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Skin complaints in buildings with indoor climate problems
Environment International, VoL15, pp. 81 - 84, 1989 Printed in the U.S.A. All rightsreserved.
0160-4120/89 $3.00 +.00 Copyright O1989 Pergamon Pressplc
SKIN COMPLAINTS IN BUILDINGS WITH INDOOR CLIMATE PROBLEMS B. Stenberg Department of Dermatology, Ume~iUniversity,S-901 85 Ume~i,Sweden E187-416 (Received 4 November 1987; Accepted I May 1989)
The Sick Building Syndrome (SBS), as defined by the World Health Organization (WHO), is a combination of both common and unspecific symptoms. Few studies have been published with detailed descriptions of clinical findings. One of the few dermatological references with a close relation to sick buildings is the so-calleki "low humidity occupational dermatoses." Since 1982, an increasing number of outpatients from buildings with indoor climate problems have been investigated at the Department of Dermatology in UmeA, Sweden. The most common findings regarding work-related diseases have been seborrheic dermatitis, facial erythema, periorbital eczema, rosacea, urticaria, and "itching folliculitis." It is suggested that physical, chemical, and psychological factors are of importance in producing these symptoms.
INTRODUCTION
dermatological symptoms in SBS, however, is disputable. In some reports, such symptoms are not included. During the past six years, an increasing number of patients have boon referred to the UmeA clinic from different workplaces where indoor air problems have been reported by the local medical service. Since the clinical findings tend to fall into a small number of well-defined groups, this report summarizes the findings with the hope of providing some guidance for further studies of skin symptoms reh, ted to indoor air quality.
Since the 1970s, work-related skin symptoms appearing in the office environment have been reported with greater frequency. Working with carbonlesscopy paper has been cited as a common cause of muco sal, dermatological, and general symptoms. Only occasionally has an immunological mechanism been proven. Calnan (1979) has reviewed typical findings related to working with carbonless-copy paper. Eye, nose, and throat irritation; dermatitis of the face and hands; irritation and dryness of the lips; and headache and drowsiness are typical symptoms. Symptoms that Calnan believed were of toxic nature were most often noticed in workplaces where large amounts of paper were handled in small, warm, badly ventilated rooms. Simultaneously, another phenomenon with very similar symptoms was identified, and the building itself was said to be the cause. This phenomenon has appeared under different names, with the "sick building syndrome" (SBS) being the most commonly used. SBS, as defined by WHO (1983), is characterized by irritation of mainly the upper airways and eyes; dry and ¢rythematous skin; and systemic symptoms such as headache, nausea, and fatigue. The presence of
MATERIAL AND METHODS
Clinical investigations of 77 outpatients from seven workplaces during the period 1982 to 1986 will be reported. The reasons for referring patients to the UmeA clinic include complaints and symptoms related to work within a certain building or part of a building. Patients have been investigated both at the clinic and at their place of work. Patients with eczema had patch tests for standard and office allergens performed. Standard allergens include about 20 substances that are known to be common causes of contact allergy, e.g., rubber chemicals, metals such as 81
82
B.Stenberg
nickel, cobalt, and preservatives such as formaldehyde. Office allergens include chemical substances in paper, photo copying processes, and printing inks. In some cases, biopsies have been taken to confirm diagnoses. Technical investigations will be discussed only briefly here, since they were performed by the local medical service. In all cases, the ventilation system and climatic conditions such as temperature and relative humidity have been checked. A varying number of chemical analyses have been carried out, as have airborne fungal spore counts. In order to estimate the relation of work to symptoms, patient histories have been used as a guide. In some cases, the results of sick leave have been recorded. The investigated buildings are four office buildings, one museum, one newspaper office (composing room), and one hospital. The patients are predominantly females, but in one building (a police office) only males were affected. Most patients also suffered from other symptoms, mainly eye, nose, and throat irritation; headache; and fatigue.
