On the lookout for precursor lesions: where does dry skin end and slight hand eczema begin?

BACKGROUND: The prognosis of occupational hand eczema is strongly associated with its duration, severity, and the onset of treatment. OBJECTIVES: The study was aimed at characterizing skin eruptions that might be potential precursors of occupational hand eczema, their pattern, and typical sites in a population at moderate risk of hand eczema. PATIENTS/MATERIALS/METHODS: Eight hundred German male metal workers took part in a structured interview focused on their medical history combined with a dermatological examination of their hands, by use of the quantitative Hand Eczema Score for Occupational Screenings, with follow-up 1 year later. RESULTS: The most frequent lesions were erythema (91.8%), lichenification (98.8%), crusting (70%), and scaling (35%); all other lesions were relatively rare (15%). The distribution of lesions remained stable between baseline and follow-up. The areas most affected were knuckles, palms, and finger shafts (excluding tips). Interdigital regions were uncommonly affected in this sample. CONCLUSIONS: Erythema, lichenification, and crusting, indicating constant skin 'strain', can be regarded as precursor lesions for slight hand eczema, and should be monitored quantitatively. As other occupations, for example hairdressing, have different predilection sites, it can be concluded that the pattern of occupational hand eczema is strongly influenced by the distinct strain profile of an occupation.

Health inequalities according to plant size--comparison of small- and medium-sized enterprises.

OBJECTIVES: Assessing plant size-related differences based on self-reported working conditions and their influence on perceived symptoms at workplace. METHODS: A total of 799 metal workers from 9 small-sized enterprises (SE) and 10 medium-sized enterprises (ME) German metal working plants were interviewed in 2007/2008. Inclusion criteria were "wet work" and willingness to participate (response rate: 58% in ME, 67.7% in SE). RESULTS: Workers in SE complained more often of hand eczema (20.2% vs 13.8%) whereas workers in ME more frequently reported breathing problems (4.2% vs 0.9%). Work safety was higher in ME. CONCLUSIONS: The higher rate of skin impairment in SE might be explained by a lower level of work safety. However, the higher frequency of perceived respiratory symptoms in ME seems to contradict this assumption and except plant size there might exist another potential confounder, especially for breathing impairment.

Non-invasive bioengineering methods in an intervention study in 1020 male metal workers: results and implications for occupational dermatology.

BACKGROUND: Measurements of transepidermal water loss (TEWL) as an indicator of skin barrier function and colorimetry for quantifying erythema have been recommended for monitoring persons at risk of occupational hand dermatitis. OBJECTIVE: This study examines the practicability and usefulness of biophysical measurements at the workplace. PATIENTS/MATERIAL/METHODS: A sample of 1020 male metal workers was enrolled; 800 participants were followed up for 1 year. TEWL results and colorimetry (a* value), respectively, were used as effectiveness outcomes, comparing the findings in the four study arms (skin care, skin protection, both combined, and control group). RESULTS: At 1 year follow-up, the TEWL was slightly but significantly lower in the group of participants randomized for application of barrier cream alone, indicating a protective effect. However, addressing both the individual absolute change of a* value and the differences of TEWL (delta-TEWL) of the dominant hand over the study period, no significant difference was found between the four groups. CONCLUSIONS: Dermatological examinations at the workplace cannot be replaced by bioengineering techniques. The supplementary benefit is apparently low, possibly because of difficulties in achieving standardized measurement conditions and other technical reasons.

Spoilt for choice--evaluation of two different scoring systems for early hand eczema in teledermatological examinations.

