case study developing thick skin

This monograph is one in a series of self-instructional publications designed to increase the primary care provider’s knowledge of hazardous substances in the environment and to aid in the evaluation of potentially exposed patients. See page 45 for more information about continuing medical education credits and continuing education units.

Reviewed by the American Academy of Dermatology

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Agency for Toxic Substances and Disease Registry

Introduction

Unlike most organs, the skin is in constant contact with the external environment. The skin ensures the body’s integrity by preserving internal fluids and electrolytes, maintaining thermoregulation, and protecting against physical injury and entry of harmful agents. Because the skin has such a prominent and protective role, many factors affect it adversely, including mechanical agents (friction, vibration, pressure, and trauma); physical agents (heat, cold, and radiation); biologic agents (plants, insects, animals, and microbes); and a variety of chemical agents.

The large number of chemicals in the home and workplace and the accidental and intentional releases to air, water, and soil potentially allow ever-increasing contact with chemicals in the environment. Dermatitis from chemical exposures in the workplace accounts for about 30% of all reported occupational illness; the prevalence of skin lesions due to chemicals encountered outside the workplace (i.e., environmental exposures) may never be known.

Seven common skin conditions that can have environmental etiologies are presented in this monograph. Accurate diagnoses and identification of etiologies are necessary, not only to properly treat skin diseases, but also to prevent future occurrence of disease or exposure.

Familiarity with the vocabulary of dermatology is helpful in understanding this specialized topic. A glossary of terms begins on page 42.

(a) What are the most likely nonoccupational etiologies for four of the more common skin conditions: irritant and allergic contact dermatitis, urticaria, and photosensitivity?

_________________________________________________________________

(b) What are the most effective treatments and preventive measures for each of these skin conditions?

Answers begin on page 39.

Case 1—Irritant Contact Dermatitis

A husband and wife consult you because of skin rashes that have developed since they began renovating a recently purchased older home. They have no history of skin problems.

The man complains of severe itching of the hands and an erythematous rash with papules and excoriations on the arms and lower legs. This rash began during the time he was placing new insulation in the attic.

The woman complains of a rash with redness and a small amount of blistering on the hands and wrists. There is mild itching, and some painful fissures have formed on the fingertips. The rash developed over a period of several days, beginning with only erythema while she was using a commercial paint-stripping product to remove old paint from interior trim. Although she wore rubber gloves, some of the stripping compound came in contact with her skin by running down into the gloves from the wrist area and through small holes in the fingers.

Description

❑ More than 90% of skin lesions caused in the workplace are contact dermatitis.

❑ Lesions of irritant contact dermatitis are localized and the symptoms are generally less severe than those of allergic contact dermatitis.

In the occupational exposure setting, the most common skin lesions (greater than 90%) are dermatitis due to either contact irritation or contact allergy, with irritant contact dermatitis being reported more frequently.

Irritant contact dermatitis caused by chronic exposure to mild irritants typically begins with erythema and progresses to eczema with exudative vesicles and papules, most often limited to the area of direct contact. Itching, stinging, and burning sensations may be noted—especially with stronger irritants—but are generally not as severe as symptoms of patients who have allergic contact dermatitis. (For a discussion of allergic contact dermatitis, see page 9.)

After days to weeks of chronic irritant exposure, the skin may become lichenified. Painful fissures may develop, along with hyperpigmentation, crusts, and scales. When contact with the offending irritant is discontinued, the rash usually resolves spontaneously in 1 to 3 weeks. Irritant contact dermatitis rarely spreads to areas of the body remote from the site(s) of direct contact.

Cutaneous hardening can develop when patients with irritant contact dermatitis have daily exposure to irritating substances. The skin becomes tough and resistant at the sites of contact, allowing further exposure to the irritant but without reaction. If exposure ceases, however, this protective adaptation is lost rapidly.

Pathophysiology

❑ Irritant contact dermatitis is caused by direct action of irritants on the skin.

Irritant substances cause dermatitis by direct chemical action (i.e., nonimmune-mediated) on contacted components of the skin. Irritants may be acidic substances, which coagulate skin proteins, or alkaline substances, which remove surface lipids. Both types of substances may cause drying and cracking of the skin. Epidermal necrosis with separation of the epidermis from the underlying dermis results in formation of vesicles that contain mainly polymorphonuclear (PMN) leukocytes. Vesicles and bullae with both PMN leukocytes and lymphocytes occur in the upper portion of the dermis.

Common Etiologies

Almost any substance can be a contact irritant ( Table 1 ), although some substances, such as some alcohols, oils, and glycols cause irritant contact dermatitis in only a small percentage of exposed persons. In contrast, strong irritants, such as concentrated mineral acids, alkalies, and amines, cause chemical burns or irritant contact dermatitis in almost everyone exposed. Mild to moderate irritants (e.g., dilute acids, organic hydrocarbon solvents, and some detergents) generally produce irritant dermatitis in only a small percentage of persons after a single contact but will cause a reaction in nearly everyone after prolonged or repeated exposure.

Table 1 . Common irritants in the home and workplace *

The young are generally more susceptible to irritant contact dermatitis than adults are because the threshold for skin irritation is low in children, particularly infants. Irritation reactivity gradually lessens after about 8 years of age. During play, children are likely to have skin contact with soils containing hazardous substances or with wooden playground structures that may have been treated with irritating chemicals such as arsenate and pentachlorophenol. The occurrence of skin problems is also common in the elderly. Besides age, personal factors that predispose persons to irritant contact dermatitis include genetic constitution and previous episodes of eczema.

Environmental and physical factors influence the skin’s susceptibility to irritant contact dermatitis. Susceptibility is often enhanced by wet work and conditions such as cold and windy weather, low relative humidity, and high temperatures that cause sweating. Some anatomic regions are more sensitive than others. Friction and lacerations or other mechanical skin injury may facilitate the development of irritant contact dermatitis. Occlusion by protective equipment such as gloves provides a humid environment, minimizing evaporation and making the stratum corneum more permeable to chemical substances that come in contact with the skin.

❑ Onset of irritant contact dermatitis tends to be insidious.

Irritant contact dermatitis is often difficult to differentiate from allergic contact dermatitis. Routine skin biopsy generally is not helpful because the histologic appearance of irritant and allergic contact dermatitis is similar. However, unlike allergic contact dermatitis, irritant contact dermatitis tends to localize at the exposed area and to cause mild itching and more erythema than vesiculation. The onset of irritant contact dermatitis is insidious rather than explosive. Patch testing by, or in consultation with, a dermatologist may be necessary to reach a diagnosis or to exclude allergic contact dermatitis. If fibrous glass is the suspected irritant, skin scrapings suspended in a few drops of 10% potassium hydroxide and examined under a light microscope at low power may reveal glass fibers.

❑ Removal from exposure is the most important step in treating irritant contact dermatitis.

The most important step in treatment is to remove the patient, at least temporarily, from further exposure to the offending agent. Substituting less irritating chemicals for the offending substance and correctly using protective materials, such as gloves and barrier creams, may help reduce exposure. During healing, the skin should be protected from other insults such as frequent washing, trauma, wind, and rapid changes in temperature.

❑ Topical corticosteroids may be useful in cases of irritant contact dermatitis.

Treatment for acute vesicular irritant contact dermatitis includes topical application of wet dressings for 15 to 20 minutes, 3 to 6 times daily. Domeboro’s solution (diluted 1:40) or Burow’s solution may be used to soak the dressings. Dressings should be discontinued after 2 to 3 days to avoid drying the skin.

Topical application of corticosteroid preparations may be efficacious. A low-potency corticosteroid should be used for mild to moderate skin conditions, with progression to more potent corticosteroids as required ( Table 2 ). Some over-the-counter and prescription topical medications or their excipients can further irritate the skin or provoke allergic contact dermatitis. Administering mild sedatives and antihistamines to relieve itching may also be beneficial.

Clinical signs of secondary bacterial infection include increased erythema and tenderness; development of a yellow, crusting, or purulent exudate; and occasionally, formation of small pustules around the edges of the dermatitis. Infection with monilia has an appearance similar to bacterial infection, except that the exudate is usually white. Infection may be difficult to recognize initially because the serous exudate and erythema of the dermatitis can obscure the signs. Obtaining samples of the exudate for culture and sensitivity before initiating topical or systemic antibiotic therapy is generally advisable.

Table 2 . Groups of topical corticosteroid products, in order of decreasing potency *

Case 2—Allergic Contact Dermatitis

You are consulted by a 44-year-old male office worker who has a chief complaint of a rash on his hands and wrists. His company recently relocated from a building where each employee had a private office to an older, renovated building with large bay areas. New wallboard was placed, the area was painted, and new carpet was laid just before the move. Employees now work in cubicles; the patient’s cubicle is located in an interior area with no windows. A copying machine is adjacent to his work area.

Since the move, many of the patient’s coworkers have been complaining of unpleasant odors, a feeling of fatigue or excessive tiredness, and mild irritation of the eyes, nose, and throat. They associate these symptoms with working in the new area. Although the patient has not noted such symptoms, he does complain of the increased noise and distraction in the new work area; he feels that his rash is somehow related to the new location.

The rash began 5 days ago with itching and redness. It then developed weeping and raised, vesicular lesions that spread from the initial location on the hands to the volar surfaces of the wrists. The patient states that he has a history of reaction to poison ivy, which produces a similar rash, but he has not been in an infested area for the past 2 months. He has no direct contact with industrial cleaning agents or carbonless copy paper in his work. He does have contact with chemicals through his woodworking hobby. He recently built an end table from exotic Japanese woods and has been applying a varnish that a friend brought from Japan.

❑ About 30% of occupational skin disorders are allergic contact dermatitis.

❑ In sensitized persons, inflammation begins about 12 hours after exposure to an allergen.

Although contact allergens produce sensitization in only a small percentage of exposed persons, allergic contact dermatitis constitutes about 30% of the skin disorders found in the workplace. Once a person has been sensitized to an offending substance, further exposure may result in relatively rapid development of local inflammation with erythema, papule formation, induration, and weeping vesiculation. Inflammation usually begins about 12 hours after exposure; intensity peaks in 50 hours or more. The rash may spread locally around the margins of the original site or to distant sites that did not have contact with the allergen. Potentially, the entire skin surface could become involved (a condition known as erythroderma or exfoliative dermatitis).

❑ Cross-reactivity with antigenically similar substances can occur with allergic contact dermatitis.

❑ The clinical and histologic appearances of allergic and irritant contact dermatitis are similar.

Allergic contact dermatitis results from a true allergic (i.e., cell-mediated) sensitization to the offending substance. Cross-reactivity with antigenically similar substances may occur. Initially, during the refractory period, the patient may be exposed without developing a reaction. During the induction phase, which may last from 4 days to several weeks (usually about 14 to 21 days), the development of complete allergic sensitization occurs as the allergen comes in contact with the skin. After the skin is fully sensitized, further contact with the allergen may result in rapid and severe dermal manifestations. When no further contact with the allergen occurs, the patient is in the period of persistence of sensitivity. The level of sensitivity can decrease over time, but sensitization may be lifelong.

Most allergens that cause allergic contact dermatitis have molecular weights of less than 500 daltons. The allergens are haptens rather than complete antigens; they must penetrate the skin and combine with endogenous proteins to form full antigens. Langerhans cells play a key role in then presenting the antigen to T lymphocytes, thereby activating the T cells. The sensitized T cells proliferate in the paracortical regions of the lymph nodes and produce effector and memory lymphocytes that remain in the general circulation. On subsequent contact with the complete antigen, the effector cells release lymphokines that may result in rapid and severe, local inflammation.

Many factors can affect the development of allergic contact dermatitis, including characteristics of the allergen itself, patient factors, and environmental conditions. Allergen factors include the physiochemical nature of the allergen (e.g., lipophilicity, solubility, and inherent sensitizing potency), concentration, total dose that comes in contact with the skin, anatomic site of contact, number and frequency of exposures, and occlusion by clothing or gloves.

The most important predisposing patient factors are a history of irritant contact dermatitis and the presence of an inflammatory skin condition that may promote absorption of the allergen. Irritant dermatitis caused by household cleaning agents on women’s hands may continue as allergic nickel dermatitis (from costume jewelry). In addition, age and genetic predisposition can influence the development of allergic contact dermatitis. Persons who have histories of atopic dermatitis have been reported to have decreased risk of developing allergic dermatitis but increased risk of developing irritant dermatitis.

Common predisposing environmental factors for allergic contact dermatitis are pressure, friction, heat, and prolonged immersion in water (such as occurs during wet work). Relative humidity, ambient temperature, and season of the year also play roles in development of allergic contact dermatitis.

❑ Aromatic compounds with polar or ionic substituents are potent sensitizing agents.

Only several hundred of the thousands of chemicals used are known to cause allergic contact dermatitis. With the exception of nickel, cobalt, and some forms of chromium, most metals do not produce sensitization. Strong inorganic alkalies and acids seldom cause allergic reactions. Although a substance’s sensitization potential cannot be determined from its chemical structure alone, some chemical classes are more likely to cause allergic contact dermatitis (see Table 3 ). Aromatic compounds with polar or ionic substituents are typically sensitizing agents (e.g., p -aminophenol and hydroquinone used in photographic film developers).

In addition, chemicals that are structurally similar to the original sensitizing agent may provoke recall of the specifically sensitized lymphocytes, a phenomenon known as cross-sensitization. For example, persons exposed to p-phenylenediamines used in the rubber industry may react to related substances used in photographic developers and dyes. Persons sensitized to Rhus plants such as poison ivy or poison oak may be sensitive to cross-reacting substances found in exotic trees and their derivative products (lacquers, varnishes, and oils).

Table 3 . Some chemical groups known to cause allergic contact dermatitis

Synthetic substances that commonly cause allergic contact dermatitis are rubber products, plastic resins, organic dyes, topical medications, germicidal and biocidal preparations, and various commercial and medication ingredients ( Table 4 ). Natural products can also produce allergic contact dermatitis. Exposure to certain airborne contaminants may also cause allergic contact dermatitis. Airborne contaminants include dichromates in cement dust, rosins used in soldering operations, and sawdust.

Table 4 . Common causes of allergic contact dermatitis

❑ Allergic contact dermatitis often spreads to areas remote from the site of contact.

