A 17-year-old male came to clinic because of irritated feet. He had started a summer job at a car wash and was spending long days in a humid, wet environment. He initially had used the impermeable coat, pants and boots that his employer offered, but found the coat and pants were very uncomfortable as he felt they made him hotter and wetter. Therefore he wore cotton clothing. He also wore the boots but noted that water often seeped into the boots and noted “I just have wet feet all day.” He used cotton socks and would not change them during his work day. “My feet are just wet and when I get home they are always wrinkled and white like being in the bathtub too long. In the past week or so, my feet are sorer too and it seems like it is taking longer for the skin to be normal after I get home. There are some places that are cracking and peeling a bit and even when I put the athlete’s foot lotion on that I used before. It’s not helping,” described the teenager. He complained also that his hands were becoming more reddened.
The pertinent physical exam showed normal vital signs and growth. His feet were palish, with wrinkling especially around the nail beds, and edges of the heel and ball of foot with some small cracking in those areas. There was no specific scale or erythema or obvious trauma such as a blister. His feet felt somewhat cold but there was good capillary refill and pulses were intact. His hands also showed marked dryness and mild erythema overall. His legs and arms also showed some mild dryness but less severe than his hands and feet.
The diagnosis of immersion injury was made. The teen was instructed to use layered water-wicking socks with some cushion to protect his feet in the boots. These he should change whenever he has a break. The doctor also recommended that he use the impermeable pants and make sure they go over the boots to direct the water away from the boots and feet. “I’d recommend using gloves too to protect your hands,” noted the doctor. The teen protested that other workers didn’t do this and he didn’t have time during breaks, but the doctor said, “I know it can be a problem, but the water is worse for you. Besides fisherman and other people who work outside all the time seem to be able to do it. If you don’t take care of your feet it will get worse and you won’t be able to walk and work. That won’t be great will it?,” he stated. “It’s also loud at the car wash so you should wear your ear plugs too,” the doctor noted as he left the room.
All occupations have some type of potential health consequences. Some are obvious because of the environment such as kitchen workers, first responders, helicopter pilots, etc. Others are may be less obvious or not considered such as slip and falls, cleaning supply chemical exposure, animal bites for postal and utility workers, etc. Noise and lifting objects are often overlooked problems in some settings but obvious in others such as construction. Protective measures, especially appropriate education and training and protective clothing and safety gear are obviously important for performing the work as safely as possible. Most employers want to keep their employees safe and well. Teenagers especially often do not have the experience and may also not be aware of the potential health hazards at their workplace. Parents and teens should consider all the potential occupational risks when deciding to take a job. Teens and parents can look at the US Department of Labor’s website for more information about laws here and other government websites for safety tips at Youth.Gov and OSHA.
Water is necessary for life. It is needed for growing of organic materials and also one of the most ubiquitous and easiest solvents to use for hygiene and cleaning. Therefore water is important in almost any job including: farming, landscaping, industrial production and manufacturing, and recreational activities such as lifeguarding etc. Some jobs are obvious such as fishing, shipping, commercial diver, oil rig worker, sailor, river guide, etc. But others are less obvious such as working in a car wash. When considering occupational health, it is important to ask specifically about what the person does in the job. For example, a surveyor or archaeologist may work in very wet settings and are outside in all types of weather.
A car wash has many potential occupational hazards. There are moving vehicles and moving washing equipment which can cause mechanical and noise injuries. Additionally, there are chemicals being used as well as gas fumes which can cause lung, eye and dermatological problems. It is obviously a wet environment as well. The working surfaces are impermeable and hard which can cause orthopaedic problems too.
Exposure to wet or muddy conditions whether they are in warm or cold conditions can cause immersion skin problems. Prolonged contact with water increases irritation and dermatitis of the skin, increases the risk of mycosal and bacterial infections, and makes the skin more at risk for trauma effects such as thermal injury, pressure or chemicals. Over time changes can include hyperkeratosis, pain and parethesias, and even necrosis and gangrene.
“Warm-water-immersion foot [or tropical immersion foot] is a syndrome characterized by painful, white, wrinkled soles due to hyperhydration of the plantar straum corneum. This leads to maceration and chronic inflammation and vasculitis.” Because it is a warm environment, infections can be common.
Cold-water-immersion foot is better known as trench foot and has been well described in many literatures, especially the military. Similar problems to wet immersion occur. Additional injuries such as hypothermia and frostbite can occur.
The main treatment for immersion skin problems is prevention. Preventing skin from becoming wet in the first place by using protective clothing that is properly fitted (ill-fitting clothing cause localized trauma), changing into dry clothing regularly (e.g. clean, layered and loose to promote circulation), monitoring for trauma such as blisters and secondary infections such as tinea, allowing enough time between exposures for the skin to recover, and decreasing venous stasis by keeping legs elevated and gently rubbing mild lubricants to prevent drying and increase venous circulation. Keeping the body a normal temperature and preventing hypothermia is important. The skin is usually best warmed at room temperature as additional heating could potentially cause thermal injury.
Questions for Further Discussion
1. How is frostbite similar to trench foot? A review can be found here
2. How do you treat hyperthermia and hypothermia?
3. How do you treat a drowning victim?
4. What were some of your own jobs and the potential occupational health risks?
- Disease: Immersion Foot Injury | Foot Injuries and Disorders
- Symptom/Presentation: Rash
- Specialty: Dermatology | Preventive Medicine and Health Maintenance
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Foot Injuries and Disorders and Frostbite.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Zani MLC, Lazzarini R, Silva-Junior JS. Warm-water immersion foot among car wash workers. Rev Bras Med Trab. 2017;15(3):217-221. doi:10.5327/Z1679443520170021
Hall A, Sexton J, Lynch B, et al. Frostbite and Immersion Foot Care. Mil Med. 2018;183(suppl_2):168-171. doi:10.1093/milmed/usy085
Rathjen NA, Shahbodaghi SD, Brown JA. Hypothermia and Cold Weather Injuries. Am Fam Physician. 2019;100(11):680-686.
Mistry K, Ondhia C, Levell NJ. A review of trench foot: a disease of the past in the present. Clin Exp Dermatol. 2020;45(1):10-14. doi:10.1111/ced.14031
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa