Numerous occupations in industry, skilled and unskilled trades, hospitals, medical practices and private households involve frequent washing of the hands, intensive work in wet conditions, or regular skin contact with potentially irritant or allergenic substances (for example, metal salts, cooling lubricants, solvents, detergents, disinfectants or hairdressing products). Due to the often simultaneous influence of these load factors, the natural skin barrier may become distressed or damaged, especially in persons with sensitive, dry skin, which is low in sebum. As a consequence, cumulative-toxic or, in extreme cases, allergic contact eczemas may occur, especially on the hands (Figures 1 to 3).


Figure 1: Wear dermatosis affecting an employee of a cleaning business as a consequence of intensive "wet" work.

Figure 2: Cumulative-toxic eczema affecting a painter after regular use of nitro dilutions to clean the skin.



Figure 3: Allergic contact eczema affecting an assistant who works in a photo laboratory, caused by developer solution.

Severe or recurrent occupational eczemas qualify as occupational diseases under the German regulations governing occupational diseases (Berufskrankheiten-Verordnung). Affected persons may have to change their job or place of work, and in the worst cases may even have to stop working completely. Statistical surveys carried out by the German accident insurers reveal the extent of the problem: For example, according to the annual report of the German association of occupational accident insurers (Hauptverband der gewerblichen Berufsgenossenschaften) (1), in 1995 alone more than 18,000 notifications of suspected occupational dermatoses were received by the German accident insurers. More than 7,000 of these were confirmed.

The costs incurred by the occupational accident insurers for treatment, rehabilitation and compensation measures amounted to more than DM 300 million. If the costs of the German health insurance funds, and the employers’ absenteeism-related costs are also included, the total economic loss caused by occupational dermatoses is probably at least DM 1 billion per year in Germany alone.

As well as the cases of occupational dematosis that are reported to the accident insurers, there are cases that do not appear in the statistics. These must also be taken into consideration. Although any attempt to estimate the number of undisclosed cases is necessarily speculative, it can be assumed that the figure is considerable. Fear of dismissal, in particular, is one reason why far from all cases of jobrelated dermatosis are reported to the occupational accident insurers. Moreover it can be assumed that there is a high incidence of occupational dermatoses among workers who are not compulsorily insured – for example, home workers.

General skin protection measures

In view of the considerable costs and the possible social disadvantages for those affected, a high priority is generally assigned to prophylactic measures against occupational dermatoses (2-5). Such prophylactic measures include the correct choice of job; technical protective measures in the workplace; wearing protective clothing; using suitable skin protection and skin care products; and the provision of mild skin cleansing systems (2).

The choice of an occupation that suits the job-seeker’s skin is the most important prerequisite for the prevention of occupational dermatoses. It has long been known that people with a susceptibility to atopic dermatitis are at greater risk of suffering from eczema if they take up jobs that distress the skin, such as in the metal or metalworking industries, hairdressing or other “wet” jobs (3). Before they choose a particular job, or change their job or place of work, they should ask a dermatologist to test their skin to ensure that they are kept away from any activity that would be dermatologically unsuitable for them.

In the workplace, collective technical protective measures should always take priority over personal measures. Technical solutions aimed at totally, or at least partially, eliminating the possibility of employees coming into direct skin contact with harmful substances, can best be achieved in large companies by organizational changes in work procedures or by replacing aggressive substances with harmless or far less aggressive substitutes. In smaller companies, as well as in the home and the private sphere, such measures are usually impracticable. The emphasis must therefore be on wearing protective clothing, especially protective gloves, and using skin protection and skin care products.

When protective gloves are worn, care must be taken to ensure that the glove material has been sufficiently tested for resistance to the materials against which it is supposed to provide protection. Permeable gloves not only provide no protection, but under some circumstances they can even reinforce the effects of harmful substances – for example, by the occlusion effect of the glove material (3, 5). Moreover, if closely fitting gloves are worn for a long period of time, heat and moisture may build up, causing the skin to swell and soften, with subsequent decomposition of perspiration and buildup of odors. Other constraints on wearing protective gloves apply in workplaces where the sense of touch is extremely important and where it must be possible to move the fingers freely. These considerations clearly reveal why, for many tasks, prophylactic measures must be limited to the use of suitable skin protection and skin care products and to the provision of mild skin cleansing systems.

