Office environment

ELSEVIER

OfSice Environment JAN E. WAHLBERG,

MD

T

he classical occupational dermatoses allergic and nonallergic contact dermatitis, chloracne, skin tumors, and so forth arose chiefly in heavy industry, manufacturing, the building industry, agriculture and forestry, and in health and medical care. Thanks to various prophylactic measures-both primary and secondary-such as predictive testing before the introduction of new chemicals and products, concentration limits on the use of contact allergens, examination as a part of job appointment procedures, automation, the development of more reliable protective gloves, and so forth, these diseases in the industrial world have become increasingly manageable, controllable, and treatable. During the past few decades we have noted an appreciable increase in the office sector in the volume and numbers of people engaged. In the industrialized world today, more than half the working population are employed in this sector, a current figure for Sweden being 80%. Exposure is essentially different from that in the manufacturing industry and the other areas mentioned above; and the sources of skin complaints most frequently discussed are paper, computers and other electrical equipment, building materials, climatic conditions (temperature, humidity, ventilation), and stress. The intention of the present survey is to give an account of our experience with the panorama of complaints, their investigation, treatment, and prevention among people working in offices and referred to our clinic for occupational skin disease at the Karolinska Hospital. A summary of relevant literature is included. Review articles regarding skin trouble among office workers have been published earlier.l-4

manifestations in other skin regions are seldom related to the work environment. There are several complaints pertaining to the skin which are related to the office environment. These are presented in Table 1. The most common complaints by our patients are unspecific irritation of the skin and the mucous membranes, often combined with general symptoms. Objective findings are small or nonexistent. Exacerbation in individuals with earlier-diagnosed atopic dermatitis and a number of common, nonoccupationally-related skin diseases are also rather frequent among the patients referred to our clinic. Irritant contact dermatitis among individuals without atopic constitutions is uncommon among our patients. Allergic contact dermatitis and photosensitive contact eczema acquired primarily in an office environment are rare; however, exacerbations have been observed in individuals with earlier known contact allergies.

Skin Complaints Among Office Workers-a Survey

Paper and Contact Allergy to Colophony

Women are clearly overrepresented among those presenting with skin complaints associated with office work.5 This is probably because more women than men work in subordinate positions in offices, but women are also said to be more susceptible. The absolutely most common location is the face, followed by the hands;

From the Department of Occupational and Environmental Dermatology, Karolinska Hospital and National Institute for Working Life, Stockholm, Sweden. Address correspondence to Dr. Jan E. Wahlberg, Department of Occupational Dermatology, Karolinska Hospital, SZ7176 Stockholm, Sweden.

0 1997 by Elsevier Science ltzc. 655 Avenue of the Americas, New York,

NY 10010

Allergic Contact Dermatitis Allergic contact dermatitis caused primarily by chemicals or products in the office environment are rare in our patient population. Examples of such products are glues and ink dyes. Far commoner are exacerbations in nickel allergies following contact with scissors, paper clips, hole-punching machines, nickel-containing parts of office machines, drawer handles, and the like. Contact with erasers, rubber bands, rubber sponges, and fingerstalls can cause exacerbation in individuals with known contact allergy to rubber chemicals. Thiourea in photocopying paper can give rise to contact allergy and photosensitivity.6-s

Extensive studies at our department have identified the most important contact allergens in colophony (rosin) and their clinical relevance following exposure to various materials and products.g-I3 The handling of paper (writing paper, copying paper, fax paper, self-copying paper, wrapping paper, envelopes, newspapers, cardboard boxes, etc) is widespread in the office environment. We have observed no convincing case where paper handling in an office induced colophony allergy; however, we have seen cases of allergic contact dermatitis on the basis of colophony allergy and in which paper handling was a contributory cause.11-13 Following re0738-082X/97/$32.00 PI1 50378.08lX(97~00060-6

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Table 1. Complaints and Skin Diseases Among Ojjice Personnel-an Overview Condition

Time Period

“Epidemic”

Frequency

Allergic contact dermatitis Irritant contact dermatitis Photo contact dermatitis Symptoms from skin and mucous membranes, sometimes accompanied by general symptoms Deterioration in individuals with history of atopic dermatitis Impetigo, scabies, urticaria, psoriasis, pustulosis, and so forth; incorrectly blamed on the office environment

IL3 lx! Uncommon Rarf Common

1970s 1980s

Carbonless copy paper ilziCR) Repetitive strain injury (Ii!3 Mainly in Australia Visual displav terminals (VD’T, Mainly in Sweden and Norway 7 ~__ ~-._-_-__-.--..

