Pittfall in the diagnosis of Occupational Skin Diseases

Sri Awalia Febriana

Department of Dermatology and Venereology Faculty of Medicine Univaersitas Gadjah
Mada/ Sardjito General Hospital Yogyakarta

Abstract
Occupational skin diseases are those arising during occupational activity. These
diseases, currently increasing in prevalence, are of great socioeconomic importance. Not
only do they have major consequences for the affected patients and their families, but the
annual cost to health insurance companies is equal to or even greater than that of other
chronic inflammatory skin diseases like psoriasis and eczema.1 In the USA the average
annual cost per claim of Occupational Skin Disease was $3,552 and the average disability
time 23.9 days.2 In Germany, the annual cost to health insurance companies for each
case of occupational hand eczema is about 9000.3
Establishment of the diagnosis of occupational contact dermatitis is quite
complicated since there are no specific clinical and histopathological characteristics.4
Diagnosis of OCD involves two fundamental steps: 1) recognizing the existence of an
occupational exposure and 2) assessing whether that exposure represents a cause or
substantial aggravating factor in the patients dermatitis. Usually, OCD improves when the
patient is off work for more than a week and intensifies when work is resumed. To reach an
accurate diagnosis, the dermatologist relies on comprehensive history taking, thorough
skin examination and skin testing. A workplace visit is also included to gain important
information in the investigationn. To arrive at an accurate diagnosis of OCD it is vital that
the physicians involved have an adequate level of knowledge and skill as well as
experience in this field. Moreover, it is important and often difficult to be able to confirm the
relationship between OCD and a patient's exposure. Screening of the complete study
population by one or more trained dermatologists using standardized criteria is the most
reliable and therefore preferred method.5
Some studies have shown that thorough investigation of exposure to contact
allergens is beneficial for the prevention, treatment, and prognosis of patients with allergic
contact dermatitis.6-8 Exposure information can be acquired from different sources such
as: 1) publications; 2) product labelling and declarations; 3) material safety data sheets
(MSDS); 4) inquiries to manufacturers or suppliers; 5) chemical analysis and product
databases; and 6) Online data bases and sources of information.9-11

Unclear definitions of OSD and limited surveillance data, as well as differences in work
situations and diagnostic criteria, make it difficult to determine the actual prevalence of
occupational skin disease.12 Moreover, current data are available only in voluntary or
mandatory reporting schemes and compensation registries, or from specialized dermatology
clinics.13 Therefore for our study we used the active case ascertainment approach involving
the use of questionnaires and/or clinical examinations.
Legal and financial consequences make it important to ensure the validity of diagnoses of
occupational contact sensitization. To improve the reliability of the patch testing technique
researchers worked continuously to compose series of tests, focusing on concentrations and
vehicles of chemicals and on standardization of patch test reading 14 and interpretation of
clinical relevance.15 Patch tests can have a limited reproducibility as a standard diagnostic
procedure, partly due to meteorological conditions and changes of season. One multicentre
study showed an increase of irritation and doubtful reactions with dyes and biocides during
cold and arid conditions, but not with adhesives, plastic and rubber. The authors thus had to
consider the influence of weather conditions on the diagnostic value of the test.16 We were
patch testing subjects at work in a hot climate; because perspiration could loosen the
patches they had to be reinforced with extra tape, making them uncomfortable to wear.
Many workers refused to participate or withdrew from the study. Some subjects took off the
patches before 48 hours occlusion or showered or scrubbed the patch test area. To get
workers to agree to patch testing and follow proper procedures we had to convince them of
the importance of the study. They were more enthusiastic once they realized its importance
for other workers in the same industry and for leather and shoe consumers. Clear results
from our study could lead to recommendations for factory management, government and
stake holders and also for the chemical industry providing substances for leather and shoe
manufacture.
The most difficult and intricate part of the patch test procedure is assessing the clinical
relevance of positive patch test reactions in the occupational setting, a task requiring skill,
experience and curiosity.15 Based on International Contact Dermatitis Research Group
(ICDRG) criteria, we concluded that a positive patch test reaction is relevant if the allergen
has been traced. Current relevance refers to the patients present dermatitis. Past
relevance refers to a past clinical disease and is not directly related to current symptoms.15,16
During patch testing we found sensitization to 15 allergens relevant to tannery work and 16
allergens relevant to shoe factory work. Judgement as to the clinical relevance of those
allergens was possible only after we were able to establish, first, an exposure and, second,
whether the workers dermatitis was partially or totally linked to the exposure.

For some allergens in finished materials (rubber, plastic or synthetic materials) we used the
information from the material suppliers. There is, however, a possibility that the suppliers did
not disclose complete information about all chemicals used. We can consulted refferal
research cente for additional information on additives and other chemicals used in the
production of rubber and synthetic materials. In spite of our care in these matters, however,
the possibility remains that some finished materials contained allergens which we were
unable to detect. We will therefore need further chemical analysis to identify these allergens.
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