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Occupational Medicine Advance Access originally published online on June 16, 2006
Occupational Medicine 2006 56(6):398-405; doi:10.1093/occmed/kql039
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© The Author 2006. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Incidence by occupation and industry of work-related skin diseases in the United Kingdom, 1996–2001

J. C. McDonald1, M. H. Beck2, Y. Chen3 and Nicola M. Cherry4

1 Occupational and Environmental Medicine, Imperial College School of Medicine, London, UK
2 Dermatology Centre, Hope Hospital, Salford, UK
3 Centre for Occupational and Environmental Health, University of Manchester, Manchester, UK
4 Department of Public Health Sciences, University of Alberta, Edmonton, Canada

Correspondence to: Nicola M. Cherry, Department of Public Health Sciences, 13-103 Clinical Sciences Building, University of Alberta, Edmonton T6G 2G3, Canada. Tel: 001 780 492 7851; fax: 001 780 492 0498; e-mail: nicola.cherry{at}ualberta.ca


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background Work-related skin disease is common but few cases are documented in statutory reports or disability systems. Voluntary reporting by specialist physicians provides more complete information.

Aims To summarize incidence rates of work-related skin diseases reported by consultant dermatologists and occupational physicians, with emphasis on contact and allergic dermatitis by occupation and industry.

Methods Cases reported in 1996–2001 to the EPIDERM and OPRA national surveillance schemes were analysed by causal agent, occupation and industry, with incidence rates calculated against appropriate denominators.

Results Average annual incidence rates based on data from dermatologists were 97 per million overall, 74 for contact dermatitis and 14 for neoplasia. The corresponding rates for occupational physicians were 623 overall, 510 and 2, respectively. For infective disease, the rates for occupational physicians were 28 compared to 2 for dermatologists. Contact dermatitis was most frequently attributed to rubber chemicals, soaps and cleaners, wet work, nickel and acrylics; most cases of contact urticaria were attributed to rubber chemicals or foods and flour. The pattern of incidence rates by occupation and industry was complex, but correlated with the probable type of exposure. Rates of contact dermatitis were highest among skilled workers in the petrochemical and rubber and plastic manufacturing industries, with machine operators and technical workers in metal and automotive industries also at increased risk. High proportions of cases attributed to rubber chemicals were in nurses and technicians in the health and social services.

Conclusions These findings identify jobs and types of work where contact with causal agents is common and potentially preventable.

Keywords      Industry and occupation; reported incidence; work-related skin disease


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
The evolution of the Occupational Disease Intelligence Network (ODIN), from its inception in 1996, was recently outlined in relation to the Surveillance of Work-related and Occupational Respiratory Disease (SWORD) reporting scheme for work-related respiratory diseases, which itself began in 1988 [1]. In 1991, a pilot scheme, known as the OCC-DERM project, was initiated in Manchester by 17 consultants in dermatology who reported new cases of work-related skin diseases. In 1993, this project was extended to all consultant dermatologists and to interested occupational physicians throughout the United Kingdom; it was then renamed EPIDERM, with reporting procedures closely analogous to SWORD. Since 1996, with the creation of ODIN for all types of occupational diseases, the surveillance of work-related skin disorders has been based on continuing reports from a small core group of specially interested dermatologists, complemented by random sampling procedures for all other dermatologists and occupational physicians, described below. Analyses of data from the outset in 1991 to the end of 1998 have been published [2], and in more detail for contact dermatitis [3]. The present paper will deal only with the 6-year period, 1996–2001, with concentration on incidence rates by occupation and industry made possible by the present availability of separate denominators appropriate for both dermatologists and occupational physicians.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
Reporting procedures in all seven schemes of ODIN are closely similar and, for EPIDERM, have already been fully described [2]. During the period 1996–2001, a high proportion of consultant dermatologists seeing adult patients in the United Kingdom, ~250 in total, have taken part either as core participants or within a randomly assigned monthly sampling scheme. The separate Occupational Physicians Reporting Activity (OPRA) has similarly entailed the participation, since 1996, of almost all the United Kingdom's 800 or so full- or part-time doctors working in industry. Both EPIDERM and OPRA have their own report cards, which allow all newly diagnosed cases of skin disease, which, in the doctor's opinion, were caused or made significantly worse by work, to be notified, together with sex, age, postcode, diagnosis, industry, occupation and suspected agents for each case.