Allergic contact dermatitis is often misdiagnosed as irritant contact dermatitis. Other conditions to consider in the differential diagnosis are atopic dermatitis, pustular eruptions on the palms and soles, psoriasis, Herpes simplex and Herpes zoster, insect bites, parasite infestation such as scabies, fungal infections of the feet with idiopathic vesicular reactions, nummular eczema, drug eruptions, and erythema multiforme.

❑ The clinical and microscopic appearances of skin lesions due to allergic contact dermatitis are the same as those due to irritant contact dermatitis.

No distinctive features of the lesions facilitate the differentiation of allergic from irritant contact dermatitis. An important diagnostic clue to allergic contact dermatitis is the spread of rash to areas remote from the site of contact; the mucous membranes are usually spared, and the scalp, soles, and palms are often unaffected.

Patch testing (see Diagnostic Procedures , page 35) may help differentiate allergic from irritant contact dermatitis. Because the histologic appearance of lesions due to allergic or irritant contact dermatitis is the same, routine skin biopsy is not helpful in their differentiation.

❑ Treatment for allergic contact dermatitis is identical to that for irritant contact dermatitis.

At present, there are no satisfactory means of desensitizing humans to allergens. The most important step is to remove the patient from exposure to the offending substance. In the workplace, options such as protective clothing and substitute chemicals should be explored. The therapy for allergic contact dermatitis is the same as that for irritant contact dermatitis (see Treatment, Irritant Contact Dermatitis, page 6).

Systemic corticosteroids may be indicated for some patients who have allergic contact dermatitis, especially when large areas of the skin (20% total body surface area or greater) are involved. Short courses of oral corticosteroids, particularly if used for a Rhus -induced contact dermatitis, may be given for 2 to 3 weeks (up to 21 days). Corticosteroids administered even for a short period of time should always be delivered in decreasing doses over the course of therapy to prevent adrenal suppression.

Case 3—Photosensitivity Contact Dermatitis

You are consulted by the headmaster of a children’s summer camp because of an outbreak of skin rashes in 20 of the campers. No counselors are affected. On examination, the rashes, which are confined to the hands, wrists, and forearms, consist of discrete linear streaks and patches that are hyperpigmented and do not itch.

One of the staff members speculates that the rashes are caused by contact with an epoxy glue used in building a model. However, only two of the children who have rashes have been involved in this activity. All the affected children had participated in a craft class in which they made lime sachets by puncturing lime skins and inserting sprigs of cloves over the surfaces of the limes. During the class, they also prepared gift cards from recycled paper. While the children attended to these activities, the counselors were engaged in planning an outdoor activity that was to follow the craft session.

❑ Photosensitivity reactions occur mainly on sun-exposed areas of the body.

❑ Photoallergic reactions are immune-mediated responses; phototoxic reactions are not.

Photosensitivity contact dermatitis occurs mainly on sun-exposed areas such as the face, upper chest, posterior portion of the neck, extensor surfaces of the forearms, dorsum of the hands and feet, and anterior surfaces of the lower legs. Areas of the skin normally covered by jewelry and clothing are spared, as are eyelids, areas under the chin, and upper portions of the ears covered by hair. Photosensitivity contact dermatitis may be the result of phototoxicity or photoallergy.

Lesions of phototoxic and photoallergic contact dermatitis resemble those of irritant and allergic contact dermatitis. They have been described as discrete, confluent, polymorphous linear streaks and patches that are macular and nonpruritic. The patient may experience a stinging or burning sensation of the skin, typically beginning shortly after exposure to sunlight and resolving rapidly when the skin is shaded. Lichenification and hyperpigmentation may occur, and the lesions may persist for months or years. In some cases, widespread involvement of the skin develops later. The photoallergic response usually occurs in only a small number of persons who have been previously sensitized to the photoactive agent.

❑ Sunlight can cause formation of the agents that result in photosensitivity contact dermatitis.

The mechanisms of photosensitivity contact dermatitis are broadly analogous to the mechanisms of irritant and allergic contact dermatitis except for the added requirement of appropriate ultraviolet (UV) radiation (i.e., wavelengths of 315 to 400 nanometers, known as UV-A). The agent that provokes the irritant or allergic response is formed after its precursor has been exposed to UV-A.

In phototoxicity, the excited state of the agent produced during irradiation is thought to lead to oxidation of cellular components or to allow binding of the agent with nucleic acids. In photoallergy, the initial reaction of the topical agent with UV-A forms either an excited molecule that can bind with protein to form a complete allergen or a product that is itself a strong contact allergen.

❑ Many topical products can produce photosensitivity dermatitis.

Many products that cause photosensitivity dermatitis are applied topically. Common examples are lotions containing fragrances; suntanning products with ultraviolet absorbers such as 6-methylcoumarin, homosalicylate, or p -aminobenzoic acid (PABA); and aftershave lotions containing musk ambrette. Germicides in soaps and detergents may also cause photosensitivity dermatitis. A major epidemic of allergic contact dermatitis occurred in Great Britain in 1960 after the introduction of two soaps that contained tetrachlorosalicylanilide, a photoactive antibacterial agent.

❑ Psoralens, which can cause phototoxic dermatitis, are useful in the treatment of psoriasis.

Certain systemically administered medications have caused photoallergic drug reactions. Examples include nalidixic acid, phenothiazines, sulfonamides, sulfonylureas, tetracyclines, and thiazide diuretics. Pharmacists, nurses, and others who routinely have skin contact with these drugs are prone to photosensitivity dermatitis.

Plants such as celery and citrus fruits have caused phototoxic dermatitis in persons who handle them extensively; farm workers are particularly susceptible. Contact with oil released from lime skins or with coal tar and pitch has resulted in phototoxic dermatitis, especially in lightly pigmented persons.

Psoralens, which are photoactive and can cause phototoxic dermatitis, are also used therapeutically in the treatment of psoriasis. In PUVA (psoralen plus UV-A radiation) treatment, a psoralen is painted on the affected skin or given systemically to patients who are then exposed to UV radiation. The photoadduct that is formed between the psoralen and DNA serves to slow the rate of the psoriatic overgrowth.

❑ A thorough drug history will usually rule out photoallergic drug reactions.

Photoallergy from chemical contact must be differentiated from polymorphous light eruption, systemic lupus erythematosus, pellagra, dermatomyositis, porphyria, allergic contact dermatitis and photoallergic drug reaction. A thorough history of medication treatment will usually rule out photoallergic drug reaction.

Photopatch testing may be useful in confirming the diagnosis, but results of photopatch testing are often difficult to interpret and are best left to dermatologists with specialized equipment and knowledge in this field.

❑ Treatment for phototoxic and photoallergic dermatitis is the same as that for irritant and allergic contact dermatitis.

The treatment for phototoxic or photoallergic dermatitis is the same as the treatment for irritant and allergic contact dermatitis (see pages 6 and 13). Identifying the offending agent and counseling the patient to avoid further exposure to it are the most important interventions. When the photosensitizing agent cannot be avoided, limiting sunlight exposure and wearing protective clothing, such as hats, gloves, long-sleeved garments, socks, and shoes, may help. Sunscreens may be used if reaction or cross-sensitivity between the causative agent and components in the sunscreen is not a possibility.

Case 4—Chloracne

A 42-year-old man consults you because of a persistent skin condition that he feels resembles the cosmetically displeasing acne he had as a teenager. His present skin condition consists of pale yellowish, cystic lesions and comedones localized on the face, below and lateral to the eyes, and behind the ears. Similar lesions are present on the cheeks, forehead, and neck; a few are present on the buttocks, where, according to the patient, he never had lesions with his prior affliction. He also complains of moderately severe itching.

History reveals no changes in diet, and the patient is not taking medications. For the last 15 years, the patient has worked for a local utility company. His most recent job duties have included replacing the heat exchange fluids in transformers. He first noted the rash about a month ago; he is not certain whether the rash appeared before or after he began this activity.

❑ Chloracne is rare and is usually due to occupational exposure to chloracnegenic agents.

❑ Chloracne may be an indication of systemic toxicity.

Environmental acne is a variety of acne venenata typically caused by industrial chemicals. It may result from contact with petroleum and its derivatives (oil acne), coal tar products (coa-tar-pitch acne), and halogenated aromatic hydrocarbons (chloracne). Environmental acne may also be caused by certain physical, mechanical, and biologic agents. Although the occurrence of chloracne is rare (probably fewer than 4000 cases worldwide), it is of great concern because it is an extremely refractory acne and because it may be indicative of systemic toxicity by a highly toxic chemical.

The lesions of chloracne consist of straw-colored cysts, numerous comedones, milia, and papules. The lesions are located on the face (especially at “crow’s feet” and below and to the outside of the eyes [malar crescent]), neck, earlobes, shoulders, abdomen, legs, buttocks, and genitalia. The nose is often spared. With severe chloracne, all the follicles in an area may be involved, resulting in a rather bizarre “pebbled” appearance. Pruritus is common and occurs in about 50% of chloracne cases.

❑ Chloracne is often refractory to treatment.

Onset of disease is typically delayed 2 to 4 weeks after exposure to a chloracnegenic agent. The first changes are a thickening of the follicular epithelium, development of comedones, and a slow disappearance of the sebaceous glands as they are replaced by keratinous cysts. Initially, inflammation is uncommon; inflammatory lesions with larger cysts and abscesses are later developments. Severe scarring may occur. Increased fragility of the skin, hypertrichosis, widespread follicular hyperkeratosis, or hyperpigmentation may develop. A brownish discoloration of the nails, swollen eyelids, and conjunctivitis or discharge may be present in some patients.

With no additional exposure, the disease will first progress, then regress over a 4- to 6-month period. A few cases of chloracne have persisted for 30 years or more after contact with the chloracnegenic agent has ceased.

❑ Chlorinated aromatic hydrocarbons cause chloracne.

Many chlorinated aromatic hydrocarbon compounds used in the workplace can cause chloracne. These compounds include chlorinated naphthalenes, polychlorinated biphenyls (PCBs), polybrominated biphenyls (PBBs), dioxins, polychlorinated dibenzofurans, pentachlorophenol, azobenzenes, and azoxybenzenes. (See Case Studies in Environmental Medicine: Polychlorinated Biphenyl (PCB) Toxicity , Case Studies in Environmental Medicine: Dioxin Toxicity , and Case Studiies in Environmental Medicine: Pentachlorophenol Toxicity .)

❑ Chloracne must be differentiated from other more common acnes.

Chloracne must be differentiated from oil acne or folliculitis due to exposure to grease and oils; acne vulgaris; acne cosmetica from heavy cosmetic use; acne mechanica from local pressure and friction; acne medicamentosa from medications such as corticosteroids, hormonal preparations, phenytoin, iodides (e.g., in kelp tablets), bromides and solar elastosis with comedones.

A history of exposure to agents known to cause chloracne and the typical appearance of the rash on physical examination are usually sufficient for diagnosis. Chloracne may be distinguished from acne vulgaris by the distribution of the lesions, age at onset, and morphology. Chloracne lesions typically affect the face, neck, earlobes, shoulders, abdomen, legs, buttocks, and genitalia, whereas lesions of acne vulgaris are found primarily on the face, neck, chest, and back (down to the waist). Chloracne can appear at any age, whereas acne vulgaris is seen most often in patients aged 13 to 26 years. Chloracne lesions consist of straw-colored cysts, numerous comedones, milia, and papules; whereas the lesions of acne vulgaris are typically comedones, papules, pustules, and scars.

Histologic examination of cysts may show typical changes, but the usefulness of biopsy in establishing the diagnosis is questionable. Associated noncutaneous conditions found in some patients who have chloracne include hepatotoxicity, porphyria cutanea tarda, and peripheral neuropathies.

❑ Removal from exposure to chloracnegenic agents is the most important treatment for chloracne.

Primary interventions are prevention of exposure to chloracnegenic chemicals and good hygiene because a satisfactory treatment regimen cannot be found in many cases. Administration of oral antibiotics and acne surgery have been of limited success. Retinoic acid (vitamin A) preparations or 13-cis-isoretinoic acid (Accutane) have been successful in carefully selected patients. (Note: Accutane is a known teratogen and should be used cautiously.) Injecting inflamed lesions with dilute triamcinolone, a glucocorticoid, may be helpful, as may dermabrasion for severe scarring.

Case 5—Pigment Alterations

Fifteen children from a local school are referred by the school nurse for evaluation of skin lesions. The lesions consist of decreased pigmentation in a scattered distribution. Two of the children have histories of itchy, weeping, vesicular rash on the neck and face that cleared before the pigment changes became noticeable. A public health evaluation of the drinking water and food served at the school has not revealed toxic or infectious agents. The school is located near a chemical manufacturing facility, in which the parents of several children work, including the parents of the two children who have histories of vesicular rash.

❑ Pigment changes are usually associated with post-inflammatory effects from physical or chemical agents.

A variety of physical and chemical agents may affect the color of the skin. Insults to the skin may cause either increased pigmentation (hyperpigmentation), decreased pigmentation (hypopigmentation), or both in contiguous areas (dyschromia). Inflammation, which may be subclinical and not apparent, usually precedes pigment alterations. Postinflammatory reaction (e.g., to contact dermatitis) is the most common cause of increased pigmentation, although pigment loss may also occur.

❑ Hypopigmentation is caused by damage to the melanocyte or through inhibition of melanin synthesis.

❑ Hyperpigmentation is often caused by nonspecific skin damage that leads to melanin or hemosiderin accumulation.

In hypopigmentation, depigmentation probably occurs either by damage to the melanocyte, which leads to cell distortion and death, or through inhibition of melanin synthesis by the offending substance. It may be significant that industrial compounds that cause hypopigmentation ( Table 5 ) are structurally similar to tyrosine, the building block of melanin. In industrially related hypopigmentation (leukoderma), the hands, wrists, and forearms invariably are affected; symmetry is usual. Depigmentation may also appear in body sites remote from the chemical contact (e.g., axillae, genitalia, and torso). The process of depigmentation usually takes 2 to 4 weeks and may require up to 6 months of repeated contact to become visible. The fact that many exposed workers do not lose pigment indicates that host factors are important in susceptibility.

Table 5 . Compounds known to cause hypopigmentation

Hyperpigmentation (also known also as melanosis or melanoderma) is due to accumulation of melanin from damaged melanocytes or to deposition of hemosiderin from extravasation of erythrocytes in the dermis. Another possible mechanism is overproduction of melanin by melanocytes in response to the offending agent. Hyperpigmentation is more likely to occur in dark-complexioned persons and can persist for years.

