case study developing thick skin answers

This monograph is one in a series of self-instructional publications designed to increase the primary care provider’s knowledge of hazardous substances in the environment and to aid in the evaluation of potentially exposed patients. See page 45 for more information about continuing medical education credits and continuing education units.

Reviewed by the American Academy of Dermatology

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Agency for Toxic Substances and Disease Registry

Introduction

Unlike most organs, the skin is in constant contact with the external environment. The skin ensures the body’s integrity by preserving internal fluids and electrolytes, maintaining thermoregulation, and protecting against physical injury and entry of harmful agents. Because the skin has such a prominent and protective role, many factors affect it adversely, including mechanical agents (friction, vibration, pressure, and trauma); physical agents (heat, cold, and radiation); biologic agents (plants, insects, animals, and microbes); and a variety of chemical agents.

The large number of chemicals in the home and workplace and the accidental and intentional releases to air, water, and soil potentially allow ever-increasing contact with chemicals in the environment. Dermatitis from chemical exposures in the workplace accounts for about 30% of all reported occupational illness; the prevalence of skin lesions due to chemicals encountered outside the workplace (i.e., environmental exposures) may never be known.

Seven common skin conditions that can have environmental etiologies are presented in this monograph. Accurate diagnoses and identification of etiologies are necessary, not only to properly treat skin diseases, but also to prevent future occurrence of disease or exposure.

Familiarity with the vocabulary of dermatology is helpful in understanding this specialized topic. A glossary of terms begins on page 42.

(a) What are the most likely nonoccupational etiologies for four of the more common skin conditions: irritant and allergic contact dermatitis, urticaria, and photosensitivity?

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(b) What are the most effective treatments and preventive measures for each of these skin conditions?

Answers begin on page 39.

Case 1—Irritant Contact Dermatitis

A husband and wife consult you because of skin rashes that have developed since they began renovating a recently purchased older home. They have no history of skin problems.

The man complains of severe itching of the hands and an erythematous rash with papules and excoriations on the arms and lower legs. This rash began during the time he was placing new insulation in the attic.

The woman complains of a rash with redness and a small amount of blistering on the hands and wrists. There is mild itching, and some painful fissures have formed on the fingertips. The rash developed over a period of several days, beginning with only erythema while she was using a commercial paint-stripping product to remove old paint from interior trim. Although she wore rubber gloves, some of the stripping compound came in contact with her skin by running down into the gloves from the wrist area and through small holes in the fingers.

Description

❑ More than 90% of skin lesions caused in the workplace are contact dermatitis.

❑ Lesions of irritant contact dermatitis are localized and the symptoms are generally less severe than those of allergic contact dermatitis.

In the occupational exposure setting, the most common skin lesions (greater than 90%) are dermatitis due to either contact irritation or contact allergy, with irritant contact dermatitis being reported more frequently.

Irritant contact dermatitis caused by chronic exposure to mild irritants typically begins with erythema and progresses to eczema with exudative vesicles and papules, most often limited to the area of direct contact. Itching, stinging, and burning sensations may be noted—especially with stronger irritants—but are generally not as severe as symptoms of patients who have allergic contact dermatitis. (For a discussion of allergic contact dermatitis, see page 9.)

After days to weeks of chronic irritant exposure, the skin may become lichenified. Painful fissures may develop, along with hyperpigmentation, crusts, and scales. When contact with the offending irritant is discontinued, the rash usually resolves spontaneously in 1 to 3 weeks. Irritant contact dermatitis rarely spreads to areas of the body remote from the site(s) of direct contact.

Cutaneous hardening can develop when patients with irritant contact dermatitis have daily exposure to irritating substances. The skin becomes tough and resistant at the sites of contact, allowing further exposure to the irritant but without reaction. If exposure ceases, however, this protective adaptation is lost rapidly.

Pathophysiology

❑ Irritant contact dermatitis is caused by direct action of irritants on the skin.

Irritant substances cause dermatitis by direct chemical action (i.e., nonimmune-mediated) on contacted components of the skin. Irritants may be acidic substances, which coagulate skin proteins, or alkaline substances, which remove surface lipids. Both types of substances may cause drying and cracking of the skin. Epidermal necrosis with separation of the epidermis from the underlying dermis results in formation of vesicles that contain mainly polymorphonuclear (PMN) leukocytes. Vesicles and bullae with both PMN leukocytes and lymphocytes occur in the upper portion of the dermis.

Common Etiologies

Almost any substance can be a contact irritant ( Table 1 ), although some substances, such as some alcohols, oils, and glycols cause irritant contact dermatitis in only a small percentage of exposed persons. In contrast, strong irritants, such as concentrated mineral acids, alkalies, and amines, cause chemical burns or irritant contact dermatitis in almost everyone exposed. Mild to moderate irritants (e.g., dilute acids, organic hydrocarbon solvents, and some detergents) generally produce irritant dermatitis in only a small percentage of persons after a single contact but will cause a reaction in nearly everyone after prolonged or repeated exposure.

Table 1 . Common irritants in the home and workplace *

The young are generally more susceptible to irritant contact dermatitis than adults are because the threshold for skin irritation is low in children, particularly infants. Irritation reactivity gradually lessens after about 8 years of age. During play, children are likely to have skin contact with soils containing hazardous substances or with wooden playground structures that may have been treated with irritating chemicals such as arsenate and pentachlorophenol. The occurrence of skin problems is also common in the elderly. Besides age, personal factors that predispose persons to irritant contact dermatitis include genetic constitution and previous episodes of eczema.

Environmental and physical factors influence the skin’s susceptibility to irritant contact dermatitis. Susceptibility is often enhanced by wet work and conditions such as cold and windy weather, low relative humidity, and high temperatures that cause sweating. Some anatomic regions are more sensitive than others. Friction and lacerations or other mechanical skin injury may facilitate the development of irritant contact dermatitis. Occlusion by protective equipment such as gloves provides a humid environment, minimizing evaporation and making the stratum corneum more permeable to chemical substances that come in contact with the skin.

❑ Onset of irritant contact dermatitis tends to be insidious.

Irritant contact dermatitis is often difficult to differentiate from allergic contact dermatitis. Routine skin biopsy generally is not helpful because the histologic appearance of irritant and allergic contact dermatitis is similar. However, unlike allergic contact dermatitis, irritant contact dermatitis tends to localize at the exposed area and to cause mild itching and more erythema than vesiculation. The onset of irritant contact dermatitis is insidious rather than explosive. Patch testing by, or in consultation with, a dermatologist may be necessary to reach a diagnosis or to exclude allergic contact dermatitis. If fibrous glass is the suspected irritant, skin scrapings suspended in a few drops of 10% potassium hydroxide and examined under a light microscope at low power may reveal glass fibers.

❑ Removal from exposure is the most important step in treating irritant contact dermatitis.

The most important step in treatment is to remove the patient, at least temporarily, from further exposure to the offending agent. Substituting less irritating chemicals for the offending substance and correctly using protective materials, such as gloves and barrier creams, may help reduce exposure. During healing, the skin should be protected from other insults such as frequent washing, trauma, wind, and rapid changes in temperature.

❑ Topical corticosteroids may be useful in cases of irritant contact dermatitis.

Treatment for acute vesicular irritant contact dermatitis includes topical application of wet dressings for 15 to 20 minutes, 3 to 6 times daily. Domeboro’s solution (diluted 1:40) or Burow’s solution may be used to soak the dressings. Dressings should be discontinued after 2 to 3 days to avoid drying the skin.

Topical application of corticosteroid preparations may be efficacious. A low-potency corticosteroid should be used for mild to moderate skin conditions, with progression to more potent corticosteroids as required ( Table 2 ). Some over-the-counter and prescription topical medications or their excipients can further irritate the skin or provoke allergic contact dermatitis. Administering mild sedatives and antihistamines to relieve itching may also be beneficial.

Clinical signs of secondary bacterial infection include increased erythema and tenderness; development of a yellow, crusting, or purulent exudate; and occasionally, formation of small pustules around the edges of the dermatitis. Infection with monilia has an appearance similar to bacterial infection, except that the exudate is usually white. Infection may be difficult to recognize initially because the serous exudate and erythema of the dermatitis can obscure the signs. Obtaining samples of the exudate for culture and sensitivity before initiating topical or systemic antibiotic therapy is generally advisable.

Table 2 . Groups of topical corticosteroid products, in order of decreasing potency *

Case 2—Allergic Contact Dermatitis

You are consulted by a 44-year-old male office worker who has a chief complaint of a rash on his hands and wrists. His company recently relocated from a building where each employee had a private office to an older, renovated building with large bay areas. New wallboard was placed, the area was painted, and new carpet was laid just before the move. Employees now work in cubicles; the patient’s cubicle is located in an interior area with no windows. A copying machine is adjacent to his work area.

Since the move, many of the patient’s coworkers have been complaining of unpleasant odors, a feeling of fatigue or excessive tiredness, and mild irritation of the eyes, nose, and throat. They associate these symptoms with working in the new area. Although the patient has not noted such symptoms, he does complain of the increased noise and distraction in the new work area; he feels that his rash is somehow related to the new location.

The rash began 5 days ago with itching and redness. It then developed weeping and raised, vesicular lesions that spread from the initial location on the hands to the volar surfaces of the wrists. The patient states that he has a history of reaction to poison ivy, which produces a similar rash, but he has not been in an infested area for the past 2 months. He has no direct contact with industrial cleaning agents or carbonless copy paper in his work. He does have contact with chemicals through his woodworking hobby. He recently built an end table from exotic Japanese woods and has been applying a varnish that a friend brought from Japan.

❑ About 30% of occupational skin disorders are allergic contact dermatitis.

❑ In sensitized persons, inflammation begins about 12 hours after exposure to an allergen.

Although contact allergens produce sensitization in only a small percentage of exposed persons, allergic contact dermatitis constitutes about 30% of the skin disorders found in the workplace. Once a person has been sensitized to an offending substance, further exposure may result in relatively rapid development of local inflammation with erythema, papule formation, induration, and weeping vesiculation. Inflammation usually begins about 12 hours after exposure; intensity peaks in 50 hours or more. The rash may spread locally around the margins of the original site or to distant sites that did not have contact with the allergen. Potentially, the entire skin surface could become involved (a condition known as erythroderma or exfoliative dermatitis).

❑ Cross-reactivity with antigenically similar substances can occur with allergic contact dermatitis.

❑ The clinical and histologic appearances of allergic and irritant contact dermatitis are similar.

Allergic contact dermatitis results from a true allergic (i.e., cell-mediated) sensitization to the offending substance. Cross-reactivity with antigenically similar substances may occur. Initially, during the refractory period, the patient may be exposed without developing a reaction. During the induction phase, which may last from 4 days to several weeks (usually about 14 to 21 days), the development of complete allergic sensitization occurs as the allergen comes in contact with the skin. After the skin is fully sensitized, further contact with the allergen may result in rapid and severe dermal manifestations. When no further contact with the allergen occurs, the patient is in the period of persistence of sensitivity. The level of sensitivity can decrease over time, but sensitization may be lifelong.

Most allergens that cause allergic contact dermatitis have molecular weights of less than 500 daltons. The allergens are haptens rather than complete antigens; they must penetrate the skin and combine with endogenous proteins to form full antigens. Langerhans cells play a key role in then presenting the antigen to T lymphocytes, thereby activating the T cells. The sensitized T cells proliferate in the paracortical regions of the lymph nodes and produce effector and memory lymphocytes that remain in the general circulation. On subsequent contact with the complete antigen, the effector cells release lymphokines that may result in rapid and severe, local inflammation.

Many factors can affect the development of allergic contact dermatitis, including characteristics of the allergen itself, patient factors, and environmental conditions. Allergen factors include the physiochemical nature of the allergen (e.g., lipophilicity, solubility, and inherent sensitizing potency), concentration, total dose that comes in contact with the skin, anatomic site of contact, number and frequency of exposures, and occlusion by clothing or gloves.

The most important predisposing patient factors are a history of irritant contact dermatitis and the presence of an inflammatory skin condition that may promote absorption of the allergen. Irritant dermatitis caused by household cleaning agents on women’s hands may continue as allergic nickel dermatitis (from costume jewelry). In addition, age and genetic predisposition can influence the development of allergic contact dermatitis. Persons who have histories of atopic dermatitis have been reported to have decreased risk of developing allergic dermatitis but increased risk of developing irritant dermatitis.

Common predisposing environmental factors for allergic contact dermatitis are pressure, friction, heat, and prolonged immersion in water (such as occurs during wet work). Relative humidity, ambient temperature, and season of the year also play roles in development of allergic contact dermatitis.

❑ Aromatic compounds with polar or ionic substituents are potent sensitizing agents.

Only several hundred of the thousands of chemicals used are known to cause allergic contact dermatitis. With the exception of nickel, cobalt, and some forms of chromium, most metals do not produce sensitization. Strong inorganic alkalies and acids seldom cause allergic reactions. Although a substance’s sensitization potential cannot be determined from its chemical structure alone, some chemical classes are more likely to cause allergic contact dermatitis (see Table 3 ). Aromatic compounds with polar or ionic substituents are typically sensitizing agents (e.g., p -aminophenol and hydroquinone used in photographic film developers).

In addition, chemicals that are structurally similar to the original sensitizing agent may provoke recall of the specifically sensitized lymphocytes, a phenomenon known as cross-sensitization. For example, persons exposed to p-phenylenediamines used in the rubber industry may react to related substances used in photographic developers and dyes. Persons sensitized to Rhus plants such as poison ivy or poison oak may be sensitive to cross-reacting substances found in exotic trees and their derivative products (lacquers, varnishes, and oils).

Table 3 . Some chemical groups known to cause allergic contact dermatitis

Synthetic substances that commonly cause allergic contact dermatitis are rubber products, plastic resins, organic dyes, topical medications, germicidal and biocidal preparations, and various commercial and medication ingredients ( Table 4 ). Natural products can also produce allergic contact dermatitis. Exposure to certain airborne contaminants may also cause allergic contact dermatitis. Airborne contaminants include dichromates in cement dust, rosins used in soldering operations, and sawdust.

