ACNE Background and Clinical

Features:
Different forms of acne have been observed in several work settings associated with certain
chemical exposures. Machinists with skin exposed to industrial or cutting oils can develop oil acne not
only in oil-soaked clothing regions but in other areas exposed to potential airborne oil mists.47
Additionally, coal tar plant workers, roofers, and road and construction workers exposed to coal tar
oils, creosote, and pitch can develop comedonal acne particularly on the face and malar regions.48
These compounds also contain polycyclic aromatic hydrocarbons (PAH), which are carcinogenic as
well.
Exposures to certain dioxins, naphthalenes, biphenyls, dibenzofurans, azobenzenes, and
azoxybenzenes also have been associated with one of the more notable forms of acne, chloracne.49
Chloracne from these chemical exposures are typically characterized by multiple closed comedones
and straw-colored cysts primarily over the malar crescents and retroauricular folds that may also
involve the neck, trunk extremities, buttocks, scrotum, and penis. Specifically, a potent inducer of
chloracne includes 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), which was a contaminant in some
batches of Agent Orange used during the Vietnam War as well as a by- product in other industrial
processes. MECHANICAL EXPOSURES MECHANICAL EXPOSURES
The skin is exposed to various forms of mechanical insults on a daily basis, and numerous
occupations involving repetitive tasks may lead to mechanical trauma of the skin. Friction, pressure,
pounding, and vibration of the skin may create changes ranging from calluses and blisters to myositis,
tenosynovitis, osseous injury, nerve damage, lacerations, shearing of tissue, or abrasions. Lacerations,
abrasions, tissue disruption, and blisters additionally pave the way for secondary infection by bacteria,
or less often, fungi, parasites, and viruses. Though the skin is well adapted to cope with such insults,
the time allowed for adaptation determines the reaction of the skin. The effects on the skin
manifestations induced by the trauma are modified by age, gender,
humidity, sweating, nutritional status, infection, preexisting skin disease, as well as genetic and racial
factors.50
Certain occupations are prone to having distinct mechanically induced skin dermatoses. For
instance, musicians may develop lesions in areas of chronic rubbing specific to the instrument Being
played (harpist's finger, fiddler's neck, guitar nipple, cellist's chest, flautist's chin). Athletes who
experience repetitive trauma while running or shearing forces from quick changes in directional
movements may develop black heel or talon noir as well as blisters and jogger's toe. A relatively new
group of skin disorders has been described with prolonged computer use with either repetitive trauma
(mousing callus) or prolonged pressure (computer palms).51 Fiberglass may cause a mechanical
irritation by penetration into the skin in those who work with the man- made fibers, often causing a
pruritic eruption that may resemble scabies. Plants may also induce mechanical irritant dermatitis from
delicate hairs (trichromes) or hairs with barbs (glochids). The irritation is caused by both the
mechanical action of the oxalate crystal and subsequent penetration of plant toxin or enzyme into the
skin.52 Onycholysis has been reported from repetitive pressure leading to total or partial anoxia of the
distal finger tips in housewives and slaughter house workers who skin cattle.53,54
 The use of vibration-producing tools can induce painful vascular spasms in the fingers and
hands known as white finger or vibration-induced white finger (VWF), which is a secondary type of
Raynaud phenomenon.55 In addition to neurovascular, soft tissue, fibrous, and bone injury to the hands
and forearms, workers who use pneumatic riveters, chippers, chainsaws, drills, and hammers are at
greater risk of suffering from VWF, especially in cold climates. Vibration frequencies between 30 and
300 Hz are most strongly associated with VWF and smoking is a known risk factor. Continued
improvements in design of modern equipment has helped to reduce vibration and decrease the
prevalence of these symptoms.
In today's society with increasing automation, less frequent manual operation of tools, and
better protective gear, mechanically induced occupational skin lesions have greatly decreased in
prevalence.30

