Skin Lesions in Carpet Hand-weavers

Abstract

Carpet hand-weaving is an important industry in Iran. The repetitive trauma to hands in this occupation produces typical nodules andplaques. The skin lesions from 150 carpet weavers are reported. Thecharacteristic carpet nodule is clinically and histologically described

Introduction

Carpet hand-weaving is a common practice in countries suchas Iran, China, Turkey, India, and Pakistan. In Iran, hand woven carpets are produced in home-based workshops categorized as informal small-scale industry. The work is oftenorganized around families and done in homes [1].

Hand-woven carpets are the most important Iranian non-oilexport and this industry has an outstanding place in the country's economy witha share of 1 percent in the GNP [2]. In Iran nearly 2.2 million fulltime and part time weavers are working [3] and about 8.5 million peopledirectly or indirectly live on the hand-woven carpet industry [4].

Carpet weaving is one of the most tedious professions, requiring long hours of static work (Fig. 1). It can be a high-risk occupation fordeveloping musculoskeletal and nerve injury, such as carpel tunnel syndrome [5]. Radjabi reported that the repeatedtying of knots with non-ergonomic hand tools can result in swollen fingerjoints, arthritis, and neuralgia, causing permanent deformity of the fingers [6]. Injuries of the soft tissue, wrists,and median nerve are common [7, 8, 9].

Material and methods

In this study one hundred and fifty weavers from twenty activeweaving workshops in several rural and urban districts of Yazd province in the central area of Iran were surveyed and examined by a dermatologist. Aquestionnaire was developed to collect required data from each weaver. Thequestionnaire consisted of personal information, workshop conditions, and pastmedical history.

Results

Table 1 shows the personal characteristics of carpetweavers. The majority of weavers were female (92%) and nearly half of them weregirls under sixteen years old, working more than eight hours daily.

Table 1: Some personal detail ofcarper weavers

Table 2 shows the frequency of skin lesions in carpetweavers. The majority of skin lesions were on the hands. The most common lesionon weavers' hands was "carpet nodule," observed in nearly two-thirdsof weavers.

Table 2: Frequency of skin lesionsin carpet weavers

Clinically the lesion consists of a broad, hyperkeratotic nodule or plaque over the fingers, especially on the dorsum of the third finger of the right hand. Mild scaling and occasionally fissuring may be seen. The lesions usually are 1-5 cm in length and 2-4 cm in width. They are asymptomatic except for mild pruritus and mild to moderate disfigurement (Figs. 2 & 3).

On X-ray examination, increased thickness of soft tissue was noted, but no abnormality of bone and joint was seen (Fig. 4).

Histological study of lesions showed severe hyperkeratosis, slight focal parakeratosis, slight hypergranulosis, and regular acanthosis (Fig. 5 & 6).

No spongiosis, basal layer damage, inflammation, vasculitis, edema, neoplasia or other pathologic processes were present. In the thickened dermis, thickened collagen fibers in the reticular dermis and increased vascular lumens were noted. Epidermal appendages were normal; eccrine glands were abundant.

Other skin lesions seen in weavers are shown in Table 2. A lesion clinically similar to knuckle pads (Fig. 7), consisting of hyperkeratotic plaques over the dorsum of fingers (particularly over interphalangeal joints) was seen in 21 percent of weavers. Other skin lesions were scanty except for non-specific callosities, seen in 38 percent of weavers. Acne vulgaris, contact dermatitis, melasma and pityriasis versicolor were also common.

Discussion

This study shows that skin problems were common among carpet hand-weavers. The most common skin lesions were hyperkeratotic nodules and plaques on the hands and fingers; we suggest the name, "carpet nodule." The lesion clinically resembles a callosity but is much larger and thicker and has little to moderate lichenification. Histological study does not show spongiosis, inter- or intra-cellular edema, or inflammatory cells, ruling out dermatitis.

