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Common Dermatoses and Predisposing Factors in Food Handlers in a

University Campus: A Cross-sectional Study

Alexis Paula D. Ibañez, Patricia Anne Nicole O. Ramirez, Ma. Angela M. Lavadia

Department of Dermatology, East Avenue Medical Center, Quezon City, Philippines

Keywords: food handlers, occupational skin disease.

Abstract: Behind food industries are the food handlers that thoroughly prepare the meals we consume on a daily basis.

Food and food preparation activities are noted to be a cause of skin conditions. Since dermatoses are often

multifactorial in origin, the various contributing factors to disease can be difficult to determine. The

objectives of this study are to describe the demographic characteristics of food handlers, identify the

common dermatoses seen and possible inherent individual factors, work-related events and external triggers

in the workplace that contribute to the common skin conditions. A prospective cross-sectional study was

done. 160 food handlers participated in this study. All went to the UP Health Service and underwent a

complete dermatologic history and physical examination, and managed accordingly. The most common

diagnoses of food handlers are xerosis, post-inflammatory hyperpigmentation (PIH) secondary to burn,

melasma, chronic hand dermatitis and verruca plana, atopic dermatitis and dermatophytoses. Melasma, solar

lentigenes, dermatosis papulosa nigra and compound nevus were significantly associated to sun exposure.

Exposure to cleaning agents was significantly associated with xerosis, chronic hand dermatitis and acne

vulgaris. Food handlers exposed to heat were significantly associated with PIH secondary to burn. Skin

disease has a large number of factors instrumental in the development and progression of disease. All food

handlers should be encouraged to report all potential work-related dermatoses and seek consult for full

evaluation by a physician. Further research on occupational skin disease is vital towards improving

environmental and occupational research in the Philippines.

1 INTRODUCTION

Food is a basic necessity. With this, the food service

industry is and will always remain in high demand.

Behind the various food industries in our country are

the food handlers that thoroughly prepare and

deliver the meals we consume on a daily basis and

they play a paramount role in ensuring food safety

and prevention of food poisoning. Food handlers in

the University of the Philippines Diliman (UPD) are

present in basically every building in the university.

They can be seen in various food establishments,

restaurants, cafeterias, indoor and outdoor food

stalls, and even on the streets pushing food carts or

carrying baskets of their products. And due to the

number of students they cater to, efforts have been

established to ensure food safety management

procedures. Hence, it is imperative to examine them

for any sign of disease that could predispose to the

spread of infection, as contamination of food may

progress into an outbreak.

A significant proportion of occupational disease

is accounted for by occupational contact dermatitis.

Several studies have stressed the frequency of these

dermatologic conditions in food handlers. However,

the National Institute of Occupational Safety and

Health still emphasized that there has been relatively

scarce occupational studies to establish a clear

connection between the occupational setting and the

cutaneous presentation. This is important as

measures could be done to be able to assist workers

who have developed skin conditions that commonly

afflict them for the rest of their lives. Therefore,

there continues to be a need to further research on

this subject as local studies have not been made.

2 METHODS

A prospective cross-sectional study on the common

skin conditions in food handlers was conducted at

the University of the Philippines Diliman Health

Service (UPHS). 160 food handlers working at the

262

Ibañez, A., Ramirez, P. and Lavadia, M.

Common Dermatoses and Predisposing Factors in Food Handlers in a University Campus: A Cross-sectional Study.

DOI: 10.5220/0008155302620266

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 262-266

ISBN: 978-989-758-494-7

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UPD participated. The participants went to the

UPHS for assessment by a Primary Care Physician

for their annual medical examination. All

participants were directed to the dermatology clinic

for a full cutaneous assessment by dermatologists.

The participants were briefed on the purpose of the

study, assured confidentiality and were asked to sign

an informed consent form if willing to participate in

the study. Those who have agreed to participate and

who have signed an informed consent form were

included and were assigned case numbers. All

subjects underwent a complete dermatologic history

and physical examination by the investigators and

were managed accordingly.

All valid data from evaluable subjects were

included in the analysis. Input and descriptive

analyses of data was performed using Microsoft

Excel. Mann Whitney U test was used to compare

averages. Chi-square test, Fisher’s exact test or

Yates’ chi-square test was used to compare

proportions. Statistical significance was based on p-

values ≤ 0.05. STATA v13 was used in data

processing and analysis.

3 RESULTS

A total of 160 food handlers participated in the

study, with no noted refusals to participate nor

dropouts. 95.6% (153) of the study participants were

assessed to have dermatoses. Of the patients with

dermatoses, majority of them were females (87,

56.9%). Age of study participants ranged from 19-

79 years old, wherein the average age of those with

dermatoses was 38 years. The types of work were

food serving (79.7%), food preparation (68%),

cleaning (64.1%), and cooking (62.7%). It was

found that the food handlers with dermatoses had

longer length of service (p=0.049).

