Position paper: Telemedicine in occupational dermatology - current status and perspectives.

Teledermatology is the use of telecommunication technologies to exchange medical information for diagnosis, consultation, treatment and teaching in dermatology. While its use has been evaluated in a wide range of dermatological diagnoses, only few studies exist on its validity, diagnostic precision, feasibility, and cost-effectiveness in occupational dermatology. However, these studies show a considerable potential for diagnosis, prevention, treatment support and follow-up of patients with occupational skin diseases. Asynchronous (store and forward; SAF) or synchronous dermatology teleconsults could assist occupational medicine specialists not only in occupational preventive care, but also in the context of skin cancer screening in outdoor workers. Thus, teledermatology might contribute to earlier prevention and notification of occupational skin diseases. Modern smartphone apps with artificial intelligence technologies may also facilitate self-monitoring in employees working in high-risk jobs.

Cooperation between the occupational health insurance and physicians practicing occupational dermatology: optimization potential in quality assurance.

BACKGROUND: Quality assurance is a task of the medical profession, but it is also a duty of the occupational health insurance (OHI). Data on the interaction quality between physicians practicing occupational dermatology and the OHI are limited. MATERIAL AND METHODS: An online survey was performed in 854 German members of the Working Group on Occupational and Environmental Dermatology in October 2013. Items included demographic data, a judgment on the cooperation between the dermatologists and OHI companies, an economic grading of the current compensation scheme, and prioritization of optimization tasks. RESULTS: 182 members (21.3 % of the invited population) participated in the survey. The cooperation with the OHI companies was judged as "very good" by 10.8 %, as "good" by 56.7  %, as "satisfactory" by 24.2 %, as "sufficient" by 7.0 % and as "inadequate" by 1.3 %. 93.4 % of the interviewed mentioned problems and improvement potentials in the cooperation of their practice or clinic with OHI companies. Main points of criticisms were reimbursement (44.7 %), followed by impairments of the treatment options (36.5 %) and the delay or scope of the treatment in the dermatologist's procedure (29.4 %). CONCLUSIONS: While most physicians practicing occupational dermatology give a positive judgment of their cooperation with OHI companies, quality optimization potentials exist regarding the reimbursement of dermatological services, especially regarding time-intensive counselling in the prevention of occupational skin diseases, in the enablement of diagnostic and therapeutic procedures according to current guidelines and in a timely preventive intervention to use the therapeutic window before chronification of skin diseases may occur.

UV-induced occupational skin cancer: possibilities of secondary individual prevention in the "Dermatologist's Procedure".

Invasive squamous cell carcinoma (SCC) as a "quasi occupational disease" according to §9 Section 2 of the German Social Code Book (SGB) VII typically develops on chronically UV-damaged skin from actinic keratoses. After the Medical Scientific Committee of the Federal Ministry of Labor and Social Affairs has confirmed the legal criteria for acknowledging UV-induced SCC as an occupational disease, it is expected that the condition will be added to the official list of occupational diseases issued by the Federal Government in the near future. The Social Accident Insurance is required by law (§3 Occupational Disease Regulation) to prevent these tumors by "all appropriate means". There are excellent therapeutic and preventive measures for the management of actinic keratoses to avoid the development of SCC. The "Dermatologist's Procedure" according to §§ 41-43 of the agreement between the Social Accident Insurance and the Federal Medical Association was established in Germany in 1972 to take preventive measures in insured persons with skin lesions possibly developing into an occupational disease, or worsening it, or leading to a recurrence of it This procedure proved to be very successful in the prevention of severe and/or recurring skin diseases forcing a worker to leave his job. On the basis of this agreement, the Social Accident Insurance has the instruments to independently provide preventive measures for the new occupational skin disease SCC induced by natural UV light according to §9 Section 2 of the German Social Code Book (SGB) VII.

First results from the multicentre study rehabilitation of occupational skin diseases--optimization and quality assurance of inpatient management (ROQ).