PHYSICAL EXPOSURES
Physical agents such as extremes in temperatures, ionizing, and nonionizing radiation are
well-known causes of occupational skin disease. THERMAL STRESS Background and Clinical
Features:
Heat may cause burns, hyperhidrosis, erythema, and telangiectasias. Workers in hot
environments such as farmers and construction workers may develop miliaria in areas of chronic
rubbing with clothing, leading to symptoms of pruritus, papule formation, and even a small risk of heat
exhaustion due to an inability to maintain normal homeostasis through sweating. Relief may be
obtained with wearing loose clothing and cooling the skin. Erythema ab igne also has been observed
in repeated, prolonged exposure to heat and in those using laptops on their laps for extensive periods
of time. In addition, preexisting skin conditions and diseases may be aggravated by heat exposure, such
as rosacea, herpes simplex, and acne vulgaris.
Work-related burn injuries often result in hospitalizations with extensive treatment. Hot grease
burns may be seen in kitchen workers, roofers may incur hot tar burns, and flammable and explosive
liquids are known to cause most industry-related burns. Specific occupations are associated with higher
rates of burn injuries, with welders having the highest incidence rates for all burn injuries.56 Cooks,
laborers, food service workers, mechanics, and nurse aides are also
occupations at higher risk. One report noted that almost one third of all hospitalized burn injuries
were work-related, highlighting the impact of this occupational hazard.57
Cold exposure may lead to Raynaud phenomenon. Frostbite is another common cold injury
that may be seen affecting acral body surface areas such as the nose, ears, fingers, and toes of firemen,
construction workers, postal workers, and military personnel. Individuals engaged in winter sports,
refrigeration workers, icemakers, liquefied gas makers, ski patrolmen, and mountain rescue workers
are also at risk.

IONIZING AND NONIONIZING RADIATION

Background and Clinical Features:
Occupational skin cancers are more common than generally recognized, although it is difficult
to obtain an accurate estimate of their prevalence. Ultraviolet radiation (UV), both natural and artificial,
is the most important cause for all types of skin cancer to include melanoma, squamous cell carcinoma,
and basal cell carcinoma.58 It is estimated that avoiding this risk factor alone could prevent more than
3 million cases of skin cancer each year.59
Occupational skin cancer is characterized by long induction periods, often decades, with the
first manifestations often not seen until many years after the occupational exposure.60 Outdoor
workers, loosely defined as individuals who work outdoors for 3 or more hours on a typical workday,
are at high risk of harmful UV exposure and development of skin cancer.61 These may include workers
in industries such as agriculture, building and construction, fishing, transport, and landscaping as well
as physical education teachers and police officers.
Other professions at risk include pilots and cabin attendants. A meta-analysis identified twice the rate
of melanoma in pilots and cabin crew compared with the general population.62 Because UV
radiation is recognized to increase by 10% to 12% for every 1000 m in elevation, airline crews have
the potential for increased UV exposure by as much as 2 to 3 times at cruising altitude.63 One study
identified that pilots and cabin crew flying for approximately 56 minutes at cruising altitude receive
the same amount of UV-A as that from a 20-minute tanning bed session.64 As 90% of squamous cell
carcinoma and basal cell carcinoma and two-thirds of melanomas may be attributed to excessive UV
radiation exposure, the aim of primary skin cancer prevention is to limit UV radiation exposure.60
Three measures successful in the prevention of skin cancer in outdoor workers include regular use of
sunscreen, protection from direct UV radiation by suitable clothing, and changes in behavior with
awareness of health and diseases resulting from exposure to UV radiation. Even with recommended
strategies to use protective measures such as wide- brimmed hats, long sleeve shirts and pants,
sunscreen, and avoiding peak UV times (10 ÏÐ to 3 ÑÐ), many studies have shown inadequate use of
sun protection measures by outdoor workers.65 An Australian study of construction workers
discovered that only 10% of workers were using adequate sun protective measures.66 This highlights
the continued need for an increase in skin cancer awareness and safe sun practices in individuals with
high levels of work-related UV radiation exposure.
To determine the role of the workplace in the development of skin cancer and actinic skin
damage, one must take into consideration not only detailed occupational history with job descriptions
from earliest worker employment but also nonoccupational activities, hobbies, and outdoor
recreational pursuits from a worker's past. Ionizing radiation, such as X-rays, can also cause skin
cancer, primarily squamous cell carcinoma and less often basal cell carcinoma. High levels of acute
exposure may lead to acute radiation dermatitis observed as erythema, itching, and cutaneous
inflammation. Higher doses may manifest as skin blisters, hemorrhage, and even
necrosis (Fig. 27-6). Delayed sequelae from exposure may result in chronic radiation dermatitis with
skin atrophy, abnormal pigmentation, keratinization disorders, increasing sclerosis, telangiectasias,
hair loss, and xerosis due to loss of sebaceous glands.
Ionizing radiation sources may be found in a wide range of occupational settings, and examples
include health care facilities, nuclear weapon production facilities, nuclear reactors and their support
facilities, and various manufacturing settings.67
 Figure 27-6 Finger injury from overexposure to an industrial gamma radiation source. (From Sahin C, Cesur C, Sever
C, Eren F. Finger injury from over-exposure to an industrial gamma radiation source. Burns. 2015;41:e8-e10, with
permission. Copyright © Elsevier. BIOLOGIC EXPOSURES BACKGROUND BIOLOGIC
EXPOSURES
A number of infectious agents are responsible for occu- pational skin disease, especially in
occupations that involve contact with animals. With greater awareness and implementation of public
health measures, many historically prominent infections have greatly diminished in the general
population. However, certain infectious agents are still observed in at-risk occupational groups such as
health care workers, military personnel, farmers, and forestry workers. These infections, in turn, may
affect the productivity of a worker and ultimately the employer when conditions favor disease
transmission.

