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.

Occupational palmoplantar psoriasis: a clinical case series with consideration of the S1 guidelines on expert medical assessments of occupational psoriasis.

BACKGROUND: Constitutional diseases represent a challenge in the expert assessment of occupational diseases. It is necessary to distinguish professional causes from the spontaneous course of the disease. Recently, a guideline for the assessment of work-related psoriasis has been consented in Germany. We present a case series in which it was applied. PATIENTS AND METHODS: 129 expert assessments from the Department of dermatology University hospital Erlangen and court cases in established juridical databases were researched for cases with psoriasis and the applicability of the guideline. RESULTS: The guideline was applicable in the n = 6 (3.6 %) identified medical expert opinions. They were fully recognized by the workers compensation boards. The search for law sentences on work-related psoriasis in German court cases yielded a total of four sentences, in one of which the psoriasis was recognized as an occupational disease (BK 5101). CONCLUSIONS: In comparison with hand eczema psoriasis of the hands is rare. As has been demonstrated in our case series psoriasis as a constitutional disease may be recognized as an occupational disease (BK 5101) according to the legal system in Germany, if the influence of occupational exposure can be made sufficiently probable and other legal conditions of an occupational disease are met.

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.

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.

[Hand eczema and occupational disorders]. / Eczéma des mains et maladie professionnelle.

Hand eczema (HE) is a frequent skin disease, combining endogenous and exogenous factors. Occupational -or work-related- hand eczema (OHE) is frequently a chronic and relapsing disease, due to irritant and allergenic contacts. Burden of disease is important, since OHE strikes quality of life of the patient, has significant social and economic impact, and may jeopardize his professional future. The management of OHE combines etiological assessment, efficient symptomatic treatment and adaptation of working conditions.

[Rehabilitation for occupational dermatoses. Outpatient and inpatient measures]. / Rehabilitation bei Berufsdermatosen. Ambulante und stationäre Massnahmen.

In recent years, the number of reports of suspicions of occupational diseases, received by the public statutory employer's liability insurance bodies, has remained constant. The recognition of occupational diseases under number 5101 BKV, however, has decreased considerably. This is more than likely due to improved prevention management concepts by the public statutory employer's liability insurance bodies. Nevertheless there are still severe occupational skin diseases that are resistant to or relapse under therapy, thus threatening discontinuation of the occupation. For these cases, an interdisciplinary inpatient treatment as a tertiary individual prevention measure was introduced. This consists of a three-week inpatient period followed by a three-week outpatient sick leave for further stabilization of the skin condition. During the inpatient stay intensive dermatological diagnosis and treatment are accompanied by in-depth health education seminars and psychological interventions. The selection of individually suitable skin protection measures and their practical trial in a workplace simulation model with an ergotherapist are of particular importance. Evaluations of this program showed that two-thirds of the participants with the defined risk of having to give up their occupation were able to continue with their occupation on a long-term basis.

[Applications for medical rehabilitation in the field of dermatology]. / Beantragung medizinischer Rehabilitation in der Dermatologie.

New rehabilitation guidelines and laws have been introduced to promote competition. As a result, the application procedures for rehabilitation measures have been reformed. Since 2007, the application procedure depends on the type of benefit (e.g. secondary or tertiary prevention) and the insurance provider (statutory health or pension insurance company). Thus in order to prescribe rehabilitation as a form of tertiary prevention payable by a statutory health insurance company, accredited doctors have to demonstrate that they have the necessary qualifications as stipulated by the rehabilitation guidelines. As before 2007, any accredited doctor may however apply for rehabilitation in the sense of tertiary prevention payable by a statutory pension insurance company, and for benefits associated with primary and secondary prevention payable by a statutory health insurance company, without providing corresponding proof of qualification. In addition, dermatologists should report occupational skin diseases to the statutory accident insurance using the "optimized dermatologist's report" which also allows them to recommend secondary and tertiary preventative measures. Every insurance-accredited dermatologist should understand the application process and the contents of preventative and rehabilitation measures to ensure their patients' right to participate.

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]).

Relation between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema.

BACKGROUND: Epidemiological studies indicate that occupational hand eczema (OHE) often is associated with persistent dermatitis and prolonged sick leave, which may lead to unemployment. Previous studies suggest that OHE caused by allergic contact dermatitis and atopic dermatitis (AD) carries the worst prognosis. OBJECTIVES: To evaluate and compare the severity and consequences of recognized OHE in different diagnostic and subdiagnostic groups. METHODS: Between October 2001 and November 2002, all new cases of recognized OHE were identified from the Danish National Board of Industrial Injuries Registry (758 cases). Severity was graded from 0 to 2 depending on the intensity of skin response and the frequency of relapse. To supplement the information from the Registry, we surveyed the study population using a postal questionnaire which included questions about disease duration, sick leave, current occupation and loss of job. RESULTS: The overall response rate to the questionnaire was 82%. We observed substantially greater severity among those with occupational irritant contact dermatitis (ICD) and AD than for any other diagnoses. Age above 50 years was also associated with increased severity of OHE. Prolonged sick leave due to OHE was reported by 19.9% and was associated with AD and severe OHE. We found a higher proportion of prolonged sick leave among those in food-related occupations (27.2%) compared with those in wet occupations (20.1%) and other occupations (16.5%). Twenty-three per cent reported that they had lost their job at least once during the past 12 months due to OHE. The only strong association with loss of job was food-related occupations. CONCLUSIONS: Occupational ICD and AD appear to be strongly associated with severity of OHE. AD and severity of OHE were independently associated with prolonged sick leave. Having a food-related occupation appears to be associated with increased risk of loss of job.

