ask about:
• previous/repeated/ongoing intense and exaggerated skin rash or sunburn
Investigations
Investigations for photosensitivity include:
• photopatch tests
• phototests
• full blood count
• connective tissue antibodies, including antinuclear antibodies (ANA)
• extractable nuclear antigens (ENA)
• porphyrin in blood, urine, and feces
Treatment
Treatment for photosensitivity includes:
• topical or systemic therapy, usually based on corticosteroids
• immunosuppressant medications
For systemic origin, it is sufficient to interrupt drug assumption; prevention consists of high sunscreen protection
and the use of filtering clothing.
Ray's itchy hands
Ray has arrived in clinic because he is struggling to cope with his itchy hands.
Select each tab to review Ray's record.
• Employee
1. Name: Ray
2. Age: 29
3. Occupation: Hairdresser
o Severe intermittent pruritis on both hands, up to the lower wrists, accompanied at the time by
tingling and burning
o Repeated episodes having led to redness, multiple mild eruptions, dryness, cracking
• Medical history
o In general, Ray is in good health

o Childhood eczema that cleared up around puberty
o Not currently taking any medication
• Known allergies
o Penicillin
Which of the following work-related conditions might the occupational physician be considering with the current
information?
Select 3 correct options.
• Airborne contact dermatitis (ABCD)
• Protein contact dermatitis
• Radiodermatitis
• Irritant contact dermatitis
• Allergic contact dermatitis
• Urticaria
• Photosensitivity to a systemic agent
Partially correct.
The occupational physician would be correct to consider ICD, ACD, and urticaria.
Given that Ray is a hairdresser, it is unlikely that he would be suffering with protein contact dermatitis (since he
does not work with food, animals, or organic matter) or occupational radiodermatitis.
The fact that the rash is appearing solely on Ray's hands makes it unlikely that the cause would be ABCD as other
exposed areas would likely be affected. For the same reason, systemic photosensitivity is not a logical
consideration.
There is a small chance Ray could be experiencing photo irritant contact dermatitis (PICD) or photoallergic contact
dermatitis (PACD), but considering the history and lack of direct contact with photosensitizers in his work, this also
seems unlikely.
History-taking and clinical examination
In many cases of occupational dermatoses, a diagnosis can be made from an accurate history and clinical
examination. Further testing enables confirmation of this.
The occupational physician has some more questions to ask Ray. What do you think these might be?
Select Continue to see the conversation between the occupational physician and Ray.
So tell me, Ray, how often are you having these reactions?
Ray
I work part-time, and the rash always seems to appear on the days I'm in the salon. Just as soon as it clears up, I go
to work and it appears again.
And how long have you been experiencing this?
Ray
About 6 months. But I've been a hairdresser for over 10 years now. And I never had this kind of problem in the
past—apart from when I was a kid. In fact, I would have thought my hands would be in better condition. We
recently reviewed our health and safety policy, so now I wear gloves for all treatments involving potential irritants.
What exactly does your job involve?
Ray
I'm a senior stylist, so it's mainly cutting and styling hair. I don't color hair myself, but most days I help colleagues
by mixing up the dyes—but, like I said, I wear gloves for that, and it only takes a few minutes. I don't do any hair-
washing—I haven't since I was an apprentice.
I see. And when the reaction is at its worst, do you experience anything other than itching, tingling, and burning?
Ray
Yes. These small bumps appear. They're a bit like insect bites, surrounded by a red area. But they disappear quite
quickly—within a day or so.
Based on the conversation above and the image shown, which of the following do you think Ray is most likely to be
suffering with?
• Irritant contact dermatitis (ICD)
• Allergic contact dermatitis (ACD)
• Urticaria
Correct.
The following factors indicate occupational urticaria:
• He has severe pruritis (burning is the more common prevailing symptom with ICD).
• He has a history of atopy and an existing allergy.
• Symptoms clear up when Ray is not at work and reappear on his return.
• Wet work is not in his job remit (and it likely would be for ICD).
• Ray avoids direct contact with harsh chemicals and does not handle detergents (which tend to be more
involved with ICD).
• The small bumps Ray describes fit the "wheal and flare" presentation of urticaria; his explanation that they
usually reduce within 24 hours also indicates a type I reaction (with ACD, symptoms tend to last for longer).
To confirm the diagnosis, further testing will need to be done. However, assuming Ray does have contact urticaria,
what do you suspect might be causing it?
Latex allergy
Ray mentioned that he had recently started wearing gloves at work. While this is only intermittent and for a short
period of time, it is highly likely—if the gloves are made from natural latex—that this is what is causing the reaction.
Based on the diagnosis above, Ray is probably allergic to latex protein as opposed to the chemicals used in their
production (which would be more likely to provoke a type IV reaction, as observed in ACD).
Interestingly, Ray only wears the gloves for a few minutes on each occasion, which is probably why he had not
made the association. However, this would certainly be enough to provoke a reaction, which likely appeared within
minutes (at most an hour) of removing the gloves.
Which of the following tests would give the most reliable confirmation of a diagnosis of urticaria?
• Prick/scratch test
• Patch test
• RAST test
Correct.
An immediate response prick/scratch test is the most reliable (and widely used) test in a case like Ray's, and a
positive result would confirm the diagnosis.
A patch test would be used if Ray's history and clinical examination pointed toward a type IV reaction.
A RAST (allergen specific IgE) test might be helpful, although it is considered less accurate.
A use test (whereby a latex glove is placed on one finger for 15–20 minutes to see if a reaction occurs) is another
option, although this is also considered less effective and, given the potential severity of a latex allergy, may put the
worker at risk.
Management of a latex allergy
Ray's prick test confirmed that he is sensitive to latex products. Fortunately, elimination of latex in a hairdressing
environment is relatively straightforward.
Ray's employer should be advised to:
• eliminate latex gloves within the workplace
• carry out workplace risk assessments with all products in use
• provide a latex-free alternative so that employees can continue to observe the health and safety guidelines
in place with regard to handling other potential irritants/allergens
Ray should be advised to avoid latex outside of work also.
Warning: Ray's reaction to latex was relatively mild—for some people, symptoms such as breathing difficulties
and anaphylaxis pose a direct risk to their life. Repeated exposure can cause an increase in severity of response.
Info: In some industries (such as healthcare), where latex use is more prolific, latex allergy can be much more
difficult to manage. The occupational physician should, as always, work with the employer to keep the employee in
work through reasonable accommodation, e.g., relocation to a latex-free area.
Summary for further subtypes of contact dermatosis
Key learning points
• Airborne contact dermatitis (ABCD), protein contact dermatitis (PCD) and radiodermatitis are notable
subtypes of contact dermatitis, which may be acute or chronic. Their underlying pathologies are as follows:
ABCD—irritation/allergy; PCD—allergy; radiodermatitis: irritation.
• Urticaria is a much less common dermatosis than occupational contact dermatitis (OCD). Its key
differentiating factor lies in the immediacy and short duration of symptoms following exposure.
• Etiology of urticaria is understood to be primarily a type I allergy (immunoglobulin E-mediated), and this is
confirmed with a positive prick test.
• Exposure to UV light is one of the most important health risks for workers, both outdoor workers (exposed
to solar UV) and indoor workers (exposed to artificial sources of UVR).
• Photosensitivity is caused by the interaction of light and an exogenously acquired chemical agent
(photosensitizer). Both the chemical and radiation are necessary for the response to be produced.
• Exposure to a photosensitizer can be topical or systemic; the mechanism can be irritant (phototoxicity) or
allergic (photoallergy type IV). Photopatch testing will produce a positive response in sensitized individuals.
• Latex allergy (which is especially prevalent in jobs that require glove use) continues to present a potentially
life-threatening risk for sensitive individuals. Etiology tends to be contact urticaria (type I reaction), but
sensitivity can also be an allergic contact dermatitis (ACD) response (type IV) to the chemicals used in latex
production.
Non-eczematous reactions
Occupational acne
Occupational acne is a disorder of the sebaceous glands, which

