A morbidity study of former pentachlorophenol-production workers.

Pentachlorophenol (PCP) is a pesticide that was once widely used for wood preservation. Commercial PCP contained impurities including higher chlorinated dibenzo-p-dioxins (CDDs) and chlorinated dibenzofurans (CDFs). We investigated the effects of occupational exposure to PCP and its CDD and CDF contaminants on the skin, liver, porphyrin metabolism, and central and peripheral nervous systems. In 1986 we conducted a medical survey of 366 workers who had been engaged in the production of PCP at a single plant between 1938 and 1978. The referent group consisted of 303 workers from the same plant who were not exposed to these or related compounds. Exposure was determined from computerized personnel records. The medical survey included an administered questionnaire, medical record review, physical examination by dermatologists, internists, and neurologists, and analysis of 24-hr urine for quantitative porphyrins among other tests. In this paper we present the results of analyses of the general health, chloracne, and porphyrin metabolism end points. The general health status of PCP workers was similar to unexposed workers, but 17.8% of PCP workers had evidence of current or past chloracne. PCP workers with chloracne had significantly higher mean urinary excretion of coproporphyrins (117. 0 vs. 90.6 microg/24 hr) than unexposed workers after controlling for potential confounders. Workers with chloracne who had worked with both PCP and polychlorinated biphenyls had significantly higher mean urinary excretions of hepta-, penta-, and coproporphyrins than unexposed workers. We conclude that occupational exposure to PCP is associated with chloracne and biochemical abnormalities which may persist years after exposure.

Erythema nodosum associated with all-trans-retinoic acid in the treatment of acute promyelocytic leukemia.

A patient with acute promyelocytic leukemia is presented. During treatment with all-trans-retinoic acid, erythema nodosum developed. Treatment with all-trans-retinoic acid was continued, the erythema nodosum resolved with steroid treatment, and a complete remission was attained. This case is the first report of erythema nodosum associated with all-trans-retinoic acid.

Chloracne. Clinical manifestations and etiology.

Chloracne is a rare but important acneiform eruption often associated with the ingestion of chlorinated phenolic agents such as dioxins with subsequent toxicity from these chemicals. Clinically, chloracne can be distinguished from acne vulgaris by the distribution and appearance of the lesions and by taking a detailed history. In some instances, it may be associated with particularly xerotic skin, pigmentation, follicular hyperkeratosis, conjunctivitis, and actinic elastosis. Histologically, the primary lesion is a follicular plug containing keratinous material. Chloracne is difficult if not impossible to treat adequately and once present, may persist for years. Consequently, good hygiene, safe manufacturing processes so that no inhalation or skin contact is possible, and the elimination of atmospheric contamination are all necessary in the prevention of this potentially debilitating disease.

The lips: anatomy and differential diagnosis.

The lips are composed of striated muscle and connective tissue and are anatomically positioned to be maximally exposed to sunlight, environment, food, and tobacco. A number of topics relevant to the lips are presented, including contact dermatitis, contact urticaria, benign and malignant systemic processes, and the effect of systemically administered pharmacologic agents on the lips.

Histiocytosis X. Flow cytometric DNA-content and immunohistochemical and ultrastructural analysis.

A 76-year-old man developed a generalized orange-red nodular eruption associated with constitutional symptoms. A biopsy specimen of a nodule revealed an extensive infiltration of histiocytes with relatively abundant cytoplasm and folded nuclei. Electron microscopy showed Langerhans' cell granules, which confirmed the diagnosis of histiocytosis X. Results of immunohistochemical studies revealed a pattern of antigen expression usually found in histiocytosis X, including Ia, T6, and S100. Analysis of the DNA content of the cells with flow cytometry revealed an aneuploid peak. The patient responded partially to topical mechlorethamine hydrochloride therapy.

Cutting fluids. Their use and effects on the skin.

