o ther dermatoses R:Rosenstock - PowerPoint Presentation

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o

ther dermatosesR:Rosenstock

By M.H.Davari MDShahid Sadoughi University of medical sciences

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

Problem

Musculoskeletal Dermatological Respiratory Hearing loss Other

P.M

Percentage 45.323.49.28.713.9

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

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Occupational acne

1. Oil acne (folliculitis)Pathogenesis: hair follicle is particularly susceptible to irritation from lipidsplugging of the follicle (comedo formation) or induce an inflammatory reaction by rupture of the follicular wall (folliculitis)Petroleum distillates, cutting oils, pitch, and tarClinical course: dorsae of the hands and forearmsDiagnosis: area of involvement history

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Age:

any agePrevention: Protective clothing Mandatory daily laundering of work clothesTreatment: similar to those for routine acneOral antibiotics (tetracycline and erythromycin)Topical antibiotics (clindamycin; erythromycin)Refractory Comedones long-term topical retinoids

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Acne vulgaris

Persons at

risk: workers in fast food restaurants, actors, actresses, models, and cosmeticiansAge: peak 11-20 yrsPathogenesis: in addition to oil, Friction, heat, and sweatingClinical course: face, neck, upper chest and backDiagnosis: history of exposureTreatment and prognosis: like oil acnea

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Viktor

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

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chloracne

Sensitive

indicator of systemic exposure to specific polyaromatic hydrocarbonsPersons at risk include workers: hydrocarbonbased pesticides and herbicides, electrical workers exposed to older polychlorinated biphenyl (PCB)Pathogenesis: follicular level of the agent may be of greatest importanceClinical course: pale yellow (straw) cyst + comedoinflammatory papules and pustules of acne vulgaris are not evidentpostauricular folds, the malar crescent, and the genitalia.The nose typically is sparedonset within 2w–2mregress over a 4–6m (1-2 yr)

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Non-cutaneous findings: Hepatomegaly, Hepatic porphyria, Peripheral neuropathyTCDD causing chloracne at the lowest concentrationsDiagnosis: history of exposure (suggest) Serum levels of suspect compounds and metabolites should be obtained (confirmation of exposure) (GC/MS)Biopsy cause loss of follicular sebaceous glands (DDX: actinic elastotic comedones)

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Treatment

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DifficultOral antibiotics, topical retinoic acid, and oral isotretinoinCyst formation prevent by early retinoid therapyPrevention: Even minute exposures must be avoidedshower facilitiesUse disposable clothing for workersRoutinely monitor for plant contamination using wipe samplesRoutinely educate and monitor workers.

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Pigmentary

disorders

1. HyperpigmentationTypes:Exogenous pigment depositionDeposition in skin systemicallyPhotoeruptions (more common)PIH (more common)Or by wood lamp examination:Epidermal?DermalMix Workers at risk: heavy metals, organic nitrogen compounds and dyes

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Hyperpigmentation: nitro compounds and dyes

that

stain skin

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Hyperpigmentation: metals that may be systemically or locally deposited in

skinClinical course:The most striking form of dyspigmentation is argyria due to systemic deposition of silver.Pigmentation from heavy metal toxicity exacerbated by exposure to the sunPIH occurs at the sites of skin injuryDiagnosis:History & examinationWood lamp examinationBiopsy

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Prevention

:Sun screenProtective clothes (exposure to organic dye-like component)Treatment:Tattoos and systemic heavy metal toxicity may be irreversiblePIH: may persist for months (dark skin)Retinoic acidHydroquinone

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2. Hypopigmentation:PIHCutaneous injury, from inflammation or traumaLeukodermiaHydroquinone or derivatives of alkyl phenols and catecholsWorkers at risk: rubber workers, photographic developers, hospital housekeepers, printers, and workers in the oil, paint and plastics industriesPathogenesis: direct cytotoxic effect on melanocytesformation of antigens, which activate lymphocytesDiagnosis : wood lampTreatment: long-term PUVAallograft

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Picture of a phototoxic drug reaction

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Photodermatoses

UVA: aging, occupational dermatosis UVB: sun burnUVA,B,C: carcinogenOutdoor occupationsPhototoxic: Nonimmunologic, reactive O2, improve immediately with avoidancePhoto allergic: type IV imune reaction, substance convert to hapten, Not improve immediately with avoidance

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Phototoxic agents

Some common plants containing furocoumarins

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Picture of

photoallergic and phototoxic dermatides

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Contact

photodermatitis

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Diagnosis: History of sun exposureTypical photodistributionExposure to photoactive substancesbiopsy may be helpful to exclude other causes of photosensitivity (lupus erythematosus, medications)Prevention:Sunscreens: (SPF) rating of #15 or better ,(which is less effective in preventing UVA)Use of protective clothingEPA (enviromental protection agency)

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

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Treatment:

open-wet dressingsbland emollientsRarely systemic steroids for severe cases.Prognosis:Workers with clinical signs of chronic sun exposure are at risk for cutaneous malignancies and should be followed closely

