The study aimed at assessing frequency of skin diseases and symptoms related to working on farm. 145 farmers from the Lublin Province (large administrative district in eastern Poland) were involved: 67 women and 78 men aged 18 - 75 (median 43) years. Their employment on farm lasted from 3 - 62 (median 26) years.
Methods: Every farmer underwent a detailed questionnaire regarding skin symptoms at workplace and the possible provoking factors. Diagnosis was established by a dermatologist based on data from the questionnaire, and in some cases also on the morphology of skin changes (if present) and medical records from previous treatment.
Results: 36 farmers (24.8%) complained of work-related skin symptoms. The most frequent clinical form was dermatitis of uncovered skin areas (19 persons, 13.1%), followed by pruritus of uncovered skin areas (7 persons, 4.8%), hand dermatitis (6 persons, 4.1%), urticaria (3 persons, 2.0%), disseminated dermatitis (1 person, 0.7%) and foot dermatitis (1 person, 0.7%). The frequency of work-related skin symptoms was significantly (p = 0.04) higher among women (32.8%) than men (17.9%). In 35 farmers, skin symptoms were provoked by plant material, in 2 - by animals and their excrements, in 3 - by exposure to soil and soil dust and in 1 - by microtraumas. Among plant material provoking skin symptoms, most frequently mentioned was grain dust (26 persons), straw dust, hay dust and hops (each in 5 persons). Only 2 farmers indicated farm animals (cows, pigs) and their excrements as the cause for skin symptoms. Only 1 person indicated exposure to pesticides as the cause of skin symptoms.
Conclusion: One of four farmers suffers from work-related skin symptoms, provoked in vast majority by plant material, mostly grain dust, straw dust, hay dust and hops.
Key words: work-related dermatoses, farmers, clinical forms, provoking factors, questionnaire-based study, eastern Poland.
Little is known about the frequency of work-related skin symptoms and diseases among farmers in Poland. In the years 1995-1999, the Farmers' Social Insurance Institution registered annually from 9 - 22 new cases of occupational skin diseases among self-employed farmers. The incidence calculated from these data accounted in 1998 for 0.018 new cases/1000/year . Confrontation of this value with observation from the authors' practice leads, however, to the suspicion that detection of farmers' occupational dermatoses in Poland is very low. This study was aimed at assessing the real frequency of work-related skin problems among farmers of the Lublin Province (eastern Poland).
The study was carried out between 1998 - 2000 and comprised 145 farmers: 67 women and 78 men aged 18 - 75 (median 43) years, from 37 randomly selected family farms located in 9 villages of the Lublin Province. The criteria for inclusion in the study were 1) 18 years or more years of age, and 2) working on the farm for at least 3 preceding years. All included persons were working on traditional family farms with mixed production of grain, sugar beet, potatoes, rape and livestock of cattle and pigs. Due to good climate and soil in the study area hop, flax and herbs were also grown on many farms participating in the study. The examination of the farmers was carried out by a dermatologist with the help of a previously described questionnaire that includes a series of detailed questions on work-related skin symptoms and provoking activities and substances . Based upon answers to the questionnaire, the most probable diagnosis was set by a dermatologist. Also skin symptoms (if present) and previous medical records (if available) were taken into consideration during the diagnostic process.
The duration of employment in agriculture of the examined farmers ranged from 3 - 62 (median 26) years. 36 farmers (24.8%) complained of skin symptoms provoked by occupational activities on the farm (95% confidence interval: 17.8 - 31.9%): 22 of 67 women (32.8%) and 14 of 78 men (17.9%). The symptoms were significantly (p=0.04) more frequent among females. Age of the symptomatic farmers ranged from 20 - 69 (median 39) years, and duration of their work on the farm lasted for 9 - 53 (median 24) years. The most common complaint was dermatitis on uncovered skin areas (19 farmers, 13.1%), followed by pruritus of uncovered skin (7 farmers, 4.8%), hand eczema (6, 4.1%), disseminated urticaria (3 farmers, 2.1%), disseminated dermatitis (1 farmer, 0.7%) and foot dermatitis (1 farmer, 0.7%). One female farmer suffered both from dermatitis of uncovered skin areas and generalised urticaria.
Among factors causing skin symptoms at the work place, substances of plant origin prevailed, as they were indicated by 35 of 36 symptomatic farmers. Grain was the most frequent cause, mentioned by 26 farmers: 15 specified barley, 4 oats, 4 wheat, and 2 rye; 8 farmers were not able to declare what kind of grain caused their skin problems. 5 persons pointed on hay (4 on dry hay and 1 on freshly cut grass). Also 5 farmers each named straw and hops. 3 farmers reported on skin symptoms provoked by flax dust. Herbs (thyme, sage, marjoram, St. John's wort, savory, lemon balm) were also indicated by 3 persons. Contact with strawberry leaves caused skin problems in 2 persons, with leaves and green bean leaves, hemp and sawdust - each in 1 farmer. Contact with wet soil was causing hand eczema in 1 person, whereas soil dust provoked dermatitis of uncovered skin in 2 farmers. Skin problems associated with tending farm animals occurred in 2 farmers and were triggered by contact with cows, pigs and manure. One farmer complained of skin symptoms related to work with pesticides, another one reported his hand eczema be caused by repeated small traumas to the skin (microtraumas). Table 1 contains detailed information on the kind of skin symptoms reported and their causes.