UNLABELLED: BACKGROUND AND OBJECTIVES. The German stepwise procedure of handling occupational skin diseases (OSDs) offers interdisciplinary integrated (inpatient/outpatient) rehabilitation measures [tertiary individual prevention (TIP)] for severe OSD. In 2005, a prospective cohort multicentre study was started in order to evaluate TIP. METHODS: One thousand seven hundred and eighty-eight patients with severe OSD were treated and educated in five clinics with follow-up before and 4 weeks after return to work. RESULTS: During the inpatient phase, there was a significant improvement in the severity of OSD (Osnabrueck Hand Eczema Severity Index, p < 0.001) and in the quality of life (Dermatology Life Quality Index, p < 0.001). These effects were largely sustained during the outpatient follow-up phase and in the 4 weeks after return to work. Among all patients, 89.4% used topical steroids before TIP, including 52.5% using high-grade topical steroids; 93.2% of the patients were able to refrain from using topical steroids before returning to work. As a result of TIP, return to work was possible for 1587 patients (88.8%). CONCLUSIONS: The primary objectives of TIP (return to work, improvement of OSD, enhancement of quality of life, and reduction in the use of topical steroids) were successfully met. The long-term follow-up (1 and 3 years after TIP) will examine whether these favourable outcomes can be sustained.

CARPE: a registry project of the German Dermatological Society (DDG) for the characterization and care of chronic hand eczema.

BACKGROUND: The aim of the CARPE (German acronym: Chronisches Handekzem-Register zum Patienten-Langzeitmanagement; meaning: chronic hand eczema registry on long-term patient management) registry is to investigate characteristics and treatment modalities in patients affected by chronic hand eczema in Germany. METHODS: The registry was built up under the auspices of the German Dermatological Society (Deutsche Dermatologische Gesellschaft, DDG). Patients with chronic hand eczema are prospectively assessed by dermatological examination and patient questionnaire. Socio-economic data and data on diagnostics, skin status, severity and treatment of chronic hand eczema and atopy criteria are repeatedly assessed. Here, we present baseline characteristics of the first 515 patients. RESULTS: 53.8 % of the patients were female, mean age was 47.3 years. The average duration of CHE was 7.7 years. 30.4 % had already received inpatient care, 31.2 % had been on sick leave in the past 12 months. 94.5 % had received topical corticosteroids prior to inclusion in the registry, 31.9 % topical calcineurin inhibitors, 38.3 % UV therapy, 28.6 % systemic antihistamines, 36.5 % systemic treatments, 14.9 % systemic corticosteroids, 25.8 % systemic retinoids. CONCLUSIONS: The CARPE project demonstrates the high medical burden and therapeutic challenge of chronic hand eczema and presents first data for health care research. Furthermore, the designed follow-up study will present important data about the natural history and prognosis of this chronic skin disease.

Assessment of the effects of a work-related allergy to seafood on the reduction of earning capacity in the context of BK No. 5101.

Fish, crustaceans, and mollusks are among the most potent allergenic foods of animal origin and are thus important triggers of work-related immediate-food allergies. In Germany, work-related seafood allergies are of great importance in the fishing and processing industries as well as in the areas of food preparation, food control, and food sales. There is no causal therapy of seafood allergy, only the strict and lifelong avoidance of allergens remains. The following recommendations serve to assess the impact of a seafood allergy with regard to the work opportunities ended by it for the assessment of the reduction of earning capacity (MdE (German for Minderung der Erwerbsfähigkeit)) in the context of the occupational disease number 5101 of the Annex to the German regulation for occupational diseases. As a special feature of work-related seafood allergy with regard to insurance law aspects, it must be taken into account that there is a potential risk of systemic reaction with subsequent multi-organ involvement. For the estimation of MdE in the general labor market, the impact of a seafood allergy can therefore be assessed, depending on its clinical severity, as generally "mild" to "severe" in justified individual cases.

Health-related quality of life in health care workers with work-related skin diseases.

