This material is supported in part with funds from the National Institute for Occupational Safety and Health (NIOSH) through CPWR – Center for Construction Research and Training to a consortium of CPWR, the Operative Plasterers & Cement Masons International Association, and FOF Communications. Researched, developed, and produced by FOF Communications. The material does not necessarily reflect the views or policies of NIOSH. Mention of trade names, commercial products or organizations does not imply endorsement by NIOSH, the U.S. Government, CPWR, OPCMIA, or FOF Communications. The Occupational Safety and Health Act of 1970 makes the employer responsible for providing a safe and healthful workplace that is free of recognized hazards. © 1999, 2000 FOF Communications Table of Contents 1.
Recognizing Skin Problems Glossary
If your
employees work with wet cement productsconcrete, mortar, plaster,
grout, stucco, or terrazzo, this handbook is for you. It will help you
prevent employee skin problems from cement. Recognizing Skin Problems Ted Jasons
eight-year old daughter got a painful rash that would not go away. The
Jasons took her to several doctors. They applied ointments. They washed
her sore skin with prescribed soaps. Nothing they did made a difference. Ted found out that
alkaline cement dust from his work had contaminated his life in a way
he had never before appreciated. He realized his daughter had been exposed. So Ted began following the tips given in the course. He cleaned his car interior and began removing his work clothes before getting into it. He switched to pH-neutral soap for his daughter. Within a few weeks, her skin problem was goneand so was his. WHY WORRY ABOUT
CEMENT? Ted Jasons
problems are not uncommon. Maybe you have a skin problem from cement or
know someone who does. Portland cement is estimated to account for 25%
or more of all work-related skin problems worldwide.
11
Reported lost work days for skin problems in US masonry trades are 2.5 times the national average. Concrete workers lose time at 7 times the average. Concrete workers report 4 times more lost work days for skin problems than do all construction workers. 24 Most experts agree that reported lost time is just the small tip of a very large iceberg of disease. So a statistically reliable survey 15 of apprentice cement masons was especially alarming.
A surprising 71% of apprentices reported one or more skin problems. Only 29% reported no skin problems. The apprentices averaged only 3.3 years of experience in the trade.
Only 7% of those with skin problems reported lost time or doctor visits for their problems. 93% of the apprentices with skin problems continued to work without seeking medical treatmentsetting themselves up for lifelong health problems. Four types of
skin problems happen most often among cement products workers:
There are different ways to get a long-lasting skin problem. There is no single pattern. You cannot predict who will get skin problems based on experience or on medical tests.
WHAT DO SKIN PROBLEMS
COST? What
do occupational skin problems cost the US economy each year? Estimated costs for medical care, lost production, and disability payments for reported skin disorders total up to $1 billion a year, according to NIOSH. The costs to employers include worker compensation disability claims, lower productivity, and poor morale. The costs to workers include reduced earnings, medical bills, loss of a trade, social disability, embarrassment, and lower quality of life. The rates of most other occupational injuries and disease have fallen. But skin disease rates have increased. Little progress is made, even though the causes are better understood and more methods of control exist now than ever before. DERMATITIS WONT KILL YOU A nameless industry leader said this not long ago before a training class on preventing contact dermatitis. It may be truealthough some workers with disfiguring cement burns or rampant chrome allergy dermatitis might wish it would. Skin problems from cement are widespread and, unfortunately, they are too often tolerated as part of the price of work in some trades. Our tolerance permits the high rates of occupational skin problems in the United States to continue. But put yourself in the place of a worker with a persistent skin problem. If your hands or other skin are covered with rashes, irritation, or sores, it can make you less socially acceptable as well. Many male cement products workers have said their wives or girlfriends do not appreciate their skin problems. Young single men and women with occupational skin problems often feel at a disadvantage when socializing. Whether the cement products worker goes to a school conference and shakes the teachers hand, goes to a bank and shakes the loan officers hand, or goes to a broker to make an investmentin every aspect of American life, an occupational skin problem can make the individual feel less than comfortable. Social disadvantages do not take into account physical pain and suffering, the loss of morale, the loss of income, or the loss of personal leisure time devoted to grappling with an ongoing health problem. As a conscientious employer, you have many motives for caring about your employees skin. Some of them are financial. Some of them involve productivity. Some
of every employers motivation WHAT CAUSES SKIN PROBLEMS? Skin
may be affected by one or more of the following factors:
The skin is the single largest organ. It covers 20 square feet of surface. The skin's purpose is to protect the body from outside substances, chemicals, and bacteria. Skin has two layers.
Together both are less than 1/8-inch thick.
The skin contains oil glands, hair follicles, and sweat glandsall are like tiny holes. So the skin can be like a leaky roof or a sponge when it contacts chemicals. Skin also contains blood vessels. Some chemicals can penetrate the skin and enter the bloodstream. Normal surface skin
is moderately acidic. Recent research has shown that this acid mantleis
necessary to allow the skin to repair itself after an external insult.An
alkaline pH impedes repair. Worksite materials can cause skin problems. Some materials insult and injure skin. Some pass through it into the bloodstream.
