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Abstract: A case of localized argyria in a 36-year-old female jeweler is described who presented with 2 discrete and asymptomatic bluish-black pigmented macules on the pulp of her left middle finger. A skin biopsy from both lesions demonstrated deposition of brown/black pigmented granules along the basement membrane zone of eccrine glands, blood vessels, nerves, and the dermo-epidermal junction fully in keeping with silver deposition. In addition, there was yellow-brown deposition seen within the interstitial dermis mimicking an early form of ochronosis, so called "pseudo-ochronosis." This latter feature is rarely described in cases of argyria. Transmission electron microscopy and energy dispersive x-ray spectroscopy confirmed the presence of electron dense particles up to 150 nm in diameter and the presence of silver, respectively. On further questioning, the patient had a history of localized and chronic exposure to silver, which specifically involved holding and manipulating silver wires and rings over the left middle finger. This case highlights an unusual and rare presentation of localized argyria in a jeweler. In addition, our case showed preferential silver deposition on dermal elastic fibers which has not been previously described in the literature., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a significant health problem globally. The virus has spread widely and become a global pandemic. The pathophysiology for SARS-CoV-2 has not been explained clearly. It has been associated with several multiorgan symptoms, among which its dermatological manifestations are of great interest. Primarily, there has been no report of skin features among COVID-19 patients. Nevertheless, recently there have been several reports regarding COVID-19 patients who presented with cutaneous manifestations. In the current review, we focus on the various cutaneous manifestations of COVID-19 infection., (© 2021 Wiley Periodicals LLC.)

Occupational immune diseases are a serious public health burden and are often a result of exposure to low molecular weight (LMW) chemicals. The complete immunological mechanisms driving these responses are not fully understood which has made the classification of chemical allergens difficult. Antimicrobials are a large group of immunologically-diverse LMW agents. In these studies, mice were dermally exposed to representative antimicrobial chemicals (sensitizers: didecyldimethylammonium chloride (DDAC), ortho -phthalaldehyde (OPA), irritants: benzal-konium chloride (BAC), and adjuvant: triclosan (TCS)) and the mRNA expression of cytokines and cellular mediators was evaluated using real-time qPCR in various tissues over a 7-days period. All antimicrobials caused increases in the mRNA expression of the danger signals Tslp (skin), and S100a8 (skin, blood, lung). Expression of the T H 2 cytokine Il4 peaked at different timepoints for the chemicals based on exposure duration. Unique expression profiles were identified for OPA ( Il10 in lymph node, Il4 and Il13 in lung) and TCS ( Tlr4 in skin). Additionally, all chemicals except OPA induced decreased expression of the cellular adhesion molecule Ecad . Overall, the results from these studies suggest that unique gene expression profiles are implicated following dermal exposure to various antimicrobial agents, warranting the need for additional studies. In order to advance the development of preventative and therapeutic strategies to combat immunological disease, underlying mechanisms of antimicrobial-induced immunomodulation must be fully understood. This understanding will aid in the development of more effective methods to screen for chemical toxicity, and may potentially lead to more effective treatment strategies for those suffering from immune diseases.

Background: Hand eczema is the most common occupational skin disease. The etiology is multifactorial. Systemic alitretinoin, a pan-retinoic receptor agonist, has proven efficacy in the treatment of recalcitrant chronic hand eczema; however, its precise mechanism of action in hand eczema is not fully understood., Aims: Assessment of the level of expression of retinoid receptors (RAR and RXR) in the skin of patients with hand eczema in an attempt to explain their possible role in the pathogenesis of the disease., Methods: Thirty patients with hand eczema and 30 age- and sex-matched healthy controls were included. Full clinical examination was done, and tissue levels of retinoic acid receptor (RAR) and retinoid x receptor (RXR) were measured by quantitative real-time PCR (qRT-PCR)., Results: The levels of RAR and RXR expression were significantly downregulated in the patient group compared to the control group; (P < 0.001) for both. In addition, there was a statistically significant negative correlation between Osnabrück Hand Eczema Severity Index (OHSI) and the levels of RAR and RXR expression (P < 0.001)., Conclusion: Deficient retinoid receptor expression has a primary role in the pathogenesis, clinical phenotype, and severity of hand eczema and sheds light on the mechanism of action of retinoids in the treatment of chronic hand eczema., (© 2020 The International Society of Dermatology.)