Continuous trauma plays a major role in the formation of lesions. A similar entity, known as surfer's nodules have been reported on the anterior tibial prominence [10], dorsa of the feet, or knuckles of athletes [11]. Sports-related connective tissue nevi of the collagen type (collagenomas) have also been referred to as athlete's nodules. Surfers, boxers, marble-players, and football players are some of the athletes in whom these lesions have been observed. The nodules can be found on the dorsal aspect of the feet, knees, or knuckles and can be differentiated from other conditions by clinical history or microscopic features. Recurrent trauma and friction are the likely causative factors. Enhanced synthesis or accumulation of collagen may have a contributory role. These asymptomatic nodules show dermal fibrosis as well as epidermal hyperplasia, similar to our findings.

Nakamura A et al. reported ovoid, largely dermal nodules occurring in the sacrococcygeal area of four Japanese students and attributed these to continuous pressure from the bicycle saddle on an abnormally posteriorly projecting sacrum [12]. Kawaura K et al. also reported a similar lesion on the sacrococcygeal area in an additional bicycle rider [13].

The repetitive movement of wrist and fingers required for carpet weaving and the use of non-ergonomic tools (knife, combs, scissors and others) can lead to injury. Certainly continuous trauma to hands and fingers during carpet-making have a major role in producing the papules and nodules we would like to call, "carpet nodules."

References

1. Choobineh AR, Lahmi MA, Shahnavaz H, Khani jazni R, Hosseini M. Musculoskeletal symptoms as related to ergonomic factors in Iranian hand woven carpet industry and general guidelines for workstation design. International journal of occupational safety and ergonomics 2004;10(2):157-68 PubMed

2. Mahdavi H, What should be done for Iranian carpet export? Keyhan newspaper(a Persian newspaper), 2000, no, 16940:5

3. Sobh k, a research in international market of Iranian carpet and its export development. Iran hand woven carpet Mag. 1997;10:31-46 (in Persian)

4. Jso, Carpet weavers' Health, Solaleh pub. co. Zanjan /Iran 1998 (in Persian)

5. Kutluhan S, Akhan G, Demici S, Duru HR, Koyuncuoglu HR, Ozturk M, Cirak B. Carpal tunnel syndrome in carpet workers, international archive of occupational health 2001;74:454-57 PubMed

6. Radjabi A, Carpets, hand-woven, in: Encyclopedia of occupational health and safety, Third ed,vol,1, ILO, Geneva:416-18

7. Senveli,ME, Turker A, Arda,MN, Altinors MN, Bilateral carpal tunnel syndrome in a young carpet weaver. Clinical Neurology and Neurosurgery 1987;89(4):281-82 PubMed

8. Tan M, Tan U, Correlation of carpel tunnel size and conduction velocity of the sensory median and ulnar nerves of male and female controls and carpet weavers, Perceptual and Motor Skills. 1998;87:1195-1201 PubMed

9. Budac F,Yenigun F, Ozbek A, Orhan S, Komsuglu S, Carpal tunnel syndrome in carpet weavers. Electromyography and Clinical Neurophysiology 2001;41:29-32 PubMed

10. Erickson JG, von Gemmingen GR. Surfer's nodules and other complications of surfboarding. JAMA. 1967 Jul 10; 201(2):134-6. PubMed

11. Cohen PR, Eliezri YD, Silvers DN. Athlete's nodules: sports-related connective tissue nevi of the collagen type (collagenomas).Cutis. 1992 Aug; 50(2):131-5. PubMed

12. Nakamura A, Inoue Y, Ishihara T, Matsunaga W, Ono T. Acquired coccygeal nodule due to repeated stimulation by a bicycle saddle.J Dermatol. 1995 May; 22(5):365-9. PubMed
    
    
13. Kawaura K, Yano K, Takama H, Matsumoto Y, Ida K. Nodular lesion on the sacrococcygeal area in a bicycle rider. Br J Dermatol. 2000 Nov; 143(5):1124-6. PubMed