BACTERIAL INFECTIONS
Staphylococcus and Streptococcus:
Staphylococci and streptococci are gram-positive bacteria that can contaminate minor
lacerations, burns, puncture wo unds, or abrasions leading to impetigo, cellulitis, furuncles,and
abscesses. Though all occupations may be at risk, they are prevalent in meat packers, construction
workers, farm workers, and those working in close contact with other infected individuals, for example,
nurses, athletes, hairdressers, and manicurists. Epidemics of methicillin-resistant Staphylococcus
aureus infections that have been difficult to control have been documented in professional football
players in the United States.68

Anthrax: Anthrax, though endemic in parts of Africa and Asia, is rare in the United States and
predominantly a cutaneous infection (Woolsorter disease) found in occupations in which workers
handle imported goat hair, wool, and hides contaminated with the spores from the bacterium Bacillus
anthracis.69 Only 49 anthrax-related epidemiologic investigations were conducted by the US Centers
for Disease Control and Prevention between 1950 and 2001, with most involving
agricultural settings or textile mills.70 Because of the highly infectious nature of its spores and recent
world events including the 2001 bioterrorism anthrax attacks in the United States, Bacillus anthracis
is also considered a high-priority pathogen by several US government agencies for its potential as a
bioterrorist agent.

Fish Tank Granuloma:

Mycobacterium marinum is an acid-fast, nontuberculous mycobacterium that was first isolated
in 1926 from salt water fish carcasses in the Philadelphia aquarium. 71 It is responsible for fish tank
granuloma (also known as swimming pool granuloma), a distinct infection presenting as a warty nodule
or plaque usually at a point of trauma, often 6 weeks after exposure. Individuals with fish- or water-
based occupations and hobbies are most at risk. Vectors of the infection include fresh or salt water fish,
shellfish, snails, water fleas, or dolphins.72,73

Erysipeloid (Fish-Handler Disease):

 The gram-positive bacterium Erysipelothrix rhusiopathiae is responsible for the acute infection
of erysipeloid, which is almost always an occupational disease. Human infection is associated with
handling of decaying animal products such as fish, shellfish, mammals, and poultry. Infection occurs
when a worker has a predisposing insult to the skin, such as an abrasion or cut that allows entry of the
bacteria. A localized sharply demarcated bright red to violaceous infection, often involving the hands,
then ensues. Occupations at risk include fisherman, butchers, farmers, veterinary surgeons, and poultry
dressers.74