Skin protection and skin care products

Employees in many workplaces have to wash their skin several times each day with soaps, syndets or other skin cleansing products. This means, especially for persons who tend to have dry skin, low in sebum, that there is increased risk of developing cumulative-toxic and allergic contact eczemas. Even the water used to wash the skin removes considerable amounts of the natural moisturizing factors localized in the stratum corneum. Moreover, surfactants and other components of skin cleansing products can remove the skin’s sebum, causing impairment of the epidermal barrier function. Both processes cause increased transepidermal water loss (TEWL), resulting in the clinical picture of dry, rough skin (Figure 1). This skin condition, which can be described as a wear dermatosis, prepares the ground for the further progress of the disease. Surfactants and other job-related irritants, as well as potential contact allergens, can penetrate more easily into the deeper skin layers and trigger the pathogenetic mechanisms for a cumulative-toxic or an allergic contact eczema (Figure 5).

Efforts to ensure mild cleansing of the skin should be focused on reducing the risk of these side-effects as far as possible. Several aspects should be taken into account, concerning both personal behavior and the choice of the skin cleansing product that is to be used (Table 2). The wide variety of soils that are encountered in the industrial sector require a wide range of different skin cleansing products whose action is based on a number of different cleansing principles and a mild cleansing effect. Depending on the type and intensity of the soil, a choice can be made between simple soaps and syndets, hand cleansers that contain abrasive components, and specialty products containing additives such as solvents, reducing agents or other components that enhance the cleansing action (2-4).

Table 2
Conditions for mild skin cleansing
·	Use skin cleansing measures only when essential (no unnecessary washing)
·	Use skin cleansing products that are tailored to the type and intensity of the relevant soiling and do not have an excessively strong cleansing action
·	Avoid skin cleansers that contain surfactants with a strong irritant action
·	Use additional skin protection and skin care products

Within the individual product classes, the skin compatibility of the relevant commercial products depends primarily on the types of surfactants used. Comparative irritation tests with various methods have shown that there are sometimes considerable differences between the individual classes of surfactants in terms of their irritant effect (Table 3). These differences are reflected in the individual commercial preparations (12-15) and should be taken into account in the choice of product. Skin cleansers based on surfactants with a strongly irritant effect, such as soap raw materials or fatty alcohol sulfates, should be avoided, especially by persons with dry skin, which is low in sebum, or with sensitive or damaged skin. Instead they should use products based on surfactants with better skin compatibility, such as ether carboxylic acids, sulfosuccinates or alkyl polyglycosides. Only under these circumstances can skin cleansing contribute to skin protection in the workplace.

Table 3
Classification of some important classes of surfactants in terms of skin compatibility (from 4)
Surfactant class		Skin compatibility
Alkyl polyglycosides ("sugar surfactants")		good to very good
Ethoxylated fatty acid glycerides
Betain derivatives
Castor oil sulfonates
Sulfosuccinates
Ethoxylated fatty alcohols
Isethionates
Fatty alcohol ether sulfates		moderate
Alkylolamides
alpha-Olefinsulfonates		poor
Secondary alkane sulfonates
Alkylbenzolsulfonates
Fatty alcohol sulfates
©Skin Care Forum