3.1 History of Atopy

A few of the food handlers with dermatoses had a

personal history of asthma (17, 11.1%), allergies

(21, 13.7%), atopic dermatitis (AD) (4, 2.6%), and

allergic rhinitis (AR) (9, 5.9%). Some also had a

family history of asthma (28, 18.3%), allergies (8,

5.2%), AD (2, 1.3%) and AR (7, 4.6%). About

37.3% (57) had a history of previous skin conditions.

However, there was insufficient evidence to show

significant association between personal and family

history of atopy and the presence of dermatoses.

History of present skin condition was significantly

associated with dermatoses (p<0.0001).

3.2 External (Occupational and

Environmental) and Inherent

Factors

About 86.9% (133) food handlers with dermatoses

had contact with food such as vegetables (98,

73.7%), fruits (56, 42.1%), meat (112, 84.2%) and

dairy (28, 21.1%). About 64.7% (99) had contact

with cleaning agents like soap or detergent (98,

99%) and solutions (45, 45.5%). About 79.7% (122)

had contact with pans. Of the 72.5% (111) food

handlers with common dermatoses, 89.2% (99) had

contact with hot containers and 10.8% (12) with cold

containers. Out of those with outdoor food

establishments, food kiosks/stalls comprised of

62.5% (35) while ambulant vendors made up 37.5%

(21). Cafeterias were the majority of the indoor food

establishments at 48.5% (47), followed by food

kiosks/stalls (28, 28.9%) and restaurants (22,

22.7%).

3.3 Common Diagnoses

The top 10 most common diagnoses of food handlers

in the study are as follows: xerosis (54, 35.3%),

post-inflammatory hyperpigmentation (PIH)

secondary to burn (37, 24.2%), melasma (22,

14.4%), chronic hand dermatitis (CHD) and verruca

plana (VP) (19, 12.4%), atopic dermatitis (AD) and

dermatophytoses (18, 11.8%), acne vulgaris and

dermatosis papulosa nigra (DPN) (17, 11.1%), solar

lentigenes (15, 9.8%), contact dermatitis (13, 8.5%),

burn scar (12, 7.8%) and scar secondary to knife cut

(11, 7.2%) (Table 1).

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3.4 Environmental Factors

Exposure to outdoor environmental factors was

significantly associated with the following

diagnoses: 28.6% (16) had melasma (p<0.0001),

23.2% (13) had solar lentigenes (p<0.0001), 25%

(14) had DPN (p<0.0001), and 12.5% (7) had

compound nevus (p=0.038).

3.5 Exposure to Cleaning Agents

Exposure to cleaning agents was significantly

associated with the following diagnoses: 43.4% (43)

xerosis (p=0.005), 17.2% (17) chronic hand

dermatitis (CHD) (p=0.019) and 15.2% (15) acne

vulgaris (p=0.033).

3.6 Exposure to Extreme Temperature

About 28.8% (32) of food handlers exposed to

extreme temperature were diagnosed with post-

inflammatory hyperpigmentation (PIH) secondary to

burn (p=0.034), which was noted to be significant.

4 DISCUSSION

Food handlers are at high-risk for developing

occupational skin disease (OSD) as they habitually

come into contact with a wide range of hazards

potentially responsible for causing skin disease. A

review of several articles discussed the influence of

age, gender, endogenous conditions associated with

atopic constitution, or exogenous triggers such as

environmental factors and specific occupational

risks, on the occurrence of occupational dermatitis

(Iston et al., 2007, Warshat et al., 2007).

4.1 Demographic Data

In our study, most of the participants with

dermatoses were female. This is consistent with a

study by Kibret in 2012, who reported that majority

(73.4%) of the food handlers were females while

(26.6%) were males (Kibret, 2012). Another study

by Warshaw et al also mentioned that women were

found to have a higher prevalence of hand dermatitis

compared to men primarily because females washed

Table 1: Diagnoses of food handlers with dermatosis

n: count; Data presented as n (%). * Significant at 5% level.

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their hands more than males (Warshaw et al., 2007;

Williams, 2009; Kibret, 2012). Age of our study

participants ranged from 19-79 years old, wherein

the average age of those with dermatoses was 38

years. According to the The European Agency for

Occupational Safety and Health at Work (EU-

OSHA), workers between 15–44 years old have a

slightly higher risk of being affected by skin diseases

than workers over 45 (Warshaw et al., 2007). It

could be presumed that those among the older age

group have been employed for a longer amount of

time, which is consistent in our study that the food

handlers with dermatoses had significantly longer

length of service.