occurs when certain chemicals block the pores, causing
accumulation of skin oils and keratin.
This leads to the formation comedones, cysts, lesions, nodules,

papules, and/or pustules. These may be compounded by contact
dermatitis caused by irritants or sensitizers also present in causative
agents. Pustules may be sterile or contain the harmless skin bacteria, Staphylococcus epidermidis. They may be
painless or painful.
[Source: Oakley; Baxter et al.]
Different forms of occupational acne are:
• oil acne
• coal-tar acne
• chloracne—sometimes referred to metabolising acquired dioxin induced

skin hamartomas (MADISH)
Of these, oil acne is the most common, which is not surprising considering the
widespread exposure to causative agents. In the US alone, over 1 million workers regularly use solvents and
lubricants on the job. Also at risk are those with previous cystic acne.
[Source: Wattanakrai and Taylor; Peate]
Substances commonly involved
Oil acne is associated with petroleum and its derivatives, including crude oil and fractions, and cutting oils.
Coal tar acne is associated with coal tar products, including oils, pitch, and creosote.
Chloracne is associated with halogenated aromatic compounds, including chloronaphthalenes, PCBs, PCDFs,
and dioxin.
(Chloracne is most often caused by direct skin contact with a halogenated aromatic compound, but can also
occur after ingestion or inhalation.)
Workers affected
• Oil acne: Car mechanics, metalwork machine operatives
• Coal tar acne: Coal-tar plant workers, construction workers, roofers, road paving workers, paper tube
impregnation workers, wood and cable preservation workers
• Chloracne: Chemical manufacturing/laboratory workers, maintenance workers, workers in waste handling

or industries using certain halogenated hydrocarbons
Occupational acne: Key facts
Symptoms
Symptoms of oil acne include:
• pimples or blackheads on any exposed skin (usually affects the arms and hands, but other areas may be
affected, especially if they are covered with oil-soaked clothes)
• systemic symptoms such fatigue, parenthesis, and hyperhidrosis
Symptoms of coal tar acne include:
• blackheads, usually around the eyes

• skin darkening
• burning sensations and flushing of the skin after exposure to light
• systemic symptoms such fatigue, parenthesis, and hyperhidrosis
The differential diagnosis for occupational acne is acne vulgaris.
[Source: Government of Canada; European Agency for Safety and Health at Work]
History
Ask about:
• onset (with oil acne and coal tar acne, the sudden appearance of cysts, papules, and pustules typically
follows chemical exposure by weeks to months)
• symptoms
• presence of spots in areas that are exposed/in contact
• previous cystic acne
Investigations
Investigations for occupational acne include:
• biopsy (biopsies of affected skin may show a reduction of the normal sebaceous gland density and skin
hamartomas)
• immunohistochemical tests
Treatment
Treatment for occupational acne includes:
• reducing, eliminating, or substituting exposure
• enclosing the workspace and install adequate local exhaust systems
• practicing good occupational and personal hygiene (PPE: face mask, goggles, gloves, apron)
• using routine acne treatment
Symptoms of chloracne include yellow cysts, blackheads, and nodules, mainly on the face, but in severe cases
more widespread, which may not appear until 3 to 4 weeks after toxic exposure. If massive exposure occurs,
symptoms may appear within days.
Alert: The effects of occupational acne can be long-lasting and potentially serious. Although symptoms may clear
up quite quickly, they might persist long after exposure stops. For some workers, chloracne lasts for up to 15
years. If left untreated, lesions caused by coal tar acne and petroleum-induced oil acne may develop into skin
cancer.
Depigmentation and hyperpigmentation
Pigmentation of the skin normally varies according to racial origin and amounts of sun exposure. Occupational
exposure to either UV radiation or certain chemicals can exacerbate normal variation in pigmentation as a result of
the injury inflicted on the skin.
In cases of hyperpigmentation, the melanocytes (pigment cells), which are located at the base of the epidermis,
produce more of the melanin. The converse is true for depigmentation, which results from the selective (usually
permanent) destruction of melanocytes.
Contact leukoderma (vitiligo)
Occupational leukoderma usually appears at the site of contact with a