19805, ‘1990s 1990s and 2000s

Not

uncommon

‘\“cR = 110inutw

V’Dl.‘i

requmd.

Not uncommon

Symptoms From the Skin and the Mucous Membranes ‘The most common group of office employees referred

duction of contact with paper and the use of cotton gloves when reading newspapers, the eczema tended to heal. In testing known colophony allergies with moistened paper “as is,” we have not noted any positive test reactions. With paper extract (in acetone, ethanol or water), positive reactions have been obtained,“-‘3 and with more advanced chemical methods the frequency of positive patch-test reactions to paper material can probably be increased. Further aspects of test methods for use in the investigation of skin complaints in office staff are given below.

Irritant

Contact Dermatitis

The office environment includes a number of products that may conceivably cause skin irritation, for example glues, correcting liquid, solvents, cleaning solutions for typewriters (keys and types), carbon paper, duplicating machines, and toner in copying machines. The handling of large volumes of paper, sorting, bundling, packaging, and so forth can cause friction wear on the skin, particularly the palms. Airborne paper dust can irritate the mucous membranes, but if it can also cause irritant contact eczema is unclear. Irritant contact dermatitis is an exclusion diagnosis, for which reason the evidence that a given material or product has caused the eczema is relatively weak; however, patch testing is recommended so as to exclude elements of contact allergy (see below). Where the patch-test result is negative the course (improvement) consequent upon reduced handling supports the diagnosis of irritant contact dermatitis. If the patient then worsens during “normal” handling, the connections with various materials may be analyzed. Regarding irritant contact dermatitis in individuals of an atopic constitution, see below.

for assessment comprises those with symptoms from the skin and the mucous membranes. The symptoms most often reported are pricking sensations, burning, redness, and dry complexion. There is a discrepancy between reported symptoms and objective signs of skin disease, Redness can be a component of many common skin diseases, and represents no diagnosis in itself. Several patients report the simultaneous occurrence of irritation in the mucous membranes (eyes, lips, mouth, and throat) and general symptoms such as headache, fatigue, concentration difficulties, palpitations, and difficulties in getting to sleep; however, these are unspecific and most frequently hard to record and evaluate objectively. Certain of these symptoms are also reported as parts of various syndromes that have gained increasing attention during the past few decades;iJ these include multiple chemical sensitivity, environmental illness, 20th-century illness, chronic fatigue syndrome, sickbuilding syndrome, galvanism, and so forth, and there is probably a certain amount of overlapping. Patients who initially have skin symptoms in association with office work may thus later develop symptoms that fit better with one or more of the syndromes listed. Here, however, skin symptoms seldom appear to be included initially; and when they do occur, they are described as relatively mild (dryness, redness, irritation). The first large “epidemic” in Sweden with this configuration of symptoms (Table 2) occurred at the end of the 1970s and was blamed upon self-copying paper. Despite very extensive investigation, no certain cause of the complaints could be demonstrated, but solvents were suspected. Contact allergy to the ingredients in the paper was excluded.‘5--1h The epidemic gradually ebbed, and whether this was because the manufacturers changed the composition or the ingredients of the paper is unclear. No casewith this picture has been referred to us during the past five years.

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Terminals

Skin problems among the users of visual display terminals (VDTs) were reported at the beginning of the 1980s from Norway and Sweden. Patient materials, possible causes, treatment and prevention have been reported on continuously. ‘7-20The literature includes three doctoral dissertations from Sweden, in which relevant literature is reviewed and commented upon.21-23 Regarding the causes, discussion continues, and after 10 years disagreement still prevails. The causes discussed range from physical, that is, “radiation” and various electromagnetic fields from VDT screens,24via chemical (flame-retardant material) to psychological explanation mechanisms.25-26In this connection the concept of “technostress” has been launched.27

