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Chloracne is an
acne Acne, also known as ''acne vulgaris'', is a long-term skin condition that occurs when dead skin cells and oil from the skin clog hair follicles. Typical features of the condition include blackheads or whiteheads, pimples, oily skin, and ...
-like eruption of
blackhead A comedo is a clogged hair follicle (pore) in the skin. Keratin (skin debris) combines with oil to block the follicle. A comedo can be open (blackhead) or closed by skin (whitehead) and occur with or without acne. The word "comedo" comes from the ...
s,
cyst A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac (like the manner in which water molecules group together to form a bubble) ...
s, and
pustule A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. The major function of this s ...
s associated with exposure to certain
halogen The halogens () are a group in the periodic table consisting of five or six chemically related elements: fluorine (F), chlorine (Cl), bromine (Br), iodine (I), astatine (At), and tennessine (Ts). In the modern IUPAC nomenclature, this grou ...
ated
aromatic compound Aromatic compounds, also known as "mono- and polycyclic aromatic hydrocarbons", are organic compounds containing one or more aromatic rings. The parent member of aromatic compounds is benzene. The word "aromatic" originates from the past groupin ...
s, such as chlorinated dioxins and
dibenzofurans Dibenzofuran is a heterocyclic organic compound with the chemical structure shown at right. It is an aromatic compound that has two benzene rings fused to a central furan ring. All the numbered carbon atoms have a hydrogen atom bonded to each of th ...
. The
lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classif ...
s are most frequently found on the cheeks, behind the ears, in the armpits and groin region. The condition was first described in German industrial workers in 1897 by Siegfried Bettmann, and was initially believed to be caused by exposure to
chlorine Chlorine is a chemical element with the symbol Cl and atomic number 17. The second-lightest of the halogens, it appears between fluorine and bromine in the periodic table and its properties are mostly intermediate between them. Chlorine i ...
(hence the name "chloracne"). It was only in the mid-1950s that chloracne was associated with aromatic hydrocarbons. The substances that may cause chloracne are now collectively known as chloracnegens. Chloracne is particularly linked to toxic exposure to
dioxin Dioxin may refer to: * 1,2-Dioxin or 1,4-Dioxin, two unsaturated heterocyclic 6-membered rings where two carbon atoms have been replaced by oxygen atoms, giving the molecular formula C4H4O2 * Dibenzo-1,4-dioxin, the parent compound also known ...
s (
byproduct A by-product or byproduct is a secondary product derived from a production process, manufacturing process or chemical reaction; it is not the primary product or service being produced. A by-product can be useful and marketable or it can be consid ...
s of many
chemical process In a scientific sense, a chemical process is a method or means of somehow changing one or more chemicals or chemical compounds. Such a chemical process can occur by itself or be caused by an outside force, and involves a chemical reaction of some ...
es, including the manufacture of
herbicides Herbicides (, ), also commonly known as weedkillers, are substances used to control undesired plants, also known as weeds.EPA. February 201Pesticides Industry. Sales and Usage 2006 and 2007: Market Estimates. Summary in press releasMain page fo ...
such as
Agent Orange Agent Orange is a chemical herbicide and defoliant, one of the "tactical use" Rainbow Herbicides. It was used by the U.S. military as part of its herbicidal warfare program, Operation Ranch Hand, during the Vietnam War from 1961 to 1971. It ...
)—so much so that it is considered a clinical sign of dioxin exposure. The severity and onset of chloracne may follow a typical
asymptotic In analytic geometry, an asymptote () of a curve is a line such that the distance between the curve and the line approaches zero as one or both of the ''x'' or ''y'' coordinates tends to infinity. In projective geometry and related context ...
dose-response relationship
curve In mathematics, a curve (also called a curved line in older texts) is an object similar to a line, but that does not have to be straight. Intuitively, a curve may be thought of as the trace left by a moving point. This is the definition that ...
.


