Covid-19 pandemic and the skin

In the beginning of the COVID-19 outbreak, skin manifestations, if present, were not paid enough attention. Then, the focus moved toward the impact of the prolonged use of personal protective measures in both healthcare workers and patients. In the meantime, attention is increasingly paid to dermatology as a result of the concern for certain groups of dermatologic patients, including those whose condition may worsen by the thorough disinfection measures and those treated with immunosuppressants or immunomodulators. Following patients with psoriasis on biological therapy, as well as other inflammatory and autoimmune cutaneous disorders such as atopic dermatitis, pemphigus, pemphigoid diseases, and skin cancer provoked the interest of dermatologists. Finally, an intriguing question to the dermatologic society was whether skin changes during COVID-19 infection exist and what could be their diagnostic or prognostic value. Here, we summarize skin conditions during the COVID-19 pandemic, patient information, and expert recommendations and give an overview about the registries launched to document skin changes during COVID-19, as well as details about certain patient groups infected with SARS-CoV-2, for example, psoriasis, atopic dermatitis, and autoimmune bullous diseases.     

Occupational allergic contact dermatitis in a company manufacturing boards coated with isocyanate lacquer

Over a short period of time, there was an outbreak of work-related skin lesions among workers at a company producing flooring laminate boards, after the introduction of a water-repellent lacquer based on diphenylmethane-4,4'-diisocyanate (MDI). In 5 workers, patch testing was performed with a standard series, an isocyanate series and work-environmental products when indicated. 3 of the workers were tested with the lacquer, and contact allergy was found with concurrent reactions to 4,4'-diaminodiphenylmethane (MDA). 1 of the 3 workers also showed a simultaneous reaction to MDI, whereas 1 showed a positive reaction to dicyclohexylmethane-4,4'-diisocyanate (HMDI). Of the 2 individuals not tested with the lacquer, 1 reacted to both MDI and MDA, whereas the other reacted to a soap used at work. In 3 of 4 cases, the isocyanate reactions appeared after D3. Occupational contact with isocyanates should not exclusively be focused upon respiratory hazards, as this report shows that skin contamination probably increases the risk of developing contact allergy to isocyanates and isocyanate-related substances. When aiming at diagnosing contact allergy to isocyanates, it is desirable to perform a late reading, as positive reactions appear late. MDA appears to be a good marker for isocyanate hypersensitivity.     

Pachydermodactyly from repetitive motion in poultry processing workers: a report of 2 cases

BACKGROUND Pachydermodactyly is a rare, benign, acquired form of digital fibromatosis. The etiology of pachydermodactyly is unknown but is believed to be due to repeated mechanical injury of the skin. We report 2 cases identified in poultry processing workers and review other conditions associated with these cutaneous findings. OBSERVATIONS The 2 workers in this report were employed as a chicken catcher and a chicken hanger. On examination, both workers had marked lateral thickening of the digits, with associated pain and pruritus. The workers' skin condition developed despite the use of protective gloves, and their symptoms improved when removed from work. However, the swelling due to fibromatosis persisted. CONCLUSIONS Similar cutaneous findings have been reported in other occupations exposing individuals to repetitive skin trauma, and many patients demonstrating a compulsive habit of hand manipulation. This supports the conclusion that pachydermodactyly in these patients reflects repeated skin trauma. Repetitive mechanical injury in the poultry processing environment can result in considerable compensatory tissue changes. Preventive measures are needed to protect workers.     

Clinical aspects of Borrelia burgdorferi infections

Skin lesions due to Borrelia burgdorferi-like erythema migrans, lymphadenosis cutis benigna, and acrodermatitis chronica atrophicans - are hall-marks of a systemic infection, which tends to a chronically relapsing course. Even if the skin lesions are missing, or disappear spontaneously, the infection may persist and affect other organs. This presumption is supported by the outcome of a long-term follow-up study on seropositive forest workers. In association with meningopolyneuritis (Garin-Bujadoux-Bannwarth disease) and acrodermatitis chronica atrophicans - myositis and fasciitis have been recently reported as further possible manifestations of Borrelia burgdorferi infection. Borrelial infection during pregnancy should promptly be treated with antibiotics in high dosages, in order to prevent maternal-fetal transmission of borrelial organisms resulting in stillbirth or congenital defects of the newborn.     

