Irritant contact dermatitis (ICD), the most common occupational skin disease, is a

nonimmunologic inflammatory reaction

following exposure of the skin to an external chemical or physical agent. Irritation
accounts for up to 80 percent of
occupational skin disease cases and affects the most often exposed areas of skin,
such as the hands and forearms. The
clinical spectrum of irritation is very broad and in addition to the more common acute
and chronic eczematous reactions
also includes ulceration, folliculitis, acneiform eruptions, miliaria, pigmentary
alterations, alopecia, contact urticaria and
granulomatous reactions ( Table 137-1). 4
TABLE 137-1 Clinical Features That May Suggest the Etiology of Irritant
Dermatitis*
Major Categories
The two major types of irritant contact dermatitis are acute ICD, including chemical
burns, and cumulative ICD.
ACUTE ICD, INCLUDING CHEMICAL BURNS Acute eczematous dermatitis after
exposure to a potent irritant, often to a
single chemical acid or alkali solution, may overlap with chemical burns. Highly
irritating chemicals induce a reaction in
any person's skin if the concentration and duration of action are sufficient; the
intrinsic nature of the chemical is also
important. Strong alkalis and acids, such as sodium and potassium hydroxides and
hydrochloric and sulfuric acids are
common irritants, among others. In national statistics for work-related injuries, acute
ICD reactions are often classified as
chemical burns ( Fig. 137-1).
FIGURE 137-1 Vesiculobullous hand eruption in a 42-year-old man from prolonged
wearing of solvent-soaked gloves.
CUMULATIVE ICD Cumulative ICD, the most common type of ICD, develops slowly
after cumulative but additive
subthreshold exposures to mild irritants (soap, water, detergents, industrial
cleansers, solvents, etc.) under a variety of
conditions. Dermatitis is usually localized to the finger webspaces, but later spreads
to the sides and dorsal surface of
the hands, and finally to the palmar surface. The volar aspect of the wrist is usually
spared in contrast to allergic hand
eczema. The hallmark is the absence of vesicles and the predominance of dryness
and chapping. However, the
diagnosis is complicated by hybrids, where there is a combination of ICD and allergic
contact dermatitis, or of ICD and
atopy, or even of all three. 5 High-risk occupations for cumulative ICD include bakers,
canners, caterers, cleaners, cooks,
health care workers such as dental assistants and technicians and nurses,
hairdressers, mechanics, printers, and
butchers. 6
Other Categories
To more accurately define irritant dermatitis, other types have been described; some
represent subcategories or overlap
forms:
ACUTE DELAYED ICD Reaction is not seen until 8 to 24 h after exposure and may
be misdiagnosed as allergic contact
dermatitis. Examples include anthralin, bromine, 7 hexanediol diacrylate, podophyllin,
ethylene oxide, and propylene
glycol.
IRRITANT REACTION Irritant reaction is an early, almost subclinical dermatitis, or
sentinel event, often seen on the
hands of individuals exposed to wet work, such as hair dressers or metal workers, in
their first several months of training.
5, 8 The eruption is monomorphous and is characterized by one or more of the
following signs: dryness, erythema,
vesicles, pustules, and erosions.
TRAUMATIC ICD See posttraumatic eczema in the section “ Physical Causes.”
NONERYTHEMATOUS ICD Another subclinical type characterized by changes in
the stratum corneum barrier function
without a clinical correlate.
SUBJECTIVE ICD Also called sensory ICD, this condition is characterized by lack of
clinical signs but is accompanied by
burning and stinging after contact with certain chemicals, such as lactic acid.
PREDISPOSING FACTORS IN ICD
Specific factors Occupational ICD, especially of the chronic, cumulative type, is a
prime example of the concept of
multifactorial causation of disease. Not only are the properties of the irritating
substance important (pH, solubility, and
detergent action), but also its physical state (gaseous, liquid, or solid). Important host
factors include the presence or
absence of occlusion, sweating, pigmentation, dryness, and sebaceous activity, and
the simultaneous presence of
another skin disease, especially one that is reactivated by contact with irritant(s).
Important environmental factors include
temperature, humidity, friction, pressure, occlusion, and coexisting lacerations. A
worker's age, gender, skin type, and
genetic background may also be important.
Other factors Atopy is one of the most important contributing factors to ICD.