Cement products
are abrasive and physically damage the skin surface, making it
a less effective barrier against chemicals. The moisture in eyes, mucous,
and sweaty or damp skin can activate dry cement, making it caustic.
These factors allow cement to cause dry skin and irritant contact dermatitis. Sensitizers
in workplace materials may cause an allergic response. The reaction
may be local or widespread. Sensitization is an immune response. The
immune system fights a foreign substance. Usually, the material causes
no change on first contact. Once a person is sensitized, small amounts
can trigger a strong reaction. Many people cannot tolerate further exposure. Possible sensitizers
used by cement products workers include: hexavalent chromium (Cr6+
) in cement, chemical admixtures in concrete, epoxies, additives in
rubber gloves, and other trace metals in cement products. Hexavalent chromium
(Cr6+) is a sensitizer. It is an important cause of
allergic contact dermatitis. Cements alkalinity increases skin
absorption of this soluble chromate. Some studies show that Cr6+
penetrates the skin and enters the bloodstream. Worksite cleaners too often are caustic and abrasive. They also may contain sensitizers like lanolin, limonene, or perfume and irritants like alcohol. Worksite conditions
can determine whether a worksite material will cause skin problems.
Individual factors
can affect work-related skin problems. These include:
Worksite Exposures More than 92.7 million metric tons of cement were consumed in US construction in one recent year, according to the Portland Cement Association . Cement consumption has increased every year since 1991. 21 Cement is a mixture
of lime, silicates, aluminum, iron, magnesium, and other additives such
as gypsum, fly ash, and blast furnaceslag.
1
Cement is a component in:
Portland Cement
Products Workers More than 1,300,000
American workers in 30 occupations are regularly exposed to wet cement. Following is a partial list of the construction trades workers who may be regularly exposed to cement:
Portland Cement
Work Tasks Below are some of the work tasks that expose construction workers to Portland cement:
The Nature of
Cement Cement has many properties which are damaging to skin. Cement is alkaline, or caustic. The pH of wet cement ranges from 12 to 13. Cement is hygroscopic, pulling moisture from the skin. Cement is abrasive. Cement may contain sensitizing chemicals and metals, such as hexavalent chromium (Cr6+). The composition of cement varies somewhat from region to region. However, the alkaline, abrasive, and hygroscopic properties of cement in concrete, mortar, grout, plaster, stucco, and other products are universal. Perhaps most frequently damaging of all these properties is the alkaline pH. Normalizing pH Wet cement is an alkali, or caustic. A caustic is any strongly alkaline material with a corrosive or irritating effect on living tissue. Alkalinity is essential in the development of irritant contact dermatitis (ICD) from cement. 4 pH is a measure of
the alkalinity or acidity of a material. Pure water has a pH of 7 and
pH 7 is considered pH-neutral. Strong alkalies are
pH 12 to 14. Cement is extremely alkaline, or caustic, with a pH value
of 12 to 13. Strong acids are pH 1 to 3. pH represents the acidity or alkalinity of a watery solution on a scale. The pH scale is like the Richter scale for earthquakes. Both are logarithmic. On a logarithmic scale, the intervals between numbers are not equal. Rather, each number may be many times greater or smaller than the previous number.
pH Values Like the earthquake
scale, the pH scale is logarithmic. So the intervals between numbers are
not equal.
Acids ionize in water to give H + (hydrogen) ions. Alkalies (bases) produce OH - (hydroxyl group) ions in water. You can learn more about the technical chemistry of pH by looking in a chemical dictionary or a chemistry textbook. The pH Of Healthy Skin Normal skin is pH
4.5 to 5.5, meaning it is moderately acidic. The acidic pH of skin has
been recognized for a century. However, the purpose of the acid
mantle of skin is not completely understood. Scientists believe
it has to do with processing of lipids (fats) required for skin barrier
function. Contact with wet cement changes skin pH to alkaline. At alkaline
pH, skin barrier repair is slowed, damage is prolonged, and skin problems
are worsened. The slightly acidic
pH of normal skin also helps it to resist bacterial infection. Bacteria
dont like acidic environments. In fact, meat inspectors test pH
as a measure of freshness. When the pH of meat becomes slightly alkaline,
bacteria are more likely to multiply.
Further, alkalinity
contributes greatly to skin absorption of the hexavalent chromium (Cr6+)
in cement.3 So a cement workers absorption of Cr6+ can
be greatly increased when it contacts skin in cement.
Acids Examples of strong
acids are hydrochloric acid (HCl), nitric acid (HNO3), and sulfuric acid
(H2SO4). Strong acids burn skin immediately.
Strong alkalies can
be more dangerous because they damage skin slowly without immediate pain.
An alkali can remain on skin for hours before a burn is felt.
Weaker acids include
vinegar and citric acid (oranges).
When an acid is added
to an alkali, it tends to neutralize the pH. For example, if you add vinegar
to cement water, it can reduce the pH from 12 to 8. You can do this experiment
with small amounts of cement water and vinegar using the pH indicator
papers pictured below. (The reaction of acids and alkalies together can
release heat.)
