Document BRYk3kNvpNgBzzD277Oon0XJE

Reprinted from The Journal of the American Medical Association May 20, 1944, Vol. 125, pp. 190-196 . Copyright, 1944, by American Medical Association (VMAwlmkk DERMATITIS FROM CUTTING OILS, SOLVENTS AND DIELECTRICS, INCLUDING CHLORACNE U! t= >- SAMUEL M. PECK, M.D. Senior Surgeon (R), Dermatoses Investigations Section, Divi sion of Industrial Hygiene National Institute of Health, U. S. Public Health Service BETH ES DA, MD. The use of solvents and cutting oils is so widespread that it is not possible to inspect any large manufac turing plant without encountering some department where one or the other is used. All operations in which cutting tools are used are literally bathed in oil of one type or another. It is almost impossible under ordinary conditions and much more so under the pressure of war production for the workers to avoid intimate con tact with either the solvents or the cutting oils used in their operations. Dermatitis from cutting oils, especially those of the insoluble type, occurs more frequently than any other occupational disease of the skin. If its incidence could be decreased, one of the most vexing problems of the industrial physician would be solved. The use of the dielectrics, especially the chlorinated hydrocarbons, is rapidly increasing. The latter give rise to a characteristic cutaneous eruption, known pop ularly as chloracne, which was first described in this country by Schwartz.1 The early diagnosis of this condition and the knowledge of its possible occurrence in any industrial process is of great importance. Once the condition develops, it is very persistent and takes many weeks to cure, even after the exposure has been This paper, in a symposium on "Wartime Industrial Dermatoses,'* is published under the auspices of the Section on Dermatology and Syphilology. 1. Schwartz, Louis: Dermatitis from Synthetic Resins and Waxes* Am. J. Pub. Health 20: 586* (June) 1936. Purnh^od "by tbi latlonal Ins V ..3 of Eealtb for official uso DSW 254968 2 eliminated. Chloracne can be prevented almost entirelv by the institution of proper preventive measured' ** - While it is true that at times dermatologists may not be entirely acquainted with the exact chemical entity which is responsible for an occupational derma titis, they have in the last few years learned enough about the mechanism of the production of industrial dermatitis to institute proper preventive measures. This is especially true as far as the cutting oils and the solvents are concerned. It is important to stress over and over again that proper preventive and protective measures can decrease the incidence of occupational dermatoses. CUTTING OILS Cutting oils not only are the most frequent causes of dermatitis among the workers with machine tools and metals but have been shown to give rise to more occupational dermatitis than any other agent. The cuta neous eruptions which they elicit are usually of the acneform group, but they sometimes cause allergic dermatitis as well. This is not due to the fact that they are the most potent producers of acne or to the fact that they contain substances having unusual sensi tizing properties but to the fact that more workers are exposed to their action and fewer precautions are taken against their effects on the skin. The cutting oils can be divided into two main groups, the insoluble and the soluble. Of the two, the insoluble cutting oils are most frequently the etiologic agents in cutting oil dermatitis.' The insoluble cutting oils vary in their composition according to the particular types of machining for which they are to be used. The formulas of these oils are rarely known by their users, since they are trade secrets. Essentially they consist of a large percentage of petro leum oil to which is added a small amount of animal and vegetable oil ("lard oils"), chlorine compounds, sulfur and an inhibitor to prevent deterioration of the fatty oil. _ "Lard oils" were first used, but the oils derived from petroleum have been substituted, both because of their cheapness and because, unlike the vegetable or the animal oils, they do not become rancid. The min eral oils may be obtained from crudes of various types. DSW 254969 STLCOPCB4060660 3 The so-called lard oils, which are now added only in small amounts, may be oleic acid, fish oils, lard oils and vegetable oils. The inhibitors which are incorpo rated to prevent rancidity of the lard oils should not have the property of rusting iron and usually are phenolic amines. The insoluble cutting oils are used chiefly as aids to help in the cutting operation. One of their chief functions is the reduction of adhesion between the chip and the tool face. According to Ernst and Merchant a chemical reaction may take jJlace between the cutting fluid and the freshly ruptured chip surface. It is important to bear this in mind, as the chemical com pounds which are formed may act as a possible