Epidemiology of occupational skin diseases in Poland in the period 2003–2017

INTRODUCTION

In 2017 occupational dermatoses were the 7th most commonly diagnosed occupational diseases in Poland. In many other countries of the European Union such disorders took the 2nd place among the most commonly occurring occupational diseases [1], while the economic loss due to cutaneous occupational diseases reached approximately 600 million euro per year in the European Union [2].
Occupational diseases are characterised by a diverse aetiology. The triggering factors might be of chemical, physical or biological nature. The term itself is both legal and medical. The definition of occupational disease is regulated by the Polish Labour Code (of 26 June 1974) – “an occupational disease, listed in the occupational disease registry, is a disease that might be undoubtedly or with a high probability caused by noxious factors, called occupational exposure factors, which are found within the environment of labour or attributed to the form of labour”, art. 235 paragraph 1 [3]. The majority of countries have established occupational disease registries of their own; there are however registries recommended by the International Labour Organization and the European Union.
Cutaneous occupational diseases in Poland are presented in the Polish registry in operation within point 18 (table 1). This registry can be found in the Regulation of the Council of Ministers of 30 June 2009 concerning occupational diseases [4].
Additionally, points 16, 17, 24 and 26 include records that might be considered as cutaneous occupational diseases (table 2).
Point 16 includes diseases caused by ionising radiation, while point 17 includes malignant neoplasms caused at workplace by factors, which are considered carcinogenic for humans. Point 24 deals with diseases caused by exposure to high or low temperatures of the environment, while point 26 deals with infections or parasitic diseases or their after-effects.
Only nosological entities found in the registry of occupational diseases in operation may be formally considered as occupational diseases. Therefore, cutaneous diseases that had occurred before the onset of labour and were intensified due to noxious and burdensome factors found within the labour environment (intensification of seborrhoeic dermatitis due to UV radiation) or entities not mentioned in the registry may not be considered as occupational.
Until 2009, the Regulation of the Council of Ministers of 30th July 2002, concerning the registry of occupational diseases, specific code of conduct for registration of suspected cases, diagnosis and recognition of occupational diseases, as well as the entities dealing with such cases, was in operation [5]. Based on this regulation one could additionally recognise such nosological entities as contact lichen planus caused by chemicals used in colour photography (point 18.8), toxic dermatitis with skin discolouration caused by greases and oils (point 18.7), widespread disfiguring hypopigmentation or hyperpigmentation, and incrustation of skin with foreign body particles (point 18.10) (table 3).

RESULTS

Between 2003 and 2017 there were 43 127 occupational disease cases registered, including 1694 cutaneous occupational disease cases assigned to point 18 of the registry. At the same time one could observe a significant decrease in the number of registered occupational diseases, including cutaneous occupational diseases. The rate of occupational diseases and occupational skin diseases per 100 000 paid employees is presented in table 4.
The most commonly diagnosed cutaneous occupational disease in the years 2003–2017 was allergic contact dermatitis (table 5) [6–20]. There were 1364 cases of this entity, which corresponds to 80.5% of all cutaneous occupational disease records. Allergic contact dermatitis is a chronic disorder with periods of activity and remissions. It is characterised by the presence of inflammatory foci at allergen contact sites [21]. The majority of substances triggering allergic contact dermatitis are haptens, being chemicals smaller than 500 daltons that easily covalently bind to skin proteins [21–23]. The most common allergenic substances in this case include chromates (the most prevalent chromium exposure factors are: cement, foundry sand, worn-out greases and industrial oils, galvanizing liquids, tanning chemicals, coolants, shielding gases, and anti-corrosive liquids), rubber chemicals, formaldehyde, resins, and glues. On the other hand, nickel is the most common non-occupational allergen, yet might be the cause of occupational allergic contact dermatitis to, e.g. hairdressers, cleaning personnel, ward nurses, and food and drink staff.
The second most common cutaneous occupational disease was irritant contact dermatitis – 219 cases, which corresponded to 12.9% of total occupational diseases mentioned in point 18. Reported cases of irritant contact dermatitis in the years 2003–2017 are presented in table 6.
This dermatosis presents itself within the irritant contact sites, while the most prevalent site is the skin of the hands. Depending on the irritant, the disease might be of acute (caused by strong irritants – changes similar to chemical burns) or chronic nature (caused by weak irritants) [21, 24]. The most common factors triggering irritant contact dermatitis at workplaces are chemicals, while one of the most important risk factor in this case is performing work in wet or moist conditions [25]. Atopic dermatitis predominantly promotes the occurrence of such dermatoses [24].
Contact urticaria was diagnosed in 68 persons, that is 4.0% of total occupational diseases. Reported cases of contact urticaria in the years 2003–2017 are presented in table 7. Urticaria was the third most common occupational disease. Taking into consideration the aetiology of contact urticaria, one can distinguish immunologic, non-immunologic or uncertain types [23]. Occupational urticaria is mostly of immunologic nature, while one of the most important aetiological factors in this case is latex [25].
There were 26 diagnosed cases of cutaneous candidiasis in the years 2003–2017, which was only 1.53% of the total number of occupational diseases. Reported cases of cutaneous candidiasis in the years 2003–2017 are presented in table 8. Candidiasis at the workplace is caused predominantly by frequent hand soaking, working in a moist environment that might include the presence of yeast growth stimulating conditions, such as sugar, or by contact with infectious material [24]. Skin changes usually include candidal intertrigo or candidiasis of nail folds and plates. Groups of workers at risk of this disease include food and drink staff, confectionery and fruit-processing industry workers, laundresses, flax rettery workers, microbiological laboratory personnel, nurses, and ward nurses [24].
Dermatophytosis in persons exposed to animal biological material was diagnosed only in 11 patients (0.65%). Reported cases of dermatophytosis in persons exposed to animal biological material in the years 2003–2017 are presented in table 9. The most common aetiological factors of animal derived mycoses are Trichophyton mentagrophytes, Trichophyton verrucosum, Microsporum canis, Microsporum persicolor, and Trichophyton equinum [2, 24]. Such dermatoses are the most common in farmers, breeders, veterinarians, and meat or tanning industry workers [24]. In order to diagnose occupational dermatophytosis, a mycological identification of the infectious species is necessary as well as the confirmation of the source of infection by growing the same pathogen from the animal which the worker had contact with [2].
There were only two cases of oil acne, coal tar acne or chloracne of diffuse nature in the years 2003–2017 [6–20]. Oil acne is caused by the action of industrial oils, tar and greases primarily in mechanics, metalworking and machine industry workers, construction workers and oil refinery personnel. The most common location is the skin of forearms, arms, shanks, thighs and buttocks, at sites exposed to dirty workwear [24]. There have been cases of intensification of acne in young fast-food workers, due to exposure to oil during hamburger frying [2]. Coal tar acne might occur in roofers, construction workers, roadmen, or coke and tar industry workers [2]. On the other hand, chloracne is caused by certain halogenated aromatic hydrocarbons and can be found in paper or wood impregnation workers and personnel working with pesticides [24].
There were only two confirmed cases of photodermatosis [6–20]. Photodermatoses may be divided into two groups: photoallergic (present only in certain people) and phototoxic (might occur in anyone provided that a high dose of UV radiation along with a photosensitiser is present). Photoallergies were most commonly found in farmers, horticulturists, arboriculturist, foresters, and veterinarians [2, 22, 23]. Aetiological factors include feed additives, plant protection chemicals, veterinary medicines and plants [2].
Toxic dermatitis with skin discolouration caused by greases and oils is an entity found in the 2002 registry but not present in the 2009 registry in operation. Toxic dermatitis was most commonly associated with exposure to tarmac, cresol and mineral oils, while the changes involved the face, neck and cleavage areas [24]. There were only two cases of such occupational dermatosis between 2003 and 2008.
However, not a single case of contact lichen planus caused by chemicals used in colour photography was diagnosed in the years 2002–2009 (point 18.8), toxic dermatitis with skin discoloration caused by greases and oils (point 18.7), nor a widespread disfiguring hypopigmentation or hyperpigmentation or incrustation of skin with foreign body particles (point 18.10).
Cutaneous occupational dermatoses were more common in women (1006 cases, 59.39%) than in men (688 cases, 40.61%) in the period 2003–2017. Reported cases of cutaneous occupational diseases by sex in the years 2003–2017 are presented in table 10.
Table 11 and figure 1 show reported cases of allergic contact dermatitis and irritant contact dermatitis by sex in the years 2003–2017.