Unusual distributions of contact dermatitis often lead to identification of the offending agent. We present a case of unilateral dermatitis of the chest developing in a patient with a history of allergy to metal. A name tag attached magnetically to his work uniform was identified as the cause of the eruption. Unilateral eruption of the chest can be a manifestation of allergic contact dermatitis to metal objects in breast pockets or attached to clothing.

Background: The fishing colony of the Picinguaba neighborhood is located at the northern end of the coast of the state of São Paulo. It has about 300 residents, of which approximately 100 are professional fishermen., Objectives: This study aimed to identify the main dermatoses of the community in comparison with other populations, and their frequency., Methods: The dermatoses were identified and tabulated for two years, in a prospective study carried out on monthly trips to the fishermen's colony in Picinguaba., Results: One hundred and eighteen patients were attended and followed up, which is equivalent to about 1/3 of the colony's inhabitants. Of these, 43 were children (under the age of 14) and 75 were adolescents and adults. The diseases observed were catalogued according to the age groups. Although most dermatoses in the community were similar with those observed in the general population, some specific cases could be seen, such as folliculitis on the legs of fishermen and an unexpected low frequency of actinic lesions in the colony, as well as dermatitis by aquatic animals., Study Limitations: The limitations were monthly attendance and the spontaneous demand of the patients., Conclusions: The finding of community-specific dermatoses and the low incidence of malignant and pre-malignant tumors associated with sun exposure needs further studies for better clarification.

An 11-year-old boy presented with a 1-year history of multiple comedonal lesions distributed over his body. The lesions (Figure 1) were densely distributed throughout his body. Ophthalmologic examination revealed hyperpigmented conjunctival mucosae and enlarged meibomian glands (Figure 2). His nails were also hyperpigmented. In addition, he had been coughing and had a fever, each present for a month. Significant laboratory studies included mild anemia (hemoglobin 11.6 gm%) and leukocytosis of 20,800. A chest x-ray was suggestive of interstitial lung disease. Similar lesions were present on his two siblings and parents. Additionally, his father had developed multiple, acne-like lesions, large abscesses, palmar and plantar peeling, and severe jaundice with hepatic failure. He had a history of frequent exposure to a pesticide mixed with a herbicide, as a result of leakage from a spray container. The patient was diagnosed with chloracne, based on the history, clinical features, and histologic examination.

Milker's nodule is an occupational dermatovirose caused by Parapoxvirus, which is self-limited and, due to the lack of information of health professionals, may lead to underdiagnosis. We present two cases with exuberant manifestations and classic histopathologic findings. Case 1: Male, 19 years of age, milker, presented nodules and blisters on his palm for 15 days. Case 2: Male, 33 years of age, administrative assistant, presented erythematous nodules on his palms with lymphangitis for 5 days. He had milked a cow one week before the onset of the lesions. In both cases, the histopathology was representative and coincident with the clinical hypothesis. The lesions have presented complete involution. Milker's nodule diagnosis is based on clinical presentation, epidemiology, and histopathology. The knowledge of this disease is essential for its correct diagnosis, as well as to guide the implementation of public health measures and the appropriate treatment of sick cattle.