The scaling dermatitis of the scalp and outer ears is suggestive of seborrheic dermatitis and in some eases other typical areas, i.e., the central part of the face, eyebrows, and eyelids, were affected. Facial erythema has been found mostly in the flushing area on cheeks, chin and on the sides of the neck. Rosacea is a disease characterized by facial erythema, ectatic small blood vessels, papules, and pustules. "Itching folliculitis" is a relapsing, itching, ache-like rash appearing mostly on the upper chest and back (Back et al. 1985). Patch testing did not in any case disclose contact allergy as a cause of symptoms. All investigated buildings were mechanically ventilated, and utilized a heat exchanger. The results of the technical investigations are briefly summarized below.
Building No. 1 (office). This building suffered extensive water damage when it was new. High water content in the concrete construction was recorded when symptoms started to appear. Self-leveling putty was removed. High indoor temperature and odour problems were reported, as was low supply airflow rates.
RESULTS
Building No. 2 (office) Since this building was occupied for use, repeated water damage due to a leaking roof has occurred. Odour problems were reported. Recently, the building was examined thoroughly as part of a research
The clinical findings are listed in Table 1. According to patient histories, these symptoms are clearly related to work. In most cases, the symptoms diminished at sick leave.
Table 1. Skin symptoms related to buildings with indoor climate Clinical findings in referred patients. Building No.
I
N~ of employees N& of p a t i e n t s examined
problems.
2
3
4
5
6
7
90
108
30
46
13
54
9
15
18
11
7
6
16
4
5
2
6
3
2
2
No of patients f o r each diagnosis Diagnosis Scaling d e r m a t i t i s of scalp, ears and face (seborrheic dermatitis) Facial erythema P e r i o r b i t a l eczema
13 5 4
Rosacea Urticaria/pruritus 'Itching folliculitis'
2
10
2 11
1
2
7
1 1
Skin problems from indoor climate
project. Supply airflow rates were normal in most rooms. The amount of return air was found to be up to 50% under summer conditions because of leakage from the closed return air valve. This condition had probably been present since the ventilation system was installed.
Building No. 3 (museum) In some rooms, mould spore counts were high enough to explain three cases of allergic alveolitis. The staff complained of too high and too low indoor temperatures during the summer and winter. No details are known about the ventilation system but it was reported to be "not satisfactory" by the local medical service. Building No. 4 (hospital) Building No. 4 has water damage from a leaking roof. Supply airflows were 25 to 50% lower than expected. Building No. 5 (office) This building has a high indoor temperature. The spreading of odours from different workplaces within the building was explained by the shunting of exhaust air into the supply air intake.
Building No. 6 (newspaper office) The building's rooms were mainly supplied by return air, since the supply air intake valve was stuck in the closed position.
Building No. 7 (office) A too high supply air temperature led to a short circuit under the roof, resulting in a very poor mixture of air. Supply airflow rates were too low. Wall paint was still "sticky" four years after painting. The climatic conditions were normal for this part of Sweden during the study period. Since Umea is situated 305 km south of the Arctic circle, the relative humidity of indoor air is often as low as 10 to 20% during the wintertime. In only one case was a chemical substance identified as a possible source of symptoms. This was in the newspaper office, where a mounting wax was suspected to play a pathogenetic role in the symptoms recorded. Typical complaints could be provoked at the clinic using wax from the workplace. Blind provocations with used wax produced symptoms in repeated tests, whereas unused wax did not. It was concluded that substances contaminating the wax were one reason for the complaints. Later provocations have shown
83
