The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that she was not entitled to benefits beyond May 17, 2020. A teleconference hearing was held on June 21, 2022 to consider the worker's appeal.

Issue

Whether or not the worker is entitled to benefits after May 17, 2020.

Decision

The worker is not entitled to benefits after May 17, 2020.

Background

On May 6, 2020, the employer provided an Employer's Accident Report to the WCB reporting an injury to the worker's face that occurred at work on May 4, 2020. The employer reported the worker "Had an allergic reaction to PPE (mask)."

On May 14, 2020, the WCB contacted the worker to discuss the claim. The worker provided information regarding the masks she had tried and the reactions she had experienced. She advised the employer had discussed moving her to a position where she would be required to wear a mask for only two hours per day, as opposed to the full shift in her current position. The worker further advised that she remained off work as they had been unable to find a mask which did not cause her to react.

On May 18, 2020, the worker provided her Worker Injury Report, along with a Dermatitis Questionnaire to the WCB. On the Questionnaire, the worker reported her face "…started to get red bumpy irritated and extremely hot when wearing my PPE (face mask); it stayed hot feeling for days…" The worker noted she had never had skin problems prior to wearing the PPE; that her skin issues had improved since she stopped wearing the face mask, and they were trying other masks to see if something else would work.

On May 27, 2020, the WCB spoke with the employer, who confirmed that prior to the end of April/beginning of May 2020, the worker was not required to wear PPE face masks regularly, but only on a very limited basis. Due to the Covid-19 pandemic, public health orders came into effect that required the wearing of PPE face masks on a full-time basis, and the worker experienced an immediate reaction to her face from the mask. The employer advised that they did not have any concerns regarding the worker's face condition being caused by the wearing of face masks. The employer noted the worker had shared pictures of her face and "…the mask/reaction all looks to be within the area of wear (sic) the mask would be." The employer advised they had tried several different types of masks but the worker had reacted to all of them, and the worker had been off work from May 5 to May 17, 2020 recovering and waiting for her face to heal. The employer further advised that the worker returned to work on May 18, 2020 in an accommodated position, where she was not required to wear a mask.

The worker also contacted the WCB on May 27, 2020, and confirmed she had returned to work on May 18, 2020 on full hours, with modified duties, where she was not required to wear a mask. The worker said her return to work was going well; that she had been using the medication prescribed by her treating physician, and her face was "…really clearing up." The worker also confirmed the medical attention she had sought, and provided a detailed chronology of events before and after the workplace accident. On May 28, 2020, the worker provided photographs of her face from prior to the date of accident to May 28, 2020, showing the progression of the reaction on her face.

On June 2, 2020, the WCB received a copy of a hospital report of an attendance by the worker on May 3, 2020, where the worker reported a progressively worsening facial rash that appeared every time she wore the masks. The attending physician recorded the worker looked flush with a "diffuse small papular rash over her cheeks and her forehead," provided a diagnosis of "Contact dermatitis vs allergic reaction less likely to be Rosacea," and prescribed medication.

The worker attended the hospital again on May 5, 2020, complaining of a red rash having increased after wearing a mask and being itchy and red hot to the touch. The attending physician noted a red papular rash over the worker's cheeks and chin, in the mask distribution area, and recommended the worker not wear a mask and follow up with her family physician.

At her initial assessment with her family physician on May 19, 2020, the worker reported pain and pruritus and was diagnosed with contact dermatitis. The worker attended the hospital again on June 1, 2020, and the attending physician referred her to a dermatologist, and recommended "no mask wearing."

On June 9, 2020, the employer provided a list of the types of masks provided to the worker and the dates she tried those masks. The employer advised the worker could not try other masks after May 27, 2020, as her treating physician had advised she was to wait until she had been seen by the dermatologist. On November 16, 2020, the WCB received chart notes from the worker's family physician for the period of June 2, 2020 to November 4, 2020. Included with the chart notes was a copy of the June 16, 2020 report from the treating dermatologist. Due to the Covid-19 pandemic, the worker had a virtual appointment with the dermatologist, who reviewed photographs provided by the worker and noted the worker had "…an erythematous acneiform rash to the face with sparing of the eyelids and possibly the nasolabial folds. It does seem to involve the central forehead but spares the nose." The dermatologist provided a diagnosis of perioral dermatitis versus allergic contact dermatitis. The dermatologist went on to opine that "It certainly seem (sic) that this episode was triggered by the mask use and therefore there is some component of allergic contact dermatitis at play. ACD can present with inflammatory papules and vesicles. For the time being [the worker] should avoid wearing any masks and once we have the current eruption under control…we can consider patch testing to masks." The dermatologist prescribed antibiotic medication and recommended the use of sun protective clothing and sunscreen.