Background: Recently, many cases of acrylate-associated allergic contact dermatitis have appeared among nail salon workers. Common acrylate-containing products in nail salons include traditional nail polish, ultraviolet-cured shellac nail polish, ultraviolet-cured gel nails, and press-on acrylic nails., Methods: Nail salon technicians seen in the occupational medicine clinic in 2015 and 2016 were identified, and their patch test results and clinical features were summarized. Patch testing was done with the Chemotechnique (Meth)Acrylate nail series, and either the North American Standard series or the North American Contact Dermatitis Group screening series., Results: Six patients were identified, all women, ages 38 to 58. Common presentations included erythematous dermatitis of the dorsa of the hands, palms, and forearms and fissures on the fingertips. Less common sites of eruptions included the periorbital region, cheeks, posterior ears, neck, sacral area, lateral thighs, and dorsa of the feet. All patients reacted to hydroxyethyl methacrylate, and 5 patients reacted to ethyl acrylate. Each patient also reacted to (meth)acrylates that are not found on either standard series, including ethyleneglycol dimethacrylate, 2-hydroxypropyl methacrylate, and 2-hydroxyethyl acrylate., Conclusions: The authors report 6 cases of allergic contact dermatitis to acrylates in nail technicians seen over the past year, representing a new trend in their clinic. These cases are reflective of a growing trend of nail technicians with allergic contact dermatitis associated with occupational (meth)acrylate exposure. Efforts to improve prevention are needed.

Fiddler's neck is a common dermatologic condition associated with instrument use in violin and viola players. It typically manifests as a submandibular and/or supraclavicular lesion. It is a benign condition, but it may be mistaken for lymphedema or a salivary gland malignancy. Otolaryngologists who treat patients with fiddler's neck should be aware of appropriate management protocols and the need to avoid surgical excision. We obtained informed consent from 3 violinists to present their cases as specific examples of fiddler's neck. In addition, we present a literature review based on our PubMed search for articles about this instrument-induced dermatitis. The literature suggests that submandibular fiddler's neck is caused by mechanical pressure and shear stress on the skin and that it can present as erythema, scarring, edema, and lichenification. Supraclavicular fiddler's neck, on the other hand, is caused by allergic contact dermatitis, and it can present as an eczematous, scaly, and/or vesicular lesion. In most cases, a good history (especially of string instrument use), physical examination, and a patch test are sufficient to diagnose this condition. Management of fiddler's neck includes a topical steroid, proper instrument handling, neck padding, changing the instrument's materials, and/or reducing the amount of playing time. Surgical excision is usually not advisable.

Review Question/objective: The objective of this quantitative systematic review is to identify, appraise and synthesize the best available evidence on the effectiveness of moisturizers, barrier creams, protective gloves, skin protection education and complex interventions (a combination of two or more of the interventions listed) in preventing occupational irritant hand dermatitis (OIHD) in wet workers. These interventions will be compared to an alternative intervention or to usual care (workers regular skin care regime). The specific review question is: "What is the effectiveness of moisturizers, barrier creams, protective gloves, skin protection education and complex interventions in preventing OIHD in wet workers?"

Background: Mechanic's hands are a well-known symptom often associated with dermatomyositis and are similar to hand eczema clinically. Histopathology of them usually shows hyperkeratosis, focal parakeratosis, psoriasiform acanthosis, basal vacuolar changes and necrotic keratinocytes in the epidermis and upper dermal mucin deposition. However, there have been few comparative histopathologic evaluations of mechanic's hands and palmoplantar eczema., Methods: We evaluated the histopathology of mechanic's hands in 6 patients with dermatomyositis who visited our hospital between 2006 and 2014 comparing with histopathology of 27 patients with palmoplantar eczema, retrospectively., Results: As previously reported, hyperkeratosis, basal vacuolar change and necrotic keratinocytes were seen in all cases of mechanic's hands. Basal vacuolar change was not observed in any cases of palmoplantar eczema. Three cases of mechanic's hands demonstrated a characteristic finding, a pseudocheckerboard pattern, in the hyperkeratotic horny layer; there were areas of alternating parakeratosis and orthokeratosis in a vertical arrangement and these areas alternated with the completely orthokeratotic areas in a horizontal arrangement. This pattern has not been focused in mechanic's hands so far. Same pattern was also observed in four patients with palmoplantar eczema., Conclusion: 'Pseudocheckerboard pattern' was not specific but may be a possible diagnostic clue for mechanic's hands., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background and Objective: Hand dermatitis is the most common subtype of occupation-related skin disease. Regardless of its underlying cause, hand dermatitis results in significant impairment and a negative impact on quality of life. Any case of unilateral hand dermatitis should have a high index of suspicion for an allergic contact dermatitis., Conclusion: We report two cases of unilateral hand dermatitis. The first case is a 53-year-old female with a unilateral dermatitis of the left hand. The second case is a 53-year-old male with dermatitis of the right hand. Both cases highlight an interesting presentation of unilateral hand allergic contact dermatitis secondary to an occupational exposure.