The cause of hypopigmentation is contact with alkylphenols (see Table 5 , page 24), skin damage due to chemical and thermal burns, or blunt or repeated trauma to the skin. Hyperpigmentation typically follows a bout of dermatitis or other episode of inflammation. Coal tar pitch, creosote, and various aromatic chlorinated hydrocarbons are a few of the compounds that can stimulate overproduction of melanin. UV radiation-induced stimulation of melanin synthesis (tanning) is the most common cause of hyperpigmentation in dark-complexioned persons.

❑ Hypopigmentation may be the result of environmental exposures or of idiopathic vitiligo.

❑ Skin staining and birthmarks can be misdiagnosed as hyperpigmentation.

Chemically induced hypopigmentation is indistinguishable from idiopathic vitiligo. Vitiligo affects about 1% of the general population and may be associated with autoimmune or endocrine abnormalities. Hypopigmentation must also be differentiated from depigmentation due to tissue destruction by chemical or thermal burns.

Hyperpigmentation should not be confused with birthmarks or direct skin staining or discoloration from contact with substances such as heavy metals (e.g., silver salts), nitrosylated compounds (e.g., nitric acid or dinitrophenol), derivatives of coal distillation (e.g., tar, pitch, and asphalt), and coal dust.

In most cases, the patient’s history and physical examination are sufficient to diagnose cases of pigment alterations. The loss of melanin in light-complexioned persons can be detected by failure of the skin to fluoresce under a Wood’s lamp.

❑ Hypopigmented and hyperpigmented areas should be protected from sunlight.

No effective treatment exists to reverse pigment changes. Hypopigmentation may last months to years after contact with the offending substance is discontinued, or it may be permanent. Depigmented skin should be protected from sunlight. Small depigmented areas may be camouflaged with agents such as Covermask, Dy-O-Derm, or Dermablend. Oral administration of psoralens and carefully graded UV radiation exposure (PUVA treatment) may be attempted if hypopigmentation involves large areas of skin.

In patients who have hyperpigmentation, worsening of the condition can be prevented by using sunscreens and covering affected areas

with clothing, hats, and gloves. Topical bleaching creams prepared from hydroquinone or its monobenzyl ether must be used cautiously to prevent widespread depigmentation. A preparation consisting of 0.1% hydrophilic tretinoin (Retin-A), 5% hydroquinone, and 0.1% dexamethasone in a hydrophilic ointment has been used in a 5- to 7-week treatment regimen with some success.

Case 6—Contact Urticaria

A 35-year-old woman consults you because of episodes of generalized hives that develop about 20 minutes after she uses certain brands of shampoo. The hives are preceded by sensations of itching, burning, and stinging of the skin on the scalp, upper face, and posterior aspect of the neck. The patient also experiences redness and tearing of the eyes, clear rhinorrhea, and nausea. She relates that a similar constellation of symptoms occurred after she applied an over-the-counter topical pain-relieving ointment for sunburn. A mild eczematous rash has been present on her forehead and posterior neck for about 6 weeks.

❑ Contact urticaria is a skin reaction that appears immediately after contact with the offending agent.

Contact urticaria is a localized wheal-and-flare response (hives) that develops almost immediately (a few minutes to about 1 hour) after direct contact with the eliciting agent. Many afflicted patients complain of skin sensations such as itching, burning, or tingling. Symptoms typically disappear within 24 hours.

❑ Contact urticaria may be due to immunologic-, nonimmunologic-, or uncertain-mediated mechanisms.

❑ Anaphylactic reactions may occur in patients who have contact urticaria syndrome.

Contact urticaria may be mediated by mechanisms classified as immunologic (allergic), nonimmunologic (nonallergic), or uncertain. Nonimmunologic urticaria, the most common type of contact urticaria, is caused by a direct action of the offending substance on the skin vasculature and a nonimmunologic release of vasoactive substances such as bradykinin, histamines, or other inflammatory mediators. The reaction remains localized.

Immunologic contact urticaria is an immediate allergic reaction in persons who have previously become sensitized to the offending agent. Parts of the skin that are remote from the contact site may be affected. The vasoactive effects in the immunologic form of contact urticaria are caused by an IgE-mediated reaction. The resulting erythema and edema are elicited mainly by histamines released from mast cells. Activation of the complement cascade and generation of anaphylatoxins can result in systemic effects (contact urticaria syndrome) in which the typical rash is accompanied by symptoms of asthma, rhinitis, conjunctivitis, orolaryngeal effects (itching and tingling sensations or edema of the lips, tongue, and mouth; or throat irritation), or gastrointestinal signs and symptoms. In rare cases, patients who have contact urticaria syndrome have experienced otherwise unexplained attacks of vascular collapse (anaphylactoid reactions).

The cause of the third type of contact urticaria is uncertain but includes both allergic and nonallergic mechanisms. Formaldehyde is an example of an urticant that has features of both types.

❑ Latex rubber gloves are a common cause of immunologic contact urticaria.

Immunologic contact urticaria is usually caused by proteins or protein complexes. It may also be caused by a wide variety of common chemicals, medications, cosmetics, and other agents ( Table 6 ). The rubber in latex gloves is a common cause of contact urticaria among healthcare professionals, as is the cornstarch used in the gloves. Food-

stuffs are also a common cause of contact urticaria. The orolaryngeal area is a site where immediate reactions are provoked by food allergens, most often among atopic persons.

Table 6 . Some substances that cause allergic contact urticaria

Nonimmunologic contact urticaria has been provoked by contact with substances as diverse as acids (acetic, benzoic, butyric, cinnamic, sorbic), alcohols (ethyl and butyl), balsam of Peru, benzocaine, cinnamic aldehyde, cobalt chloride, dimethylsulfoxide, formaldehyde, witch hazel, sodium benzoate, and esters of nicotinic acid. Cold temperatures can also cause nonimmunologic contact urticaria.

Uncertain mechanism-mediated contact urticaria has been associated with exposure to ammonium persulfate, which is used to boost peroxide hair bleaches to achieve a platinum-blond effect. Sunlight, which can produce rapid development of a wheal-and-flare reaction in exposed areas, and aquagenic agents (water, saline, or the patient’s own perspiration) are also associated with uncertain mechanism-mediated contact urticaria.

❑ A clear cause is seldom identified in cases of chronic contact urticaria.

Nonimmunologic contact urticaria must be differentiated from allergic contact urticaria and other forms of urticaria. The most important factor in making the correct diagnosis is taking a careful history of the relationship between possible exposures and development of symptoms. In cases of chronic urticaria, a clear cause is seldom identified.

Patch or scratch/prick tests may be used with suspected etiologic agents. These tests should be used initially on normal areas of skin,

then on involved skin (previously or currently affected) only when no reaction occurs on normal skin. Testing should be done by, or in consultation with, a dermatologist; resuscitation equipment and medications should be available in case a severe anaphylactoid reaction results.

❑ Antihistamines can alleviate symptoms of urticaria.

Chlorpheniramine-like antihistamines are of value in treating urticaria. The newer agents that have less sedative effects, such as terfenadine (Seldane) and astemizole (Hismanal), are not as efficacious. (Note: Seldane and Hismanal are contraindicated in patients who are taking ketoconazole, itraconazole, erythromycin, or other medications known to impair the metabolism of Seldane or Hismanal, and in patients who have significant hepatic dysfunction.)

Nonsteroidal anti-inflammatory medications have proved useful in certain cases of nonimmune urticaria; however, they may cause anaphylaxis in patients who have immune urticaria, especially patients who exhibit the triad of asthma, nasal polyps, and rhinitis. These patients should be cautioned about the use of nonsteroidal anti-inflammatory agents. All patients suffering from urticaria should be advised to avoid further contact with the eliciting substance.

Case 7—Malignant Neoplasms

A couple in their 60s who are native to a nearby rural area consult you because of the insidious development of a variety of skin lesions over the past 2 years. Both have hyperkeratotic lesions on the palms and the soles of the feet, as well as mottled-appearing hyperpigmented areas on the temples and neck. The man has a lesion on the right cheek that appears to be a basal cell carcinoma. Both patients complain of numbness and tingling in the feet and a general feeling of fatigue.

❑ Skin cancer is the most common neoplasm in adults in the United States.

❑ Sunlight, either alone or in conjunction with other agents, is a major contributing factor to skin cancer.

❑ Reasons for the 700% increase in malignant melanoma in the past 60 years have not been well established.

❑ PAHs and inorganic arsenic are well-known causes of cancerous skin lesions.

Cancer of the skin is the most common neoplasm among adults in the United States. More than 500,000 new cases of nonmelanoma skin cancer and about 28,000 cases of melanoma occur annually. Skin cancers associated with environmental factors include basal cell carcinoma, squamous cell carcinoma, malignant melanoma, and Bowen’s disease (intraepidermal squamous cell carcinoma). Pre-nonmelanoma skin cancers, such as actinic keratoses, can also be induced by environmental factors.

Sunlight, either alone or in conjunction with other agents, plays an important role in the development of most skin cancers, especially malignant melanoma. The incidence of melanoma has increased more than 700% in the past 60 years. If the incidence continues to increase at the present rate, within the next decade a person’s lifetime risk of developing melanoma will be approximately 1% (i.e., 1 case of melanoma per 100 persons). The reasons for this increased risk have not been well established but may be related to ozone depletion in the upper atmosphere; increased recreational sun exposure, especially early in life; increased use of industrial chemicals; and increased air pollution.

The usual wavelength in sunlight that causes skin cancers is 280 to 315 nanometers (UV-B). This range is capable of producing direct photochemical damage to the skin (e.g., alterations in DNA and other cellular constituents). UV-B also reacts with photoactive exogenous chemicals in or on the skin, causing them to absorb UV radiation and initiate or accelerate an adverse reaction in normal tissue. Industrial contaminants and air pollutants often contain photoactive chemicals, which can act as photosensitizers, additive carcinogens, or promotors.

The first association between occupational or environmental chemicals and malignancy was noted in 1775 by Percival Pott who reported a high incidence of scrotal cancer among London’s chimney sweeps. Years later, it was discovered that the cancers were caused by exposure to certain polynuclear aromatic hydrocarbons (PAHs). PAHs are found in soot, pitch, creosote, petroleum, and oils such as cutting oil, mineral oil, and shale oil. (See Case Studies in Environmental Medicine: Polynuclear Aromatic Hydrocarbon [PAH] Toxicity .) Other chemicals found to be associated with skin tumors include phenolic compounds, aliphatic hydrocarbons, and inorganic arsenic compounds.

Inorganic arsenic compounds are known to cause a variety of skin lesions, including malignant neoplasms. Initial dermal manifestations of arsenic exposure may be mild erythema and hyperhidrosis of the palms and soles, followed by development of slightly raised, firm, generally symmetrical punctate keratoses. White-colored, nonraised hyper-keratoses may also develop on the ankles, shins, and dorsum of the hands. A diffuse hyperpigmentation of the skin interspersed with white, somewhat atrophic macules (“raindrops on a dusty road”

appearance) may also be seen. Basal cell and squamous cell carcinomas may then develop. (See Case Studies in Environmental Medicine: Arsenic Toxicity .)

Bowen’s disease, a squamous cell carcinoma, may arise spontaneously in situ or may develop after chronic exposure to inorganic arsenic or other chemicals. Bowen’s disease consists of randomly distributed, sharply demarcated, erythematous, scaling lesions that range in size from a few millimeters up to 1 to 2 centimeters in diameter. The lesions grow slowly and rarely metastasize.

❑ The latency period for development of cancerous lesions can be 20 years or more.

Many chemical substances associated with malignant neoplasia are thought to interact directly with cellular macromolecules, resulting in neoplastic transformation of the affected cell. In some cases, absorbed chemicals are converted by skin enzymes (specifically, aryl hydrocarbon hydroxylases) to forms that then combine with DNA and other cellular constituents. Arsenic is thought to inhibit the enzymes involved in DNA replication and repair.

Some chemical agents act either concomitantly (cocarcinogens) or serially (promoters) to cause neoplastic transformation. In many cases, precancerous lesions, such as actinic or arsenical keratoses and tar warts, may precede the development of frank cancerous lesions. A latency period of several decades may lapse between exposure to a carcinogen and appearance of a cancerous lesion.

❑ Sunlight is the most important cause of malignant melanoma.

Certain chemical agents, such as PAHs and inorganic arsenic, are known to cause skin cancer. Nonchemical agents that may cause malignant neoplasms include sunlight, ionizing radiation, and physical trauma. Sunlight is the most important cause of malignant melanoma.

❑ Diagnosis of a malignant skin lesion requires a biopsy.

All potentially cancerous skin lesions must be differentiated from benign lesions. Suspected malignant skin lesions are diagnosed most accurately by histologic examination of excisional biopsies. A punch biopsy of suspect lesions may also be performed.

❑ Treatment of skin cancer depends on whether the cancer is localized or is metastasizing.

Prevention is the first line of defense for skin cancer. Avoiding overexposure to sunlight is most important. Protection from UV radiation can be accomplished by wearing tightly woven clothing and wide-brimmed hats and by applying sunscreens as absorbers. Sunscreens, which contain p-aminobenzoic acid (PABA) derivatives to absorb UV rays, can provide sun-protective factors (SPFs) ranging from 2 to 50 or more. An SPF of 15 allows most persons to remain out of doors for 5 hours before developing minimal erythema. Light-complexioned persons, persons of Celtic origin (i.e., Scotch, Irish, Welsh), and those with certain conditions (e.g., albinism, xeroderma pigmentosum, and erythropoietic protoporphyria) appear to be at increased risk for developing skin cancer. These sensitive populations may require more potent sunscreens.

Surgical excision and radiation are the most common treatment modalities for localized malignant skin lesions. All excised tissue should be sent for histologic examination to confirm the diagnosis and to be certain that an adequate margin of normal skin was removed. Surveillance for the development of further skin cancers should be continued. The treatment of metastasizing skin cancers or lesions with extensive local infiltration is beyond the scope of this review. Patients who have malignant tumors should be referred to, or treated in consultation with, a physician knowledgeable in cancer therapy.