Buffers
A buffer is a substance
that can neutralize either an acid or an alkali. A buffer may be a mixture
of a weak acid and a salt of that acid that is intended to maintain a
desired pH. Phosphates are often used as buffering agents.
In addition to eliminating
the caustic effect of cement, neutralizing pH may convert hexavalent chromium
(Cr6+) to trivalent (Cr3+), reducing the risk of
ACD. pH-Neutral and
Acidic Soaps
Caustics like wet
cement can dry and irritate the skin. But did you know the soaps your
employees use for cleanup at work and at home could make the problem worse?
Many well-known soaps and cleaners are caustic. These soaps or cleaners
can add to the dryness and irritation caused by the caustics used at work.
Your employees may
be better off with a soap that is pH-neutral or slightly acidic. These
soaps are closer to the pH of healthy skin. They also help neutralize
the effect of worksite caustics.
For best results
in selecting the right soap, the worker should consult a doctor.
To help select appropriate
soaps, we tested the pH of some popular brands. We also checked the ingredients
listed on the MSDSs.
The chart lists pH
values for 39 soaps and cleaners.
pH-neutral and slightly
acidic soaps and cleaners are good bets.
pH-neutral is 7.
Soaps with pH below 7 are more acidiclike citrus or vinegar. Soaps
above pH 7 are more causticlike cement.
Regardless of pH,
any soap containing lanolin, limonene, or perfume probably should be avoided
if you are sensitive to those ingredients.
The chart is advisory
only. To obtain reliable information, ask your pharmacist or ask the soap
manufacturer for an MSDS. The authors do not endorse any products or claim
the list to be accurate or complete.
Modify Cement at the Plant?
As industry leaders
learn about skin problems, they often ask whether cement can be modified
to reduce the hazards. Different modifications are proposed depending
on the specific skin problem. Remember, cement causes two main problems:
irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD).
Cement causes ICD because it is alkaline, hygroscopic, and abrasive. Cement
causes ACD because it contains sensitizers, mainly hexavalent chromium
(Cr6+).
Neutralize pH?
Some in the industry
have asked that manufacturers reduce the alkalinity of cement. By nature,
wet cement is pH 12 to 13. It will always be alkaline. Attempts to neutralize
the pH of cement would chemically alter it and possibly invalidate its
specified integrity. Upholding the structural integrity of cement and
concrete is paramount. Rather than attempt to neutralize the pH of an
entire batch of cement at the plant, it seems more practical to neutralize
the pH of the small amount of cement that may contact the surface skin
of cement products workers at the jobsite. This can be done with a neutralizing
solution.
Reduce Hexavalent
Chromium?
When ferrous (iron)
sulfate is combined with hexavalent chromium in cement, it forms
an insoluble trivalent compound when water is added.
Trivalent chromium
(Cr 3+ ) is not easily absorbed by skin. Finnish, Danish, and Swedish
scientists have published studies showing that this way of modifying cement
at the plantas required by legislation in those countriesgreatly
reduced ACD in cement products workers.
20
ACD from cement is a common occupational dermatitis among construction
workers and a reduction in the chromate content of cement would be a reasonable
preventive measure.
2,3
American cement makers
experimented with iron sulfate but could not duplicate the Scandinavian
results for several reasons.
First, more than
120 plants make US cement and the product ships long distances in this
country. If iron sulfate is added, the time it takes to transport the
cement may result in spontaneous oxidation of the ferrous ion to the ferric
form, rendering the iron sulfate inactive.
Second, the addition
of iron sulfate during grinding is a patented process. Royalties and the
cost of iron sulfate as an additive (variously estimated at $.05 to $1.00
per ton) would increase the cost of cement products. Added costs may be
incurred in reconfiguring manufacturing processes to allow for the addition
of iron sulfate.
As an alternative,
some researchers have recommended that iron sulfate be added during mixing
of concrete or when delivering premixed cement products to the worksite.
8,12
Finally, cement products
may be modified in another way to reduce Cr6+ levels. Slag
can be substituted for clinker at the plant.
11
American manufacturers
express concern about possible effects of such methods on the structural
integrity of finished concrete. For example, some argue that addition
of substantial amounts of iron sulfate to concrete might cause durability
problems or necessitate adjustment of the amount of gypsum added. (Concrete
in Scandinavia and Singapore appears unaffected by modifications to cement
in those countries.) Manufacturers point out that American specifications
for concrete are rigid, that any changes must be well researched, and
that research is ongoing. So change may be possible some day.
Best Protective Practices
Protecting skin is
not simply a matter of wearing gloves. Alarge percentage of cement products
workers already wear gloves. But, to be effective, glove wear must go
hand-in-hand with proper hygiene. Hygienic practices and use of the correct
gloves will prevent contact with cement. Glove wear without hygiene practices
is no more protective than no gloves at all.
4
In fact, it can make problems worse.
