Occupational skin disease in nail salon workers

Introduction

Professional manicure work has been recognised as a profession since the 1980s. It is a fast-growing industry popular with women and increasingly with men, as nails play an essential role in patient appearance. Billions are spent on nail salon services.

Nail salons offer manicure and pedicure treatments, acrylic, ultraviolet (UV) gel and silk or fibreglass coatings and extensions, and acrylic and UV gel-sculpted extensions. The increasing use of gel nails and sculptured nails has led to a rise in the incidence of (metha)crylate allergy among nail technicians. Methacrylate is a raw material that is used for adhesives, coatings, in the application of artificial nails, and in the gel nails, with polymerisation on exposure to UV light. Clients are exposed to volatile, strong irritants, and unstable chemicals.

People who work in nail salons are prone to skin disorders as a result of their work. Manicurists have also reported respiratory problems and headaches.

Why are nail salon workers particularly at risk of skin disorders?

Nail salon workers are prone to skin problems because of:

• Wet work or frequent exposure of the hands to water
• Exposure to chemicals in nail cosmetics
• Exposure to nail lamps emitting ultraviolet (UV) radiation
• Failure to wear protective gloves or use other personal protective equipment
• Lack of education or understanding about the need for skin protection.

Understanding occupational skin disorders

The terms occupational skin disorder or occupational skin disease are used to refer to dermatological conditions that develop or worsen due to the nature of a person’s work. Skin disorders are believed to account for 40–70% of all occupational diseases. Skin disorders occur when the natural defences of the skin are compromised by mechanical, chemical or biological agents, leaving the skin more vulnerable to infections and the breakdown of the skin barrier.

Occupational skin disorders in nail salon workers

Skin problems arising in nail salon workers include hand dermatitis, stomatitis, mechanical injuries, infections, and the effects of exposure to ultraviolet radiation.

Hand dermatitis

Hand dermatitis can be due to both irritant contact dermatitis and allergic contact dermatitis. It has been classified into acute ‘wet’ and chronic ‘dry’ types.

• The wet form of hand dermatitis involves the back of the hand and fingers as well as the palms. Its signs and symptoms include severe itching, inflammation and blistering.
• Common causes of this type of acute contact dermatitis include irritants such as water, detergents and rubber gloves, and allergens such as nickel, fragrances, and nail cosmetics. This type of dermatitis tends to persist throughout the year.
• The dry chronic form of hand dermatitis starts at the tips of the first three fingers but may spread to other fingers and palms or backs of the hands.
• Signs and symptoms of chronic hand dermatitis include mild itching, hyperpigmentation, dryness, and nail deformity. The chronic dry form of hand dermatitis tends to be more severe during the winter months.
• Periungual dermatitis, onycholysis and nail shedding (onychomadesis) can occur

Mechanical injuries

Mechanical injuries may include minor abrasions and cuts, often associated with scrubbing floors or contact with other rough surfaces.

Infections

• Secondary bacterial skin infections can complicate dermatitis and wounds.
• Candida yeast infections in the finger webs (intertrigo) can be due to wet work.

Effects of ultraviolet radiation

Exposure to UV radiation is known to cause premature skin ageing, wrinkles and brown spots. UV breaks the DNA strands within the cells predisposing to skin cancer [1] and also damages eyes [2,3]. Cutaneous squamous cell carcinoma has been reported in clients exposed to UV radiation for cosmetic nail treatment [4] but the risk has been calculated to be negligible [5,6].

People working in nail salons are repeatedly exposed to UV radiation each day, as nail lamps emitting UV radiation are used to speed-dry regular manicures. Typically, 3 separate coats of gel are applied, each followed by curing under UV light for 3 minutes. Nail fill-ins are often required every 2–3 weeks as the expected nail grows out, and the nails are typically replaced every 3–4 months.

Nail-curing lamps mainly emit high-intensity UV-A (95%) with a small component of UV-B (5%). UVA penetrates into the dermis and in high doses can cause damage to skin cells, photoageing, and increase the risk for skin cancer. Nail salons predominantly use fluorescent UV lamps although some use light-emitting diode (LED) lights. Exposure time to UV radiation is shorter with the more powerful LED lights.

Nail lamps deliver the same UV rays as tanning beds but have much lower power (typically 4 W to 54 W). It has been estimated that hundreds of exposures to a nail lamp are required to cause enough damage to raise the risk of skin cancer [6].

Some precautions are advisable:

• Consider air-drying nails instead of exposing them to UV
• Use nitrile gloves
• Suggest the client wear cotton gloves with chopped off fingertips
• Avoid cutting the cuticle
• Apply generous waterproof broad-spectrum SPF 50+ sunscreen to the backs of the fingers and hands.

Assessing the risks

Factors to consider in a nail salon include:

• The safe handling and storage of chemicals
• Following the directions for the use carefully
• Select the safest chemical products
• Using appropriate protective gloves to reduce exposure to water and chemicals
• Ventilation of the work area.

Personal protective equipment

The most important piece of personal protective equipment for nail salon workers should be gloves, preferably of a non-latex type to avoid possible sensitisation to latex; nitrile gloves provide better protection than latex gloves.

• If working with volatile/airborne chemicals, protective aprons and masks or goggles should also be considered.
• Avoid contact with uncured acrylates.
• Diagnosing and treating occupational skin disorders

How is occupational skin disorder diagnosed?

The diagnosis of an occupational skin disorder should include:

• A careful patient history, particularly relating to specific tasks and contact with irritants and potential allergens
• Consideration of the patient’s other medical conditions, especially those relating to the immune system or atopic dermatitis
• A clinical examination to note the appearance and location of dermatitis.

How is occupational skin disorder treated?

The treatment of an occupational skin disorder can include:

• Education on how to reduce contact with irritants and allergens, with safe handling of sharps and disposable items
• Barrier creams and emollients
• Topical steroids
• Use of gentle non-soap cleansers
• Oral antibiotics for secondary infections
• Oral steroids and immune-modulating drugs for severe or persistent dermatitis.