Individuals with a personal or past history of
atopic eczema (see Chap. 122) have an increased susceptibility to skin irritation and
account for a large percentage of
workers compensation dermatitis claims. Low relative humidity in the workplace,
especially in atopics is also an important
factor in developing dermatitis, especially with the presence of other irritants. With
relative humidity below 35 to 40
percent, the stratum corneum becomes drier and more brittle, with increasing
permeability to marginal irritants. Low
humidity dermatitis has been reported in closed, windowless offices, in
manufacturing of soft contact lenses, and in the
clean rooms of silicon-chip manufacturing plants. Symptoms, such as pruritus and
burning may be the only complaints
and are more distressing than physical signs, which may involve exposed or covered
areas. Differential diagnosis
includes airborne irritation, other dermatoses, and psychogenic causes. Treatment
includes liberal use of emollients and
increasing the indoor relative humidity to about 50 percent, if possible.
Airborne Irritant Dermatitis
Airborne irritants are an important cause of contact dermatitis. The pattern is fairly
characteristic with distribution on the
face, neck, anterior chest and arms. The most frequent causes are irritating dusts
and volatile chemicals, such as
solvents, ammonia, formaldehyde, epoxy resins and their hardeners, cement dust,
fibrous glass, and sawdust- especially
from irritating woods.
Diagnosis of Irritant Dermatitis
There are no reliable confirmatory tests for the diagnosis of ICD. Diagnosis is
primarily based on a history of exposure to
a known potential irritant that is consistent with the observed clinical appearance and
anatomic distribution. Because of
their close resemblance to allergic contact dermatitis, subacute and chronic irritant
dermatitis are almost always
diagnoses of exclusion and it is necessary to patch test most affected patients.
Rietschel 9 has proposed criteria for the
clinical diagnosis of ICD ( Table 137-2).
TABLE 137-2 Diagnostic Criteria of Irritant Contact Dermatitis
Common Occupational Irritants
Examples of common occupational irritants are described in the following sections.
SOAPS AND DETERGENTS Most toilet soaps do not irritate normal skin in normal
usage. If the skin is already even
slightly damaged from contact with other irritants, the use of industrial skin cleansers,
designed to remove heavy
industrial soil from the skin, can be very irritating, especially to atopic skin. Industrial
skin cleansers are available
commercially as cakes, liquids, powders, or creams. The choice of cleanser varies
with the job for which it is intended.
Machinists and auto-mechanics need a cleanser with a high detergent and abrasive
action. Borax has been used for
years for this purpose, and has the advantage of dissolving as it cleans. Somewhat
more irritating are abrasives of
vegetable origin. Sand and pumice have been used in some hand cleansers but are
highly irritating and should generally
be avoided or used sparingly, mainly on the palms and only for removal of the most
tenacious soils.
WATERLESS HAND CLEANSERS Waterless hand cleansers are formulated to
remove difficult oil and grease stains
and are widely used at worksites where there is no convenient source of water.
These products should not be used for
skin cleaning when ordinary hand soaps would suffice, and they may provoke
dermatitis from unnecessary overuse. They
should be used sparingly during the workday, because they contain a higher
percentage of petroleum-derived solvent.
Rags are often used to remove these cleansers, and by the end of a shift they can
be saturated with a variety of irritants.
After use, the potentially irritating residual film should be washed off with mild soap
and water. Disposable towels or
presaturated wipes from dispensers are better choices and are useful in many
situations, especially in the clean rooms of
the semiconductor industry. They usually contain antibacterial agents as
preservatives, which also may be contact
allergens. Instant hand sanitizers, often containing high concentrations of alcohol,
are now available. Some of these can
be drying to skin. Many chemicals are capable of causing skin damage, making
chemical burns an important cause of
occupational injury. 10Copious washing is the primary measure required in treating all
chemical burns. However, certain
types of burns require specific antidotes and therapies ( Table 137-3). 11
TABLE 137-3 Selected Burns That Require Unique Therapies
Acids and Alkalis, Including Chemical Burns
Inorganic acids are used in enormous quantities in industry, especially sulfuric,
hydrochloric, chromic, hydrofluoric, nitric,
and phosphoric acids. Sulfuric acid is one of the largest chemical commodities
produced in the United States and is
widely used in the manufacture of fertilizers, inorganic pigments, textile fibers,
explosives, pulp and paper. Hydrochloric
acid is used in the production of fertilizers, dyes, paints, and soaps. Sodium and
potassium hydroxide, ammonium
hydroxide, sodium and potassium carbonate and calcium oxide are widely used in
the manufacture of bleaches, dyes,
vitamins, plastics, pulp and paper, soaps and detergents. 12 Many of these acids and
alkalis are common causes of
chemical burns. Strong acids cause erythema, blistering and necrosis, and may
discolor the skin. Strong alkalis saponify
surface lipids and penetrate easily, leading to more severe and extensive tissue
destruction, including deep ulcerations
that heal very slowly.