causative agent and can affect any part of the body. It is characterized by the
presence of pale, white patches on the skin with low or even no melanin
pigment.
Since systemic absorption of the substance may occur, white patches may
appear well beyond sites of direct skin contact, thus closely mimicking idiopathic vitiligo. Such loss of cutaneous
pigment increases skin vulnerability to agents such as solar and ultraviolet radiations, both for non-cancer and
cancer effects.
The most common substances associated with contact leukoderma are:
• phenols and catechols, and alkyl catechols/phenols
• hydroquinone
• monobenzone
• germicides such as para-tertiary butylphenol (PTBP)
• pyrethroid insecticides
• adhesives (e.g., hexamethylenetetramine)
• mercurials
• arsenics
• sulfhydryls
• azo dyes
• paraphenylenediamine (PPD)
Workers typically affected include:
• chemical workers
• engineering workers (from oil)
• automobile workers (from adhesive)
• hospital personnel (from germicide)
Contact leukoderma (vitiligo): Key facts
Symptoms
Symptoms of contact leukoderma include:
• hypopigmented (depigmented) patches, which usually appear on the exposed areas of the hands and
forearms, and sometimes on covered areas of the body
• depigmentation on distant sites, which is often symmetrical
• [Source: Oakley; Baxter et al.; Adisesh et al]
The differential diagnoses for contact leukoderma are Idiopathic vitiligo and post-inflammatory pigment loss.
[Source: Oakley; Baxter et al.; Adisesh et al]
History
Ask about:
• onset
• symptoms (which may become evident within few months to several years from the beginning of exposure)
• work-related direct and repeated skin contact with or systemic absorption (e.g., by inhalation) of causative
agents
Investigations
Investigations for contact leukoderma include:
• Wood’s light, which may help to discover depigmented areas, especially in light-skinned individuals
• exposure assessment
Note: Clinico-histopathologically, no absolute criteria can differentiate chemical leukoderma from idiopathic
vitiligo.
Treatment
Treatment for contact leukoderma includes:
• elimination; substitution, and engineering controls followed by exposure control
• PPE to avoid contact; good housekeeping (e.g., application and removal of PPE without contamination)
While permanent depigmentation is possible, a slow spontaneous re-pigmentation is seen when occupational
exposure is terminated.
Photo-aging
Cutaneous skin aging from occupational exposure has traditionally been

observed in sun-exposed sites of outdoor workers (such as fishermen
and farmers). Its characteristics reflect the profound structural changes
occurring in the dermis.
Characteristic presentation involves mottled pigmentation and the

development of tiny but highly visible, superficial blood vessels.
However, these are just a few of many signs of general photo-ageing
(which also include dryness, deep wrinkles, and accentuated skin
furrows).
A precursor to photo-aging is repeated episodes of tanning (and related

thickening of the skin). These represent other consequences of skin
adaptation to UV light.
Treatment and prevention of photo-aging are the same as for other photosensitive skin conditions.
Examples of specific conditions associated with photo-aging include seborrheic keratoses, solar lentigos, and
lichenoid keratoses.
Select each card to learn more about these conditions.
Seborrheic keratosis
These are harmless lesions that appear during adult life (>90% of adults >60 years old have them). Sunlight does
contribute to their development, but they can occur without UV exposure. Typically, they are flat or raised papules
or plaques, which:
• are 1 mm to several cm in diameter
• are skin colored, yellow, grey, light brown, dark brown, black, or mixed colors
• have a smooth, waxy, or warty surface

• are solitary or grouped in certain areas
Solar lentigo
A solar lentigo is a harmless patch of darkened skin. Exposure to UV radiation causes

local proliferation of melanocytes and accumulation of melanin within the skin cells (keratinocytes).
Solar lentigos are very common, especially in people over the age of 40 years, and are:
• flat, well-circumscribed, and possibly slightly scaly
• round, oval, or irregular in shape
• skin-colored, tan, dark brown, or black
• between a few mm to several cm in diameter
Lichenoid Keratosis
A lichenoid keratosis is a small, inflamed macule/thin pigmented

plaque, which is usually solitary and arises in a regressing existing solar lentigo or seborrheic keratosis. Its cause is
unknown but may include sun exposure.
It generally develops in fair-skinned patients (often female) aged 30–80 years and involves:
• a solitary lesion, often on the upper trunk, ranging from a few mm to one cm or more
• a smooth, scaly, or warty surface
• no sensation (but may sting mildly)
Clinical tip: Frequently, the lesions of PICD heal with pigmentation, especially when due to furocoumarin
sensitizers. In fact, many patients present with only hyperpigmentation, without a history of preceding
inflammation.
Hyperpigmentation is one of the potential conditions found in workers who have been exposed to coal tar.
[Source: DeLeo; Moustafa et al.]
If you want to learn more about occupational vitiligo, read this article.
On the Etiology of Contact/Occupational Vitiligo
If you want to learn more about photo-aging, read this article (NOTE: abstract only; access to full article via
subscription only).
Photoageing: mechanism, prevention and therapy
If you want to learn more about arsenical keratosis—which has impacted those working with arsenic-containing
substances—read this article.
Arsenical Keratosis
Skin infections
Infectious agents can be contracted from various sources during work. They could be bacterial, fungal, viral, or
parasitic in etiology.
Further considerations include:
• the potential for colonization (presence of microorganisms on worker without apparent disease)
• manifest infection with antibiotic resistant bacteria (e.g., MRSA among healthcare workers)
General prevention measures include personal and work hygiene, germicide agents, and protective gloves.
Diagnosis (clinical signs, history, microscopy, cultures, etc.) and treatment are the same as for non-occupational
disease.
Bacterial infection
Select each card to learn more about different kinds of bacterial infection.
Occupational pyoderma
Presentation: Folliculitis, furuncle, carbuncle, impetigo, ecthyma and paronychia. Etiology is commonly (although
not exclusively) Streptococcus/Staphylococcus (bacteria that generate pus)
Risk factors: Working in dirty environments where micro-traumas of the skin are common; contact with infected
individuals
Workers commonly affected: Car mechanics, sewage workers, butcher, slaughterhouse workers, metal
machinery operatives, nurses, beauticians
Skin TB
Presentation: A granulomatous, slowly progressing, wart-like skin lesion with regional lymph-node involvement
Risk factors: Exposure to Mycobacterium tuberculosis hominis, Mycobacterium tuberculosis bovis,