In an August 15, 2020 chart note, the worker's family physician indicated "Currently symptoms are subsided, a few small spots are still on her face, no other complaints. Client is not wearing the facial mask." In a medical note dated September 16, 2020, the treating dermatologist noted that due to a dermatological condition, the worker was unable to wear face masks and required an accommodation to wear a face shield in place of a regular face mask. A November 4, 2020 chart note from the worker's family physician noted the worker had reported she was off work since November 3, 2020 due to mask use being mandatory. The physician also noted the worker's skin was currently clear.

On January 29, 2021, the worker contacted the WCB and advised that she had been off work since November 2020 when the public health orders had been updated due to the Covid-19 pandemic to require mandatory masks. The worker noted she was unable to work as she could not wear a mask, and queried whether the WCB would cover her time loss. The WCB advised the worker that she was not entitled to benefits, as she was off work not because of an illness or injury, but because her employer could not accommodate her due to masks being mandatory, which was an employment-related requirement. On February 2, 2021, the WCB provided the worker with a decision letter noting she was not entitled to wage loss or medical aid benefits beyond May 17, 2020 as they were unable to establish her current absence from work was related to an injury or illness arising out of or in the course of her employment.

On March 10, 2021, the worker requested the WCB reconsider their decision that she was not entitled to further benefits. The worker noted she had not been seen by a dermatologist in person, or been properly diagnosed for her skin issues. The worker advised that she was scheduled for an in-person appointment with a different dermatologist on April 27, 2021. On March 12, 2021, the WCB advised the worker that they would request a copy of the report from the dermatologist after the worker's appointment.

On April 30, 2021, the WCB received the dermatologist's April 27, 2021 report. The dermatologist noted the worker had a "…differential diagnosis of periorificial dermatitis (POD) versus rosacea" and had been referred for patch testing as contact dermatitis for a facial rash had been queried. On examination, the dermatologist noted the worker had "…monomorphous erythematous papules with some scale on the entire face (Worst on forehead and cheeks)," and that patch testing was being done and would be followed up after 48 hours. On April 29, 2021, the dermatologist advised that the results of the patch testing were all negative, and provided a differential diagnosis of perioral dermatitis, rosacea, or dermatitis. On May 27, 2021, the WCB provided a further decision letter indicating the results from the patch testing confirmed a diagnosis of perioral dermatitis, which was not a work-related condition. The WCB advised that they were therefore unable to establish the worker's loss of earning capacity was due to an illness or injury arising out of or in the course of her employment, and the worker was not entitled to further benefits.

On August 13, 2021, the worker requested that Review Office reconsider the WCB's decision to deny further benefits. The worker submitted that the extended use of the PPE face masks caused her diagnosed dermatitis, resulting in long-term effects that required further treatment and benefits. On September 1, 2021, the worker forwarded a copy of an August 30, 2021 report from a family physician with additional training in dermatology to Review Office as part of her request for reconsideration. The physician opined in that report that the worker had developed a facial rash for several months after masks were mandated at work, and received multiple types of treatment for recurrent facial rash, which was currently being controlled with avoiding triggers and medication. The physician noted the worker underwent patch testing, but the mask could not be tested, and opined that while the patch testing was otherwise negative, it was hard to know if the worker was "…getting recurrent contact dermatitis vs periorificial dermatitis/rosacea exacerbated by masks…" On October 18, 2021, the employer's representative provided a submission in support of the WCB's decision.

At the request of Review Office, the worker's file was reviewed by a WCB internal medicine, allergy and immunology consultant on November 5, 2021. The consultant noted allergic contact dermatitis to a face mask should result in the development of skin symptoms only at the site of prolonged and direct skin contact with the face mask, and the medical information on file indicated the worker's skin symptoms also involved her central forehead, an area which was not expected to be in prolonged and direct contact with a face mask. The June 16, 2020 report from the worker's dermatologist also noted the presence of a rash that involved the worker's central forehead but not the worker's nose, and the WCB consultant noted that a face mask would be expected to be in prolonged and direct contact with a person's nose. The worker's skin symptoms involving the worker's central forehead were therefore not medically accounted for by the worker wearing a face mask.

The WCB consultant also noted the patch testing undertaken came back negative for a true contact allergy, and opined that "The aforementioned normal patch test result is not concordant with a diagnosis of an allergic contact dermatitis to account for [the worker's] skin symptoms." The consultant further noted the worker's second treating dermatologist provided differential diagnoses on April 29, 2021 of perioral dermatitis, rosacea and dermatitis, and opined that perioral dermatitis and rosacea were not medically accounted for in relation to wearing a face mask at work, and dermatitis was not a specific medical diagnosis. The WCB consultant's opinion was shared with the parties, and on November 17, 2021, the worker submitted a response to the employer's October 18, 2021 submission and the WCB consultant's November 5, 2021 opinion.