Diagnostics As mentioned, the skin symptoms are unspecific; and inspection and palpation give no help. In our earlier investigations we found that many patients referred to us had well-known skin diseases such as rosacea, seborrhoeic dermatitis, acne, and atopic eczema that flared in connection with the use of VDT (computer) screens. It has not been possible to determine the relative importance of screens for the conditions; and in the office environment, a number of other factors also contribute and probably act together, for example, climatic factors such as temperature and relative humidity, paper and paper dust, ventilation, tobacco smoke, cleaning, potted plants, and stress. It was initially thought that certain histological peculiarities could be demonstrated in skin biopsies from VDT-screen patients, but further controlled studies failed to verify this preliminary findings28

Provocation

Studies

Sophisticated provocation studies have been conducted “blind,” so that neither the patient nor the investigator knew whether the VDT screen was switched on. So far none of about 140 provoked subjects has been able to distinguish whether the apparatus was switched on, that is, the complaints appeared regardless of the electromagnetic fields, which militates against physical causes; however, in an open provocation study, changes were demonstrated with immunohistochemistry.Z9

“Electrosensitivity” A number of Swedish patients have developed what is termed “electrosensitivity.” They experienced initial skin symptoms, which gradually decreased and in some cases disappeared entirely. Instead, they developed symptoms such as fatigue, headache, concentration difficulties, palpitations, and difficulties in getting

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Table 3. Skin ComplaintsAmong Office Personnel-Contributorsto SomeRecent“Evidemics” Medical profession Mass media Unions Workers’ compensation

to sleep on contact with electrical apparatus. While the complaints were most pronounced in the office environment, they also appeared later at home, where they were related to telephones; radios; television sets; cookers, toasters, and other kitchen machines; and car batteries. They also appeared in outdoor environments such as trains and near electric power cables. The patients, who were severely handicapped, elected to move to the forests, live in tents or caravans, and use candles for lighting. They have received much attention in the media.

Atopic

Dermatitis-worse

in the Office

Various factors that can induce irritant contact dermatitis have been reported above. A particularly vulnerable group comprises those who have or have had atopic dermatitis, and there is a risk that this may flare up in the office environment. Chemical products, paper and paper dust, friction, climatic factors, and stress are present; and their relative importance is hard to specify in the individual case. Wet work is relatively rare in the office, and compared with cleaning and work in the kitchen and in health care, a transfer to office work often brings an improvement of atopic dermatitis. Definitive healing cannot be promised, however, since exacerbating factors are also present in offices.

Non-Office-Related

Skin

Diseases

The large numbers employed in the office sector, together with other factors (Table 3) make it easy to relate skin diseases to the work environment. Cases of urticaria, scabies, impetigo, psoriasis, pustulosis, warts, and the like have been referred, and the patients have been anxious and fully convinced that some kind of exposure in the office has caused their skin complaint. Rapid attention, diagnosing and differential diagnosing, and treatment, are a top priority in these cases. A single case in an office can create anxiety, with the result that colleagues also feel threatened and the “contagiousness” can be pronounced. In these cases we normally request the company medical officer to refer the index case and the 2-3 colleagues with the most pronounced symptoms. Rapid attention usually stops these incipient “epidemics.”

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4. Recommended Investigations to be Carried out at Vepartmetzts of Dermatology 0~ Occupational Dermatology

Table

Patch tests Prick, scratch, and/or rub tests, including controls Provocation tests, including placebo IgE, RAST tests Photographic pictures-taken repeatedly Biopsy, cultivations and so forth for differentat diagnoses

-

Investigations Apart from customary, detailed record keeping and clinical examination to allow diagnosis if possible, a number of tests and other investigations are recommended (Table 4).

Patch Tests Patch testing is important both diagnostically and differential-diagnostically. As stated (Table l), allergic contact dermatitis induced by factors in the work environment is rare. Frequently, however, cases with facial skin complaints that have been related to the office environment have turned out to be contact allergies to materials such as nail polish, mascara, perfume, colophony, flowers such as primulas, or herbicides.“” Apart from the standard panel tests with paper and paper extracts, glues, soaps and other cleaning preparations, and with the patient’s own cosmetics, nail polish, after shave lotion, and so forth are recommended. Concerning tests with paper and paper extracts, see above.

Prick, Scratch, and Rub Tests Prick, scratch, and rub testing have been used to a limited extent on suspicion of paper as the cause of skin complaints in office staff. For “positive” reactions it is important to test controls also, since the specificity of scratch and rub tests in the investigation of paper has not been sufficiently investigated.

