Skin Care: Starting from Scratch

Experts say basic, but often neglected, prevention measures offer the best protection against occupational skin disease.

America's second most common type of occupational illness is skin disease, according to the Bureau of Labor Statistics. But unlike repeated trauma illness, which is No. 1, there is no OSHA standard in the works for skin disorders.

For the foreseeable future, therefore, it will be up to workers and employers to take the steps needed to prevent occupational skin diseases. Prevention is crucial, skin care experts say, because occupational contact dermatitis (OCD), which makes up 90 percent to 95 percent of occupational skin disorders, often turns into a problem that is chronic, debilitating and incurable.

The good news is that OCD prevention measures can be effective, especially with regard to irritant contact dermatitis, which accounts for 60 percent to 80 percent of OCD, and allergic contact dermatitis, the other major piece of the puzzle. In addition, the National Institute for Occupational Safety and Health (NIOSH) has launched a major skin research initiative, and some skin care authorities point to a number of innovative products that may reduce the number of people afflicted with occupational skin disorders.

The Sissy Factor

The real economic impact of occupational skin disease is hard to estimate, according to NIOSH, largely because severe underreporting masks the actual annual incidence of the disorder by as much as a factor of 50.

Using data from the mid-1980s, NIOSH took a stab at estimating the annual cost of occupational skin disease. The figure it came up with is somewhere between $222 million and $1 billion.

"It's a very rough estimate, but it's the only thing we've got," said Dr. Boris Lushniak, team leader of the National Occupational Research Agenda (NORA) allergic and irritant dermatitis team. This estimate includes direct costs of medical care and workers' compensation, as well as indirect costs of lost workdays and lower productivity. It leaves out expenses of occupational retraining and effects on workers' quality of life.

If NIOSH is right that most occupational skin diseases are not reported, this may point to something far more important than the difficulty of making accurate economic impact calculations. Underreporting not only masks the extent of the illnesses, but contributes to the lack of awareness or even outright denial of the problem.

"It's sissy to complain about your hands," said Dr. Eleanor Fendler, manager of formula development at GoJo Industries Inc. "It's macho to have these rough, tough hands, even if they do hurt. It's considered part of the job."

The culture of skin care is quite different in Europe, according to Armand Coppotelli, senior technical manager at Stockhausen Inc., a company with many years of experience in the European and American skin protection markets.

"In Europe, the unions are more involved in skin care issues. They often write into their contracts requirements for skin protection at the job," Coppotelli said. In the United States, people often just want to get cleaned up after the exposure, though this attitude is beginning to change, he added.

To get through to people, the plainspoken Fendler advises avoiding terms like "contact dermatitis." "Contact dermatitis is a word the medical profession dreamt up to confuse the lay public so that we pay them lots of money." What the term really means, she said, is dry, cracked, red or flaky skin that usually hurts or itches. Speak to people in these terms, Fendler maintains, and you will discover that the problem is quite widespread.

Lushniak agreed that the tendency to minimize occupational skin disease, or to assume it is just part of the job, is shared by workers and employers alike. In addition, just as with repeated trauma illness, some employers question whether the skin ailment is truly work-related.

If denial is part of the problem, awareness is part of the solution, according to Fendler. Being conscious of your skin and refusing to accept that your hands have to be hurt, cracked and red is an important step in reducing occupational skin disease, she said. It is more effective to reduce hazard exposure and recondition the skin early before dermatitis becomes a chronic condition.

The Prevention Hierarchy

Until now, NIOSH has had no coordinated program on skin research, but this is about to change, according to Sidney Soderholm, director of the dermal exposure research program at NIOSH.

One of the purposes of the new research, Lushniak said, will be to "refine the hierarchy of prevention." In the meantime, he, along with other skin care experts, explained that current knowledge identifies four levels in this hierarchy:

  • Substitution. The best option is to find a chemical that is neither an irritant nor an allergen to the skin, and substitute the more benign chemical for the one that is causing a problem.
  • Controls. If there is no feasible replacement for the troublesome chemical, use administrative or engineering controls to keep it away from the worker.
  • Work practices. Keep the workplace and workers' skin as clean as possible.
  • Personal protective equipment. Finally, use gloves and barrier creams to protect exposed skin.

This hierarchy of prevention is great in theory but is often not followed in practice, according to industrial hygienist Jeff Stull, a faculty member of Kimberly-Clark's Skin Wellness Institute and president of International Personnel Protection Inc. in Austin, Texas.

Stull said that, when it comes to skin care, too many industrial hygienists begin -- and end -- at the bottom of the prevention hierarchy, with a pair of gloves. He criticized industrial hygienists for not looking at workers' skin health to prevent or understand the exposure.

"The hierarchy of controls is not followed in construction," agreed Chris Trahan, an industrial hygienist with the Center to Protect Workers' Rights, the research arm of AFL-CIO's Building and Construction Trades Department.