Pitted Keratolysis:
Pitted keratolysis is a rather common dermatologic condition caused by grampositive
bacterium (usually Corynebacterium species) that infects the stratum corneum of the plantar skin,
leading to malodor, hyperhidrosis, and sliminess of the skin. Though well documented among bare-
footed laborers, such as paddy farmers in the tropics, it is also observed in soldiers, miners, and laborers
as a result of occlusive, protective shoe-wear that creates a warm and moist environment for the
bacteria. Because of pain while marching and walking, the condition may cause reduced operational
deployability when observed in military personnel.75 A study of 144 US Marine volunteers in combat
in Vietnam during monsoon months discovered that 49% of soldiers were affected with this
condition.76

Brucellosis:
Brucellosis is a worldwide zoonosis caused by gram-negative bacterium of the genus Brucella
that is primarily a disease of animals in which humans are an accidental host.77 Occupationally, the
disease is contracted through inhalation of contaminated aerosols, contact with conjunctival mucosa,
or entry of bacteria through cuts in the skin as a result of contact with infected animals or their
products.78 Occupations at highest risk include slaughterhouse workers, farmers, veterinarians, meat
packers, livestock breeders, and laboratory workers. Nonoccupational sources of exposure include
ingestion of infected milk or milk products. Brucellosis is a multisystem disease that presents with
symptoms such as fevers, night sweats, myalgia, weight loss, and arthralgia but has a propensity for
more serious chronicity. Skin manifestations are generally infrequent and have been reported to affect
anywhere from 1% to 14% of those infected.79 Cutaneous findings of brucellosis are often nonspecific,
and findings include disseminated papular
and nodular eruptions, nodosum-like erythema, extensive purpura, diffuse macular and papular rash,
chronic ulcerations, and abscesses.80

Tularemia:
Tularemia is a potentially severe zoonosis caused by Francisella tularensis, a gram- negative
bacterium transmitted by ticks, fleas, deerflies, as well as by ingestion, inhalation, or direct contact
with infected tissues. The most common presentation of tularemia is the ulceroglandular form, where
an ulcer arises at the site of inoculation and regional lymphadenopathy develops. The more severe,
though less common, pneumonic form may develop after inhalation of the bacteria. Historically,
tularemia has been reported among laboratory workers, farmers, veterinarians, sheep workers, hunters,
cooks, and meat handlers; however, recent literature supports an increased risk in landscapers,
particularly for the pneumonic form of the disease. Health care workers in tularemia-endemic areas
should consider a diagnosis of tularemia in landscapers who have fever or pneumonia.81

FUNGAL AND YEAST INFECTIONS

A wide variety of mycoses may be responsible for occupational dermatoses including most
kinds of dermatophytoses, candidiasis, and even deep mycoses. Tinea pedis is a common infection of
the general population but certain workers are at even greater risk of infection as a result of humid,
occlusive footwear such as miners, military personnel, athletes, and laborers.25 Zoophilic
dermatophytes such as Trichophyton verrucosumn are associated with cattle, farm buildings, and straw;
Trichophyton mentagrophytes may be transmitted by cattle and domestic animals; Microsporum canis
is identified in domestic animals, especially cats; and, Microsporum nanum may be found in
pigs.26,27,82 Thus, occupations at risk for these zoophilic dermatophytes include slaughterhouse
workers, veterinarians, farmers, and pet shop workers.
Bartenders, waitresses, and food handlers are prone to developing candida skin infections as a
result of their wet work, which provides a favorable environment for the yeast in macerated skin near
the nails and between the digits. Prevention is key through proper drying of the skin and wearing
protective gloves.
Inoculation of Sporothrix schenckii via puncture wounds from thorns, splinters, sticks, and
sphagnum moss can lead to sporotrichosis. Those at risk include gardeners, forestry workers, nursery
workers, miners, and farmers. Since the late 1990s, there has been an epidemic of sporotrichosis
associated with transmission by cats in Rio de Janeiro, Brazil, thus adding veterinarians as an at-risk
occupation.83 Other subcutaneous and deep mycoses known to be responsible for OSDs include
histoplasmosis, with at-risk occupations being construction workers and farmers who participate in
demolition, soil-disrupting activities, and excavation in endemic areas. Chromoblastomycosis,
phaeohyphomycosis, andeumycetoma (Madura foot) are subcutaneous mycoses that are all acquired
as a result of penetrating trauma to the skin.84 Farmers and outdoor workers are most at risk for these
chronic and challenging mycoses.