Table 4 . Common causes of allergic contact dermatitis

❑ Allergic contact dermatitis often spreads to areas remote from the site of contact.

Allergic contact dermatitis is often misdiagnosed as irritant contact dermatitis. Other conditions to consider in the differential diagnosis are atopic dermatitis, pustular eruptions on the palms and soles, psoriasis, Herpes simplex and Herpes zoster, insect bites, parasite infestation such as scabies, fungal infections of the feet with idiopathic vesicular reactions, nummular eczema, drug eruptions, and erythema multiforme.

❑ The clinical and microscopic appearances of skin lesions due to allergic contact dermatitis are the same as those due to irritant contact dermatitis.

No distinctive features of the lesions facilitate the differentiation of allergic from irritant contact dermatitis. An important diagnostic clue to allergic contact dermatitis is the spread of rash to areas remote from the site of contact; the mucous membranes are usually spared, and the scalp, soles, and palms are often unaffected.

Patch testing (see Diagnostic Procedures , page 35) may help differentiate allergic from irritant contact dermatitis. Because the histologic appearance of lesions due to allergic or irritant contact dermatitis is the same, routine skin biopsy is not helpful in their differentiation.

❑ Treatment for allergic contact dermatitis is identical to that for irritant contact dermatitis.

At present, there are no satisfactory means of desensitizing humans to allergens. The most important step is to remove the patient from exposure to the offending substance. In the workplace, options such as protective clothing and substitute chemicals should be explored. The therapy for allergic contact dermatitis is the same as that for irritant contact dermatitis (see Treatment, Irritant Contact Dermatitis, page 6).

Systemic corticosteroids may be indicated for some patients who have allergic contact dermatitis, especially when large areas of the skin (20% total body surface area or greater) are involved. Short courses of oral corticosteroids, particularly if used for a Rhus -induced contact dermatitis, may be given for 2 to 3 weeks (up to 21 days). Corticosteroids administered even for a short period of time should always be delivered in decreasing doses over the course of therapy to prevent adrenal suppression.

Case 3—Photosensitivity Contact Dermatitis

You are consulted by the headmaster of a children’s summer camp because of an outbreak of skin rashes in 20 of the campers. No counselors are affected. On examination, the rashes, which are confined to the hands, wrists, and forearms, consist of discrete linear streaks and patches that are hyperpigmented and do not itch.

One of the staff members speculates that the rashes are caused by contact with an epoxy glue used in building a model. However, only two of the children who have rashes have been involved in this activity. All the affected children had participated in a craft class in which they made lime sachets by puncturing lime skins and inserting sprigs of cloves over the surfaces of the limes. During the class, they also prepared gift cards from recycled paper. While the children attended to these activities, the counselors were engaged in planning an outdoor activity that was to follow the craft session.

❑ Photosensitivity reactions occur mainly on sun-exposed areas of the body.

❑ Photoallergic reactions are immune-mediated responses; phototoxic reactions are not.

Photosensitivity contact dermatitis occurs mainly on sun-exposed areas such as the face, upper chest, posterior portion of the neck, extensor surfaces of the forearms, dorsum of the hands and feet, and anterior surfaces of the lower legs. Areas of the skin normally covered by jewelry and clothing are spared, as are eyelids, areas under the chin, and upper portions of the ears covered by hair. Photosensitivity contact dermatitis may be the result of phototoxicity or photoallergy.

Lesions of phototoxic and photoallergic contact dermatitis resemble those of irritant and allergic contact dermatitis. They have been described as discrete, confluent, polymorphous linear streaks and patches that are macular and nonpruritic. The patient may experience a stinging or burning sensation of the skin, typically beginning shortly after exposure to sunlight and resolving rapidly when the skin is shaded. Lichenification and hyperpigmentation may occur, and the lesions may persist for months or years. In some cases, widespread involvement of the skin develops later. The photoallergic response usually occurs in only a small number of persons who have been previously sensitized to the photoactive agent.

❑ Sunlight can cause formation of the agents that result in photosensitivity contact dermatitis.

The mechanisms of photosensitivity contact dermatitis are broadly analogous to the mechanisms of irritant and allergic contact dermatitis except for the added requirement of appropriate ultraviolet (UV) radiation (i.e., wavelengths of 315 to 400 nanometers, known as UV-A). The agent that provokes the irritant or allergic response is formed after its precursor has been exposed to UV-A.

In phototoxicity, the excited state of the agent produced during irradiation is thought to lead to oxidation of cellular components or to allow binding of the agent with nucleic acids. In photoallergy, the initial reaction of the topical agent with UV-A forms either an excited molecule that can bind with protein to form a complete allergen or a product that is itself a strong contact allergen.

❑ Many topical products can produce photosensitivity dermatitis.

Many products that cause photosensitivity dermatitis are applied topically. Common examples are lotions containing fragrances; suntanning products with ultraviolet absorbers such as 6-methylcoumarin, homosalicylate, or p -aminobenzoic acid (PABA); and aftershave lotions containing musk ambrette. Germicides in soaps and detergents may also cause photosensitivity dermatitis. A major epidemic of allergic contact dermatitis occurred in Great Britain in 1960 after the introduction of two soaps that contained tetrachlorosalicylanilide, a photoactive antibacterial agent.

❑ Psoralens, which can cause phototoxic dermatitis, are useful in the treatment of psoriasis.

Certain systemically administered medications have caused photoallergic drug reactions. Examples include nalidixic acid, phenothiazines, sulfonamides, sulfonylureas, tetracyclines, and thiazide diuretics. Pharmacists, nurses, and others who routinely have skin contact with these drugs are prone to photosensitivity dermatitis.

Plants such as celery and citrus fruits have caused phototoxic dermatitis in persons who handle them extensively; farm workers are particularly susceptible. Contact with oil released from lime skins or with coal tar and pitch has resulted in phototoxic dermatitis, especially in lightly pigmented persons.

Psoralens, which are photoactive and can cause phototoxic dermatitis, are also used therapeutically in the treatment of psoriasis. In PUVA (psoralen plus UV-A radiation) treatment, a psoralen is painted on the affected skin or given systemically to patients who are then exposed to UV radiation. The photoadduct that is formed between the psoralen and DNA serves to slow the rate of the psoriatic overgrowth.

❑ A thorough drug history will usually rule out photoallergic drug reactions.

Photoallergy from chemical contact must be differentiated from polymorphous light eruption, systemic lupus erythematosus, pellagra, dermatomyositis, porphyria, allergic contact dermatitis and photoallergic drug reaction. A thorough history of medication treatment will usually rule out photoallergic drug reaction.

Photopatch testing may be useful in confirming the diagnosis, but results of photopatch testing are often difficult to interpret and are best left to dermatologists with specialized equipment and knowledge in this field.

❑ Treatment for phototoxic and photoallergic dermatitis is the same as that for irritant and allergic contact dermatitis.

The treatment for phototoxic or photoallergic dermatitis is the same as the treatment for irritant and allergic contact dermatitis (see pages 6 and 13). Identifying the offending agent and counseling the patient to avoid further exposure to it are the most important interventions. When the photosensitizing agent cannot be avoided, limiting sunlight exposure and wearing protective clothing, such as hats, gloves, long-sleeved garments, socks, and shoes, may help. Sunscreens may be used if reaction or cross-sensitivity between the causative agent and components in the sunscreen is not a possibility.

Case 4—Chloracne

A 42-year-old man consults you because of a persistent skin condition that he feels resembles the cosmetically displeasing acne he had as a teenager. His present skin condition consists of pale yellowish, cystic lesions and comedones localized on the face, below and lateral to the eyes, and behind the ears. Similar lesions are present on the cheeks, forehead, and neck; a few are present on the buttocks, where, according to the patient, he never had lesions with his prior affliction. He also complains of moderately severe itching.

History reveals no changes in diet, and the patient is not taking medications. For the last 15 years, the patient has worked for a local utility company. His most recent job duties have included replacing the heat exchange fluids in transformers. He first noted the rash about a month ago; he is not certain whether the rash appeared before or after he began this activity.

❑ Chloracne is rare and is usually due to occupational exposure to chloracnegenic agents.

❑ Chloracne may be an indication of systemic toxicity.

Environmental acne is a variety of acne venenata typically caused by industrial chemicals. It may result from contact with petroleum and its derivatives (oil acne), coal tar products (coa-tar-pitch acne), and halogenated aromatic hydrocarbons (chloracne). Environmental acne may also be caused by certain physical, mechanical, and biologic agents. Although the occurrence of chloracne is rare (probably fewer than 4000 cases worldwide), it is of great concern because it is an extremely refractory acne and because it may be indicative of systemic toxicity by a highly toxic chemical.

The lesions of chloracne consist of straw-colored cysts, numerous comedones, milia, and papules. The lesions are located on the face (especially at “crow’s feet” and below and to the outside of the eyes [malar crescent]), neck, earlobes, shoulders, abdomen, legs, buttocks, and genitalia. The nose is often spared. With severe chloracne, all the follicles in an area may be involved, resulting in a rather bizarre “pebbled” appearance. Pruritus is common and occurs in about 50% of chloracne cases.

❑ Chloracne is often refractory to treatment.

Onset of disease is typically delayed 2 to 4 weeks after exposure to a chloracnegenic agent. The first changes are a thickening of the follicular epithelium, development of comedones, and a slow disappearance of the sebaceous glands as they are replaced by keratinous cysts. Initially, inflammation is uncommon; inflammatory lesions with larger cysts and abscesses are later developments. Severe scarring may occur. Increased fragility of the skin, hypertrichosis, widespread follicular hyperkeratosis, or hyperpigmentation may develop. A brownish discoloration of the nails, swollen eyelids, and conjunctivitis or discharge may be present in some patients.

With no additional exposure, the disease will first progress, then regress over a 4- to 6-month period. A few cases of chloracne have persisted for 30 years or more after contact with the chloracnegenic agent has ceased.

❑ Chlorinated aromatic hydrocarbons cause chloracne.

Many chlorinated aromatic hydrocarbon compounds used in the workplace can cause chloracne. These compounds include chlorinated naphthalenes, polychlorinated biphenyls (PCBs), polybrominated biphenyls (PBBs), dioxins, polychlorinated dibenzofurans, pentachlorophenol, azobenzenes, and azoxybenzenes. (See Case Studies in Environmental Medicine: Polychlorinated Biphenyl (PCB) Toxicity , Case Studies in Environmental Medicine: Dioxin Toxicity , and Case Studiies in Environmental Medicine: Pentachlorophenol Toxicity .)

❑ Chloracne must be differentiated from other more common acnes.

Chloracne must be differentiated from oil acne or folliculitis due to exposure to grease and oils; acne vulgaris; acne cosmetica from heavy cosmetic use; acne mechanica from local pressure and friction; acne medicamentosa from medications such as corticosteroids, hormonal preparations, phenytoin, iodides (e.g., in kelp tablets), bromides and solar elastosis with comedones.

A history of exposure to agents known to cause chloracne and the typical appearance of the rash on physical examination are usually sufficient for diagnosis. Chloracne may be distinguished from acne vulgaris by the distribution of the lesions, age at onset, and morphology. Chloracne lesions typically affect the face, neck, earlobes, shoulders, abdomen, legs, buttocks, and genitalia, whereas lesions of acne vulgaris are found primarily on the face, neck, chest, and back (down to the waist). Chloracne can appear at any age, whereas acne vulgaris is seen most often in patients aged 13 to 26 years. Chloracne lesions consist of straw-colored cysts, numerous comedones, milia, and papules; whereas the lesions of acne vulgaris are typically comedones, papules, pustules, and scars.

Histologic examination of cysts may show typical changes, but the usefulness of biopsy in establishing the diagnosis is questionable. Associated noncutaneous conditions found in some patients who have chloracne include hepatotoxicity, porphyria cutanea tarda, and peripheral neuropathies.

❑ Removal from exposure to chloracnegenic agents is the most important treatment for chloracne.

Primary interventions are prevention of exposure to chloracnegenic chemicals and good hygiene because a satisfactory treatment regimen cannot be found in many cases. Administration of oral antibiotics and acne surgery have been of limited success. Retinoic acid (vitamin A) preparations or 13-cis-isoretinoic acid (Accutane) have been successful in carefully selected patients. (Note: Accutane is a known teratogen and should be used cautiously.) Injecting inflamed lesions with dilute triamcinolone, a glucocorticoid, may be helpful, as may dermabrasion for severe scarring.

Case 5—Pigment Alterations

Fifteen children from a local school are referred by the school nurse for evaluation of skin lesions. The lesions consist of decreased pigmentation in a scattered distribution. Two of the children have histories of itchy, weeping, vesicular rash on the neck and face that cleared before the pigment changes became noticeable. A public health evaluation of the drinking water and food served at the school has not revealed toxic or infectious agents. The school is located near a chemical manufacturing facility, in which the parents of several children work, including the parents of the two children who have histories of vesicular rash.

❑ Pigment changes are usually associated with post-inflammatory effects from physical or chemical agents.

A variety of physical and chemical agents may affect the color of the skin. Insults to the skin may cause either increased pigmentation (hyperpigmentation), decreased pigmentation (hypopigmentation), or both in contiguous areas (dyschromia). Inflammation, which may be subclinical and not apparent, usually precedes pigment alterations. Postinflammatory reaction (e.g., to contact dermatitis) is the most common cause of increased pigmentation, although pigment loss may also occur.

❑ Hypopigmentation is caused by damage to the melanocyte or through inhibition of melanin synthesis.

❑ Hyperpigmentation is often caused by nonspecific skin damage that leads to melanin or hemosiderin accumulation.