Metalworking fluids are liquids that flow or are sprayed over metal that is being altered mechanically or physically. Cutting fluids tend to be alkaline and are often soap-like. As such they denature keratin, defat the skin, and remove water from it, causing dryness, fissures, and frank eczematization. Cutting oil dermatitis is a difficult problem for the involved worker who must continue to support his family despite the presence of this progressive, pruritic, and painful eruption.

Contact dermatitis to yellow iron oxide.

After epicutaneous patch testing, a 43-year-old non-atopic white female with eyelid dermatitis was found to be allergic to yellow iron oxide used as a dye in her mascara. Yellow iron oxide, also known as limonite or yellow ochre, is a common cosmetic dye which has not previously been described as a source of contact dermatitis. Formulation of mascara as well as classification of naturally occurring iron oxides are discussed.

Dermatology in the workplace.

Dermatoses related to the industrial environment are costly and underreported. Contact dermatitis is due to irritants in 75 percent of cases and to true allergy in only 25 percent. Differences between these two types of dermatitis include a longer induction period for allergy. Patch testing may be useful for diagnosis of allergic contact dermatitis. Photoallergy, chloracne, occupational leukoderma and neoplasia are special occupational problems. A precise history and physical examination as well as a visit to the plant are essential elements in evaluating the patient.

Iatrogenic hyperadrenocorticism during topical steroid therapy: assessment of systemic effects by metabolic criteria.

Systemic absorption of topically applied glucocorticoids in quantities sufficient to replace endogenous production is not uncommon. However, iatrogenic Cushing's syndrome resulting from the use of topical corticosteroids is very rare. Thus the possibility that systemic absorption may cause hyperglucocorticism has been deemphasized and examined only sporadically. We have studied changes in carbohydrate metabolism induced by topical glucocorticoids in a psoriatic patient who had developed Cushing's syndrome from topical desoximetasone (Topicort). The results indicated that (1) fasting hyperglycemia and increased insulin-glucose ratios could be induced within 24 hours of administration of topical glucocorticoids, (2) insulin resistance accompanied abnormal carbohydrate tolerance, and (3) fluctuations in circulating leukocytes paralleled the changes in carbohydrate metabolism. The findings suggest that metabolic indexes of glucocorticoid action action may provide useful parameters for assessing systemic absorption of topical glucocorticoids. glucose relationship as one such index to assess the risk of treatment of extensive chronic skin disease with potent topical glucocorticoids.

Dermatitis from transcutaneous electric nerve stimulation.

Transcutaneous electric nerve stimulation (TENS) is an effective treatment modality for chronic pain. Electrical impulses produced by a portable stimulator are transmitted by cable to electrodes which are attached to specific areas of the body by tape or adhesive. A conductive electrolyte jelly is utilized in order to make good electrical contact with the skin. Several dermatologic complications have been associated with the use of this technic, including allergic and irritant contact dermatitis and micropunctate burns caused by the improper use of poorly conductive lubricant jellies. A patient is reported herein who developed allergic contact dermatitis to propylene glycol in a conductive jelly (Neuromod TENS gel). In an attempt to continue therapy, the patient changed to a poorly conductive surgical lubricant jelly which caused irritation and micropunctate burns. Subsequently, electrodes not utilizing conductive jelly were applied, with excellent results.

Persistent photosensitivity caused by musk ambrette.

Persistent photosensitivity developed in a man after use of an after-shave lotion containing musk ambrette. His eruption, present over ligh-exposed areas of the face, the "V" area of the neck, and the dorsa of the hands, has persisted for more than three years despite therapy. The patient demonstrated a minimal erythema after an ultraviolet B dose of 5 s, and was strongly ultraviolet A photosensitive to a 2% musk ambrette solution in petrolatum and to the after-shave lotion that contained musk ambrette. A persistent light reactivity induced by musk ambrette has most likely developed in this patient.

Photosensitivity and Sézary syndrome.

An elderly black man with photosensitivity suggestive of actinic reticuloid, ultimately developed Sézary syndrome, suggesting a relationship between the two conditions. This case illustrates a possible causal role of antigen persistence in the etiology of Sézary syndrome.