VIRAL INFECTIONS
Herpes Simplex Virus:
The high prevalence and infectious nature of herpes simplex virus (HSV) makes it an
occupational hazard among health care workers, particularly for dental practices, where HSV can be
easily spread by direct (lip) or indirect (finger) contact, especially when a lesion is present in the
patient.85

Orf (Ecthyma Contagiosum):

Orf, or ecthyma contagiosum, is a zoonotic infection caused by a parapoxvirus that commonly
infects sheep and goats and is transmitted to humans through contact with infected animals or fomites.
Veterinarians, sheep herders, and farmers are most at risk, though it has been reported in children after
visiting petting zoos and livestock fairs.86

Pseudocowpox (Milker Nodule):

 Milker nodule, also known as pseudocowpox, is an occupational viral infection transmitted by
direct contact from infected cows' udders to farmers, veterinarians, and also fresh meat handlers.
Painful nodules similar to orf develop on exposed sites, become crusted, and then spontaneously
resolve. Prevention consists of treating the cows' mastitis as well as using preventive measures such as
gloves, soap, water, and disinfectants before and after handling these animals.87

Human Papilloma Virus:

Viral warts causes by human papilloma virus (HPV) have been well documented in butchers
and meat and fish handlers. Though these warts may be due to many different serotypes of HPV, HPV-
7 (Butcher wart virus) is almost exclusive to this group of workers.88 Recent innovations in
dermatology as well as other medical specialties in the treatment of HPV-induced diseases have
brought up questions regarding the controversial nature of the risk of nasopharyngeal HPV in health
care personnel. However, a recent study supports a low HPV transmission risk of oral and nasal HPV
in employees performing CO2-laser evaporation of genital warts or loop electrode excision procedure
(LEEP) of cervical dysplasia by gynecologists, though more studies are likely needed to further assess
this relatively new occupational risk.89

Bloodborne Pathogens:
The 3 bloodborne viruses that are known to pose a serious occupational threat to health care
workers include hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Although infections by
these bloodborne pathogens generally do not exhibit acute skin findings, untreated and prolonged viral
burden may have skin manifestations as well as other systemic dysfunctions. Acquisition of infection
from body fluids and accidental puncture wounds are known routes of risk to health care personnel.
Though safer needle devices for performing procedures anduniversal infection control precautions are
in place, they will not completely eliminate the risk, and prophylactic treatment will remain an
important component of prevention efforts.90