Cause

Chloracne normally results from direct skin contact with chloracnegens, although ingestion and
inhalation Inhalation (or Inspiration) happens when air or other gases enter the lungs. Inhalation of air Inhalation of air, as part of the cycle of breathing, is a vital process for all human life. The process is autonomic (though there are exceptions ...
are also possible causative routes. Chloracnegens are
fat-soluble Lipophilicity (from Greek λίπος "fat" and φίλος "friendly"), refers to the ability of a chemical compound to dissolve in fats, oils, lipids, and non-polar solvents such as hexane or toluene. Such non-polar solvents are themselves li ...
, meaning they persist in the body fat for a very long period following exposure. Chloracne is a chronic inflammatory condition that results from this persistence, in combination with the toxin's chemical properties. It is believed, at least from
rodent Rodents (from Latin , 'to gnaw') are mammals of the order Rodentia (), which are characterized by a single pair of continuously growing incisors in each of the upper and lower jaws. About 40% of all mammal species are rodents. They are n ...
models, that the
toxin A toxin is a naturally occurring organic poison produced by metabolic activities of living cells or organisms. Toxins occur especially as a protein or conjugated protein. The term toxin was first used by organic chemist Ludwig Brieger (1849 ...
activates a series of
receptors Receptor may refer to: *Sensory receptor, in physiology, any structure which, on receiving environmental stimuli, produces an informative nerve impulse *Receptor (biochemistry), in biochemistry, a protein molecule that receives and responds to a n ...
promoting
macrophage Macrophages (abbreviated as M φ, MΦ or MP) ( el, large eaters, from Greek ''μακρός'' (') = large, ''φαγεῖν'' (') = to eat) are a type of white blood cell of the immune system that engulfs and digests pathogens, such as cancer ce ...
proliferation, inducing
neutrophilia Neutrophilia (also called neutrophil leukocytosis or occasionally neutrocytosis) is leukocytosis of neutrophils, that is, a high number of neutrophils in the blood. Because neutrophils are the main type of granulocytes, mentions of granulocytos ...
and leading to a generalised inflammatory response in the skin. This process may also be augmented by induction of excess
tumor necrosis factor Tumor necrosis factor (TNF, cachexin, or cachectin; formerly known as tumor necrosis factor alpha or TNF-α) is an adipokine and a cytokine. TNF is a member of the TNF superfamily, which consists of various transmembrane proteins with a homolog ...
in the
blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the cir ...
serum Serum may refer to: * Serum (blood), plasma from which the clotting proteins have been removed **Antiserum, blood serum with specific antibodies for passive immunity * Serous fluid, any clear bodily fluid *Truth serum, a drug that is likely to mak ...
. The inflammatory processes lead to the formation of
keratin Keratin () is one of a family of structural fibrous proteins also known as ''scleroproteins''. Alpha-keratin (α-keratin) is a type of keratin found in vertebrates. It is the key structural material making up Scale (anatomy), scales, hair, Nail ...
ous plugs in skin pores, forming yellowish
cyst A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac (like the manner in which water molecules group together to form a bubble) ...
s and dark
pustule A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. The major function of this s ...
s. The associated pus is usually a color of green approximating that of a tennis ball. The skin lesions occur mainly in the face, but in more severe cases they involve the shoulders and chest, the back, and the abdomen. In advanced cases, the lesions appear also on the arms, neck, thighs, legs, hands and feet. In some instances, chloracne may not appear for three to four weeks after toxic exposure; however, in other cases—particularly in events of massive exposure—the symptoms may appear within days.


Treatment

Once chloracne has been identified, the primary action is to remove the patient and all other individuals from the source of contamination. Further treatment is symptomatic. Secondary infections on severe or persistent lesions may need to be treated with oral
antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and preventio ...
or
isotretinoin Isotretinoin, also known as 13-''cis''-retinoic acid and sold under the brand name Accutane among others, is a medication primarily used to treat severe acne. It is also used to prevent certain skin cancers (squamous-cell carcinoma), and in th ...
. However, chloracne itself can be highly resistant to any treatment. The course of the disease is highly variable. In some cases the lesions may disappear within two years or so; however, in other cases the lesions may be effectively permanent (mean duration of lesions in one 1984 study was 26 years, with some workers remaining disfigured over three decades after exposure).


Related conditions

Chloracne is very often seen in combination with
hyperhidrosis Hyperhidrosis is a condition characterized by abnormally increased sweating, in excess of that required for regulation of body temperature. Although primarily a benign physical burden, hyperhidrosis can deteriorate quality of life from a psychologi ...
(clammy, sweaty skin) and
porphyria cutanea tarda Porphyria cutanea tarda is the most common subtype of porphyria. The disease is named because it is a porphyria that often presents with skin manifestations later in life. The disorder results from low levels of the enzyme responsible for the fift ...
(a skin condition of increased pigmentation, hair coarsening and blistering).