BACKGROUND: Occupational skin diseases (OSDs) are common among health care workers (HCWs). Little is known about how OSD impacts on health-related quality of life (HRQoL) in HCWs with suspected OSD and associated factors. OBJECTIVES: To describe HRQoL in 278 HCWs with suspected OSD, compare data with the general and populations with skin diseases and analyse HRQoL's associations with clinical and demographic variables. METHODS: HCWs with suspected OSD completed a generic (SF-36) and specific (Skindex-29) instrument. RESULTS: Seven of 8 SF-36 dimensions were significantly lower in HCWs than the general population. Compared with norms for patients with skin disease and cleaning and kitchen employees (CKEs) with suspected OSD, physical functioning (PF) and general health perception were less impaired in HCWs. Skindex-29 scores were similar to CKEs' while they appeared better than patients' norms. Multivariate analysis found severity unrelated to SF-36, apart from pain but associated with all Skindex-29 scales. CONCLUSIONS: Although HCWs with suspected OSD display considerable HRQoL impairments, (general) PF and general health perception appear less affected than expected. Severity appears to affect specific and to a lesser extent general HRQoL. Clinical and demographic variables contributed moderately to the prediction of specific and little to the prediction of general HRQoL.

Polyvalent type IV sensitizations to multiple fragrances and a skin protection cream in a metal worker.

Fragrances are very common in everyday products. A metalworker with chronic hand eczema and previously diagnosed type IV sensitizations to epoxy resin, balsam of Peru, fragrance mix and fragrance mix II was diagnosed with additional type IV sensitizations to geraniol, hydroxycitronellal, lilial, tree moss, oak moss absolute, citral, citronellol, farnesol, Lyral, fragrance mix II and fragrance mix (with sorbitan sesquioleate). In addition, a type IV sensitization to the skin protection cream containing geraniol and citronellol used at the workplace was detected, and deemed occupationally relevant in this case. The patient could have had contact to fragrances through private use of cosmetics and detergents. On the other hand, the fragrance-containing skin protection cream supports occupational exposure. This case report demonstrates that fragrance contact allergy has to be searched for and clarified individually, which requires a thorough history and a detailed analysis of the work place.

Multicenter study "Medical-Occupational Rehabilitation Procedure Skin--optimizing and quality assurance of inpatient-management (ROQ)".

Scientifically based prevention and patient management concepts in occupational dermatology have substantially improved during recent years. Currently the public statutory employers' liability insurance bodies fund a multi-step intervention approach designed to provide quick preventive help for all levels of severity of occupational dermatoses. An administrative guideline (hierarchical multi-step intervention procedure for occupational skin diseases--"Stufenverfahren Haut") insures professional support and optimal patient orientation by the statutory insurers' representatives. For secondary prevention, the so-called dermatologist's procedure ("Hautarztverfahren") was recently updated in order to provide more rapid dermatologic consultations which are covered for by the public statutory employers' liability insurance bodies. Additionally, combined outpatient dermatologic and health-educational intervention seminars ("secondary individual prevention"[SIP]) are offered to affected employees in a nationwide scheme. For those cases of occupational dermatoses in which these outpatient prevention measures are not successful, interdisciplinary inpatient rehabilitation measures have been developed ("tertiary individual prevention"[TIP]). TIP requires 3 weeks inpatient treatment including intensive health care instruction and psychological counseling, followed by outpatient treatment by the local dermatologist. In 2005, a German prospective cohort multicenter study ("Medical-Occupational Rehabilitation Procedure Skin--optimizing and quality assurance of inpatient-management"-"Medizinisch-Berufliches Rehabilitationsverfahren Haut--Optimierung und Qualitätssicherung des Heilverfahrens"[ROQ]) started which will further standardize TIP and evaluate scientific sustainability in depth (3-year dermatological follow-up of 1,000 patients). The study is being funded by the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung [DGUV]).

Occupational UV-Exposure is a Major Risk Factor for Basal Cell Carcinoma: Results of the Population-Based Case-Control Study FB-181.