source for some of the dermatitis from the cutting oils. Appar ently this possibility has not been previously considered. The sulfur which is added gives somewhat different characteristics to the cutting oils than do the chlorine compounds. At low cutting speeds chlorinated fluids are more effective in reducing the friction between the tool and the tool face as compared with sulfurized fluids. Sulfurized fluids are more effective at high cutting speeds or under severe cutting conditions. The insoluble cutting oils are usually sterile in spite of the high incidence of folliculitis that they produce. It is not necessary and in fact adds to the possibility of a cutaneous irritation when antiseptics are added because of the mistaken idea that the bacterial content of the cutting oils is the cause of the folliculitis. The soluble cutting oils act mainly to cool the cutting tools. Lubrication is a secondary function. According to Schwartz 3 the main constituents of the soluble cut ting oils are sulfonated mineral and fatty oils 60 to 95 per cent, soap 5 to 30 per cent and volatile contents 0 to 10 per cent. Inhibitors such as phenolic amines are added to prevent rancidity. The soluble cutting oils are diluted many times with water (5 to 100 or 1 to 100^ before they are used. It is the soluble cutting oils which have a high con tent of bacteria, many of them pathogens. However, folliculitis and infections and even contact dermatitis are relatively rare among workers exposed to them as 2. Ernst, Hans, and Merchant, M. E.: Chip Formation, Friction and Finish, Cincinnati, Cincinnati Milking Machine Company, August 1940. 3. Schwartz, Louis: Dermatitis from Cutting Oils, Pub. Health Rep. 56: 1947 (Oct. 3) 1941. I STLCOPCB4060661 4 compared with those exposed to the insoluble cutting oils. This can readily be understood when one con siders how they are diluted before being used. Spolyar and Ferree * recently reported systemic effects from the hydrogen sulfide encountered in a cutting oil. Dermatitis from Cutting Oils.--The cutting oils con tain metal slivers which may cause small wounds. Often the worker will use old waste impregnated with the oil containing the metal particles to wipe his hands and thus cause wounds and scratches. The petroleum oils may defat the_ skin. This is only slightly modified by their content of fatty oils. Just as in dermatitis due to solvents, especially in older persons with dry skins, the degreasing action may lead to drying and Assuring of the skin. Secon dary infection may occur through the wounds and scratches. Papillomas may be seen on the hands and arms of those exposed for many years to mineral oils and greases. These are small, flat, brownish verrucous lesions, usually seen on the backs of the hands. Allergic eczema is relatively of infrequent occurrence. It may be due to idiosyncrasy for the animal or the vegetable oil, the inhibitors, such as the nitrobenzenes, cresols and phenols, or the other antiseptics which may be added. As has been pointed out previously, chemical compounds may be formed in the cutting oper ation by the interaction between the cutting tool, the face of the cut metal and the sulfur and chlorine com pounds in the cutting oil. These chemical compounds may be factors in allergic dermatitis. The specific hypersensitivity can be demonstrated by means of the patch test. Not only may the dermatitis be aggravated by the use of harsh cleansers, but these themselves may often give rise to dermatitis. The lesions most frequently seen after exposure to the cutting oils (usually the insoluble and rarely the soluble cutting oils) are folliculitis and comedos. The hairy portions of the arms and the anterior surfaces of the thighs are the sites of predilection. They are also seen on the backs of the hands and fingers and on the abdomen (figs. 1 and 2). ' 4r Spotyir* W. L., and Ferree, J. W.: Some Occupational Diseases Associated with the War Production Program, J. Indiana M. A. 35: 402 (Ang.) 1942. DSW 254971 DSW 254972 STLCOPCB4060663 6 The eruptions are especially prone to appear in hairy persons with a well developed pilosebaceous apparatus. Those areas of the body, such as the waist and the anterior parts of the thighs, which are exposed to intimate contact with oil soaked clothing, may also be affected. , Comedos may be seen occupying almost all the fol licular openings on the forearms and the upper anterior surfaces of the thighs, with relatively little inflammatory reaction. Usually, however, there are interspersed papules, pustules and patchy areas of perifollicular ery thema. The papules and pustules are usually peri follicular. When secondary infection occurs, abscesses or even carbuncles become evident. The histologic nature of oil folliculitis was recently studied.5 The process could be seen to consist of a stimulus to the formation of keratin leading to the formation of a keratogenous plug in the follicular opening (comedo