Xerosis cutis with secondary bacterial infection: An occupational disease of scrubbers in public bathhouses (2017)

Occupational skin diseases are ranked internationally as the second largest group of occupational diseases after musculoskeletal disorders1. Although they are rarely found in foreign countries, scrubbers are common in Korea and work at public bathhouses. They work in hot and humid environments on their feet all day, which can easily cause skin dryness and promote bacterial and fungal infections. Degos disease is a marker of cutaneous thrombo-obliterative vasculopathy and not a specific disease per se. It is characterized by pathognomonic skin lesions and centrally porcelainwhite atrophic papules with erythematous and telangiectatic rings2,3. A 55-year-old man presented with erythematous papules, patches, and multiple asymptomatic small depressed porcelain-white atrophic papules with a rim of rosy erythema spots 2 to 5 mm in diameter and dry skin on both lower extremities for 2 months (Fig. 1). The patient had been working at a public bathhouse as a scrubber on his feet all day for 10 years and had poor and irregular meals. He had no specific medical history. Mild pitting edema was observed on both lower legs. A punch biopsy was performed, and the histology showed hyperkeratosis and confluent parakeratosis in the epidermis. In the dermis, there were ectatic vessels with mild swelling of endothelial cells and both superficial and deep perivascular lymphocytic infiltrations (Fig. 2). We performed an atypical mycobacterial analysis, including nested polymerase chain reaction (PCR), which revealed negative results. However, gram staining of the tissue showed the presence of gram-positive cocci (1＋), and bacteriological culture indicated the presence of methicillin-sensitive Staphylococcus aureus. His nutritional status was assessed by measuring the serum levels of several vitamins and minerals, which indicated normal levels of vitamin D3 and vitamin B12, but decreased levels of Zn (60 g/dL, normal range 70∼ 121) and Fe (59 ng/dL, normal range 70∼180). The lesion was finally diagnosed as xerosis cutis with secondary bac-terial infection. The skin lesions almost cleared after 2 months of oral administration of cefaclor (750 mg/day), pentoxifylline (800 mg/day), and epinastine (20 mg/day) together with the application of a moisturizer. Pentoxifylline was used to improve blood circulation of the lower ex-tremities. In this case, dry and chapped skin caused by hot and humid working environments may cause disruption of the skin barrier, which can lead to secondary infection by Staphylococcus aureus. In addition to the complications caused by the harsh environment, venous stasis resulting from prolonged standing at work and malnutrition owing to irregular meals may exacerbate healing impairment and pro-mote secondary infection, leading to the aforementioned unique clinical features. Although zinc deficiency can also cause xerosis and impairment of wound healing, the scrubber`s working environment is considered as a major precipitating factor in this case. The amount of zinc deficiency was insignificant in the patient, and other symptoms or signs that can accompany zinc deficiency, such as alopecia, sto-matitis, and diarrhea were not observed. In Korea, there are many public bathhouses and pro-fessional scrubbers who work in hot and humid environ-ments near the bathtubs. Because of this scrubbing culture in Korea, we often meet patients with folliculitis, irritant dermatitis, or xerotic eczema due to intense scrubbing. Herein, we report a case of xerosis cutis with secondary infection of the chapped skin in a scrubber of a public bathhouse. This case may be worth knowing because such unusual clinical features could develop in specific occupa-tional groups in countries where scrubbing is common.