Keywords

Introduction

Work-related and occupational dermatoses lead to frequent use of health care services, high occurrence of sick leave, job loss, job change, and mental distress [1]. Both occupational dermatoses and its consequences are highly preventable by eliminating and reducing exposure to occupational hazards.

Scope of Preventive Measures

Prevention can be defined as:

“measures adopted by or practiced on persons not currently feeling the effects of a disease, intended to decrease the risk that disease will afflict them in the future” [2].

The ultimate goal for prevention in occupational dermatology is to maintain a healthy skin in a safe work environment. Thus, prevention focuses on human, organizational, and technical and organizational measures for avoidance and limitation of exposure to skin irritants, urticariogens, allergens, and carcinogens at the workplace according to legislation and the provision of regular training in the use of personal protective measures adapted to the needs of the employees [3].

Thus, from a public health perspective preventive measures comprise:

  1. 1.

    Universal measures: include strategies for health promotion to benefit the full population. Legislation regulating the availability of skin irritants, allergens, and urticarigens is the best example of universal measures. For instance, a significant decline of occupational contact urticaria attributed to latex in gloves was observed in Germany, France, and the United Kingdom after legislation to reduce occupational exposure [4,5,6]. Preservatives such as methylchloroisothiazolinone/methylisothiazolinone (CMIT/MIT, also known as MCI/MI, Kathon CG®), methyldibromo glutaronitrile (MDBGN), and several formaldehyde releasers are substances which have caused a rapid and alarming increase in contact allergy and dermatitis [7]. Liquid soaps, industrial hand cleansers, detergents, skin care products, paints, metal-working fluids, and their biocides, as well as fountain solution additives in printing work, are the most common sources of exposure to MIT or MCIT/MIT. Julander and a group of experts from the Nordic countries summarize important dates concerning legislation, classification, and restriction of sensitizing preservatives in Europe [8].

  2. 2.

    Selective measures: include specific preventive actions focusing on specific risk factors and risk groups. Examples include education about risk factors for developing work-related skin problems, training on skin protection such as proper use of protective equipment, provision and training on use of moisturizers, and periodical health surveillance in risk occupations. The effectiveness of these measures to prevent work-related and occupational dermatoses depends on the knowledge, awareness, and motivation of both employers and employees. Firstly, employers should be aware about the risks at work to develop immediate contact reactions and provide the workers with proper skin education and protective elements. Secondly, workers should be motivated to carry out or seek out specific preventive measure. Occupational health professionals and health educators have an essential role to facilitate the effective design and implementation of these actions.

  1. 3.

    Indicated measures: comprise the application of specific diagnostic procedures in workers with already established skin problems. Indicated prevention is most commonly applied in the clinical setting, as indication is ordinarily one discovered through medical examination or laboratory testing, and many of the preventive measures require professional advice or assistance for optimal results [2]. The German “Dermatologist’s procedure” serves as a model on how to identify early work-related skin problems by mandatory reporting and prevent its social, psychological, and economic consequences [9].

Figure 8.1 summarizes the scope of prevention based on a population approach for whom the measure is advisable according to scientific evidence and cost-benefit analysis.

Fig. 8.1
An illustration depicts a universal, full population; selective, risk groups; and indicated, individuals with skin problems, preventive measures, on the left, from top to bottom. Secondary prevention includes atopy and risk occupations. Two photos of a patient's wrist who has skin rashes are given in tertiary prevention.

Preventive measures according to population groups. Servier Medical Art kindly provided graphic images for the design of this figure

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International Standards for Prevention

Scientific evidence-based criteria and standards are necessary to assess workers at risk for developing work-related and occupational dermatoses and patients with these conditions in order to prevent and treat occupational dermatoses.

Evidence-based recommendations for the prevention, identification, and management of occupational contact dermatitis and urticaria were first developed by Nicholson et al. after a systematic review of the literature (Table 8.1) [10].