or Mycobacterium marinum (fish tank granuloma)
Workers commonly affected: Pathologists, dissectors, surgeons, vets, animal handlers, butchers, farmers,
workers involved with fish tanks pools
Erythema Chronicum Migrans (ECM)
Presentation: A ring-like slowly growing red rash—the early sign of Lyme-disease (Borrelia burgdorferi infection)
Risk factors: Lyme disease is caused by the bacteria Borrelia burgdorferi (transmitted to humans through infected
ticks)
Workers commonly affected: Forestry/horticultural workers
Fungal infection
Select each card to learn more about different kinds of fungal infection.
Yeast infection:
Presentation: Usually occurs on the hands: onychomycosis (nail), paronychia (around the nail bed), interdigital
mycosis (between fingers)
Risk factors: Exposure to Candida albicans; prolonged wearing of rubber gloves/boots; working with confectionary
(handling sweets)
Workers commonly affected: Those working in healthcare/canneries
Dermatophyte Infection (ringworm)
Presentation: A ring-like rash with the appearance of a deep bacterial skin infection; sub-types include
Trichophytia profunda and Microsporiasis
Risk factors: Exposure to Trichophytia verrucosum, Microsporum canis (common amongst pets), Microsporum
gypseum (lives in soil)
Workers commonly affected: Farmers, milkers, animal handlers, vets, breeders, agricultural workers
Viral infection
Select each card to learn more about different kinds of occupational viral infection.
Milker’s Nodules:
Presentation: Small, red, raised, flat-topped spots that develop into red-blue, firm, tender
blisters/nodules, sometimes with a greyish, crust; usually 2–5, but may be solitary/more numerous; usually on
hands; possible secondary bacterial infection, lymphangitis, and enlarged lymph glands; lesion heals
spontaneously within weeks
Risk factors: Exposure to the paravaccinia virus (source is the udder of a cow, and less frequently sheep/goats)
Workers commonly affected: Milkers, animal handlers
Orf:
Presentation: a small, firm, red/reddish-blue lump (usually solitary) enlarges to a tender flat-topped, blood-
tinged pustule or blister (usually 2–3 cm in diameter), usually on hands; incising the 'pus' under the skin will reveal
firm, red tissue; may be regional lymphatic inflammation, possibly mild fever; heals spontaneously unless
secondary infection is present
Risk factors: exposure to the Parapox virus—common in sheep and goats.
Workers commonly affected: shepherds, goatherds, vets
Parasitic infection
Select each card to learn more about different kinds of occupational parasitic infection.
Bites and Stings:
Presentation: Localized reaction—redness, swelling, pain; allergic individuals may experience a more severe
reaction and potentially serious/life-threatening complications (severe urticaria, anaphylaxis)
Risk factors: Exposure to anthropods (animal parasites), granary mites, bees/wasps
Workers commonly affected: Agricultural workers; beekeepers (who often develop a resistance where no effect
is caused)
Scabies:
Presentation: Typically an itchy rash (4–6 weeks after exposure) with symmetrical lesions that mainly affects skin
below the neck; erythematous papules; excoriations; linear scratch marks; dermatitis; nodules (skin colored/red-
brown/violaceous); hyperkeratosis (in crusted scabies); vesicles (may also indicate secondary infection)
Risk factors: Exposure to a person infested with a tiny ectoparasitic mite that digs itself into the skin
Workers commonly affected: Those carrying out care duties
If you want to learn more about occupational skin infections, read these articles.
Bacterial skin infections
Milker's nodule
Orf
Bee and wasp stings
Scabies
Fungal skin infections
Amy's painful spots
Amy has been referred to an occupational physician by her manager as she attributes painful spots on her body to
work.
Select each tab to review Amy's record.
• Employee
o Name: Amy
o Age: 30
o Occupation: Car mechanic
o Several pustules on the back of the hand, forearm, and thighs

