Keywords

1 Core Messages

  • A multifactorial etiology is common.

  • Posttraumatic eczema may persist and recur for a long time.

  • Friction is the most common cause of physical irritant contact dermatitis.

  • Frictional dermatitis can be seen in all trades, from office workers to craftsmen.

  • Post-traumatic eczema may be associated with endogenous dermatosis or be idiopathic.

2 Introduction

The skin is normally flexible and can resist mechanical trauma to a certain degree. Excessive friction or superficial skin injuries such as abrasions, pressure, stretching, compression, and cuts may affect the integrity of the skin and lead to symptomatic skin changes. These may, if not counteracted properly by protective measures such as use of gloves, develop into disease (Elsner 2007). Multiple job categories, from office workers to craftsmen, carry a risk of mechanical trauma to the skin and subsequent development of physically induced skin disorders. In the clinic, dermatitis patients may complain that their eczema appeared after an injury to the skin. Although coincidental in some cases, mechanical trauma can precipitate symptomatic skin disease and lead to post-traumatic eczema that persist or recur for long periods of time (Mathias 1988; Greiling et al. 2014). Furthermore, patients with preexisting skin disease may experience localized aggravation of the disorder as a consequence of mechanical trauma to the site. If a dynamic relationship between mechanical trauma end the development of hand eczema is made probable, it has important medical implications when the injury is job related. Clinical features associated with mechanical insults to the skin include (Samitz 1985):

  • Lichenification

  • Hyperpigmentation

  • Hyperkeratosis/calluses

  • Fissuring

  • Blistering/friction injury

  • Increased susceptibility to infections

  • Increased susceptibility to irritants and contact allergens

  • Development of foreign body reactions

  • Traumatic tattoos

  • Pressure urticaria

  • Scars and keloids

  • Cutaneous neoplasms

  • Koebner’s phenomenon (psoriasis) from friction

  • Raynaud’s phenomenon from vibration

This chapter focuses on occupational skin diseases caused by friction and mechanical insults. Darrell S. Wilkinson has previously reviewed dermatitis from repeated trauma in a broader perspective (Wilkinson 1985).

3 Individual Factors

Only a minor fraction of individuals exposed to repetitive mechanical stimuli develop physical irritant contact dermatitis. In addition to the ambient environment, it is likely that genetic factors play a role in determining the response of the skin to mechanical strain. Exacerbation of atopic dermatitis and psoriasis (both partly inheritable skin diseases) may occur after mechanical trauma. In some patients, contact dermatitis resolves in spite of continued exposure to an irritant, in a phenomenon known as “hardening” or “accommodation” (Watkins and Maibach 2009). Why these adaptive alterations are only seen in some exposed individuals remains unknown. However, physiological factors such as the hydration of the skin are important. Moderate sweating hydrates the corneal layer and increases the coefficient of friction, whereas dry or wet skin diminishes the friction of resistance (Pedersen and Jemec 2006; Schürer and Dickel 2007). Regarding injuries, neurological diseases may impair the withdrawal response to mechanical stimuli and lead to increased risk of injury of the skin.

4 Causes and Frequency of Disease

By convention, traumatic injuries result from single and brief episodes of cutaneous exposure and a subsequently rapid onset of skin ailment. This is opposed to irritant cutaneous reactions which most often require multiple and prolonged exposures and show a relatively delayed onset of the disorder. Mechanical stress also significantly affects the barrier properties of the skin measured by transepidermal water loss and capacitance (Pedersen and Jemec 2006).

Figure 1 summarizes the distribution of occupational injury and illness cases in the US private industry in 2015. Cuts, lacerations, and punctures constituted close to 10% of injuries, while skin diseases constituted about 15% of all registered illnesses. However, several studies have found trends suggesting both an underestimation of, and regular increase in, the frequency and gravity of observed skin diseases (De Craecker et al. 2008). Contact dermatitis comprises around 95% of all recognized occupational skin diseases. In a Danish study among 1500 cases with recognized occupational contact dermatitis, mechanical irritation was ranked as the fifth most common irritant exposure in relation to occupation (Carøe et al. 2014). Among patients diagnosed with physical irritant contact dermatitis, friction has been found to be the most common causal exposure, and the hands are the primary body site most often affected (Morris-Jones et al. 2002). Regarding skin injuries, common complications include scar formation, infection, persistent pain, and contact dermatitis from topical drugs used for treatment. Further, local eczema may also appear and is common, particularly in susceptible individuals such as amputees (Meulenbelt et al. 2007).