formation) similar to that seen after irritation with coal tar, coal tar distillates, coal tar pitch and the chlorinated hydrocarbons. The lesions produced by the cutting oils usually begin as folliculitis, and the process is much more inflammatory and extends some distance into the skin surrounding the affected hair follicles. Even the sweat glands may be involved. No bacteria were demonstrated in the lesions. for a long time it was thought that the inflammatory reaction caused by the cutting oils was due to their content of pathogenic bacteria. It has been shown time and again that the insoluble cutting oils with their high incidence of folliculitis are sterile while the soluble cutting oils which may contain bacteria rarely cause any inflammatory reactions. Secondary infection may occur, but the bacteria are not from the insoluble cut ting oils; they find their entrance through the wounds and scratches from the metal slivers or the abrasions caused by friction of the clothing against the inflamed skin. The bacteria may originate from the clothing and even from the skin of the affected worker. It seems clearly brought out both by the study of histologic sections from areas of oil folliculitis and by the bacterial examination of insoluble cutting oils that 5. Schwartz, Louis, and Peck, Samuel M.: Occupational Acne, New York StateXMed. 43:1711-1718 (Sept. 15) 1943.- - DSW 254973 STLCOPCB4060664 i 7 the inflammatory reaction which is produced by the oils is due to the presence of irritants in them. These irritants may be sulfur compounds, chlorine compounds, the inhibitors or other not as yet identified chemical substances in the insoluble cutting oils. Schamberg conducted exhaustive experiments with the insoluble cutting oils in an attempt to reproduce oil folliculitis in human subjects. According to his findings it was the organically combined hydrocarbon sulfonate which was mainly responsible for the irrita- Fig. 2.--Cutting oil dermatitis on thigh. .Vote the comedo formation. The patient was a safety glass worker in contact with petroleum oil (patient ut Dr. Louis Schwartz, L\ S. Public Health Service). tion. This is substantiated by the well known fact that petroleum products which are not sulfurized. such as petrolatum, which is widely used as a dermal applica tion, soothe rather than irritate. The formation of the comedo is due to the stimulation of keratin formation by the mineral oils acting on the cells lining the follicular openings. When in addition these oils con tain solid chlorinated hydrocarbons, acneform lesions of the more cystic type such as will be described under chloracne may be seen associated with the folliculitis and comedo formation. 6. Schamberg. J. F : Causes of Skin Sores and Boils Among Metal Workers, Philadelphia, E. F. Houghton & Co., 1920. DSW 254974 STLCOPCB4060665 8 A discussion of the possible relationship between con tact with some of the insoluble cutting oils and the elicitation of latent epidermophytids is beyond the scope of this paper. BiramT has called attention to this possibility. It is hoped that from the work now being done more light will be thrown on this possible rela tionship. Prevention.--The llowing suggestions with a few changes to suit a particular problem can be used as the basis for an attempt to prevent almost any occupational dermatitis. The problem consists essentially in reduc ing to a minimum the contact between the worker and the irritant. 1. The machines should be kept as free from grease and dirt as possible by a daily cleansing. The oil should not be allowed to accumulate at the base of the machine or on the floor. In some manufacturing plants metal aprons are attached to the machines to prevent splashes of oil coming in contact with the workers or reaching the floor. The oil should be changed at least once a week. If it is to be reused it should be filtered to remove metal slivers. Instead of adding antiseptics which increase the hazard of dermatitis, sterilization can be employed, but this applies only to the soluble cutting oils. The rancidity can be removed by neutralization. It must be borne in mind, however, that a number of the chemical compounds which are formed in the oil by the cutting operation or which are due to sulfurization or to the addition of chlorinated hydrocarbons cannot be removed by reprocessing or cleaning the oil. 2. Adequate washing facilities with hot and cold run ning water and shower baths should be provided. The use of the showers should be compulsory and super vised, and enough time should be allotted for their use. Clean towels should be given to the workers daily, and they should have free accesss to clean waste at the machines. Old waste with its content of metal slivers should be discarded. The dressing rooms should have two rows of lockers: one in which the street clothes are removed and the other preferably in a room which would be entered only through the showers for 7. Birajn, J. H.: Prevention of Skin Rashes, Indust. Med. 12:208 (April) 1943. DSW 254975 9 the work clothes. To guard against epidermophytosis, wooden soled sandals should be worn to and from the showers. Proper antiseptic foot baths should also be provided. 