o Surrounding smaller whiteheads around the areas, progressing to blackheads
• Medical history
o History of cystic acne as a teenager
• Current medication
o Contraceptive pill
• Known allergies
o None
What follow-up questions should the occupational physician seek answers to?
Do the questions below match the ones you thought of?
Select each question to learn more about Amy's presentation.
What products do you work with in your role?
Motor oil, grease, and cooling agents.
Have any colleagues had a similar experience?
Yes. Other colleagues have experienced similar spots.
When did you first notice the spots?
I had some similar spots in the past, but they cleared up.
Normally I work in vehicle testing, but the past few months I have been training apprentices so have been more
"hands on." I first noticed the spots about a month ago.
Do you wear any PPE?
Yes. I wear coveralls all the time, and gloves and an apron whenever I'm working on vehicles.
The images below are of people with the same condition that Amy is suffering with.
Based on what you know about Amy's job and the clinical presentation, what condition do you think she has?
• Chloracne
• Oil acne
• Impetigo
• Orf
• Candidiasis
Correct.
Amy's primary condition is oil acne. Her comedones and pustules are typical features, and the diagnosis fits with
the nature of her job and the substances she handles.
Chloracne is found in workers who handle halogenated aromatic compounds, whereas Amy commonly handles
oil-based substances.
Impetigo can occur as a secondary complication (but would usually present as crusted lesions), which may then
require antibiotic treatment.
Candidal intertrigo is observed in workers who wear occlusive clothing, gloves, and footwear. Presentation can
involve superficial satellite papules or pustules, but these would be secondary to erythematous and macerated
plaques with peripheral scaling (which Amy does not have).
Orf is a viral infection that workers can contract from sheep or goats, which does not apply to Amy. Infected
humans typically develop a single ulcerative lesion or nodule on their hand.
The occupational physician now has some issues he wants to investigate with Amy's employer.
What do you think these might be?
• Can the hazardous materials be substituted with any less hazardous ones?
• Are the gloves Amy is wearing made out of the correct material?
• Is the PPE provided in good condition, and is it being used effectively according to the manufacturer's
instructions?
• Do employees have washing and changing facilities in the workplace?
• Have employees been trained on the importance of effective hand washing?
The conversation with Amy's employer revealed that health and safety guidelines were being followed. However, it
transpired that Amy was not laundering her overalls as instructed, and was incorrectly donning/doffing of her
gloves (resulting in oil contact with her skin).
The occupational physician gave the following advice:
• Where possible, eliminate hazardous acne-causing products, or substitute them with nonhazardous
alternatives.
• Continue to encourage workers to make use of the hand-washing and showering facilities and changing
room
• Consider installing laundering facilities in the workplace to ensure hygiene standards are being met
• Review existing training and consider delivering a recap session on the importance of PPE
Clinical tip: Because Amy's employer is UK-based, the following advice also applies:
• Depending on outcome of risk assessments and the legislative requirements of the context of work, notify
the relevant authorities about a case of disease under the accident and dangerous occurrence reporting
regulations.
• Implement a health surveillance scheme for all exposed workers under the Safety Health and Welfare at
work (Chemical Agents) Regulation.
What are the next steps for Amy, and what advice do you think the occupational physician gave her?
Do the suggestions below match your ideas?
Select each icon to learn more about the treatment and advice offered to Amy.
Medication
Amy was referred to her primary care physician, who prescribed topical corticosteroids.
Antibiotics were not indicated at this stage; however, if Amy's symptoms persist, her primary care physician will
refer her to a dermatologist for further intervention.
Hygiene
The occupational physician offered the following hygiene advice:
• Always remove skin contaminants by washing with clean warm water and suitable products (gentle
detergents).
• Follow all guidelines for effective hand-washing.
• Wear clean coveralls daily, and wash these separately to other clothes.
PPE
The occupational physician offered the following advice about PPE:
• Avoid direct contact with causative substances (wherever possible, your workplace should substitute
hazardous acne-causing products with nonhazardous alternatives).
• Use PPE according to the manufacturers' instructions and ensure it is within date.
• Contact may be unavoidable, so it is crucial to wear adequate PPE to protect your hands and any other
parts of your body that oil may be transferred to.
Prognosis
The occupational physician offered the following prognosis:
• Your job does put you in a high-risk group for occupational acne, but with the treatment provided and no
exposure to offending chemicals, I would expect your spots to clear up.
• However, the underlying cystic acne is a risk factor, and we should be mindful of that and closely monitor
the condition of your skin.
To learn more about skin conditions that affect workers like Amy, read this article.
Skin problems in motor vehicle repair workers
To learn more about the diagnostic and exposure criteria for a whole range of occupational diseases, read this
comprehensive guide (see section 2.2 for information on skin diseases).
Diagnostic and exposure criteria for occupational diseases

Summary for non-eczematous reactions
Key learning points
• Occupational acne is a disorder of sebaceous glands in response to a chemical agent. There are three
recognized forms: oil acne (most common), chloracne, and coal tar acne.
• The effects of occupational acne can be long-lasting and potentially serious; certain forms— if left
untreated—may turn into skin cancer.
• Occupational exposure to either UV radiation or certain chemicals can cause hypopigmentation (e.g.,
contact leukoderma) or hyperpigmentation (e.g., photo-aging) as a result of the injury inflicted on the
skin.
• Skin infections could be bacterial (e.g., occupational pyodermas), fungal (e.g., ringworm), viral (e.g., orf), or
parasitic (e.g., scabies) in etiology. The type of contact (i.e., human/animal/plant) worker has in their job is
key to accurate diagnosis.
• Even in cases where health and safety guidelines are apparently being followed, the likelihood of human
error, e.g., providing out-of-date or inappropriate PPE, means that further investigation is required.
Tumors
The images below show the three most common types of occupational skin cancer. Can you identify what each
one is?
Select each card to reveal the type of tumor shown.
Melanoma
This often presents as an unevenly multi-shaded brown and black lesion, with an irregular border (although this
depends on the type of melanoma).
Basal cell
carcinoma (BCC)
This often presents as a crusty, nodulated, and ulcerated lesion, with uneven coloration and a translucent/waxy
appearance.
BCCs can look different from person to person. They may look like open sores, red patches, pink growths, shiny
bumps or scars, and they sometimes have slightly elevated, rolled edges and/or a central indentation.
At times, BCCs may ooze, crust, itch, or bleed.
Squamous cell
carcinoma (SCC)
This often presents as a pink (or pale brown) raised nodule, with a regular border and central ulcerated depression.
They may look like scaly red patches, open sores, or rough, thickened or wart-like skin. At times, SCCs may crust
over, itch, or bleed.
Red flags
General awareness about the incidence and severity of melanoma has increased in recent years. As a result, many
workers present with a new pigmented lesion, or an existing mole that has changed in shape, color, size, or how it
feels.
The ABCDE rule can be helpful in distinguishing normal moles from potential melanomas; however, it cannot
reliably recognize all melanomas.
Select each marker to reveal the features.
Asymmetry: The shape of one half of the lesion does not match the other half.
Border that is irregular: The edges are often ragged, notched, or blurred in outline. The pigment may spread into the
surrounding skin
Color that is uneven: Shades of black, brown, and tan may be present. Areas of white, gray, red, pink, or blue may
also be seen.
Diameter: There is a change in size, usually an increase. Melanomas can be tiny, but most are larger than 6 mm
wide.
Evolving: The mole has changed over the past few weeks or months.
Incidence
Melanoma is relatively rare—US data shows it accounts for only about 1% of skin cancers. However, cases are on
the rise. In the UK, it remains the fifth most common cancer, accounting for 4% of all new cancer cases between
2016 and 2018. Despite its rarity, and due to its aggressive nature, it causes the large majority of skin cancer
deaths.
Cases of BCC and SCC—collectively known as non-melanoma skin cancers (NMSCs)—are also constantly
increasing, and they account for 90% of malignant skin tumors. Between 2007and 2017, the incidence of NMSCs
increased by 33%, reaching 7.7 million cases worldwide.
[Source: CIUCIULETE et al.; Cancer Research UK; American Cancer Society]
UV radiation is the main contributing factor to the development of skin cancer, so there is an occupational link for
workers exposed to natural and artificial UV light in their jobs.
There are three kinds of UV radiation, and they each have a different impact on the skin.
Select each tab to learn more each kind of UV radiation.
• UVA
UVA makes up about 95% of the UV radiation that reaches the earth’s surface. It penetrates deep into the
dermis and can pass through window glass and fabrics.
[Source: Peharda et al.]
• UVB
UVB accounts for around 5% of the solar photons reaching the earth’s surface. It causes erythema
and inflammation (probably due to mediators, e.g., histamine). UVB has a direct mutagenic affect
and is the type of UV radiation that is mainly responsible for cancers.
• UVC
UVC is the most energetic type of UV radiation but is predominantly absorbed by ozone in the
stratosphere. It has a germicidal impact, and its artificial form is used in sterilization processes.
Non-UV factors
Exposure to UV radiation initiates approximately 90% of NMSC. However, other agents can trigger the development
of BCC and SCC, including:
• some chemicals, such as polycyclic aromatic hydrocarbons (PAHs) from coal tar; pitch and unrefined
mineral oils; soot; anthracene and its compounds; raw parafin; and carbazole and its compounds
• ionizing radiation, e.g., from radioactive substances and X-rays
The interaction of sunlight and a chemical agent such as those above (cocarcinogenesis) is often implicated.
[Source: European Agency for Safety and Health at Work; Griffin et al.; HSE]
Clinical tip: It is not easy to draw a causal link between exposure and the development of skin cancer, because
there tends to be a long time (frequently two or three decades) between exposure and development of a tumor.
What other predisposing factors might increase a worker's risk of skin cancer?
• Fair skin (Fitzpatrick skin phototypes I,II and III)
• Personal or family history of skin cancer
• Certain genetic mutations (e.g., melanocortin-1 receptor) and genetic conditions (e.g., albanism, Bloom
syndrome)
• Existing viral infection (e.g., HIV, HPV)
• Longstanding skin disease (e.g., lichen sclerosus, skin TB)
• A longstanding wound or scar (e.g., a thermal burn)
• Smoking
• Drug-induced immune-suppression
Info: While it is unequivocal that UV exposure via outdoor work significantly increases a worker's risk of BCC and
SCC, its implication in the development of melanoma is uncertain. Recent research shows that the risk of all types
of skin cancer increases for workers with ≥ 5 years of outdoor work, although no significant associations were
found for melanoma.
[Source: Trakatelli et al.]
Workers typically affected by occupational skin cancer include:
• outdoor workers (especially those who work where/when UV levels are highest), including farmers,
construction workers, and airline pilots
• indoor workers who work directly with UV, including welders, healthcare workers using UV
therapies/investigations
Occupational skin cancer: Key facts
Select each icon to learn more about this condition
Symptoms
Tumors generally appear as a progressive lump or nodule, an ulcer, or a changing lesion. They tend to present in
sun-exposed body parts (e.g., face, arms, backs of hands), especially NMSCs. Melanoma can appear on any body
part, including areas not exposed to the sun).
[Source: Peate; DermNet]
The differential diagnoses for melanoma are dysplastic nevus, squamous cell carcinoma, and melanocytic naevi.
The differential diagnoses for BCC are actinic keratosis, malignant melanoma, melanocytic naevi, and moluscum
contagiosum.
The differential diagnosis for SCC is actinic keratoses.