Skin complications in immunosuppressed patients: follow-up of kidney recipients

Thirth-five patients who received thirty-seven kidney transplants (two patients received live; the rest cadaver kidneys) were followed up for skin complications. There were thirty-nine instances of overt skin infection. In twenty-one instances we encountered fungal, in ten pyogenic and in eight viral infection. The course of these infections was more severe and more protracted than is usual in other patients. In nine instances, the skin infection contributed directly to the death of the patient. One patient developed Kaposi's sarcoma and another pyoderma gangrenosum. This study suggests that immunosuppressive treatment, which all our patients were continuously receiving, enhances their susceptibility to infection and to malignancy and may have been an aetiological factor in pyoderma gangrenosum.     

Occupational skin diseases caused by UV radiation

This overview highlights the risk of skin diseases arising in workers exposed to ultraviolet radiation (UVR) at their workplace. There is a plethora of skin manifestations in outdoor workers such as seamen, fishermen, farmers after acute intense or long-term exposure to solar UVR, but some cutaneous diseases may also develop in indoor workers exposed to artificial sources. In recent years, investigations of the biological effects and damage caused by UVB and UVA on the skin have improved our understanding of the cellular and molecular mechanisms of photoaging, skin cancer and other skin diseases caused by UVR exposure. The necessity of primary prevention in workers exposed to UVR is emphasized.     

Eczema herpeticum in three siblings: clinical features and acyclovir treatment

Three atopic siblings with sequential primary herpes simplex virus (HSV) infection on their eczematous lesions following their father's recurrent herpes labialis were presented. Eczema herpeticum was diagnosed on the basis of their characteristic grouped umbilicated vesicles superimposed on pre-existing atopic eczematous lesions. HSV type 1 was identified from the three patients' Tzanck smears and viral isolation of vesicular contents by monoclonal antibodies. The skin lesions faded spontaneously in the first case, although this elder brother did not receive any antiviral treatment. Later, he developed mild recurrence of skin lesions on his extremities. His younger twin sisters were treated with systemic acyclovir and no recurrences occurred during 2 years of follow up. All of them developed anti-HSV antibody about 7 to 14 days after clinical onset. Acyclovir seems to be an effective antiviral agent in treating eczema herpeticum and reducing subsequent recurrences after primary herpes simplex virus infection.     

SPREAD OF TRICHOPHYTON MENTAGROPHYTES VAR. GRAN. INFECTION TO MAN

ABSTRACT: The occurrence of T. mentagrophytes var. gran. infection of small mammals in their natural habitat was studied. The most common host of the exoanthropic mammals was Clethrionomys glareolus (bank vole); the next most common hosts were hemisynanthropes Sorex araneus (common shrew) and eusynanthropes Mus musculus (common mouse). Occurrence of infection increased during the winter months. Because small mammals gather in farm outbuilding during cold weather, man is more likely to be exposed to infection from them during this time. Infection from T. mentagrophytes var. gran. is more likely to occur among agricultural workers than among others. The type of work influences the location of skin infection.     

Dermatologist‐diagnosed skin diseases among immigrant Latino poultry processors and other manual workers in North Carolina,USA

Background Immigrant Latino workers represent an expanding workforce in rural areas of the USA, where their employment is concentrated in occupations such as poultry processing that entail chemical, infectious, and mechanical skin exposures. Occupation‐related skin illnesses in this vulnerable population are not well characterized. Objectives This study was designed to describe the prevalences of skin diseases among immigrant Latino poultry processors and other manual workers in North Carolina. Methods Community‐based sampling was used to recruit 742 immigrant Latino workers, 518 of whom underwent a physical examination supervised by a board‐certified dermatologist. The presence or absence of skin disease on the face, neck, arms, hands, and feet was recorded. Results Workers ranged in age from 18 years to 68 years. Slightly over half of the sample were male (52.6%). Poultry workers represented 55.8% of the study sample. Infectious skin diseases were the most common diagnosis, present in 52.3% of workers. Inflammatory skin diseases were present in 28.2% and pigmentary disorders in 21.8% of workers. The most common skin conditions were tinea pedis (37.6%), onychomycosis (31.9%), scars (13.7%), acne (11.8%), and melasma (9.3%). Age, sex, first language, and work as a poultry processor accounted in part for the prevalence of these diseases. Conclusions Several skin diseases are highly prevalent in immigrant Latino workers and may relate to work environment. These may impair the quality of life of these workers and predispose them to further illness.     

