Interdisciplinary and multiprofessional outpatient secondary individual prevention of work-related skin diseases in the metalworking industry: 1-year follow-up of a patient cohort.

BACKGROUND: In Germany, work-related skin diseases are predominant within the spectrum of reported occupational diseases. Metal workers are among the high-risk professions. Offering effective prevention programs to affected patients is of utmost importance to avoid deterioration of the disease and job loss. We conducted a 1-year follow-up in patients who participated in a multidisciplinary, complex outpatient prevention program representing a standard procedure of patient care by the respective statutory accident insurance. METHODS: The multi-component prevention program consists of multiprofessional individual patient counseling, a structured skin protection seminar in a group, as well as workplace visits and on-site counseling in terms of appropriate skin protection (e.g. gloves). An observational study with a 1-year follow-up and four measurements (T1-T4, longitudinal pre/post-test design) including dermatological examinations and standardized written questionnaires was conducted between 2013 and 2016 to assess changes over time regarding job loss and disease severity. RESULTS: Data from 94 patients (87 male, mean age: 45.4 years) were included in the analysis. One year after the skin protection seminar (T4), 83 patients (88.3%) remained in their original professional metalworking activity and four patients (4.3%) had given up their profession because of their skin disease. At baseline (T1), irritant contact dermatitis of the hands was the most frequent diagnosis (80.7%). Methods for self-reported disease severity showed good correlation with the clinical gold standard at T1 and T2 (dermatological examination with the Osnabrück Hand Eczema Severity Index / OHSI), and a significant decrease of the self-reported disease severity was found over time from T1 to T4 (p < 0.001). Further results indicate an improved self-perceived disease control and an overall satisfaction with the prevention program. CONCLUSIONS: The results of this observational study demonstrate that the comprehensive prevention program positively influences the course of work-related skin diseases, increases the possibility to continue working in a "high-risk" profession and improves the disease management of metal workers. In the long term, the prevention program may lead to cost savings by preventing high therapy costs or professional retraining.

Multicentre cohort study 'Rehabilitation of Occupational Skin Diseases - Optimization and Quality Assurance of Inpatient Management (ROQ)': results from a 3-year follow-up.

BACKGROUND: A tertiary individual prevention programme (TIP) is offered to patients with severe occupational skin disease (OSD) in Germany. Previously, it was shown that the burden of OSDs is considerably reduced in patients up to 1 year after the TIP. OBJECTIVES: To evaluate the long-term effects of the TIP. PATIENTS AND METHODS: In a prospective multicentre cohort study, the clinical and patient-reported outcome data 3 years after the TIP were evaluated. RESULTS: Of the 1788 patients initially included in the study, 1410 were available for the 3-year follow-up analysis. The severity of OSD, the use of topical corticosteroids and days of absence from work were significantly reduced 3 years after the TIP, and the quality of life and skin protective behaviour were significantly improved. Of the patients, 96.9% were able to resume work. One thousand one hundred and sixty-six patients (82.7%) were still working 3 years after the TIP, 874 of them (75.0%) in the same occupational field. Hairdressers had the lowest rate of remaining in their original profession (41.3%). CONCLUSIONS: The follow-up during 3 years of this unique cohort of patients with OSDs shows that the TIP is associated with sustained improvements in terms of disease severity, ability to work, quality of life, and prognosis.

Evaluation of structured patient education in occupational skin diseases: a systematic assessment of the disease-specific knowledge.

PURPOSE: The aim of this study was to evaluate the effectiveness of patient education in occupational skin diseases (OSD) regarding changes of the disease-specific knowledge. METHODS: One hundred and five patients participated in structured patient education as part of an interdisciplinary outpatient prevention measure. In a prospective one-group pre-post-design, the disease-specific knowledge was assessed with the validated "Occupational Skin Diseases Knowledge Questionnaire" (OSD-KQ) before (T0) and after the intervention (T1). A subcohort (n = 68) was examined 2-3 months later (T2). RESULTS: The mean OSD-KQ score significantly improved from 38.5 (59.2% of correct answers, T0) to 55.6 (85.5% of correct answers, T1). A pronounced heterogeneity was observed among the participants regarding the pre-interventional knowledge (10.8-84.6% of correct answers, T0) and the individual knowledge gain. Patients who worked in health-related occupations scored significantly higher. Age and sex did not influence the knowledge. In a subcohort, a significantly improved disease-specific knowledge of 52.3 (80.5% of correct answers) could still be found 2-3 months after the intervention (T2). CONCLUSIONS: Structured patient education significantly improves the disease-specific knowledge in patients with OSD. The study indicates not only positive short- but also sustainable long-term effects on the knowledge gain. The OSD-KQ can serve as a tool to evaluate and improve patient education. Health educators need to be aware of the heterogeneity regarding the participants' knowledge and take this into account during educational practice. Additional counseling may be necessary to meet the individual learners' needs.