3. Proper solid or liquid skin cleansers should be provided. For those workers whose skins become defatted and for those who have dermatitis, the neutral sulfonated skin cleanser advocated by Schwartz 8 should be used or a similar preparation. Schwartz has recom mended the use of a neutral sulfonated castor oil to which 2 per cent of a synthetic wetting agent has been added. He has further suggested that for ordinary use the cleanser should consist of a neutral toilet soap plus a w.etting agent or a synthetic detergent and a scrubber which softens or dissolves in water and does not clog the plumbing. 4. Clean work clothes should be provided daily for the workers and laundered by the plant. 5. To protect the exposed portions of the body, the workers should be provided with impervious sleeves; aprons and gloves made from one of the synthetic resin films. The sleeves should fasten over the gloves and be long enough to extend over the elbows. 6. Protective ointments are often used. They are not as efficacious as protective clothing and should be used only on those parts of the body, such as the face, which cannot be protected otherwise. The invisi ble glove type of protective ointment can be used, which leaves a film on the skin insoluble in oil but soluble in water, or a greasy ointment made of animal or vegetable fat, which fills up the pores and acts as a buffer between the skin and the cutting oil. In all such ointments a wetting agent should be incorporated to make them easily removable.8 Treatment.--The best treatment of dermatitis caused by cutting oils is the prevention of further contact with the cutting oils. When folliculitis and inflammation are present, wet dressings of 50 per cent alcohol, solution of aluminum acetate or solution of boric acid are helpful. The wet dressings can be applied to the arms and cov ered with one of the impervious sleeves suggested under prevention, and thus the worker can continue his occu- 8. Schwartz, Louis: Protective Ointments and Industrial Cleansers. M. Gin. North America 26: 1195 (July) 1942. DSW 254976 2 STLCOPCB4060667 10 pation. Several times during the day he can visit the first aid room to have the wet dressings renewed. Thus no time is lost, and the worker actually receives better treatment than if he were to stay home. If an abscess or a carbuncle develops, surgical treatment is necessary. Unless there is definite secondary infec tion, the local use of the sulfonamides is not only unnecessary but often increases the dermatitis. For the defatted skins a soothing ointment, such as a cold cream, perhaps one containing hydrous wool fat or lecithin, or any good emollient cream rich in vegetable and animal fats can be used. SOLVENTS Dermatitis is a frequent occurrence among persons exposed to solvents. It frequently occurs among the users of solvents but is relatively rare among the work ers who are engaged in their manufacture. This is due to the fact that the processes of their manufacture are almost entirely enclosed. Among the solvents are included the organic liquids which are used as cleansers in degreasing operations of various kinds, also those used to extract oils, fats and wastes, the solvents for plastics, resins and rubber and those used to dissolve varnishes, paints and lacquers. The organic solvents can be divided into the follow ing groups: 1. Petroleum derivatives. () Pentane. (ft) Petroleum ether. (c) Benzine in that portion of crude petroleum distilled below ISO C. (d) "Stoddard solvent," a petroleum distillate which boils between 150 and 200 C. It is popular as a degreas ing agent. (e) Yarsol, also popular as a degreasing agent. (/) Kerosene. 2. Coal tar derivatives. (o) Coal tar naphtha, or light oil. It is a complex com pound containing phenols, aniline, toluidine, naph thalene, pyridine and other sulfur compounds. () Benzol (benzenes), the fraction which distills below 120 C. It is not pure benzene (CH) but consists mainly of benzene and toluene with small amounts of carbon disulfide and hydrocarbons. DSW 254977 11 (c) Toluene (toluol) (C;HS). It is obtained from the fractional distillation of coal tar naphtha. (d) Xylene (xyol) (C8H.,,). (e) Light solvent naphtha. (/) Heavy solvent naphtha. Co) Tetralin (tetrahydronaphthalene) (CiHn). (h) Dekalin (CioHis). 3. Turpentine: Turpentine is derived chiefly from the resin ous exudation of various species of pine and other Coniferae. ,, (a) Gum turpentine, obtained by closed distillation of the oleoresin from the pine tree. The turpentine comes off, and the resin remains. (b) Russian turpentine, obtained by destructive distillation of wood. (r) American steam distilled turpentine, made from pine tree stumps. It contains 70 to 90 per cent of alpha beta pinene, about 10 per cent dipentene (inactive limonene) and a small amount of paramenthane. (d) Pine oil, a by-product of the steam distillation of turpentine. It consists of a mixture of higher alcohols. (r) Terpineol, spirit of resin, spirit of tar and oil of pine needles. 