that symptoms can be induced by photochemicals contaminating the wax. In most cases, symptoms and complaints diminished when the ventilation system was corrected. Most patients felt that the symptoms grew worse during the wintertime. In one Case (a hospital building), however, an investigation was carried out in January, and a follow-up was conducted in May. In spite of the climatic changes between the investigation periods, no changes in clinical findings were noted. Psychological factors were considered in every case, but since the buildings were not subject to research projects, it is not possible to comment on whether such factors were of a magnitude different from other workplaces. DISCUSSION This study's findings indicate that the clinical symptoms in persons suffering from SBS are more complex than those included in the WHO definition. Since an acceptable etiological and pathogenic explanation for this syndrome has not yet been found, it is impossible to state today exactly which symptoms should be included in the syndrome. It is possible that different combinations of symptoms exist and that the present study sees a different spectrum of the SBS complex since patients reaching the Ume~ clinic are selected due to dermatological symptoms. Facial erythema, which is a common finding, has a complex background. It can be provoked by nervous, hormonal, psychological, chemical and physical stimuli. Therefore, psychological stress as well as chemical compounds and indoor temperature might stimulate this symptom. In rosacea, erythema is supposed to be a primary change; this means that rosacea might be a secondary skin reaction to erythema provoking factors (Wilkin 1983). This might also be the case for facial eczema in individuals suffering from erythema who have a disposition for eczema. The periorbital localization of eczema that is noted might not be of any pathogenetical interest. It can be a reflection of the fact that periorbital skin is highly reactive. However, sometimes it is a sign of manually handled substances being brought to the eyes by the fingers. Seborrheic dermatitis has a complex etiology where climatic conditions, such as dry air, may be aggravating. Psychological stress is a well-known provocative factor. It is of special interest that patients with this disease have a tendency to develop facial erythema as well (Burton et al. 1986).
84
There is strong evidence that "itching folliculitis" is caused by a yeast, Pityrosporum ovale, but there is no acceptable explanation for this disease appearing as a work-related problem (Back e t a l . 1985). Climatic changes impacting sebum production, as well as psychological stress, are only hypothetical causes. Urticaria and pruritus are common conditions that are mostly of a nonimmunological nature. Climate conditions, such as dry, warm air, and psychological stress are plausible factors that could aggravate, and even sometimes provoke, these symptoms. The fact that eye irritation, pruritus, facial erythema, and headaches could be provoked by contaminated mounting wax indicates that chemical factors are also able to provoke most of the symptoms of SBS. Based on provocation studies, and as far as is known, the possible culprit is rarely found in "sick buildings." In most cases, the evidence for a defined single factor is circumstantial. In reports in 1980 and 1982, Rycroft e t a l . described "low humidity occupational dermatoses" in some workplaces where the relative humidity had been lowered dramatically. The symptoms included scaling of the scalp, ears, and face; facial erythema; and pruritus and urticaria on areas covered by clothes (Rycroft and Smith 1980; White and Rycroft 1982). These findings are very much in agreement with the present study. Still, low humidity is not considered to be the only explanation of the symptoms in patients. In fact, very low relative humidity is a normal state in this part of Sweden, and no dramatic changes in climate had taken place in the buildings studied. Although an important factor, winter climate is not considered to be the main cause of these symptoms. At first glance, there seems to be little consistency among buildings in the skin symptoms reported. However, the number of cases in each building is quite small and, therefore, the variation is highly dependent on variations in individual disposition for skin disease. From this viewpoint it is probably most beneficial to look at the total spectrum of symptoms. After all, it might have been expected that the variation would be greater if the findings reflected only a normal prevalence of skin disease. For example, no cases of psoriasis, which otherwise would have been expected, were seen. Later investigations of two of the buildings (No. 1 and No. 2) where a greater proportion of the employees were examined have verified the clinical picture already described above. At this point, epidemiological studies are of importance to find out the normal prevalence of the