This chapter presents
the best protective practices for preventing skin problems from
cement. Not everyone can
do all these practices. But your employees should do as many as possible,
beginning with the easiest ones. There is no guarantee that any or all
of these practices will prevent skin problems from cement. But these practices
are recommended by experts and they represent the best protections known. What are your
companys best practices for preventing dermatitis? Before you read
this chapter, take a few minutes to list them on a separate piece of paper.
BEST PROTECTIVE
PRACTICES AT HOME Recommend to your
employees that they wash with pH-neutral or acidic soaps. A pharmacy
can identify one. Remember the discussion
about neutralizing caustics? Cement products workers
who wash with alkaline soaps unknowingly continue to insult
their skin with alkalies. During the day they are exposed to caustic cement.
At home they are exposed to caustic soap. If cement products
workers wash with pH-neutral or acidic soaps at home, it may help restore
the desired pH balance of the skin surface. This allows skin barrier repair
to proceed. If skin remains at an alkaline pH, skin barrier repair is
impeded. Employees should
change out of work clothes at work. Work clothes can be brought home in
a separate container. A trash bag works great. This practice keeps cement
out of the car or truck interior. Launder work clothes
separately to protect family or roommates. For extra safety, run washer
empty after laundering work clothes. ICD due
to alkaline soap. Alkaline soaps can cause dermatitis even in
the absence of other exposures. Alkaline soaps can worsen skin problems
caused by cement and are not recommended for cement products workers. BEST PROTECTIVE
PRACTICES AT WORK Each Employee
Needs At Least 5 To 7 Gallons of Clean Running Water Per Day Bring clean running
water to the jobsite. Employees need clean water for washing before work,
whenever they break, and at the end of the shift. Prohibit cleaning with
abrasive solvent containing
products. These include waterless hand cleaners like the alcohol-based
gels or citrus cleaners. Such cleaners are not suitable for cement
exposure. Require Employees
To Wash Hands Before Putting On Gloves Employees should
wash with pH-neutral soap and clean running water, as recommended by the
Portland Cement Associations sample MSDS. Dry Hands Workers should dry
hands thoroughly with a clean cloth or paper towel before putting on gloves. Wash Hands Again
If Gloves Are Removed If employees remove
gloves during work, they
must wash again with clean water and pH-neutral or acidic soap. If not,
cement residue will enter the gloves. Dont allow employees to rinse
their hands in tool rinse buckets. Long Sleeves Buttoned
Or Taped Inside Gloves Many experts recommend
wearing long sleeves and taping them inside gauntlet gloves. But if the
sleeves become saturated with wet cement, they must be removed immediately. Rubber Boots With
Pants Taped Inside Never Let Cement
Remain On Skin Or Clothes When wet cement gets
on permeable clothing, it must be removed immediately. When wet cement
gets on skin, it must be washed with clean water and pH-neutral or acidic
soap. At the least, consider providing a buffering solution to neutralize
the pH of cement residue. Provide Or Require
Proper Gloves Prohibit Barrier
Creams Barrier creams or
invisible gloves are not recommended for cement work.
19
The abrasive cement probably breaks the seal of the barrier cream. Also,
reapplying the cream in the work area may occlude or seal cement to the
skin. Provide Glove
Liners Glove liners of thin
cotton help make gloves more comfortable. They can help keep hands clean
and dry. But they must not be contaminated with cement inside the gloves.
The goal is to keep the insides of the gloves clean. Throw Out Grossly
Contaminated Gloves Gloves should be
cleaned every day before and after removal. Sometimes gloves get so contaminated
they cannot be cleaned. Throw them out. Require Employees
To Clean Gloves Daily Consider Providing
Disposable Gloves Disposable gloves
can make it easier for employees to keep their hands clean. Disposable
gloves can be less expensive than reusable gloves. Discard disposable
gloves at the jobsite each day. Teach Employees
How To Remove Gloves Before removing
gloves, always clean off the outsides. Follow the
manufacture's instructions. Watch for pinholes which can let in
contaminated rinse water. To remove gloves,
loosen them on both hands. Hold hands down so contaminated water
will not drip onto skin or clothing. The cuff of
the glove will remain over the palm. Now, grabbing
the second glove with the first glove, remove the second glove. The first glove
should slip off. Try to handle
gloves by the insides only. Dont
touch the outsides. No Jewelry at
Work Encourage Employees
To Change Work Clothes At Work Removing work clothes
at work cuts cement exposure for employees and their family members. It
keeps cement out of the car or truck interior. If work clothes cannot
be left at the job, they should be taken home in a separate container.