Background: The prevalence of occupational and non-occupational textile dermatitis seems to be increasing, probably because of changed textile manufacturing techniques., Objective: Evaluation of the clinical features and epidemiology of textile contact dermatitis (TCD) in Italy., Methods: Demographic data, clinical history aspects, atopy and positive patch test reactions to occupational and non-occupational allergens were investigated in 277 textile dermatitis patients., Results: Contact dermatitis was the most frequent clinical presentation (95.3%). TCD was more common in females, in the fourth to fifth decades of life, and in atopic dermatitis patients. The lesions were prevalently eczematous (74.2%), and mostly located on the trunk and lower limbs in non-occupational cases, and on the hands in textile workers. Allergic TCD (58.3%) was more frequent than irritant TCD. The dyes (Disperse Blue 124, Disperse Blue 106, and Disperse Yellow 3) were most frequently responsible (79.8%), especially in non-occupational TCD. Formaldehyde and resins were more important in occupational TCD. Concomitant reactions among textile dyes and/or finishing resins were observed in 50.0% of patients., Conclusions: Some strategies (sensitization potential of new textile chemicals, more stable dyes, reduced levels of formaldehyde in clothing, and collaboration with textile industry and trade associations) should be adopted to decrease the TCD incidence and update the textile patch testing series., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Erythema multiforme is a relatively common skin disorder; the most common cause is herpes simplex infection, but topical sensitivities reportedly also provoke this reaction. We report here a case that progressed to toxic epidermal necrolysis due to contact with ultraviolet (UV)-cured inks. The diagnosis was confirmed by patch tests to acrylates in the UV-cured inks, histopathological studies of the lesions, and positive patch test to 1,6-hexanediol diacrylate.

Background: The prognosis of occupational hand eczema is strongly associated with its duration, severity, and the onset of treatment., Objectives: The study was aimed at characterizing skin eruptions that might be potential precursors of occupational hand eczema, their pattern, and typical sites in a population at moderate risk of hand eczema., Patients/materials/methods: Eight hundred German male metal workers took part in a structured interview focused on their medical history combined with a dermatological examination of their hands, by use of the quantitative Hand Eczema Score for Occupational Screenings, with follow-up 1 year later., Results: The most frequent lesions were erythema (91.8%), lichenification (98.8%), crusting (70%), and scaling (35%); all other lesions were relatively rare (15%). The distribution of lesions remained stable between baseline and follow-up. The areas most affected were knuckles, palms, and finger shafts (excluding tips). Interdigital regions were uncommonly affected in this sample., Conclusions: Erythema, lichenification, and crusting, indicating constant skin 'strain', can be regarded as precursor lesions for slight hand eczema, and should be monitored quantitatively. As other occupations, for example hairdressing, have different predilection sites, it can be concluded that the pattern of occupational hand eczema is strongly influenced by the distinct strain profile of an occupation., (© 2011 John Wiley & Sons A/S.)

Elaioconiosis is a work-related acneiform dermatosis which affects the exposed skin of individuals working with oils or greases. Its incidence has decreased with the introduction of personal protective equipment, personal hygiene measures and the cleaning of work clothes. Although not a rare disease, elaioconiosis is seldom reported in the literature, particularly in Brazil. Sufferers need to take time off work to proceed with the prolonged treatment to resolve the lesions caused by this condition.

