18occupational skin diseases and management, dr. dincy peter

OCCUPATIONAL DERMATOSES

IN HEALTHCARE WORKERS

Dr. Dincy Peter

Department of Dermatology, DVL2

Christian Medical College, Vellore.

Outline

Introduction to OSD

Clinical presentation

Hand eczema

Contact dermatitis to glove, glutaraldehyde

Diagnosis and management

Introduction

workplace exposure to some physical, chemical or

biologic hazard has been a causal or a major

contributing factor

high index of suspicion and a knowledge of the

worker’s environment

Impact of OSD

Change of occupation

prolonged sick leave

limiting leisure activities

interfere with the ability to perform household

chores

time-consuming treatment

OCD- health personnel

Fifth high risk occupational category

Annual incidence of 7.3 OSD per 10,000 workers

Highest incidence in younger people

Health personnel- 3 groups

OCD- health personnel

First group- physicians, surgeons, medical specialists,

dental personnel

Second group- nurses, laboratory and radiology

technicians, biologists, pharmacists, physiotherapists

and dialysis workers

Third group- office personnel, technical service workers,

Kitchen and laundry workers, cleaners and disinfection

and sterilization area workers

Contact dermatitis.fifth ed. Johansen DJ, Frosch PJ, Lepoittevin JP editors.

OSD

Contact dermatitis is reported to comprise 90–95%

of cases of occupational dermatoses:

irritant contact dermatitis (70–80%)

allergic contact dermatitis (20–25%)

contact urticaria (<5% , latex allergy)

History

Is the worker exposed to irritant or allergen?

Is there a temporal relationship between dermatitis

and the work?

Is the dermatitis associated with particular tasks?

Does it resolve/improve when the worker is away

from work for a week or more?

Clinical presentation

Acute

– Itching

– Redness

– Scaling

– Vesiculation

– papulovesicles

Chronic

Fissuring

Hyperkeratosis

lichenification

Irritant contact dermatitis

irritant - induce dermatitis in anyone if applied to the

skin

acids,alkalis, solvents, detergents/soaps, abrasives,

enzymes

only affects the site of primary contact (forearm,hands)

Occasionally the face - an irritant dust, vapour or

aerosol

cleaners, sterilisation area, kitchen and laundry workers

Irritant contact dermatitis

Acute

Chronic – cumulative irritant dermatitis

result of multiple subthreshold insults induced by

weak irritants

Frequent use of disinfectant solutions, detergents

and soaps – epidermal barrier defect

Nurses, surgeons, laboratory personnel

ICD

Cumulative irritant dermatitis

Management

Treat with steroids, emollients, antibiotics, etc.

Reduce the exposure to irritant

Reduce frequency or duration of exposure

Substitute less irritating chemical(s)

Avoid occlusion

Avoid excessive heat and humidity

Prevention - hand dermatitis

Wash with warm, not hot water

Use the least harsh soap or lowest concentration of

antibacterial soaps

Use alcohol sanitizing emulsion gels if feasible

(Avant, Sterillium, Desderman and Allsept S)

Use water-based moisturizers liberally

Use non-latex gloves

Protect and treat the hands when away from the work

environment

CASE

32 year old surgeon

presented with itchy

skin lesions over the

hands for 1 month

duration. What is your

diagnosis?

Allergic contact dermatitis

delayed hypersensitivity reaction

chemical spills/exposure often initiate sensitisation

sensitisation takes about 7–21 days

dermatitis develop within 24 hours after the next

exposure

at any time of a person's career

Sites- ACD

not only the site of primary contact, but also distant

sites where small amounts have been accidentally

transferred, e.g. by the fingertips

Thick skin (such as the palms) is relatively resistant to

contact dermatitis

thin skin (face, genitals) is much more susceptible

Contact urticaria

Erythema and wheals occurring at the site of

contact ,within an hour of exposure, and resolving

within 24 hours

Immunogenic (Type 1, IgE-mediated) - rubber

latex, formaldehyde

Rubber gloves

irritant dermatitis (by making the hands hot and sweaty)

allergic dermatitis to rubber additives(thiurams,

carbamates, thioureas and mercaptobenzothiazoles)

Site- flexor wrist, dorsa of the hand

contact urticaria to latex

Glove powder not incriminated in cutaneous reactions

adsorb chemicals in the glove , airborne vehicle of

allergens — provoking respiratory reactions

Management

Avoid contact

Medical alert bracelet – latex allergy

Use vinyl or totally synthetic rubber gloves

Nitrile gloves- latex free, but may contain

additives

Glutaraldehyde

Skin contact – cold disinfection of equipment, fixing

specimens for microscopy, Processing of X-ray films

Strong irritant and sensitizer

Skin irritation, contact dermatitis , chronic dermatitis

Substituition- hydrogen peroxide, peracetic acid-

hydrogen peroxide (PAHP) or orthophthaldehyde

Minimization of contact

Special allergens in nurses

Cetrimide

Chlorhexidine

Chlorpromazine

Chlorxylenol

Formaldehyde

Glutaraldehyde

Penicillin

Povidone-iodine

Diagnosis of OCD

Detailed history

In-depth information on workplace

Results of careful patch testing

Observation of the course of the disease

Complex cases – follow up

Management

Topical corticosteroids of medium to strong potency

Tacrolimus ointment

Systemic steroids

Ciclosporin

Azathioprine

Acitretin/ alitretinoin

Phototherapy

Patch test

A small 0.5 cm strip of

allergens are placed on

the patient’s clean back.

The strips are removed

in 48 hours and a

preliminary reading

done.

Late reading is done at

72, 96 or 120 hours.

Control of OSD

Elimination

Substitution

Engineering controls

Administrative control

Personal protective equipment

Learning points

OCD most frequent cause of occupational skin

disease

Treatment goal is to avoid chronicity

All work place contact allergens and irritants must

be evaluated as the cause or contributory factors

References

Fischer's Text book of contact dermatitis

Contact dermatitis, JD Jeann, FJ Peter. 5Th ed

Occupational skin diseases.ENVIS-NIOH news

letter. Vol 5, No.2 Apr-Jun 2010.

A guide to occupational skin disease. Oct 1995.

Dept of Labour, New Zealand.

Occupational dermatoses. Australian Family

Physician Vol 34; May 2005