PRECÍS Occupational seborrheic dermatitis is seldom reported. Occlusion under personal protective equipment, such as a flame-retardant balaclava, can predispose one to developing occupational seborrheic dermatitis. DISCUSSION A 38-year-old male steel worker presented to our outpatient dermatology practice with a several-year history of relapsing and remitting mildly pruritic coalescing red papules on the face, scalp, neck, and upper chest (Fig. 1). He reported minimal improvement with miconazole powder and hydrocortisone 1% cream. The rash did seem to be related to his occupation and cleared completely on vacation. A presumptive diagnosis of allergic contact dermatitis (ACD) was made, and the patient was given 60 mg of intramuscular triamcinolone acetonide and started on topical triamcinolone 0.1% cream twice daily. Three-millimeter punch biopsies of the occipital scalp and chest were obtained and showed mounds of scale crust containing neutrophils at lips of follicular ostia, spongiotic mild psoriasiform hyperplasia, and a perivascular mixed-cell infiltrate around dilated vessels in the upper part of the dermis, suggestive of seborrheic dermatitis (SD; Fig. 2).Figure 1: Steel worker with scaly coalescing red papules on the face, scalp, neck, and upper chest. Comparison of patient's rash and that of his PPE (a flame-retardant balaclava).Figure 2: Hematoxylin and eosin stain (×10) of punch biopsy of occipital scalp: mounds of scale crust containing neutrophils at lips of follicular ostia and spongiotic mild psoriasiform hyperplasia.On 2-week follow-up, the patient noted only moderate improvement. Given the temporal association with his occupation, he was instructed to bring in his personal protective equipment (PPE); his flame-retardant balaclava, which he wore daily, closely matched the distribution of his rash (Fig. 1). The patient reported wearing this balaclava 4 to 8 hours per day while working in a hot steel mill. The patient was treated with ketoconazole 2% shampoo daily, to be used both as a shampoo and body wash, and ciclopirox 0.77% solution twice daily. The patient reported complete resolution at 2 weeks and maintained resolution at 6 months with only intermittent ketoconazole shampoo use and without job change. While both allergic and irritant contact dermatitis were considered in this case, especially considering the potential overlap histopathologically between ACD and SD, we favor a definitive diagnosis of SD given the lack of significant eosinophils on biopsy, minimal pruritus, failure of ACD-directed therapy, and near-complete resolution on SD-directed therapy. Occupational SD is rarely reported. Flares of pre-established SD were reported in health care workers with increased mask use during the COVID-19 pandemic.1,2 Interestingly, SD also has an increased prevalence among mountain guides, thought to be secondary to long-term ultraviolet radiation–mediated immune suppression.3 With the onset of the digital age, there was concern that long-term occupational exposure to digital screens may cause or worsen SD.3 We posit that the occlusive warm environment under the patient's balaclava created an optimal environment for SD development. While the pathophysiology of SD is complex, it has been noted that SD is more common in warmer areas of the face.4 Similarly, cases of worsening SD in health care workers wearing face masks highlight the potential role of occlusion in SD pathogenesis.2 Occupational SD under PPE has not been reported outside health care professions but may be underreported or misdiagnosed as allergic or irritant contact dermatitis, because it was initially in this case. Suboptimal response to treatment and histologic analysis of skin biopsy specimens were key to an accurate diagnosis in this case. ZEBRA Occupational SD may be underreported and should be considered in cases of refractory SD and in professions where occlusive PPE is required, particularly in warmer environments.
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Jun 26, 2024
E Y Larbah 
Open Access