CLASSIFICATION OF SKIN CONDITIONS
Dermatoses can usefully be divided into two categories:
The distinction between occupational and non-occupational dermatoses is often difficult to make, largely because the majority of occupational dermatoses and a sizeable proportion of non-occupational dermatoses have a similar clinical appearance. This clinical and histopathological entity is termed eczema or dermatitis; the two words are used synonymously by most dermatologists in this country. However, proper advice on fitness for work cannot be given until the distinction between occupational and non-occupational pattern of disease has been drawn as accurately as possible.
Occupational dermatoses may be broadly divided into two groups:
The vast majority of dermatoses are not infectious or contagious.
EFFECT OF THE COMMON OCCUPATIONAL DERMATOSES ON FITNESS FOR WORK
An accurate assessment and determination of the causal factors of the dermatosis is essential. Once guided by a precise diagnosis, changes in working methods and other preventive measures (such as substitution, enclosure, mechanical handling, ventilation, rotation and personal protective equipment) can be helpful. The Control of Substances Hazardous to Health (COSHH) Regulations now provide the legislative mandate for such an assessment, and require that every employee should have adequate information, instruction and training on the substances they handle at work. For those at special risk, regular health surveillance may be required to identify any indication of disease at an early stage.
In most cases of occupational dermatoses, continuation in the same employment is a realistic goal, sometimes with minor adjustments to work practices. This is particularly important in the many occupational dermatoses where prognosis is known to be little altered by change of job. Carefully considered preventive skin care programmes make both the primary and the secondary prevention of occupational dermatoses more effective.
Occasionally, a change of occupation may be in the best interests of the individual. It must be stressed that this should always be preceded by accurate diagnosis. There are certain groups in which a change of job is likely to be indicated. Those who have most of their working life ahead, such as first-year apprentices, may be well advised to give up a job that is already causing them persistent contact dermatitis.
When a decision has been made to advise a change of occupation, it is essential that the alternative occupation should genuinely be more suitable. Clearly, the major requirement is avoidance of the original contact factor(s). This may need expert guidance, particularly when the contact factor is widely used, e.g. allergens such as formaldehyde or irritants such as detergents.
EFFECT OF THE COMMON NON-OCCUPATIONAL DERMATOSES ON FITNESS FOR WORK
Atopic eczema is considered to render the potential employee more susceptible to contact irritants, but only if the condition was severe in childhood and particularly if it involved the hands. Indeed, there is some evidence that it is harder for the atopic to become sensitized to contact allergens than the non-atopic. However, atopics are more susceptible to contact urticaria from Natural Rubber Latex (NRL), and, in this situation, advice will be required not only about the prevention of urticaria but also about asthma and anaphylaxis.
There are few jobs for which a history of severe childhood atopic eczema with hand involvement can be regarded as an absolute contra-indication, but three notable exceptions are hairdressing (shampoo), catering (wet work and detergent), and production engineering (soluble oil). Other occupations that entail significant exposure to contact skin irritants are domestic cleaning, nursing, construction work, motor vehicle maintenance, horticulture, and agriculture.
Involvement of the hands in atopic eczema can pose an entirely separate problem in certain occupations. Lesions of eczema are may be colonized by Staphylococcus Aureus, and sometimes by Streptococcus pyogenes. Any organism which colonizes or contaminates the skin surface is dispersed into the environment on naturally shed skin scales. This has implications in healthcare (patient infection), catering (food poisoning), and the pharmaceutical industry (product contamination). The risk to hospital patients is increased in the immunologically suppressed, though it is not confined to such patients. Hospitals with methicillin-resistant S. aureus (MRSA) strains need to be particularly vigilant as to staphylococcal carriage in staff. The hazard posed by active eczema in these particular occupations is real and requires individual assessment of risk. One further consideration may influence the advice given to atopic subjects. Many essentially endogenous dermatoses are then stated to be aggravated by work exposure, especially if there is known to be a high risk substance, such as chromate, epoxy resin, or a powerful irritant, in the occupational environment.
Psoriasis: Mild psoriasis that does not affect the hands can probably be safely ignored from the point of view of fitness for work, although individual assessments may be necessary according to job requirements. Aggravation of psoriasis by physical or chemical trauma (Kobner phenomenon) can occur occupationally. Occupational factors may elicit it on the hands for the first time in psoriasis-prone individuals though patients with psoriasis vary widely in their liability to hand involvement. If the hands are affected, work involving heavy manual labour, such as scaffolding, or contact with irritants (e.g. in production engineering) may aggravate psoriasis. Colonization of psoriatic lesions with potentially pathogenic bacteria is less of a problem than in atopic eczema and occurs chiefly in people with severe psoriasis who have been hospital in-patients. People with psoriasis which is well-controlled do not generally present a risk to others from bacterial carriage. Psoriasis becomes a potential hazard in those working in hospitals, catering or the pharmaceutical industry if lesions involve the hands, forearms, scalp (common) and face (rare). Nevertheless, the lesser degree of staphylococcal colonization in psoriasis compared to atopic eczema, as well as the wider spectrum of suppressive treatments that now exist for psoriasis, allow greater scope for employment of psoriatics even in such high-risk occupations.
How long (duration) have you had the rash?
Enquire about the rash - Colour Papular/vesicular/pustular/macular/scaly
Distribution- Where did it start?
Speed of onset?
Any known exacerbating factor?
Is there a history of a similar rash in the past?
Any known medical problems? (Hypertension, diabetes, connective tissue disease)
Use of prescribed or OTC medication?
What is your occupation?
Length of time in the job?
Any history of
Home environment? (hobbies, DIY, pets)
Anyone else in the family with similar rashes?
4 aspects of the lesion(s) need to be recorded: - Morphology - Shape - Distribution - Colour
|Linear:||line, narrow streak or stripe|
|Zosterform:||Resembling herpes zoster|
Majority of skin diseases have a characteristic distribution or a predilection for certain sites. Other dermatoses vary in extent of involvement according to their severity.
The distribution of lesions can also be described according to regional involvement, the recognition of which can help pinpoint a diagnosis.
Cutaneous lesions can be flesh coloured, demonstrate a change in pigmentation or be characterised by redness. Erythema is redness due to microvascular dilation which can be blanched by pressure. Purpura is a darker cutaneous redness due to erythrocyte extravasation: purpura cannot be blanched by pressure.
Handwashing - How often?
Use of Detergents, Moisturising/emolients
State of toilets, washing facilities?
Records of risk assessments - Findings and recommendations?
Have the recommendations been acted upon?
COMPARISON OF IRRITANT AND ALLERGIC CONTACT DERMATITIS
|Irritant Contact Dermatitis||Allergic Contact Dermatitis|
|Caused by chronic irritation.|
|Not as common as irritant.|
|Less allergen needed, therefore, less amenable|
|Provokes cell-mediated allergy.|
|Varying individual susceptibility.||Varying individual susceptibility.|
|More at risk if severe childhood hand eczema.||Atopics not at higher risk.|
|More likely for work colleagues to be involved.|
|Sensitisation after one or many contacts.|
|Months to years of exposure prior to onset.||Contact gives dermatitis in a few hours - two days.|
|Often occurs after a few months of repeated contact.|
|Improves away from work.||Improves away from work but more slowly.|
|More rapid relapse on return to work.|
|Distant spread more common.|
|Diagnosed with patch testing.|
|Provoking Agents||Provoking Agents|
|detergents||epoxy resins and hardeners|
|reducing||plant & wood products|
|Associated Occupations/Industries||Associated Industries|