DISCUSSION

There were 1694 recorded cases of cutaneous occupational diseases in the years 2003–2017. The most common entity was allergic contact dermatitis (80.5% of total occupational skin disease cases), while the skin of the hands was the most frequent location of occupational dermatoses [2]. In contrast, in the other European Union countries irritant contact dermatitis was far more common (90%) than allergic contact dermatitis [1]. In Poland women suffered more frequently from occupational dermatoses, while in the other European Union countries men were more prevalent [1]. Within the aforementioned period there was a significant decrease of the reported occupational dermatosis cases from 214 in 2003 (which corresponded to 4.9% of all occupational diseases reported in 2003) down to 65 in 2017 (3.4% of all occupational diseases reported in 2017). In 2003 cutaneous occupational diseases were the 5th most commonly diagnosed occupational diseases, while in 2017 such entities were the 7th most common.

CONCLUSIONS

In the past 14 years there has been a decrease in the number of reported occupational dermatoses. The decrease in the number of cutaneous occupational diseases as well as occupational diseases as a whole may be attributed to more stringent control of the labour environment in terms of noxious factors as well as the action of the preventive health care system and the system of obtaining vocational qualifications. The elimination of old technologies, automation and production containment have led to a substantial decrease of the levels of noxious factors at workplaces [26]. On the other hand, the problem of occupational dermatoses in Poland seems underestimated, due to a low number of registered occupational disease cases compared to the other countries of the European Union [22]. Apparently, the number of currently registered cutaneous occupational disease cases does not reflect the true scale of incidence, which is probably due to low awareness of this problem within the group of both workers and primary care physicians. Dermatoses diagnosed among workers are not always the basis for the recognition of an occupational disease, yet might serve as a contraindication for working at the same workplace. Therefore patients are usually rather reluctant to report the presence of skin changes during their prophylactic examinations, as they fear job insecurity. An occupational health physician, having diagnosed an intensification of skin changes caused by noxious factors found at the workplace or by the way the work is performed, may issue a certificate “regarding the need of moving a worker to a different workplace due to the presence of negative effects of work on the health of the worker” (article 55§1 of the Polish Labour Code). Such a certificate, however, does not guarantee a successful change of workplace.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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Received: 15.01.2019
Accepted: 21.07.2019

Otrzymano: 15.01.2019 r.
Zaakceptowano: 21.07.2019 r.

How to cite this article
Jałowska M., Szymoniak-Lipska M., Żaba R., Adamski Z.: Epidemiology of occupational skin diseases in Poland in the period 2003–2017. Dermatol Rev/Przegl Dermatol 2019, 106, 384–395. DOI: https://doi.org/10.5114/dr.2019.88255