[Secondary individual prevention and rehabilitation in female hairdressers suffering from skin diseases]. / Sekundäre Individualprävention bei FriseurInnen.

The risk of contracting occupational skin diseases is highest in hairdressers. A job-specific secondary prevention programme was created to enable hairdressers to stay on the job despite their skin problems. The effect of this prevention programme on both, the severity of skin disorders and the hairdressers' behaviour regarding skin protection are evaluated in this paper. Between 1997 and 2002 a total of 2437 hairdressers participated in the programme. Complete data for the evaluation are available for 635 hairdressers (26 %). This selection is partly due to the fact that the evaluation is restricted to certain regions in Germany. The percentage of hairdressers with severe skin symptoms dropped from 49 % at the start of the rehabilitation programme to 11 % after completion of the programme. The proportion of hairdressers using gloves and applying skin care doubled. Therefore the rehabilitation programme appears to be successful regarding the ability of hairdressers to cope with skin problems.

[Quality of life of patients with occupationally-induced hand eczema]. / Lebensqualität bei Patienten mit berufsbedingten Handekzemen.

In recent years quality of life has been studied in a growing number of different dermatological diseases. Internationally validated questionnaires such the RAND-36 (identical to the SF-36) do not contain enough questions which are relevant for skin diseases. There is no publication on quality of life issues in occupational skin diseases, and only one short report gives data on quality of life in hand eczema. The widely used skin specific instrument DLQI has only 2 questions that indirectly refer to employment issues. A quality of life questionnaire on occupational skin diseases (mostly hand eczema) should ideally include questions on work-related impairment of both physical functioning and interaction with colleagues.

[Pilot study on hairdresser eczema]. / Pilotstudie über Friseurekzeme.

From 1990 to 1992 the allergy profile of 1042 prospective hairdressers (personal and family history, atopic skin, serum IgE, patch and prick tests) was determined and their occupational suitability was evaluated. Up to 1997 a follow up of 375 hairdressers was obtained by way of questionnaires, re-examination, official reports and expert opinions of the social accident insurance. The frequency of initial eczema was 30%. A change of occupation on account of hairdresser eczema was documented in 11%. The prognostic evaluation of occupational suitability proved to be unsatisfactory. In this longitudinal study, the frequency of pre-occupational skin symptoms increased from 13 to 18%. The other atopic criteria indicated no uniform tendency. There was a significant increase in nickel allergy from 18.7 to 45.5% resulting partly from sensitization after entering the occupation and partly from an increase in nickel allergy at time of entry. Both atopic skin and pre-occupational nickel allergy increase the risk of hairdresser eczema, it is not so great as to justify dissuading such young people from entering the profession.

[Value of psychotherapy in expert assessment of skin diseases. Recommendations and indications for additional psychotherapy evaluation in expert assessment from the viewpoint of dermatology]. / Stellenwert der psychotherapeutischen Medizin bei der Begutachtung von Hautkrankheiten. Empfehlungen für die Indikation eines Zusatzgutachtens "Psychotherapeutische Medizin" in der Begutachtung aus der Sicht der Dermatologie.

Skin diseases, the psyche and psychological changes are often intertwined, especially in patients presenting for expert dermatologic opinion. In many cases an additional evaluation provided by psychotherapeutic medicine may be necessary. This resource may help with the diagnosis, explanation of the problem and estimation of the degree of disability. The different legal guidelines of the various evaluation boards must be considered. The role of psychotherapeutic evaluation is demonstrated through case examples. The evaluation of new possibly occupationally-related disorders such as multiple chemical sensitivity and mobbing is considered.

Contact dermatitis: prognosis, risk factors, and rehabilitation.

This article reviews the prognosis for irritant and allergic contact dermatitis and occupational and nonoccupational contact dermatitis. Factors adversely affecting prognosis are discussed. Rehabilitation of the patient with disabling contact dermatitis is considered. The importance of the various risk factors for contact dermatitis are reviewed.

[The fate of patients with occupational skin diseases]. / Zum Schicksal von Patienten mit beruflich bedingten Hautkrankheiten.

The experts judgment on an occupational dermatosis is of existential character for those concerned. The results of such decisions were examined in 100 patients 4-5 years later trough interviews and documents of the professional associations. The reactions were as follows: change of occupations (n = 42, including 18 retrainees), change of job within company/business (n = 34), quitting job/occupation (n = 11), remaining on the job (n = 12). At the time of questioning were half of the retrainees unemployed; loss of income was present in other groups, the loss was lowest in those changing occupations without retraining and highest in those prematurely pensioned. The condition of the skin was best in retrainees, of which 2/3 were unemployed, and worst in those prematurely pensioned. The examination concludes, that at the time of initiation of the occupational dermatosis process by the doctor, the keeping of the workplace must be more critically considered. Some practical guidelines are given.