On November 25, 2021, Review Office determined that there was no entitlement to benefits beyond May 17, 2020. Review Office accepted the November 5, 2021 opinion of the WCB's internal medicine, allergy and immunology consultant that the worker did not have a contact allergy to wearing a facial mask and her diagnosis of perioral dermatitis and rosacea were not medically accounted for by the wearing of a face mask at work. Review Office further noted the worker's position that she now has a condition she has to manage for the rest of her life, but could not find evidence to support wearing a face mask at work caused the worker to develop a long-standing skin condition. Review Office concluded they were unable to establish a relationship between the worker's further skin difficulties in relation to the May 4, 2020 workplace injury, and the worker was not entitled to benefits after May 17, 2020.

On April 5, 2022, the worker appealed the Review Office decision to the Appeal Commission and a teleconference hearing was arranged.

Reasons

Applicable Legislation

The Appeal Commission and its panels are bound by The Workers Compensation Act (the "Act"), regulations under the Act and policies of the WCB's Board of Directors. The provisions of the Act in effect as of the date of the worker's accident are applicable.

Subsection 4(1) of the Act provides that where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid.

Subsection 4(2) provides that a worker who is injured in an accident is entitled to wage loss benefits for the loss of earning capacity resulting from the accident, but no wage loss benefits are payable where the injury does not result in a loss of earning capacity during any period after the day on which the accident happens.

Subsection 27(1) of the Act states that the WCB "…may provide a worker with such medical aid as the board considers necessary to cure and provide relief from an injury resulting from an accident." Subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until such time as the worker's loss of earning capacity ends, or the worker attains the age of 65 years.

Worker's Position

The worker was self-represented. The worker provided a written submission in advance of the hearing and made an oral presentation to the panel.

The worker's position was that she continued to suffer from the effects of her workplace injury after May 17, 2020 and is entitled to further benefits.

The worker submitted that she never had any skin issues or problems with her face prior to her injury. The worker noted that she had multiple documented statements from numerous sources, including the employer and five different doctors, all of whom stated that the reaction she experienced was clearly from the facial mask. The worker stated that the only thing that changed in her life was the requirement that she wear the PPE which the employer provided for extended periods of time. The worker noted that the WCB accepted her claim and provided compensation for her injury, then denied further benefits after her skin did not return to its pre-injury state.

The worker noted that while the WCB had stated there is no clear diagnosis, her injury was clearly from the mask. She noted that she cannot wear a mask at all, and feels that she has been treated unfairly. She said that her face got better with medication, but her skin would flare up again as soon as she finished her medication. She said she just wants help to figure out what has happened to her face and to get back to her pre-injury state.

Employer's Position

The employer was represented by an advocate.

The employer's position was that they agreed with the WCB's decision to end the worker's entitlement to benefits effective May 17, 2020, and the appeal should be dismissed.

The advocate noted that the claim was accepted for a possible allergic reaction, or contact dermatitis, where the worker developed a rash on her face due to the use of a facial mask or PPE. It was noted that since that time, there has been some question as to the origin of the worker's skin condition, with the condition having been subsequently diagnosed as perioral or periorificial dermatitis, which is generally not considered to be occupationally induced.

The advocate submitted that contact dermatitis claims are generally very brief, where the worker gets better once the offending substance is removed. This did not seem to have occurred in this case. In addition, the condition seemed to have spread beyond the area of the worker's face which was initially covered by the PPE, and could not be medically accounted for in the absence of prolonged direct contact with the PPE.

In conclusion, the advocate submitted the WCB adjudicated the claim correctly in accepting the acute effects of PPE exposure at work, if that was where it occurred, but the acute effects of that exposure would have passed. It was submitted that at the end of the day, the working diagnosis seems to be periorificial dermatitis which is not an occupational-based disease, and the worker is therefore not entitled to further benefits.

Analysis

The issue before the panel is whether or not the worker is entitled to benefits after May 17, 2020. For the worker's appeal to be successful, the panel must find, on a balance of probabilities, that the worker had a loss of earning capacity and/or required medical aid beyond May 17, 2020 as a result of her May 4, 2020 workplace accident. The panel is unable to make that finding, for the reasons that follow.

The worker has an accepted claim for injury to her face that developed after wearing a face mask at work, and was first reported on May 4, 2020. The panel accepts that the wearing of the face mask irritated the worker's face. Based on the our review of the evidence which is before us, however, the panel is unable to account for the worker's ongoing skin issues or condition as being causally related to or enhanced by her workplace accident or injury.