BACKGROUND: Besides improving working conditions and using personal protective equipment, early detection is most important in managing work-related hand eczema. Implementing regular teledermatological skin screenings could be helpful, but none of the published hand eczema-scores has hitherto been used in teledermatology. OBJECTIVE: Testing and comparing two validated scores [Osnabrück hand eczema severity index (OHSI); hand eczema severity index (HECSI)] for their suitability in an occupational telemedical screening. PATIENTS/MATERIALS/METHODS: One hundred and twenty photographic records of the hands of 30 male wet workers were examined twice with each score. Results were tested for reproducibility, intra-observer reliability and inter-score-correlation. RESULTS: Examination time, mean score values, and score ranges reached did not differ significantly. The inter-score-correlation was moderate (correlation coefficients: 0.651 for first examination; 0.642 for second examination). In the qualitative assessment, the HECSI showed a better overall agreement between results of first and second examinations. CONCLUSIONS: Both scores are suitable for assessing the skin condition in a teledermatological setting. The comparability is limited to qualitative assessment, as the strictly objective OHSI measures the extent of hand eczema and the finer graduated HECSI measures the intensity of hand eczema, adding a subjective component. For assessing minimal skin changes, a scoring system that reduces subjective elements while at the same time it offers a differentiated grading is advisable.

UV-induced skin cancer at workplace and evidence-based prevention.

PURPOSE: The present review is aimed at providing an overview of skin cancer with particular focus on occupational concern and giving evidence-based recommendation for effective prevention at workplace. METHODS: We performed a systematic search of literature using PubMed and the Cochrane Library. RESULTS: Outcome of preventive strategies depends either on efficacy of the strategy itself but also on acceptance and implementation of protective means among the persons at possible risk for hazardous health effects. Epidemiological studies have reported significantly more non-melanoma skin cancer in men than in women. Life-style choices and difference in immunosuppression play a major role in this gender disparity. Tumor biology of skin cancer is diverging: severe blistering sunburns corresponding to intermittent intense UV exposures are associated with an increased risk for both melanoma and basal cell carcinoma (BCC); whereas the risk of squamous cell carcinoma (SCC) and actinic keratoses (AK) is strongly associated with chronic UV exposure. Several clinical trials give evidence that long-term use of sunscreen prevents the appearance of non-melanotic skin cancer such as AK and SCC, but not of BCC. All technical and organizing measures aimed at reducing UV exposure at workplace belong to first-line prevention; however, there is much room for improvement. The efficacy of personal protection means (second-line strategy) strongly depends on the workers' compliance which is quite low at workplace. CONCLUSION: Evidence-based data confirming the benefit of sun protective strategies are scarce, general recommendations are mainly based on the avoidance of UV radiation being identified as potential risk factor for non-melanoma skin cancer in epidemiological studies. Occupational screenings should include regular interventions aimed at enhancing a clear understanding of risk factors for individuals and finally improving the acceptance and maintenance for UV-protective means at workplace.

Characterization of initial clinical symptoms and risk factors for sinonasal adenocarcinomas: results of a case-control study.

PURPOSE: Sinonasal adenocarcinoma is a rare cancer, frequently associated with occupational exposure to inhalable wood dust. Among the EU member States, Germany was reported to have the highest number of exposed workers. Location and long latency make early diagnosis difficult. This case-control study was aimed at assessing potential risk factors and at characterizing initial clinical symptoms, both serving as matrix to identify persons at increased risk and to improve management of this cancer. METHODS: Of 58 patients, 31 diagnosed with sinonasal adenocarcinoma (cases) between 1973 and 2007 were identified and underwent standardized interview on clinical data. A total of 85 patients diagnosed over the same period with carcinoma of the oral cavity served as controls. RESULTS: The ethmoid was confirmed as the predominant site of adenocarcinoma associated with wood dust exposure, whereas the nasal cavity was most commonly affected in patients denying any exposure to wood dust. Cases were significantly engaged in mainly woodworking occupations compared to controls. The main initial clinical symptoms were nasal obstruction 6 months (71%) and epistaxis 4 years (41.9%) prior to diagnosis. Hardwood dust from beech and oak proved to be the most common occupational exposure, with a mean exposure period of 32.3 years and a latency of 43.5 (34-58) years. CONCLUSIONS: Our investigation confirms the importance of regular screenings for persons exposed to wood dust even years after the end of occupational or private exposure. Banal clinical symptoms such as epistaxis and nasal obstruction might be predictive, requiring early and thorough investigation.

Prevention of work-related skin diseases: teledermatology as an alternative approach in occupational screenings.