Organic acids, such as acetic, acrylic, formic, glycolic, benzoic and salicylic acids,
tend to be less irritating than inorganic
acids, but especially after prolonged exposure, even in weak concentrations, they
can cause chronic irritant dermatitis.
Formic acid is used in the textile industry in dyeing and finishing, as a delimer and
neutralizer in leather manufacture, and
as a coagulant in the production of natural latex, among other uses. It has greater
corrosive potential than most other
organic acids. Acrylic acid, used chiefly as a monomer for acrylic plastics, is irritating
and corrosive to the skin. Fatty
acids, such as palmitic, oleic, and stearic acids tend to be less irritating. 12
HYDROFLUORIC ACID Hydrofluoric acid (HF) is a strong acid with many uses
including etching and frosting of glass,
rust removal, and “spot cleaning” in dry cleaning. HF is extremely irritating to skin,
even in concentrations of 15 to 20
percent. Fluoride ions penetrate deep into the tissues and bind to the calcium and
magnesium ions, causing severe
tissue damage including bone destruction, especially of the terminal digits of the
hand. 11 Following exposure to lower
concentrations of HF, the onset of symptoms may be delayed until release of fluoride
ions occurs in deep tissues.
Exposure to HF is a medical emergency requiring topical or subcutaneous calcium
gluconate after lavage to bind the
fluoride ions ( Table 137-3).
CEMENT Exposure to wet cement may cause severe alkaline and thermal burns due
to the exothermic reaction of
calcium oxide with water forming calcium hydroxide. 13Kneeling in wet cement for
prolonged periods leads to deep burns
of the knees (cement knees) and shins; 14lesions may become deep enough to
require excision and grafting. Burns may
also result from the trapping of wet cement in gloves and boots.
CHROMIC ACID Chromic acid is highly irritating to the skin, causing ulcerations of
the skin (“chrome holes”) and
perforation of the nasal septum. Exposures occur in chrome plating, copper
stripping, and aluminum anodizing
operations. Chromic acid may be absorbed and lead to renal failure. 15
PHOSPHORUS Phosphorus is used in the manufacture of insecticides and
fertilizers, and can cause deep, destructive
burns. It ignites spontaneously on exposure to air so that the affected area should be
kept moist until the chemical is
completely removed. Severe metabolic derangements have been reported following
phosphorus burns and patients
should be closely monitored for multiorgan failure. 16
ETHYLENE OXIDE Ethylene oxide is used commercially and in hospital central
supply units for sterilization of surgical
and medical instruments and devices as well as textiles and plastic material. Burns
may result from contact with porous
materials and devices that have been sterilized with ethylene oxide but not properly
aerated. 17
PHENOL Phenol is rapidly absorbed through intact skin and can cause local
necrosis and nerve damage.
METAL SALTS Arsenic compounds such as arsenic trioxide, the dust of which can
be contacted during the smelting of
copper, gold, lead, and other metals, can cause a persistent folliculitis in addition to
systemic poisoning. In the
semiconductor industry, exposure to arsenic can occur during maintenance activities
and especially during the handling
of raw materials. Allergic contact dermatitis has been reported from sodium
arsenate. Beryllium compounds are employed
in the aerospace and other industries for the production of hard, corrosion-resistant
alloys, among other uses. They may
cause an irritant dermatitis, but especially characteristic are ulcerating granulomas
from implantation of beryllium salts. 12
Allergic contact dermatitis and allergic granulomas are also reported. Calcium oxide
(quicklime), used as a refractory, as
a flux in the manufacture of steel (among many other uses) is a strong skin irritant
that releases heat on contact with
water, causing painful skin ulcerations. Copper salts are skin irritants and
occasionally contact allergens. Inorganic
arsenic may contaminate coppers ores. Metal fume fever, a flulike illness of brief
duration, may result from inhalation of
the fine particle of oxides of copper, as well as from magnesium and zinc. Today, it is
usually associated with welding
operations performed with inadequate ventilation. 18Cobalt salts, used in alloys,
ceramics, electroplating, electronics,
magnets, paints and varnishes, cosmetics, and the like, may be irritants and also
cause allergic contact dermatitis. When
used in hard metal alloys, the dust may also cause pulmonary sensitization.