History
Ask about:
• previous UV exposure
• previous exposure to other causative agents
• existing predisposing factors
Investigations
Investigations for occupational skin cancer include:
• dermoscopy
• skin biopsy (excision)
• genetic testing/blood testing for melanoma
• further testing if there is suspicion of spread
Treatment
Treatment involves:
• wide local excision
• micrographic surgery
For superficial skin cancers. treatment involves curettage, cautery, electrosurgery, cryotherapy, topical creams
(such as fluorouracil cream), photodynamic therapy (photosensitizing cream plus light), radiotherapy, and laser
treatment.
Targeted therapies are used to treat advanced or metastatic diseases.
Non-malignant tumors
Actinic keratosis (AK) (also called solar keratosis)
Actinic keratoses (usually pluralized as they rarely present as a single lesion) are
abnormal growths of cells in sun-exposed areas that are caused by long-term
UVB damage.
They are not malignant, but a small fraction (around 10%) of them will develop into skin cancer; some people
consider them an early form of SCC. Because of their unpredictability, dermatologists recommend treatment of
these lesions.
Actinic keratosis: Key facts
Select each icon to learn more about this condition
Symptoms
Symptoms of actinic keratosis include:
• dry, rough, scaly patch(es)
• sandpapery feel
• could be flat or thickened; white, yellow, skin-colored, red pigmented; and maybe with a warty or horny
surface
• usually found on the backs of hands, face, forehead, and balding scalp
• usually between 1–2 cm in size
• often asymptomatic, but may be itchy; rarely painful
The differential diagnosis for actinic keratosis is SCC.
History
Ask about:
• age (especially common in people over 55)
• history of poor immune function or predisposing disease
• current medication
Investigations
Investigations for actinic keratosis is clinical examination or by dermascopy—biopsy if there is uncertainty or if

treatment fails.
Treatment
Single patches or asymptomatic keratoses may not require active treatment but should be kept under
observation.
For multiple patches (or if it is thickened, tender, or itchy), treatment is recommended:
• prescription creams/gels (e.g., diclofenac, imiquiod, tirbanibulin)
• cryotherapy using liquid nitrogen (lesions turn into blisters and fall off after a few weeks, sometimes leaving
minor scarring or hypopigmentation)
• surgery to cut or scrape (curettage) them away