B.Stenberg
symptoms described. If buildings with raised prevalences of symptoms of statistical significance can be identified, it would be of great interest to look for correlations to specific chemical, physical, and psychological work environmental factors. This might lead investigators to the mechanisms for these symptoms. An extensive epidemiological study designed to answer some of these questions was started in northern Sweden in 1988 and will be completed in 1990. The importance of inadequate ventilation, exposure to paperwork, and VDU work is being studied. The fact that skin symptoms are not reported in some studies may not reflect the absence of such signs. Since the construction of questionnaires highly influences the results, the lack of reported symptoms may be a reflection of the fact that too little is known about clinical skin signs of indoor air problems. It is the present study's hope that this report will contribute to more accurate questioning. Quite recently, a new "outbreak" of skin disease related to office work has appeared in Sweden; skin rashes related to VDU work have been reported (Liden and Wahlberg 1985a, 1985b; Stenberg 1986). Since these findings are in part in agreement with what has been related to "sick buildings," this problem is clearly gaining even more interest. REFERENCES Burton, J.L.; Rook, A.; Wilkinson, D.S. Eczema, lichen simplex, erytroderma and prurigo. In: Textbook of Dermatology, Rook, A.; Wilkinson, D.S.; Ebling, F.J.; Champion, R.H.; Burton, J.L., eds., BlackweU Scientific Publications, Oxford; 1986. BAck, 0 4 Faergemann, J.; H0rnqvist, R. Pityrosporum folliculitis: a common disease of the young and middle-aged. J. Amer. Acad. Dermatol. 12:56-61; 1985. Calnan, C.D. Carbon and carbonless copy paper. Acta Dermatovenet. (Stockh.) 59, suppl. 85:27-32; 1979. Lid6n, C.; Wahlberg, J.E. Work with video display terminals among office employees: dermatologic factors. Scand. J. Work Environ. Health 11:489-493; 1985a. Lid6n, C.; Wahlberg, J.E. Does visual display work provoke rosacea7 Contact Derm. 13:235-241; 1985b. Rycroft, R.J.G.; Smith, W.D.L. Low humidity occupational dermaroses. Contact Dcrm. 6:488-492; 1980. Stenberg, B. A rosacea-like skin rash in VDU-operators. In: Work with display units 86. Knave, B.; Wideblick, P.-G., eds. Amsterdam, North Holland; 1987, p. 160-164. White, I.R.; Rycroft, RJ.G. Low humidity occupational dermatosis - an epidemic. Contact Derm. 8:287-290, 1982. WHO. Indoor air pollutants: Exposure and health effects. EURO Reports and Studies 78. World Health Organization, Copenhagen, Denmark; 1983. Wilkin, J.K. Rosacea. Int. J. Derm. 22:393-400; 1983.
0160-4120/89 $3.00 +.00 Copyright O1989 Pergamon Pressplc
SKIN COMPLAINTS IN BUILDINGS WITH INDOOR CLIMATE PROBLEMS B. Stenberg Department of Dermatology, Ume~iUniversity,S-901 85 Ume~i,Sweden E187-416 (Received 4 November 1987; Accepted I May 1989)
The Sick Building Syndrome (SBS), as defined by the World Health Organization (WHO), is a combination of both common and unspecific symptoms. Few studies have been published with detailed descriptions of clinical findings. One of the few dermatological references with a close relation to sick buildings is the so-calleki "low humidity occupational dermatoses." Since 1982, an increasing number of outpatients from buildings with indoor climate problems have been investigated at the Department of Dermatology in UmeA, Sweden. The most common findings regarding work-related diseases have been seborrheic dermatitis, facial erythema, periorbital eczema, rosacea, urticaria, and "itching folliculitis." It is suggested that physical, chemical, and psychological factors are of importance in producing these symptoms.
INTRODUCTION
dermatological symptoms in SBS, however, is disputable. In some reports, such symptoms are not included. During the past six years, an increasing number of patients have boon referred to the UmeA clinic from different workplaces where indoor air problems have been reported by the local medical service. Since the clinical findings tend to fall into a small number of well-defined groups, this report summarizes the findings with the hope of providing some guidance for further studies of skin symptoms reh, ted to indoor air quality.