Fig. 1
figure 1

Distribution of occupational injury and illness cases in the US private industry in 2015 Source: U.S. Bureau of Labor Statistics, U.S. Department of Labor, October 2016 (https://www.bls.gov/iif/oshwc/osh/os/osch0057.pdf)

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5 Hand Eczema Following a Mechanical Injury

Post-traumatic eczema is a poorly understood complication of skin injuries caused by thermal or chemical burns, lacerations, punctures, or abrasions. The interval between the trauma and the development of eczema is usually a few weeks. Mathias (Mathias 1988) divided post-traumatic eczema into two types: It may occur in association with an underlying endogenous dermatosis (isomorphic reaction of Koebner’s phenomenon) or occur as an isolated idiopathic reaction, when longtime follow-up shows that no new lesions develop on nontraumatized skin. “Koebner’s phenomenon” is a term applied when the dermatosis develops at the site of trauma (Weiss et al. 2002). It is well known in relation to psoriasis but also occurs in other conditions, such as lichen planus, vitiligo, Darier’s disease, and discoid lupus erythematosus. Isomorphic reactions may also be seen in patients with eczema during its active phases. The isomorphic reaction may be the primary manifestation of an endogenous eczema, and probably more frequently, it occurs as a secondary eczema at the site of trauma. The clinical features of post-traumatic eczema are indistinguishable from other types of hand eczema. Often, it presents within a few weeks of the acute injury as a discoid or nummular eczema with or without vesicles around the site of trauma (Beukers and van der Valk 2006). The trauma itself causes obvious damage accompanied by inflammation and regeneration. Fissures, pain, and itching may be pronounced to varying degrees. The post-traumatic eczema may become chronic. The differential diagnoses include noneczematous skin diseases associated with Koebner’s phenomenon, foreign body reactions, bacterial infections, herpes simplex, and secondary allergic contact dermatitis to topical preparations.

6 Hand Eczema Following Repeated Friction

Repeated minor mechanical trauma to the skin such as friction, pressure, abrasion, puncture, and shearing forces can cause a variety of skin changes including dermatitis. Dermatitis from friction affects only a small proportion of exposed individuals, depending on constitutional factors and special patterns of exposure. However, frictional dermatitis may often go unrecognized (McMullen and Gawkrodger 2006). The effects of mechanical forces may as well be accentuated by other physical agents such as heat, cold, and vibration.

In a few cases, frictional dermatitis may develop into chronic hand dermatitis. The frictional dermatitis may be elicited by highly variable exposures. These include small metal parts, paper and cardboard, driving, fabrics, and other items with a rough surface not immediately visible to the naked eye such as counter tops (Menne 1983). Although the various materials are often handled frequently over longer periods of time, duration from onset of exposure to development of frictional dermatitis can be highly variable, ranging from weeks to years (Bennike et al. 2016).

A Swedish field study among carpet installers revealed that over years, they develop hyperkeratosis on their knuckles and dorsal aspects of the hands as a result of repeated trauma to the skin from friction and pressure (Wahlberg 1985). Similar clinical findings have been described in shoemakers (Mancuso et al. 1996). In more recent years, frictional hand dermatoses caused by occupational use of personal computers (PCs) have been reported, often characterized by lichenified lesions (Corazza et al. 2016). In some manual labor occupations, mechanical injuries may be an aggravating factor, which together with constitutional factors and exposure to irritants and allergens intensify the degree of hand eczema. Meneghini has previously reported that contact allergy is more prevalent among workers who have sustained cuts, abrasions, and other mechanical injuries compared to those who have not (Meneghini 1985). Further, a Swedish study of 853 hard-metal workers suggested that the traumatic, frictional effect of grinding and etching was an important factor in the development of cobalt allergy (Fischer and Rystedt 1983).