|Year : 2018 | Volume
| Issue : 2 | Page : 111-115
Frequency and associated factors of instrument-specific dermatoses among musicians in a military band: A cross-sectional study
Jandhyala Sridhar, Rahul Ray
Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
|Date of Submission||02-Jul-2018|
|Date of Acceptance||01-Nov-2018|
|Date of Web Publication||10-Jan-2019|
Surg Cmde, VSM Rahul Ray
Department of Dermatology, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Background and Aim: Continual contact with musical instruments may cause distinctive skin conditions among musicians. The site and degree of contact with the instrument may determine the type of presentation, further influenced by the amount of time spent in training. These conditions may be severe enough to even compromise musicians' careers. Since data on the subject are lacking in India, a study was conducted to assess the frequency and factors associated with the occurrence of instrument-related skin disorders among musicians in a military band. Materials and Methods: This was a cross-sectional study. A universal sample comprising all the members of a military band was included. A total of 162 musicians were evaluated using a questionnaire that included questions related to age, instrument played, current skin disorders, and the impact of skin symptoms on music making. Dermatological examination was done for all the participants. Statistical Analysis Used: Mean, median, and frequencies; Pearson's Chi-square test. Results: Of 162 musicians, 49 (30.2%) had at least one skin disease not correlated with instrument playing. Instrument-specific dermatoses were found in 55 (34%) of the 162 musicians and correlated with years of experience and the time spent in musical activity. Conclusions: Wind instrumentalists had the highest risk of developing skin problems. The occurrence of the tear trough deformity and lip dyschromia correlated significantly with the playing of a wind instrument. The impact of vibratory stress of wind instruments on the facial tissues needs further inquiry. Although not life-threatening, instrument-specific dermatoses may lead to impaired performance, occupational risk, and cosmetic disfigurement.
Keywords: Musical instrument, musicians, specific dermatoses
|How to cite this article:|
Sridhar J, Ray R. Frequency and associated factors of instrument-specific dermatoses among musicians in a military band: A cross-sectional study. J Mar Med Soc 2018;20:111-5
| Introduction|| |
Musicians may suffer not only from common skin diseases of the population at large but also from conditions that are a direct result of their work. During music making, there is usually an intense and repetitive contact between the instrument and the skin that predisposes musicians to a variety of dermatoses., Furthermore, differences in presentation depend on the instrument and the body site involved. The duration that musicians spend to advance their skill may also impact the severity of these dermatoses.
Some of these conditions may be of a nature severe enough to cause functional distress and may constrain the musician to give up the instrument, compromising his/her professional career. Despite the importance of this problem, there is a lack of information about the frequency or the factors that lead to their development in the Indian setting. This study aimed to assess the frequency and associated factors of instrument-related dermatoses among the members of a military band.
| Materials and Methods|| |
This was a cross-sectional study. A universal sample comprising all the members of a military band posted at Mumbai, India, during the 2-year period from March 2016 to March 2018, was included. A total of 162 musicians were subjected to an 8-item questionnaire after obtaining consent for the processing of personal data. The questionnaire was drawn from another study, customized, pilot tested, and validated. It featured questions related to age, instruments, experience and duration of musical activity, previous or current skin disorders, and the impact of skin symptoms on music making. Musical instruments were categorized into four groups: brass (cornet, euphonium, French horn, trombone, trumpet, and tuba), string (cello, guitar, sitar, viola, and violin), woodwind (bassoon, clarinet, flute, oboe, piccolo, and saxophone), and percussion (drums, mridangam, and tabla). The dermatological examination was done for all the study participants. Musicians with suspected contact dermatitis were subjected to epicutaneous patch testing, with the Indian standard series of allergens of the Contact and Occupational Dermatitis Forum of India. Descriptive statistics were generated and included the mean, median, and frequencies. The contingency data were analyzed using the Pearson's Chi-square test. P < 0.05 was considered statistically significant.
| Results|| |
All the members were male. The mean and median age of the participants was 26.9 and 25 years, respectively, with age ranging from 18 to 45 years. Among the group of instruments, brass instruments were the most frequently played (49.4%), followed by woodwind (27.1%), percussion (14.2%), and string instruments (9.3%). Musicians had an average experience of 9 years and spent a mean duration of 21 h a week playing the instrument.
Of the 162 musicians, 49 (30.2%) reported that they suffered from at least one skin disease that was causally not related to playing the instrument. On examination, acne was diagnosed in 10 (6.2%), dermatophyte infections in 8 (4.9%), warts in 7 (4.3%), and hyperhidrosis in 5 (3.1%) musicians.
