Decreasing sunbed use in the German population between 2001 and 2015: survey in 155 679 working persons.

BACKGROUND: UV radiation is a proven cause of skin cancer. Use of sunbeds has been shown to provide an attributable risk. OBJECTIVE: To evaluate the proportion of regular sunbed use in Germany based on large-scale population-based surveys over 15 years. METHODS: Skin cancer screenings by dermatologists were conducted between 2001 and 2015 in more than 500 German companies, including a clinical examination and interviews on the risk behaviour related to sunburns and sunbeds. RESULTS: Among 155 679 persons included regular sunbed use significantly declined from 11.0% in 2001 to 1.6% in 2015 (P < 0.001). There were significantly higher rates of sunbed use in women (12.5%/2.0%) vs. men (7.3%/1.3%; P < 0.001), in younger persons and in participants with darker skin (type II and III) vs. fair skin (type I). Individuals with sunburns in childhood were significantly more often sunbed users (5.1% vs. 4.6%; P = 0.002). A remarkable decline of sunbed use was observed after 2009 (7.0% in 2001-2008 and 2.2% in 2009-2015). This reduction occurred in the time of a legal ban of sunbed use for minors but also with the start of the national skin cancer screening programme. CONCLUSION: Use of sunbeds in the German adult population has dropped by more than 85% in the past decade. Primary prevention, including the large public awareness following the legal ban of sunbed use for young people and the effects of the statutory skin cancer screening programme may have contributed to this.

Perception and image of dermatology in the German general population 2002-2014.

BACKGROUND: In contrast to other European countries, dermatologists in Germany provide health care for a broad spectrum of diseases of the skin and mucous membranes. Current population-based data on the perception of dermatology were lacking to date. OBJECTIVE: Analysis of the perception of dermatology from the general population's perspective with regard to utilization, satisfaction and responsibility. METHODS: Nation-wide survey on awareness, utilization, rating and image of dermatology in October 2014 through computer-assisted telephone interviews on a representative sample of the adult general population (n = 1015), performed by the FORSA institute. RESULTS: Dermatologists as a medical specialist group are familiar to 88% of the population (2002: 65%), and approx. 82% of respondents underwent dermatological treatment in the past. Satisfaction with this treatment is high to very high in 80-90% of respondents. The majority (60-80%) name dermatologists as the desired primary provider of care for the largest share of common skin diseases. For allergic diseases, mucous membrane diseases, venous disorders and paediatric skin diseases, this rate is significantly below 50%. CONCLUSIONS: In Germany, dermatologists are perceived and valued as providers of care. In the case of skin cancer and chronic inflammatory skin diseases, they are experienced as primary care givers, whereas they are associated less frequently than their competence would justify with providing treatment for allergic and mucous membrane diseases and venous disorders. Further education of the general public and medical profession is required.

[Perception of statutory skin cancer screening in the general population : Current findings on participation, knowledge and evaluation]. / Die Wahrnehmung des gesetzlichen Hautkrebsscreenings in der Allgemeinbevölkerung : Aktuelle Erkenntnisse über Teilnahmequote, Kenntnisstand und Beurteilung.

BACKGROUND: Since 2008, German statutory health insurances offer routine skin cancer screening (rSCS) as a standard benefit. Insured persons aged 35 years and older are eligible for screening every 2 years. OBJECTIVES: The aim of the study was to evaluate perception and utilization of rSCS in the general population. MATERIALS AND METHODS: A representative random sample of n = 1004 adult members of the German statutory health insurances were surveyed by the Forsa Institute via computer-assisted telephone interviews in a cross-sectional study in April 2015. RESULTS: On 39% of all persons interviewed, skin cancer screening had been executed at least once; the percentage of those entitled for rSCS was 45%. Of the participants, 50% were aware of the rSCS eligibility framework, with multiple sources of information. In 82% of cases, rSCS was performed by a dermatologist. The majority (87%) of those who had already undergone rSCS stated that the advantages of the procedure outweighed inconveniences. While participation in rSCS constantly increased (2011-2013-2015), knowledge of eligibility did not. CONCLUSIONS: Seven years after implementation, rSCS has been utilized by almost half of those entitled and was rated positively by the majority. However, lack of knowledge about rSCS eligibility is also present in 50%. Further targeted informative measures are needed to increase awareness of rSCS.