19Inorganic mercury exposure sometimes
causes a bluish linear pigmentation on the gums and tongue, which should be
considered a marker for systemic
poisoning. Compounds of mercury have been widely used as bactericides, dental
amalgams, catalysts, and the like.
Alkyl mercury compounds cause severe burns and corrosion of the skin. Exposure to
selenium compounds can cause a
conjunctivitis termed rose eye, as well as a reddish discoloration of the skin and hair.
Selenium dioxide and selenium
oxychloride are strong skin vesicants.
SOLVENTS Millions of workers are exposed to solvents daily. Until recently, most
solvents were used to dissolve other
substances or as diluents for adhesives or surface coatings. Today the chief uses
are in the manufacture of other
chemicals; as carriers for chemical reactions; as pressure transmitters for hydraulic
systems; and in coatings, industrial
cleaners, printing inks, and pharmaceuticals. After water, the most common solvents
are aliphatic and aromatic
hydrocarbons, esters, ethers, ketones, amines, and nitrated and chlorinated
hydrocarbons ( Table 137-4). 20Volatile
solvents, especially, act by dissolving the intercellular lipid of the epidermis, causing
“whitening” of the skin and a feeling
of dryness. By dissolving the skin's lipid barrier layer, percutaneous absorption of the
solvent, and any chemical it
contains is increased. The more lipophilic the solvent, the greater the absorption.
Prolonged skin contact with
solvent-soaked clothing can result in systemic symptoms, as well as severe burns,
and sometimes even death. There is
an inverse correlation between the boiling point of a solvent and its primary irritant
effect. 21
TABLE 137-4 Selected Industrial Solvents That Are Skin Irritants
Workers are rarely exposed to a single solvent. More often they are exposed to
mixtures of several solvents, but
clinically, it is often difficult to demonstrate the relative importance of an individual
ingredient of a mixture. Mineral spirits,
kerosene, gasoline, and various thinners are widely used as mixtures.
FIBROUS GLASS Glass fibers, also called man-made vitreous fibers (MMVF),
causes a characteristic highly pruritic
contact dermatitis, that may resemble scabies. Fibers larger than 3.5 μm are
generally responsible, causing pruritus and
furious scratching and excoriations. Symptoms usually subside in a week or two and
workers can usually return to the
same work without recurrence. Patients with atopic eczema or dermographism may
have to change jobs. Pathogenesis is
via direct, indirect (through clothing), or airborne irritant dermatitis. Symptoms may
occur through simple mechanical
irritation by sting, penetration of fibers into the skin and a secondary allergic contact
dermatitis from the associated
finishing resins, for example, epoxy.
FABRICS Wool and rough synthetic clothing are well known to cause itching
dermatitis, especially in atopic individuals.
Fire-retardant fabrics, “NCR” paper, and paper face masks, as used in the
semiconductor and other industries, also
frequently induce irritation in such persons.