Of the 162 musicians, 55 (34%) had at least one specific dermatosis that was causally related to playing the instrument [Table 1]. Thirteen musicians had ≥1 specific dermatosis. Among these 55 musicians, instrument-specific dermatoses strongly affected the music making in 2 (3.6%), slightly affected the music making in 10 (18.2%), and did not affect the music making in 43 (78.1%) musicians. One brass instrumentalist with chronic cheilitis with lip dyschromia tested positive to both nickel sulfate 5% and p-phenylenediamine (PPD) 1% and was diagnosed as pigmented contact dermatitis. Musicians having specific dermatoses played the instrument for a mean of 13 years and 28 h a week. The occurrence of specific dermatoses significantly correlated with the years of experience (P < 0.05), hours of play/week (P < 0.0001) [Table 2], and the playing of a wind instrument (P < 0.05) [Table 3].
|Table 2: Experience, practice duration, and occurrence of instrument-specific dermatoses|
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|Table 3: Wind instrument playing and occurrence of (a) instrument-specific dermatoses and (b) the tear trough deformity|
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| Discussion|| |
Instrument-specific dermatoses in musicians may be influenced by several adverse factors, including mechanical (friction, pressure, shearing, and stretching), physicochemical (skin temperature, humidity, and pH), toxic (irritant and phototoxic), and allergic factors. Further, each instrument category exposes the player to peculiar dermatoses whose nature depends on the points of contact of the instrument with the skin, as well as the playing technique. Other factors such as the coexistence of atopy, hyperhidrosis, and psychoemotional factors may modify these dermatoses. They may impact the musician's ability to play, leading to occupational hazards.
In this study, the occurrence of instrument-specific dermatoses significantly correlated with the years of experience, hours of play/week, and the playing of a wind instrument [Table 3]. In one large study of music students in Tunisia, the prevalence of instrument-specific dermatoses was linked to musical experience >5 years and weekly duration of practice >10 h. Specific skin conditions that correlated with the use of a musical instrument were found in 34% of musicians in this study, as against 49.7% in the Tunisian study, 21.6% in a self-reported questionnaire study of German university-level music students, and 20.5% in another self-reported questionnaire study of Italian music teachers and students. In this study, each participant underwent a directed dermatological examination relevant to the instrument played, facilitating the improved detection of instrument-specific skin conditions.
A common skin condition experienced by instrumental musicians is the development of callosities on sites where the skin is repetitively irritated because of intense contact with certain parts of the instrument.,, Of 162 musicians in this study, 21 (13%) suffered from instrument-related callosities, which was the most common specific dermatosis. Of these, 14 (66.7%) had experienced preceding friction blisters or erosions at their callosity sites. One large study found callosities in 249/594 (41.9%) music students. Another large survey reported callosities in 106/628 (16.9%) musicians. The localization of callosities is specific – in violinists, they are seen as “Garrod's pads” on the left second and third fingers over the proximal interphalangeal joints, while in drummers, they are seen on the lateral phalanx of the left ring finger. Wind instrumentalists may develop callosities of the mid portions of their lips. In this study, out of 21 musicians who had callosities, 19 had finger callosities (drummer's digit – 9, Garrod's pads – 5, and others – 5), and two had callosity of the upper lip (one clarinettist and horn player each) [Figure 1].
A notable finding in this study, not reported elsewhere in the literature, was the presence of a tear trough deformity observed in 20 (12.3%) musicians [Figure 2], all of them playing wind instruments (P < 0.05) [Table 3]. The tear trough refers to the medial periorbital hollow extending obliquely from the medial canthus to the mid-pupillary line. There is a loss of fat tissue along with laxity of the orbicularis retaining ligament, and loss of elasticity and thickness of the overlying skin. While the tear trough deformity is mainly a feature of aging, the mean and median age of the participants with tear trough deformity was only 27 and 26.2 years, respectively. In 2010, Hirmand proposed a classification system of the tear trough deformity based on the clinical evaluation [Figure 3]. Of the 20 musicians, 11 (55%) had Class I, 7 (35%) had Class II, and 2 (10%) had Class III tear trough deformity in this study. Wind instrumentalists produce sound by creating an “embouchure,” the purposeful contraction of the facial muscles in order to blow an intense, focused column of air into the instrument (causing vibration) and manipulate it by articulating the lips, cheeks, and tongue In the process, facial anatomical components also vibrate, particularly the tear troughs that have thin tissue coverage. The consequences of vibrational injury to the skin have been studied extensively in the hand-arm vibration syndrome due to mechanized hand tools; vibrational injury to the vascular endothelium, muscle, and nerve fibers has been correlated with impaired vascular circulation, loss of muscle volume, and fat atrophy. Although the frequencies of wind instruments belong to a comparatively lower range of 30–2000 Hz as compared to mechanized hand tools, it has been established that frequencies as low as 125 Hz can induce changes in the blood circulation. It is conjectured that the observation of the tear trough deformity in this study may be a consequence of vibration-induced tissue injury.