For the calculation of incidence rates, Labour Force Survey statistics for the winter of 1999 [4] were used for the dermatologists' reports. For the data from occupational physicians, denominators obtained from a special survey made in 2001 were used, based on the 12% of UK employees which they serve [5]. Diagnoses of occupational physicians were coded using the International Classification of Diseases, 10th Revision, and occupation and industry using the Standard Occupational Classification (SOC) [6] and Standard Industrial Classification (SIC) [7]. These were then recoded to the categories used in this and previous reports. Full lists of the SOC and SIC codes, with definitions, can be obtained from the authors on request.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
Incidence rates
During the 6-year period, 1996–2001, 7319 new cases of work-related skin diseases were reported by dermatologists and 1240 by occupational physicians, with estimated totals, using the sampling fraction, of 15 756 and 11 910, respectively. However, as more than one diagnosis could be recorded for a given patient, the total number of estimated diagnoses was greater, 16 082 and 12 006, respectively. Of these, a small proportion (2.3%) was reported by government medical inspectors. Average annual estimates based on these figures are shown by diagnosis in Table 1, together with incidence rates per million employees at risk. In both EPIDERM and OPRA, contact dermatitis was by far the most common skin disease reported. Apart from the rarity of skin cancer in patients of working age seen by occupational physicians and of infective disorders by dermatologists, the distributions of diagnoses in the two data sets were fairly similar, with comparatively little, if any, important trends over the 6-year period. It should be mentioned, however, that the markedly lower rate by occupational physicians in the second period (1999–2001) was offset by a small increase by dermatologists. The incidence rates are about six times higher for diseases reported by occupational physicians than by dermatologists. Further analyses (data not shown) by age and sex indicated that in data from dermatologists, neoplasia were almost all in males >60 years of age, rates for contact urticaria in women were twice those in men but rates for other diagnoses were fairly similar in men and women. Analyses by age were not possible on the data from occupational physicians as age was not recorded in their denominator, but rates for contact dermatitis were 40% higher in men and for contact urticaria again twice as high in women.


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  		Table 1. Estimated average annual incidence rates of work-related skin diseases reported by dermatologists and occupational physicians, 1996–2001

 
Causal agents
The agents reported as responsible for contact dermatitis and contact urticaria are presented in Table 2. As more than one agent was often mentioned in a given case, it can be seen that the numbers shown in this table considerably exceeded the annual average numbers in Table 1. Contact urticaria was far less frequently cited than contact dermatitis in both data sets, with rubber chemicals and foods and flour prominent in both diseases. Apart from an apparent increase in contact dermatitis, attributed by dermatologists to rubber chemicals and wet work, the percentage distribution of agents by type did not show any important change over the 6-year period studied (data not shown).


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  		Table 2. Agents most frequently reported as responsible for contact dermatitis and contact urticaria, 1996–2001

 
Among the 326 estimated cases of infective disorders reported by dermatologists, 35% were due to fungal infection and 20% due to other unspecified pathogens; 16% were viral warts or orf and 14% were attributed to insect bites or zoonoses. Among the 542 estimated cases reported by occupational physicians, 29% were due to insect bites or zoonoses, 18% were due to fungal infection, 16% were due to other pathogens and 7% were viral warts or orf. For folliculitis and acne, the most frequently reported agents by both dermatologists and occupational physicians were petroleum products, cutting oils and coolants; wet work was usually incriminated in mechanical, traumatic and nail complaints. Petroleum products were cited in only a very small proportion of skin neoplasia; almost all the remaining cases were attributed to sunlight.

Incidence rates by occupation and industry
In Tables 3 and 4 are compared the estimated average annual incidence rates of contact dermatitis and contact urticaria by occupation and industry, based on reports to EPIDERM by dermatologists and to OPRA by occupational physicians. As already mentioned, the latter rates overall were some six times higher than the former, but it can be seen that in some industries and occupations, the difference was far greater. For contact dermatitis, rates based on data from dermatologists were highest in craft-related occupations and in the petrochemical, rubber and plastic manufacturing industries. The pattern of reports from the occupational physicians was similar, but more extreme and widely distributed. Thus, plant and machine operatives and associated professional and technical occupations have high rates in addition to craft-related occupations. Rates were also high in the metal and automotive product manufacturing industries and mining and quarrying, as well as in petrochemicals. Moreover, categories shown to be at high risk by the occupational physicians had rates far in excess of average.


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  		Table 3. Estimated average annual cases and incidence rates per million of contact dermatitis and urticaria by occupation, 1996–2001

 

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  		Table 4. Estimated average annual cases and incidence rates per million of contact dermatitis and urticaria by industry, 1996–2001

 
The distributions of the very much lower rates for contact urticaria are broadly similar, though the relatively high incidence for associated professional workers and the health and social services reported by dermatologists, and the wider range of industries implicated by occupational physicians, should be noted.

Agents
A further insight into the relationship between occupation and industry in contact dermatitis is given by analysis of the agents most frequently cited by dermatologists (Table 5) and occupational physicians (Table 6). It should be remembered that more than one agent was often reported in contact dermatitis, especially if associated, for example with wet work. Interpretation is helped by considering first the figures in bold for agents reported 50 or more times per annum, in columns which identify the main agents responsible by occupational and industrial categories. Some indication of the extent to which occupation and industry are linked is then obtained by inspecting the rows for each specific agent. For example, in Table 5 (for dermatologists), rubber chemicals and materials are those most frequently linked with associated professional and technical workers and with the health and social services and resins and acrylics with craft-related jobs and with metal and automotive product manufacture. In Table 6 (for occupational physicians), these and other similar associations can be seen.