BACKGROUND: Prevention of occupational skin diseases is of high socio-economic impact. Implementing teledermatology into preventive occupational screenings holds obvious advantages; nevertheless, studies concerning this subject are scarce. OBJECTIVES: The present cross-sectional study was aimed at determining if results of a teledermatological examination are equally sensitive and specific at detecting minimal skin lesions as the conventional face-to-face examination. METHODS: The skin condition of the hands of 100 male wet workers was assessed in a face-to-face examination and a tele-examination by means of a score for minimal skin lesions. RESULTS: The comparison of the total score values that each participant received in face-to-face examination with those obtained in tele-examination proved the skin condition to be estimated significantly worse when seen in tele-examination (P < 0.0001). The median values of the sum totals and the median values for secondary lesions were higher in the tele-examination than in the face-to-face examination. CONCLUSIONS: Our findings show a tendency in tele-examination to assess the skin condition more critically in comparison with face-to-face examination. The teledermatological examination is sufficiently sensitive in detecting early signs of hand eczema, whereas signs for chronicity may get overestimated.

Acrylamide as environmental noxious agent: a health risk assessment for the general population based on the internal acrylamide burden.

The present population-based cross-sectional study in 1008 volunteers was aimed at quantifying the internal burden of acrylamide (AM) in the general population using hemoglobin adduct levels as biomarker of exposure. Based on these adduct levels the risk of (AM) related hazardous health effects in the general population is assessed. Hemoglobin adducts of acrylamide were detected in 999 out of 1008 analyzed blood samples (99.1%). Smoking can be regarded as a main source of overall acrylamide intake in persons without occupational exposure to acrylamide but a second main influence factor, i.e. food intake, is of environmental importance. Due to the sizable study population the 95th percentile differentiated in smokers and non-smokers are actually the best available reference values for an internal environmental acrylamide burden. Based on our data neurotoxicity and reproductive toxicity due to acrylamide are not likely to occur in the general population except very high consumers. However, carcinogenicity and mutagenicity are possible hazardous health effects for the general population.

Monoarylamines in the general population--a cross-sectional population-based study including 1004 Bavarian subjects.

AIM: The population-based cross-sectional study including 1004 Bavarian volunteers aged 3 up to 84 years (median: 42 years) was aimed to quantify the internal burden of monocyclic arylamines in the general population and to yield reference values. MATERIAL AND METHODS: Participants were asked to complete a questionnaire, to give a venous blood sample and a urinary sample. The selected monoarylamines (aniline, o-anisidine, all isomers of toluidine, single and double chlorinated anilines) represent main sources of potential environmental exposure. The venous blood sample was taken to determine the smoking-specific acrylonitrile-adduct N-cyanoethylvaline. RESULTS: Detectable levels of aniline were found in the urine of 93.9% of the participants, whereas 3-chloroaniline was only detected in 16% of the samples. The influence of smoking on the urinary arylamine concentration was weak. Only for o-toluidine, m-toluidine and o-anisidine values were significantly higher in smokers. Therefore, while the 95th percentile based on the total sample (n=1004) is the best reference value for all other arylamines (i.e. p-toluidine, 3-chloroaniline, 4-chloroaniline, 3,4-dichloroaniline) we suggest separate reference values for smokers and non-smokers for the former three compounds. A statistically significant difference in urinary arylamine concentration between men and women was observed for 3,5-dichloroaniline, o-anisidine and aniline (p<0.001). Therefore we suggest gender-specific reference values for dichloroaniline and aniline; for o-anisidine we suggest gender- and smoking-specific reference values. The observation of o-toluidine in 178 urinary samples in concentration above the limit of quantification raises concern regarding human carcinogenicity. CONCLUSION: This study supports the notion of further relevant sources of o-toluidine exposure except smoking and occupation. Compared to other environmental risk factors (e.g. environmental tobacco smoke) the risk of o-toluidine-induced cancer seems to be extremely low for the general population.

The association between self-reported acrylamide intake and hemoglobin adducts as biomarkers of exposure.

