A 19-year-old fireman developed itchy blisters,
redness and swelling along the sides of his fingers and on the palms
in the ten days before presenting to his doctor. He had never had
any previous skin problem and was otherwise fit.
This pattern of
dermatitis is sometimes known by the pretentious and confusing name
of cheiropompholyx. It is quite often accompanied by the same type
of vesicles occurring on the soles of the feet and around the toes.
The cause is unknown but is considered to be constitutional in origin
although it can be precipitated or aggravated by any stress, physical
The patient was very keen to return to work and did
not believe that his work was to blame. He was treated at home with
wet dressings and weak corticosteroids for one week and given clean,
dry work for another two weeks. He was then encouraged to return
Severe, acute. symmetrical hand dermatitis. The lesions began as small vesicles which wept; the area then became much more inflamed and swollen
This shows typical coalescing vesicles of pompholyx affecting the foot. The hadns and feet are frequently affected together in this type of dermatitic disease.
his normal duties after advice on care of the skin and avoidance
of unnecessary injury. He remained well apart from one other episode
just before he got married.
Wear and tear dermatitis
mother of two noticed irritant rough scaling and sore cracked patches
over the backs and sides of her fingers and on the palms. These
had started three months
Typical chronic hand dermatitis. The fissuring occurs because the abnormal stratum cornenum cracks when the hadn extends. This can be very painful and disablin this was due to peristent physical and mechanical trauma.
Example of chronic hand dermatitis, due to wear and teare in a motor mechanic.
previously in midwinter and had gradually
worsened. Enquiry revealed that she had a part-time job as a domestic
cleaner and received little help in the house from her husband.
The picture described was typical of what has come to be known as
'housewives' dermatitis'. It is better described as 'wear and tear'
dermatitis as it is the result of persistent or repeated physical
and chemical injury to the skin of the hands.
Allergic contact dermatitis on the dorsum of the foot due to sensitivity to a component of a protective shoe worn at work
She was urged to wear
household gloves (cotton gloves under rubber or rye gloves) while
doing housework, to use a simple moisturizing cream, to ask her
husband to help out at home as much as possible, and to take a rest
from her part-time job. She did not follow this advice and developed
an unpleasant infection in one of the cracks that developed on her
palms. This solved the problem temporarily as she was admitted to
hospital where, away from the traumas of everyday life, her hands
Some occupations at risk from 'wear and tear' dermatitis
- Mechanics and machinists
- Builders' laborers
Allergic contact dermatitis
A 35-year-old electronics technician
developed an irritant red rash that occasionally blistered and wept
on the fingers of the hands. When he was first examined it was noticed
that the eruption was worse on the right hand and maximal at the
tips of the thumb and index fingers. This man remarked that the
rash improved at weekends and was almost clear on holidays. It was
gradually worsening and beginning to spread up his arms and onto
his face and neck. The distribution and nature of the rash and the
occupational history was suggestive of an allergic contact dermatitis
to one of the materials encountered at work. Patch testing at a
later date did in fact reveal a strong positive to epoxy resin -
the base material of the glues he was handling every day in the
course of his work.
Specialist advice This is urgently required
for this type of problem for two reasons. First, a definitive diagnosis
is only possible after formal patch testing by someone with experience
(see Chapters 34 and 38). Second, expert advice is necessary concerning
what to avoid in future and what can be handled with impunity. It
is not uncommon for such patients to resort to litigation (this
one, in fact, did), and it is better to have an informed opinion
early on in the march of events rather than later when all symptoms
have abated and the history is hazy.
Treatment When there is a strong
suspicion that occupational exposure is the cause of a rapidly worsening
eruption, as in this case, it is foolhardy to permit the individual
to return to work until the condition has completely subsided. The
acute stage, when the rash is swollen, sore and blistering, should
be treated by saline compresses or bathing in dilute potassium permanganate
solution (1 :8000). A little later, bland emollient creams are useful.
If no further exposure occurs the rash will often settle within
three or four weeks, but it is quite common for it to flare up unexpectedly.
Whether this is due to unmentioned or unknown exposure to the allergen,
or whether this happens independently of further contact with the
sensitizing agent, is not known.
Return to work After a few weeks
the patient and the physician are often both bored with the problem.
At this stage it is quite tempting to suggest a return to work.
If arrangements can be made for the patient to do only clean, dry,
non-manual work, well away from the sensitizer, then this may be
the best plan. But make no mistake; even this sometimes provokes
a fresh crop of spots.
Some occupations at risk from allergic contact dermatitis
- Dental technicians
- Chemical workers
- Rubber industry workers . Electroplating workers
There was no choice for the electronics technician but to
try to change jobs. As far as the company was concerned he was no
use to them unless he could handle the adhesive containing the epoxy
resin, and anyway the atmosphere had been soured by the legal process
resulting from the claim he had made. In times such as these, when
employment is at a premium, such decisions are difficult, but this
man's best option was to agree with the employers and try to find
work elsewhere, well away from epoxy resin glues.
The last example concerns a 19-year-old nurse in her second year
of training. She was referred to me by the occupational health service
of the hospital, who said that she had developed 'an itchy skin
problem' affecting the hands, arms, face and scattered patches elsewhere.
It turned out that her father was asthmatic and that she suffered
from hay fever and had always had an itchy dry skin and a few scaling
itchy patches. Clearly she was suffering from a mild type of late-onset
atopic dermatitis. Sometimes, as in this patient, the brunt of the
disease does fall on the hands and then diagnosis can be quite difficult.
Of course, patch tests were carried out just to be certain that
she did not in fact have some type of allergic contact dermatitis
to one of the drugs she often handled (such as penicillin). All
patch tests were negative. She was a bright and keen young woman
who was alarmed at the thought of being kept off work by a rash.
Generalized otopic dermatitis. This patient was quite distressed by his persistently itching dermatitic rash. Scratch marks can be seen around the elbows and buttocks. This eruption would make it impossible to work in a hot, sweaty environment, such as on a hot factory floor
Return to work This type of problem can be quite difficult and there
is no easy formula to apply. Each patient should be carefully evaluated
- Their keenness for their present job.
- The disability
caused by the skin problem.
- The role of the job in causing, precipitating
or aggravating the rash.
- The potential danger to workmates or
the public by continuing to work with the rash.
- The attitudes
of the employers.
The nurse was keen and popular with patients and
the nursing hierarchy. Although the job had obviously precipitated
and then aggravated her constitutional dermatitis she could be given
jobs that were less damaging to the skin than routine nursing duties.
However, it had to be arranged that she did not assist at sterile
procedures or dress wounds, because damaged, scaling skin can easily
be colonized by pathogenic bacteria. Good nursing recruits were
particularly difficult to find in the area. For all these reasons
it was decided that she should continue her nursing studies. I am
not sorry now that we made this decision, as she is now an excellent
senior nurse involved in teaching!