Background: Skin scoring systems have to meet specific demands depending on their particular settings and indications, e.g. occupational screenings vs. clinical examinations, evaluating progress of treatment or supervision of preventive strategies. Until now, most scoring systems have been developed for severe cases of hand eczema. A validated quantitative scoring system for early hand eczema is still missing., Objectives: The present cross-sectional study was aimed at assessing the practical value of a quantitative hand eczema score for occupational screenings (HEROS) at the workplace and its potential for identifying individuals at increased risk of work-related skin disease., Methods: Both hands of 800 male metal workers were examined for characteristic morphological patterns of hand dermatitis and quantified with HEROS. The score was validated by testing inter- and intraobserver reliability in random samples. Results of validation were compared with three already validated skin scores for distinct hand eczema (Osnabrück hand eczema severity index, hand eczema severity index, Manuscore)., Results: The score values ranged from 0 to 82 (theoretical maximum 2260), reflecting the skin condition of healthy, fit-for-work subjects. Inter- and intraobserver reliability was good to excellent. Results for reliability of the HEROS were in line with all three validated scores for hand eczema. The predictive value for identifying persons at increased risk for developing hand eczema was low., Conclusions: The HEROS seems to be an adequate tool for observer near-independent assessment of early hand eczema, especially for quantifying minimal skin impairment. Therefore, we propose the implementation of this scoring system for quantifying early hand dermatitis in occupational screenings., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Patients having a generalised rash with severe liver dysfunction associated with exposure to trichloroethylene (TCE) have been reported mainly in Asian countries. However, no case has been reported in Japan since the 1990s. Here, we describe a case of hypersensitivity syndrome (HS) caused by TCE in a 30-year-old Japanese man. The patient developed a rash, fever and liver dysfunction 21 days after he had been exposed to TCE at his workplace. Serum human herpesvirus (HHV)-6 and cytomegalovirus (CMV) DNA were detected 4 and 7 weeks, respectively, after the onset; the IgG antibody titres to HHV-6 and CMV were significantly elevated 6 and 9 weeks, respectively, after the onset. Patch testing was positive for the metabolites of TCE (i.e. trichloroethanol, trichloroacetic acid and chloral hydrate) but not for TCE itself; these results suggest that the TCE metabolites induced this disease. Human leucocyte antigen-B*1301, which has been reported to be strongly associated with TCE-induced HS, was identified in this patient. In addition, the clinical findings, laboratory data and period of virus reactivation after onset were quite similar to those of drug-induced hypersensitivity syndrome (DIHS). We also review TCE-induced HS from the viewpoint of the similarity to DIHS in this article., (Copyright 2010 S. Karger AG, Basel.)

A 28-year-old man developed urticaria while he was working in the garage. We suspected contact urticaria, which can be caused by some products used in his field, and we carried out a prick test using his work gloves and shoes. His gloves were orange and black in colour, his shoes were black and white in colour, and the materials they were made of were unknown. The results of the prick test using the gloves and shoes were positive. Gas chromatography/mass spectrometry was applied, and a fluorescent dye was found to be present in his gloves and shoes. The results of a prick test using the fluorescent dye were positive. His urticaria improved after he stopped using these gloves and shoes. This was a rare case of contact urticaria caused by a fluorescent dye in clothing.

Background: Measurements of transepidermal water loss (TEWL) as an indicator of skin barrier function and colorimetry for quantifying erythema have been recommended for monitoring persons at risk of occupational hand dermatitis., Objective: This study examines the practicability and usefulness of biophysical measurements at the workplace. PATIENTS/MATERIAL/METHODS: A sample of 1020 male metal workers was enrolled; 800 participants were followed up for 1 year. TEWL results and colorimetry (a* value), respectively, were used as effectiveness outcomes, comparing the findings in the four study arms (skin care, skin protection, both combined, and control group)., Results: At 1 year follow-up, the TEWL was slightly but significantly lower in the group of participants randomized for application of barrier cream alone, indicating a protective effect. However, addressing both the individual absolute change of a* value and the differences of TEWL (delta-TEWL) of the dominant hand over the study period, no significant difference was found between the four groups., Conclusions: Dermatological examinations at the workplace cannot be replaced by bioengineering techniques. The supplementary benefit is apparently low, possibly because of difficulties in achieving standardized measurement conditions and other technical reasons.