DIAGNOSIS OF OCCUPATIONAL SKIN DISEASES

PATCH TESTING AND ALLERGIC CONTACT DERMATITIS

PATCH TESTING AND ALLERGIC CONTACT DERMATITIS

Patch testing is the gold standard in diagnosing ACD and is pivotal in helping to determine the
etiology of OSDs when assessing contact dermatitis. Early evaluation and diagnosis of ACD has been
associated with decreased health care costs and improved disease course and quality of life of the
patient.91 Taking a careful exposure and occupational history is pivotal in guiding appropriate
selection of allergens to be tested. Testing is performed using commercially prepared
allergens, which are mixed in petrolatum or water and sold in individual syringes or vials. Allergens
are grouped in series, such as the rubber, metals, glues and adhesives series, or by profession, such as
the dental, hairdressers', or bakers' series. The TRUE Test® is a prepackaged, ready-to-apply kit that
now consists of 3 adhesive panels of 35 allergens and allergen mixes that are reported to be responsible
for the majority of cases of ACD. The North American Contact Dermatitis Group (NACDG) standard
screening tray includes a greater range of allergens and is also widely used among other commercially
available series.
It may be necessary to test products from the workplace, as not all allergens may be included
in the panel used. However, a basic principle is to never test an unknown substance or test with
known irritants such as solvents, cements, and soaps. Patch testing should be performed by a trained
provider, who has access to a wide range of allergens for testing purposes and experience in
interpreting results. The successful management of ACD requires a meticulous and dedicated
physician who is able to not only recognize and treat the skin disease but also has an understanding
of the ramifications of the results in regard to the patient's occupation and potential legal aspects of
workers' compensation boards. SKIN PRICK TESTING AND SKIN PRICK TESTING AND
CONTACT URTICARIA
In contrast to patch testing, skin prick testing (SPT) is an allergy test used for the identification
of IgE-mediated immediate hypersensitivity reactions (eg, immunologic contact urticaria). The skin
prick introduces a small amount of allergen into the epidermis eliciting a localized response in the form
of a wheal and erythema at the site of testing when positive. In regard to OCD, the test is used to help
make a diagnosis when contact urticaria is suspected. Conventionally, it is also used for diagnosing
other type I immediate hypersensitivity reactions in patients with rhinoconjunctivitis, asthma, atopic
eczema, and food allergy. Specifically for ICU, a diagnostic algorithm is illustrated in Fig. 27-7. Of
note, alternatives similar to SPT include scratch testing and scratch-chamber testing, which may be
used for nonstandardized allergens because routine use in place of SPT is not recommended.92
Figure 27-7 Diagnostic algorithm for evaluation of contact urticaria.92,93,94 *Open test: application of the substance in a
vehicle (petrolatum, ethanol, water) is applied over a 3 × 3-cm area and usually read at 20-, 40-, and 60-min intervals.
Immunologic contact urticarial usually presents earlier (15-20 min), whereas nonimmunologic contact urticarial may be
delayed (45-60 min) afte application. † Patch should be removed after 15-20 min after application and interpreted at
similar intervals to the open test.38 Appropriate resuscitation equipment and medications should be readily available
when testing for contact urticaria.
RADIOALLERGOSORBENT TESTING AND CONTACT URTICARIA
Blood tests may be used to help measure the amount of allergen-specific antibodies present in
the blood and guide the diagnosis in regards to an allergy. For instance, the radioallergosorbent test
(RAST) measures serum-specific IgE, though it has become outdated and is now often replaced with
the more sensitive enzymelinked immunosorbent assay (ELISA) tests that do not require radioactivity.
In 2010 the United States National Institute of Allergy and Infectious Diseases recommended that the
RAST measurements of specific IgE for the diagnosis of allergy be abandoned in favor of testing with
more sensitive fluorescence enzymelabeled assays.95

OTHER DIAGNOSTIC TESTING

Depending on the potential exposure based on occupational history and clinical examination,
other diagnostic modalities may be used to make a definitive diagnosis. Common procedures in
nonoccupational settings such as skin scraping with potassium hydroxide (KOH) preparation and skin
biopsies can similarly be utilized in the occupational setting.
In addition, several other biomonitoring methods may be employed particularly for certain
occupational exposures. For example, exposure to arsenic can be detected in the blood, hair, nails, and
urine; however, measuring arsenic in the urine provides the most reliable indicator of exposure. In
addition, when measuring arsenic in the urine, it is important to request speciation to determine the
specific amounts of organic versus inorganic arsenic. Inorganic arsenic, elemental arsenic, and arsine
gas are the toxic forms leading to adverse health effects. Organic arsenic (eg, arsenobetaine), on the
other hand, is relatively benign and can be found in seafood, which can significantly elevate total
arsenic levels up to 72 hours after ingesting a seafood meal.
Furthermore, although beryllium sensitization can be detected through patch testing, laboratory
testing of the blood is also commonly used in the occupational setting. The beryllium lymphocyte
proliferation test (Be-LPT) exposes the separated white blood cells drawn from a venipuncture to a
beryllium solution and measures the proliferation of these white blood cells. In one large study of more
than 12,000 individuals, the sensitivity and specificity of the Be-LPT were 68.3% and 96.9%,
respectively.96 Identifying sensitization to beryllium is paramount because sensitized workers can
develop chronic beryllium disease (CBD), a permanent and potentially progressive granulomatous
restrictive lung disease. Observational studies suggest that early treatment of clinically apparent CBD
is associated with improved pulmonary function, radiographic findings, respiratory symptoms, and
functional status.97 When beryllium sensitization is initially suspected, additional testing in
conjunction with temporary or permanent work restriction may be recommended.

