Vocational Guidance for Young Patients with Atopic Dermatitis: A Survey of Physicians’ Opinions and Practices

Marie-Noëlle Crépy1,2, Lynda Bensefa-Colas1,3, François Aubin4, Michel Simon5 and Angèle Soria6,7; for the French research group for atopic dermatitis (Groupe de Recherche sur l’Eczéma Atopique) in collaboration with the French Society of Dermatology and Venereology, French Society of Allergology, French Society of Pediatrics and French Society of Occupational Medicine

1Department of Occupational and Environmental Diseases, Hôpital Hotel Dieu, 2Department of Dermatology, Hôpital Cochin, Université de Paris, AP-HP, 3Health Environmental Risk Assessment, INSERM UMRS_1153, Faculty of Pharmacy, Université de Paris, Paris, 4Department of Dermatology, University Hospital and INSERM 1098 RIGHT, Franche Comté University, Besançon, 5Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Université de Toulouse, CNRS, Inserm, UPS, Toulouse, and 6Department of Dermatology and Allergology, Hôpital Tenon, Paris HUEP, Universités Sorbonne, Paris APHP, and 7Centre d’Immunologie et des Maladies Infectieuses – Paris (Cimi-Paris), INSERM U1135, Paris, France. E-mail: marienoelle.crepy@aphp.fr

Accepted Mar 1, 2022; Epub ahead of print Mar 1, 2022

Acta Derm Venereol 2022; 102: adv00671. DOI: 10.2340/actadv.v102.205

Although patients with atopic dermatitis (AD) have an increased risk of developing occupational eczema, there are few data on medical practices concerning vocational guidance for young patients with AD (1–3). To help address this issue, relevant professionals, i.e. dermatologists, paediatricians, allergologists and occupational physicians, were asked to complete a survey of their opinions and practices regarding vocational guidance for young patients with AD.

MATERIALS AND METHODS

The survey consisted of 12 questions, of which 3 were conditional and 9 were statements followed either by yes/no, or by possible responses of “always against”’, “sometimes against”, and “not against”’ (see Appendix S1 for complete questionnaire). The survey was sent electronically to members of French Learned Societies (the French Society of Dermatology and Venereology, the French Society of Pediatrics, the French Society of Allergology, and the French Society of Occupational Medicine).

A total of 273 members responded to the survey: 66% were dermatologists; 12% allergologists; 11% occupational physicians; 6% pediatricians, and 5% other specialists. The majority of respondents worked in a hospital (37%), or in both private practice and in a hospital (19%). Among the members of the French research group for atopic dermatitis (Groupe de Recherche sur l’Eczéma Atopique; GREAT), 82% responded to the survey.

DISCUSSION

More than two-thirds of respondents (68%) asked young patients with AD older than 15 years about their future career plan, and less than one-third (29%) asked younger patients (<15 years old) this question. More than one-third of respondents (39%) asked patients or patients’ parents about the impact of AD on their career plan. Half of the respondents (142/273; 52%) advised against some professions or occupational sectors for young patients with past or active AD (Fig. 1).

Experimental studies have shown that the barrier function of the skin in patients with AD is reduced, even in uninvolved skin areas, compared with healthy controls (4–6). The dysfunctional epidermal barrier in patients with AD facilitates the penetration and absorption of irritants and allergens through the skin. As a result of the strong associations between AD and occupational hand eczema (HE), clinicians are advised to guide patients with AD away from occupational sectors with a high risk of HE, such as hair and beauty, food-related occupations, cleaning, healthcare, construction, factory work, mechanical work, and machine operation (7–9).

In this study the sectors of activity and professions that participants advised against in more than half of cases (sometimes or frequently) were beauty, construction, metal work, automobile repair, food-related sectors, cleaning, and agriculture (Fig. 1A). In more than half of cases, the main criteria used to advise against some professions and/or sectors of activity was either hand involvement with past history of AD or active AD, or active and severe AD (Fig. 1B). Although most participants (68%) asked young patients with AD about vocational guidance, only 52% warned patients against some professions or occupational sectors and provided advice for the management of AD at work, in the case of occupational diseases or diseases with occupational impact. Only 20% of respondents advised young patients with AD to consult a health structure/healthcare worker to discuss their vocational project, with occupational disease departments advised in most cases (59% of the 54 respondents). However, some previous studies have shown that many individuals with a history of AD manage to stay free of dermatitis problems despite current occupational/professional risk factors. For example, in a population-based follow-up to a childhood study with people aged 31–42 years with AD (n = 378) and without AD (n = 405), half of the cases in high-risk occupations for HE and more than one-third of the cases with the highest exposure (water, detergents or chemicals > 2 h/day or hand washing > 20 times/day) did not report HE (10). In another study, approximately a quarter of the patients with AD with high-risk occupations, such as hairdressers and nursing assistants, did not develop HE (11). Therefore, knowledge of susceptibility factors and identification of persons at risk in jobs with high skin exposure could contribute to more targeted prevention of occupational HE (9, 11–13). For many authors, individuals with several risk factors for atopy should be regarded as high-risk individuals and be advised against a choice of occupation that involves excessive exposure to wet work and irritants (9, 11, 12). Risk factors identified are eczematous involvement of the hands in childhood, persistent dermatitis on other parts of the body in adult life, and severe widespread eczema in childhood (11). A history of only bronchial asthma and/or allergic rhinitis is not considered a risk factor. Based on a review of the literature, practical guidelines for occupational pre-employment counselling of persons with AD were proposed by Coenraads & Diepgen (12). For the authors, occupations with wet work or other exposure to irritants are not advisable in cases of moderate-to-severe AD with hand involvement or chronic HE.