Diagnostic Procedures

Obtaining and recording a detailed history of exposures (workplace, home, and environment) is essential in diagnosing skin disease. Besides physical examination, several special techniques may aid in the diagnosis of skin lesions. These include patch tests to detect contact allergy, skin biopsy, cultures, and microscopic scrapings of skin to detect yeasts, fungi, parasites, and fibrous glass. Referring patients to, or consulting with, a dermatologist who can perform or interpret dermatologic diagnostic testing, may be advisable.

Patch Testing

❑ Patch testing can help differentiate allergic from other forms of dermatitis.

Patch testing is frequently used to differentiate between allergic contact dermatitis and other forms of dermatitis. The presence of a delayed hypersensitivity reaction to an offending substance can be determined by placing a suitably prepared, nonirritating amount of a sample on the skin (usually on the back) under a chamber or impervious bandage (patch). If an eczematous dermatitis lesion develops under the patch during the 48 hours after application, allergy to the test substance or to an antigenically similar cross-reacting substance can be inferred. If no reaction is evident, the patches are removed, and the sites are reexamined for delayed reaction at 72 and 96 hours after application.

Interpretation of patch testing is often difficult, and it is usually recommended that the testing be carried out in specialized centers or by consultants who routinely do patch testing. If no response is provoked, it does not mean unequivocally that the patient is not allergic. For example, if an offending or cross-reacting substance was not included, or was not applied in proper concentration, a false-negative result will occur.

Complications of patch testing include the “angry back syndrome,” in which the patient’s entire back becomes edematous and erythematous. Flare-up of previously existing eczema can also occur, especially when testing materials are not obtained from standard commercial sources. Even local response to the test substance may be extensive, causing patient discomfort. Patch testing itself can result in allergic sensitization to a substance to which the patient was not allergic previously, although this is a rare occurrence. Infections, scarring, and pigment alterations may also be complications of patch testing.

Photopatch Testing

❑ Photopatch testing may help reveal the cause of photosensitivity dermatitis.

When photosensitivity dermatitis is suspected, a combination of chemical patch testing and special light exposure may reveal the cause. Duplicate patches are used; one set is covered, and the other

set is exposed to a measured amount of UV radiation. There are several difficulties in the performance and interpretation of photopatch testing, and it should be performed by practitioners who have experience and the requisite special equipment.

Skin Biopsy

❑ Skin biopsy is not helpful in differentiating allergic contact dermatitis and irritant contact dermatitis.

The appropriate skin biopsy (punch biopsy or excision of the lesion) usually can be performed under local anesthesia by experienced practitioners in an outpatient setting. Microscopic examination of the specimens obtained can allow differentiation between benign and malignant skin conditions. Irritant and allergic contact dermatitis cannot be readily differentiated on routine skin biopsy.

Other Diagnostic Procedures

❑ Skin scrapings, UV-light examinations, cultures, and serologic testing are diagnostic tools used for various skin lesions.

Other procedures include skin scrapings, UV-light examinations, cultures, and serologic testing.

Skin scrapings can be used to look for fungal hyphae, for strands of fiberglass in suspected fibrous glass dermatitis, or for scabies mites and eggs. A Wood’s lamp, which produces UV radiation, can be used to examine suspected areas of hypopigmentation in light-complexioned persons. Areas deficient in melanin will not fluoresce under UV light, whereas areas of skin with normal melanin content will fluoresce.

Bacterial, viral, or fungal cultures may be indicated if dermal infections are considered in the differential diagnosis. Crusts, when present, should be lifted with a scalpel blade before swabbing the lesion with a sterile cotton-tipped applicator to obtain material for bacterial cultures. Fungi may be collected for culture media by gently scraping the skin with a sterile scalpel blade. Viral cultures from skin lesions require specialized laboratory facilities. Viruses can be collected for special media by unroofing lesions and swabbing with a sterile cotton-tipped applicator.

Patients who have immunologic-mediated contact urticaria may be evaluated by serologic testing. Protein electrophoresis and measurement of circulating IgE may be useful.

Suggested Reading List

Adams RM. Occupational skin disease. 2nd ed. Philadelphia: W.B.Saunders Co., 1990.

Maibach HI, ed. Occupational and industrial dermatology. 2nd ed. Chicago: Year Book Medical Publishers, Inc., 1987.

Mathias CGT. Occupational dermatoses. In: Zenz C, ed. Occupational medicine: principles and practical applications. 2nd ed. Chicago: Yearbook Medical Publishers, Inc., 1988:132–65.

Raffle PAB, Lee WR, McCallum RI, Murray R, eds. Occupational diseases of the skin. In: Hunter’s diseases of occupations. Boston: Little, Brown & Company, 1987:917–48.

Rosenstock L, Cullen MR. Skin disease. In: Clinical occupational medicine. Philadelphia: W.B.Saunders Co., 1986:147–73.

Rycroft RJG. Occupational dermatoses among office personnel. Occup Med 1986;1:323–8.

Seidenari S, Manzini BM, Danese P, Motolese A. Patch and prick test study of 593 healthy subjects. Contact Dermatitis 1990;23:162–7.

Shama SK. Occupational skin disorders, In: McCunney RJ, ed. Handbook of occupational medicine. Boston: Little, Brown & Company, 1988:216–35.

Suskind RR. Environment and the skin. Med Clin North Am 1990;74:307–24.

Irritant and Allergic Contact Dermatitis

Abel EA, Wood GS. Mechanisms in contact dermatitis. Clin Rev Allergy 1986;4:339–52.

Dahl MV. Chronic irritant contact dermatitis: mechanisms, variables, and differentiation from other forms of contact dermatitis. Adv Dermatol 1988;3:261–75.

Lammintausta K, Maibach HI. Exogenous and endogenous factors in skin irritation. Int J Dermatol 1988;27:213– 22.

Photosensitivity Dermatitis

Emmett EA. Drug photoallergy. Int J Dermatol 1978;17:370–9.

Emmet EA. Evaluation of the photosensitive patient. Dermatol Clin 1986;4:195–202.

Gross TP, Ratner L, de Rodriquez O, et al. An outbreak of phototoxic dermatitis due to limes. Am J Epidemiol 1987;125:509–14.

Harber LC, Bickers DR. Photosensitivity diseases. Philadelphia: W.B.Saunders Co., 1981.

American Medical Association. The Health effects of “Agent Orange” and polychlorinated dioxin contaminants: an update, 1984. Chicago: American Medical Association, 1984.

Taylor JS. Environmental chloracne: update and overview. Ann NY Acad Sci 1979;320:295–307.

Tindall JP. Chloracne and chloracnegens. J Am Acad Derm 1985;13:539–88.

Zugerman C. Chloracne. Clinical manifestations and etiology. Dermatol Clin 1990;8:209–13.

Pigment Abnormalities

Gellin GA, Maibach HI, Misiaszek MH, Ring M. Detection of environmental depigmenting substances. Contact Dermatitis 1979;5:201–13.

Gian C, Lu MY, Wang XS, et al. Epidemiologic study on the skin lesions of workers exposed to N,N’-methylenebis-(2-amino-1,3,4-thiadiazole) and of children in the neighborhood of the factory. Scand J Work Environ Health 1985;11 Suppl 4:55–9.

Ortonne J-P, Mosher DB, FitzpatrickTB. Chemical hypomelanosis. In: Ortonne J-P, Mosher DB (eds). Vitiligo and other hypomelanoses of hair and skin. New York: Plenum Medical Book Co., 1983:479–508.

Carcinogenesis

Austin DF, Reynolds P. Occupation and malignant melanoma of the skin. In Gallagher RP (ed). Epidemiology of malignant melanoma. Recent results in cancer research. Vol 102. Berlin: Springer-Verlag, 1986:98–107.

Callen J, Headington J. Bowen’s and non-Bowen’s squamous intraepidermal neoplasia of the skin. Arch Dermatol 1980;116:422–6.

Emmett EA. Occupational skin cancers. Occup Med: State Art Rev 1987;2:165–77.

Epstein JH. Photocarcinogenesis: A review. Natl Cancer Inst Monogr 1977;50:13.

Shannon RL, Strayer DS. Arsenic-induced skin toxicity. Hum Toxicol 1989;8:99–104.

Van der Leun JC. UV carcinogenesis. Photochem Photobiol 1984;39:861–8.

Sources of Information

More information on skin lesions and treating and managing cases involving skin lesions due to environmental exposure can be obtained from ATSDR, your state and local health departments, and university medical centers. Case Studies in Environmental Medicine: Skin Lesions and Environmental Exposures—Rash Decisions is one of a series. To obtain other publications in this series, please use the order form on the inside back cover. For clinical inquiries, contact ATSDR, Division of Health Education, Office of the Director, at (404) 639–6204.

Answers to Pretest and Challenge Questions

Pretest questions are on page 1. Challenge questions begin on page 3.

The Pretest questions (a) and (b) are answered in Challenge answers 1, 2, 3, and 6 below.

(1a) The man in Case No. 1 has most likely developed an irritant contact dermatitis from the insulating material (e.g., fiberglass, rock wool). This possibility could be investigated by placing skin scrapings on a microscope slide with 1 to 3 drops of 10% potassium hydroxide (KOH) and examining the specimen under a light microscope using low power. The presence of fibrous strands would confirm the diagnosis. Dermatitis elicited by fibrous glass is variable and depends on individual characteristics and extent of exposure.

(1b) The woman probably has either irritant or allergic contact dermatitis. The basic histopathologic appearance of these two conditions is essentially the same, and differentiating between them by appearance or routine skin biopsy is difficult. However, most paint-stripping products contain one or more of the following compounds: isopropyl alcohol, cresylic acid, methylene chloride, glacial acetic acid, aliphatic hydrocarbons, and aqueous ammonia, all of which tend to be irritants rather than allergens. The presence of mild rather than severe itching, more erythema than vesiculation, localized lesions, and insidious rather than explosive onset are more consistent with irritant contact dermatitis than with allergic contact dermatitis.

(1c) Both the man and the woman should be advised to avoid exposure to the offending substances, at least temporarily. Applying and rapidly removing adhesive or Scotch tape from the man’s affected skin may remove the fibers and help relieve the itching.

The contact dermatitis of both patients may be treated using Domeboro’s solution (1:40 dilution) or Burow’s solution. Dressings soaked with one of these solutions should be applied topically for 15 to 20 minutes, 6 times daily. Topical corticosteroids may be applied, starting with a steroid of low potency and progressing to more potent corticosteroids as needed. Mild sedatives and antihistamines may be administered to relieve itching. Topical or systemic antibiotic therapy may be used to combat secondary bacterial infection. Repeated exposure to UV radiation may be therapeutic in some cases, causing hardening or increased resistance to further irritation.

(2a) The rash of the patient in Case No. 2 is not likely to be due to airborne allergens or irritants in the new office location. Although some cases of allergic or irritant contact dermatitis can develop from exposure to airborne allergens or irritants, the patient’s occupational history and the location of the rash do not suggest this etiology. Eyelids, cheeks, nasal folds, and the neck most probably would be involved if an airborne agent in the workplace were responsible. The hand and wrist location suggests contact with an allergen that is handled.

(2b) Yes, the patient’s woodworking hobby, with recent introduction of various exotic woods and Japanese varnish (possibly derived from the Japanese lacquer tree), suggests a cross-sensitivity reaction to agents related to Rhus plants, to which he is known to be sensitized.

(2c) The patient probably has allergic contact dermatitis. Therapy would be identical to the regimen for irritant contact dermatitis described in (1c) above. Attempts to desensitize sensitive persons have been unsuccessful in most cases.

(3a) Given the rural location and outdoor activities in which the children in Case No. 3 were involved, airborne allergic contact dermatitis to Rhus -type plant oleoresins (e.g., poison ivy, poison oak, poison sumac) or pollen could be the cause. However, vesiculation would be expected with allergic contact dermatitis. Patch testing could rule out this diagnosis.

Puncturing lime skins while making sachets during craft class could have exposed the children to psoralens, which are known photoirritants. Immediately after the craft class, the children engaged in outdoor sports. This combination of activities could lead to photosensitivity dermatitis. Because the counselors were involved in a staff meeting during the craft class and did not puncture the limes, only the children were affected.

(3b) One of the most important components in therapy for photoreactions is identification and avoidance of the photoactive agent. When exposure to the offending agent cannot be avoided, sunlight exposure should be minimized. Light exposure can be reduced by wearing protective clothing such as broad-brimmed hats, long sleeves, and tightly woven fabrics, or by using sunblocking agents. Symptomatic topical treatments may also be used.

(4a) The rash of the patient in Case No. 4 is more consistent with chloracne than with acne vulgaris. Acne vulgaris has a different appearance, and its distribution is typically the central face, back, and chest; it seldom affects the buttocks. The sebaceous glands are usually active in acne vulgaris, but chloracne gives the skin a “dry” appearance. Comedones are small in size and number in cases of acne vulgaris, whereas typical straw-colored cysts are almost pathognomonic for chloracne.

The patient’s occupation is a potentially relevant factor. A telephone call to a manager at the utility company reveals that old heat exchanger fluids contain PCBs, and in the process of replacing these fluids with less hazardous materials, the workers could have accidental contact with the material. The finding that PCBs are the most probable cause of the patient’s chloracne should prompt a health hazard evaluation by the appropriate regulatory authorities and should encourage action to prevent further exposure.

(4b) The chloracnegenic agent should be identified and exposure stopped. Chloracne is resistant to treatment in many cases. Medications used for acne vulgaris are ineffective for chloracne, but oral and topical antibiotics, acne surgery, injection of inflammed cysts with triamcinolone, and dermabrasion of scars may be efficacious. Topical application of retinoic acid (Vitamin A) or 13-cis-isoretinoic acid (Accutane) has been used on carefully selected patients with some success. In addition to treating the skin lesions, examination and testing should be performed to rule out hepatotoxicity, porphyria cutanea tarda, and peripheral neuropathy—all possible systemic effects of PCB exposure. (For further information, see Case Studies in Environmental Medicine: Polychlorinated Biphenyl [PCB] Toxicity .)

(5a) Yes, the manufacturing plant could be associated with the children’s skin lesions in Case No. 5. A similar outbreak among workers at a manufacturing facility and children in a neighboring school was reported in 1985; a powdered thiadiazole was responsible in that case. Because an etiologic agent for the pigment changes in the children has not been found in routine testing of the water and food at the school, it would be advisable to consider other common sources in the neighborhood, such as the school playground. The nearby chemical manufacturing facility should also be investigated as a possible source, especially because the parents of the two children with more severe manifestations are employed at this plant. The parents could be carrying contamination home on their skin, clothing, and shoes. In addition, the children may be playing in an area with contaminated soil.

(5b) You could begin your investigation by contacting the nurse or health and safety manager at the parent’s workplace to determine whether a workplace agent or process is associated with the rashes of some workers. You could request from the manufacturer Material Safety Data Sheets (MSDSs) or other information about the raw materials, byproducts, chemical intermediates, and finished products used or produced at the plant.

The Toxic Chemical Release Inventory (TRI), which is maintained by the U.S. Environmental Protection Agency (EPA) and is available to the public either online through the National Library of Medicine or on CD-ROM, could be used to determine the normal releases from the plant. Plant management, the local EPA, or the local fire department could be consulted to determine whether any accidental chemical releases have occurred recently at this facility. If soil contamination is suspected, soil samples from nearby playgrounds, school yards, or other play areas should be tested. Local or state health officials may be contacted for assistance.

(5c) If the lesions are persistent, large, and cosmetically displeasing, you could refer the children to a dermatologist for consideration of PUVA treatment. Sunscreens and protective clothing can protect areas with depigmented skin and prevent hypopigmentation from worsening.

(6a) The constellation of complaints of the patient in Case No. 6 is consistent with contact urticaria syndrome. Balsam of Peru and various alcohols (especially propyl alcohol and ethyl alcohol) in numerous consumer cosmetic products and benzocaine in many over-the-counter topical analgesic preparations could be causative agents.

(6b) Evaluation might include correlating the history of the illness with probable exposures, serologic studies of circulating IgE, and patch or scratch testing (performed by, or in consultation with, a dermatologist in a setting with resuscitation equipment in case of anaphylactoid reaction).

(6c) Usual treatment for contact urticaria includes advice to avoid suspected or known causative substances and administration of antihistamines. In certain patients, nonsteroidal anti-inflammatory medications have shown some efficacy.

(7a) The constellation of complaints of the couple in Case No. 7 suggests chronic arsenic poisoning. Arsenic toxicity from criminal activity, intentional surreptitious self-injury, occupational exposure, and environmental exposure should be investigated.

On questioning, the couple reveals that they have obtained drinking water from a private well for the past 40 years and that they heat their home with a wood stove fueled with scrap wood. Analysis of the well water reveals arsenic at 0.62 milligrams per liter (mg/L), a concentration significantly above the EPA maximum contaminant level (MCL) of 0.05 mg/L. Ashes collected from the wood stove and soot from the chimney also contain arsenic in concentrations of several hundred parts per million; the most likely source of this contamination is arsenic-containing preservatives in the scrap wood.

(7b) Initial action should be taken to terminate further arsenic exposure; it will be futile to treat the skin lesions (or provide chelation therapy to reduce body burden) if exposure continues. An alternative source of drinking water should be substituted immediately, contaminated lumber should not be burned, and the home should be decontaminated. Advice on abatement and remediation and aid in investigating any other possible sources of arsenic may be obtained from the state or local health department. (For further information on arsenic and arsenic poisoning, see Case Studies in Environmental Medicine: Arsenic Toxicity .)

Treatment of the man’s basal cell carcinoma may involve radiation therapy or excisional biopsy, including a suitable margin of normal-appearing skin. All tissue removed should be submitted for histologic confirmation of diagnosis and to be certain the tissue borders are free of cancerous cells. The patient should be counseled to avoid prolonged exposure to sunlight and to use sunscreens or protective clothing whenever exposure to sunlight is anticipated.

anaphylaxis.

Commonly used to denote the immediate, transient kind of immunologic (allergic) reaction characterized by contraction of smooth muscle and dilation of capillaries due to release of pharmacologically active substances (histamine, bradykinin, serotonin, and slow-reacting substances), classically initiated by the combination of antigen (allergen) with mast cell-fixed, cytophilic antibody (chiefly IgE).

acne mechanica.

Acne caused or exacerbated by friction.

acne medicamentosa.

Acne caused or exacerbated by several classes of drugs including antiepileptics, halogens, and steroids.

acne venenata.

Acne produced by external irritants or drugs internally administered.

acne vulgaris.

Simple acne, probably caused by hormonal fluctuations.

bullae (singular bulla).

Large bubble-like structures (vesicles) appearing as a circumscribed area of separation of the epidermis from the subepidermal structure, typically filled with serum.

Acne-like eruptions due to prolonged contact with certain chlorinated aromatic hydrocarbon compounds.

chloracnegenic agents.

Substances that cause chloracne.

A plug of sebaceous matter, capped with a blackened mass of epithelial debris, filling the pilosebaceous orifice.

dermatitis.

Inflammation of the skin.

Characterized by the distinctive phenomena of atopy, a Type I allergic reaction, specifically one with strong familial tendencies, caused by allergens such as pollens, foods, dander, and insect venoms, and associated with the Prausnitz-Küstner (IgE class) antibody.

allergic contact d.

A delayed type of induced sensitivity (allergy) of the skin with varying degrees of erythema, edema, and vesiculation, resulting from cutaneous contact with a specific allergen.

irritant contact d.

Irritation of skin caused by contact with substances that are toxic to epidermal or connective tissue cells; lesions are usually erythematous and papular, but can be purulent or necrotic, depending on the nature of the toxic material applied.

dermatomyositis.

A progressive syndrome characterized by muscular weakness with a purplish erythematous skin rash on the face.

Generic term for acute or chronic inflammatory conditions of the skin, typically erythematous, edematous, papular, vesicular, and crusting; often followed by lichenification and scaling and occasionally by duskiness of the erythema; often accompanied by sensations of itching and burning.

Inflammatory redness of the skin.

erythema multiforme.

An acute eruption of macules, papules, or subdermal vesicles presenting a multiform appearance, the characteristic lesion is typically over the dorsal aspect of the hands and forearms; its origin may be allergic, seasonal, or from drug sensitivity, and the eruption may be recurrent or may run a severe course (Stevens-Johnson syndrome), possibly ending in death.

An inert substance such as gum arabic, syrup, lanolin, or starch, that acts as a diluent or forms a vehicle for drug delivery.

folliculitis.

An inflammatory reaction in hair follicles; the lesions may be papules or pustules.

exfoliative dermatitis.

General scaling of the skin, usually with erythema.

Incomplete or partial antigen; an antigen that is incapable, alone, of causing the production of antibodies.

See urticaria.

hyperkeratosis.

Hyperkeratinization; hypertrophy of the horny layer of the epidermis.

hyperpigmentation.

Increased pigmentation of the skin.

hypertrichosis.

Growth of hair in excess of normal.

hypopigmentation.

Decreased pigmentation of the skin.

Any lesion on the epidermis marked by the presence of circumscribed overgrowths of the horny layer.

lichenification.

Leathery induration and thickening of the skin with hyperkeratosis, due to a chronic inflammation caused by scratching or long-continued irritation.

leukoderma.

An absence of pigment, partial or total, in the skin.

Relating to or marked by a small, discolored patch or spot on the skin, neither elevated nor depressed below the skin’s surface.

malar crescent.

Around the cheek or cheekbones.

Pigment that occurs in the hair, skin, or retinas.

melanocytes.

Pigment cells of the skin.

melanoderma.

An abnormal darkening of the skin by deposition of excess melanin, or of metallic substances such as silver and iron.

A malignant neoplasm derived from cells that are capable of forming melanin, which may occur in the skin of any part of the body; in the early phases, the lesion is characterized by proliferation of cells at the dermal-epidermal junction, and the neoplastic cells soon invade adjacent tissue extensively. Melanomas frequently metastasize widely; most examples of this neoplasm occur in adults and may originate de novo or from a pigmented nevus or malignant lentigo.

milia (singular milium ).

Sebaceous tubercle; whitehead; a small subepidermal keratin cyst, usually multiple, therefore commonly referred to in the plural.

An eruption of minute vesicles and papules due to retention of fluid at the mouths of the sweat follicles.

Marked by circular or oval lesions.

Small, solid elevations on the skin.

photoallergy.

Sensitization of the skin to light.

phototoxicity.

The condition arising from overexposure to ultraviolet light.

Furo[3, 2-g]coumarin; a phototoxic chemical derived from fruits of the citrus family (e.g., limes).

A condition characterized by the eruption of circumscribed, discrete and confluent, reddish, silvery scaled macropapules.

A genus of trees and shrubs (family Anacardiaceae) containing various species that are used for their ornamental foliage; poison ivy, poison oak, and poison sumac belong to this genus.

solar elastosis.

Degenerative change in elastic tissue of the dermis due to repeated or constant exposure to sunlight over a period of years.

Hives; an immediate eruption of itching wheals, which may be due to physical and chemical agents, foods or drugs, foci of infection, or psychic stimuli.

urticaria syndrome.

Consists of the typical urticarial rash with systemic involvement.

vesiculation.

Blistering.

The appearance on the otherwise normal skin of loss of melanin pigment with white patches of varied sizes, often symmetrically distributed; the skin bordering the affected sites is usually hyperpigmented, and hair in the affected areas is usually white.

People are increasingly concerned about potential environmental health hazards and often ask their physicians questions such as: "Is the tap water safe to drink?" "Is it safe to live near power lines?" Unfortunately, physicians often lack the information and training related to environmental health risks needed to answer such questions. This book discusses six competency based learning objectives for all medical school students, discusses the relevance of environmental health to specific courses and clerkships, and demonstrates how to integrate environmental health into the curriculum through published case studies, some of which are included in one of the book's three appendices. Also included is a guide on where to obtain additional information for treatment, referral, and follow-up for diseases with possible environmental and/or occupational origins.

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Growing a thicker skin

Nicholas Evans, Lecturer in Bioengineering, is developing therapies for stimulating skin regeneration that may someday benefit millions of people each year recovering from surgeries like caesarean sections, or from skin cancer, accidents and burns.

“When we have a skin wound, keratinocytes – the predominant cell type in the outermost layer of the skin – need to know that there is a wound and how to crawl back over it,” says Nick. “In my research I am asking questions about the stiffness and topography of a wound and how its three-dimensional shape affects this healing process.”

For years, medical researchers have observed that a cut made to a foetus at an early stage of its development will heal without a scar. Nick is probing the secrets of why this happens by growing skin cells in vitro on synthetic wound surfaces to see how they affect the behavior of cells in wound healing. He is collaborating with colleagues in Engineering and the Environment, who help create the simulated wounds on polymers through a process called micro-fabrication.

Though their research is in its early stages, Nick believes that the questions they are asking about the mechanical characteristics of skin wounds – like the amount of tension on the wound site– along with advances in technology, point the way to a hopeful future for skin healing.

Other University of Southampton sites

• Nicholas Evans staff page

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Operations and Policy

How to Develop a Thicker Skin in Your Medical Practice

Laura Hills, DA

December 8, 2019

Medical practice managers and their employees do extremely important work. And yet, doing just about anything important means that we will need to cope with at least some amount of criticism and nay-saying. Although we can’t disregard negative feedback and live in our own fairytale world, we can’t let other people’s comments derail us from our goals. This article highlights the differences between external and internal expectations, and underscores the importance of weighting each appropriately. It offers medical practice personnel 15 practical strategies for thickening their skin, and what to do when they find their skin thinning. This article also explores why human beings tend to take things personally, and what to do about it. Finally, it suggests 10 ways that medical practice employees and their managers can thicken their skin against criticism.

Do you have an employee who frequently has his or her feelings hurt, who seems to take everything personally, or who is prone to tears? Do you replay scenes from work in your head at night, beating yourself up for not handling or anticipating things better, or for making an honest mistake? Or do you or your employees find yourselves feeling hurt, embarrassed, or betrayed by a careless remark, a funny look, or the least bit of criticism? If so, you would all benefit greatly from having a thicker skin.

Making everything about ourselves can give us a skewed view of our world and make us overly sensitive and self-absorbed.

Of course, developing a thicker skin may be easier said than done. It may be human nature to make everything about us and to take things personally. However, as Ma(1) succinctly puts it, “You are not the center of the universe.” Making everything about ourselves can give us a skewed view of our world and make us overly sensitive and self-absorbed. It also can encourage us to invent stories and imagine things that aren’t there. For example, Ma says, we may encounter a person who is not paying enough attention to us. We may brood and ask ourselves, “‘Is she mad at me?’ ‘Did I say something wrong?’” Our gloomy thoughts can intensify, Ma says, leaving us emotionally crippled and thinking that we have ruined everything. Yet, there may be a good reason for the inattention that has nothing to do with us. The person may not have noticed us or be distracted. But even if he or she is intentionally ignoring us, Ma asks, “Why are you fussing about it?”

Coworkers may feel they need to tiptoe around or avoid a thin-skinned colleague or manager.

Of course, no one enjoys being ignored, facing criticism, or dealing with social rejection. However, it may be impossible to interact with people day in and day out without an occasional brush with these challenges. This is especially true in a busy medical practice, where emotions and stakes can run very high, and where there is going to be a fair amount of pressure put upon us. However, being thin-skinned will help no one. Coworkers may feel they need to tiptoe around or avoid a thin-skinned colleague or manager. And the thin-skinned person is going to feel a great deal of pain, which is unpleasant and unproductive, of course, but which will also deplete energy and focus and diminish performance.

Fortunately, the medical practice manager is in an excellent position to develop a thicker skin and to teach his or her employees to do the same. As Licht(2) suggests, “Learning how to be emotionless in the office is a gift and one that you have to give yourself. The thicker your skin, the less stress you will have.” Of course, it can be challenging to take yourself completely out of the equation, remove your ego, and remain objective. Striving to be emotionless, as Licht suggests, may not be the best goal for a medical practice employee. No one advocates that medical practice personnel become so tough that they become rigid, unfeeling, and incapable of compassion. The good news is that going to that extreme is not necessary. In the following sections we explore skin-thickening strategies that you and your employees can use to reduce or eliminate stress in your medical practice, without closing your hearts to others.