MANAGEMENT
Treatment of OSDs is dependent on the initial cause and is practically the same as that for skin
diseases of nonoccupational origin. Identifying the specific cause(s) of the patient's disease and
outlining the appropriate steps to avoid exposure and recurrences is an important role to be played by
the provider. As most occupational skin disorders are preventable, patients should be educated on the
appropriate preventive measures. Employers should work with their employees to mitigate hazards
through the hierarchy of controls (Fig.27-8), with the last resort for prevention being protective
clothing and topical barriers, if practical. Ideally, medical providers and occupationally related
disciplines including industrial hygiene should work with employers to eliminate or substitute known
hazards. However, if elimination or substitution is unrealistic, engineering controls should be
considered that protect workers through physically isolating
hazardous processes. Other methods to help reduce exposure include administrative controls, which
include alterations in work cycles to decrease exposure time to hazards.

Figure 27-8 Hierarchy of controls. The hierarchy of controls highlights the major categories of mitigating hazards. The
most protective to least protective are (1) complete elimination of the hazard, (2) substitution to a nonhazardous or lesser
hazardous substance, (3) engineering controls to prevent exposure to the employee, (4) administrative controls to limit the
duration of potential exposure, and (5) donning personal protective equipment (PPE).

RISK FACTORS
Understanding risk factors for OSDs is important for potential prevention of disease. Risk
factors may be endogenous and beyond the control of the individual, such as age, gender, race and
genetics. Or, risk factors may be exogenous and potentially modifiable, including specific occupations
and duties, work practices and environment, experience level of the worker, and protective measures
used.
In regard to age, reports have indicated that older individuals have reduced reactivity to
irritants.98 However, research on age and development of ACD is less clear, with studies showing
mixed results.99 Several studies have also shown that occupational ICD is seen more commonly in
females. At the same time, many epidemiologic assessments may be biased by chemical exposure
patterns and specific genderrelated occupations, which may give a perception that females are more
reactive to irritants than males, and this difference is not necessarily supported by direct comparative
testing.98 Females may be more predisposed to developing ACD, but again, this is likely related to
exposure patterns and not to intrinsic skin characteristics.100 Racial differences in dermatologic
response to chemical agents also have been described, with some evidence that Asian skin may be
more reactive and black skin less reactive than white skin.101
Increasing research on genetic factors has found genetic susceptibility markers associated with
ICD and ACD. For ICD and ACD, alterations in production of pro-inflammatory cytokines interleukin
(IL)-1alpha, IL-1beta, IL-8, tumor necrosis factor (TNF-alpha), and anti-inflammatory IL-1 have been
associated with increased risk.102 Additionally, mutations in the filaggrin gene have been shown to
affect skin barrierfunctions and contribute to the development of atopic dermatitis and potential
susceptibility towards contact dermatitis. Maceration and other skin disease that disrupt the skin barrier
can enhance penetration of both irritants and allergens. Atopic dermatitis is known to increase the
susceptibility of skin to irritants but not to allergens.102 Consequently, workers with atopic skin
disease are more likely to develop OSDs when also exposed to wet work conditions (defined as
exposure of skin to liquid for more than 2 hours per day, use of occlusive gloves for more than 2 hours
per day, or frequent handwashing). 103 And studies of polymorphisms in genes encoding for metabolic
enzymes, such as N-acetyltransferases, suggest a role in developing ACD.102
Certain industries and occupations also appear to pose a higher risk of developing occupational
dermatoses. Based on the 2010 Occupational Health Supplement of the National Health Interview
Survey (NHIS) that sampled 17,524 adults who had worked in the preceding 12 months, the period
prevalence of occupational dermatitis was highest in arts, entertainment, and recreation (12.6%)
followed by health care and social assistance (12.5%) and accommodation and food services (12.4%)
industries after adjusting for age, sex, and race/ethnicity.104 Similarly, occupational categories
(defined by the Standard Occupational Classification) identified with the highest prevalence of
reported dermatitis included life, physical, and social sciences (18.2%) and art, design, entertainment,
sports, and media (15.1%).104 In contrast, the overall prevalence rate among the surveyed
current/recent workers for dermatitis was 9.8%.
Other exogenous risk factors beyond industry and occupation may include chemical
concentration, exposure duration, and use of personal protective equipment (PPE). The use of PPE,
including gloves and clothing, can often limit hazardous exposures; however, if used improperly, it
may actually increase permeation and penetration of irritants and allergens. Furthermore, the PPE itself
may directly irritate the skin or contain allergens (eg, latex gloves), so correct use of PPE is paramount.
Although handwashing is generally encouraged, excessive hygiene measures and use of soaps and
detergents can lead to ICD.