The evidence shows that the worker was taken off work on May 5, 2020 and remained off work for approximately two weeks, during which time she was not wearing a face mask except when trying other masks for short periods of time to see if they would work. In her Questionnaire dated May 14, 2020, the worker indicated that since she had stopped wearing a mask, her skin condition "has gotten better," but they were trying other masks to see if something else would work.

On May 27, 2020, the worker further indicated to her WCB case manager that she had been taking medication and her face was "really clearing up." The worker returned to work full-time on May 18, 2020, in an accommodated position where she was not required to wear a mask, and continued working in that position until the end of October, when mask wearing again became mandatory.

The worker submitted at the hearing that her skin condition had not cleared up when she returned to work or subsequently, but was essentially suppressed by the medication she was prescribed. The worker stated that her symptoms would flare up as soon as she went off the medication, noting that she had recently been off her medication for five weeks and her symptoms started to come back around her mouth, but nowhere else.

Based on our review of all of the evidence which is before us, the panel is not satisfied that any clear or definitive diagnosis has been provided for the worker's facial skin symptoms or condition.

While the worker was initially diagnosed with contact dermatitis, the panel understands that contact dermatitis is generally of short duration, showing up on skin that has been directly exposed to the irritant causing the reaction, and clearing up once that irritant is avoided. The worker did not disagree with such a description of contact dermatitis. In response to questions from the panel, the worker also indicated that she could not explain how she experienced symptoms on other parts of her face, including her forehead, which were not in direct contact with the face mask.

The panel is satisfied that the diagnosis of contact dermatitis is not confirmed by the medical evidence on file. The worker ultimately underwent patch testing, involving 20 regular tests and tests of four of the worker's own substances, the results of which were all negative. Following the tests, the treating dermatologist provided a differential diagnosis of "perioral dermatitis, rosacea, dermatitis," and concluded that she was "…not suspicious that she has a contact dermatitis based on the results today."

With respect to the differential diagnosis which was provided by the dermatologist, it is the panel's understanding that perioral dermatitis and rosacea are not medical conditions that would have been caused by mask wearing or a reaction to something that touches the skin. It is the panel's further understanding that perioral dermatitis and rosacea are not caused by or related to contact dermatitis.

When the worker was asked at the hearing what medical condition she was relying on and asking the panel to consider, she responded that she thought her condition was contact dermatitis initially, but believes that it is now perioral dermatitis, noting:

I feel that it was contact dermatitis at first because the only thing that changed was the mask. And then for the longest time I honestly thought it was contact dermatitis and it just wasn't going away. And I do understand…that it should go away if it was contact dermatitis…

How do you wear a mask for six days and break out with a horrible perioral dermatitis? So, I never thought it was perioral dermatitis. I thought it was contact dermatitis. But I have not worn a mask. So, yes. You would think it would go away. And just recently is when it came around just my mouth. And I had been researching…all this time, and it makes sense to be perioral dermatitis. So, now after it's just appearing where it says when you research perioral dermatitis…I would think it would be perioral dermatitis. When I got my patch testing done, I'm not allergic to anything I'm doing in my house. So, it's nothing I'm doing. But it would have started off as contact dermatitis the minute I had those masks on my face…

It's switched over I'm assuming because it's just around the orifice area, which is around my mouth…I don't have it on my cheeks. I don't have it on my chin. I don't have it on my forehead.

While the worker indicated that she believed the initial contact dermatitis had developed into perioral dermatitis, the panel notes that no medical information was identified to support that position. Without some medical confirmation that contact dermatitis can evolve into or enhance perioral dermatitis or rosacea, the panel is unable to accept that position. The panel is therefore not satisfied that the diagnoses of perioral dermatitis, rosacea, or dermatitis are related to the May 4, 2020 workplace accident.

In this regard, the panel also places weight on the November 5, 2021 opinion of the WCB internal medicine, allergy and immunology consultant, who opined, in part, with respect to the differential diagnoses of perioral dermatitis, rosacea or dermatitis, that:

The diagnoses of a perioral dermatitis and rosacea are not likely medically accounted for by the wearing of a face mask at work.

The word "dermatitis" is used as an umbrella term to denote a variety of specific skin conditions. The worker "dermatitis" alone is not a specific medical diagnosis.

and concluded that:

In summary, the medical information on file does not substantiate a specific medical diagnosis to account for [the worker's] skin symptoms, both initial and current.

Based on the foregoing, the panel is unable to find, on a balance of probabilities, that the worker had a loss of earning capacity or required medical aid after May 17, 2020 as a result of her May 4, 2020 workplace accident. The panel therefore finds that the worker is not entitled to benefits after May 17, 2020.

The worker's appeal is dismissed.

Panel Members

M. L. Harrison, Presiding Officer
J. Peterson, Commissioner
M. Kernaghan, Commissioner

Recording Secretary, J. Lee

M. L. Harrison - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 19th day of August, 2022