When gloves are properly matched against hazards present in the workplace and used correctly, they can protect against many job-related risks. However, Stull warned that gloves can also create a hazard. The glove material may be irritating to the skin or provoke an allergic reaction, as many people are allergic to latex. In addition, gloves confine the hand and occlude the skin, preventing the air exchange that can lead to healthier skin while holding in a hazardous chemical that will pass more easily through the skin barrier.

"If you can't wash your hands before putting gloves on, the gloves will do more harm than good," Trahan agreed. Many construction sites do not even have clean, running water, making it difficult for workers to keep their hands clean.

Barrier Creams

There are those in the skin care community who seem excited about the possibilities of a new wave of protective lotion products.

"The whole protective cream market has been reinspired," Lushniak said, citing this as one of the most important recent innovations in skin care. Some of the products have been shown to be effective against skin irritants, and producers are testing barrier creams against known allergens.

Lushniak also sounded a note of caution about some of these new products. "Part of the problem with barrier creams is that most of the testing is done in laboratory situations," he said. "The real difficulty is what goes on in the workplace."

Stull explained there are two ways a barrier cream can work. It can serve as a protective layer on the skin where irritants or allergens accumulate so that, upon cleaning, the contaminants can be removed more easily. A second application would be to use the cream to shield the skin from contact with a harmful agent.

"The first application is like greasing a pan," said Stull. Though it could be effective, he worried it might lead users to take risks they otherwise would avoid.

It is the second application that bothers Stull the most. Relying on barrier creams to provide a shield can lead to a false sense of security, he warned, because movement and friction, over time, can leave the skin exposed.

Trahan noted that, if workers are using abrasive materials such as cement, the effectiveness of barrier creams is greatly reduced.

When used in the right way, however, Fendler argued protective lotions can play an important part in preventive skin care. In addition to providing an extra layer of protection, she said, a good product should moisturize the skin and help repair the skin barrier, while not being so greasy that it interferes with work. The skin treatment should be used before work and after washing hands.

Staying Clean

Even with new research, innovative products and sophisticated new tests coming on the market, skin care experts agree that one of the best ways to avoid dermatitis is also the simplest: Wash your hands or other affected areas thoroughly with the right kind of cleanser.

"It is amazing how poorly [hand-washing] is practiced," Stull said. One problem is that, once skin is damaged, a worker will be less likely to wash, because cleaning the affected area will hurt, thus provoking a vicious cycle.

A second problem is the use of abrasive cleansers that do more harm than good. Stull said there are now soaps on the market that remove oils and chemicals without being abrasive. He also recommended a two-step process: clean, then recondition the skin.

NIOSH's Soderholm said research into abrasive cleansers and the importance of matching the cleanser to the chemical is one of the areas where NIOSH will focus its work.

A third reason why washing is so poorly done is the most basic: Sometimes there is no place to wash. Obviously, ensuring that workers have a place to wash near their work area will increase the chances they will keep their hands clean. Yet, Trahan noted that if this is not possible, there are effective hand rinses available that do not require soap and water.

Experts advise washing several times a day when exposed to hazardous materials, so having a wash area that is convenient for workers is critical.

If attitudes toward skin care change as new products become available, there may be some hope that OCD rates will eventually start to come down.

Fendler reported how workers respond to occupational research she has done on some of the new cleansers and moisturizers.

"They're positively amazed when we give them something that works," she said. "It doesn't smell like roses or come in a pink and white bottle ... and they love it."

Measuring Skin Damage

New instruments may help to measure skin irritation quantitatively.

Until recently, it was not possible to measure skin irritation quantitatively, frustrating policy-makers, researchers and diagnosticians of occupational contact dermatitis (OCD).

But new instruments measuring "transepidermal" water loss (TEWL) may be among the most promising of the many products and tests available in the world of skin care.

The way the TEWL test works is simple, according to Gary Grove, a skin physiologist and vice president of research and development at the KGL Skin Study Center.

"The primary function of skin is to keep bad things out and good things like water in," Grove said. If the skin surface is damaged, the barrier will be disrupted, and there will be a corresponding loss of water through the skin. This is what TEWL tests measure.

The exams have been widely used by companies testing mildness claims of new consumer products such as soaps and detergents. Previously, machines testing for TEWL had to be used in laboratory settings. Thanks to new designs now available, Grove said, "I see no reason why we can't move these out into the workplace."

The TWEL exam is used in fish processing and metalworking plants in Germany and Scandinavia, according to Grove.

NIOSH's Dr. Boris Lushniak confirmed there are a variety of tools, including TEWL instruments, to measure skin damage. "These bioengineering machines are starting to be used more in workplace investigations, and that will be helpful," he said.

TEWL tests can function like an early warning system of skin damage, according to Grove, a crucial advantage in treating OCD. "The sooner you stop doing the bad practices, the less likely the condition will become chronic and job-threatening," he said.

At over $8,000 a unit, the cost of the machine being marketed by Grove's company, CyberDERM of Media, Pa., may be beyond the reach of many companies. Safety and health professionals, however, might consider referring at-risk workers to dermatologists who can conduct TEWL tests.

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