Notable cases

* In 1949, 226 workers became ill after a container of
herbicide Herbicides (, ), also commonly known as weedkillers, are substances used to control undesired plants, also known as weeds.EPA. February 201Pesticides Industry. Sales and Usage 2006 and 2007: Market Estimates. Summary in press releasMain page f ...
exploded at a
Monsanto Company The Monsanto Company () was an American agrochemical and agricultural biotechnology corporation founded in 1901 and headquartered in Creve Coeur, Missouri. Monsanto's best known product is Roundup, a glyphosate-based herbicide, developed i ...
plant in Nitro, West Virginia. Many were diagnosed with chloracne; a medical report at the time described "systemic intoxication in the workers involving most major organ systems." * 193 cases of chloracne occurred in
Seveso Seveso (; lmo, label= Lombard, Séves ) is a town and ''comune'' in the Province of Monza and Brianza, in the Region of Lombardy. The economy of the town has traditionally been based on the furniture industry. Its name comes from the river of ...
,
Italy Italy ( it, Italia ), officially the Italian Republic, ) or the Republic of Italy, is a country in Southern Europe. It is located in the middle of the Mediterranean Sea, and its territory largely coincides with the homonymous geographical ...
, in 1976 following an industrial accident in which up to a few kilograms of TCDD were released into the atmosphere. * Thousands of individuals were exposed at
Fort McClellan Fort McClellan, originally Camp McClellan, is a decommissioned United States Army post located adjacent to the city of Anniston, Alabama. During World War II, it was one of the largest U.S. Army installations, training an estimated half-million tr ...
, Alabama, when a chemical weapons training center and a nearby
Monsanto The Monsanto Company () was an American agrochemical and agricultural biotechnology corporation founded in 1901 and headquartered in Creve Coeur, Missouri. Monsanto's best known product is Roundup, a glyphosate-based herbicide, developed in ...
factory disposed of chemicals into a creek over several decades. Many individuals settled out of court, but a class-action suit is still ongoing. Although the incineration of the chemical weapons at Fort McClellan ended in 2011, areas of the base remain closed or off-limits due to the residual contamination. * In 1968, almost 2,000 individuals in northern
Kyūshū is the third-largest island of Japan's five main islands and the most southerly of the four largest islands ( i.e. excluding Okinawa). In the past, it has been known as , and . The historical regional name referred to Kyushu and its surround ...
, Japan, suffered chloracne, among other symptoms, after chronic exposure to cooking oils contaminated with PCBs and PCDFs. The syndrome came to be called '' Yushō disease'' or "Rice Oil" disease. * In 1979, a similar case of mass contamination of cooking oil was reported in central
Taiwan Taiwan, officially the Republic of China (ROC), is a country in East Asia, at the junction of the East and South China Seas in the northwestern Pacific Ocean, with the People's Republic of China (PRC) to the northwest, Japan to the no ...
. Over 2,000 individuals were affected by what came to be called ''Yu-Cheng''. * Ukrainian President
Viktor Yushchenko Viktor Andriyovych Yushchenko ( uk, Віктор Андрійович Ющенко, ; born 23 February 1954) is a Ukrainian politician who was the third president of Ukraine from 23 January 2005 to 25 February 2010. As an informal leader of th ...
suffered from prominent facial chloracne and was diagnosed with dioxin poisoning in late 2004. *A Hong Kong journalist from the Stand News, Chan Yu-hong, declared in a Facebook post that he was diagnosed by a
traditional Chinese medicine Traditional Chinese medicine (TCM) is an alternative medical practice drawn from traditional medicine in China. It has been described as "fraught with pseudoscience", with the majority of its treatments having no logical mechanism of acti ...
practitioner with chloracne after exposure to
tear gas Tear gas, also known as a lachrymator agent or lachrymator (), sometimes colloquially known as "mace" after the early commercial aerosol, is a chemical weapon that stimulates the nerves of the lacrimal gland in the eye to produce tears. In ...
while covering the
2019 Hong Kong Protests Nineteen or 19 may refer to: * 19 (number), the natural number following 18 and preceding 20 * one of the years 19 BC, AD 19, 1919, 2019 Films * ''19'' (film), a 2001 Japanese film * ''Nineteen'' (film), a 1987 science fiction film Music ...
.


References


External links

{{Disorders of skin appendages Acneiform eruptions Toxicology Chlorine