A trash bag works great. Skin-softening products
can occlude or seal cement to skin, can increase the skins
ability to absorb contaminants, or can irritate the skin. Never use petroleum
jelly or other emollients to treat cement burns. Applying such products
can intensify burns by trapping the cement against the skin. Skin-softening products
should be applied only to clean skin in clean environments. A cement products
worker may use these products, if desired, at home after showering or
bathing with pH-neutral or slightly acidic soap. But be careful. Some
skin-softening products may contain fragrances, lanolin, or other chemicals
that can cause ACD in susceptible workers. Urge Employees
To See A Physician Any employee with
a persistent skin problem, even a minor one, should see a doctor. A statistically
valid survey of apprentice cement masons showed only 7% of those with
skin problems saw doctors even though 71% had had problems in the last
year.15 Some did not think the problems were serious. Others were afraid
of losing employment. The question of covering
the treatment under worker compensation or a health & welfare plan
is not a topic of this handbook. A Physician Alert
brochure is available from CPWR – Center for Construction Research and Training
(301-578-8500). The brochure can be given by a worker to a doctor. The
brochure helps explain the skin hazards of cement work. Encourage employees
to follow the doctors prescriptions and recommendations. That action,
combined with other best practices, can lead to the successful control
of most cement-related skin problems. Follow A Model
MSDS Find the best Material
Safety Data Sheet in the industry and follow its recommendations. The
best MSDS is the one that is most complete and provides the most protective
recommendations. The Portland Cement
Association (PCA) has published a sample MSDS report.19 It
includes a few of the best practices recommended by experts. Cement Burns An acid will burn
skin immediately. Cement is sneakier. An employee can work with wet cement
on the skin for hours without feeling any discomfort. But the alkaline
burn of the cement is damaging the skin microscopically. That damage may
be just a cement burn or it also may be the cumulative injury that leads
to irritant or allergic dermatitis. Cement burns (caustic
burns) are alkali burns. Cement burns progress. This means they get worse
even without more exposure. Anyone who feels a cement burn starting should
go immediately for emergency treatment in an ER or by a burn specialist.
Dont assume the burn will not get worse. By the time an employee
becomes aware of a burn, much damage has already been done and further
damage is difficult to stop. Medical experts recommend
flushing the skin with lots of clean water. Some suggest adding vinegar,
citrus, or a buffer to the water to help neutralize the caustic effect.
6,9,14,23
Put Protection into Action Your workers deserve
training and protective gear. As an employer, you expect workers to follow
through by using to the fullest the training and protective gear you provide. The construction
industry has made many strides in protecting its workers from many safety
hazards. Almost everyone agrees it must do more to protect workers from
skin problems. But how can you achieve more protection for your employees?
As an employer, youve
shown your interest in progress by looking at this handbook. What more
can you do to protect your workers and to help them protect themselves? This chapter presents
some additional pointers and resources you can use to help put your concerns
into action. Choosing And Wearing
Gloves The main goals for
successful glove wear are: To meet these goals,
you must make sure that: Three types of gloves
are often used for work with wet cement: Some
gloves combine rubber or butyl with cotton, other fabrics, or leather.
Glove thickness and the length of the cuffs vary by task or worker preference.
Fabric or leather gloves are not recommended because they may become saturated
with wet cement. Without good hygiene,
gloves are no better than no protection at all. If employees cant
wash with clean water and pH-neutral soap whenever they remove their gloves,
the insides become contaminated. Dont fool yourself. Gloves on employees
are no proof of protection.
4
Below are the websites
of two well-known glove manufacturers. You can purchase from these and
others through your local safety supply store listed in the business section
of the telephone directory. http://www.bestglove.com Training Video A video for
worker training Skin Safety with Cement and Concrete
is available for sale from the Portland Cement Association. The video presents
good safety tips and is reasonably candid about the hazard. It focuses
more on cement burns than on preventing dermatitis. Portland Sample Material
Safety Data Sheet The Cement
Burn Awareness Kit is available from the National Ready
Mixed Concrete Association. The kit contains
color photographs, warning tools, and a sample MSDS to help prevent
cement exposure. Commercial products
are marketed for neutralizing the pH of cement. Masons Hand Rinse
is an acidic rinse. Neutralite is a buffering solution. In theory, either
product or other similar products could be helpful if they neutralize
cement on the skin surface. pH indicator papers
(pH test strips) can be ordered through your local safety supply company
or from Markson LabSales, Inc., at 1-800-528-5114 or Lab Safety Supply
at 1-800-356-0783. Evaluating Your Success Lets say your
company wants to invest time and effort in improving conditions with the
aim of preventing skin problems from cement. How will you know
if your efforts pay off? You might say its
easy. Ill see it with my own eyes. It will be plain to everyone.
But thats probably not true. Whether your company
employs five cement workers or 500, you can set up a system for measuring
the success of your prevention efforts. This chapter gives some simple
ideas about how to do it. Compared To What? When you evaluate
anything, you need a basis for comparison. Two classic methods
are criteria-based and norm-based
comparison. In school, did your
teacher grade your test by an objective standard and give As
only for 100%, for example? Thats criteria-based evaluation.
Criteria-based means comparing something to an objective standard thats
set up ahead of time. If your teacher graded
on a curve by comparing you with other students in your class, thats
norm-based evaluation. Norm-based means comparing something
with other things in the same category. Measuring Tools Norm-Based Evaluation Consider comparing
your workers with themselves before and after beginning your efforts. Before starting your
efforts, take some baseline measurements. Use written checklists.
Watch your employees work and take reports from them of what they do.
