Supplementary evidence

A recent occupational skin diseases study examined the effect of a multivitamin supplement on infection and quality of life and produced some interesting results

With a surface area of 1.5-2m2 and a thickness of 0.5-5mm, the skin makes up 15% of total body weight, making it the largest organ of the human body. It also forms a border between our body and the external world. No other organ in the human body is attacked by so many hostile environmental factors. Skin is exposed to chemical, physical and biological agents, from UV radiation to bacterial and fungal invaders. Fortunately the unique structure of the skin is capable of defending the body against all these different agents, but every system has its limitations.

In daily life, numerous factors are hostile to our skin. Skin diseases constitute more than 47% of all occupational diseases and up to 25% of all lost workdays. Euroderm Research recently completed a client study looking at the effects of occupational dermatoses in workers at a company in India. The study involved the assessment of 250 local Indian workers on a tea plantation. Experienced clinical assessors from the UK led by an experienced dermatologist made the evaluations over three months.

Physical factors examined included kinetic energy, high and low temperature and radiation. Apart from other major injuries to the skin, kinetic energy may cause micro traumas, often not noticed by individuals themselves. These are normally provoked by poor working conditions or by not wearing the effective protective clothing and may accumulate over time and contribute to the development of skin disease. Some skin injuries were caused by the heat. Prolonged exposure to atmospheric changes during working hours was inducing irreversible changes in the skin. The UV radiation was also a physical factor and was seen to be accelerating degeneration of the workers’ skin (ie photoageing). This condition was so prevalent among the workers that it is referred to as field-hand skin in the area and is looked down upon by other more professional workers.

Biological factors may be roughly divided into infectious and non-infectious agents. The elements - soil, water and air - to which the workers are continuously exposed, contain considerable amounts of infectious agents. Fungal infections are extremely high among the workers; some 78% of the workers wear rubber boots that provide an ideal microclimate for the development of fungal infections. Of the 100 workers whose feet were examined, 87 had fungal infections.

In some cases, the tea plants were hostile to the workers’ skin. On contact with the plant the skin of some workers was becoming inflamed (ie Dermatitis venenata). The dust on the plants that was disturbed when the leaves were picked was also provoking allergic and immunotoxic reactions and in some cases regular exposure to pesticides and fertilisers was causing irritant contact dermatitis; for example, pronounced allergizing properties are characteristic of the insecticide chlorfenvinphos and the herbicide dichlorophrnoxyacetic acid. Unlike the physical and biological factors that affect the skin, and that the skin has become more accustomed to, chemicals are relatively new in the evolution of mankind and at this stage the skin appears less prepared for protecting the body against them.

Health check

All workers were offered a full medical examination. Of the 600 employees, 397 accepted, some never having seen a doctor or other health care professional in their lives. Initial examinations showed other areas of concern, including Actinic keratosis, carcinoma (basal cell, squamous cell), melanoma, sunburn, photoallergic dermatitis, melanosis, discoid and systemic lupus erythematosus, Granuloma annulare, porphyria and rosacea.

Reducing exposure to some of these factors could be achieved by various means. A decrease in the daily hours worked would be the best way, but with already very low wages (the equivalent of just £20 a month) workers could not afford to do this. Avoidance of sun exposure would also help, but 90% of the field workers work in direct sunlight at the hottest times of day. There was no UV protection from direct sunlight; no sun cream and not even blocking shields in tractor and harvester cabins. In fact, when asked about sun cream, 67% of workers had never used it or in some cases had no idea what it was.

Study protocol

The variability of workers’ skin relativity was evaluated by performing the skin prick test, a widely used tool in the diagnosis of Gell and Cooms type 1 allergy. The classic interpretation of test results is based on comparison of the skin’s response to substances tested to the standard histamine wheal/erythemal response. It is based on the assumption that the skin forms some kind of physiological and pharmacological continuum.

For each subject four skin prick tests were performed on the volar forearm in one sitting. Theoretically, the inter-individual reaction to histamine should show a minor variability compared to reactions to allergens because some sources of variability, like a different grade of sensitisation to given allergen, were excluded. To avoid circadian variability, workers were tested during the early part of the evening after finishing their shifts for the day and the same grader was always used.

Intra-individual variations bet-ween the workers’ results were more than slight. Workers that had been employed by the company for many years showed higher results to the histamine than newer workers. Years of burning sun had made their skin much more sensitive to the test. Results varied from erythema and oedema with vesicles scattered within the inflamed skin. In some cases where workes had been exposed to many years of the sun and pesticides etc, they were also found to be suffering some kind of skin changes in the periorbital area.

Vitamin value

Of the workers examined, 150 were invited to take part in further testing to evaluate the possibility of skin improvement with the aid of simple vitamin supplements.

Two-punch biopsies were taken from the volar forearms of participants to provide a point of reference. Participants were then split into three groups of 50. Two of the groups (A + B) were given a two week supply of well known, currently marketed multivitamins and the remaining group was given a two week supply of a placebo, sugar-base tablet. After two weeks, compliance checks were carried out and urine samples taken and participants were issued with a further two weeks of their test product. The same process was repeated two weeks later. On a final visit to the test centre, compliance checks were carried out, urine samples were taken and two-punch biopsies were taken. Results of urine analysis was normal at each stage.

While the human body is able to store vitamins, fat soluble vitamins A, D, E and K can be locked away in the liver and body fat and stored for several weeks and this can cause overdose. The water soluble vitamins, including B complex and vitamin C, are stored for a shorter period of time.

During the course of the study, the study team found over 30 instances of adverse events, including nausea, abdominal cramps, headaches, fatigue and diarrhoea. Most reports came in after the second week of the study and only from participants that were taking the actual vitamins, not the placebo. A sudden influx of multivitamins to a population that was not getting many of the added vitamins from their regular food source was having an adverse effect on some study participants.

Even though the vitamins in supplements are synthesised to the exact chemical composition of naturally occurring vitamins, they also had inherent problems. Research has shown that a food component that has a particular effect on the body when present in food may not have the same effect when it is isolated and taken as a supplement. This could be because the vitamins and minerals in foods are also influenced by other components of the food, not just the active ingredient.

The biopsy samples were evaluated and the results returned to the UK for data manipulation; these will be discussed in a future paper with the client of that project.

Participants receiving a placebo reported no change in their daily routine or lives over the six week study period. Of the participants receiving multivitamin supplements, reports of chronic nausea, abdominal cramps, headaches, fatigue and diarrhoea were taken from 36 participants from week two through to week six, although the incidence of infection-related issues was higher in the placebo group than in the treatment group. Among the participants receiving the treatment products, 85% reported a decrease in fungal infections and other skin problems that had been noted on enrolment to the study.

A multivitamin supplement reduced the incidence of participant reported skin infections. It also highlighted two significant points: firstly the high prevalence of subclinical micronutrient deficiency, and secondly the effects of the quick fix of taking multi-supplements regularly for a six week period. A larger clinical trial is needed to determine whether these findings can be replicated not only in this group but also in any population with a high rate of sub-optimal nutrition or potential underlying disease impairment.

Source / Bylines

Barrie Drewitt-Barlow - Anglia Ruskin University; Mandie Mayes, Robert Blake (project manager), Imtiaaz Sali (project manager) - Euroderm Research Ltd, 10 Village Square, Chwlmwe Village, Chelmsford, Essex