BACKGROUND: The validity of epidemiological studies assessing a lifetime cancer risk due to environmental factors, such as nutrition or smoking behavior strongly depends on the validity of the patient's history. OBJECTIVES: This study assesses whether a standardized questionnaire is a valid tool to identify exposure with acrylamide by relating the self-reported food and smoking history with a biomarker, namely hemoglobin-adduct levels of acrylamide. METHODS: Objective parameters of previous exposure, such as hemoglobin-adduct levels of acrylamide and of the smoking-specific acrylonitrile, respectively, were related to self-reported data in 1,008 volunteers of the general population in bivariate analyses and a multiple linear regression analysis using the log-transformed biomarker levels as outcome. RESULTS: Smoking was significantly associated with adduct levels of acrylamide (p < 0.0001) and had a main contribution to the internal burden with acrylamide. In cigarette smokers a strong correlation between the number of cigarettes smoked daily and the corresponding biomarkers was observed. Focusing on non-smokers (n = 828), a significant but weak correlation was found in bivariate analyses (Spearman rank correlation coefficient: 0.178 (95% CI: 0.089-0.268) in females and 0.168 (95% CI: 0.063-0.273) in males. A multiple linear regression analysis similarly yielded evidence of a significant association between the highest intake category and adduct levels; however, explained variability was very small (R(2) = 0.08). CONCLUSION: Self-reported data concerning smoking behavior were highly valid, while self-reported food intake is apparently not as useful for estimating food-related acrylamide exposure.

German cattle allergy study (CAS): public health relevance of cattle-allergic farmers.

INTRODUCTION: Allergic reactions caused by animals are a common and significant occupational health concern. In a large population-based study on occupational asthma in Europe, farming has been among the occupations with the highest risk. OBJECTIVES: Characteristics of cattle-allergic farmers are described in a retrospective observational design. METHODS: The study covers farmers from all regions of Germany which were reported to the Agricultural Institutions for Statutory Accident Insurance and Prevention (Landwirtschaftliche Berufsgenossenschaften, LBGs) between 1990 (January) and 2002 (December) with a suspected occupational cattle-allergic airways disease. For these farmers, the following parameters were considered: age, gender, onset of airways symptoms related to contact with cattle, begin of employment disability, total and specific Immunoglobulin E (IgE) against cattle allergens, and results of lung function measurements. RESULTS: A total of 513 patients (age 14-74, mean 40.7 years; 45.6% women, 54.4% men) had been reported for a suspected occupational cattle-allergic airways disease. Of these patients 24.8% showed cattle-related symptoms of asthma, 11.7% of rhinitis, and 60% of both asthma and rhinitis, while only 34.5% of all reported patients showed an airways obstruction in the first documented lung function test. A total of 62.5% out of the group of patients with an officially recognized occupational disease (42.1%, n=216) have an initial employment disability with a rating of 20% or above. CONCLUSIONS: Our results underline the high public health relevance of cattle allergy in farmers, especially in the light of the large number of young patients. Considering the known difficulties in diagnosing cattle allergy due to the number of false negative test results, we are convinced that its relevance is even higher than the number of reported cases suggests. The high rate of initial employment disability among the affected patients underlines the need for improved preventive measures.

Evaluation of skin-protective means against acute and chronic effects of ultraviolet radiation from sunlight.

Apart from erythema, sunlight triggers many biological processes such as photoaging, immune suppression and mutation of skin cells. Numerous epidemiological investigations have shown that sunlight is carcinogenic to humans, and the IARC classifies sunlight within group 1, which includes human carcinogens. Hereby, the UVB component of the solar spectrum presents the greatest degree of risk to the development of cutaneous neoplasms, but a certain carcinogenic potential of UVA has also been discussed. Practical steps to achieve optimal sun protection include avoidance of the sun during the peak hours of radiation, avoidance of photosensitizing drugs, use of photoprotective clothes and diligent application of broad-spectrum sunscreens. Of all recommended protective measures, sunscreens are often the most feasible to use, particularly during outdoor leisure, sport of aquatic activities. Therefore, the following chapter focuses mainly on the biological activity and efficacy of short- and long-term use of sunscreen products, but other recommended strategies of UV protection (such as intake of beta-carotene or application of liposomes) are critically evaluated as well. Although the short-term efficacy of sunscreens in the prevention of sunburn is undisputed, there is also some evidence that long-term use of sunscreens prevents the appearance of certain forms of skin cancer.