PLANTS Irritant dermatitis is the most frequent type of plant-related dermatitis and
can appear as erythema,
hyperkeratosis of the hands and fingers, papules, vesicles, necrosis, abrasions, or
granulomas. Plant families most
commonly associated with irritation are the Euphorbiaceae (various spurges,
crotons, poinsettias, manchineel tree);
Ranunculaceae (buttercup) and Cruciferae, also termed Brassicaceae (black
mustard); Urticaceae (nettles); Solanaceae
(pepper, capsaicin); and Opuntia vulgaris (prickly pear). 22 Many plants cause only
simple irritation, as from spines,
thorns, sharp-edged weeds, and trichromes and barbs (glochids) of certain cacti. 23
Sabra dermatitis, for example, is a
term used for dermatitis caused by contact with tiny glochids on the surface of the
Indian fig ( Opuntia ficus-indica), which
penetrate the skin and cause a dermatitis resembling scabies. Sometimes foreign-
body granulomas are formed. The
chemicals present in various sections of plants are responsible for much of the
irritation from plants. These include
oxalic, formic and acetic acids; various glycosides; proteolytic enzymes; phorbol
esters; isothiocyanates; and crystals of
calcium oxalate. 24 Phototoxic eruptions from plants (phytophotodermatitis) are fairly
common among farm workers,
nursery personnel, florists, and gardeners, and occur more frequently than
photoallergic reactions. Plants containing
furocoumarins, such as 5-methoxypsoralen (bergapten, 5-MOP), are the most
common causes of phototoxic reactions,
which result from contact with the plant followed by exposure to ultraviolet light
(UVA) at wavelengths of 320 to 400 nm in
sunlight. Large bullae appear on exposed skin, which are almost always nonpruritic.
After resolving in a week or so,
characteristic linear, hyperpigmented streaks remain, which may last for months.
Outdoor workers exposed to moist
plants, either from fog or irrigation, and sunlight may develop these characteristic
lesions, which usually appear a few
hours after exposure but sometimes not until 36 to 48 h later. Plant families
responsible for most of these eruptions are
the Umbelliferae (parsley, celery, parsnip, giant hogweed, and others), Rutaceae
(rue, burning bush or gas plant,
bergamot), and Moraceae (fig tree). A widespread phytophotodermatitis may result
from contact with weeds, such as cow
parsley ( Anthrisis sylvestris) and hogweed ( Heracleum sphondylium). The term
strimmer dermatitis (or “weed-whacker
dermatitis”) is applied to a photodermatitis caused by contact with newly mowed,
moist plant fragments on sunny days.
The eczematous eruption is often bullous, leaving characteristic hyperpigmented
streaks. Celery harvesters and grocery
clerks handling celery may develop a phytophotodermatitis, as well as bartenders
squeezing limes, especially
out-of-doors on sunny days. By testing celery pickers with serial dilutions of 8-
methoxypsoralen, 5-methoxypsoralen, and
trimethylpsoralen, Ljunggren was able to differentiate allergy from phototoxicity. 25
ALLERGIC CONTACT DERMATITIS (See also Chap. 120)
Allergic contact dermatitis (ACD) in the working environment is reported less
frequently to workers' compensation
authorities than irritant dermatitis, in part because most workers with contact
dermatitis are never patch tested to
determine the presence of contact allergy; thus many cases are not diagnosed and
reported. In a recent multicenter
study from the North American Contact Dermatitis Group, of 839 occupational
dermatitis cases (29 percent of 2889
patients referred for evaluation of contact dermatitis), 54 percent were primarily
allergic, 32 percent irritant, and 14
percent were diagnoses other than contact dermatitis, aggravated by work. 26 In this
series, nursing was the occupation
most commonly found to have allergic contact dermatitis. Other occupations were
assemblers, nurse's aides and
orderlies, machinists, students, machine operators, auto mechanics, compressing
and compacting jobs, and cooks.
Allergens strongly associated with occupational exposure were rubber (thiuram and
carbamate accelerators), epoxy
resin, and ethylenediamine. The hands are the most commonly affected site in
occupational allergic contact dermatitis.
The dorsal hands are typically involved along with the finger webspaces and the
forearms. Nail dystrophy may occur if
there is involvement of the periungual areas.
Table 137-5 27 lists the principal occupational contact allergens and Table 137-6
28lists blind spots in the diagnosis of
allergic contact dermatitis. Also see “ Patch Testing” later in this chapter.
TABLE 137-5 Major Occupational Contact Allergens
TABLE 137-6 Blind Spots in the Diagnosis of Allergic Contact Dermatitis (ACD)
The mechanism of ACD is discussed in Chap. 120. It is important to remember,
however, that the induction of allergic
sensitization to a specific allergen in a nonsensitive individual requires 4 or 5 days or
more. Following subsequent
contact with the allergens, the sensitive person will develop a clearly defined
reaction, appearing as early as 24 to 48 h
later. This information is important in determining when and where sensitization took
place. If ACD develops in a worker
after only 2 or 3 days following initial contact with an allergen, the induction of
sensitivity must have occurred previously,
perhaps during an earlier occupation.