• electrocautery to remove a cutaneous horn or hypertrophic AK; photodynamic therapy (PDT); excision
Avoid sun and protect sun-exposed skin (with SPF cream, long sleeves, wide-brimmed hat, etc.)
Actinic cheilitis (AC)
Actinic cheilitis is the lip form of actinic keratosis, and is also caused by
chronic sun exposure. It usually (in 90% of cases) presents on the lower
lip, which is more vulnerable than the surrounding skin because
the mucosal epithelium is thinner and less pigmented than the epidermis.
Actinic cheilitis mainly affects adults, especially those who have existing
AK and/or solar lentigines, and it is three times more common in males
than in females. Other risk factors include having HPV,
immunosuppression, and a history of alcohol abuse.
Info: Actinic cheilitis is also called actinic cheilosis, solar cheilitis, or actinic cheilitis
with histological atypia. Actinic cheilitis also describes lip involvement in actinic prurigo, a rare form of
photosensitivity.
Actinic cheilitis: Key facts
Symptoms
Symptoms of actinic cheilitis include:
• dryness; thinning and fragility of lip
• thickened, scaly papules and plaques
• swelling, redness, and soreness
• fissures
• focal ulceration and crusting
• loss of demarcation between the vermillion border of the lip and adjacent skin
• leukokeratosis
• discoloration with pale/yellow areas
• partial thickness epidermal dysplasia
• solar elastosis
• inflammation in the dermis
• variable thickening or atrophy of the lip
[Source: Duffill]
Treatment
Single patches or asymptomatic keratoses may not require active treatment but should be kept under
observation.
For multiple patches (or if it is thickened, tender, or itchy), treatment is recommended:
• prescription creams/gels (e.g., diclofenac, imiquiod, tirbanibulin)
• cryotherapy using liquid nitrogen (lesions turn into blisters and fall off after a few weeks, sometimes leaving
minor scarring or hypopigmentation)
• surgery to cut or scrape (curettage) them away
• electrocautery to remove a cutaneous horn or hypertrophic AK; photodynamic therapy (PDT); excision
Avoid sun and protect sun-exposed skin (with SPF cream, long sleeves, wide-brimmed hat, etc.)
History
Ask about:
• age
• history of poor immune function or predisposing disease
• current medication
[Source: Duffill]
Investigations
Investigations for actinic cheilitis include:
• dermoscopy
• biopsy if there is uncertainty or if treatment fails
[Source: Duffill]
Treatment
Treatment for actinic cheilitis is similar to treatment of AK. Vermilionectomy (surgical removal of the external lip)
and carbon dioxide laser treatment have the most favorable outcomes, with fewer recurrences compared to
chemical peel and photodynamic therapy.
Avoid sun; smoking cessation and frequent application of sunscreen-containing lip balm are advised.
[Source: Duffill]
Keratoacanthoma
Keratoacanthoma (KA) is a common, rapidly growing, locally

destructive skin tumor. It may regress spontaneously with scarring,
but the clinical course can be unpredictable.
KA is most common in fair-skinned older males (over 60) with a

history of chronic sun exposure.
Keratoacanthoma arises from the base of a hair follicle. The specific

pathogenetic mechanisms are unclear, but there is an increased incidence in workers who:
• are immunocompromised
• have genetic cancer syndromes, e.g., xeroderma pigmentosum, Muir-Toree syndrome
• have received certain treatments in the past, e.g. photochemotherapy for psoriasis, BRAF inhibitors,
hedgehog pathway inhibitors
Info: Clinically, a KA may be indistinguishable from a well-differentiated SCC, so many clinicians prefer the term
"SCC, KA-type" and recommend surgical excision.
Agents that cause keratoacanthoma
• UV radiation
• chemical carcinogens
• cutaneous trauma (e.g., surgery, radiation)
• human papillomavirus infection
Workers affected
• Outdoor workers
• Industrial workers exposed to tar, pitch, and mineral oils
Keratoacanthoma: Key facts
Symptoms
Keratoacanthoma typically presents as a solitary, rapidly growing nodule on the sun-exposed skin of the face and
upper limbs, which is sharply demarcated, firm, erythematous, or skin-colored, with a classic central
hyperkeratotic plug and an even shoulder.
The differential diagnoses for keratoacanthoma are:
• SCC
• amelanotic melanoma
• nodular basal cell carcinoma

• common warts
• giant molluscum contagiosum
• metastatic deposit
• nodular prurigo
History
Ask about:
• age
• exposure to UV/causative agents
• poor immune function or predisposing disease
• current and past medication
Investigations
Investigations for keratoacanthoma include:
• dermoscopy (which cannot reliably discriminate KA from SCC)
• biopsy to determine histopathology
Treatment
It is best to assume a KA-like lesion is an SCC, so most are treated surgically. Spontaneous resolution is possible,
but excision is prudent unless regression is in progress. Experienced clinicians may consider other options, such
as cryosurgery, curettage and electrodessication, or topical/intralesional chemotherapy. Removal of the keratotic
core will leave a crater-like appearance to the lesion.
Otherwise, prognosis is generally excellent; however, there is an increased chance of other skin cancers, so sun
safety should be advised.
If you want to learn more about non-malignant tumors, read these articles.
Actinic keratosis: Diagnosis and treatment
Keratoacanthoma: a complete overview

Marx's crusty lesion
The occupational physician for a large farming organization is running a screening clinic for the employees.
Following several cases of skin cancer being reported amongst the workforce, the occupational physician
recommended the organization arrange these annual checks as part of their skin health surveillance policy. The
organization was keen to put this into practice, since their workers spend a lot of time outdoors and sometimes
have to work with agricultural photosensitizers.
Marx is a new employee. He is attending as routine, along with his other colleagues, but wants to ask about a
crusty patch he has had for some time on his hand.
Select each tab to review Marx's record.
• Employee
o Name: Marx
o Age: 48
o Occupation: Farming machinery operator (formerly self-employed before starting this new position
6 months ago)
o A crusty patch on the back of his right hand
• Medical history
o Nothing of significance (no systemic illness); however, Marx moved to the UK from South Africa 6
months ago (where he also worked as a farming machine operative) and his records have not been
fully updated
o No family history of skin cancer or other skin diseases
o Not currently taking medication
o No known allergies
Clinical examination
The occupational physician made the following observations:
• The crusty patch Marx was referring to is a raised nodule

(4 mm diameter). It has a raised pink border and a slight
depression in the center, which is yellowish and crusty.
• Multiple patches of pigmented patches are also present

on both hands, several of which are irregular, rough, and
scaly (1–2 cm in size).
The occupational physician took an in-depth history, which revealed further important findings.
Select the tabs to learn more about Marx's history.
Marx's work history