Since the 1970s, work-related skin symptoms appearing in the office environment have been reported with greater frequency. Working with carbonlesscopy paper has been cited as a common cause of muco sal, dermatological, and general symptoms. Only occasionally has an immunological mechanism been proven. Calnan (1979) has reviewed typical findings related to working with carbonless-copy paper. Eye, nose, and throat irritation; dermatitis of the face and hands; irritation and dryness of the lips; and headache and drowsiness are typical symptoms. Symptoms that Calnan believed were of toxic nature were most often noticed in workplaces where large amounts of paper were handled in small, warm, badly ventilated rooms. Simultaneously, another phenomenon with very similar symptoms was identified, and the building itself was said to be the cause. This phenomenon has appeared under different names, with the "sick building syndrome" (SBS) being the most commonly used. SBS, as defined by WHO (1983), is characterized by irritation of mainly the upper airways and eyes; dry and ¢rythematous skin; and systemic symptoms such as headache, nausea, and fatigue. The presence of
MATERIAL AND METHODS
Clinical investigations of 77 outpatients from seven workplaces during the period 1982 to 1986 will be reported. The reasons for referring patients to the UmeA clinic include complaints and symptoms related to work within a certain building or part of a building. Patients have been investigated both at the clinic and at their place of work. Patients with eczema had patch tests for standard and office allergens performed. Standard allergens include about 20 substances that are known to be common causes of contact allergy, e.g., rubber chemicals, metals such as 81
82
B.Stenberg
nickel, cobalt, and preservatives such as formaldehyde. Office allergens include chemical substances in paper, photo copying processes, and printing inks. In some cases, biopsies have been taken to confirm diagnoses. Technical investigations will be discussed only briefly here, since they were performed by the local medical service. In all cases, the ventilation system and climatic conditions such as temperature and relative humidity have been checked. A varying number of chemical analyses have been carried out, as have airborne fungal spore counts. In order to estimate the relation of work to symptoms, patient histories have been used as a guide. In some cases, the results of sick leave have been recorded. The investigated buildings are four office buildings, one museum, one newspaper office (composing room), and one hospital. The patients are predominantly females, but in one building (a police office) only males were affected. Most patients also suffered from other symptoms, mainly eye, nose, and throat irritation; headache; and fatigue.
The scaling dermatitis of the scalp and outer ears is suggestive of seborrheic dermatitis and in some eases other typical areas, i.e., the central part of the face, eyebrows, and eyelids, were affected. Facial erythema has been found mostly in the flushing area on cheeks, chin and on the sides of the neck. Rosacea is a disease characterized by facial erythema, ectatic small blood vessels, papules, and pustules. "Itching folliculitis" is a relapsing, itching, ache-like rash appearing mostly on the upper chest and back (Back et al. 1985). Patch testing did not in any case disclose contact allergy as a cause of symptoms. All investigated buildings were mechanically ventilated, and utilized a heat exchanger. The results of the technical investigations are briefly summarized below.
Building No. 1 (office). This building suffered extensive water damage when it was new. High water content in the concrete construction was recorded when symptoms started to appear. Self-leveling putty was removed. High indoor temperature and odour problems were reported, as was low supply airflow rates.
RESULTS
Building No. 2 (office) Since this building was occupied for use, repeated water damage due to a leaking roof has occurred. Odour problems were reported. Recently, the building was examined thoroughly as part of a research
The clinical findings are listed in Table 1. According to patient histories, these symptoms are clearly related to work. In most cases, the symptoms diminished at sick leave.
Table 1. Skin symptoms related to buildings with indoor climate Clinical findings in referred patients. Building No.
I
N~ of employees N& of p a t i e n t s examined
problems.
2
3
4
5
6
7
90
108
30
46
13
54
9
15
18
11
7
6
16
4
5
2
6
3
2
2
No of patients f o r each diagnosis Diagnosis Scaling d e r m a t i t i s of scalp, ears and face (seborrheic dermatitis) Facial erythema P e r i o r b i t a l eczema
13 5 4
Rosacea Urticaria/pruritus 'Itching folliculitis'
2
10
2 11
1
2
7
1 1
Skin problems from indoor climate
project. Supply airflow rates were normal in most rooms. The amount of return air was found to be up to 50% under summer conditions because of leakage from the closed return air valve. This condition had probably been present since the ventilation system was installed.