Multicentre study 'rehabilitation of occupational skin diseases -optimization and quality assurance of inpatient management (ROQ)'-results from 12-month follow-up.

BACKGROUND: Occupational skin disease (OSD) is common, and imposes a considerable personal and public burden. To tackle OSD, the German stepwise procedure of handling OSD was set up. It contains an interdisciplinary, integrated inpatient rehabilitation measure [tertiary individual prevention (TIP)] [dermatological treatment and diagnostic procedures, and patient education (health and psychological)]. The primary aims of the TIP are reduction of the severity of OSD, reduction in the use of corticosteroids, facilitation of return to work, decreased absence from work, and enhanced quality of life (QoL). It was positively evaluated for a period of 4 weeks after return to work. OBJECTIVES: To investigate whether the observed short-term effects remain significant and meaningful over a period of 12 months after discharge from the TIP. METHODS: A prospective design was used to compare clinical and patient-reported outcome data between admission to a 3-week inpatient TIP and 12 months after discharge (12-month follow-up). RESULTS: Of 1788 individuals admitted to the TIP, data from 1617 individuals were available for analysis. We observed a significant reduction in the severity of OSD, the use of topical corticosteroids, and days of absence from work because of OSD. QoL was significantly improved, and 87.4% were able to return to work and remain in the workforce. CONCLUSIONS: A randomized controlled trial would have been desirable, but was not possible, for legal and other reasons. However, the long-term 12-month follow-up shows that the TIP is associated with sustained improvements in terms of ability to work, QoL, and prognosis, and reductions in days of absence from work because of skin conditions and topical corticosteroid application. These results indicate that the TIP provided a reduction in the personal and public burden of OSD.

Teaching interprofessional collaboration among future healthcare professionals.

Healthcare has become more complex in recent years. Such complexity can best be addressed by interprofessional teams. We argue that to ensure successful communication and cooperation in interprofessional teams, it is important to establish interprofessional education in health-related study programs. More precisely, we argue that students in health-related programs need to develop interprofessional competencies and a common language, experience interprofessional contact, build inclusive identities and establish beliefs in the benefit of interprofessional diversity. We give examples how these goals can be implemented in interprofessional education. We also discuss challenges and future avenues for respective research healthcare professionals.

Long-term effectiveness of secondary prevention in geriatric nurses with occupational hand eczema: the challenge of a controlled study design.

BACKGROUND: The high prevalence of occupational dermatoses indicates the need for effective and sustainable prevention strategies. OBJECTIVES: To evaluate the long-term effectiveness of secondary prevention in geriatric nurses. PATIENTS/METHODS: One hundred and two geriatric nurses with occupational hand eczema participated in an interdisciplinary prevention programme [intervention group (IG)]. Members of the control group (CG) (n = 107) were medically treated by local dermatologists. Six years after intervention (T2), data on job continuation, skin lesions and skin protection behaviour were obtained by standardized questionnaires and compared with baseline values (T0) and data from a 3-month follow-up (T1). RESULTS: At T2, 65.3% of the IG and 56.8% of the CG still worked as geriatric nurses; 6.9% of the IG and 13.6% of the CG had given up work because of occupational hand eczema. The skin status improved in both cohorts. The data indicated a lower frequency of skin lesions and morphological signs in the IG, for example vesicles (IG, 12.8%; CG, 40.0%; χ(2) = 7.00, degrees of freedom = 1, p = 0.008). CONCLUSIONS: The results indicate long-term effects regarding job continuation and disease severity, although few results showed statistical significance. It is outlined that controlled long-term studies aiming at proving the general effectiveness of secondary prevention are no longer feasible in Germany, as the statutory accident insurance has led to a legal entitlement of all patients affected by occupational hand eczema to immediate preventive intervention.

Sustainability of interdisciplinary secondary prevention in patients with occupational hand eczema: a 5-year follow-up survey.