• Marx has worked outdoors (largely in South Africa, where UV levels are very high) for over 20 years.
• Most days, he was in the sun during times of peak UV levels (10am–2pm).
• Generally, he wore a hat, but only used sunscreens inconsistently (and rarely thought to apply it on his
hands).
Marx's observations of the skin on his hands
• The smooth, pale brown patches started appearing several years ago.
• A little while later, more patches appeared; these secondary patches were prone to dryness, occasional
itching, and a "sandpapery" feel.
• The crusty lesion Marx is presenting with now progressed from one of the secondary patches about 3
months ago.
• Marx become concerned because the lesion was not healing (no bleeding or pruritis).
Which of the following conditions do you think the occupational physician suspects Marx might be presenting
with?
Select 4 correct options.
• Basal cell carcinoma
• Squamous cell carcinoma
• Melanoma
• Actinic keratosis
• Solar lentigo
• Keratoacanthoma
Partially correct.
The occupational physician has observed lesions that suggest the following diagnoses:
• extensive solar lentigos—pigmented patches that are a harmless feature of photoaging
• several patches of actinic keratoses—the rough, scaly patches that Marx described as "sandpapery"
• squamous cell carcinoma—the raised nodule that has likely evolved from a pre-existing patch of actinic
keratosis
The occupation physician recognizes that the nodule might be a keratoacanthoma, given the difficulty to
distinguish between this and SCC.
The outcome
The occupational physician referred Marx to his general physician, who arranged a biopsy of the nodule, which
confirmed SCC.
Further investigations also confirmed solar lentigos and actinic keratoses.
Select each tab to learn more about Marx's treatment plan and the advice given to him and his employer.
Marx's treatment plan
• Nonsurgical procedure to remove the nodule: curettage and electrodessication (C and E)
• No adjuvant therapy such as radiation therapy or immune therapy
• Marx experienced no complications after treatment and made a full recovery with minimal scarring.
Advice for Marx
• Where possible, arrange work patterns to avoid exposure to peak (mid-day) UV levels.
• Always wear sunscreen (minimum SPF30), including on hands. Continue to wear a hat and long sleeves
when working outdoors.
• Early detection is key. Become familiar with your skin and use a body mole map to help detect and
diagnose skin changes quickly.
• Continue to attend the annual screenings provided by your employer.
Advice for Marx's employer
• Continue to schedule screening for employees, and provide appropriate PPE.
The American Academy of Dermatology has created this useful infographic, which could help at-risk workers to
detect skin cancer by mapping their existing moles and lesions.
Infographic: Skin cancer body mole map
Summary for tumors
Key learning points
• The three most common types of occupational skin cancer are basal cell carcinoma (BCC), squamous cell
carcinoma (SSC), and melanoma, the least common, but most lethal, of which is melanoma.
• UV radiation is the main contributing factor to the development of skin cancer, and exposure initiates
approximately 90% of non-malignant varieties. Chemicals and ionizing radiation are other causative
agents.
• Cases of skin cancer are increasing. While it is not easy to draw a causal link between exposure and
development of a tumor, since there is often decades between the two, an occupational link is highly likely
for affected outdoor workers.
• Non-malignant tumors, such as actinic keratoses (and the "lip form" of this: actinic cheilitis), can be
precursors to malignancy. Because of their unpredictability, dermatologists recommend treatment of these
lesions, especially if they are numerous or symptomatic.
• The specific pathogenetic mechanisms for keratoacanthoma (KA) is unclear; it may resolve spontaneously,
but surgical removal is standard because of the difficulty in discrimination between KA and SCC.

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Skin disorders and the occupational physician

In the US alone, occupational skin diseases:

...account for approximately 50% of occupational illnesses.

...are responsible for an estimated 25% of all lost workdays.

...have been estimated as costing up to $1 billion each year.

[Source: Peate; Baxter et al.]

Workers of all ages in a wide variety of settings are affected.

Which occupations do you think are most prone to work-related dermatoses?

• Healthcare (including dentists and vets)

• Laboratory work (including scientists and laboratory technicians)

• Painting and decorating

• Motor vehicle repair

On successful completion of this week, you will be able to:

• identify the main clinical features of work-related skin conditions

The fundamentals of occupational dermatology

The basic physiology of the skin

Select the icons to learn more about the three layers.

This constantly-renewing surface layer of the skin is comprised of

• are stacked on top of each other to form sub-layers

The epidermis’ most superficial layer, also known as the barrier

• is a paper-thin lipoprotein membrane that is remarkably

• hinders water loss from deeper layers

• is responsible for the skin’s pliability and mechanical resistance

• is involved in the regulation of body temperature

Sitting below the dermis, the subcutaneous layer:

• consists of loose connective tissue and fat

• acts as a protective cushion

• impacts the appearance of the skin

Sub-features of the epidermis

Sub-features of the dermis

• Nerve fibers forward information.

• Blood vessels are tiny pipes that supply

• Arrector pili muscles are attached to the

• Pacinian corpuscules function as

• Meissner’s corpuscules are touch

[Source: European Agency for Safety and Health at Work]

Select each heading to learn more about each kind.

Numerous substances can trigger a response, including:

• acids and alkalis

• mineral oil and other oils

• natural and artificial resins

• additives, preservatives, flavorings, and optical brighteners

• epoxyresins and acrylates

• tar derivatives and halogen-containing compounds

• catechols, phenols, and vinyl chlorides

• unsanitary or inherently dirty environments (e.g., sewers)

• animals (notably, horses, cattle, pigs, cats, and dogs)

• mechanical trauma—including recurring rubbing, vibration, or increased pressure

• environmental factors—including prolonged heat/cold or high/low humidity

• ionizing or non-ionizing radiation—from either superficial or natural sources

• physical irritants—such as particulates, rough surfaces, and fibers (e.g., in fiberglass)

Examples of occupational skin disorders

Skin disorders of chemical origin include:

Skin disorders of biological origin can be bacterial, viral, fungal, or parasitic.

Viral: Orf, Milker's nodules

Fungal: Tinea corporis/trichophytia profunda (ringworm), candida albicans

Parasitic: Scabies, head lice

Skin disorders of physical origin include:

• intertrigo, fissures, blisters, callosity

• progressive vasoconstriction, chilblains, thermal burns