|Disease/Symptom||F||M||F+M||Age (miedian)||Years of work||Non-occup.||Factors provoking skin symptoms (number of susceptible farmers)|
|Hand dermatitis||4||2||6||20-69 (42)||9-53 (28.5)||1||grain dust** (1), cows (1), pigs (1), manure (1), strawberry leaves (1), hop (1), wood dust (1), soil (1), microtraumas (1)|
|Foot dermatitis||1||0||1||57||39||0||grain dust** (1)|
|Dermatitis of uncovered skin (airborne dermatitis)||11*||8||19||24-59 (35.5)||9-49 (19)||4||grain dust** (4), barley dust (14), wheat dust (3), rye dust (3), oats dust (3), straw dust (3), cows (1), pigs (1), dry hay (3), freshly cut grass (1), hop (1), flax (3), hemp (1), common valerian (1), thyme (2), sage (2), savory (1), lemon balm (1), marjoram (1), St John's wort (1), pesticides (1), soil dust (2)|
|Disseminated dermatitis||0||1||1||48||31||0||grain dust** (1)|
|Pruritus of uncovered skin||5||2||7||28-55 (40)||12-41 (25)||0||grain dust** (1), barley dust (3), straw dust (2), hay (1), hop (2), strawberry leaves (1), cucumber leaves (1), green bean leaves (1)|
|Generalised urticaria||2*||1||3||26-44 (30)||10-29 (17)||2||grain dust** (1), barley dust (1), hay (1), hop (1), pesticides(1)|
|Total||22*||14||36||20-69 (39)||9-53 (24)||7|
|F - females, M - males, Non-occup. - number of farmers in whom similar symptoms are provoked also by non-occupational factors;
* in 1 female, airborne dermatitis co-existed with generalised urticaria;
** the term "grain dust" was only used if the farmer was not able to specify the grain species causing skin symptoms.
Occupational disease and work-related skin symptoms are in farming more frequent than generally assumed . Epidemiological data show that people working in agriculture are at the highest risk for occupational dermatosis among all industries . In Italy, hand dermatitis was found in 12% farmers as compared to 6% in a control population . In the USA, the incidence rate of occupational skin diseases in farming amounts to 2.8 cases per 1000 farmers per year, while the mean ratio for all industry branches is 0.6/1000/year [6, 7]. In the State of Washington between 1982 and 1986, the incidence rate for occupational dermatoses among farmers was 3.82/1000/year and exceeded by far other economy branches (0.98/1000/rok). Moreover, the rate was over 30 times higher than incidence rates of occupational respiratory diseases (0.09/1000/year in agriculture and 0.05/1000/year in remaining branches) . In California, skin diseases amounted to 62.4% all occupational diseases diagnosed in farmers from 1973 to 1984 . The incidence rate of occupational dermatoses in Finnish agriculture was 1.6/1000/year, also exceeding most other industries .
It must be, however, stressed that methodology of data acquisition varies from country to country, as does the definition of occupational diseases. The statistics are mostly based on records of insurance institutions, which mainly register cases severe enough to qualify for compensation. In contrast to this, questionnaire-based surveys are characterised by higher sensitivity (also less severe complaints are recorded) but they have lower specificity (they rely partly on observations and interpretations by farmers with no possibility for verification through tests or controlled exposures). Therefore, comparison of data from different sources requires a reasonable dose of caution.
In the present study, 1 of 4 farmers complained of work-related skin symptoms. In previous studies the frequency of work-related skin symptoms among hop growers amounted to 11 - 15% [11, 12], whereas thyme dust provoked airborne dermatitis in 8.7% growers  and grain dust caused skin symptoms in 5.6% of crop farmers . Remarkably lower figures may be found in a study on the health status of Polish rural residents, which estimated the prevalence of skin diseases at 16.43/1000, i. e. approximately 1.6% . This low percentage may be due to the fact that questions about skin problems were a scanty part of a large general health questionnaire and skin diseases were only recorded, if responsible internists found them of relevance to the general health status of the examined. The present study was instead carried out by a dermatologist and all skin symptoms were recorded, also the minor ones. The rationale behind this was that one couldn't predict whether or not these minor symptoms could develop into a serious disease in the future. Nevertheless, most of the recorded symptoms were of minor or moderate severity.
In 26 of 36 cases skin changes were located on uncovered areas of the skin, which turns attention to the importance of airborne agents (allergens, irritants) in farmers' work environment. After exclusion of photodermatoses, inflammatory skin conditions of uncovered areas suggest airborne dermatitis . Six farmers (4.1%) in the present study complained of work-related hand dermatitis. In a study of Californian farmers, chronic hand dermatitis was found in 13%, including 2% of contact dermatitis , 13% Italian farmers had hand dermatitis . Women reported skin symptoms more frequently (32.8%) than men (17.9%). A similar pattern was observed among Norwegian farmers, where skin diseases were reported by 4% of men and 16.2% of women . A reverse ratio (skin disease in 1.4% among men and 1.2% among women) was found in the above-mentioned study on the general health status of Polish rural inhabitants .
Among factors provoking skin symptoms, farmers most frequently named plant allergens, which were indicated by 35 of 36 farmers with skin symptoms. 26 of them indicated grain dust, 5 farmers each indicated straw, hay and hop. Also among Californian farmers plants were the main cause of occupational skin disease . Substances of animal origin seem to cause significantly less skin problems among Polish farmers. This was also observed in a previous study on the presence of work-related symptoms and antibodies specific to animal allergens among Polish cattle and pig breeders .
© Radoslaw Spiewak
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