References

(1) Hauptverband der gewerblichen Berufsgenossenschaften (Hrsg.), Übersicht über die Geschäfts- und Rechnungsergebnisse der gewerblichen Berufsgenossenschaften im Jahre 1995, Sutter Druckerei, Essen (1996)
(2) Kresken, J.; Reinigung, Schutz und Pflege der Haut am Arbeitsplatz, Pharm. Ztg. 137, Nr. 37, Supplement Dermopharmazie (1992) 3-9
(3) Tronnier, H.; Kresken, J.; Jablonski, K.; Komp, B.; Haut und Beruf, Strategien zur Verhütung berufsbedingter Hauterkrankungen, Grosse Verlag, Berlin (1989)
(4) Kresken, J.; Maßnahmen zur Verhütung berufsbedingter Hauterkrankungen, in: Dicke, W.; Mehlem, P. (Hrsg.), Alles über Hautschutz, Hautreinigung, Hautpflege, 3. Aufl., 51-69, Wirtschaftsverlag NW, Bremerhaven (1993)
(5) Gloor, M.; Köhler, S.; Gehring, W.; Hautschutzmaßnahmen, ein Stiefkind prophylaktisch dermatologischer Tätigkeit, Z. Hautkr. 66 (1991) 201-207
(6) Wulfhorst, B.; Schwanitz, H.J.; Zur Wirksamkeit von Hautschutzpräparaten, Arbeitsmed. Sozialmed. Umweltmed. 29 (1994) 84-92
(7) Frosch, P.J.; Kurte, A.; Efficacy of skin barrier creams (IV), the repetitive irritation test (RIT) with a set of four standard irritants, Contact Dermatitis 31 (1994) 161-168
(8) Grünewald, A.M.; Lorenz, J.; Gloor, M.; Gehring, W.; Kleesz, P.; Lipophilic irritants, protective value of urea- and of glycerol-containing oil-in-water emulsions, Dermatosen 44 (1996) 81-86
(9) Schlüter-Wigger, W.; Elsner, P.; Efficacy of four commercially available protective creams in the repetitive irritation test (RIT), Contact Dermatitis 34 (1996) 278-283
(10) Kresken, J.; Klotz, A.; Rosenberger, V.; Gewerblicher Hautschutz: Wirksamkeitsprüfung nichtwassermischbarer Hautschutzsalben im repetitiven Irritationstest (RIT), in: Korting, H.C.; Braun-Falco, O.; Gloor, M.; Hautreinigung und Hautpflege: Nutzen und Risiko, Berichtsband über ein Symposium am 6./7. September 1997 in Dessau, Springer Verlag (in press)
(11) Schnetz, E. et al.; Development and evaluation of an in vivo test model for cumulative irritation, first results of a multi center study, poster presentation, 3rd International Symposium on Irritant Contact Dermatitis, 2.-4. October 1997 in Rome
(12) Kresken, J.; Boullon, G.; Syndets und ihre Inhaltsstoffe, Pharm. Ztg. 134 (1989) 2545-2551
(13) Kresken, J.; Eckert, J.; Wassilew, S.W.; Zur Problematik von Hautverträglichkeitsprüfungen, Untersuchungen von Hautreinigungsmitteln in Modifikationen des Duhring-Kammer-Tests, Dermatosen 37 (1989) 63-66
(14) Kresken, J.; Wassilew, S.W.; Untersuchungen zur Irritationspotenz gewerblich verwendeter Hautschutz-, Hautreinigungs- und Hautpflegepräparate, in: Meyer-Falcke, A.; Jansen, G. (Hrsg.): Verhandlungen der Deutschen Gesellschaft für Arbeitsmedizin, 29. Jahrestagung in Düsseldorf vom 26.-29. April 1989, Gentner Verlag, Stuttgart (1990) 173-176
(15) Gottfreund, J.; Jander, B.; Schweitzer, K.-D.; Chemischer Aufbau und dermatologische Leistung von Syndets, SÖFW-Journal 120 (1994) 755-761



From 1984 to 1988 Dr. rer. nat. Joachim Kresken was head of the medical research department of a major manufacturer of skin protection, skin cleansing skin care preparations. Since 1989 he has worked as a self-employed druggist in Viersen, Germany, and as a part-time technical journalist and scientific consultant. He was a founder member of the Society for Dermopharmacy in 1995, and is its president.