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ERYTHEMA AB IGNE

The area usually is regional corresponding to the site of repeated applications of heatWorkers exposed to furnaces, such as cooks, stokers, glass blowers, and kiln operatorsClinical course: Early: vasodilation (livedo reticularis)Later:Poikiloderma(epidermal atrophy, telangiectasia, and pigment alteration)SCC and Merkel cell carcinomas occur in the poikilodermatous area

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Diagnosis: The local nature of the condition, along with a history of exposure to heat, is suggestiveBiopsy: exclude other conditions associated with livedo reticularisPrevention: Repeated exposure avoidedEducation of workers at risk is the key to prevention.TreatmentCessation of exposure in early changes.permanent change: monitored for future development of skin carcinoma

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MILIARIA

Bakers, foundry workers, cooks, coke oven operators,

and workers with similar exposure to excessive heat that causes sweatingblockage of the sweat ductsTrunk: most commonly affected location, especially the chest, back, submammary, and axillary areasClinical lesions are on a spectrum encompasssing clear vesicles if the blockage is in the superficial epidermis (miliaria crystallina) macules or papules if the blockage is in the lower epidermis (miliaria rubra) or flesh-colored to pale white papules if the obstruction is in the dermis (miliaria profunda).

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Symptoms usually are absent with miliaria crystallina, while miliaria rubra and miliaria profunda may be pruritic or painfulMay lead to inadequate body thermoregulation with accompanying heat exhaustionPathogenesis: Sweating and maceration cause plugging of the eccrine sweat duct with ductal keratin. Microbial organisms may invade the macerated keratin and cause further plugging of the ductDiagnosis: clinical picture, symptoms, and the history of onset after excessive heat exposure and sweating.

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Prevention: exposures should be avoided Hexachlorophene soap decrease bacterial population. Maceration of the skin should be avoided by frequent clothing changes when sweating is profuse.Treatment and prognosisRemoval A period of a week or more should elapse before re-exposure of the individual to the hot environment is attempted, particularly if the eruption is severe enough to cause a decrease in systemic heat tolerance.

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Cleaners of

vinyl chloride polymerization reactor tanksRaynaud’s phenomenon Osteolytic bone changessclerodermiaSilica dust have been reported to be at risk for developing:Raynaud’s phenomenonSclerodermaorganic solvents has also been associated with:systemic sclerosis

OCCUPATIONAL ACRO-OSTEOLYSIS AND SCLERODERMA

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Diagnosis

:Patients presenting with Raynaud’s phenomenon without a history of vibration exposure should be questioned regarding exposure to vinyl chloride, silica, organic solvents, and epoxy resinsPreventionWorkers cleaning polymerization reactor tanks of vinyl chloride need complete skin and respiratory protection.Respiratory protection also is critical in those workers exposed to silica. All workers with Raynaud’s phenomenon, whether or not the condition is job related, should have protection of their hands from cold weatherTreatment and prognosisAcro-osteolysis stabilize after withdrawal from vinyl chloride monomer exposureScleroderma of any cause, however, tends to be progressive.

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FOREIGN BODY REACTIONS

Workers in construction, electronics, metal working,

and miningFiberglass (extremely pruritic)BerylliumSillica unusual form clam diggers as a result of exposure to avian schistosomesHairdressersAcute reactions resemble irritant dermatitis.Chronic reactions typically are more papulonodularSecondary bacterial infection may complicate the clinical picture

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Pathogenesis: A granulomatous respons is typically a non-allergic responseBeryllium is due to delayed hypersensitivityTreatment and prognosisLocalized granulomas of any cause may be treated surgically. Topical therapies including open wet dressings and topical steroids are useful in the treatment of acute foreign body reactions.Fiberglass may be removed by using tape stripping of the skin.

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BIOLOGIC CAUSES OF OCCUPATIONAL DISEASESbacterial diseases:

work with animals and those in the construction trades

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Fungal diseases

workers at greatest risk are thosein the agricultural tradesCandida and dermatophyte infections are the most common superficial fungal infections

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An unusual variant of tinea pedis (one hand–two feet tinea) needs to be considered in the differential diagnosis of hand dermatitisDiagnosis:potassium hydroxide examination of scale fungal cultureTreatment: Topical antifungal agents usually are adequate for treatment, although occasionally administration of oral antifungals (griseofulvin, ketoconazole, itraconazole, terbinafine) is necessary

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Viral diseases

HSV1/2 infection of the finger (herpetic whitlow) Healthcare workers.Farm workers Meat handlersUntreated infections last for 1 to 2 weeksAthough therapy with oral antivirals is helpful in shortening the course. Diagnosis:Tzanck smear, showing multinucleated giant cells viral culture

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Parasitic diseases

Parasites are unusual causes of occupational disease in temperate climatesHowever, workers in developing countries are at particular risk.

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