Module 4: Skin Management

Operational aspects of industry - Process in work place:

The tasks and process undertaken in the workplace need to be established. What precisely is done during each task and who is involved? To fully understand this, the processes must be observed regularly and workplace assessments form part of the routine occupational health surveillance. The training given to the worker needs to be formalised and re-inforced on a regular basis. A skin risk assessment is thus needed.

Skin risk assessment:

A risk assessment should include an evaluation of raw materials, substances and products, the activities undertaken during the execution of the task and the personnel involved.

In any factory setting the raw materials that are being used need to be listed and a full set of MSDs (for what they are worth) kept handy and available for workers to access at any time. Hazards that are recognised toxins and listed in occupational health and safety acts, are usually identified in MSDs.

As raw materials used in industry are seldom pure, contaminants and additives that are potential hazards for skin disease seldom are listed in MSDs.

Substance bioavailability for each exposure affects the potential to do harm:

• Is the substance a solid, liquid or gas?
• Is the substance present in pure form or as a mixture?
• Is the substance dissolved in a solvent that can aid skin barrier penetration?
• Is the substance dissolved in a solvent that can damage the skin barrier function?

The routes of exposure also affect the potential to do harm:

• Is the worker constantly exposed via the open skin surfaces to gas, fumes or vapours?
• Is the worker exposed through contamination of work clothes or PPE?
• Is the worker exposed by immersion?

Activity assessment should include a full appreciation of the task being undertaken and a complete knowledge of all substances used in its execution. Ideally the worker should be observed while executing the task to identify unexpected exposures due to personal behaviour - no two workers carry out a task in exactly the same way.

Risk assessment should include the worst-case scenario. By asking the question, "what if" during a work assessment, one will not miss unexpected exposures that are not immediately obvious.

Knowledge of all substances to which a worker is exposed during a task implies those hazards in the raw products, mixtures, intermediates of production and final products can be identified and included in the risk assessment.

While engineering can eliminate most exposures in a work environment, the one process that is not guaranteed is personal behaviour. Workers are often placed in tasks with little understanding of the exposures and hazards involved. No athlete would be expected to run a marathon without training. Management would not fail to service and maintain their personal cars. Unfortunately this same logic is not applied to the worker, leading to poor management of a huge slice of capital investment. Personal behaviour, the use of personal protective equipment and respect for colleagues and others in the environment, all influence the potential for exposure and hence the development of skin disease.

One needs to observe workers at work when conducting a workplace assessment. This allows for the unexpected to be included as, despite written task prescriptions, what is actually done may be very different. Unfortunately tasks are often designed and prescribed by people who do not do the work and so the recorded task may not be the same as what is practised in the workplace, the worker modifying it to suit personal needs.

Ongoing training and reminders need to be posted to limit exposures.

Having undertaken a good evaluation of the workplace, one next needs to evaluate the probability of an exposure occurring and the significance of that exposure. A risk rating for each exposure is needed in order to identify the potential for involvement in a skin disease. While this seems good theoretically, the time required for its execution makes it impractical. Very little work has been done to develop good, practical, skin risk rating assessments. Mr Chris Packham of EnviroDerm Service has developed such a rating and this can be found on his website http://www.enviroderm.co.uk. My approach is more pragmatic and practical. Being a good observer is usually sufficient to provide risk identification for a particular problem in the work place. Furthermore many skin diseases are the consequences of multiple exposures and insults. If this is not recognised, no risk rating system will lead to problem solution.

Engineering controls:

Having identified hazards or potential hazards these should be engineered out of the workplace in the best way possible. This can often be done inexpensively if practicality is introduced by getting advice from the workers. Issuing personal protective equipment must be seen as the last resort to solving an exposure problem.

The first level of hazard management is to remove the risk. Elimination of the hazard means that it has to be removed, substituted with something less toxic or the process changed, so that exposure does not occur. If the identified hazard cannot be replaced or substituted or the process modified then one has to reduce the risk by introducing control of the process.

The second level of hazard management is to control the process, rather than trying to control the way in which the workers perform the task.

If there is a potential for exposure, it is best to automate the process rather than relying on a worker to execute it correctly and avoid exposure. Always operate to account for the "what if," worst scenario, to reduce the risk of exposure.

Should personnel be a necessary requirement to perform the task, the task should be carried out under confined, and enclosed conditions with limited handling of the product to limit exposure and thus risk. Very often many of these process controls are in place but exposure occurs because of a small, overlooked design fault, such as loading a hopper or cleaning the machinery after use or for maintenance.

If a hazard cannot be eliminated from an environment and if exposure cannot be prevented by engineering controls so that some exposure of the worker is inevitable, the next level of unreliable exposure management is to control the worker. Adopting such a strategy is itself a hazard as there are often various workers assigned to a task on different shifts, all of whom have their own personal preferences for executing the task and these lead to unexpected exposures.

The use of personal protective equipment is a last resort and as soon as it is needed a further hazard is introduced into the environment.

Personal hygiene and ablution facilities are essential at this level of control.

The last level of control is to limit the effect of exposure. This represents a failed skin management programme.

Regular surveillance of workers in a workplace allows for early detection of skin disease. Limiting exposure frequency of the worker and the duration of exposure also reduces the risk of a skin disease occurring in a particular individual.

Finally, personnel must be well educated as to the risks involved in a particular task and the hazards of exposure. This needs to be an ongoing process for the regular workforce and part of task orientation for intermittent, temporary or new employees.

No hazard management should rely on PPE to prevent exposure. Please refer to the section on gloves for a more in-depth discussion of the problems associated with the choice and use of PPE and of their performance limitations.

The use of personal protective equipment is a last resort control measure in any good skin management programme. PPE should not be seen as a panacea for prevention and management of skin diseases. PPE should provide backup protection in the event of an accidental exposure.

Aspects of problems associated with the choice and use of PPE and of their performance limitations that need to be accounted for in any risk assessment and skin management plan are listed here as a reminder.

If gloves fail, barrier crèmes almost certainly will.

Barrier crèmes are at best the equivalent of emollients and form part of a skin-care plan. Simple emollients work as well as barrier crèmes. There have been multiple papers in the journals showing that barrier creams have no specific function except in certain circumstances where special products have been engineered to bind and inactivate specific chemicals, reducing exposure on contact.

Barrier crème use introduces further hazards or hazard modifications. Barrier crèmes may cause degradation of the glove material and increase exposure. The crèmes might act as reservoirs for hazardous substances and thereby increase the risk rather than preventing it. The crème constituents might be irritants or allergens.

In Conclusion:

A good skin management programme should be in place in the work environment, not a simple skin-care programme as it ensures an overall approach that will prevent skin diseases and toxicity.

Skin disease prevention should receive the same attention as noise induced hearing loss or respiratory disease by ensuring an effective management programme is in place.