You dont have to record the employees names. You are not comparing
individuals. You are comparing your employees as a group
before and after your efforts. Which best practices
are your employees currently doing? Which are they failing to do? Keep
a written record of your observations. Have your employees complete the
symptoms checklist of the skin problems they currently have. Assure them
their names are not recorded and their answers have no effect on employment.
Ask them to do a pH test of surface skin. Again, this is not a test of
the individual employee. Instead, it is a measure of the success of the
protective practices you implement. Once you have a baseline
record, then begin your effort to reduce skin problems. Instruct employees
in best practices and beegin enforcing these practices on the job. Take the same measurements
periodically to assess progress. The results can help you adjust your
efforts. What If Employees
Are Transient? In construction,
workers come and go. Turnover varies from company to company. Some larger
companies have a steady cadre of core workers and hire or layoff more
as projects demand. Other companies have no steady workers, only transient
ones. This makes evaluation more difficult. But not impossible. Always keep in mind
that you are not evaluating individual workers. You are evaluating the
success of your efforts by looking at your employees as a group. If all your workers
are transient and other employers have poor hygiene conditions, you may
not see immediate improvements in the symptoms checklist. But you should
see improvements in the pH tests of surface skin and in compliance with
best protective practices. This should help prevent future dermatitis. Work With Others If you work with
other employers and with employees unions, you can bring about a
reduction in skin problems in your labor pool. Working together
and involving your health & welfare plan, you can implement a plan-wide
evaluation. It can look at the reduction in medical costs and worker compensation
disability settlements. One attribute of
a good health care provider is a willingness to learn about a new group
of patients. As you begin working with health care providers who will
focus on treating and preventing skin problems among your employees, you
will want to give them appropriate background information. This will be
true whether they are dermatologists, occupational medicine physicians,
or other specialists. Health care providers
should be aware that cement products workers are exposed to materials
that cause dry skin, irritation, irritant dermatitis, allergic dermatitis,
and alkali burns. Occupational skin
disorders may develop not only at the hands but at any of several body
sites including arms, neck, ankles, feet, and other locations.
1
Portland cement is
alkaline (pH 13). Alkalinity is associated with development of ICD and
ACD.4 Further, the human skin is more permeable at alkaline
pH.
Cement contains trace
amounts of hexavalent chromium (Cr 6+ ), a sensitizing agent responsible
for allergic dermatitis (ACD) i cement products workers worldwide. Other
sensitizing agents include epoxy adhesives, sealants, and admixtures in
cement.
Some cement products
workers use lanolin creams or petroleum-based emollients to soften their
skin. If these products are applied to skin that is not thoroughly clean,
they can intensify exposure.
Other skin disorders
among cement workers include disorders caused by mechanical trauma; disorders
caused by solar radiation, climate, or temperature, and contact urticaria
(hives).
Development of skin
disorders from cement cannot be predicted based on experience. Exposure
may cause irritation or dry skin, ICD, ACD, or burns. PHYSICIAN ALERT The next three sections
present etiologic agents, surveillance, and intervention/treatment options
which may be helpful to a physician evaluating the skin of a cement products
worker. Etiologic Agents Xerosis (dry skin).
Alkalies; abrasive cleaners; solvents; alkaline soaps; water; sun; heat;
cold; low humidity. ICD. Portland
cement; plaster; lime; epoxies; solvents; abrasive cleaners; alkaline
soaps; hand/barrier creams; skin care products. ACD. Portland
cement; hexavalent chromium (Cr6+); trace metals in cement
or concrete; plaster; stucco; mortar; grout; lime; epoxy resins, hardeners,
reactive diluents; some admixtures; lanolin; rubber; perfumes. Cobalt
sensitivity is reported from cements in Europe but not from American cement.
1 Burns. Portland
cement; lime; other alkalies; epoxy components. The Elements.
Sun; heat; cold; sweat; low or high humidity. Contact Urticaria
(Hives). Latex; rubber; epoxy resins; leather; clothing; cold; heat;
sun; water. Workers exposed to
cement include concrete masons, bricklayers, hod carriers, laborers, plasterers,
drywall finishers, terrazzo masons, tile setters, sidewalk pavers, construction
laborers, carpenters, ready mixed concrete truck drivers, and many others. Surveillance Dry Skin (xerosis,
mild ICD). Scaling; itchiness; burning; redness. ICD. Exam;
stinging; burning; pain; itching; blisters; dead skin; scabs; scaling;
fissures; redness; swelling; bumps, dry or with watery discharge. Diagnostic
aids: open application tests; do not patch test to known irritants;
do not patch test to unknown chemicals. ACD. Exam;
stinging; burning; pain; itching; blisters; dead skin; scabs; scaling;
fissures; redness; swelling; bumps, dry or with watery discharge; usually
concentrated where exposure occurs, but also occurs on other body parts;
onset 2 to 7 days or more after exposure. Diagnostic aids: open
application tests; commercially available skin patch tests (e.g., to some
rubber, epoxy, and cement compounds); do not patch test to known irritants;
do not patch test to unknown chemicals. Burns. Blisters,
dead or hardened skin, black or green skin. Trauma. Redness;
blisters; abrasions; thickening; discoloration; fissures; corns/callosities,
hives. The Elements.