In hypopigmentation, depigmentation probably occurs either by damage to the melanocyte, which leads to cell distortion and death, or through inhibition of melanin synthesis by the offending substance. It may be significant that industrial compounds that cause hypopigmentation ( Table 5 ) are structurally similar to tyrosine, the building block of melanin. In industrially related hypopigmentation (leukoderma), the hands, wrists, and forearms invariably are affected; symmetry is usual. Depigmentation may also appear in body sites remote from the chemical contact (e.g., axillae, genitalia, and torso). The process of depigmentation usually takes 2 to 4 weeks and may require up to 6 months of repeated contact to become visible. The fact that many exposed workers do not lose pigment indicates that host factors are important in susceptibility.

Table 5 . Compounds known to cause hypopigmentation

Hyperpigmentation (also known also as melanosis or melanoderma) is due to accumulation of melanin from damaged melanocytes or to deposition of hemosiderin from extravasation of erythrocytes in the dermis. Another possible mechanism is overproduction of melanin by melanocytes in response to the offending agent. Hyperpigmentation is more likely to occur in dark-complexioned persons and can persist for years.

The cause of hypopigmentation is contact with alkylphenols (see Table 5 , page 24), skin damage due to chemical and thermal burns, or blunt or repeated trauma to the skin. Hyperpigmentation typically follows a bout of dermatitis or other episode of inflammation. Coal tar pitch, creosote, and various aromatic chlorinated hydrocarbons are a few of the compounds that can stimulate overproduction of melanin. UV radiation-induced stimulation of melanin synthesis (tanning) is the most common cause of hyperpigmentation in dark-complexioned persons.

❑ Hypopigmentation may be the result of environmental exposures or of idiopathic vitiligo.

❑ Skin staining and birthmarks can be misdiagnosed as hyperpigmentation.

Chemically induced hypopigmentation is indistinguishable from idiopathic vitiligo. Vitiligo affects about 1% of the general population and may be associated with autoimmune or endocrine abnormalities. Hypopigmentation must also be differentiated from depigmentation due to tissue destruction by chemical or thermal burns.

Hyperpigmentation should not be confused with birthmarks or direct skin staining or discoloration from contact with substances such as heavy metals (e.g., silver salts), nitrosylated compounds (e.g., nitric acid or dinitrophenol), derivatives of coal distillation (e.g., tar, pitch, and asphalt), and coal dust.

In most cases, the patient’s history and physical examination are sufficient to diagnose cases of pigment alterations. The loss of melanin in light-complexioned persons can be detected by failure of the skin to fluoresce under a Wood’s lamp.

❑ Hypopigmented and hyperpigmented areas should be protected from sunlight.

No effective treatment exists to reverse pigment changes. Hypopigmentation may last months to years after contact with the offending substance is discontinued, or it may be permanent. Depigmented skin should be protected from sunlight. Small depigmented areas may be camouflaged with agents such as Covermask, Dy-O-Derm, or Dermablend. Oral administration of psoralens and carefully graded UV radiation exposure (PUVA treatment) may be attempted if hypopigmentation involves large areas of skin.

In patients who have hyperpigmentation, worsening of the condition can be prevented by using sunscreens and covering affected areas

with clothing, hats, and gloves. Topical bleaching creams prepared from hydroquinone or its monobenzyl ether must be used cautiously to prevent widespread depigmentation. A preparation consisting of 0.1% hydrophilic tretinoin (Retin-A), 5% hydroquinone, and 0.1% dexamethasone in a hydrophilic ointment has been used in a 5- to 7-week treatment regimen with some success.

Case 6—Contact Urticaria

A 35-year-old woman consults you because of episodes of generalized hives that develop about 20 minutes after she uses certain brands of shampoo. The hives are preceded by sensations of itching, burning, and stinging of the skin on the scalp, upper face, and posterior aspect of the neck. The patient also experiences redness and tearing of the eyes, clear rhinorrhea, and nausea. She relates that a similar constellation of symptoms occurred after she applied an over-the-counter topical pain-relieving ointment for sunburn. A mild eczematous rash has been present on her forehead and posterior neck for about 6 weeks.

❑ Contact urticaria is a skin reaction that appears immediately after contact with the offending agent.

Contact urticaria is a localized wheal-and-flare response (hives) that develops almost immediately (a few minutes to about 1 hour) after direct contact with the eliciting agent. Many afflicted patients complain of skin sensations such as itching, burning, or tingling. Symptoms typically disappear within 24 hours.

❑ Contact urticaria may be due to immunologic-, nonimmunologic-, or uncertain-mediated mechanisms.

❑ Anaphylactic reactions may occur in patients who have contact urticaria syndrome.

Contact urticaria may be mediated by mechanisms classified as immunologic (allergic), nonimmunologic (nonallergic), or uncertain. Nonimmunologic urticaria, the most common type of contact urticaria, is caused by a direct action of the offending substance on the skin vasculature and a nonimmunologic release of vasoactive substances such as bradykinin, histamines, or other inflammatory mediators. The reaction remains localized.

Immunologic contact urticaria is an immediate allergic reaction in persons who have previously become sensitized to the offending agent. Parts of the skin that are remote from the contact site may be affected. The vasoactive effects in the immunologic form of contact urticaria are caused by an IgE-mediated reaction. The resulting erythema and edema are elicited mainly by histamines released from mast cells. Activation of the complement cascade and generation of anaphylatoxins can result in systemic effects (contact urticaria syndrome) in which the typical rash is accompanied by symptoms of asthma, rhinitis, conjunctivitis, orolaryngeal effects (itching and tingling sensations or edema of the lips, tongue, and mouth; or throat irritation), or gastrointestinal signs and symptoms. In rare cases, patients who have contact urticaria syndrome have experienced otherwise unexplained attacks of vascular collapse (anaphylactoid reactions).

The cause of the third type of contact urticaria is uncertain but includes both allergic and nonallergic mechanisms. Formaldehyde is an example of an urticant that has features of both types.

❑ Latex rubber gloves are a common cause of immunologic contact urticaria.

Immunologic contact urticaria is usually caused by proteins or protein complexes. It may also be caused by a wide variety of common chemicals, medications, cosmetics, and other agents ( Table 6 ). The rubber in latex gloves is a common cause of contact urticaria among healthcare professionals, as is the cornstarch used in the gloves. Food-

stuffs are also a common cause of contact urticaria. The orolaryngeal area is a site where immediate reactions are provoked by food allergens, most often among atopic persons.

Table 6 . Some substances that cause allergic contact urticaria

Nonimmunologic contact urticaria has been provoked by contact with substances as diverse as acids (acetic, benzoic, butyric, cinnamic, sorbic), alcohols (ethyl and butyl), balsam of Peru, benzocaine, cinnamic aldehyde, cobalt chloride, dimethylsulfoxide, formaldehyde, witch hazel, sodium benzoate, and esters of nicotinic acid. Cold temperatures can also cause nonimmunologic contact urticaria.

Uncertain mechanism-mediated contact urticaria has been associated with exposure to ammonium persulfate, which is used to boost peroxide hair bleaches to achieve a platinum-blond effect. Sunlight, which can produce rapid development of a wheal-and-flare reaction in exposed areas, and aquagenic agents (water, saline, or the patient’s own perspiration) are also associated with uncertain mechanism-mediated contact urticaria.

❑ A clear cause is seldom identified in cases of chronic contact urticaria.

Nonimmunologic contact urticaria must be differentiated from allergic contact urticaria and other forms of urticaria. The most important factor in making the correct diagnosis is taking a careful history of the relationship between possible exposures and development of symptoms. In cases of chronic urticaria, a clear cause is seldom identified.

Patch or scratch/prick tests may be used with suspected etiologic agents. These tests should be used initially on normal areas of skin,

then on involved skin (previously or currently affected) only when no reaction occurs on normal skin. Testing should be done by, or in consultation with, a dermatologist; resuscitation equipment and medications should be available in case a severe anaphylactoid reaction results.

❑ Antihistamines can alleviate symptoms of urticaria.

Chlorpheniramine-like antihistamines are of value in treating urticaria. The newer agents that have less sedative effects, such as terfenadine (Seldane) and astemizole (Hismanal), are not as efficacious. (Note: Seldane and Hismanal are contraindicated in patients who are taking ketoconazole, itraconazole, erythromycin, or other medications known to impair the metabolism of Seldane or Hismanal, and in patients who have significant hepatic dysfunction.)

Nonsteroidal anti-inflammatory medications have proved useful in certain cases of nonimmune urticaria; however, they may cause anaphylaxis in patients who have immune urticaria, especially patients who exhibit the triad of asthma, nasal polyps, and rhinitis. These patients should be cautioned about the use of nonsteroidal anti-inflammatory agents. All patients suffering from urticaria should be advised to avoid further contact with the eliciting substance.

Case 7—Malignant Neoplasms

A couple in their 60s who are native to a nearby rural area consult you because of the insidious development of a variety of skin lesions over the past 2 years. Both have hyperkeratotic lesions on the palms and the soles of the feet, as well as mottled-appearing hyperpigmented areas on the temples and neck. The man has a lesion on the right cheek that appears to be a basal cell carcinoma. Both patients complain of numbness and tingling in the feet and a general feeling of fatigue.

❑ Skin cancer is the most common neoplasm in adults in the United States.

❑ Sunlight, either alone or in conjunction with other agents, is a major contributing factor to skin cancer.

❑ Reasons for the 700% increase in malignant melanoma in the past 60 years have not been well established.

❑ PAHs and inorganic arsenic are well-known causes of cancerous skin lesions.

Cancer of the skin is the most common neoplasm among adults in the United States. More than 500,000 new cases of nonmelanoma skin cancer and about 28,000 cases of melanoma occur annually. Skin cancers associated with environmental factors include basal cell carcinoma, squamous cell carcinoma, malignant melanoma, and Bowen’s disease (intraepidermal squamous cell carcinoma). Pre-nonmelanoma skin cancers, such as actinic keratoses, can also be induced by environmental factors.

Sunlight, either alone or in conjunction with other agents, plays an important role in the development of most skin cancers, especially malignant melanoma. The incidence of melanoma has increased more than 700% in the past 60 years. If the incidence continues to increase at the present rate, within the next decade a person’s lifetime risk of developing melanoma will be approximately 1% (i.e., 1 case of melanoma per 100 persons). The reasons for this increased risk have not been well established but may be related to ozone depletion in the upper atmosphere; increased recreational sun exposure, especially early in life; increased use of industrial chemicals; and increased air pollution.

The usual wavelength in sunlight that causes skin cancers is 280 to 315 nanometers (UV-B). This range is capable of producing direct photochemical damage to the skin (e.g., alterations in DNA and other cellular constituents). UV-B also reacts with photoactive exogenous chemicals in or on the skin, causing them to absorb UV radiation and initiate or accelerate an adverse reaction in normal tissue. Industrial contaminants and air pollutants often contain photoactive chemicals, which can act as photosensitizers, additive carcinogens, or promotors.

The first association between occupational or environmental chemicals and malignancy was noted in 1775 by Percival Pott who reported a high incidence of scrotal cancer among London’s chimney sweeps. Years later, it was discovered that the cancers were caused by exposure to certain polynuclear aromatic hydrocarbons (PAHs). PAHs are found in soot, pitch, creosote, petroleum, and oils such as cutting oil, mineral oil, and shale oil. (See Case Studies in Environmental Medicine: Polynuclear Aromatic Hydrocarbon [PAH] Toxicity .) Other chemicals found to be associated with skin tumors include phenolic compounds, aliphatic hydrocarbons, and inorganic arsenic compounds.

Inorganic arsenic compounds are known to cause a variety of skin lesions, including malignant neoplasms. Initial dermal manifestations of arsenic exposure may be mild erythema and hyperhidrosis of the palms and soles, followed by development of slightly raised, firm, generally symmetrical punctate keratoses. White-colored, nonraised hyper-keratoses may also develop on the ankles, shins, and dorsum of the hands. A diffuse hyperpigmentation of the skin interspersed with white, somewhat atrophic macules (“raindrops on a dusty road”

appearance) may also be seen. Basal cell and squamous cell carcinomas may then develop. (See Case Studies in Environmental Medicine: Arsenic Toxicity .)

Bowen’s disease, a squamous cell carcinoma, may arise spontaneously in situ or may develop after chronic exposure to inorganic arsenic or other chemicals. Bowen’s disease consists of randomly distributed, sharply demarcated, erythematous, scaling lesions that range in size from a few millimeters up to 1 to 2 centimeters in diameter. The lesions grow slowly and rarely metastasize.

❑ The latency period for development of cancerous lesions can be 20 years or more.

Many chemical substances associated with malignant neoplasia are thought to interact directly with cellular macromolecules, resulting in neoplastic transformation of the affected cell. In some cases, absorbed chemicals are converted by skin enzymes (specifically, aryl hydrocarbon hydroxylases) to forms that then combine with DNA and other cellular constituents. Arsenic is thought to inhibit the enzymes involved in DNA replication and repair.

Some chemical agents act either concomitantly (cocarcinogens) or serially (promoters) to cause neoplastic transformation. In many cases, precancerous lesions, such as actinic or arsenical keratoses and tar warts, may precede the development of frank cancerous lesions. A latency period of several decades may lapse between exposure to a carcinogen and appearance of a cancerous lesion.

❑ Sunlight is the most important cause of malignant melanoma.

Certain chemical agents, such as PAHs and inorganic arsenic, are known to cause skin cancer. Nonchemical agents that may cause malignant neoplasms include sunlight, ionizing radiation, and physical trauma. Sunlight is the most important cause of malignant melanoma.

❑ Diagnosis of a malignant skin lesion requires a biopsy.

All potentially cancerous skin lesions must be differentiated from benign lesions. Suspected malignant skin lesions are diagnosed most accurately by histologic examination of excisional biopsies. A punch biopsy of suspect lesions may also be performed.

❑ Treatment of skin cancer depends on whether the cancer is localized or is metastasizing.