4.2 History of Atopy

There was insufficient evidence to show a

significant association between a personal and

family history of atopy and the resulting common

dermatoses. Previous studies have showed that a

history of atopy and pre-existing skin disease are

influential factors for the development of the work-

related skin conditions, and that these workers were

also observed to fare worse in severity and are more

likely to have persistent disease than non-atopic

workers (Belsito, 2005; Saary et al., 2005). This

finding was not evident in our study probably

because only a small portion of our participants had

a history of atopy (36 out of 153). However, among

the 36 people noted with atopy, all presented with a

skin condition: 18 (50%) were noted to have AD, 13

(36%) had xerosis, 10 (27.8%) had CHD, 3 (8.3%)

ACD, 2 (5.5%) with ICD and KP were noted.

4.3 Common Dermatoses

The statistics on occupational skin diseases (OSD)

are different for each country because of the

different definitions used to classify occupational

diseases (Lee et al., 2017). Based on literature, those

dermatoses we expect to see in association with food

preparation, cooking, serving and cleaning would be

xerosis, PIH secondary to burn, CHD, contact

dermatitis, burn scar, and scar secondary to knife

cut. These were all significant in our study. For our

setting, we have noted the numerous various food

establishments in the university as well as the

multitude of food handlers seen in practically every

corner. Given that our food handlers are subject to

various environmental factors, such as exposure to

sunlight and humidity, the presence of the other

noted dermatoses in our study may be justified.

4.4 Exposure to Environmental Factors

There is a different impact depending on the

geographic region, being worse in places where the

weather is always warm, and the skin becomes more

exposed (Warshaw et al., 2007). Consequently, the

Philippine weather and environment is very different

from that in Western and first-world countries where

majority of studies were conducted. This could

probably explain the significance of why most of

those diagnosed with melasma, dermatosis papulosa

nigra, solar lentigenes and compound nevus were

noted to have been observed mostly in food handlers

who worked outdoors as these diseases are all

associated with sun exposure.

4.5 Exposure to Cleaning Agents

Another environmental risk factor is “wet work,”

wherein the cumulative effects of water, soaps and

detergents induces maceration of the skin, leading to

increased penetration of irritants and allergens

(Jones & Horn, 2014). This is consistent with the

significant finding that those with xerosis and

chronic hand dermatitis mostly had cleaning as part

of their job. Acne was also found to be significantly

associated to exposure to cleaning agents. We could

probably attribute this to wearing of protective

clothing such as caps and masks, which could trigger

acne mechanica. We also note that the food handlers

with acne are in the 19-30 year old age range, which

we can all deduce that they must have gotten acne

due to more common factors- increase in sebum

production and proliferation of P. acnes.

4.6 Exposure to Extreme Temperature

PIH is characterized by increased pigmentation

acquired after a cutaneous inflammatory process.

People with higher skin phototypes such as

Filipinos, are more prone to this skin condition,

because they already have a higher basal amount of

epidermal melanin (Cestari et al., 2014). Frequent

contact with hot containers such as pans while

cooking predisposes one to burns, with subsequent

post-inflammatory hyperpigmentation after the burn

has healed on the area of contact. With that, we have

found an association between exposure to hot

containers and burn post-inflammatory

hyperpigmentation. There was no association

evident between cold containers (ice cream vendors

mostly) and dermatoses.

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5 CONCLUSION

It could not be emphasized more that skin disease

has a large number of occupational and non-

occupational predisposing factors that are

instrumental in the development and progression of

disease. Several factors were identified throughout

the course of the study that may differentiate our

study population from those in foreign studies, thus

affecting the results of the study. In summation, it

was found that food handlers with dermatoses had

significantly longer length in service. Our study also

shows that the common dermatoses found in the

food handlers in UP Diliman are more dependent on

occupational and environmental factors and not so

much on inherent factors or atopy. The location of

the food establishment, as well as their type of work

proved to be major contributing factors to the skin

conditions noted. Food handlers who worked

outdoors and had considerable sun exposure were

significantly associated with solar-induced

dermatoses such as melasma, dermatosis papulosa

nigra, solar lentigenes and compound nevus. Those

that had daily exposure to cleaning agents were

mostly found with xerosis, chronic hand dermatitis

and acne vulgaris. Lastly, food handlers who are in

constant contact with hot containers had a significant

association with post-inflammatory

hyperpigmentation secondary to burn. Studies on the

prognosis of occupational dermatoses point out that

primary prevention is very important. Hence, further

research on OSDs is indeed vital towards improving

environmental and occupational research in the

Philippines.

ACKNOWLEDGEMENTS

Ethel M. Estanislao, MoS – statistician for this

study; Ma. Angela M. Lavadia, MD, FPDS –

research adviser; Alexis Paula D. Ibanez, MD – co-

investigator; Deejay B. Arcega, MD, FPDS –

research coordinator; Ma. Cecilia Onjoco, MD,

FPDS – research coordinator.

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