HEALTH RISK ASSESSMENT

Although occupational dermatologic hazards exist in many workplaces, the risks to workers
are often variable and depend on a multitude of factors. In the occupational environment, this
probability is evaluated through a methodical approach known as a health risk assessment. Health
risk assessments encompass 4 main components: (1) hazard identification, (2) doseresponse
relationship, (3) exposure assessment, and (4) risk characterization. HAZARD IDENTIFICATION
HAZARD IDENTIFICATION
The initial step to identify workplace hazards should incorporate knowledge from industries
involving similar work practices and recognize potential injuries and illnesses that can result from
related exposures. Hazardous chemicals, in particular, legally require Safety Data Sheets (SDSs,
formerly known as Material Safety Data Sheets [MSDSs]), which display not only chemical
properties but also adverse health effects, protective equipment necessary for safe handling, and first
aid measures for acute exposure treatment among others.105 Employers must have SDSs readily
available to employees for all hazardous chemicals in the workplace. DOSE_RESPONSE
RELATIONSHIP DOSE_RESPONSE RELATIONSHIP
 The dose-response assessment helps delineate relative threshold concentrations of an
exposure that results in adverse health effects. For many OCDs, the adverse effects are often dose-
dependent with exposure. However, it is important to recognize health conditions (eg, atopic
dermatitis) that can contribute to adverse health effects (eg, ICD) at lower exposure doses.
EXPOSURE ASSESSMENT EXPOSURE ASSESSMENT
Because not all OCDs are purely from direct dermal exposures, careful assessment should be
taken to determine the potential routes of exposure in the particular workplace. The work task duration
and frequency should also be noted as adverse health effects can not only be dose- dependent but time-
dependent as well. Furthermore, monitoring is often performed since certain
toxic substances have legal permissible exposure limits (PELs) enforced by OSHA. One important
caveat is that PELs do not necessarily represent safe limits. The National Institute for Occupational
Safety and Health (NIOSH) and American Conference of Governmental Industrial Hygienists
(ACGIH) provide recommended exposure limits that are based on adverse health effects. RISK
CHARACTERIZATION RISK CHARACTERIZATION
By analyzing the collected data from hazard identification, dose-response assessments, and exposure
evaluations, an overall level of risk can be assigned to the evaluated hazards. Some assessors use a
risk matrix incorporating toxicity and probability of exposure to determine risk level, but regardless
of the method, a safe margin of error should be in place to buffer a higher risk hazard misclassified in
a lower risk category. Ultimately, risk characterization also allows recommendations on control
measures, if necessary, which may include substitution of chemicals, changes in ventilation, addition
of local exhaust, alterations in work cycles,