BACKGROUND: Occupational hand eczema (OHE) is common in 'wet work' occupations. Thus, effective and sustainable prevention strategies are needed. OBJECTIVES: To investigate the long-term effectiveness (sustainability) of an interdisciplinary secondary prevention programme. METHODS: One hundred and thirty-four patients with OHE consecutively participated in an outpatient skin protection seminar comprising dermatological and educational interventions. Data were obtained at baseline (T0) and at 9 months (T1) and 5 years (T2) after participation. A cohort of 84 patients was available for analysis of the outcomes 'job continuation', 'skin condition', 'skin protection behaviour', and 'disease management'. RESULTS: At T2, 71.4% of patients remained in their occupation. The prevalence and severity of self-reported OHE were significantly reduced as compared with T0 (p = 0.007, p = 0.002). Of the patients, 13.1% gave up work because of OHE at T2. The intervention was most successful in patients suffering from milder forms of OHE, and there was less success in patients with severe OHE. The results showed a significant reduction in the frequency of 'hand washing' (p = 0.003) but no measurable change in the use of skin care products (p = 1.000). CONCLUSIONS: The intervention showed sustainable long-term effects. Early detection and reporting of OHE in the initial stages of the disease is of utmost importance for the effectiveness of secondary prevention. In cases of severe OHE, inpatient programmes may be indicated.

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.

Is story-based blended learning a promising avenue for skin and sexual health education? Results from the PAEDIMED project.

The PAEDIMED study group developed a learning and teaching scenario for school health education in the area of skin and sexual health in Italy, Romania and Germany, combining web-based and traditional learning ("blended learning"). A questionnaire-based needs assessment and context analysis were conducted, based on which an education scenario was designed. Particular emphasis was put on emotional and motivational aspects, using narrative components in the didactic concept. The design process occupied a central role in the project (design-based research). Evaluation was both formative and summative. Continuous feedback was obtained from relevant stakeholders. Following a prototypical implementation, the scenario was evaluated using questionnaires. The results revealed a high level of acceptance of the education scenario as well as an increase in students' knowledge concerning skin and sexual health. Evaluation also suggested that health education is highly influenced by cultural background and habits as well as diverse contextual and personal conditions.

Semipermeable glove membranes--effects on skin barrier repair following SLS irritation.

BACKGROUND: Transepidermal water flux is the regulatory signal for barrier regeneration. OBJECTIVE: In this study, we evaluated the impact of glove membranes, which provide a partial barrier and different water loss rates, on barrier recovery after standardized irritation with sodium lauryl sulfate (SLS). METHODS: Twenty-five healthy volunteers were irritated for 24 hr with SLS 1%. Four test areas were marked on clinically normal skin on the upper back. Barrier repair under consecutive dressing with semipermeable membranes (GoreTex, Sympatex, an occlusive membrane (Meditrate Vinyl), and in an uncovered control area were evaluated by measurements of transepidermal water loss (TEWL) and erythema (a*). RESULTS: Areas semipermeably covered showed an enhanced barrier recovery and a reduced inflammatory response compared to the area under occlusion and the control. During healing process, TEWL (P < 0.01) and a* (P < 0.001) values were significantly lower in areas semipermeably covered than in the vinyl covered area and in the control. CONCLUSIONS: The results support the hypothesis that semipermeable materials improve barrier recovery rates by providing an optimized water vapour gradient during the healing process. This underlines the unique benefit of semipermeable gloves in the prevention of occupational skin disease: (i) by minimizing glove-induced irritation and (ii) by enhancing barrier recovery through protective glove materials at the work place in cases of pre-existing minor irritant dermatitis.

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]).

Skin Protection Seminars to Prevent Occupational Skin Diseases: Results of a Prospective Longitudinal Study in Apprentices of High-risk Professions.

BACKGROUND: Occupational skin diseases (OSDs) are frequent in professions with exposure to skin hazards. Thus, a health educational intervention for apprentices of high-risk professions was conducted. It was the aim of this study to gain insight into possible effects of this intervention. METHODS: A one-time skin protection seminar was conducted in 140 apprentices of health-related and non-health-related professions [trained cohort (TC)]. In addition, 134 apprentices of the same occupations were monitored [untrained cohort (UTC)]. The OSD-specific knowledge and the skin condition of the hands were assessed at baseline (T0), after the seminar (T1), and after 6 (T2) and 12 months (T3). RESULTS: The OSD-specific knowledge increased in all cohorts from T0 to T3, but we found a significantly higher knowledge in the TC at T2 (p < 0.001, t = 3.6, df = 196, 95% confidence interval = 0.9, 3.3) and T3 (p < 0.001, t = 3.8, df = 196, 95% confidence interval = 1.0, 3.2) compared to the UTC. Our results indicated a better skin condition of the hands in the TC of the health-related professions but not in the non-health-related professions. CONCLUSION: The study indicates that an educational intervention may positively influence the disease-specific knowledge and the prevalence of OSD in apprentices. However, definite conclusions cannot be drawn because of the heterogeneous study cohorts and the study design. Future research should aim at tailoring primary prevention to specific target groups, e.g., in view of the duration and frequency of skin protection education, different professions, and gender-specific prevention approaches.