Burns; dry skin; scaling; itchiness; burning; blisters; sweat pore blockage
(miliaria); maceration; frostbite; immersion foot; discoloration; waxy
skin; redness; swelling; tenderness; numbness; hives; gangrene. Contact Urticaria
(Hives). Exam; hives; swelling; redness; itchiness; pain. Intervention/Treatment Xerosis (dry skin).
Exam and treatment: skin lubrication; change work practices; protective
clothing; gloves; mild soaps; temperature/humidity control. ICD. Exam;
prevent exposure; proper gloves; long sleeves; remove work clothes if
soaked with wet cement; skin lubrication, antibiotics for infections;
astringent soaks; topical or systemic corticosteroids; antihistamines;
UV; wash hands at least before eating or leaving work with pH-neutral
soap; possibly add vinegar or buffering agent to neutralize alkaline wash/rinse
water. ACD. Exam;
identify offending agent and prevent exposure; may require change in work
as reintroduction to exposure poses serious problems; proper gloves; long
sleeves inside gloves; remove work clothes if soaked with wet cement;
skin lubrication; antibiotics for infections; astringent soaks; topical
or systemic corticosteroids; antihistamines; UV; wash hands with pH-neutral
soap at least before eating or leaving work. Cement Burns.
Flush with copious amounts of water; buffered solution to neutralize alkalies;
burn wound care; surgery; skin grafting; physical therapy. Cement burns
are alkali burns. They can progress and should be referred to a specialist
without delay. Trauma. Exam
and specific treatment; change work practices; use of proper tools and
protective clothing. The Elements.
Exam and specific treatment; sunscreens; change work practices; protective
clothing; temperature/humidity control. Contact Urticaria
(Hives). Identify and avoid offending agent; skin exam and treatment;
antihistamines; systemic corticosteroids. Visiting the workers
worksite or reviewing the Material Safety Data Sheets of products used
there may help to determine what substances the worker is exposed to,
the degree and duration of the exposure, the methods and agents used to
clean the skin, and the type of protective clothing used. Outlook Irritant Contact
Dermatitis (ICD). The prognosis of occupational irritant contact
dermatitis is poor.
7
Prevention is imperative. One study showed that 75% of patients with occupational
contact dermatitis developed chronic skin disease. Allergic Contact
Dermatitis (ACD). Chrome allergy is persistent. Trace amounts
of chrome (Cr) are found in many articles of daily life, including food,
water, and cigarettes. Cr may persist in tissues for a long time. A change
of work does not always assure healing of the dermatitis and workers with
mild to moderate dermatitis may be encouraged to remain at work. There
is some evidence that the skin has the ability to reduce Cr6+
to Cr3+ enzymatically.
1,12
It also may be that neutralizing the pH of cement at the skin surface
may convert Cr6+ to Cr3+ . (See reduction of Cr6+
in Scandinavian cement.) For some years, iron sulfate has been added to
cement manufactured in Scandinavia. In one in vivo study, cements with
and without iron sulfate were compared concerning their capacity to elicit
allergic patch-test reactions in eight chromate-hypersensitive individuals.
No patch-test reactions were obtained from a water extract of cement with
iron sulfate when appropriately buffered.
5
Cement Burn.
Following is a typical case history. A young male construction worker
accidentally poured cement over the top of his boots. He was careful to
rinse off all the cement from his boots immediately as advised. Three
hours later, he experienced excruciating pain over the dorsum of his toes
and on removing his boots and wet socks, discovered to his horror that
the dorsum of all his toes had turned a deadly green.' Clinically,
he had full skin thickness burns of the dorsum of all his toes over the
proximal phalanx which subsequently became infected and required hospitalization
and daily dressing for three weeks.
6,9,14,23
The damage from cement
burns may be worsened when a worker applies an emollient such as petroleum
jelly in an attempt to soothe the pain. The emollient occludes the cement
to the skin which increases the burn. acids A large class of
chemicals with pH values ranging from <7 to <1. Acids with pH 1
are one million times stronger than acids with pH 6. admixture Any substanceother
than cement, aggregate, or waterthat is mixed with concrete; usually
a chemical solution added to enhance a specific property of the concrete. alkali (al-kah-lie)
Any substance which is bitter, irritating, or caustic to the skin, and
has a pH value greater than 7. Strong alkalies are corrosive to skin and
mucous membranes. Portland cement's ingredients make it extremely alkaline.