It is notable that recent studies from Scandinavian countries did not report a history of AD as a risk factor for a poorer prognosis of occupational HE (14, 15). The impact of preventive strategies, notably career counselling for patients with AD in Scandinavian countries, could influence occupational choice, as suggested by the authors (15). Although the majority of physicians involved in the management of young patients with AD are aware of the importance of vocational guidance, our data demonstrate a lack of strategies to prevent unsuitable job choices and impairment of AD patients’ careers.

To our knowledge, this is the first study of physicians’ opinions and practices regarding the management of vocational guidance in young patients with AD. Concerning strengths and limitations, this survey asked very general questions and underlined the heterogeneity of vocational guidance for patients with AD in France. This is a relatively small survey, with an unknown response rate. In addition, due to its declarative nature it was not possible to evaluate the impact of vocational guidance on patients with AD in this survey. Moreover, this study is not an exhaustive overview, due to the high diversity of the physicians implicated in the management of patients with AD.

The great disparity in responses highlights the lack of consensus on this topic. There are no national guidelines in France aiming to provide advice for the management of vocational guidance for young patients with AD. Adolescents and young adults often have a poor understanding or appreciation of the effect that the workplace may have in causing or exacerbating eczema. They are rarely directed to specialized health structures to help them in making professional choices or to improve their knowledge of the potential effects of work on their skin.

This survey shows discrepancies in physicians’ opinions and practices regarding the management of vocational guidance for young patients with AD, with few respondents advising young atopic patients to consult a health structure/healthcare worker. There is a need to provide appropriate professional advice for young adults with AD before they enter the workforce.

ACKNOWLEDGEMENTS

We thank D. Staumont and Bernier C. for their help and advice, and the members of the French Society of Dermatology and Venereology, the French Society of Pediatrics, the French Society of Allergology, the French Society of Occupational Medicine, and the GREAT who participated in this survey.

The authors have no conflicts of interest to declare.

REFERENCES

1. Rystedt I, Nilsson E. Hazardous work and predictors of hand eczema – vocational guidance of patients with atopic allergy. Lakartidningen 1989; 86: 714–717.
2. Saunders H, Keegel T, Nixon R, Frowen K. Career counsellors and occupational contact dermatitis. Contact Dermatitis 2003; 48: 189–190.
3. Kalimo K, Lammintausta K. Vocational counselling and skin diseases. Duodecim 1985; 101: 1142–1149.
4. Jakasa I, de Jongh CM, Verberk MM, Bos JD, Kezić S. Percutaneous penetration of sodium lauryl sulphate is increased in uninvolved skin of patients with atopic dermatitis compared with control subjects. Br J Dermatol 2006; 155: 104–109.
5. Jakasa I, Koster ES, Calkoen F, McLean WH, Campbell LE, Bos JD, et al. Skin barrier function in healthy subjects and patients with atopic dermatitis in relation to filaggrin loss-of-function mutations. J Invest Dermatol 2011; 131: 540–542.
6. Angelova-Fischer I, Mannheimer A-C, Hinder A, Ruether A, Franke A, Neubert RHH, et al. Distinct barrier integrity phenotypes in filaggrin-related atopic eczema following sequential tape stripping and lipid profiling. Exp Dermatol 2011; 20: 351–356.
7. Schwensen JF, Friis UF, Menné T, Johansen JD. One thousand cases of severe occupational contact dermatitis. Contact Dermatitis 2013; 68: 259–268.
8. Uter W, Gefeller O, Schwanitz HJ. Occupational dermatitis in hairdressing apprentices. Early-onset irritant skin damage. Curr Probl Dermatol 1995; 23: 49–55.
9. Visser MJ, Verberk MM, Campbell LE, McLean WHI, Calkoen F, Bakker JG, et al. Filaggrin loss-of-function mutations and atopic dermatitis as risk factors for hand eczema in apprentice nurses: part II of a prospective cohort study. Contact Dermatitis 2014; 70: 139–150.
10. Nyrén M, Lindberg M, Stenberg B, Svensson M, Svensson Å, Meding B. Influence of childhood atopic dermatitis on future worklife. Scand J Work Environ Health 2005; 31: 474–478.
11. Rystedt I. Work-related hand eczema in atopics. Contact Dermatitis 1985; 12: 164–171.
12. Coenraads PJ, Diepgen TL. Risk for hand eczema in employees with past or present atopic dermatitis. Int Arch Occup Environ Health 1998; 71: 7–13.
13. Amat F, Soria A, Tallon P, Bourgoin-Heck M, Lambert N, Deschildre A, Just J. New insights into the phenotypes of atopic dermatitis linked with allergies and asthma in children: An overview. Clin Exp Allergy 2018; 48: 919–934.
14. Petersen AH, Johansen JD, Hald M. Hand eczema – prognosis and consequences: a 7-year follow-up study. Br J Dermatol 2014; 171: 1428–1433.
15. Olesen CM, Agner T, Ebbehøj NE, Carøe TK. Factors influencing prognosis for occupational hand eczema: new trends. Br J Dermatol 2019; 181: 1280–1286.