Prevention is the first line of defense for skin cancer. Avoiding overexposure to sunlight is most important. Protection from UV radiation can be accomplished by wearing tightly woven clothing and wide-brimmed hats and by applying sunscreens as absorbers. Sunscreens, which contain p-aminobenzoic acid (PABA) derivatives to absorb UV rays, can provide sun-protective factors (SPFs) ranging from 2 to 50 or more. An SPF of 15 allows most persons to remain out of doors for 5 hours before developing minimal erythema. Light-complexioned persons, persons of Celtic origin (i.e., Scotch, Irish, Welsh), and those with certain conditions (e.g., albinism, xeroderma pigmentosum, and erythropoietic protoporphyria) appear to be at increased risk for developing skin cancer. These sensitive populations may require more potent sunscreens.

Surgical excision and radiation are the most common treatment modalities for localized malignant skin lesions. All excised tissue should be sent for histologic examination to confirm the diagnosis and to be certain that an adequate margin of normal skin was removed. Surveillance for the development of further skin cancers should be continued. The treatment of metastasizing skin cancers or lesions with extensive local infiltration is beyond the scope of this review. Patients who have malignant tumors should be referred to, or treated in consultation with, a physician knowledgeable in cancer therapy.

Diagnostic Procedures

Obtaining and recording a detailed history of exposures (workplace, home, and environment) is essential in diagnosing skin disease. Besides physical examination, several special techniques may aid in the diagnosis of skin lesions. These include patch tests to detect contact allergy, skin biopsy, cultures, and microscopic scrapings of skin to detect yeasts, fungi, parasites, and fibrous glass. Referring patients to, or consulting with, a dermatologist who can perform or interpret dermatologic diagnostic testing, may be advisable.

Patch Testing

❑ Patch testing can help differentiate allergic from other forms of dermatitis.

Patch testing is frequently used to differentiate between allergic contact dermatitis and other forms of dermatitis. The presence of a delayed hypersensitivity reaction to an offending substance can be determined by placing a suitably prepared, nonirritating amount of a sample on the skin (usually on the back) under a chamber or impervious bandage (patch). If an eczematous dermatitis lesion develops under the patch during the 48 hours after application, allergy to the test substance or to an antigenically similar cross-reacting substance can be inferred. If no reaction is evident, the patches are removed, and the sites are reexamined for delayed reaction at 72 and 96 hours after application.

Interpretation of patch testing is often difficult, and it is usually recommended that the testing be carried out in specialized centers or by consultants who routinely do patch testing. If no response is provoked, it does not mean unequivocally that the patient is not allergic. For example, if an offending or cross-reacting substance was not included, or was not applied in proper concentration, a false-negative result will occur.

Complications of patch testing include the “angry back syndrome,” in which the patient’s entire back becomes edematous and erythematous. Flare-up of previously existing eczema can also occur, especially when testing materials are not obtained from standard commercial sources. Even local response to the test substance may be extensive, causing patient discomfort. Patch testing itself can result in allergic sensitization to a substance to which the patient was not allergic previously, although this is a rare occurrence. Infections, scarring, and pigment alterations may also be complications of patch testing.

Photopatch Testing

❑ Photopatch testing may help reveal the cause of photosensitivity dermatitis.

When photosensitivity dermatitis is suspected, a combination of chemical patch testing and special light exposure may reveal the cause. Duplicate patches are used; one set is covered, and the other

set is exposed to a measured amount of UV radiation. There are several difficulties in the performance and interpretation of photopatch testing, and it should be performed by practitioners who have experience and the requisite special equipment.

Skin Biopsy

❑ Skin biopsy is not helpful in differentiating allergic contact dermatitis and irritant contact dermatitis.

The appropriate skin biopsy (punch biopsy or excision of the lesion) usually can be performed under local anesthesia by experienced practitioners in an outpatient setting. Microscopic examination of the specimens obtained can allow differentiation between benign and malignant skin conditions. Irritant and allergic contact dermatitis cannot be readily differentiated on routine skin biopsy.

Other Diagnostic Procedures

❑ Skin scrapings, UV-light examinations, cultures, and serologic testing are diagnostic tools used for various skin lesions.

Other procedures include skin scrapings, UV-light examinations, cultures, and serologic testing.

Skin scrapings can be used to look for fungal hyphae, for strands of fiberglass in suspected fibrous glass dermatitis, or for scabies mites and eggs. A Wood’s lamp, which produces UV radiation, can be used to examine suspected areas of hypopigmentation in light-complexioned persons. Areas deficient in melanin will not fluoresce under UV light, whereas areas of skin with normal melanin content will fluoresce.

Bacterial, viral, or fungal cultures may be indicated if dermal infections are considered in the differential diagnosis. Crusts, when present, should be lifted with a scalpel blade before swabbing the lesion with a sterile cotton-tipped applicator to obtain material for bacterial cultures. Fungi may be collected for culture media by gently scraping the skin with a sterile scalpel blade. Viral cultures from skin lesions require specialized laboratory facilities. Viruses can be collected for special media by unroofing lesions and swabbing with a sterile cotton-tipped applicator.

Patients who have immunologic-mediated contact urticaria may be evaluated by serologic testing. Protein electrophoresis and measurement of circulating IgE may be useful.

Suggested Reading List

Adams RM. Occupational skin disease. 2nd ed. Philadelphia: W.B.Saunders Co., 1990.

Maibach HI, ed. Occupational and industrial dermatology. 2nd ed. Chicago: Year Book Medical Publishers, Inc., 1987.

Mathias CGT. Occupational dermatoses. In: Zenz C, ed. Occupational medicine: principles and practical applications. 2nd ed. Chicago: Yearbook Medical Publishers, Inc., 1988:132–65.

Raffle PAB, Lee WR, McCallum RI, Murray R, eds. Occupational diseases of the skin. In: Hunter’s diseases of occupations. Boston: Little, Brown & Company, 1987:917–48.

Rosenstock L, Cullen MR. Skin disease. In: Clinical occupational medicine. Philadelphia: W.B.Saunders Co., 1986:147–73.

Rycroft RJG. Occupational dermatoses among office personnel. Occup Med 1986;1:323–8.

Seidenari S, Manzini BM, Danese P, Motolese A. Patch and prick test study of 593 healthy subjects. Contact Dermatitis 1990;23:162–7.

Shama SK. Occupational skin disorders, In: McCunney RJ, ed. Handbook of occupational medicine. Boston: Little, Brown & Company, 1988:216–35.

Suskind RR. Environment and the skin. Med Clin North Am 1990;74:307–24.

Irritant and Allergic Contact Dermatitis

Abel EA, Wood GS. Mechanisms in contact dermatitis. Clin Rev Allergy 1986;4:339–52.

Dahl MV. Chronic irritant contact dermatitis: mechanisms, variables, and differentiation from other forms of contact dermatitis. Adv Dermatol 1988;3:261–75.

Lammintausta K, Maibach HI. Exogenous and endogenous factors in skin irritation. Int J Dermatol 1988;27:213– 22.

Photosensitivity Dermatitis

Emmett EA. Drug photoallergy. Int J Dermatol 1978;17:370–9.

Emmet EA. Evaluation of the photosensitive patient. Dermatol Clin 1986;4:195–202.

Gross TP, Ratner L, de Rodriquez O, et al. An outbreak of phototoxic dermatitis due to limes. Am J Epidemiol 1987;125:509–14.

Harber LC, Bickers DR. Photosensitivity diseases. Philadelphia: W.B.Saunders Co., 1981.

American Medical Association. The Health effects of “Agent Orange” and polychlorinated dioxin contaminants: an update, 1984. Chicago: American Medical Association, 1984.

Taylor JS. Environmental chloracne: update and overview. Ann NY Acad Sci 1979;320:295–307.

Tindall JP. Chloracne and chloracnegens. J Am Acad Derm 1985;13:539–88.

Zugerman C. Chloracne. Clinical manifestations and etiology. Dermatol Clin 1990;8:209–13.

Pigment Abnormalities

Gellin GA, Maibach HI, Misiaszek MH, Ring M. Detection of environmental depigmenting substances. Contact Dermatitis 1979;5:201–13.

Gian C, Lu MY, Wang XS, et al. Epidemiologic study on the skin lesions of workers exposed to N,N’-methylenebis-(2-amino-1,3,4-thiadiazole) and of children in the neighborhood of the factory. Scand J Work Environ Health 1985;11 Suppl 4:55–9.

Ortonne J-P, Mosher DB, FitzpatrickTB. Chemical hypomelanosis. In: Ortonne J-P, Mosher DB (eds). Vitiligo and other hypomelanoses of hair and skin. New York: Plenum Medical Book Co., 1983:479–508.

Carcinogenesis

Austin DF, Reynolds P. Occupation and malignant melanoma of the skin. In Gallagher RP (ed). Epidemiology of malignant melanoma. Recent results in cancer research. Vol 102. Berlin: Springer-Verlag, 1986:98–107.

Callen J, Headington J. Bowen’s and non-Bowen’s squamous intraepidermal neoplasia of the skin. Arch Dermatol 1980;116:422–6.

Emmett EA. Occupational skin cancers. Occup Med: State Art Rev 1987;2:165–77.

Epstein JH. Photocarcinogenesis: A review. Natl Cancer Inst Monogr 1977;50:13.

Shannon RL, Strayer DS. Arsenic-induced skin toxicity. Hum Toxicol 1989;8:99–104.

Van der Leun JC. UV carcinogenesis. Photochem Photobiol 1984;39:861–8.

Sources of Information

More information on skin lesions and treating and managing cases involving skin lesions due to environmental exposure can be obtained from ATSDR, your state and local health departments, and university medical centers. Case Studies in Environmental Medicine: Skin Lesions and Environmental Exposures—Rash Decisions is one of a series. To obtain other publications in this series, please use the order form on the inside back cover. For clinical inquiries, contact ATSDR, Division of Health Education, Office of the Director, at (404) 639–6204.

Answers to Pretest and Challenge Questions

Pretest questions are on page 1. Challenge questions begin on page 3.

The Pretest questions (a) and (b) are answered in Challenge answers 1, 2, 3, and 6 below.

(1a) The man in Case No. 1 has most likely developed an irritant contact dermatitis from the insulating material (e.g., fiberglass, rock wool). This possibility could be investigated by placing skin scrapings on a microscope slide with 1 to 3 drops of 10% potassium hydroxide (KOH) and examining the specimen under a light microscope using low power. The presence of fibrous strands would confirm the diagnosis. Dermatitis elicited by fibrous glass is variable and depends on individual characteristics and extent of exposure.

(1b) The woman probably has either irritant or allergic contact dermatitis. The basic histopathologic appearance of these two conditions is essentially the same, and differentiating between them by appearance or routine skin biopsy is difficult. However, most paint-stripping products contain one or more of the following compounds: isopropyl alcohol, cresylic acid, methylene chloride, glacial acetic acid, aliphatic hydrocarbons, and aqueous ammonia, all of which tend to be irritants rather than allergens. The presence of mild rather than severe itching, more erythema than vesiculation, localized lesions, and insidious rather than explosive onset are more consistent with irritant contact dermatitis than with allergic contact dermatitis.

(1c) Both the man and the woman should be advised to avoid exposure to the offending substances, at least temporarily. Applying and rapidly removing adhesive or Scotch tape from the man’s affected skin may remove the fibers and help relieve the itching.

The contact dermatitis of both patients may be treated using Domeboro’s solution (1:40 dilution) or Burow’s solution. Dressings soaked with one of these solutions should be applied topically for 15 to 20 minutes, 6 times daily. Topical corticosteroids may be applied, starting with a steroid of low potency and progressing to more potent corticosteroids as needed. Mild sedatives and antihistamines may be administered to relieve itching. Topical or systemic antibiotic therapy may be used to combat secondary bacterial infection. Repeated exposure to UV radiation may be therapeutic in some cases, causing hardening or increased resistance to further irritation.

(2a) The rash of the patient in Case No. 2 is not likely to be due to airborne allergens or irritants in the new office location. Although some cases of allergic or irritant contact dermatitis can develop from exposure to airborne allergens or irritants, the patient’s occupational history and the location of the rash do not suggest this etiology. Eyelids, cheeks, nasal folds, and the neck most probably would be involved if an airborne agent in the workplace were responsible. The hand and wrist location suggests contact with an allergen that is handled.

(2b) Yes, the patient’s woodworking hobby, with recent introduction of various exotic woods and Japanese varnish (possibly derived from the Japanese lacquer tree), suggests a cross-sensitivity reaction to agents related to Rhus plants, to which he is known to be sensitized.

(2c) The patient probably has allergic contact dermatitis. Therapy would be identical to the regimen for irritant contact dermatitis described in (1c) above. Attempts to desensitize sensitive persons have been unsuccessful in most cases.

(3a) Given the rural location and outdoor activities in which the children in Case No. 3 were involved, airborne allergic contact dermatitis to Rhus -type plant oleoresins (e.g., poison ivy, poison oak, poison sumac) or pollen could be the cause. However, vesiculation would be expected with allergic contact dermatitis. Patch testing could rule out this diagnosis.

Puncturing lime skins while making sachets during craft class could have exposed the children to psoralens, which are known photoirritants. Immediately after the craft class, the children engaged in outdoor sports. This combination of activities could lead to photosensitivity dermatitis. Because the counselors were involved in a staff meeting during the craft class and did not puncture the limes, only the children were affected.

(3b) One of the most important components in therapy for photoreactions is identification and avoidance of the photoactive agent. When exposure to the offending agent cannot be avoided, sunlight exposure should be minimized. Light exposure can be reduced by wearing protective clothing such as broad-brimmed hats, long sleeves, and tightly woven fabrics, or by using sunblocking agents. Symptomatic topical treatments may also be used.