Table 8.1 Evidence-based recommendations for the prevention of occupational contact dermatitis and urticaria. Adapted from [10]
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Minimum standards for effective prevention, diagnosis, and treatment of work-related and occupational skin diseases (Fig. 8.2 and Table 8.2) have been established by a consensus-based approach by means of the Delphi method with over 80 experts (dermatologists, occupational physicians, health educators, epidemiologists) from 31 European countries (COST Action TD 1206, STANDERM) [3].

Fig. 8.2
A flow diagram demonstrates the following. Work-related skin disease leads to listsicles of reporting or notification, which lead to secondary prevention, which further leads to primary prevention at the public health level. On the individual health level, a healthy worker leads to a worker with skin problems, then the diagnosis of work-related skin diseases, tertiary prevention, and return to work.

Minimum European standards for primary, secondary, and tertiary prevention of work-related and occupational skin diseases [3]

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Table 8.2 Standards for prevention, diagnosis, and treatment of work-related and occupational skin diseases [3]
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Primary Prevention

Primary prevention measures aim to avoid the development of work-related dermatoses in healthy workers [3]. The implementation of risk management processes involving risk analysis, risk assessment, and risk control practices constitute a basis for primary prevention [12].

Fig. 8.3
A photograph of two hands wearing nitrile accelerator-free gloves.

Nitrile accelerator-free gloves. Photo: National Institute of Occupational Health, STAMI

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Fig. 8.4
A photograph of two hands wearing gloves made of bamboo viscose fiber.

Gloves made of bamboo viscose fiber. Photo: National Institute of Occupational Health, STAMI

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Fig. 8.5
A photograph of two hands wearing half-finger gloves made of bamboo viscose fiber.

Customized gloves made of bamboo viscose fiber to keep good sensation in the fingertips. Photo: National Institute of Occupational Health, STAMI

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Table 8.3 presents the STOP concept (Substitution, Technical measures, Organizational measures, and Personal protection), which is practically orientated for prevention at the workplace [13].

Table 8.3 Preventive measures for work-related/occupational dermatoses Adapted from [3]
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If substitution, technical and organizational prevention measures are not available or are insufficient, personal protective equipment (e.g., gloves and moisturizers) must be available as well as regular training on correct application/use. Several studies have shown that protective strategies are applied insufficiently; therefore regular instructions on use and application are necessary [14, 15].

Recommendations for the Use of Protective Gloves

Accelerators-Free Gloves

Protective gloves can lead to skin irritation and allergy due to skin occlusion and the presence of allergens. For instance, while an effective reduction in the occurrence of occupational contact urticaria due to natural rubber latex has been registered [4,5,6], rubber additives are still causing occupational contact dermatitis and urticaria [22]. Low-protein rubber gloves, vulcanization accelerator-free, or gloves containing antimicrobial agents or moisturizers new technologies are now available [22]. These gloves are useful for primary prevention among healthy workers in risk occupations, and among workers with already established skin problems in terms of secondary prevention. Unfortunately, these gloves may be more expensive than regular non-accelerator-free gloves as cheaper options gloves are usually not tested for allergy and may still contain both allergens and urticariogens. Table 8.4 shows an overview of some available accelerator-free gloves.

Table 8.4 Accelerator-free gloves to prevent gloves-related skin allergies
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It is highly recommended that food handlers do not use natural rubber latex gloves, as latex proteins can be transferred to food [23, 24]. Subjects with known latex allergies can develop severe allergic reactions to foods handled by latex gloves [25]. The website of the American Latex Allergy Association provides an extensive list of alternative latex-free products at http://latexallergyresources.org/latex-free-products.

Practical Recommendations for Proper Glove Use

Table 8.5 summarizes practical recommendations for proper glove use to prevent the effects of glove occlusion on the skin barrier disruption and further development of work-related and occupational dermatoses [25, 26].