4. Alcohols. (a) Methyl alcohol (CHaOH), or wood alcohol. (b) Ethyl alcohol (CsHsOH). This is usually denatured for commercial use by the addition of naphtha, acetone or zinc sulfocarbolate, all of which render it unfit to drink. (c) The higher alcohols, such as butyl, amyl and propyl. 5. Chlorine derivatives. (o) Chloroform. (b) Carbon tetrachloride (CCh). (c) Dichloroethylene (C2H2CI2). (d) Trichloroethylene (GHCL). (e) Perchloroethylene (C2CU). (/) Tetrachloroethane (C;H2C1). (g) Monochlorobenzene, dichlorobenzene. 6. Esters. Methyl, ethyl, butyl and amyl acetate and derivatives. 7. Glycols. Ethylene glycol and diethylene glycol. 8. Carbon disulfide (CS2). 9. Ketones. Acetone, methyl ethyl ketone, methyl acetone. DSW 254978 2 STLCOPCB4060669 12 According to Schwartz,9 about 3 per cent of 6,000 cases of occupational dermatoses reported were found among painters. Paint consists essentially of a pigment in a drying oil, to which lead, manganese or cobalt is added to hasten the drying. Thinners are added to the paint both to allow for easier application and to hold in solution the oils and resins which paint contains. Turpentine, gasoline, naphtha, petroleum ether, mineral spirits, benzene and toluene are among the thinners used. The largest percentage of cases of dermatosis caused by paint is due to these thinners. The solvents frequently encountered in the war indus tries are the dopes used in spraying the wings and the control parts of planes. The dopes consist of a solution of cellulose nitrate or acetate in a volatile solvent such as acetone or amyl acetate. As these evaporate they leave the resin on the fabric. Dermatitis frequently results from contact with the solvents in the dopes. Another frequently occurring occupational dermatitis is found among workers engaged in degreasing small metal parts, for which the petroleum distillates, kero sene, varsol and others are used. In many industries large degreasing tanks are used which contain trichloro ethylene. If proper protective measures are not used in these operations, not only dermatitis but systemic poisoning may occur. Solvent dermatitis is also not infrequent!} seen in the printing industry, especially among pressmen and compositors, from the action of turpentine, xylene, ben zene and other petroleum distillates used in cleaning types and presses. Clinical Characteristics.--The solvents exert their drying effect on the skin by removing the fats and oils. This results not only in dryness but in cracking of the skin which may eventually lead to a dry fissured appearance which is characteristic (fig. 3). Those most frequently affected are older persons who natur ally have dry skins and in whom the natural fats and oils which are removed by the solvents are not easily replaced. 9. Schwartz, Louis: Skin Hazards in American Industry: III. Public Health Bulletin 249, United States Treasury Department, Public Health Service, 1939, pp. 33-42. DSW 254979 u The liands. wrists and forearms are usually affected, [n some patients not only the dorsa of the hands but the palms may show Assuring dryness and desquama tion. Patients with thin dry skins may even have actual dissolution of the keratin layers, with erythema and vesiculation as a result. Hypersensitivity may develop with the production of allergic dermatitis, which when it is acute shows typical erythema, papules and vesicules at all places of contact. In such cases cutaneous eruptions may be seen in other parts of the body, such as the legs and even the feet, which may have been in only slight contact with the Fig. 3.--Dermatitis as a result of daily contact with a solvent (diethyl ene chloride) (patient of Dr. Louis Schwartz, L*. S. Public Health Service). solvent. Turpentine is a primary cutaneous irritant and will cause dermatitis if allowed to remain on the skin any length of time. Most organic solvents are systemic poisons, and poisoning may occur as a result not only of inhalation but of absorption through the skin. Diagnosis (a history of exposure).--A visit to the plant to inspect the process and to see to what the worker is exposed plus the observation of the charac teristic dry fissured scaling dermatitis, especially when it involves the palms, are sufficient to make the diag nosis of solvent dermatitis. However, when the allergic DSW 254980 STLCOPCB4060671 14 type of eruption' is seen, a positive diagnosis can be arrived at only by a patch test properly performed. Since the solvents are primary irritants, they cannot be put on the skin as in the ordinary method of per forming a patch test. They have to be diluted so that the final concentration used on the skin is known not to irritate the skin of normal persons. About 50 per cent of the solvent in corn oil can be used for the patch test. Prevention.