(4a) The rash of the patient in Case No. 4 is more consistent with chloracne than with acne vulgaris. Acne vulgaris has a different appearance, and its distribution is typically the central face, back, and chest; it seldom affects the buttocks. The sebaceous glands are usually active in acne vulgaris, but chloracne gives the skin a “dry” appearance. Comedones are small in size and number in cases of acne vulgaris, whereas typical straw-colored cysts are almost pathognomonic for chloracne.

The patient’s occupation is a potentially relevant factor. A telephone call to a manager at the utility company reveals that old heat exchanger fluids contain PCBs, and in the process of replacing these fluids with less hazardous materials, the workers could have accidental contact with the material. The finding that PCBs are the most probable cause of the patient’s chloracne should prompt a health hazard evaluation by the appropriate regulatory authorities and should encourage action to prevent further exposure.

(4b) The chloracnegenic agent should be identified and exposure stopped. Chloracne is resistant to treatment in many cases. Medications used for acne vulgaris are ineffective for chloracne, but oral and topical antibiotics, acne surgery, injection of inflammed cysts with triamcinolone, and dermabrasion of scars may be efficacious. Topical application of retinoic acid (Vitamin A) or 13-cis-isoretinoic acid (Accutane) has been used on carefully selected patients with some success. In addition to treating the skin lesions, examination and testing should be performed to rule out hepatotoxicity, porphyria cutanea tarda, and peripheral neuropathy—all possible systemic effects of PCB exposure. (For further information, see Case Studies in Environmental Medicine: Polychlorinated Biphenyl [PCB] Toxicity .)

(5a) Yes, the manufacturing plant could be associated with the children’s skin lesions in Case No. 5. A similar outbreak among workers at a manufacturing facility and children in a neighboring school was reported in 1985; a powdered thiadiazole was responsible in that case. Because an etiologic agent for the pigment changes in the children has not been found in routine testing of the water and food at the school, it would be advisable to consider other common sources in the neighborhood, such as the school playground. The nearby chemical manufacturing facility should also be investigated as a possible source, especially because the parents of the two children with more severe manifestations are employed at this plant. The parents could be carrying contamination home on their skin, clothing, and shoes. In addition, the children may be playing in an area with contaminated soil.

(5b) You could begin your investigation by contacting the nurse or health and safety manager at the parent’s workplace to determine whether a workplace agent or process is associated with the rashes of some workers. You could request from the manufacturer Material Safety Data Sheets (MSDSs) or other information about the raw materials, byproducts, chemical intermediates, and finished products used or produced at the plant.

The Toxic Chemical Release Inventory (TRI), which is maintained by the U.S. Environmental Protection Agency (EPA) and is available to the public either online through the National Library of Medicine or on CD-ROM, could be used to determine the normal releases from the plant. Plant management, the local EPA, or the local fire department could be consulted to determine whether any accidental chemical releases have occurred recently at this facility. If soil contamination is suspected, soil samples from nearby playgrounds, school yards, or other play areas should be tested. Local or state health officials may be contacted for assistance.

(5c) If the lesions are persistent, large, and cosmetically displeasing, you could refer the children to a dermatologist for consideration of PUVA treatment. Sunscreens and protective clothing can protect areas with depigmented skin and prevent hypopigmentation from worsening.

(6a) The constellation of complaints of the patient in Case No. 6 is consistent with contact urticaria syndrome. Balsam of Peru and various alcohols (especially propyl alcohol and ethyl alcohol) in numerous consumer cosmetic products and benzocaine in many over-the-counter topical analgesic preparations could be causative agents.

(6b) Evaluation might include correlating the history of the illness with probable exposures, serologic studies of circulating IgE, and patch or scratch testing (performed by, or in consultation with, a dermatologist in a setting with resuscitation equipment in case of anaphylactoid reaction).

(6c) Usual treatment for contact urticaria includes advice to avoid suspected or known causative substances and administration of antihistamines. In certain patients, nonsteroidal anti-inflammatory medications have shown some efficacy.

(7a) The constellation of complaints of the couple in Case No. 7 suggests chronic arsenic poisoning. Arsenic toxicity from criminal activity, intentional surreptitious self-injury, occupational exposure, and environmental exposure should be investigated.

On questioning, the couple reveals that they have obtained drinking water from a private well for the past 40 years and that they heat their home with a wood stove fueled with scrap wood. Analysis of the well water reveals arsenic at 0.62 milligrams per liter (mg/L), a concentration significantly above the EPA maximum contaminant level (MCL) of 0.05 mg/L. Ashes collected from the wood stove and soot from the chimney also contain arsenic in concentrations of several hundred parts per million; the most likely source of this contamination is arsenic-containing preservatives in the scrap wood.

(7b) Initial action should be taken to terminate further arsenic exposure; it will be futile to treat the skin lesions (or provide chelation therapy to reduce body burden) if exposure continues. An alternative source of drinking water should be substituted immediately, contaminated lumber should not be burned, and the home should be decontaminated. Advice on abatement and remediation and aid in investigating any other possible sources of arsenic may be obtained from the state or local health department. (For further information on arsenic and arsenic poisoning, see Case Studies in Environmental Medicine: Arsenic Toxicity .)

Treatment of the man’s basal cell carcinoma may involve radiation therapy or excisional biopsy, including a suitable margin of normal-appearing skin. All tissue removed should be submitted for histologic confirmation of diagnosis and to be certain the tissue borders are free of cancerous cells. The patient should be counseled to avoid prolonged exposure to sunlight and to use sunscreens or protective clothing whenever exposure to sunlight is anticipated.

anaphylaxis.

Commonly used to denote the immediate, transient kind of immunologic (allergic) reaction characterized by contraction of smooth muscle and dilation of capillaries due to release of pharmacologically active substances (histamine, bradykinin, serotonin, and slow-reacting substances), classically initiated by the combination of antigen (allergen) with mast cell-fixed, cytophilic antibody (chiefly IgE).

acne mechanica.

Acne caused or exacerbated by friction.

acne medicamentosa.

Acne caused or exacerbated by several classes of drugs including antiepileptics, halogens, and steroids.

acne venenata.

Acne produced by external irritants or drugs internally administered.

acne vulgaris.

Simple acne, probably caused by hormonal fluctuations.

bullae (singular bulla).

Large bubble-like structures (vesicles) appearing as a circumscribed area of separation of the epidermis from the subepidermal structure, typically filled with serum.

Acne-like eruptions due to prolonged contact with certain chlorinated aromatic hydrocarbon compounds.

chloracnegenic agents.

Substances that cause chloracne.

A plug of sebaceous matter, capped with a blackened mass of epithelial debris, filling the pilosebaceous orifice.

dermatitis.

Inflammation of the skin.

Characterized by the distinctive phenomena of atopy, a Type I allergic reaction, specifically one with strong familial tendencies, caused by allergens such as pollens, foods, dander, and insect venoms, and associated with the Prausnitz-Küstner (IgE class) antibody.

allergic contact d.

A delayed type of induced sensitivity (allergy) of the skin with varying degrees of erythema, edema, and vesiculation, resulting from cutaneous contact with a specific allergen.

irritant contact d.

Irritation of skin caused by contact with substances that are toxic to epidermal or connective tissue cells; lesions are usually erythematous and papular, but can be purulent or necrotic, depending on the nature of the toxic material applied.

dermatomyositis.

A progressive syndrome characterized by muscular weakness with a purplish erythematous skin rash on the face.

Generic term for acute or chronic inflammatory conditions of the skin, typically erythematous, edematous, papular, vesicular, and crusting; often followed by lichenification and scaling and occasionally by duskiness of the erythema; often accompanied by sensations of itching and burning.

Inflammatory redness of the skin.

erythema multiforme.

An acute eruption of macules, papules, or subdermal vesicles presenting a multiform appearance, the characteristic lesion is typically over the dorsal aspect of the hands and forearms; its origin may be allergic, seasonal, or from drug sensitivity, and the eruption may be recurrent or may run a severe course (Stevens-Johnson syndrome), possibly ending in death.

An inert substance such as gum arabic, syrup, lanolin, or starch, that acts as a diluent or forms a vehicle for drug delivery.

folliculitis.

An inflammatory reaction in hair follicles; the lesions may be papules or pustules.

exfoliative dermatitis.

General scaling of the skin, usually with erythema.

Incomplete or partial antigen; an antigen that is incapable, alone, of causing the production of antibodies.

See urticaria.

hyperkeratosis.

Hyperkeratinization; hypertrophy of the horny layer of the epidermis.

hyperpigmentation.

Increased pigmentation of the skin.

hypertrichosis.

Growth of hair in excess of normal.

hypopigmentation.

Decreased pigmentation of the skin.

Any lesion on the epidermis marked by the presence of circumscribed overgrowths of the horny layer.

lichenification.

Leathery induration and thickening of the skin with hyperkeratosis, due to a chronic inflammation caused by scratching or long-continued irritation.

leukoderma.

An absence of pigment, partial or total, in the skin.

Relating to or marked by a small, discolored patch or spot on the skin, neither elevated nor depressed below the skin’s surface.

malar crescent.

Around the cheek or cheekbones.

Pigment that occurs in the hair, skin, or retinas.

melanocytes.

Pigment cells of the skin.

melanoderma.

An abnormal darkening of the skin by deposition of excess melanin, or of metallic substances such as silver and iron.

A malignant neoplasm derived from cells that are capable of forming melanin, which may occur in the skin of any part of the body; in the early phases, the lesion is characterized by proliferation of cells at the dermal-epidermal junction, and the neoplastic cells soon invade adjacent tissue extensively. Melanomas frequently metastasize widely; most examples of this neoplasm occur in adults and may originate de novo or from a pigmented nevus or malignant lentigo.

milia (singular milium ).

Sebaceous tubercle; whitehead; a small subepidermal keratin cyst, usually multiple, therefore commonly referred to in the plural.

An eruption of minute vesicles and papules due to retention of fluid at the mouths of the sweat follicles.

Marked by circular or oval lesions.

Small, solid elevations on the skin.

photoallergy.

Sensitization of the skin to light.

phototoxicity.

The condition arising from overexposure to ultraviolet light.

Furo[3, 2-g]coumarin; a phototoxic chemical derived from fruits of the citrus family (e.g., limes).

A condition characterized by the eruption of circumscribed, discrete and confluent, reddish, silvery scaled macropapules.

A genus of trees and shrubs (family Anacardiaceae) containing various species that are used for their ornamental foliage; poison ivy, poison oak, and poison sumac belong to this genus.

solar elastosis.

Degenerative change in elastic tissue of the dermis due to repeated or constant exposure to sunlight over a period of years.

Hives; an immediate eruption of itching wheals, which may be due to physical and chemical agents, foods or drugs, foci of infection, or psychic stimuli.

urticaria syndrome.

Consists of the typical urticarial rash with systemic involvement.

vesiculation.

Blistering.

The appearance on the otherwise normal skin of loss of melanin pigment with white patches of varied sizes, often symmetrically distributed; the skin bordering the affected sites is usually hyperpigmented, and hair in the affected areas is usually white.

People are increasingly concerned about potential environmental health hazards and often ask their physicians questions such as: "Is the tap water safe to drink?" "Is it safe to live near power lines?" Unfortunately, physicians often lack the information and training related to environmental health risks needed to answer such questions. This book discusses six competency based learning objectives for all medical school students, discusses the relevance of environmental health to specific courses and clerkships, and demonstrates how to integrate environmental health into the curriculum through published case studies, some of which are included in one of the book's three appendices. Also included is a guide on where to obtain additional information for treatment, referral, and follow-up for diseases with possible environmental and/or occupational origins.

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Developing thick skin

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Are you tired of how the words and actions of others affect you?

Do you find that others’ words strike daggers through your heart?

Perhaps you’re not as resilient as you’d like to be or you find managing emotional obstacles to be challenging.

Maybe you’re easily triggered or find it hard to process constructive feedback. Do you find yourself reacting emotionally when you’re faced with a certain tone of voice or particular words?

The solution to all these obstacles is to develop a thick skin. Becoming a thick-skinned person has many benefits. It can be a valuable tool to better your mental health, improve your relationships, and learn how to take constructive criticism.

People with thick skin aren’t often bothered by the words or actions of others. Their thick skin offers them a shield that enhances their ability to remain calm, non-judgemental, and unoffended.

Their ability to bounce back from challenging times is admirable. Because they don’t often take things personally, they can be more optimistic and hopeful about life and situations, even if they’re with people who don’t reflect that themselves.

However, you might not be sure how to develop a thick skin. Lucky for you, I’m sharing twelve ways to do just that. You’ll be able to use my tangible tips to start forming a thicker skin and reap the benefits of having it.

Be sure to read until the end to take in all the tips.

1. Find your why in life (your purpose).

Finding your purpose in life may seem daunting, but it can significantly improve your overall quality of life, happiness, and even health. Though it can be challenging, it is enormously beneficial and can serve as a life map.

Finding your purpose gives you direction even when you’re feeling lost. Whatever curveballs life tosses at you, your purpose will help you dodge them or even recover from them.

Purpose gives you stability, courage, and direction. It acts like the delicate needle of a compass, always guiding you toward your desires, dreams, and goals. Finding your purpose is a journey all on its own, but it will give your life meaning. It will make handling life’s obstacles a little bit easier and contributes to improved physical and mental health.

Finding your purpose will help to keep you focused and less invested in what others think or say. It’s a guaranteed way to bring meaning to every one of your decisions and increase your satisfaction with life.

While your purpose can change throughout life, a few things remain the same. Your purpose is a blend of your interests and things that bring you joy. You might find it in your career, hobbies, or daily activities. It can be a big idea, such as helping people, or something more specific, like writing a novel.

Your purpose is what gets you up on even the dreariest of days, lights your spark, and gives you the fire you need to keep going.

Once you find your purpose, you’ll notice that things bother you less. You’ll notice that other people’s actions and words don’t impact you like they do now, and you’ll feel more in control of your life.