External Versus Internal Expectations

Medical practice employees have many expectations placed upon them. Some of these expectations will come from a supervisor, HR, an employee handbook, a governing body, or a professional association. Some will come from a patient, a physician, or a coworker. And some will come from within. One way that you can begin to develop a thicker skin is to differentiate between external and internal expectations and to assign each its proper weight. As Hughes(3) suggests, internal expectations “should always take precedence” as we try to develop a thicker skin.

Often, we are harder on ourselves than we would be on anyone else.

Of course, you will need to fulfill the expectations of your job, and no one is suggesting otherwise. But often, we are harder on ourselves than we would be on anyone else. Unfortunately, when we place unrealistic expectations on ourselves, our skin gets thinner and thinner. For example, if we expect to be perfect, we may beat ourselves up when we goof or when someone criticizes us. If we expect that everyone is going to like us all of the time, we may become upset and worried when someone doesn’t. And if we expect to be appreciated and applauded, we may feel hurt and unappreciated when no one seems to take notice. As Hughes suggests, “When you prioritize the internal expectations you hold for yourself, you naturally develop the thick skin required to put yourself out there.”

Begin the process of thickening your skin by examining your internal expectations. Are you being fair with yourself? Are you being reasonable? If not, write and recite affirmations that help you to develop more reasonable and healthier self-expectations. For instance:

I listen to criticism with an open mind because it can help me to improve.

I do my best because that matters to me, even when no one is watching.

I make mistakes and I learn from them.

I like myself.

I am worthy of respect.

Although you may not be able to change the expectations others place on you, you can weight them differently, and you can change those you place on yourself. In time, reading or reciting your affirmations can help you to shift your self-expectations so you no longer feel crushed by external ones. As Hughes suggests, “Turn your attention back to what’s within your control.”

Fifteen Strategies for Developing a Thicker Skin

Most of us admire people who can take criticism or abrasive comments without being wounded. If you believe that you or one of your employees is too thin-skinned, here are 15 strategies that can help:

Try your best. We succumb more easily to guilt and shame when we know that we have not done things to the best of our ability. When we try our best, we can take comfort in knowing that we gave it our all, even if we fail or if others don’t like the outcome. As Weingarten(4) suggests, “If you try your best to do something right and you fail, at least you tried, and that is better than not trying.”

Reframe. If someone says something unkind to you, Ma suggests that you reframe the comment to take the sting out of it. For instance, if a patient says that you don’t care about him or her, possible reframes may include:

The patient may benefit from more of my undivided attention, more eye contact, or more TLC.

The patient may need my reassurance that she’s going to be OK.

The patient may be upset, hurt, or angry at someone and is taking it out on me.

The patient may feel lonely.

The patient does not know me or know that I care.

Dig for the softer emotion beneath the anger. Angry criticism almost always means the critic feels hurt in some way. As Hendrickson(5) explains, “Anger is a secondary emotion. It’s a reaction to a softer primary emotion underneath like hurt, shame, guilt, or humiliation.” People get hurt first, Hendrickson says, and then they get angry. But when you listen beneath the anger for the softer emotion, it’s much easier to feel sympathetic toward the critic. What then? Hendrickson suggests you try to find out what button you may have inadvertently pushed. Then, “kill them with kindness,” she says.

Don’t retaliate. If someone says something to you that hurts you, you may be tempted to respond in kind. However, getting along with people and being kind to them is better than saying something mean because you feel hurt. As Weingarten suggests, “In life, we experience highs and lows, but the lows make us stronger and more compassionate.”

Stop the self-talk. Counter self-defeating self-talk with what Ma calls “truth talk.” As Ma explains, “You can be your own worst enemy, so give yourself a break.”

Remind yourself to stay strong. If you find yourself giving in to feeling hurt, Licht suggests practicing a mental chant. For example, Licht suggests: “I am valuable, and I will not let this break me.”

Remember that everyone gets rejected sometimes. As Ma suggests, “Pick yourself up, dust yourself off and move on. Don’t be discouraged if it takes a few times to get it right.” Successful people are rejected over and over, but never stop trying, Ma says.

Encourage more rejection. The more we put ourselves out there, the more often we will deal with rejection. According to Weingarten, that is a good thing. With more rejections, we can learn to treasure criticism that can help us improve, Weingarten says. As well, we become better at separating useful criticism from nasty, destructive comments that serve no purpose other than to hurt us.

Remain cool and collected. Licht suggests that you validate the concerns others have and that you use language that makes others feel heard. Keep your voice even and calm. However, she also suggests that you explore other avenues. For instance, Licht suggests, you might say, “I hear what you are saying, but it would be really helpful if you could show me an example of what you are looking for.” Or, “I might have misunderstood your directions. Let me take another stab at this.”

Focus on your goals and the steps you need to take to get there. As Ma suggests, “Don’t be self-focused. If you do focus on yourself, you’ll likely dwell on your shortcomings.”

Agree when you can. If you’re getting panned for something beyond your control, Hendrickson suggest that you agree with the critic. For instance, if test results are late getting back from the lab, agree that the delay is disappointing. As Hendrickson suggests, “Redirect the anger away from you and toward the situation.”

Don’t become defensive. As Hendrickson warns, defensive arguments don’t come across as logical or reasonable, but rather “tiresome and difficult.” Even worse: blaming. Hendrickson strongly suggests not throwing someone under the bus. “It just looks pathetic,” she says.

Realize that you can reject criticism. It is possible that the critic is wrong. As Hendrickson suggests, “When it’s your turn to hear criticism, remember: Just because someone says it doesn’t mean it’s true.” You don’t have to heed or accept every piece of advice or criticism you receive. Rejecting useless criticism can be empowering, Hendrickson says. (For more information, see the sidebar 10 Ways to Thicken Your Skin against Criticism that accompanies this article.)

Find thick-skinned role models. The next time someone lobs a bomb your way, think about people you admire who kept forging ahead, despite their obstacles and critics. As Dinwiddie(6) suggests, “You might even want to post their picture, or quotes by them, by your workspace to inspire you to keep going.” Dinwiddie’s examples of famous people who overcame rejection include Dr. Seuss, Madonna, Lady Gaga, Hillary Clinton, and Gloria Steinem. Additionally, Bill Gates, Jim Carrey, Albert Einstein, Stephen King, Benjamin Franklin, Richard Branson, and Oprah Winfrey all overcame tremendous obstacles and criticism. Search for and learn about more examples of accomplished thick-skinned people to identify those who inspire you the most.

Reject insults. A catty, entitled, selfish, or demeaning remark reveals more about the person who says it than it does about you. As Hendrickson suggests, “The only person those remarks degrade is the critic.”

What to Do When You Feel Your Skin Thinning

Despite your best intentions to use the skin-thickening strategies listed, it is the rare person who never succumbs to having a bad day because he or she has been hurt by others. In fact, being hurt is part of the human experience. And, keep in mind that you will be more likely to be hurt when you are worn out and vulnerable, when someone has found and exploited your Achilles heel, and when you are plagued with self-doubt.

You don’t have to allow occasional bouts of thin skin to destroy you. On the contrary, you can look at them as opportunities to grow stronger. As Young(7) suggests, “The only way to develop thicker skin emotionally is to have some scar tissue.” Look to the human body for inspiration. Our bodies have an amazing healing mechanism, Young explains. For example, when we break a bone, the refusing of bone tissue makes the point of breakage stronger than it had been before. It can be that way with your emotions, too. Young suggests that the best way to absorb and handle pain is to use it to make yourself stronger against similar attacks in the future. Think of your pain as an emotional wound that will heal and scar over. However, as you build your emotional scars throughout your life, be mindful not to overdo it. Don’t scar so extensively that you close your heart completely. Remember that each scar is relatively small, just as each refused bone from a former break is in just one bone, not the entire skeletal system.

Stay True to Your Vision

Developing emotional scar tissue goes hand in hand with developing and staying true to your vision. As Young says, “It’s important to focus on your goals constantly and your vision of how you want your life to be. If you can make the picture of what you want perfectly clear and desirable, then you can take a lot more abuse before you get there.” Criticism has the potential to derail you, Young warns, to make you focus on pleasing everyone instead of staying committed to your vision. His advice: “Whenever I face a lot of criticism, I go back to my goals and what I want.” If you don’t have goals that are clear and real in your mind, Young warns, “they will be outspoken by the next jerk who doesn’t like your ideas.” Know what you want, Young says, and keep that first and foremost as you move forward.

But what if you don’t know what you want? Young suggests that you start there. Otherwise, it’s going to be very easy for people to “seduce and threaten you off track,” Young says. In the end, Young suggests, having a thick skin means that you’ll be more independent. “When you don’t rely on the constant approval of other people, you’re free to pursue what you really want,” Young says. Being able to thicken your skin is therefore not only liberating, Young adds. It will also enable you to take more risks, accomplish great things, and inspire others.

Ma L. The thick skinned: it’s not all about you, so stop picking on yourself. Psychology Today . June 9, 2016. www.psychologytoday.com/us/articles/200409/the-thick-skinned . Accessed July 22, 2019.

Licht A. Seven ways to develop a thick skin in the office. Forbes . May 4, 2017. https://www.forbes.com/sites/alizalicht/2017/05/04/7-ways-to-develop-a-thick-skin-in-the-office/?sh=1bd446cf26ee . Accessed July 22, 2019.

Hughes AJ. The secret to developing thicker skin. M: Mission Originals. July 25, 2018. https://medium.com/the-mission/the-secret-to-developing-thick-skin-a6151c33ceb1 . Accessed July 23, 2019.

Weingarten R. How to develop a thicker skin at work without being obnoxious. Ladders. January 1, 2019. www.theladders.com/career-advice/how-to-develop-a-thicker-skin-at-work-without-being-obnoxious . Accessed July 26, 2019.

Hendrickson E. How to grow a thick skin and handle criticism. Quick and Dirty Tips. January 21, 2016. www.quickanddirtytips.com/health-fitness/mental-health/how-to-grow-a-thick-skin-and-handle-criticism . Accessed July 26, 2019.

Dinwiddie M. Dealing with criticism: 5 tools to develop thick skin. Tiny Buddha. https://tinybuddha.com/blog/dealing-criticism-5-tools-develop-thick-skin/ . Accessed July 29, 2019.

Young SH. How to develop a thicker skin. Scott H. Young. October 2008. www.scotthyoung.com/blog/2008/10/20/how-to-develop-a-thicker-skin/ . Accessed July 29, 2019.

Ten Ways to Thicken Your Skin against Criticism

Criticism is the fodder for a thin-skinned person’s anxiety mill. If you or an employee crumbles at the first sign of criticism, Awosika(1) suggests that you:

Understand the limited mindset of others. People who are afraid to move outside of their comfort zone will try to project their limitations onto you, Awosika says. Unfortunately, many of us have been raised to view life with a limited mindset. Understand how your critics see the world and you won’t take offense at their comments, Awosika suggests.

Understand who you seek approval from. Why do you want others’ approval? How important is it that they approve? What is the worst-case scenario if they don’t?

Understand that haters come with the territory. As Awosika suggests, “It’s impossible to be well known or recognized without having critics.” Ask: Is this person giving me thoughtful feedback? Or is he or she just trying to get under my skin and/or one-up me?

Recognize that being upset is a choice. You may not be able to control what another person says or does. But you can choose how to react to it.

Don’t tie your well-being and self-worth to the opinion of others. Find your happiness and meaning in the effort you put forth and in what you produce, Awosika says, not on what others think of you.

Don’t respond to people who are trying to tear you down. Don’t feel the need to defend yourself when you’re being attacked. It’s a waste of your time and energy, and it probably won’t do any good, Awosika says. Put that energy toward continuing to create something positive through your work.

Google negative comments about Mother Theresa. You will find about a half-million or more results of people bashing Mother Theresa. As Awosika suggests, “Even the most pious individuals aren’t immune to criticism.” Understand this fact and embrace it.

Value work over criticism. As Awosika suggests, “No one ever built a statue of a critic.” A critic takes a small amount of time to judge work you may have spent several hours, days, months, or even years to create. “It’s much easier to critique other people’s work than to do work of your own,” Awosika says. Pay the closest attention to the people who walk the walk, not just talk the talk.

Appreciate the people who look up to you. There are going to be people who respect you for putting yourself out there. And there will be those who will appreciate your hard work. As Awosika suggests, “Keep in mind that you’re touching other people’s lives with the work you do.” It would be selfish to hide your gifts from a world that needs them because you are afraid of criticism, he says.

Do great work. When you take the time to do great work, you can thwart potential criticism. You can also feel positive about the work you do even when it’s criticized, Awosika says.

Awosika A. How to develop obnoxiously thick skin: 10 tips for facing your fear of criticism and social rejection. Be Yourself. January 12, 2016. https://byrslf.co/how-to-develop-obnoxiously-thick-skin-10-tips-for-facing-your-fear-of-criticism-and-social-dabe32a23163. Accessed July 25, 2019.

Taking Things Personally? Here’s Why, and What to Do about It

Most people who take things personally learned to do that in childhood. As Brenner(1) suggests, “When we are young, events happen that bring about emotional reactions in us. If you didn’t have the means to experience the feelings and let them go, they leave an impression in your body and mind, creating a sensitivity to reacting the same way again and again.” Decades later, Brenner explains, we experience rejection and disappointment as we did in childhood and revert to the childhood tactic of taking things personally. Then, Brenner warns, the “spinoff stories start.” For example, we tell ourselves, “I’m not deserving,” or “I’m inadequate.” These experiences congeal into an identity in which our adult selves take everything personally. That keeps us frozen and limited, Brenner says.

Unfortunately, an identity in which we take most things personally can be very real to us. It can become who we are. We then go through life thin-skinned and easily hurt. However, Brenner says, when we step back and examine things more objectively, we can begin to see that we are creating stories. When that happens, Brenner says, “you realize that you don’t have to make big deal over something that isn’t real anyway.” Brenner’s advice: Be like the sky. Let dark clouds and difficult thoughts and feelings move through you. Think of them as “nothing more than insubstantial wisps of energy that appear and disappear,” Brenner says.

It takes time and effort to erode lifelong habits that feel so real, Brenner says. Her advice: Be very kind to yourself. Brenner suggests, “When you notice that you are taking something personally, step off the habit wheel. Pause and take a breath.” Consider that your thoughts and feelings don’t accurately match up with reality, and that they don’t define you. When you discover that everything in the world is not personal, Brenner says, you will find “the deepest peace beyond imagination.”