buffer A substance that
can neutralize either an acid or an alkali. A buffer is often a weak acid
and so it releases less heat than a strong acid would when neutralizing
an alkali. caustic Any strongly alkaline
material which has a corrosive or irritating effect on living tissue. hexavalent chromium
(Cr6+) Chromium (Cr) is
a metallic element with three valences: 2, 3, and 6. Elemental and trivalent
(Cr3+) chromium are relatively non-toxic. But hexavalent
(Cr6+) compounds are irritating and corrosive. Cr6+
is more readily absorbed by skin than is Cr3+. Cr6+
is a sensitizing agent. Trace amounts of Cr6+ are in most American
cements as a production contaminant. hygroscopic (hi-jrah-skop-ik)
Having a strong tendency to absorb water, which results in swelling. Cement
is hygroscopic. It absorbs moisture from skin, drying it. logarithmic scale On a logarithmic
scale, the intervals between numbers are not equal or linear. Instead,
each number represents a value that is many times greater or smaller than
the previous number. The pH scale and the Richter scale for earthquakes
are logarithmic. neutralize To make chemically
neutral or balanced. An alkali can be neutralized by adding an acid, and
vice versa. Also see: buffer. occlude/occlusion (a-klood/a-kloo-zhun)
To seal a material in contact with the skin surface. To take in and retain
a substance on the interior rather than the exterior surface. pH pH is a value representing
the acidity or alkalinity of a watery solution on a logarithmic scale.
Pure water is the standard used in arriving at this value. Pure water
is pH 7. pH 1 is extremely acidic. pH 13 is extremely alkaline. pH 13
is one million times more alkaline than pure water. pH 1 is one million
times more acidic than pure water. A material which
can produce a pathological immune response. An allergen. Hexavalent chromium
(Cr 6+ ) is a sensitizer or sensitizing agent. Once sensitized, further
contact must be avoided. Dry, scaling, itching
skin.
SURFACE SKIN pH TESTING 1. Adams, RM, Occupational
Skin Disease, Grune & Stratton, New York, 1983. 2. Avnstorp, C, Follow-up
of workers from the prefabricated concrete industry after the addition
of ferrous sulphate to Danish cement, Contact Dermatitis, 20(5):365-71,
May 1989. 3. Avnstorp, C, Prevalence
of cement eczema in Denmark before and since addition of ferrous sulfate
to Danish cement, Acta Derm Venereol, 69(2):151-5, 1989. 4. Avnstorp, C, Risk
factors for cement eczema, Contact Dermatitis, 25:81-88, 1991. 5. Bruze, M, et al.,
Patch testing with cement containing iron sulfate, Dermatol Clin,
Vol 8, No 1:173-6, January 1990. 6. Buckley, DB, Skin
burns due to wet cement, Contact Dermatitis, 8:407-409, 1982. 7. Cooley, J and
JR Nethercott, Prognosis of occupational skin disease, Occupational
Medicine: State of the Art Reviews, Vol 9, No 1:19-25, January-March
1994. 8. Cronin, E, Contact
Dermatitis, Edinburgh: Churchill-Livingston, 1980. 9. Feldberg, L, et
al., Cement burns and their treatment, Burns, 18, (1) 51-53, 1992. 10. Fregert, S, et
al., Reduction of chromate in cement by iron sulfate, Contact Dermatitis,
5:39-42, 1979. 11. Goh, CL and SL
Gan, Change in cement manufacturing process, a cause for decline in
chromate allergy? Contact Dermatitis, Vol 34, No 1:51-54, January
1996. 12. Halbert, AR,
et al., Prognosis of occupational chromate dermatitis, Contact Dermatitis,
27: 214-219, 1992. 13. International
Labour Organization, Geneva. 14. Koo, CC, et al.,
Letter to the Editor, Regional Burns Unit, Mount Vernon Hospital, Burns,
18, (6) 513-514, 1992. 15. Larson, M, and
Wolford, R, Survey of Apprentice Cement Masons, FOF Communications,
1997. (442 apprentices were surveyed using a questionnaire designed in
consultation with BD Lushniak, MD. Response rate was 100%. Mean years
in trade: 3.3; mean age: 27; most frequent age: 20.) 16. Lushniak, BD,
Epidemiology of occupational contact dermatitis. Dermatologic Clinics,
Vol 13, No. 3:671-680, July 1995. 17. Lushniak, BD,
The public health Impact of irritant contact dermatitis, Immunology
and Allergy Clinics of North America, Vol 17, No. 3:345-358, August
1997. 18. OSHA, Interpretation
of Standard 1926.51(f), RF Gurnham, Director, Office of Construction and
Maritime Compliance Assistance, February 2, 1994. 19. Portland Cement
Association, Report of Sample Material Safety Data Sheet for Portland
Cement, Skokie, IL, 1997. 20. Roto, P, et al.,
Addition of ferrous sulfate to cement and risk of chromium dermatitis
among construction workers, Contact Dermatitis, 34(1):43-50, January
1996. 21. Toal, W, chief
economist, Portland Cement Association, Skokie, IL, personal communication
with K Sweney of FOF Communications, June 1998. 22. van der Valk
PGM. and Maibach, H, The Irritant Contact Dermatitis Syndrome,
CRC Press, Boca Raton, 1996. 23. Vickers, HR,
and Edward, DH, Cement burns, Contact Dermatitis, 2:73-78, 1976. 24. US DOL Bureau
of Labor Statistics, 1995, reported in The Construction Chart Book,
CPWR, 1998. 25. US DOL Bureau
of Labor Statistics, 1997. |