Participation and health care provision of statutory skin cancer screening in Germany - a secondary data analysis.

BACKGROUND: In Germany, skin cancer screening was introduced nationwide in July 2008. From the age of 35 years, members of the statutory health insurance are eligible for screening every 2 years. OBJECTIVE: The aim of this study is to calculate the participation rates and the proportions of health care providers of statutory skin cancer screening in Germany on a population-based level. METHODS: Data were provided by a nationwide German statutory health insurance, approximately 6.1 million members, covering the years 2008/2009. Participation rates were calculated per yearly quarter and were adjusted for age, gender and federal state. RESULTS: Approximately 920,000 insurants were screened from the third quarter of 2008 until the last quarter of 2009. Mean participation rate of skin cancer screening was 30.8%. Women had higher participation rates (31.9%) than men (29.7%). After adjusting for gender and federal state, high rates for pensioners at the age of 65-74 were confirmed at 39.4% on average for all yearly quarters. One of the highest gender- and age-adjusted rates was observed in the state of Schleswig-Holstein, where a population based pilot project had been implemented before the start of the nationwide screening programme. In general, without taking into account Berlin, former East Germany had a much lower gender- and age-adjusted participation rate (23.9%) than West Germany (33.3%). At the first quarter after implementation of screening, 58.5% of the screenings were provided by dermatologists and 41.5% by general practitioners. CONCLUSION: Participation rates and health care providers of skin cancer screening can be calculated from secondary data and contribute to identify group- and region-specific participation patterns in order to improve early detection of skin cancer.

[Regional differences in the health care of basal cell carcinoma]. / Regionale Unterschiede in der Versorgung des Basalzellkarzinoms.

BACKGROUND: Basal cell carcinoma (BCC) is the most common type of skin cancer in Germany. So far, it is unclear whether regional variations exist in the health care of the BCC. OBJECTIVES: Analysis of regional variations in health care (e. g., skin cancer screening) and their causes using the example of BCC. MATERIALS AND METHODS: Qualitative and quantitative analysis of the regional health care situation of BCC based on three studies was undertaken. These studies include the analysis of n = 7015 histopathological indications whose average tumor thickness is regarded as a characteristic of the quality of care, and a secondary data analysis of GK insured (n = 6.1 million DAK-insured persons), and a nationwide survey (FORSA) of n = 1004 participants focusing on the use of skin cancer screening. RESULTS: Analysis of the histopathological examination showed regional variations in average tumor depth of penetration. These are associated with the rural/urban characteristics of the region and individual sociodemographic indicators (e. g., employment sector or education). The results for age- and gender-specific use (DAK data) showed higher participation rates regarding skin cancer screening in western than in eastern federal states (Bundesländer). Moreover, it was revealed that the trend for using skin cancer screening was higher in urban than in rural areas. The results of population-related surveys confirm this trend. CONCLUSION: Although it is not possible to compare the studies directly, all three showed an association between city/state and the use of skin cancer screenings. In addition, sociodemographic characteristics that are related to the quality of health care were identified.

[Primary cutaneous cryptococcosis : Pigeons can carry more than letters !] / Primär kutane Kryptokokkose : Tauben können mehr als Briefe transportieren !

In the event of non-specific epidermal lesions, the importance of a comprehensive anamnesis becomes especially apparent. In the following, we report on a patient case in which only a focused anamnesis was able to bring light into the darkness of numerous differential diagnoses - and to produce the diagnosis of a rare but in this collective common illness: primary cutaneous cryptococcosis.

[Risk characteristics and survival rates of malignant melanoma in Germany and the Netherlands]. / Risikomerkmale und Überlebensrate des malignen Melanoms in Deutschland und den Niederlanden.