Building No. 3 (museum) In some rooms, mould spore counts were high enough to explain three cases of allergic alveolitis. The staff complained of too high and too low indoor temperatures during the summer and winter. No details are known about the ventilation system but it was reported to be "not satisfactory" by the local medical service. Building No. 4 (hospital) Building No. 4 has water damage from a leaking roof. Supply airflows were 25 to 50% lower than expected. Building No. 5 (office) This building has a high indoor temperature. The spreading of odours from different workplaces within the building was explained by the shunting of exhaust air into the supply air intake.
Building No. 6 (newspaper office) The building's rooms were mainly supplied by return air, since the supply air intake valve was stuck in the closed position.
Building No. 7 (office) A too high supply air temperature led to a short circuit under the roof, resulting in a very poor mixture of air. Supply airflow rates were too low. Wall paint was still "sticky" four years after painting. The climatic conditions were normal for this part of Sweden during the study period. Since Umea is situated 305 km south of the Arctic circle, the relative humidity of indoor air is often as low as 10 to 20% during the wintertime. In only one case was a chemical substance identified as a possible source of symptoms. This was in the newspaper office, where a mounting wax was suspected to play a pathogenetic role in the symptoms recorded. Typical complaints could be provoked at the clinic using wax from the workplace. Blind provocations with used wax produced symptoms in repeated tests, whereas unused wax did not. It was concluded that substances contaminating the wax were one reason for the complaints. Later provocations have shown
83
that symptoms can be induced by photochemicals contaminating the wax. In most cases, symptoms and complaints diminished when the ventilation system was corrected. Most patients felt that the symptoms grew worse during the wintertime. In one Case (a hospital building), however, an investigation was carried out in January, and a follow-up was conducted in May. In spite of the climatic changes between the investigation periods, no changes in clinical findings were noted. Psychological factors were considered in every case, but since the buildings were not subject to research projects, it is not possible to comment on whether such factors were of a magnitude different from other workplaces. DISCUSSION This study's findings indicate that the clinical symptoms in persons suffering from SBS are more complex than those included in the WHO definition. Since an acceptable etiological and pathogenic explanation for this syndrome has not yet been found, it is impossible to state today exactly which symptoms should be included in the syndrome. It is possible that different combinations of symptoms exist and that the present study sees a different spectrum of the SBS complex since patients reaching the Ume~ clinic are selected due to dermatological symptoms. Facial erythema, which is a common finding, has a complex background. It can be provoked by nervous, hormonal, psychological, chemical and physical stimuli. Therefore, psychological stress as well as chemical compounds and indoor temperature might stimulate this symptom. In rosacea, erythema is supposed to be a primary change; this means that rosacea might be a secondary skin reaction to erythema provoking factors (Wilkin 1983). This might also be the case for facial eczema in individuals suffering from erythema who have a disposition for eczema. The periorbital localization of eczema that is noted might not be of any pathogenetical interest. It can be a reflection of the fact that periorbital skin is highly reactive. However, sometimes it is a sign of manually handled substances being brought to the eyes by the fingers. Seborrheic dermatitis has a complex etiology where climatic conditions, such as dry air, may be aggravating. Psychological stress is a well-known provocative factor. It is of special interest that patients with this disease have a tendency to develop facial erythema as well (Burton et al. 1986).