Background: Tetrazepam is a muscle relaxant belonging to the benzodiazepine group. Drug eruptions following ingestion of tetrazepam tablets are well known., Objective: To draw the attention to occupational airborne dermatitis and/or hand dermatitis in nurses resulting from crushing of tablets for elderly or disabled people., Methods: Since 2003, 16 nurses with facial (eyelid) and/or hand dermatitis, suspected to be of occupational origin, were patch tested with the medication they handled during work., Results: Ten nurses presented with a positive patch test reaction to tablets containing tetrazepam, 14 controls remaining negative. Some of them also reacted to other drugs., Conclusion: Occupational airborne and/or hand contact dermatitis from tetrazepam might be much more common than suspected by dermatologists, particularly in view of the short period in which all cases have been observed.

Background: Besides improving working conditions and using personal protective equipment, early detection is most important in managing work-related hand eczema. Implementing regular teledermatological skin screenings could be helpful, but none of the published hand eczema-scores has hitherto been used in teledermatology., Objective: Testing and comparing two validated scores [Osnabrück hand eczema severity index (OHSI); hand eczema severity index (HECSI)] for their suitability in an occupational telemedical screening., Patients/materials/methods: One hundred and twenty photographic records of the hands of 30 male wet workers were examined twice with each score. Results were tested for reproducibility, intra-observer reliability and inter-score-correlation., Results: Examination time, mean score values, and score ranges reached did not differ significantly. The inter-score-correlation was moderate (correlation coefficients: 0.651 for first examination; 0.642 for second examination). In the qualitative assessment, the HECSI showed a better overall agreement between results of first and second examinations., Conclusions: Both scores are suitable for assessing the skin condition in a teledermatological setting. The comparability is limited to qualitative assessment, as the strictly objective OHSI measures the extent of hand eczema and the finer graduated HECSI measures the intensity of hand eczema, adding a subjective component. For assessing minimal skin changes, a scoring system that reduces subjective elements while at the same time it offers a differentiated grading is advisable.

Allergic contact dermatitis to cement is a delayed-type hypersensitivity reaction in which cytokines interferon-gamma (IEN-y) and vascular endothelial growth factor(VEGF) may be involved in persisting erythema and oedema. VEGF and IFN-gamma levels in serum and skin lesions were measured in 32 Egyptian building workers with chronic allergic contact dermatitis due to occupational exposure to cement and 20 healthy controls. Dermatitis patients had significantly higher levels of serum and lesional skin VEGF and IFN-gamma than controls. A significant positive correlation was found between tissue VEGF and the eczema area and severity index (EASI) score in dermatitis patients (r = 0.86). VEGF and IFN-gamma may play a role in the pathogenesis of cement allergic contact dermatitis.

Shiitake (Lentinus edodes) is a mushroom that is very popular in Asian cuisine. After ingestion of the raw fungus, dermatitis may occur in rare cases, and is commonly assumed to be a toxic reaction. We report a 52-year-old man who developed a generalized pruritic papulovesicular eruption 2 weeks after daily consumption of uncooked shiitake mushrooms. Prick-to-prick and scratch tests with uncooked mushrooms resulted in an eczematous reaction at 24 h that peaked at 72 h and persisted for 1 week. In contrast, no cutaneous reactions could be elicited in 20 healthy people. We conclude that our patient had systemic allergic contact dermatitis due to consumption of raw shiitake mushroom.

Airborne contact dermatitis (ABCD) is a commonly occurring form of allergic contact dermatitis with varied aetiology, often posing a diagnostic challenge in management. A study was carried out on patients with a clinical picture and history consistent with ABCD due to exposure to Parthenium hysterophorus (parthenium weed), who were patch tested. There were 50 patients with parthenium-induced ABCD (36 men and 14 women; age range 24-75 years). The majority (90%) of the patients were farmers and most of the patients (74.5%) had exacerbations during summer. The most common type of dermatitis was the classic pattern (46%) followed by the mixed pattern (30%), erythroderma (14%) and chronic actinic dermatitis (10%). Of the 40 cases patch tested with the Indian standard series of antigens, 36 (90%) cases had patch-test results positive for parthenium.