Provocation

Specialists in allergy and immunology, ear, nose, and throat (ENF1. occupational medicine Experts in epidemiology Experts on questionnaire investigations Information on electrical equipment, temperature, humidity, ventilation, building materials, smoking, cleansing, flowers, herbicides, and so forth -.--

positive, but in the majority it has not been possible to reproduce the symptoms. An exposure chamber is being constructed at our clinic, and we hope with its help to elucidate what proportion of given symptoms it is possible to verify under controlled conditions. More sophisticated methods such as hormone-secrrtion determination before and after exposure and the use of different objective recording methods, (laser Doppler, corneometer, temperature recording) have also been tried.27

IgE, RAST, arzd Prick Tests IgE, RAST (radioallergosorbent test), and prick tests are used to elucidate elements of atopy in the disease-picture; and they are of special value when discussing differential diagnoses.

Objective Recording

Photographing)

of Skiit Charzges

As already stated, there is often in this patient category a discrepancy between subjective complaints and objectively recordable skin changes. We have found it of value to take photographs of relevant skin areas. These have then been used to discuss whether there has been a worsening or an improvement between consultations.

Skin Biopsies, Cultivation Investigation Methods

and Other Deumatologicai

Skin biopsies, cultivation, and other methods are used as in a general dermatological clinic, and they are of value chiefly in differential diagnosis.

Tests

Provocation tests in the investigation of VDT-related skin complaints have been touched upon above and have hitherto proved negative. They are well standardized and controlled with blind techniques and the negative outcome is considered to depend on the absence of connections rather than defective methods. It is important to run this type of test to gain experience of its value in the investigation of skin complaints among office workers. Where paper is suspected as the cause of the skin complaint, we have encouraged patients to bring relevant material to the clinic and there, under careful observation, to do the same work tasks as at their workplace. In some casesthe provocation test has been

Consultations As mentioned, the patients also present with symptoms from other organs; and knowledge of dermatology and occupational dermatology is sometimes insufficient. Table 5 lists other expertise we have called upon in selected cases.

Specialists Depending on what organ-apart from the skin-from which the patient has symptoms, the following specialists are consulted: ear, nose, and throat; allergy and immunology; and/or occupational medicine. As the patients often have concurrent mucous membrane complaints, this is important; because they are not satisfied

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with a dermatological consultation alone. The cases are then discussed during joint rounds.

are particularly hard to treat, and a number Sweden have gone on sick pension.

Epidemiologists

Historical

As several cases are often referred from the same workplace, it is important to establish whether or not there is an excess risk of skin complaints. Adequate control material must be obtained, and epidemiological expertise is then of great value.

Several “epidemics” have occurred among office workers, and examples are given in Table 2. The handling of self-copying paper was suspected during the 1970s of occasioning skin and mucous membrane complaints; and we devoted extensive resources in an attempt to map a possible connection (see above). “Repetitive strain injury” referred to shoulder and arm trouble among office employees in Australia, and is an example of how extensive an epidemic can become and what consequences it has.s5 Skin complaints associated with VDT work and “electrosensitivity” have been mentioned above. Work at computer screens in offices constituted the first exposure that started the epidemic. The problems have still not been solved, even though the skin symptoms are not so predominant as in the initial phase. One may wonder why this type of “epidemic” occurs only in individual countries, even though millions of office workers all over the world work at computer screens every day. Table 3 presents some of the elements contributing to the “epidemics” that have occurred in such extensive proportions. No percentage figures are given, since the relative significance of different actors probably varies from case to case. What the medical profession can do is offer rapid care and investigation and, where necessary, refer cases to specialists to allay anxiety and prevent the “epidemics” having an uncontrolled course. In the reporting, findings must be well grounded and checked, while hypotheses on possible connections should be avoided since the media and others (Table 3) tend to select uncritically.36,37 During the 1990s we in Sweden had a fairly small “epidemic” of skin complaints and other symptoms, following exposure to “green diesel” fuel,38 and we must have the preparedness to deal with any new epidemics that may appear (Table 2).

Questionnaires To pick up the cases and examine whether or not there is an excess risk, adequate questionnaires must be produced.31 Here advice from experts in such matters is required, and the questionnaire must be tested in pilot studies. Wrongly formulated questions in a survey of this kind can cause damage, create anxiety, and prevent useful conclusions from being drawn.