Quick tips for finding your purpose in life:

• Work toward developing a growth mindset. Be open to learning and embracing change rather than working against it.
• Embrace challenges and view them as an opportunity to learn.
• Start a gratitude practice.
• Find, create, or join a community.
• Give back to the community, church, school, or another cause that is meaningful to you.
• Allow yourself to dream and wonder.
• Identify and then explore each of your passions.

When you find your purpose in life, your days will have more meaning. You’ll be able to respond to constructive criticism better and be open to experiencing more joy.

Finding your purpose in life is a gentle but effective way to develop a thick skin. It will help you understand what’s most important to you in life so you can take what other people say with a pinch of salt.

2. Increase your self-awareness.

Self-awareness is a bit of a “buzz” word. It’s trendy right now but, nonetheless, it’s a very helpful tool to develop a thick skin.

Self-awareness relates to how well you understand how your actions, words, and emotions align with your inner values and morals. It encompasses clearly understanding oneself and why you do what you do or feel what you feel.

Increasing your self-awareness can help you understand why you might be reacting to others’ actions or words and help you develop a thicker skin. Self-awareness will help you gain perspective and compassion and can even improve relationships.

With self-awareness, you can question why you feel what you feel and what to do about it. Therefore, when someone’s actions or words evoke an intense feeling in you, rather than reacting, you’ll turn inward and process it objectively.

Some self-awareness activities include:

• Start a daily journaling practice and practice self-reflection. Explore your feelings, circumstances, values, and daily life through writing.
• Incorporate mindfulness into your life. Practice being present, aware, and in the moment.
• Get out of your comfort zone. Growth happens through change. Nothing changes if nothing changes, so if you want to increase your self-awareness, then you must welcome change. Try new things, embrace new experiences, and sit with yourself for a moment to fully grasp your feelings.
• Be open to feedback. Most times, people aren’t saying things to hurt you; increasing your self-awareness will help you understand that. Being open to feedback can make you a better person and a better listener. It can even improve your relationships, employment, and so much more. Accept feedback and apply changes where you deem them necessary. Listening to feedback doesn’t mean that you’re wrong but rather that you’re open. You’re open to possibility, change, and growth.

3. Practice self-acceptance.

Self-acceptance is the unconditional act of allowing yourself to be exactly how you are and where you are while avoiding vilifying your past transgressions, actions, words, and behaviors. It’s allowing yourself to be as you are without judgment or explanations.

It’s important to practice self-acceptance to develop a thick skin because it allows you to exist as you are and where you are while also avoiding judgment. As children grow up and mature, we can only accept who we are to the level that our parental figures did.

So, people who grew up in a loving household where they were constantly reminded of their importance and significance have an easier time practicing self-acceptance

As children, we follow our parental figures lead, looking to them to teach us what is right. If we don’t feel accepted as a child, then there’s a good possibility that we won’t have a solid level of self-acceptance as adults. If you can practice self-acceptance, then the actions and words of others will not affect you as much or at all.

The connection between self-acceptance and overall happiness and satisfaction in life is solid. People who practice self-acceptance and pardon themselves for past transgressions generally have a higher level of happiness and lead more meaningful lives. Likewise, when they receive criticism, they’re better able to take what is constructive and throw away what they don’t like without self-sabotaging.

How to practice self-acceptance as an adult?

• Forgive yourself for your past deeds and cultivate an awareness that you did the best you could with what you knew and what you were given.
• Develop self-compassion.
• Acknowledge your strengths.
• Reframe your negative self-talk.
• Work toward gaining perspective on situations to avoid taking things as a personal attack and automatically going into defensive mode.

4. Remember that people aren’t against you.

Does it feel like the world is against you ? That people are out to get you? It might be challenging to keep at the forefront of your mind, but most times, this simply isn’t true.

When you receive criticism, it’s usually not because the person doesn’t like you. When we internalize the criticism, we transform it into something personal, and it becomes an attack on us.

Begin to develop the thinking that others aren’t against you. When others share something, going into defensive mode is not necessary. Once you start to believe that others aren’t the enemy, you can process their actions and words with more compassion and empathy.

5. Change your inner dialogue.

Your inner dialogue is the voice inside your head. Having a lot of negative self-talk or a negative inner dialogue can largely impact how you feel about yourself and what you do. Self-talk can build or break self-confidence, self-esteem, and self-acceptance while putting a tremendous focus on either pessimism or optimism.

A negative inner dialogue can prevent a person from reaching their full potential and feeling true happiness. A positive inner dialogue can inspire, motivate and help you in far more ways than I could list here.

Your inner dialogue is powerful and casts control over much of who you are. You’re likely to believe your thoughts, and when they’re negative, they can be difficult or impossible to recover from.

Benefits of positive self-talk:

• Improves self-esteem
• Reduces symptoms of mental illnesses, such as anxiety and depression
• Helps you feel like you’re in charge of your life
• Motivates you
• Makes you better able to manage life’s obstacles
• Improves stress management skills

Tips to change negative self-talk:

• Make an effort to become more conscious and aware of your inner dialogue.
• Challenge negative thoughts by asking for proof and reasoning.
• Redirect negative thoughts with something positive.
• Reframe the negative self-talk into something constructive and helpful.

When you’re inner dialogue stops being self-sabotaging, you can take in others’ actions and words and compartmentalize a little easier. Things that others say won’t bother you as much, and slowly, over time, you’ll develop a thicker skin. When you receive constructive criticism, upsetting news, or an insult, your inner dialogue will be better trained to know what to do with it.

6. Quiet the noise in your life.

Life is packed with noise. You’ll hear chaos anywhere you look, which can significantly impact your entire being. When you declutter your physical space and mind, you’ll notice and feel the power of silence. It can help you understand perspective, feel less agitated, and process external influences more meaningfully.

Looking for the quiet can help you understand who you are at the very core of your being and how you relate to others and the world. It can strengthen your connections with others and help you in ways you didn’t know were possible. You may be wondering how this can help you develop thick skin, and that’s okay. Sometimes it’s not obvious how one thing can affect many things.

When you focus on quieting the noise in your life, you’ll consume less from external factors and focus more on your internal being. This alone will help you develop a thick skin and allow you to focus more on yourself than on others’ actions and words.

It will make you less uncomfortable when receiving criticism and more inclined to turn inward and process things more effectively and with less judgment. You’ll be able to take what is said to you and decide whether or not it serves you.

7. Practice putting things into perspective.

Sometimes you get quite undone by a comment someone makes, an action that someone takes, or an upsetting event. Life is constantly throwing curveballs at us, and it can be challenging to understand how to dodge them. This can bring on further stress and anxiety symptoms, worsen a person’s mental health, and lead to feeling insulted more easily.

To develop a thicker skin, you must practice putting things into perspective. This will benefit you and the people surrounding you. It will help you become a better listener and more equipped to handle life. You’ll find that once you start putting things into perspective, you’ll take things less personally.

How to put things into perspective:

• Picture how you might feel about an obstacle, transgression, or event in the future. Ask yourself if you’ll still feel this way in a week, month, or year. A reminder here is to be gentle while you do this. This is not meant to invalidate your current feelings but is more of a practice that will help you thicken your skin.
• Many times our emotional selves react quicker than our mental selves can control. Before you know it, we’re internalizing what was meant to be constructive criticism as insults and injury. Ask yourself questions to help guide your perspective and thicken your skin.
• Brainstorm other perspectives. Using a pen and paper, write down potential obstacles and then take some time to ponder other perspectives. For example, was your friend giving you a little pointer, but perhaps you took it personally? Was the comment meant to be malicious? Consider the situation and write things down to help you discover unique perspectives so you can strengthen your ability to handle constructive criticism and emotional distress.
• Label your feelings. Practice giving a name to what you are feeling and then ask why. For example, “I am feeling upset that my boss suggested this. I think I’m upset because I feel like they’re saying I’m not very good at my job.”
• Reframe the feeling. Once you label your feeling, allow yourself to reframe it and ponder other conclusions. Was your boss trying to help you? You may have taken it more personally than it was intended. Try to poke holes in it and arrive at a new conclusion.
• Allow yourself time to process. You don’t need to rush to a conclusion, but sit with it. Ponder and allow your mind to wonder. This is a great way to develop a broader perspective and work on thickening your skin.

8. Accept and embrace positivity.

The power of positive thinking is undeniable. It helps with stress management and carries enormous health benefits. Though it takes practice and consistency, it is worth putting in the work to form this healthy habit.

Positive thinking might seem like a simple “glass half full” type of thinking, but it actually does take some effort, change, and persistence. However, the benefits greatly make it worthwhile.

When you begin to see things from a brighter angle, you’ll be able to increase your resilience. You’ll be better equipped to handle emotional obstacles, constructive criticism, and any other type of feedback.

When you can look at things with a positive flair on a habitual basis, you’ll notice that your relationships become stronger, you become a better listener, and your health and wellness improve.

How to develop positive thinking:

• Smile more often.
• Look for joy in daily living.
• Laugh every day.
• Start a gratitude practice and work on reframing negative thoughts into things to be grateful for. For example, rather than being upset that your boss asked you to work late, you’re grateful that you have steady employment that allows you to provide for yourself and your family.
• Focus on your abilities and things that you can control. For example, you can’t control what others say, do, or feel. But what you can control is your reaction to it and how you allow it to affect you.

9. Put self-care at the top of your priority list.

Self-care needs to be prioritized to develop a thick skin. What is the relation? You’ll be more bothered by others’ actions and words when you’re not at your best.

When you’re taking care of yourself, and you are in tune with your own needs and desires, you’ll be less likely to put significant emphasis on others. In turn, you’ll be better able to understand the perspectives of others and respond to constructive criticism more openly.

A solid self-care routine will care for all parts of yourself. These include your physical, psychological, spiritual, and emotional well-being. It emphasizes taking care of your entire person, which will impact you in many ways. Self-care can be absolutely transformational, from improved health, decreased negative emotions, and overall happiness to better satisfaction at work and more meaningful relationships.

Self-care ideas to try:

• Connect with loved ones.
• Walking outside in nature.
• Social media detox.
• Practice gratitude.
• Turn your phone off.

10. Build your self-confidence.

Self-confidence is the feeling that you can trust yourself and your abilities. People with a high level of self-confidence respond better to emotional obstacles and criticism. High self-confidence is needed if you’re looking to develop a thicker skin.

Self-confidence is how you feel about your ability to complete a task. You might be confident in some areas, not in others, or in general. Self-confidence is an essential tool for developing a thick skin. It helps you understand that you’re in charge of your reactions but can’t control others’ thoughts or feelings.

Self-confidence is vital to understand as it relates to nearly every avenue of life. A high level of self-confidence makes a person more motivated, resilient, brave, and self-assured. It means that you’ll be able to handle life’s obstacles more optimally and change your attitude surrounding failure and trying new things.

Self-confidence helps a person see things in a different light. Failures become learning opportunities, feedback transforms into improved skills, and other people’s comments and actions roll off your back like nothing.

How to build your self-confidence:

• Make a list of your best qualities and things you’re good at.
• Avoid people pleasing.
• Don’t compare yourself to others.
• Surround yourself with positivity.
• Break out of your comfort zone and start to explore new experiences.

11. Focus on yourself.

In a world constantly pulling at us in 80 million ways, it can be challenging to sort through the noise, chaos, and information. When you lack a strong sense of self, you’ll be more prone to reactive behaviors and less able to roll with the punches.

Rather than focusing on others’ actions and words, focus on yourself and your life. Step up and start uncovering your desires, wants, and dreams. Then you can cultivate a plan to pursue them. Become so invested in yourself that you don’t hear the noise anymore. Tune out the chaos and dive into loving yourself. Focus on what you want, how you feel, and what you can do to live a joyful life.

Don’t put energy into processing other people’s actions, but when you feel an emotion, label it and ask why. Why are you feeling personally attacked? Is it because you’re a tad insecure about that particular thing? Are there things you can shift to improve those areas of your life?

You’re the driver of your life, and you’ll only be as successful as you make yourself. It’s essential to realize your true power and step into the spotlight so you can live your best life.

When you bring a solid focus to yourself, you’ll start noticing that the actions and words of others don’t bother you as much. You’ll develop a thick skin and be able to handle life’s obstacles as well as the hard times.

12. Understand your emotional triggers.

Is there something specific that really gets under your skin? Does your mood shift when you’re around a particular person? Spend time unwrapping what triggers your emotional responses and start answering the why.

For example, why are you feeling personally offended? Chances are that people aren’t trying to hurt you or cause you emotional distress. What they say or do, though, can be a trigger for you. Once you understand your emotional triggers , you can create a toolbox to help yourself maneuver through obstacles.

After using your personal toolbox and caring for yourself when you’re triggered, you’ll start to notice that fewer things bother you. Less of life’s transgressions are being internalized; instead, you’re using self-care routines and various personal tools to counteract the adverse effects of them.

The takeaway.

Developing a thick skin can be a tremendously impactful tool that translates into all areas of your life. Once you develop a thicker skin, you’ll notice improved mental health, relationships, and overall satisfaction in life. Thick skin can stop you from internalizing what others feel or say—their words can roll right off your back. It allows you the grace to avoid being hurt or deferred by external factors.

Developing thick skin takes persistence, effort, and consistency. You need to grow it little by little. Slowly, your self-confidence improves, you’re more in control of your life, you’ve gained perspective, and you’ve developed a solid self-care routine.

These things may sound like a lot, but they are baby steps. Their effects compound to create a snowball effect, and before you even know it, you’ll have the thickest skin you’ve ever had and lead a life where you’ve never been happier.

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6 Ways to Build a Thicker Skin (and Be a Stronger Person)

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Published on March 20, 2023

What happened the last time someone criticized you? If you’re anything like me, you let it work you up until you were fuming. While this response is very human, it’s not healthy for us. We would all benefit from building a thicker skin sometimes.

Developing thick skin helps you navigate life’s curveballs with grace. You begin to live from a space of valuing your own opinions above those of others. And this allows you to put both the good and the bad in life into perspective.