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  		Table 5. Estimated annual average number of reports by dermatologists of agents specifically related to contact dermatitis, by occupation and industry, 1996–2001

 

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  		Table 6. Estimated annual average number of reports by occupational physicians of agents specifically related to contact dermatitis, by occupation and industry, 1996–2001

 
The data on which Tables 5 and 6 are based can if required be analysed in full detail to provide the relative frequency of any specified agent held responsible for contact dermatitis in a given job and/or industry. Tables 5 and 6 are illustrative only of this potential.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
The most important finding was that incidence rates were six to eight times higher when based on reports from occupational physicians than from dermatologists. This was true for all main diagnoses except neoplasia. It is probable that only the more serious cases are referred to clinical specialists, and also that the populations served differ enormously in terms of age, sex, industry and occupation.

It is rare that workers have sufficient disability to gain Disablement Benefit, and as relatively few apply, figures from this source are of limited value. Similarly, under-reporting of skin disease statistics by employers under present regulations is substantial. The EPIDERM and OPRA figures are probably the best source of information on the incidence of occupational dermatoses in the United Kingdom. Even so, figures presented in this paper inevitably underestimate total incidence as not all sufferers of occupational dermatoses see an occupational physician or dermatologist and not all cases seen will be recognized (or reported) as work related.

The eight categories of industry and nine of occupation used in this paper are too broad to do more than give an idea of the level and pattern of risk. However, when taken together and linked to the agents responsible, for contact dermatitis at least, the data can be more clearly interpreted. For example, rubber chemicals were the most frequently reported cause of contact dermatitis. A high proportion of reports from both dermatologists and occupational physicians were of cases among employees in the health and social services or ‘all other industries’ (Tables 5 and 6). The data on occupation suggest that in the former, the persons affected were nurses or technicians and in the latter, skilled workers in a variety of trades. These observations indicate not only where the main risks from rubber chemicals have occurred but also the extent to which other occupations and industries are affected. Greater insight can be obtained if necessary, if the second and third digits of the SIC and SOC are used, to identify priority problems more precisely.

The classification of agents incriminated in dermatitis, shown in Table 2, was not wholly satisfactory. All 22 categories, including the miscellaneous ‘others’ group, comprised numerous specific substances and proprietary products. The same classification had been used in our two previous publications [3,4], and although recoding for the entire 6 years might have been possible, it would have been extremely difficult. In distinguishing between agents responsible for contact dermatitis and urticaria, it would have been useful to separate, for example, between ‘solvents and alcohols’ (Group 8) and between acids and caustics (Group 21).

A further problem difficult to resolve resulted from reports of cases with more than one diagnosis, particularly where more than one agent was listed. Thus, in Table 2, some agents for contact dermatitis may also have been shown as causing urticaria, or vice versa. With rubber chemicals, for example, it is probably the latex protein which causes the urticaria, whereas chemical additives account for the dermatitis. Similarly, for foods and flour and other groups of agents, the mechanisms may vary. However, only 2% of cases reported by dermatologists (and <1% of those reported by occupational physicians) were given more than one diagnosis, and limiting the analysis to those with a single condition confirmed that the relation between agents and diagnoses in Table 2 was not a result of this artefact.

It is beyond the scope of this paper to infer means by which these extremely common occupational disorders can be prevented. Surveillance schemes can identify the industries and occupations at high risk, and eventually reflect the success or otherwise of control measures. They can also provide a base for more detailed studies of factors affecting susceptibility and prognosis and of important social questions concerning selection for further employment.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
We are grateful to Cornelia Zekveld for considerable help with the initial statistical analyses, to the UK Health and Safety Executive for funding provided to the ODIN reporting schemes, to the professional bodies (the British Association of Dermatologists and the Society of Occupational Medicine) whose support made the schemes possible and to the reporting physicians.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. McDonald JC, Chen Y, Zekveld C, Cherry NM. Incidence by occupation and industry of acute work related respiratory diseases in the UK, 1992–2001. Occup Environ Med 2005;62:836–842.[Abstract/Free Full Text]

  2. Cherry N, Meyer JD, Adisesh A et al. Surveillance of occupational skin disease: EPIDERM and OPRA. Br J Dermatol 2000;142:1128–1134.[CrossRef][ISI][Medline]

  3. Meyer JD, Chen Y, Holt DL, Beck MH, Cherry NM. Occupational contact dermatitis in the UK: a surveillance report from EPIDERM and OPRA. Occup Med (Lond) 2000;50:265–273.

  4. Office for National Statistics. Labour Force Survey, Winter 1999. London: The Stationery Office, 2000.

  5. McDonald JC. The estimated workforce served by occupational physicians in the UK. Occup Med (Lond) 2002;52:401–406.

  6. Office of Population Censuses and Surveys. Standard Occupational Classification. London: HSMO, 1990.

  7. Central Statistical Office. Indexes to the Standard Industrial Classification of Economic Activities 1992. London: HMSO, 1993.


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