Abstract
Occupation is an important risk factor for contact dermatitis that presents in adulthood. Occupational contact dermatitis often has significant adverse effects on quality of life and the long-term prognosis is poor unless workplace exposures are addressed. The condition often presents to general practitioners, physicians or dermatologists who will be responsible for facilitating management of the workplace issues in the event that an occupational health service is not accessible. This concise guidance summarises three sets of guidance from the Occupational Health Clinical Effectiveness Unit, the British Occupational Health Research Foundation and the British Association of Dermatologists respectively. It is aimed at physicians in primary and secondary care, covering the clinical aspects of case management but also drawing attention to the important actions they should take to address the workplace issues, either in liaison with an occupational health provider or in the absence of occupational health input.
Introduction
Contact dermatitis (CD) is common in the general population, with a point prevalence of hand dermatitis 9.7% and incidence 5.5–8.5/1,000 person years.1,2 Among patients of working age, occupation can be an important risk factor; skin disease is the third most common occupational disease, with contact dermatitis accounting for 70–90% of all occupational skin disease. Although not life threatening, dermatitis can have a serious adverse impact on quality of life, daily function and relationships. It has important social implications for patients and their families, including a potentially serious threat to employment. The prognosis for occupational CD is better when the exposure of affected individuals to causative agents at work is reduced. Therefore, good medical management in this condition comprises both clinical treatment and careful attention to risk identification and control in the workplace.
Where an individual has occupational health (OH) provision through their employer, the occupational aspects of prevention and case management will be coordinated by OH professionals. However, OH services are not provided under the NHS, and only a third of employees in the UK have access to them through their employers. Therefore for most patients, their general practitioners, physicians and dermatologists will be responsible for ensuring that the occupational risks are identified and managed alongside the clinical treatment, in the absence of specialised OH advice.
Aims of the guideline
This guideline aims to provide physicians who work in primary and secondary medical care with a standardised approach to managing CD in patients of working age. The document summarises three key sets of recently published or updated guidance (the source guidelines) from the Occupational Health Clinical Effectiveness Unit (OHCEU),3 the British Occupational Health Research Foundation (BOHRF),4 and the British Association of Dermatologists (BAD).5 It covers both the clinical and the occupational aspects of case management, with a focus on the following areas:
diagnosis and investigation of CD
clinical management of cases of occupational CD
management of the occupational aspects including facilitating exposure control, adjustments at work, and primary and secondary prevention.
The source guidelines have been produced by various multidisciplinary guideline development groups (GDGs). All have taken an evidence-based approach, using standardised scoring systems for the assessment of quality and grading of recommendations. The occupational guidelines (from OHCEU and BOHRF) have used the Scottish Intercollegiate Guidelines Network (SIGN) methodology, either alone or in combination with the Royal College of General Practitioners (RCGP) three star system. Importantly, the GDGs included patient representation. Please refer to the full texts of the source guidelines for a complete description of methodology and the membership of the GDGs. The recommendations in this concise guideline have been graded using SIGN categories.
The guidelines
Clinical background
Contact dermatitis is an inflammatory disorder of the skin. The key clinical features are acute erythema and vesiculation; while the chronic phase is characterised by dryness of the skin with thickening (lichenification), cracking and fissuring. The rash is most commonly distributed on exposed areas of skin – in particular the hands and face. Aetiology is either irritant or allergic. Irritant contact dermatitis (ICD) is caused by a direct toxic effect on the skin, most commonly due to irritant chemicals and wet work that disrupt the skin's barrier function. Allergic contact dermatitis (ACD) is a delayed type IV (T cell mediated) immune response to specific sensitising agents, including small molecular weight chemicals and naturally occurring proteins.
The prognosis of occupational CD varies widely; similar proportions of patients report either improvement or ongoing symptoms (up to 89% in some series). A significant number (up to 10%) have persistent CD in the very long-term despite removal from exposure. Loss of job or complete change of employment because of dermatitis is common, and this can lead to financial impairment for the individual and their family. However, most patients manage to continue working in some capacity.
Occupational CD is notifiable to the Health and Safety Executive under the Reporting of Incidents, Diseases, and Dangerous Occurrences Regulations (RIDDOR). The employer is responsible for reporting work-related CD when the diagnosis has been confirmed by a doctor or other health professional. Therefore, physicians have an important role in alerting a patient's employer if they think that a new case of CD has been caused by work.
Dermatitis is a prescribed disease for the purpose of Industrial Injuries Disablement Benefit (IIDB), if the patient has been exposed to chromic acid, chromates or dichromates, or any external agent in the workplace (including heat and friction) that can cause irritation of the skin. A patient would have to be deemed more than 14% disabled to qualify for benefit. Physicians should be aware of IIDB prescription, and should direct patients with severe occupational CD to seek further advice from the Department of Work and Pensions (www.direct.gov.uk/en/disabledpeople/financialsupport/otherbenefitsandsupport/dg_10016183).
Barriers to implementation
The main potential barrier to implementing these guidelines is the achievement of effective liaison between doctors in primary or secondary care and the employer. With good communication, the care pathway can be highly effective. It is important to engage the patient positively in the process of liaison with their employer, to address concerns about job security openly, and to ensure that they have given consent for treating clinicians to share limited medical information in confidence. It is advisable to share the diagnosis of occupational CD with the employer in order to ensure completion of statutory reporting and planning of appropriate risk management strategies for the patient and their employed colleagues. Where there is access to an OH service it is easier to protect the confidentiality of medical information. However, in the absence of an OH contact, doctors should aim to communicate, with the patient's consent, with their line manager or the employer's human resources adviser.
Points for specific inquiry when taking an occupational history.
Acknowledgements
I am grateful to the members of the GDGs who contributed to the editing of this concise guideline document, and the Health and Work Development Unit (formerly OHCEU) who provided administrative support.
Footnotes
Series editors: Lynne Turner-Stokes and Bernard Higgens
∗For membership of the guideline development groups please see the full guidelines3–5
- © 2010 Royal College of Physicians
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