Brenner G. It’s not personal. Dr. Gail Brenner. September 10, 2013. https://gailbrenner.com/2013/09/its-not-personal/ . Accessed July 26, 2019.

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Psych Careers

Developing a thick-skin, taking criticism well in the world of science..

Posted June 19, 2008

Most of you are familiar with the light-side of science; designing empirical experiments, discovering new information, presenting data and crafting theories. But that is only half of the picture. There is also the often ignored dark-side of science; correcting flawed experiments, criticizing inappropriate data analysis, and tearing down the ideas of fellow scientists. Yes, the peer-review process is a harsh mistress but is equally important to the scientific process (some might argue more so) as its light-sided counterpart. As such, developing a thick-skin to the criticism of others, is a vital step for any developing scientist.

Criticism can come from peers, mentors, review- committees , editors, parents, the media, and anyone else who might be privy to your work. First we should begin with an operational definition of criticism, from Merriam-Webster we find: a critical ( exercising or involving careful judgment or judicious evaluation) observation or remark . That sounds about right. We usually attach a negative connotation to criticism, but that's not necessarily the case. Criticism can come in many different forms, for example...

Praise: This is the easiest feedback to swallow. Unfortunately it is also not very useful. Don't get me wrong everyone wants to hear that they are doing things right, and to keep up the good work. Better than an "attaboy" is true critical praise where insight about where you went right is revealed. Receiving praise, however, rarely motivates you to improve .That said feel free to send me praise anytime. Please?

Constructive Criticism: Likely the easiest negative comments to swallow. The kindly advice of your peers points out ways in which you can improve. Motivated by a desire to see you achieve, constructive criticism is your best friend. It can still be tough to hear where you went wrong, but the goal of constructive criticism is to make suggestions for improvement. This is the criticism you want to take to heart,as it can only help you improve.

Self-promoting Criticism: When you have presented a research talk about disgust sensitivity and superstitious conditioning and you get the question, "Did you find any interaction with circadian rhythms ?" you know you are the victim of this type of insidious criticism. The key is to recognize it for what it is: the asker wants to talk about her own research, or a clever idea she had. Common mistakes in dealing with these questions is to argue against them ("Circadian rhythms have nothing to do with this.") or admit failure ("We didn't think about that at all."). A better solution is to throw the ball back into the asker's court and let her talk about her ideas ("That's an interesting point, how do you think circadian rhythms would affect the study as presented?"). This allows the asker to promote her ideas and you appear neither petulant nor incompetent. And it has the potential to become constructive criticism if (unlike my example) the points she raises are actually related to what you are researching.

Nitpicking: These are the annoying nettles that reviewers send. Usually about grammar (sometimes Latin grammar ), formatting or semantics. It is usually easiest to just correct any nitpicks. Unless you know you are right, go ahead and make whatever changes are suggested by the nitpicker. Since for the most part it doesn't really matter, these criticisms are just white noise.

Bad Advice: This is the worst. When what looks like constructive criticism is actually destructive. Imagine if you were looking at social development in adolescent rats, and one of your measures was playfighting (pairing the rat with a same- gender rat to see them play). And you received the note that you have to look at cross-gender social interactions in your playfighting paradigm. This might seem like good advice at first glance, eliminating your imposed gender division of play-fighting partners sounds like something you'd want to do. Except that instead of play-fighting, you will observe mating , or at least attempted mating. So be on the look-out for bad advice. Your best bet is to solicit advice from several different sources, hopefully then you can better separate the wheat from the chaff.

So now that we know what types of criticism is out there, how do you take this criticism well? There are books and books about it, but I think the best advice I ever got came from a Terry Gross interview with actor Seth Green . Seth was talking about not being cast in roles he really wanted:

"I never took it as a failure on my part, I kinda had an objectivity at a young age that I really held onto where if you believe in a director or if you believe in a project in a project you have to respect their vision for what it is and if you don't fit that vision then you just don't fit. And there's a lot of times that no matter how good an actor you are that you're just not right for it. And I became very aware and zen about that."

So by that reasoning, if you've chosen a good pool of peers (mentor, colleagues, etc.) from which to solicit criticism, then you you can be reasonably certain that they are trying to do what is best for science when they give you feedback. Don't take it personally if your vision of a project, a paper, or a presentation doesn't mesh with their vision. Remember, by integrating their suggestions into your work will help make you a better scientist. No matter what the criticism it is always worthwhile to address it, at the very least you will dissuade others from making the same critical observations. In a future post I'll show some examples of feedback I (and my colleagues) have gotten on journal submissions, or other projects. But as a teaser here is some feedback we received about this (now published) paper :

"Only the questionnaire data are analysed. However, the subjects had a keyboard to try to control words. Even if self-report may be an interesting behaviour to study, subject probably uses their keyboard with a high rate. What is the rate of responding in each condition? What is the rate of responding on each button of the keyboard? Is the rate of responding related to self reports? Is the rate of responding to try to make the word "bad" appearing comparable to the rate to try to make the word staying at the screen? All these questions are important because directly related to the central question of the research."

I'd call that constructive criticism. We did in fact collect response rate data, but there were no correlations. Not to mention that the question of the relationship of response rate to superstition has been well answered in previous research. To address the criticism however we added this line: "The tendency for these behaviors to be unique to the individual organism has made traditional operant measures, such as response rates, less useful in assessing non-contingent reinforcement."

So just remember, in science you will present your ideas often. Just as often people will comment on your ideas, and you need to be prepared to deal with that. Good luck!

Mitch Harden is a third year doctoral student in the behavioral neuroscience program at the University of Missouri - St. Louis.

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Sticking up for yourself is no easy task. But there are concrete skills you can use to hone your assertiveness and advocate for yourself.

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How to Develop a Thick Skin

Last Updated: January 23, 2024 Fact Checked

This article was co-authored by Erin Conlon, PCC, JD . Erin Conlon is an Executive Life Coach, the Founder of Erin Conlon Coaching, and the host of the podcast "This is Not Advice." She specializes in aiding leaders and executives to thrive in their career and personal lives. In addition to her private coaching practice, she teaches and trains coaches and develops and revises training materials to be more diverse, equitable, and inclusive. She holds a BA in Communications and History and a JD from The University of Michigan. Erin is a Professional Certified Coach with The International Coaching Federation. There are 9 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 237,807 times.

Do you tend to overreact when someone says something hurtful? It's normal to feel a sting when someone criticizes or insults you. However, if you tend to lash out in anger, cry, or feel upset for days, you may want to focus on developing a thicker skin. While there's nothing wrong with being sensitive, it's no fun to get knocked off balance by a casual comment. By learning to look at the bigger picture, having a positive attitude and building confidence, you can stand strong the next time you feel insulted.

Things You Should Know

• When you receive a negative comment, take a moment to let the emotions wash over you before reacting. If it helps, silently count to 10.
• Separate criticism from insult. Remember that people who habitually insult others have low self-esteem or emotional baggage they need to deal with.
• Take context into account. Did the person mean well, or were they being cruel?
• Try to spend more time with people who support you and view you in a positive light, rather than people who refuse to accept you.

Think before reacting.

• Take a moment to let the first wave of emotion wash over you. Let yourself feel it, then wait for it to subside. Do not react until that initial flush of defensiveness is gone.
• It may help to actually count to 10 before you say anything. If you're alone, you can count out loud. If you're with someone else, count silently. Ten seconds is usually enough time to clear your head.

Separate criticism from insult.

• Take the context of the comment into account. Did the person who said it mean well? Was it delivered by a person you respect in a position to critique you, like your teacher, boss or parents? Or was the person trying to hurt you?
• Confusing criticism with insult commonly leads to overreaction. Being able to separate the two will help you develop a thicker skin at school, work and in other places where valid criticism can be given.

Don't take it personally.

• Remember that an insult is opinion, not fact and it can only hurt you if you believe it. If you don’t see what the person said as part of your self-view, then it will be easier for you to let it go. For example, if someone calls you unattractive or unintelligent, you can easily reject this if you don’t see yourself that way.
• After feeling the pain the insult brings about, try to let it go. Put it into context as a barb that can sting for a minute but ultimately holds no weight.

React nobly.

• You have every right to ignore the insult. Just pretend like it wasn't said, if that seems like the best solution.
• Or try lifting your chin, making eye contact, and telling the person "you're wrong; that's not true."

Defend yourself if you need to.

• Have a face-to-face confrontation. Tell the person that you expect him or her to stop insulting you. Sometimes just calling the person out will put a stop to the behavior.
• Seek outside help. If you feel you're being bullied , a one-on-one confrontation may not help. Talk to your teacher, principal, supervisor, or someone else who can help you deal with the situation quickly.

See if you have room for improvement.

• It's also possible that the critique is dead wrong. Still, there's no need to overreact. It's just one person's opinion, after all.
• Speaking of opinions, it might help to get a second one. This can help you establish whether you actually have room for improvement.

Look at the bigger picture.

• If it seems impossible to put it into perspective, just tell yourself to wait it out until tomorrow. The pain really will fade after a day or two.
• In the meantime, distract yourself. Spend time with a friend, watch a good movie or exercise the thoughts away.

Resolve to make it into something positive.

• For example, if you received a critical review of a report you wrote, consider revising the report with the critique in mind.
• Without dwelling on the criticism, keep it in mind and resolve to do better next time.

Realize it's about the other person.

• Look for the emotion behind the insult. The person who made the comment may be sad, angry, or upset in some other way. Some people have trouble expressing emotions so they take out their problems on other people.
• Use this information to help yourself take the insult less personally. It may have hurt your feelings, but it was just a disguise for the person's real feelings.

See if you have a deeper wound.

• For example, maybe you've been feeling insecure about your intelligence ever since starting a difficult new class. Someone calling you "silly" or "dumb" may cause you to feel more deeply insulted than the person intended.
• The solution is to work on the feelings of inadequacy that are leading to the tender, sensitive spot. When you feel more confident about your intelligence you'll be able to let such comments roll off of your back.

Be proud of your strengths .

• Do you know your strengths? Try making a list of everything you admire about yourself. Having a firm grasp on what you're good at will bolster you when you're feeling down.
• Get good at what you do. Spend time practicing, learning and always working to get better. That way you'll have a core knowledge that you're good at what you do. A criticism or insult won't have as much power to bring you down.

Don't try to be perfect.

• Being a perfectionist may seem like a good thing, but perfectionists tend to have thinner skin than those who allow themselves to fail sometimes. Perfectionists are also highly critical of themselves. [12] X Trustworthy Source American Psychological Association Leading scientific and professional organization of licensed psychologists Go to source Low self-esteem is often brought on by self-criticism, so be compassionate towards yourself .
• To let go of perfectionist tendencies, challenge yourself to learn something new. Try a new skill, sport, language, or anything else that interests you. Starting from scratch is humbling. It will help you realize that perfection is impossible. It's the journey that counts.

Spend time with positive people.

• Pay attention to how you feel after hanging out with certain people. Do you feel refreshed and happy? Or do you feel worse about yourself?
• When you're with people who accept you for you are, you don't have to worry about being too sensitive. After building trust, you'll learn that your true friends will love you even when you feel insecure.

Practice good self-care.

• Eat healthy and exercise. You've heard it a million times, but it helps. Make sure you're eating a well-rounded diet and exercising at least 30 minutes each day.
• Get plenty of sleep. Being tired heightens emotions, leaving you more prone to taking things the wrong way.
• Include meditation or yoga in your daily routine. These activities can help you to be more accepting of yourself.

Seek outside help.

• Talk therapy can be very effective when it comes to building self confidence and a thicker skin. You may also come to accept that it's OK to be sensitive.
• If chronic depression or another disorder is troubling you, medication can also help. You'll need to make an appointment with a psychiatrist to discuss the best options for your situation.

Expert Q&A

• Understand that no single person in history has been without critics. Some of the most successful people in history have had more than their fair share of critics. Thanks Helpful 5 Not Helpful 0
• It takes patience and practice but it's worth it. Thanks Helpful 3 Not Helpful 0
• Sometimes what we are most sensitive about are issues we are afraid to face about ourselves. By having the courage to face them either through change or self-acceptance you will find more confidence in the long run. Thanks Helpful 2 Not Helpful 0

• Not all people who criticize you, want to hurt your feelings. There is a difference between constructive criticism and plain rudeness. Thanks Helpful 81 Not Helpful 11
• Do not think that having thick skin means being rude or indifferent. Thanks Helpful 3 Not Helpful 0

You Might Also Like

• ↑ Erin Conlon, PCC, JD. Executive Life Coach. Expert Interview. 31 August 2021.
• ↑ https://www.psychologytoday.com/intl/blog/rediscovering-love/201105/speaking-you-think-foot-in-mouth-syndrome-in-committed-relationships
• ↑ https://www.helpguide.org/harvard/benefits-of-mindfulness.htm
• ↑ https://www.psychologytoday.com/blog/hide-and-seek/201302/how-deal-insults-and-put-downs
• ↑ https://psychcentral.com/health/how-to-improve-your-life
• ↑ https://psychcentral.com/blog/5-tips-to-develop-thicker-skin#1
• ↑ https://positivepsychology.com/how-to-overcome-perfectionism/
• ↑ https://www.apa.org/monitor/may04/cons
• ↑ https://www.psychologytoday.com/blog/hide-and-seek/201205/building-confidence-and-self-esteem

About This Article

If someone says something rude, critical, or insensitive, it can be a challenge to shake it off. Next time it happens, take a moment to process before you react. This can be as simple as counting to 10 in your head before you speak. Once you’ve calmed down, think about what they said. If it was a criticism, they might have meant it well, even if they didn’t say it in the kindest way. On the other hand, if they were just insulting you, that says more about them than it does about you. Either way, try not to take it personally. It’s okay to defend yourself, but do it in a calm, non-accusing way instead of lashing out or resorting to insults. You can even say something like, “You’re right, I could have done that better. But next time, please tell me how you feel without calling me names.” For tips on developing a more positive mindset, read on! Did this summary help you? Yes No

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Novo nordisk’s ambitions.

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Develop a Thick Skin - How?

Nurses Relations

Published Oct 2, 2012

I am a new grad nurse, having worked for a couple of months, and only a short while on my own in a busy medical/surgical unit. I am a gentle soul, soft-spoken, and have manners ingrained in me from childhood. I strive to be respectful and professional, particularly at work.