Table 8.5 Tips on proper glove use
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Moisturizers

A healthy skin assures protection against physical agents, chemicals, mechanical injuries, impact, light, UV radiation, cold, and heat. Extrinsic factors such as occupational exposure to chemical, physical, and mechanical exposures may threaten skin integrity and proper restoration leading to skin barrier disruption.

Skin barrier disruption leads to irritant contact dermatitis, facilitates the penetration of skin urticariogens and allergens with further sensitization. Proper use of moisturizers promotes regeneration and reparation of a disrupted skin barrier [27, 28] and contributes to keeping a healthy skin. A lipid-rich moisturizer free from fragrances and with preservatives and the lowest allergen potential is highly recommended [29].

Moderate evidence is available on preventive effect of the regular application of moisturizers to avoid the development of occupational contact dermatitis [10, 30]. Moreover, strong evidence, from high-quality independent studies, supports that the use of moisturizers before work (“pre-moisturizers”) may help to prevent the development of occupational contact dermatitis. However, the denomination “barrier cream” is highly discouraged as it may provide with a false feeling of full skin protection.

After a literature review focusing on primary prevention through the use of skin creams in healthy populations, an expert panel suggested three moments, for skin cream application to prevent irritant contact dermatitis in the workplace: before work; during work after hand washing; and after work [31]. This suggestion can be applied to all industrial sectors, with evidence drawn from different workplace scenarios such as hairdressers, food handlers, timber, building trade, machinists, and metalworkers.

More randomized controlled trials including long-term controlled observations as well as intervention studies in risk occupations are needed to confirm the effectiveness of this suggestion.

It has to be emphasized that proper use of gloves and moisturizers should not be a substitute elimination, substitution, and reduction of hazardous skin exposures through legislation, risk assessment, and training on health and safety at the workplace.

Secondary Prevention

The aim of secondary prevention is to provide workers with accessible facilities for early diagnosis and intervention to avoid disease progression. Thus, secondary prevention measures are implemented to detect and treat early stages of the disease, to prevent relapses or chronicity by improvement of hazardous workplace situations, behavioral change, and proper skin protection at both work and free time.

Unfortunately, a significant delay between the onset of work-related skin problems and seeking health care varying from 9 months [32] to more than 30 months [33] often leads to a poorer prognosis [34].

Chapter 10 presents the basics of a proper diagnosis of work-related and occupational dermatoses and will not be repeated here. An individual approach to the worker with occupational dermatosis should ensure timely and accurate diagnosis as well as a better prognosis if early diagnosis and interventions are possible [35].

As Fig. 8.2 shows notification and surveillance systems for work-related and occupational dermatoses are necessary for early intervention, to initiate diagnostic, treatment, and interventions at the workplace.

Tertiary Prevention Measures

The aim of tertiary prevention is medical, occupational, and psychosocial rehabilitation of workers with an established disease. These measures aim to facilitate social rehabilitation and quality of life of workers who are at risk of losing their jobs or even had already suffered job loss because of their occupational dermatoses. Experiences from Germany suggest that tertiary individual programs including psychological interventions contribute to improving mental health in patients with severe occupational hand eczema [36].

Knowledge dissemination by Interdisciplinary teams composed of dermatologists, occupational physicians, allergists, safety engineers, and health educators are necessary for effective measures in all levels of prevention [37].

Conclusion

The most effective preventive measures to prevent occupational dermatoses include legislation, elimination, substitution, and reduction of exposure to skin hazardous substances. When substitution, technical, and organizational measures are not feasible, skin protection by the terms of proper use of protective gloves and moisturizers is highly encouraged.

Continuous training and education will contribute not only to keeping a healthy skin in safe workplaces, but also to recognizing early signs of skin disease and facilitate rehabilitation. Hence, early diagnosis and intervention will prevent a relapse and chronic disease course. When an occupational disease is already established, measures aim to facilitate medical, occupational, social, economic compensation and psychological rehabilitation should be available.

The practical implementation of the already developed standards for the prevention of work-related and occupational skin diseases is essential for effective prevention.