This article will help you learn how you can get a thick skin. By the end, you’ll know how to take what life throws at you and use it to grow.

What exactly is “thick skin”?

What are the perks of having thick skin, 1. love yourself first, 2. give up the need to be liked by everyone, 3. reflect on why you’re offended, 4. try to flip your perspective, 5. look for useful feedback in criticism, 6. make sure you sleep, wrapping up.

I’ve had many people in life tell me I need to get thicker skin. At first, I thought this meant people wanted me to be more calloused and apathetic.

As I’ve matured, I’ve realized that isn’t what they meant when they said thick skin.

Thick skin means you’re able to control your reaction in relation to comments and actions made by others. Controlling your reaction means not getting easily upset or offended by the situation.

It’s obvious that it’s easier said than done. And the research gives us some insight as to why.

Studies tell us that we often react because we perceive some form of threat to our well-being.

The threat can be small like your boss criticizing your work. Or the threats can be big like someone abandoning you in a relationship.

Each of these situations threatens your sense of safety. And as a result, you tend to have some form of emotional reaction.

But how intense that reaction becomes is within your control. And that’s where developing thick skin helps.

Research also shows that culture will influence your reactions. So your skin might be a little thicker or thinner based on your society’s cultural context.

It’s clear that emotional reactivity is influenced by our biological response and our culture. But despite these influences, you can still develop a healthy layer of thick skin for your mental health.

💡 By the way : Do you find it hard to be happy and in control of your life? It may not be your fault. To help you feel better, we’ve condensed the information of 100’s of articles into a 10-step mental health cheat sheet to help you be more in control. 👇

Don’t Miss Out On Happiness

Find happiness with this 10-step mental health cheat sheet.

You might be wondering what’s wrong with being sensitive. Let me make it clear that I’m not saying sensitivity is a bad thing.

It’s important to feel your feelings. But being overly sensitive to the point that your reactions quickly blow up probably isn’t serving you.

Developing thick skin helps you sharpen your emotional regulation. And the research shows that being able to regulate your emotions positively influences both your physical and mental well-being.

I can tell you personally that working on getting thick skin has been critical for my relationships. And it’s been even more important for my personal development.

If I didn’t develop a thick skin, I think I wouldn’t have lasted my work in healthcare. And I certainly wouldn’t have a healthy marriage.

As humans, we all make mistakes. If you blow up any time a friend or co-worker messes up or says something slightly offensive, it’s hard to be a good friend .

And if you can’t handle criticism, people will be afraid to give you useful feedback. And feedback is how we push ourselves to be better.

So the perks of having thick skin are cultivating a life where you’re continually growing and attracting like-minded people to your circle. Sounds like some pretty awesome perks to me.

6 ways to get thick skin

These 6 tips are designed to help you thicken up your skin to process your emotions in a healthy manner. You can ditch excessive emotional reactivity and replace it with balanced sensitivity.

I know self-love almost sounds like a cliché concept these days. But it’s essential for promoting healthy emotional regulation.

If you don’t value your own opinions, then you’ll be easily influenced by criticism and others’ behavior.

But how do you develop self-love? I think the best way is to get to know yourself.

Write out your values. Write out who you think you are. Here is an article of ours with 7 things to know about yourself .

When you see clearly who you think you are, you can see the qualities that you admire about yourself. And you can acknowledge accurately where you have room for improvement.

I have a simple practice of weekly reflection where I write out 3 things I appreciate about myself. I also write out 3 things I’m proud of myself for accomplishing that week .

These practices build a foundation of self-love that helps you gracefully accept criticism without beating yourself up . It also allows you to let inaccurate or harsh words roll off your shoulders.

This is a tricky concept that many of us struggle with. We like it when people like us. That’s just the truth.

So when someone says or does something that indicates they don’t like you, it’s easy to get upset.

But here is another harsh truth for you. There are going to be people who will not like you. And this may have nothing to do with who you are or your actions.

When I find myself getting upset about someone’s words or behavior, I remind myself that it’s okay to not be liked. This helps downregulate my overreaction in lots of situations.

I then also remind myself of all the people in my life who do value and like me. And I remember that these are the relationships that matter most in life.

And when you give up the need to be liked by everyone, you feel lighter. You get thicker skin and you feel free from the pressure to be perfect.

Sometimes you need to take a deeper look at why you’re offended in the first place.

What is it about those words or the behavior that is setting you off? This often gives you insight into why you may be so sensitive.

Just last week I got really upset when my friend told me I was being selfish. I immediately wanted to say some harsh words back.

Luckily, I didn’t. I walked away and thought about the situation.

I realized that the reason I got so upset by her words is that at some point in life, I did feel like I was very selfish. And I feel I’ve worked hard to overcome that issue.

So her words essentially opened up an old wound regarding a perception I had of myself.

By realizing this, I was able to look at the situation and ask myself if I genuinely thought I was being selfish. I realized I didn’t think I was.

So instead of internalizing those words and being upset, I let them go. And realized that her words were just a trigger and not an accurate perception of my reality.

If you are getting offended, you may need to pull a 180 flip on the situation.

Try to ask yourself what the person who said or did the offensive thing was thinking. You may come to realize that their words have more to do with them than you.

I also try to ask myself, “What would it take for those words or actions to not offend me?” Sometimes the answer tells you exactly how to have thicker skin.

Let’s go back to my friend who called me selfish. She said this because I said no to a girl’s trip.

I realized that from her perspective, it looked as if I was more concerned with my money than with her girl’s trip.

I could see how that would be perceived as selfish. But it wasn’t just about the money. It had more to do with the fact that I have to take work off the next week for an oral surgery.

This helped me feel less offended by her words. But I also still realized that my response was appropriate as well.

Sometimes hidden in the thing that is upsetting you is valuable insight or advice.

It can be hard to get past your emotions in the moment because you just feel upset. But if you take a deep breath and step back, there is often a lesson to be learned.

Not long ago, I had a coworker tell me that I needed to relax and be more flexible.

This set me off a bit because I felt like this co-worker needed to be more rigid and time efficient.

Once again, I’m lucky that I’ve trained myself to not react in the moment. Because my honest instinctual reaction isn’t always the kindest.

When I stopped and thought about it, I realized there was some real truth to their feedback. I get so caught up in being productive at work that I don’t just let the little issues slide.

This causes unnecessary stress for me and those around me. So really my co-worker was giving me external insight that was useful.

Your skin will grow thicker if you can dissociate your emotional response from the words themselves.

We have solid research indicating that poor sleep is more likely to cause you to be very emotionally reactive.

So if you find yourself getting easily offended and upset, it may be time to look at your sleep schedule.

After a solid 7 to 8 hours of sleep, you may find that your perspective on the matter completely shifts.

I know it’s simple, but sleep is powerful. Make it a priority for both your physical and emotional health.

You will probably find that your sensitivity is better balanced as your sleep quality improves.

💡 By the way : If you want to start feeling better and more productive, I’ve condensed the information of 100’s of our articles into a 10-step mental health cheat sheet here. 👇

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Thrive under stress and crush your goals with these 10 unique tips for your mental health.

Getting thick skin won’t make you calloused or apathetic. It makes you emotionally mature to help your relationships and personal growth flourish. The tips from this article will help you better regulate your emotions no matter what the scenario. And with your new thick skin, you’re freeing up the emotional energy to put towards the things that matter most.

When was the last time you’ve been told to develop a thicker skin? Did it bother you, or did you find value in this feedback? I’d love to hear from you in the comments below!

Physical therapist, writer, and outdoor enthusiast from Arizona. Self-proclaimed dark chocolate addict and full-time adrenaline junkie. Obsessed with my dog and depending on the day my husband, too.

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How do you take criticism in this industry? I’ve been working in my role for the past 2 months and I often get told I’m making too many mistakes or that I’m causing problems for very minor mistakes (maybe a sentence doesn’t read right, data is a bit off in a slide, formatting, spelling errors). It’s stressed me out quite a bit as I’m always triple checking my work but still somehow miss small stuff and get berated by my VP. If I’ve done a good job they will say thanks which is always nice but it’s a bit unprofessional the way I receive criticism sometimes I assume this is the industry norm so my question is how do I develop a thick skin? I feel like my performance might be getting worse from stressing about mistakes too much. I don’t feel like eating and have developed some pretty bad anxiety from the stress of the role. Do I just not care as much or take it with a grain of salt? Any advice is appreciated.

Well this didn’t read “write” so maybe focus on your work.

That being said, try to understand that they are working to make you the best resource possible. Once you’ve developed your skills, you’ll gain more confidence in your work product and less bothered by any unwarranted criticism.

The MS and edit shows you can’t handle valid criticism.

It was a fair point, but your inital comment didn’t give me any meaningful advice until you changed it. But fair enough thanks for the advice appreciate it.

Lift and get big so people won't give underhanded comments to try and bully you.

Nah they’ll just laugh at you bc you can’t reach your back Society always wins, we are nothing but matter

MMA is better . You need internal confidence and actual strength to knock the guy down if needed.

Just meet the VP in a back alley, put him in his place. He’ll be bowing the next day.

Avg MMA enthusiast mindset always wanting to resort to actual violence instead of just intimidating and saving energy and having peace of mind

Lot of bankers don’t have any authority or strength in life so they need to feel better about themselves by denigrating juniors.

Put them in the street, they’re crying to their mommies.

Try not to take it personally and try to remove the emotion from it. They’re just trying to help you improve, although sounds like their tone could use some improvement of its own. Receiving feedback on-the-job, however harsh, is always better than seniors keeping quiet until review time..

Sounds like your VP could do a significantly better job on that front

But regardless someone shouldn't have to rely on how other people are relaying information in order to develop. Look at stuff objectively and not emotionally, although easier said than done for sure

If you don't do this you'll be a sheeple. You're giving control over your well-being and self-control to someone who most likely isn't even aware that they're doing this to you

However, if you know your VP is a bad apple and is trying to put you down just because, then don't stay in that position. I've had to deal with people like this in high school/college

Start playing more online video games with a team chat function. 

Doesn’t work, accidentally told my vp to get cancer in teams chat

Muay Thai / BJJ

Trust me, it will put your life in order and give you the ultimate confidence. You develop thick skin naturally and also get a massive hit of oxytocin.

Isaiah_53_5 💎🙌💎🙌💎 Muay Thai / BJJ Trust me, it will put your life in order and give you the ultimate confidence. You develop thick skin naturally and also get a massive hit of oxytocin.

Oxytocin is the love hormone bro. Although you get it from BJJ due to contact, better to get your oxytocin from your girl or hugging your family.

Say endorphins and serotonin from now on. Oxytocin from martial arts just sounds ugh.

ToTheMoooooon Isaiah_53_5 💎🙌💎🙌💎 Muay Thai / BJJ Trust me, it will put your life in order and give you the ultimate confidence. You develop thick skin naturally and also get a massive hit of oxytocin.

Martial arts increase oxytocin production

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6736948/

“Numerous studies have demonstrated that oxytocin (OT), a peptide hormone, plays an important role in regulating mammalian social behaviors, linking it to social affiliation in parent-infant attachment, romantic and filial relationships, and other prosocial behaviors, such as trust and cooperation. Not surprisingly, research efforts have been made to increase endogenous levels of OT.

In the present study, we investigated whether traditional martial arts training, which integrates the natural benefits of physical exercise with dyadic prosocial interaction, would result in OT response. To this end, 68 beginner and advanced participants were recruited from several schools practicing Jujitsu (“soft art”), a form of traditional martial arts originating in Japan. Salivary OT levels were assessed at baseline, immediately following high-intensity training, and following a cool-down period. Analyses revealed a significant increase in OT immediately after a high-intensity training, returning to baseline levels following a cool-down period. Additionally, although no significant difference between beginner and advanced martial artists was found, a significantly higher increase in salivary OT followed ground grappling, as compared to “punch-kick” sparring, indicating an added benefit of close contact tactile interaction. These results suggest that the reportedly socially beneficial effects of traditional martial arts may be in part mediated by OT release and underscore the potentially therapeutic applications of these methods for disorders involving social dysfunction, such as autism, conduct problems, or schizophrenia.”

You must have never trained Muay Thai or BJJ. I’m ride or die with my teammates. We have been to hell and back together. They are family. So much more than just going to the gym with buddies to lift weights. Muay Thai and BJJ forms lifetime bonds .

• Stop making mistakes. Getting shit on for actually making mistakes isn’t a matter of thick or thin skin. You’re 2 months in so mistakes are totally normal, but you should be actively working to reduce their occurrence. Make fewer mistakes today than you did yesterday, etc. 
• This will lead to self-confidence because you will be confident in your work product. You will feel proud about what you’re doing. You will become known as a guy who your superiors can trust to get the job done right. This will lead to more self-confidence. 
• Suddenly, if and when you get shit on by your VP, you won’t care because you are certain what you are doing is correct and you have an extensive track record to back it up. The tongue lashing will no longer impact you. Your skin, in effect, will have grown thicker. You will have become ungovernable (just in time to leave for business school)

Create a “process” for reviewing materials before you send things out. If people still have comments for silly mistakes then your process if flawed and you need to fix the process.

Esse quae non sit quo vitae culpa corporis. Atque ut tenetur est et est.

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Novo nordisk’s ambitions.

Reduce the barriers to health care for larger-bodied people, ultimately changing the narrative and destigmatizing obesity.

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Novo Nordisk and Content Room co-produced a 4-part docuseries, Thick Skin , that follows four remarkable higher-weight women in Philadelphia whose stories will change hearts and minds about the last bastion of unabashed cruelty permitted, and even encouraged, by our diet-obsessed society.

The “Explainer Vignettes” focused on science and facts surrounding obesity and continued to spotlight the extraordinary women featured in the docuseries.

Overall, the premiere, encore, and 76 custom spots which aired across AMCN grossed 116.M HHs and 2.7M A25-54 throughout the campaign. The campaign delivered 5M+ views across social, exceeding the goal of 1.67M, and also generated 15M+ social impressions. Across social, Thick Skin generated over 5M+ engagements and had a reach of over 6M+.