Cheilitis was found in 15 (9.3%) of the 162 musicians in this study, all of whom were wind instrumentalists. Cheilitis was reported in 3/117 (2.6%) musicians in one study, and 5/628 (0.8%) of musicians in another survey, among wind instrumentalists in both instances. Vibration of the lips inside a cup-shaped mouthpiece produces the sound in brass instruments, while in the case of woodwind instruments, it is produced by splitting an air stream blown on a reed (a thin strip of material that vibrates to produce a sound) or a fipple (the constricted mouthpiece of end-blown flutes). A combination of friction, local pressure, shearing forces, and occlusion between the lips and mouthpiece, reed, or fipple may cause cheilitis. An irritant dermatitis called “clarinettist's cheilitis” can occur in the area where the wooden reed comes in contact with the skin [Figure 4]. It occurs on the median portion of the vermilion border of the lower lip and often extends onto the chin. Woodwind and brass players may also experience soft-tissue trauma to the lip mucosa due to pressure from their instrument pushing the lips against sharp edges of the incisor teeth. Horn players may develop fissuring, atrophy, and depigmentation of the median part of both lips due to the pressure of the mouthpiece against the lip blocking the blood supply.
|Figure 4: Cheilitis featuring fissuring, atrophy, and depigmentation in a clarinettist, and (unrelated) Fordyce's spots over the upper lip|
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Of the 15 musicians with cheilitis, 14 tested negative with epicutaneous patch testing. One brass tuba player who had chronic cheilitis with lip dyschromia tested positive to nickel sulfate 5% and PPD 1% [Figure 5]. In military as well as other performing bands, brass instruments including the mouthpieces are coated with nickel to ensure a lustre finish and for corrosion protection. The tuba player was an atopic individual, who was also dyeing his mustache hair for 5 years. He was diagnosed with pigmented contact cheilitis due to nickel and PPD. He was advised a switch to a woodwind instrument and the use of a PPD-free hair dye. Nickel is the most frequent contact sensitizer in the population at large. Nickel contact dermatitis has been reported in string players (e.g., violinists, cellists, and guitarists) and wind instrumentalists such as flautists and trumpet players. The release of nickel from metal devices is favored by friction, heat, and organic factors. The consequent chronic mechanical irritation and maceration may not only induce irritant dermatitis but also promote allergic contact dermatitis.
|Figure 5: Pigmented contact dermatitis due to nickel and p-phenylenediamine in a brass instrumentalist|
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Another finding of this study that has been sparsely reported is that of lip dyschromia in 10 (6.2%) musicians, all wind instrumentalists. All the ten musicians tested negative with epicutaneous patch testing. Of these, three musicians additionally had depigmented, atrophic lesions over the median portion of the lip, conforming to the contact surface of the wind instrument. Baccouche et al. in their study of 594 students noted hypopigmented and depigmented lesions of the lip in clarinet, saxophone, and trumpet players. Dermoscopy of the pigmented lip lesions in this study revealed superficial reticular and pinpoint whitish structures and deeper dotted, fine or coarse gray–blue to brown dots, and globules related to the dermal melanophages, suggesting a lichenoid pattern of inflammation. Lip biopsy could not be performed due to employability concerns of the affected musicians. They were prescribed a topical calcineurin inhibitor ointment and counseled about the likely worsening influence of wind instruments on their lip condition. Lip vitiligo was noted in four musicians [Figure 6] as macular, depigmented lesions (in contrast to the atrophic, depigmented lesions in the three musicians reported above). Freeman in 1943 reported vitiligo of upper lip in six players of wind instruments. There have been no subsequent reports in the published literature of lip vitiligo in musicians.
A limitation of this study is the fact that the frequency data are not representative of musicians in general as the sample comprised members of a military band. Although the musical instruments are similar to those used in other bands, the proportion of brass and woodwind instrumentalists in military bands is always higher. This has likely accounted for a higher prevalence of cheilitis in this study. Conversely, this fact enabled the identification of lip dyschromia and the tear trough deformity among musicians that have been reported sparsely or not been reported in other studies.,,,,
| Conclusions|| |
This lone study of dermatoses in musicians from India adds to the sparse data recorded on the subject from other countries. While preexisting dermatoses among the musicians did not appear to worsen with or influence musical activity, specific dermatoses correlated with the number of years and hours that musicians spent in playing the musical instrument. The occurrence of the tear trough deformity that was observed among wind instrumentalists has not been described earlier. The impact of vibratory stress of wind instruments on the tear trough merits further inquiry in larger and more diverse performance settings. Although not life-threatening, musical instrument-specific dermatoses lead to impaired performance, occupational risk, and cosmetic disfigurement. Their early recognition would thus further the healthy careers of musicians.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The study was supported by Cdr VC D'Cruz, Director of Music, Indian Navy. Dr. SL Chahar and Maj D Sapra helped with the acquisition of data, photography and artwork for the figures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]