Optimizing skin protection with semipermeable gloves.

BACKGROUND: Occlusion due to gloves is one important cause of glove irritation. Macerated softened skin gives poor protection against microbes and chemical injuries. The introduction of a breathable protective glove material would represent a significant step toward improved prevention of occupational skin disease. OBJECTIVE: Performance levels of semipermeable and occlusive gloves were examined under conditions typical of the hairdressing profession. In two studies, tests comparing breathable semipermeable gloves to single-use gloves made of occlusive materials were conducted. METHODS: In an initial study, a user survey was carried out in conjunction with bioengineering examinations. Values at baseline and values after gloves were worn were recorded by measuring transepidermal water loss (TEWL), skin humidity (SH), and skin surface hydrogen ion concentration (pH) in 20 healthy volunteers. In a second study, the gloves were tested for penetrability and permeability with three chemical compounds typically used in the hairdressing profession. RESULTS: Bioengineering examination objectively confirmed users' reports of reduced hand perspiration when semipermeable gloves were worn. The TEWL, SH, and skin surface pH values remained largely stable after 20 minutes of wearing semipermeable gloves, in contrast to the reactions observed with gloves of occlusive materials. Permeability tests indicated that the semipermeable material is effective, with some restrictions. Air leakage testing revealed that all 50 gloves tested were not airtight. CONCLUSION: Following the optimization of manufacturing methods, additional tests of the penetrability of semipermeable gloves will be necessary.

Short- and long-term effects of single and repetitive glove occlusion on the epidermal barrier.

The aim of this study was to analyse the occlusive effects of glove materials (polyvinyl chloride, natural rubber latex) on epidermal barrier function and to relate the findings to the definitions of wet work in the current German ordinance on hazardous substances (2007) and in the German technical regulations on hazardous substances (TRGS 401; 2008). Short-term effects of wearing gloves once for 4 h, as well as the long-term effects of wearing gloves for 4 h daily for 7 days were assessed in a group of 20 healthy volunteers using non-invasive methods (transepidermal water loss (TEWL), capacitance, skin colour, skin surface pH). Data were collected 30 min and 3 h after single use, as well as 1 day after a 1-week application. TEWL and capacitance data showed hyperhydration of the horny layer 30 min after a 4-h occlusion as compared to baseline (p < 0.05). Three hours later, full recovery to basal values was observed. Additionally, a significant long-term effect after daily occlusion for 4 h for 7 days could not be demonstrated. In current literature, there is controversial evidence concerning the effects of glove occlusion. This study could not verify significant damage to skin barrier after 7 days of repeated occlusion 4 h daily in healthy volunteers. These findings require further discussion regarding the definitions in the current German ordinance on hazardous substances and in the TRGS 401.

Site variations in susceptibility to SLS.

According to the European Society of Contact Dermatitis (ESCD) guidelines on the sodium lauryl sulfate (SLS) exposure test 'the flexor side of forearm skin with cubital fossa and wrist excluded is the preferred study site'. In this study we analysed the exact anatomic region within the suggested test area in respect to the outcome of the SLS exposure test. 3 test areas at the volar forearm were chosen: 'distal' with a 5-cm distance to the wrist, exact 'midvolar' and 'proximal' with a 5-cm distance to the cubital fossa. 25 healthy volunteers were irritated for 24 hr with 1% SLS. Transepidermal water loss (TEWL) measurements were taken before and 1 and 24 hr after removal of Finn Chambers((R)). Median baseline TEWL showed no significant differences in the 3 test sites. However, postexposure TEWL proximal was significantly (P < 0.01) higher than midvolar and distal. The distal volar forearm showed the lowest TEWL 24 h after the irritation. The differences were in comparison to midvolar (P < 0.01) and proximal (P < 0.001) significant. The results show that it is essential to point out the exact position of the test area at the volar forearm in study reports and to randomize the irritation areas at the volar forearm if different treatments are to be compared.

Skin care management: educational aspects.

Health education is effective in primary, secondary and tertiary prevention of occupational skin disorders, as clearly demonstrated by interventional studies carried out at the University of Osnabrueck. Health education may intervene with (a) habituated behaviour of affected employees and (b) the condition of working environments. In conclusion, prevention of occupational skin diseases and maintenance of health can be achieved by the conditioning of individual behaviour via specific educational programmes in addition to dermatological care.