84
There is strong evidence that "itching folliculitis" is caused by a yeast, Pityrosporum ovale, but there is no acceptable explanation for this disease appearing as a work-related problem (Back e t a l . 1985). Climatic changes impacting sebum production, as well as psychological stress, are only hypothetical causes. Urticaria and pruritus are common conditions that are mostly of a nonimmunological nature. Climate conditions, such as dry, warm air, and psychological stress are plausible factors that could aggravate, and even sometimes provoke, these symptoms. The fact that eye irritation, pruritus, facial erythema, and headaches could be provoked by contaminated mounting wax indicates that chemical factors are also able to provoke most of the symptoms of SBS. Based on provocation studies, and as far as is known, the possible culprit is rarely found in "sick buildings." In most cases, the evidence for a defined single factor is circumstantial. In reports in 1980 and 1982, Rycroft e t a l . described "low humidity occupational dermatoses" in some workplaces where the relative humidity had been lowered dramatically. The symptoms included scaling of the scalp, ears, and face; facial erythema; and pruritus and urticaria on areas covered by clothes (Rycroft and Smith 1980; White and Rycroft 1982). These findings are very much in agreement with the present study. Still, low humidity is not considered to be the only explanation of the symptoms in patients. In fact, very low relative humidity is a normal state in this part of Sweden, and no dramatic changes in climate had taken place in the buildings studied. Although an important factor, winter climate is not considered to be the main cause of these symptoms. At first glance, there seems to be little consistency among buildings in the skin symptoms reported. However, the number of cases in each building is quite small and, therefore, the variation is highly dependent on variations in individual disposition for skin disease. From this viewpoint it is probably most beneficial to look at the total spectrum of symptoms. After all, it might have been expected that the variation would be greater if the findings reflected only a normal prevalence of skin disease. For example, no cases of psoriasis, which otherwise would have been expected, were seen. Later investigations of two of the buildings (No. 1 and No. 2) where a greater proportion of the employees were examined have verified the clinical picture already described above. At this point, epidemiological studies are of importance to find out the normal prevalence of the
B.Stenberg
symptoms described. If buildings with raised prevalences of symptoms of statistical significance can be identified, it would be of great interest to look for correlations to specific chemical, physical, and psychological work environmental factors. This might lead investigators to the mechanisms for these symptoms. An extensive epidemiological study designed to answer some of these questions was started in northern Sweden in 1988 and will be completed in 1990. The importance of inadequate ventilation, exposure to paperwork, and VDU work is being studied. The fact that skin symptoms are not reported in some studies may not reflect the absence of such signs. Since the construction of questionnaires highly influences the results, the lack of reported symptoms may be a reflection of the fact that too little is known about clinical skin signs of indoor air problems. It is the present study's hope that this report will contribute to more accurate questioning. Quite recently, a new "outbreak" of skin disease related to office work has appeared in Sweden; skin rashes related to VDU work have been reported (Liden and Wahlberg 1985a, 1985b; Stenberg 1986). Since these findings are in part in agreement with what has been related to "sick buildings," this problem is clearly gaining even more interest. REFERENCES Burton, J.L.; Rook, A.; Wilkinson, D.S. Eczema, lichen simplex, erytroderma and prurigo. In: Textbook of Dermatology, Rook, A.; Wilkinson, D.S.; Ebling, F.J.; Champion, R.H.; Burton, J.L., eds., BlackweU Scientific Publications, Oxford; 1986. BAck, 0 4 Faergemann, J.; H0rnqvist, R. Pityrosporum folliculitis: a common disease of the young and middle-aged. J. Amer. Acad. Dermatol. 12:56-61; 1985. Calnan, C.D. Carbon and carbonless copy paper. Acta Dermatovenet. (Stockh.) 59, suppl. 85:27-32; 1979. Lid6n, C.; Wahlberg, J.E. Work with video display terminals among office employees: dermatologic factors. Scand. J. Work Environ. Health 11:489-493; 1985a. Lid6n, C.; Wahlberg, J.E. Does visual display work provoke rosacea7 Contact Derm. 13:235-241; 1985b. Rycroft, R.J.G.; Smith, W.D.L. Low humidity occupational dermaroses. Contact Dcrm. 6:488-492; 1980. Stenberg, B. A rosacea-like skin rash in VDU-operators. In: Work with display units 86. Knave, B.; Wideblick, P.-G., eds. Amsterdam, North Holland; 1987, p. 160-164. White, I.R.; Rycroft, RJ.G. Low humidity occupational dermatosis - an epidemic. Contact Derm. 8:287-290, 1982. WHO. Indoor air pollutants: Exposure and health effects. EURO Reports and Studies 78. World Health Organization, Copenhagen, Denmark; 1983. Wilkin, J.K. Rosacea. Int. J. Derm. 22:393-400; 1983.