As a nurse, I am not surprised to be the "whipping boy." From HUCs sniping at me when I ask to a question, to PCAs rolling their eyes at me when asked to do something, to other nurses being blatantly rude to me if I have a question, to doctors chewing me out on the phone ... I knew this was coming and I know it is something that I need to get used to.

My unit is not bad compared to what I have read here. But when working with people, each day, I know that some negative encounters are bound to happen. However I am very sensitive and it effects me. Mostly takes me aback and makes me upset. With the stress of the job, today I was almost in tears after a particularly rough afternoon. I do not want to be a blubbering mess at work. I can't seem to stand up for myself. What can I do to be more assertive in these kinds of situations?

Some scenarios --

Ask HUC a question, didn't realize she was on the phone, HUC snaps at me and basically tells me to shut up.

PCA tells me she is leaving a patient's tab alarm off because she feels he doesn't need it. I tell her I think it is still necessary and to put it back on, and she walks away rolling her eyes at me and avoids me the rest of the day.

Patient's daughter is a zooligist and is ranting on the phone at me because she thinks the patient needs X, Y, and Z treatment.

Doctor yells at me because I called and asked for an order that was already placed. (my fault, it was during a rapid response)

• + Add a Comment

classicdame, MSN, EdD

7,255 Posts

people are short tempered and short of manners as well. I think I would write up an employee who yelled at me for any reason. That is called bullying or harrassement and is against policy in our facility, even if an MD. Thick skinned means you don't take everything personal. But I might have waited till a calmer time then tell the nurse I did not appreciate her yelling at me and tell the PCA if she has a problem with you then both of you can go to the manager. A lot of times it is best to let things slide. It actually makes people think you don't care enough about the situation to get upset and that is revenge enough.

I, like you, am naturally on the soft-spoken and reserved side. Fortunately, I work in an environment that is not hostile, but even so I still have had my fair share of nasty encounters over the years. The best thing I have found to do is to remain as calm as possible in all situations (definitely easier said than done)-but one the flip side of the coin, I think at some point you do have to say something when you notice a pattern with someone. If someone consistently has a nasty tone with me (NOT just a few random times when it could be deduced that something stressful is happening), I tell them in a controlled way that I will not allowed myself to be talked to in that manner. If they start to argue, I calmly (sooooo hard to stay calm sometimes) tell them that it is not up for discussion; I am simply letting them know that I will not be having a conversation in this way with them.

If you had told me a few years ago that I would say this to people, I would not have believed you. But seriously, a day will come when you will just find some steeliness in you that will transcend the quiet side without you even being fully aware of it. The amazing thing is that often after saying this, people have either apologized or been shocked enough that they have been much easier to deal with.

Also, if your manager and/or charge nurse is approachable and these incidences are occurring frequently (especially with certain individuals), you should consider bringing your issues to them in an objective manner. You might find that they will deal with the issue in some way and the people you have difficulty with will be less aggressive.

Nascar nurse, ASN, RN

2,218 Posts

Some scenarios -- Ask HUC a question, didn't realize she was on the phone, HUC snaps at me and basically tells me to shut up. - Let it roll right off your back. Not really a big deal and who knows what conversation she was in the middle of. PCA tells me she is leaving a patient's tab alarm off because she feels he doesn't need it. I tell her I think it is still necessary and to put it back on, and she walks away rolling her eyes at me and avoids me the rest of the day. - Again, I'd probably let it roll off my back - the first time. Second time, I'd take them aside and explain why I thought it was appropriate and make sure they realized that my decision was final. Remind them "no attitude needed, let's just keep the patient safe". 3rd time - Start putting it in writing. This isn't about you and PCA - this is about keeping patient safe. Don't let it work on you. Just deal with it and move on. Patient's daughter is a zooligist and is ranting on the phone at me because she thinks the patient needs X, Y, and Z treatment. Urgh! Most annoying. Let her rant a bit and then tell her you will take it up with the Dr. Again, this still isn't about you...it's about the patient and you actually have little to no control on the outcome of this one. You are merely the messenger between the 2. Doctor yells at me because I called and asked for an order that was already placed. (my fault, it was during a rapid response)

Oops - so who's perfect? Kick yourself in the rear, learn from your mistake, forgive yourself and move on. The Dr. has already moved on and has probably already yelled at 6 other people by now.

How do you grow a thick skin = time. In time you will realize that most times the anger from others really had little to do with you. I used to wallow in situations but learned that others forgot some of these little incidents long before I forgot the sting. Once I learned to let it roll life got easier.

1,025 Posts

I think you just have to get used to it. Once you feel more comfortable in your job and have more confidence, you will not take that kind of crap anymore. It takes a little experience, and sometimes just getting pushed a little too far sometimes for you to stick up for yourself. And do not take it personal, everyone goes through it. The staff is overworked and overstressed and they probably do not mean it personally toward you. You also have to choose your battles. With a cna leaving an alarm off, that is one I would be certain the alarm was on, it is your responsibility to make sure the patient is safe.Maybe explain WHY it has to be on, educate instead of just order or argue with her. In time you will know who you can trust, and the cnas in turn will decide if they trust you. The secretary and Dr honestly just seem like they were too busy or too stressed. We all make mistakes, we all snap at each other on occasion. But we work like a dysfunctional family, too when we need to.

10,540 Posts

I empathize with Your Plight, sagremus. Quiet, Even-Keeled People are often seen by Bullies to be Fodder for Fanforonade, and you've recieved Some Good Advice and Perspectives from the Other Posters.

I have no trouble being Assertive and Calmly and Objectively Confronting anyone on their Inappropriate Behavior. However, My Lady Belinda tends to be more like yourself, sagremus. She worked with a Doctors Group for 17 years before going into Med/Surg Floor Nursing. She flowed with her Previous Place of Employment but was being somewhat Bullied by Some of the Staff in the Hospital Unit.

I worked with her for Quite a While before she could be Assertive, yet be Herself, when Confronting Inappropriate Behavior from Supervisors, Peers, and Co-Workers.

Belinda and I would discuss a Particular Scenerio, examine the OP's Behavior, Her Thoughts and Feelings on the Matter, and Brainstorm Ideas for Different approaches.

In One Instance, when Belinda knew she was going to be Called on the Carpet by her Supervisor for an Incident she was present for on her Unit. We practised some Role Playing, with me Playing the Part of Her Supervisor. Being somewhat familar with Belinda's Supervisor's Behavior, I approached Belinda in a Similar Manner that I believe Her Supervisor would. Belinda and I worked on Her Answers.

For example, I encouraged Belinda not to start a Statement with "I feel as though..." since Feelings are based on Emotions and Beliefs are based on Facts. If something is A Fact, a Belief, then state Your Belief as though it were A Fact. So, instead of saying something like, "I feel as though the Nurse did what she could in this Situation", Belinda rephrased her statement to say something like, "The Nurse acted according to Policy and Procedure in dealing with this Situation".

Belinda and I worked on Different Questions and Possible Retorts in Our Role Playing Session, almost like a Lawyer and a Client. By the time Belinda had her meeting with her Supervisor, her Anxiety had decreased, she felt more Self-Assurred, and went through the Interrogation Process well.

Some of Us are Naturals when it comes to Difficult Interactions. Most of Us are Uncomfortable with any Sort of Conflict. Until I learned a Few Techniques and actually put Those Techniques into Practise, I, too, was uncomfortable with Difficult Interactions. Now, after dealing with Aberrant Behaviors for the Majority of My Life and Creer, I feel much more comfortable. It took Practise, Trial and Error, Studying People and Their Behaviors, and finally, knowing that I was Correct in My Judgement before I could OBJECTIVELY approach an Individual and Confront Them on Their Inappropriate Behavior.

Now, I don't Go Looking for a Fight and I Prioritize where I will Expend My Energies. Some Circumstances ARE best Left Alone. However, if Another's Behavior can Tick Off a Saint, then That Behavior needs to be deal with. And the Culprit needs to HAVE to deal with The Natural Ramifications of Their Actions.

The Very Best to You, sagremus. Good Luck in Growing a Thick Skin without loosing any of Your Sensitivities. We need People like you as a Point of Reference for the Rest of Us.

RNperdiem, RN

4,592 Posts

Getting older and losing some of that youthful self-consciousness helps.

Developing skill and better communication skills takes time, there is no shortcut.

Learn to avoid negative self talk. Never say things to yourself like "I am so stupid", instead say "I am learning, and doing the best I can right now".

For me, becoming a parent taught me most of what I know about assertiveness. The kids would have eaten me alive a long time ago if I didn't develop a thick skin.

Best of luck.

jadelpn, LPN, EMT-B

9 Articles; 4,800 Posts

Some people have no filter. The best thing you could do for yourself is continue to conduct yourself how you have been raised to do so, and don't get caught up in the less than desirable behaviors. It may not seem so, but people will take notice of your professional and polite behaviors. That you are well mannered WILL pay off in a multitude of ways in the long run.

Doctors chew a number of nurses out on the phone, regardless if one is polite or not. It should not be a standard, but please don't take that personally. Be sure you are clear and well informed in your communication. I would most definetely start with " We are in rapid response for patient xyz, who is experiencing blah blah. He has blah blah ordered, do you want changes? Can we give ativan (be specific in what you are looking for) and are you coming in to see this patient, currently the ER doc is running this response, do you have any specific orders before we hang up? Verify and repeat if the MD does, if he doesn't than you have CYA in informing and asking.

I don't know what a HUC is, but make sure you look to see if someone is on the phone--and I would write down questions so you will remember what it is you want to ask. Sometimes (at least for me) I have to or 20 minutes later I am forgetting details of specific questions. When this person is off the phone, I would say "I have just a couple of questions. Is now a good time? They are regarding my patient and I would like your thoughts/advice/guidance". Sometimes if you are clear that as the more experienced nurse, you are looking for guidance, the communication goes much better.

And as far as the tech/aide informing you of not putting on the alarm....I would nicely state that although you appreciate her input, that for now, your assessment is such that you will keep the alarm on. But that you will go into the room and speak with the patient about the reason why. And thank you for advising me about the patient not wanting the alarm on, but please go place it back on, and let the patient know I will be down to discuss it is 15 minutes. Chart same, and education regarding same.

And patient's families DO occasionally have to impart their 2 cents worth of web MD. The only thing that you can do in that instance would be to listen, empathize, and state that this conversation needs to happen with the doctor, as you will let the doctor know when he rounds that the family has questions. Or if appropriate, let social work know a family meeting has to happen to discuss plan of care, and let daughter know that you will do that.

I have raised my children to be well mannered and polite. So I side with your parents on making it an important part of your upbringing. Please be wellll aware that there is not one thing wrong with that. It can be overwhelming when you realize that people in your work life may not feel the same way. That is them, not you. So do NOT pick up bad behaviors as a way of "survival". You will learn in time that once you leave work, you can surround yourself with whomever you choose to. But while you are at work, DEEP breath, you are OK, this is NOT personal communication, everyone has (or SHOULD have) the same goal of the best for a patient. Keep advocating, keep your polite professional tone, and do a little side research on the art of communication/negotiation, so that the tears will not come, as you are negotiating and communicating--NOT having a personal conversation that pertains to you, but what is best for your patient's outcome.

Best of luck, and it is refreshing that there are still manners left in the world!!

redhead_NURSE98!, ADN, BSN

1,086 Posts

A zoologist? "So you want me to treat your mother like you would treat a zebra? Okay!"

Wild Irish LPN, LPN

What a timely posting OP....I feel you, I really do....I too am that same gentle soul, well mannered and respectful of my fellow nurses....well everyone I come in contact with to be honest...when I started my first nursing gig out of school I found my self nursing in Corrections, and people thought I had lost my mind for making this choice...it was no secret that my new peers thought I would be chewed up and spit out by the inmates, and by them....I was told my "politeness and manners" will only set me up for manipulation by these inmates, and that my days will be few if I didn't "toughen up"....but something interesting happened along the way, I was treated with nothing but the same kindness and respect that I gave out, to the inmates as well as my fellow nurses....point is, I didn't change a damn thing, I stayed true to myself and my own convictions....and so should you....you are a rarity in my eyes, and nursing needs more of you....I am willing to bet that you're positive mojo will end up winning the day, maybe not today, but down the line....people cannot help but respect others that follow these principals, they may not show it, and in fact they may strike out against it....but that is only because they admire it, and they do not practice it themselves....stay strong, stay who you are....because honestly, you sound pretty damn good to me....

Btw, at my jail where I work I have been assigned to the "Max" floor, and this was done because of my effect on some of the worst of the worst offenders....yes, they are criminals but my role as a nurse is to care for these people...not to pass my own judgement upon them, that has already been done by the justice system....so I treat these people with the same amount of respect and dignity that I expect from others, and I get it back in buckets....being that I am the only male nurse on staff I think that these inmates are shocked that this is coming from a man, but they appreciate it and it makes my job much easier....

Stay strong and never let them tell you that you need to toughen up....you already are....Peace....:)

HippyDippyLPN

I too was like you and still am a bit. very sensitive and took things personally. with time being on the job as a nurse and just growing a bit more mature I realized other people's negativity isnt worth my energy ( now of course is someone is harrasing you that is different and calls for management involvement) but when a co worker snaps at me, a md gets *****, or a pt is being difficult I just dont react to it and i brush it off. I have a natural happy disposition and I have spent way too long of my life/nursing career letting other's people negative attitudes affect me so I dont let it anymore. I kill my difficult pts w/ kindness ( works 95% of the time, most people cant be ***** for long enough towards a nurse listening with interest and being kind and if it doesnt they cant say I was rude!) with my md's I dont even get them a second thought if they are having a moment unless its something I can learn from, and with my co workers most of the time the snips are when we are all under pressure and I have done it myself too so I think we all have a mutual understand that we all might get snippy sometimes and to not take it personally.

And I agree with pick your battles. If I am really offended or feel I have been treat un fairly I rate it on a scale of 1 to 10. If its a 1 through 7 usually its not worth my time to do anything about but if its a 8-10 I take action and its always worked well in my favor. Most of the times its a hey look I didnt appreciate XYZ, if you feel like I am doing something thats not working for you could you just discuss it with me in a appropriate time and manner and we can go from there? I think a lot of times people just dont realize how they come off and if you approach them in a calm/confident manner it can usually get resolved.