Influence of tumour necrosis factor‐α polymorphism −308 and atopy on irritant contact dermatitis in healthcare workers*

Background. Chronic irritant hand dermatitis is an issue for healthcare workers and may negatively impact infection control. Objectives. We examined the effects of a G to A transition at position ?308 on the tumour necrosis factor‐α (TNF‐α) gene on chronically damaged skin of healthcare workers during exposure and recovery from repetitive hand hygiene, after intensive treatment, and on the irritant response in normal skin. Patients/Materials/Methods. In 68 healthcare workers with irritant hand dermatitis, we genotyped TNF‐α?308 and measured the epidermal response via quantitative digital imaging, erythema, dryness, and barrier integrity. Results. Excess hand erythema decreased with hand hygiene exposure and increased during time off for AA/GA genotypes, but had opposite effects for GG. AA/GA had smaller reductions in dryness with lotion treatment and larger reductions in excess erythema than GG. The atopic diathesis and heightened neurosensory irritation resulting from water and lactic acid significantly influenced the responses. Repeated exposure to water and sodium lauryl sulfate (0.05, 0.1%) produced higher erythema in normal skin for AA/GA than for GG. Conclusions. This study provides evidence that the TNF‐α polymorphism at ?308 and an atopic history impact the severity of irritation and recovery from exposure and response to treatment for common hand skin products in both chronic irritant hand dermatitis and normal skin.     

Cutaneous Complications of BCG Vaccination in Infants with Immune Disorders: Two Cases and a Review of the Literature

Two infants, one with a T-cell-signaling defect resulting in a primary immunodeficiency syndrome and the other with severe combined immunodeficiency (SCID), are described. Both infants developed cutaneous infections secondary to their bacillus Calmette-Guérin (BCG) vaccinations. Both patients were from countries where BCG is routinely administered in infancy. The infant with the T-cell-signaling defect developed a disseminated infection involving the skin, while the infant with SCID developed a localized cutaneous infection at the site of his BCG immunization. These two cases resemble other reported cases of cutaneous BCG infection following routine vaccination in immunocompromised patients. Mycobacterium bovis infection should be considered in patients with cutaneous eruptions who have received BCG vaccination, especially those who are immunocompromised.     

Contact allergy to kojic acid in skin care products

Kojic acid (5-hydroxy-2-(hydroxymethyl)-4-pyrone), a fungal metabolic product, has increasingly been used as a skin-depigmenting agent in skin care products marketed in Japan since 1988. In order to determine its frequency of sensitization, during 1 year from October 1992 to September 1993, we performed patch testing with it in 220 female patients with suspected cosmetic-related contact dermatitis. Of the 220 patients, 8 used at least 1 skin care product containing kojic acid, 5 of whom reacted to kojic acid as well as to 1 or more their own products containing 1% kojic acid, but not to their other products not containing it, and 3 of whom were negative to kojic acid and all their own products. Patch testing with kojic acid in the remaining group of 212 patients, who had not previously used skin care products containing it, was negative without exception. The 5 kojic-acid-sensitive patients, aged 34 to 58 years, developed facial dermatitis 1–12 months after starting application of kojic-acid-containing products. Kojic acid is considered to have high sensitizing potential, as a comparatively high frequency of contact sensitivity was observed in patients using products containing it (5 out of 8).     

Primary cutaneous coccidioidomycosis in agricultural workers.

Each of two Filipino agricultural workers experienced coccidioidal infection, characterized by a solitary skin lesion, by regional lymphadenopathy, and by a benign clinical course, without evidence of involvement of the lungs or other viscera. It is believed that these are cases of primary cutaneous coccidioidomycosis incurred under "natural" conditions. A similar interpretation seems acceptable for at least six other reported cases.     

Self-reported skin symptoms in metal workers

Machinists and machine maintenance men working in the metal industry use metal-working fluids capable of causing irritant and allergic contact dermatitis. The objectives of this study were to find out the frequency of skin symptoms in machinists and machine maintenance men (metal workers) and to compare the risk of their skin symptoms to that in office workers (controls). A total of 726 male metal workers and 84 controls answered a structured telephone questionnaire enquiring about work, atopy, skin symptoms, their impact on life, etc. The risk of skin symptoms compared with that in the controls was estimated using a logistic regression analysis. Of the metal workers, 20% reported recurring or prolonged dermatitis on their hands or forearms during the past 12 months. The hand or forearm dermatitis (HD) affected mostly the metal workers' mood and their activities at work. Recurring dermatitis elsewhere (DE) than in the hands and in connection with work was reported by 10%. The risk of HD was about twofold and the risk of DE was about fourfold compared with that in the controls. The HD of machinists may be severe and affect their ability to work. DE may have clinical significance in machinists.     