Is occupational exposure to solvents associated with an increased risk for developing systemic scleroderma?

BACKGROUND: Our study was aimed to investigate in a German collective if there are any hints for an increased occupational or environmental risk to develop systemic sclerosis, especially, focussing on work-related exposure to solvents. Moreover, we tried to evaluate the feasibility of a sampling method addressing support groups. METHODS: A standardised questionnaire was published in two journals subscribed by members of two different support groups and all members were asked to complete the questionnaire and to return it anonymously. The subjects were not informed on the scientific hypotheses, nor did they know who of them belonged to the case group (scleroderma) or to the control group (multiple sclerosis). RESULTS: 175 questionnaires could be included in the statistical analysis. As expected, a female predominance was in our collective. In the male subpopulation, the occupational exposure to solvents was higher in the case group than in the control-group (70% versus 45.8%). Based only on the male subgroup, a tendency for an association between occupational exposure to solvents and the risk to develop systemic sclerosis was found. CONCLUSION: According to our experience in this case-control-study exposure misclassification, qualitative or quantitative, was an eminent problem. Within such a setting, it is generally very difficult to establish an exact dose-response relationship due to incomplete, imprecise or missing data concerning duration of exposure, frequency of use and kind of solvent. Additionally, a well-known problem in studies based on self-reported questionnaires is the so-called volunteer bias. Unfortunately, but similar to other studies assessing epidemiologic factors in such a rare disease, our study was of limited power, especially in the subgroups defined by gender.

Influence of diet on exposure to acrylamide--reflections on the validity of a questionnaire.

AIM: This pilot study attempts to assess how far the standardized questionnaires are a valid tool to detect the food-related burden of acrylamide. Acrylamide is a toxic substance classified by the International Agency of Research on Cancer, as well as the Deutsche Forschungsgemeinschaft, as a probable human carcinogen. METHODS: A venous blood sample was taken in order to determine the smoking-specific acrylnitrile adduct N-cyanoethylvaline and the acrylamide adduct N-2-carbamoylethylvaline in a female study population expecting delivery soon. A standardized questionnaire was used to determine the consumption of acrylamide-contaminated food. The results of our questionnaire were transferred to a linear evaluation system. Finally, anamnestic data of the questionnaire were correlated to objective parameters such as blood levels of hemoglobin adducts of acrylamide and acrylonitrile. RESULTS: A positive correlation between the acrylamide intake and the levels of hemoglobin adducts in our study population was not proven. CONCLUSIONS: Evaluation of food-related exposure to acrylamide is difficult due to several reasons. Firstly, the validity of anamnestic data strongly depends on the patient's ability to remember precisely all consumed food (quality as well as quantity) over a 3-month period. In addition, the contamination of acrylamide in food varies from one product to another; even the contamination of the same product is variable. Therefore, the missing correlation between the questionnaire and hemoglobin adduct rates is rather due to restricted validity of anamnestic data.

Mercapturic acids of acrylamide and glycidamide as biomarkers of the internal exposure to acrylamide in the general population.

Acrylamide (AA), a widely used industrial monomer which is categorised to be carcinogenic, was found to be generated in starch-containing foods during the heating process. This discovery has caused reasonable concern about possible health risks to humans due to dietary acrylamide uptake. In order to gain more information on human metabolism of acrylamide and to contribute to the assessment of the human carcinogenic risk due to AA uptake we measured the mercapturic acid of AA and its epoxide glycidamide (GA) i.e. N-acetyl-S-(2-carbamoylethyl)-L-cysteine (AAMA) and N-(R,S)-acetyl-S-(2-carbamoyl-2-hydroxyethyl)-L-cysteine (GAMA) in human urine. The relation between AAMA and GAMA is important in this context because GA is thought to be the ultimate carcinogenic metabolite of AA. The median levels in smokers (n=13) were found to be about four times higher than in non-smokers (n=16) with median levels of 127 microg/l versus 29 microg/l for AAMA and 19 microg/l versus 5 microg/l for GAMA. Therefore cigarette smoke proved to be an important source of acrylamide exposure. The level of AAMA in the occupationally non-exposed collective (n=29) ranged from 3 to 338 microg/l, the level of GAMA from

Prevention of work-related decompression illness events by detection of a cardiac right-to-left shunt.