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Psych Careers

Developing a thick-skin, taking criticism well in the world of science..

Posted June 19, 2008

Most of you are familiar with the light-side of science; designing empirical experiments, discovering new information, presenting data and crafting theories. But that is only half of the picture. There is also the often ignored dark-side of science; correcting flawed experiments, criticizing inappropriate data analysis, and tearing down the ideas of fellow scientists. Yes, the peer-review process is a harsh mistress but is equally important to the scientific process (some might argue more so) as its light-sided counterpart. As such, developing a thick-skin to the criticism of others, is a vital step for any developing scientist.

Criticism can come from peers, mentors, review- committees , editors, parents, the media, and anyone else who might be privy to your work. First we should begin with an operational definition of criticism, from Merriam-Webster we find: a critical ( exercising or involving careful judgment or judicious evaluation) observation or remark . That sounds about right. We usually attach a negative connotation to criticism, but that's not necessarily the case. Criticism can come in many different forms, for example...

Praise: This is the easiest feedback to swallow. Unfortunately it is also not very useful. Don't get me wrong everyone wants to hear that they are doing things right, and to keep up the good work. Better than an "attaboy" is true critical praise where insight about where you went right is revealed. Receiving praise, however, rarely motivates you to improve .That said feel free to send me praise anytime. Please?

Constructive Criticism: Likely the easiest negative comments to swallow. The kindly advice of your peers points out ways in which you can improve. Motivated by a desire to see you achieve, constructive criticism is your best friend. It can still be tough to hear where you went wrong, but the goal of constructive criticism is to make suggestions for improvement. This is the criticism you want to take to heart,as it can only help you improve.

Self-promoting Criticism: When you have presented a research talk about disgust sensitivity and superstitious conditioning and you get the question, "Did you find any interaction with circadian rhythms ?" you know you are the victim of this type of insidious criticism. The key is to recognize it for what it is: the asker wants to talk about her own research, or a clever idea she had. Common mistakes in dealing with these questions is to argue against them ("Circadian rhythms have nothing to do with this.") or admit failure ("We didn't think about that at all."). A better solution is to throw the ball back into the asker's court and let her talk about her ideas ("That's an interesting point, how do you think circadian rhythms would affect the study as presented?"). This allows the asker to promote her ideas and you appear neither petulant nor incompetent. And it has the potential to become constructive criticism if (unlike my example) the points she raises are actually related to what you are researching.

Nitpicking: These are the annoying nettles that reviewers send. Usually about grammar (sometimes Latin grammar ), formatting or semantics. It is usually easiest to just correct any nitpicks. Unless you know you are right, go ahead and make whatever changes are suggested by the nitpicker. Since for the most part it doesn't really matter, these criticisms are just white noise.

Bad Advice: This is the worst. When what looks like constructive criticism is actually destructive. Imagine if you were looking at social development in adolescent rats, and one of your measures was playfighting (pairing the rat with a same- gender rat to see them play). And you received the note that you have to look at cross-gender social interactions in your playfighting paradigm. This might seem like good advice at first glance, eliminating your imposed gender division of play-fighting partners sounds like something you'd want to do. Except that instead of play-fighting, you will observe mating , or at least attempted mating. So be on the look-out for bad advice. Your best bet is to solicit advice from several different sources, hopefully then you can better separate the wheat from the chaff.

So now that we know what types of criticism is out there, how do you take this criticism well? There are books and books about it, but I think the best advice I ever got came from a Terry Gross interview with actor Seth Green . Seth was talking about not being cast in roles he really wanted:

"I never took it as a failure on my part, I kinda had an objectivity at a young age that I really held onto where if you believe in a director or if you believe in a project in a project you have to respect their vision for what it is and if you don't fit that vision then you just don't fit. And there's a lot of times that no matter how good an actor you are that you're just not right for it. And I became very aware and zen about that."

So by that reasoning, if you've chosen a good pool of peers (mentor, colleagues, etc.) from which to solicit criticism, then you you can be reasonably certain that they are trying to do what is best for science when they give you feedback. Don't take it personally if your vision of a project, a paper, or a presentation doesn't mesh with their vision. Remember, by integrating their suggestions into your work will help make you a better scientist. No matter what the criticism it is always worthwhile to address it, at the very least you will dissuade others from making the same critical observations. In a future post I'll show some examples of feedback I (and my colleagues) have gotten on journal submissions, or other projects. But as a teaser here is some feedback we received about this (now published) paper :

"Only the questionnaire data are analysed. However, the subjects had a keyboard to try to control words. Even if self-report may be an interesting behaviour to study, subject probably uses their keyboard with a high rate. What is the rate of responding in each condition? What is the rate of responding on each button of the keyboard? Is the rate of responding related to self reports? Is the rate of responding to try to make the word "bad" appearing comparable to the rate to try to make the word staying at the screen? All these questions are important because directly related to the central question of the research."

I'd call that constructive criticism. We did in fact collect response rate data, but there were no correlations. Not to mention that the question of the relationship of response rate to superstition has been well answered in previous research. To address the criticism however we added this line: "The tendency for these behaviors to be unique to the individual organism has made traditional operant measures, such as response rates, less useful in assessing non-contingent reinforcement."

So just remember, in science you will present your ideas often. Just as often people will comment on your ideas, and you need to be prepared to deal with that. Good luck!

Mitch Harden is a third year doctoral student in the behavioral neuroscience program at the University of Missouri - St. Louis.

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How to Develop a Thick Skin

Last Updated: January 23, 2024 Fact Checked

This article was co-authored by Erin Conlon, PCC, JD . Erin Conlon is an Executive Life Coach, the Founder of Erin Conlon Coaching, and the host of the podcast "This is Not Advice." She specializes in aiding leaders and executives to thrive in their career and personal lives. In addition to her private coaching practice, she teaches and trains coaches and develops and revises training materials to be more diverse, equitable, and inclusive. She holds a BA in Communications and History and a JD from The University of Michigan. Erin is a Professional Certified Coach with The International Coaching Federation. There are 9 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 242,195 times.

Do you tend to overreact when someone says something hurtful? It's normal to feel a sting when someone criticizes or insults you. However, if you tend to lash out in anger, cry, or feel upset for days, you may want to focus on developing a thicker skin. While there's nothing wrong with being sensitive, it's no fun to get knocked off balance by a casual comment. By learning to look at the bigger picture, having a positive attitude and building confidence, you can stand strong the next time you feel insulted.

Things You Should Know

• When you receive a negative comment, take a moment to let the emotions wash over you before reacting. If it helps, silently count to 10.
• Separate criticism from insult. Remember that people who habitually insult others have low self-esteem or emotional baggage they need to deal with.
• Take context into account. Did the person mean well, or were they being cruel?
• Try to spend more time with people who support you and view you in a positive light, rather than people who refuse to accept you.

Think before reacting.

• Take a moment to let the first wave of emotion wash over you. Let yourself feel it, then wait for it to subside. Do not react until that initial flush of defensiveness is gone.
• It may help to actually count to 10 before you say anything. If you're alone, you can count out loud. If you're with someone else, count silently. Ten seconds is usually enough time to clear your head.

Separate criticism from insult.

• Take the context of the comment into account. Did the person who said it mean well? Was it delivered by a person you respect in a position to critique you, like your teacher, boss or parents? Or was the person trying to hurt you?
• Confusing criticism with insult commonly leads to overreaction. Being able to separate the two will help you develop a thicker skin at school, work and in other places where valid criticism can be given.

Don't take it personally.

• Remember that an insult is opinion, not fact and it can only hurt you if you believe it. If you don’t see what the person said as part of your self-view, then it will be easier for you to let it go. For example, if someone calls you unattractive or unintelligent, you can easily reject this if you don’t see yourself that way.
• After feeling the pain the insult brings about, try to let it go. Put it into context as a barb that can sting for a minute but ultimately holds no weight.

React nobly.

• You have every right to ignore the insult. Just pretend like it wasn't said, if that seems like the best solution.
• Or try lifting your chin, making eye contact, and telling the person "you're wrong; that's not true."

Defend yourself if you need to.

• Have a face-to-face confrontation. Tell the person that you expect him or her to stop insulting you. Sometimes just calling the person out will put a stop to the behavior.
• Seek outside help. If you feel you're being bullied , a one-on-one confrontation may not help. Talk to your teacher, principal, supervisor, or someone else who can help you deal with the situation quickly.

See if you have room for improvement.

• It's also possible that the critique is dead wrong. Still, there's no need to overreact. It's just one person's opinion, after all.
• Speaking of opinions, it might help to get a second one. This can help you establish whether you actually have room for improvement.

Look at the bigger picture.

• If it seems impossible to put it into perspective, just tell yourself to wait it out until tomorrow. The pain really will fade after a day or two.
• In the meantime, distract yourself. Spend time with a friend, watch a good movie or exercise the thoughts away.

Resolve to make it into something positive.

• For example, if you received a critical review of a report you wrote, consider revising the report with the critique in mind.
• Without dwelling on the criticism, keep it in mind and resolve to do better next time.

Realize it's about the other person.

• Look for the emotion behind the insult. The person who made the comment may be sad, angry, or upset in some other way. Some people have trouble expressing emotions so they take out their problems on other people.
• Use this information to help yourself take the insult less personally. It may have hurt your feelings, but it was just a disguise for the person's real feelings.

See if you have a deeper wound.

• For example, maybe you've been feeling insecure about your intelligence ever since starting a difficult new class. Someone calling you "silly" or "dumb" may cause you to feel more deeply insulted than the person intended.
• The solution is to work on the feelings of inadequacy that are leading to the tender, sensitive spot. When you feel more confident about your intelligence you'll be able to let such comments roll off of your back.

Be proud of your strengths .

• Do you know your strengths? Try making a list of everything you admire about yourself. Having a firm grasp on what you're good at will bolster you when you're feeling down.
• Get good at what you do. Spend time practicing, learning and always working to get better. That way you'll have a core knowledge that you're good at what you do. A criticism or insult won't have as much power to bring you down.

Don't try to be perfect.

• Being a perfectionist may seem like a good thing, but perfectionists tend to have thinner skin than those who allow themselves to fail sometimes. Perfectionists are also highly critical of themselves. [12] X Trustworthy Source American Psychological Association Leading scientific and professional organization of licensed psychologists Go to source Low self-esteem is often brought on by self-criticism, so be compassionate towards yourself .
• To let go of perfectionist tendencies, challenge yourself to learn something new. Try a new skill, sport, language, or anything else that interests you. Starting from scratch is humbling. It will help you realize that perfection is impossible. It's the journey that counts.

Spend time with positive people.

• Pay attention to how you feel after hanging out with certain people. Do you feel refreshed and happy? Or do you feel worse about yourself?
• When you're with people who accept you for you are, you don't have to worry about being too sensitive. After building trust, you'll learn that your true friends will love you even when you feel insecure.

Practice good self-care.

• Eat healthy and exercise. You've heard it a million times, but it helps. Make sure you're eating a well-rounded diet and exercising at least 30 minutes each day.
• Get plenty of sleep. Being tired heightens emotions, leaving you more prone to taking things the wrong way.
• Include meditation or yoga in your daily routine. These activities can help you to be more accepting of yourself.

Seek outside help.

• Talk therapy can be very effective when it comes to building self confidence and a thicker skin. You may also come to accept that it's OK to be sensitive.
• If chronic depression or another disorder is troubling you, medication can also help. You'll need to make an appointment with a psychiatrist to discuss the best options for your situation.

Expert Q&A

• Understand that no single person in history has been without critics. Some of the most successful people in history have had more than their fair share of critics. Thanks Helpful 5 Not Helpful 0
• It takes patience and practice but it's worth it. Thanks Helpful 3 Not Helpful 0
• Sometimes what we are most sensitive about are issues we are afraid to face about ourselves. By having the courage to face them either through change or self-acceptance you will find more confidence in the long run. Thanks Helpful 2 Not Helpful 0

• Not all people who criticize you, want to hurt your feelings. There is a difference between constructive criticism and plain rudeness. Thanks Helpful 81 Not Helpful 11
• Do not think that having thick skin means being rude or indifferent. Thanks Helpful 3 Not Helpful 0

You Might Also Like

• ↑ Erin Conlon, PCC, JD. Executive Life Coach. Expert Interview. 31 August 2021.
• ↑ https://www.psychologytoday.com/intl/blog/rediscovering-love/201105/speaking-you-think-foot-in-mouth-syndrome-in-committed-relationships
• ↑ https://www.helpguide.org/harvard/benefits-of-mindfulness.htm
• ↑ https://www.psychologytoday.com/blog/hide-and-seek/201302/how-deal-insults-and-put-downs
• ↑ https://psychcentral.com/health/how-to-improve-your-life
• ↑ https://psychcentral.com/blog/5-tips-to-develop-thicker-skin#1
• ↑ https://positivepsychology.com/how-to-overcome-perfectionism/
• ↑ https://www.apa.org/monitor/may04/cons
• ↑ https://www.psychologytoday.com/blog/hide-and-seek/201205/building-confidence-and-self-esteem

About This Article

If someone says something rude, critical, or insensitive, it can be a challenge to shake it off. Next time it happens, take a moment to process before you react. This can be as simple as counting to 10 in your head before you speak. Once you’ve calmed down, think about what they said. If it was a criticism, they might have meant it well, even if they didn’t say it in the kindest way. On the other hand, if they were just insulting you, that says more about them than it does about you. Either way, try not to take it personally. It’s okay to defend yourself, but do it in a calm, non-accusing way instead of lashing out or resorting to insults. You can even say something like, “You’re right, I could have done that better. But next time, please tell me how you feel without calling me names.” For tips on developing a more positive mindset, read on! Did this summary help you? Yes No

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How to develop a thick skin.

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How do you "develop a thick skin"?