Concurrent cytomegalovirus and herpes simplex virus infections in skin biopsy specimens from two AIDS patients with fatal CMV infection

Cytomegalovirus (CMV) infection involving the skin is rare. Only a few cases have been documented by skin biopsies, including three patients with acquired immunodeficiency syndrome (AIDS). We report concurrent CMV and herpes simplex virus (HSV) infections in skin biopsy specimens from nonanogenital sites in two adult AIDS patients with fatal CMV infection. In one case, a nonhealing ulcer on the lower lip provided the first clue to systemic CMV infection. In the other case, two necrotic papules developed on the legs during the course of systemic CMV infection. Microscopically diagnostic findings for both infections were present. Immunoperoxidase stains were positive for CMV in both cases and HSV in one case. In both cases, the infections were not appreciated in the original interpretations of the biopsy material. This may reflect either a low index of suspicion and/or unfamiliarity of the microscopic features of CMV and, to a lesser extent, of HSV infection in the skin. Familiarization with the diagnostic cytopathic changes of these viral infections and a high index of suspicion are essential for correct diagnosis in evaluation of skin lesions of immunocompromised hosts.     

Primary cutaneous aspergillosis

A 6-year-old boy with acute monocytic leukemia and therapy-induced leukopenia developed multiple necrotizing skin lesions where an intravenous administration unit had been secured to his arm and hand. Biopsy and cultures demonstrated Aspergillus flavus as the etiologic agent without evidence of systemic dissemination. Resolution of the infection occurred following systemic amphotericin B therapy and a granulocyte transfusion.     

Irritant cutaneous reactions to N-methyl-2-pyrrolidone (NMP)

Several workers in a small electrotechnical company in Norway experienced irritant reactions of the skin after a few days of working with the solvent N-methyl-2-pyrrolidone (NMP). Due to concern about the health risk of commonly-used organic solvents, the company had chosen to use NMP when one of its products had to be treated with a solvent. After 2 days of work with NMP, 10 of the 12 involved workers displayed acute irritant contact dermatitis of the hands. According to published reports, NMP is not considered to be particularly irritant to the skin. The Safety Data Sheet of a Norwegian sales firm contained no information on cutaneous hazards, but the Safety Data Sheet of an American producer of NMP stated the risk of severe dermatitis upon prolonged contact. NMP seems to be more irritant to the human skin than reported thus far.     

Allergic contact dermatitis from resin hardeners during the manufacture of thermosetting coating paints

5 production operators from 2 factories manufacturing thermosetting coating paint developed work-related skin disorders within 12 months of the introduction of a new powdered paint product. All 5 workers were found to have allergic contact dermatitis from 2 epoxy resin hardeners, both of which were commercial preparations of triglycidyl isocyanurate (TGIC). 2 of the workers had concomitant sensitization to epoxy resin in the standard series and several of the epoxy resin preparations at the workplace. TGIC has been reported as a contact sensitizer both in persons producing the chemical and among end-users of TGIC-containing products. These 5 reported cases document allergic contact dermatitis from commercial TGIC among exposed workers during an intermediate process of powdered paint manufacture. The possibility of substituting this epoxy resin hardener with less sensitizing alternatives should be explored.     

Avoiding unnecessary fragrance-induced pigmented contact dermatitis: the 'pulse point' myth

Molluscum contagiosum is a common viral skin infection in children with atopic diathesis and not rare in HIV patients. We report a 45-year-old psoriasis patient who developed eruptive mollusca contagiosa during an antipsoriatic treatment with efalizumab.     

Molluscum contagiosum infection associated with pimecrolimus use in pityriasis alba

Abstract:  Atopic dermatitis is an inflammatory, chronically relapsing, highly pruritic skin disorder that has considerable impact on the quality of life. As corticosteroids are not ideal for long-term control of the disease because of their potential side effects, steroid-free topical immunomodulators have recently been developed for the treatment of atopic dermatitis. Although clinical trials do not indicate an increased risk of cutaneous infection, the clinician must be careful about viral infections such as eczema herpeticum or molluscum eczema that can be observed during treatment with pimecrolimus and tacrolimus. We report molluscum contagiosum that developed on the preauricular area treated with topical pimecrolimus.