--To prevent the fumes of the volatile solvents from reaching the workers, hoods, suction devices and other mechanical means should be used. The suggestions for individual protection, however, must be followed to prevent dermatitis from the sol vents. Protective clothes made of synthetic rubber must be used, since rubber is attacked by many of the carbons of petroleum and by carbon disulfide also; gloves made from the polyvinyl alcohols can be substituted for those of synthetic rubber. Impervious sleeves which fasten over the gloves and reach over the elbow made from the same materials should also be worn. Aprons long enough to protect the body should, of course, be made from the same fabric. As far as the rest of the clothing is concerned, includ ing its laundering and other care, the rules laid down for the prevention of cutting oil dermatitis can be carried out. As to cleanliness, because of the defatting action of the solvents on the skin, the suggestions made for washing and other cleansing measures under cutting oils may not be carried out in the same way. The workers should be taught not to use the solvents to clean off paints and other materials from their skins. Those who show the effects of the solvents oh their skins must use safe cleansers, and the cleanser for dry skins previously recommended should be used. As has been stated previously, after washing an emollient like that mentioned under cutting oils should be rubbed into the skin. . DIELECTRICS CAUSING CHLORACNE The increasing use of dielectrics in insulating wires and condensers, especially chloro compounds, has increased the incidence of the so-called chloracne. These compounds are important dielectrics or insu- DSW 254981 STLCOPCB4060672 15 lators because they are heat resistant, flameproof and waterproof. The chloronaphthalenes, the chlorodi phenyls and the chlorodiphenyloxides are especially prone to cause occupational acne. The solid chlorobenzols and the solid chlorophenols are also potent acne producers. Nearly every worker who is sufficiently exposed to these compounds for a few months will have chloracne. Even members of .the immediate family who come in contact with work clothes soiled with these chloro compounds have been known to acquire these acneform lesions. The term "chloracne" is a misnomer. Chlorine itself does not cause occupational acne either by contact or by oral administration. Neither the solvent chlorinated hydrocarbons nor naphthalene, ben zene, diphenyl or phenol have caused acneform erup tions. Only the highly viscous or the amorphous solid chlorinated hydrocarbons cause acneform lesions. The solid chloronaphthalenes are made by substitu tion of chlorine for the hydrogen in the naphthalenes. Any number of the hydrogen atoms may be replaced. Those most frequently used as dielectrics are the trichloronaphthalenes. Usually these are combined with the chlorodiphenyls (sold under the trade name Halowax). Not all compounds sold as Halowax necessarily consist of the chlorinated hydrocarbons. Chlorodiphenoloxide is a semisolid compound made by chlorinating diphenoloxide. The chloronaphthalenes and chlorodiphenols not only cause lesions of the skin but give rise to acute yellow atrophy of the liver. While the acne caused by them has been known abroad for some time, the systemic effect was first pointed out by Schwartz in 1935.10 Recently because of the pressure of war. work an increasing incidence of acne-like lesions has been reported among electricians installing cables on ships. It was found that cables were coated with chloronaph thalenes and chlorodiphenyls (halowax). The acne was found usually in electricians engaged in "strip- 10. Drinker, Cecil: Certain Chlorinated Hydrocarbons, in Symposium held at Harvard University School of Public Health, Boston, June 30, 1937. Fulton, W. B., and Mathews, J. L.: Dermatological and Sys temic Effects of Exposure to Hexachlomapbthalene and Chlordiphenyl, Special Bulletin 43, Pennsylvania Department of Labor and Industry, pp. 1-15. Myer, May R., and Silverberg, Mabel G.: Skin Conditions Resulting from Exposure to Certain Chlorinated Hydrocarbons, J. Indust. Hyg. & Toxicol. 20:244 (March) 1938. Jones, J. W., and Alden, H. S.: Acneform Dermatergosis, Arch. Dermat. & Syph. 33:1022 (June) 1936. Morris, G. E.. and Tabershaw, I. R.: "Cable Rash": Note on a New Cleansing Mixture, J. A. M. A. 121: 192 (Jan. 16) 1943. DSW 254982 STLCOPCB4060673 16 ping" the coated cables; the halowax was impregnated into asbestos which was wrapped around the wires as insulation. In shipyards visited by Schwartz 11 it was found that only those exposed continuously for relatively long periods to cables from which the halowax containing the chlorinated hydrocarbons flaked off easily were affected with the acne. He did not see any cases of yellow atrophy of the liver. Workers exposed to the fumes of halowax also had acneform lesions. Clinical Characteristics of Chloracne.