The Physical Environment at an Ofice Workplace We have found it of value-often through a safety engineer-to obtain detailed written reports on the office workplace. Particulars have been obtained as to whether the referred patient has had a room of her/his own (area?) or works in a landscape office; what electrical machines are present (computers, printers, faxes, telephones, internal telephones, copying machines, typewriters, calculators etc); lighting (point or ceiling illumination); temperature; relative humidity; ventilation; smoking; wall-to-wall carpeting; cleaning frequency; flowers; herbicides; and the like. In addition, sorts of paper, glues, skin cleaning preparations, and emollient creams used at the workplace have been reported.

Treatment Visible skin changes and defined dermatoses are treated according to accepted dermatological principles. In “low-humidity dermatoses,” raising the air humidity and the use of emollient creams are recommended 32,33 Decontamination of the patient’s workplace via the company health-care service, safety engineer, or equivalent, in which all electrical apparatus is grounded, less frequently used electrical apparatus moved out from the work room, lighting adjusted, ventilation and cleaning improved, and temperature checked, often alleviates the subjective complaints. Whether this is because of the steps taken or the psychological aspects-that the individual feels noticed and looked after-cannot be verified with any objective method. Other more unconventional methods of treatment such as psychological talks and acupuncture have also been tried.r4,z4 Individuals with symptoms of “electrosensitivity”

of these in

Aspects

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21. Koh D, Goh CL, Jeyaratnam J, et al. Dermatologicai symptoms among visual display unit operators using plasma display and cathode ray tube screens. Ann Acad Med 1990;19:617-20. 22. Koh D, Goh CL, Jeyaratnam J, et al. Dermatologic corn plaints among visual display unit operators and office workers. Am J Cont Derm 1991;2:136-7. 23. Berg M. Facial skin complaints and work at visual display units. Epidemiological, clinical and histopathological studies. Thesis. Acta Derm Venereol (Stockh) 1989;Suppl1.50. 24. Bergqvist U. Health problems during work with visual display terminals. Thesis. Arbete och Halsa 1993;28:1-59. 25. Stenberg 8. Office illness. The worker, the work and the workplace. Thesis Umea University Medical Dissertations 1994;No 399:1-53. 26. Elektriska och magnetiska fait och halsoeffekter. Rapport fran Socialstyrelsen 1995;1(English summary):203-4. 27. Berg M, Arnetz BB, Liden S, et al. Techno-stress. A psvchophysiological study of employees with VDU-asso& ated skin complaints. J Occup Med 1992;34:698-703. 28. Berg M, Hedblad M-A, Erhardt K. Facial skin complaints and work at visual display units. A histopathological study. Acta Derm Venereol (Stockh) 1990;70:216-20. 29. Johansson 0, Hilliges M, Bjornhagen V, et al. Skin changes in patients claiming to suffer from “screen dermatitis”: a two-case open-field provocation study. Exp Dermatol 1994;3:234-8. 30. Liden C. Contact Allergy: A cause of facial dermatitis among visual display unit operators. .4m J Cont Derm 199@;1:171--6. 31. Berg, M. Evaluation of a questionnaire used in dermatnlogical epidemiology. Discrepancy between self-reported symptoms and objective signs. Acta Derm Venerenl (Stockh) 1991;Suppl 156:13-7. 32. Rycroft RJG, Smith WDL. Low humidity occupational dermatoses. Contact Dermatitis 1980;6:488-92. 33. White IR, Rycroft RJG. Low humidity occupational dermatosis-an epidemic. Contact Dermatitis 1982;8:287-90. 34. Arnetz RR, Berg M, Anderzen I, et al. A nonconventional approach to the treatment of “environmental illness”. J Occ~~p Environ Med 1995;37:838-44. 35. Ferguson DA. “RSI”: putting the epidemic to rest. Med j Austr 1987;147:213-14. 36. Colligan h4J, Murphy LR. Mass psychogenic illness in organizations: An overview. J Occup Psycho1 1979;52:7790 37. Boxer PA. lndoor air quality: A psychosocial perspectne. J Occur Med 1990;32:425-8. 38. Wahlberg JE. “Green diesel”-skin irritant properties of diesel oils compared to common solvents. Contact Der-~ matitis 1995;33:359-60.