A 44-year-old tunnel worker was studied who suffered from several unexplained decompression illness events for almost 15 years. This caisson worker was affected after standard pressure profiles that did not cause symptoms of decompression illness in his colleagues on the same shift. Transesophageal echocardiography revealed an atrial septal defect (grade II) in this otherwise healthy man. Cranial magnetic resonance imaging showed ischemic brain lesions. Among divers, patent foramen ovale, the most common cause of cardiac right-to-left shunts, was shown to increase the risk for decompression illness events by a factor of 4.5 and to double the risk of ischemic brain lesions. Hyperbaric workers with symptoms of unexplained decompression illness, even if they are only slight, should immediately be transferred to a cardiologist so that a cardiac right-to-left shunt will not be overlooked.

Allergic contact dermatitis in children: strategies of prevention and risk management.

Over recent years, allergic contact dermatitis in children has repeatedly been reported as a significant clinical problem. It is generally accepted that allergic contact dermatitis is rare in the first years of life, and with increasing age (by the age of 10 years) reaches the incidence seen in adults. As in adults, metals are one of the most common sensitizers in children, along with rubber chemicals and fragrances. The influence of fashion trends and lifestyle such as piercing, decorative skin paintings, the hype of natural remedies and cosmetics (e.g. tea tree oil) or the use of cosmetical products with fragrances or herbal ingredients play an important role in developing allergic contact dermatitis. This review aims to give an overview on allergic contact dermatitis in childhood by focussing on strategies for prevention, potential risk factors and recommendations for parents as well as for physicians. By reporting typical cases of our outpatients clinic we point out several characteristics of allergic contact dermatitis. Prevention of allergic contact dermatitis in children is a current problem of interdisciplinary concern not only for dermatologists and paediatricians, but also for midwives. Frequently, children are already exposed at an early age to well-known allergens, and therefore, strategies of avoidance have to gain or regain importance and should start as early as possible.

Determination of haemoglobin adducts of acrylamide and glycidamide in smoking and non-smoking persons of the general population.

Acrylamide (AA) is a food-borne toxicant suspected to be carcinogenic to humans. It is formed in the heating process of starch-containing food. Currently, there is a great discussion about the possible human health risks connected with the dietary uptake of acrylamide. Haemoglobin adducts of acrylamide and its oxidative metabolite glycidamide are both markers of biochemical effect. However, because glycidamide has a higher carcinogenic potency than acrylamide itself, the glycidamide adduct might mirror the genotoxicity better than acrylamide adducts. In order to gain more information about the human metabolism of acrylamide, we investigated a small group of persons for the effective internal doses of acrylamide and glycidamide using haemoglobin adducts as parameters of biochemical effect. The collective was subdivided into non-smokers (n=13) and smokers (n=16) by determining the smoking-specific acrylonitrile haemoglobin adduct (N-cyanoethylvaline, CEV). The mean values for the adducts of acrylamide (N-2-carbamoylethylvaline, AAVal) and glycidamide (N-(R,S)-2-hydroxy-2-carbamoylethylvaline, GAVal) in nonsmokers was 19 pmol/g globin AAVal (range 7-31 pmol/g globin) and 17 pmol/g globin GAVal (range 9-23 pmol/g globin). For smokers mean levels of AAVal were 80 pmol/g globin (range: 25-199 pmol/g globin) and those of GAVal were 53 pmol/g globin (range: 22-119 pmol/g globin). Metabolism to glycidamide turned out to be significantly more effective in non-smokers than in the higher exposed smokers. Compared with studies in rats, the metabolic conversion of acrylamide to glycidamide as measured by haemoglobin adducts seems to occur to a similar extent in humans as in rats. Risk estimations on acrylamide based on experimental data obtained in rats obviously did not overestimate the cancer risk for the general population. Furthermore, our results might indicate that the dose-response curve for acrylamide is not linear. This would be in line with the results of animal experiments on rodents.