OBJECTIVE: The aim of this study was to investigate the role of occupational and nonoccupational ultraviolet (UV)-exposure concerning the development of basal cell carcinoma (BCC). METHODS: We undertook a population-based multicenter case-control study. Patients with first incident BCC (n = 836) were propensity score matched by age and sex to controls without skin cancer (n = 836). Sociodemographic characteristics, clinical characteristics, and lifetime UV-exposure were assessed by trained investigators. The differential estimation of occupational and nonoccupational UV-exposure dosages was based on validated instruments and established reference values. Associations were assessed using multivariable-adjusted conditional logistic regression models. RESULTS: Individuals with high levels of occupational UV-exposure were at significantly increased BCC-risk compared with individuals with low [odds ratio (OR) 1.84; 95% confidence interval (95% CI) 1.19 to 2.83 and moderate (OR 1.97; 95% CI 1.20 to 3.22) occupational UV-exposure. Nonoccupational UV-exposure was not independently associated with BCC. CONCLUSION: Skin cancer prevention strategies should be expanded to the occupational setting.

[Certificate: "Occupational Dermatology (ABD)". New curriculum 2006 of the CME-seminars of the Task Force of Occupational and Environmental Dermatology]. / Zertifizierung: "Berufsdermatologie (ABD)": Neues Seminar-Curriculum 2006 der Arbeitsgemeinschaft für Berufs- und Umweltdermatologie.

The certification of experts is an important component in the overall concept of quality management in occupational dermatology. With the certificate "Occupational Dermatology (ABD)" the Task Force on Occupational and Environmental Dermatology (ABD) has developed a comprehensive CME concept in the field of medico-legal evaluations. The ABD seminars meet the current requirements of the statutory accident insurances and social welfare courts. The new CME seminar curriculum 2006 of the ABD takes into account the recent pioneering achievements in occupational dermatology, e.g. the Bamberg leaflet, the optimized dermatologic report and other prevention/early intervention measures. The ABD seminars (total of 21 hrs) are subdivided into 3 consecutive modules: basic, advanced and special seminar (7 hrs each). The seminars are interactive, based on practice-oriented discussions with experts from different disciplines (occupational dermatology, social law). The seminars should be attended in chronological order; there are no time limits during which they must be completed. Prerequisite for the certification is a specialist's degree in dermatology. To maintain the certificate it is expected to attend one of the newly-created ABD "quality management workshops" (7 hrs) within 5-year-intervals; these focus on interdisciplinary case discussions of the current legal regulations and recent social welfare court decisions. More than 400 dermatologists have already been certified by the ABD.

The relationship between occupational sun exposure and non-melanoma skin cancer: clinical basics, epidemiology, occupational disease evaluation, and prevention.

BACKGROUND: The cumulative effect of solar ultraviolet (UV) radiation is responsible for the worldwide increase in non-melanoma skin cancer, a category that includes squamous cell carcinoma and its precursors (the actinic keratoses) as well as basal-cell carcinoma. Non-melanoma skin cancer is the most common type of cancer in areas of the world with a light-skinned population. The occupational exposure to UV radiation is high in many outdoor occupations; recent studies suggest that persons working in such occupations are more likely to develop non-melanoma skin cancer. METHODS: On the basis of a selective review of the literature, we present the current state of knowledge about occupational and non-occupational UV exposure and the findings of meta-analyses on the association of outdoor activity with non-melanoma skin cancer. We also give an overview of the current recommendations for prevention and for medicolegal assessment. RESULTS: Recent meta-analyses have consistently documented a significantly higher risk of squamous cell carcinoma of the skin among persons who work outdoors (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.40-2.22, p<0.001). There is also evidence for an elevated risk of basal-cell carcinoma (OR 1.43, 95% CI 1.23-1.66, p = 0.0001), but the effect is of lesser magnitude and the study findings are not as uniform. CONCLUSION: The association of occupational exposure to solar UV radiation with squamous cell carcinoma, including actinic keratosis, has been conclusively demonstrated. It follows that, in Germany, suspected non-melanoma skin cancer in persons with high occupational exposure to UV radiation should be reported as an occupational disease under § 9, paragraph 2 of the Seventh Book of the German Social Code (Sozialgesetzbuch, SGB VII). Preventive measures are urgently needed for persons with high occupational exposure to UV radiation.