--The lesions of chloracne consist of pinhead to pea sized or even larger pale straw colored cysts. Comedos are present but are not a striking feature. The cysts are located on the face and the lobes of the ears, behind the ears, on the back of the neck, the shoulders, the abdomen, particularly around the umbilicus, and on the thighs and even on the scrotum and the shaft of the penis (fig. 4). Everywhere that the fumes or the clothing soiled with the chlorinated hydrocarbons might come in contact with the skin is an area of predilection. The individual lesions increase in size for a few months and then remain stationary. They may still be present months or even years after exposure has been elimi nated. Systemic absorption does not seem to be the cause of the lesions. This is suggested by the fact that they occur on exposed parts of the body or those intimately in contact with soiled clothing. Even experimental local reproduction of the chloracne has been accom plished by long continued local application of these acne producing substances.12 . The lesions are due to chloro compounds deposited as fine particles or condensations on the skin from the fumes and from solution. They plug the orifices of the pores and by their keratogenous action cause the forma tion of comedos. This in turn gives rise to cysts by a combination of mechanical plugging of the mouths of the glands plus actual keratinization of their walls. This is well brought out in microscopic studies of the lesions 13 in sections of characteristic straw colored 11. Schwartz* Louis: An Outbreak of Halowax Acne ("Cable Rash") Among Electrician*, J. A. M. A. 123: 158 (May 15) 1943. 12. Nakauchi. Y.: Acneform Lesions* Jap. J. Dermal. & Urol. 48?87 (Oct.) 1940. Schwartz* Louis: Personal communication to the author. 13. DrinkeT.1* Schwartz and Peck.* 17 cysts. Large cysts can he seen with very thin walls filled with keratinous material hut little sebaceous mat ter. Associated with such cysts are the wide follicular openings filled with keratin plugs and having hyper plastic follicular walls. Cocci are not evident in the comedos. Just as in acne vulgaris, a foreign bodv Fiy. 4.--Chloracne from hslowax (patient ut Dr. Louis Schwartz, L\ S. Public Health Service). granuloma may occur due to rupture of a cyst wall and contact of the sebum with the collagen. Coal tar pitch is sometimes used as an insulating material. It may also cause acneform lesions, but the lesions can be differentiated from chloracne by the accompanying melanosis and the presence of comedos rather than cysts as prominent features. DSW 254984 r) STLCOPCB4060675 18 Acne due to the chlorinated hydrocarbons can be differentiated from acne vulgaris by the history of exposure, by the occurrence at any age, by the distribu tion on areas of the body where acne vulgaris is usually not seen, such as the abdomen, the back of the neck and even the forearms, by the much less inflammation as compared with acne vulgaris, sometimes by the dryness of the skin, by the fact that comedos are not a pre dominant feature, by the persistence of the lesions and by the much greater amount of keratinous material contained in the cysts. Cocci are easily demonstrated in the comedos of acne vulgaris, while they are not seen in those due to the chlorinated hydrocarbons. Prevention.--1. Workers engaged in stripping the cables should wear hood respirators containing proper filters.. Where hoods cannot be worn, proper ventila tion should be installed to remove fumes and dust. 2. The exposed parts, such as the face, should be covered with protective ointments of the invisible glove type reinforced with inert powders. Clean coveralls should be supplied daily and must be laundered by the plant or the shipyard. It is important that the underclothes should be cleaned daily also. 3. Adequate washing facilities should be provided, and taking showers at the end of the working day should be compulsory. Workers should be instructed to wash their hands thoroughly before eating lunch, and no smoking should be allowed without similar precautions being taken. The soap furnished the work ers should preferably contain one of the synthetic wet ting agents, such as one of the duponols (a group of higher aliphatic alcohol sulfates and derivatives of them) or santamerse (alkylated argylsulfonate), which will remove soil more easily than ordinary soap. Treatment.--The only way to remove the cysts is by manual expression. Keratolytic local applications are not sufficient to remove them. In most cases use of x-rays is not indicated, because the patients have dry skins and it is not a question of reducing the activity of the sebaceous glands as it is in acne vulgaris. Printed and Published the United States of America DSW 254985