BACKGROUND: Mortality and lethality of malignant melanoma (MM) show marked variations throughout Europe, thereunder a higher risk within the Netherlands (NL) when compared to Germany (D). GOAL AND METHODS: Comparison of systems and exploration of possible causal factors that could explain the difference between D and NL. Comparative healthcare research analysis using published international literature, as well as publicly accessible databases, and a subsequent hypothesis-generating analysis. RESULTS: The higher rate of excised MM less than 1 mm in diameter in D (65 % vs. 45 %) confirms the clinical reports of the cancer registries. The biological factors for the emergence of MM, such as skin type, do not seem to significantly differ from each other. Among the further potential predictors there are no relevant differences within, for example, geographical conditions and the qualifications of the treating physicians. Primary prevention has a longer continual tradition in D. Here, secondary prevention is characterized by population-based extensive screening, which does not occur within the NL. In addition, distinct differences are found regarding access to dermatologists. CONCLUSION: System access to a medical specialist and the prevention of skin cancer are currently the most distinctive potential determinants of more favorable MM survival rate in Germany.

[Care for skin cancer in Germany : Provision and providers]. / Versorgung des Hautkrebses in Deutschland : Leistungsvolumina und -erbringer.

BACKGROUND: Treatment for skin cancer is a major component of dermatological care in western countries. OBJECTIVE: The purpose of this work is to analyze health care provision and providers for skin cancer care in Germany. METHODS: From the complete claims data set from 2007-2009 of the German statutory health insurance DAK (approximately 6.1 million insured persons), insurees with skin cancer and melanocytic naevi were extracted by ICD-10 codes. Surgical procedures and physician specialties were identified by specific codes. Data from the German statistical agency (Destatis) were derived from public domain for the years 2008-2010. RESULTS: Among the annual ambulatory surgical treatments (n = 6695) for melanoma, 83.6 % were conducted by dermatologists, followed by general surgeons (11.1 %), and facial surgeons (3.0 %). In melanocytic naevi (n = 51,659), 79.1 % were treated by dermatologists, followed by general surgeons (15.5 %), facial surgeons (3.6 %), and general practitioners (1.1 %), while in epithelial cancers (ICD-10 C44), 76.4 % were operated by dermatologists, followed by general surgeons (12.7 %) and facial surgeons (7.9 %). Overall, related to Germany, about 830,000 ambulatory operations for skin cancer were conducted in 2009 which is about 40 % more than in 2007. In hospitalized patients, 79,448 out of 195,558 inpatient cases (45.5 %) were treated in dermatological departments in the year 2012. Average annual growth rates of the inpatient cases in the DAK between 2007 and 2010 were 8.9 % for MM and 11.1 % for SCC/BCC. CONCLUSION: Skin cancer is associated with a significant and still growing need for surgical care in which dermatology has a leading role in Germany. Thus, there is an increasing need for dermato-surgical specialist training.

Prevalence and risk factors of actinic keratoses in Germany--analysis of multisource data.

BACKGROUND: In Europe, only few and inconsistent data on the prevalence and treatment of actinic keratoses (AK) are available. OBJECTIVES: To determine the prevalence of AK in Germany, to identify potential predictors and to estimate the number of AK cases treated in dermatological practices. METHODS: In a multiple-source approach, prevalence was assessed from whole-body examinations in a cohort of 90 800 employees and from nationwide statutory health insurance (SHI) data of 2008. The number of cases documented in dermatological offices was estimated from statistics of a SHI Physicians Association. RESULTS: Standardized prevalence of AK from dermatological examinations was 2.7%; the rate increased with age (11.5% in the group 60-70 years) and was higher for men (3.9%) than for women (1.5%). Significant associations were also identified for skin phototype I, sunburns in childhood and solar lentigines. Vitiligo and a history of melanoma were also, but not significantly, associated with AK. In the SHI data analysis, standardized AK prevalence was 1.8%. Age-specific rates were below 1.5% up to 60 years and rose to 8.2% (13.2% in men) in the group 80-89 years. The prevalence from these large data sets--which is at the lower limit of studies from other countries--suggests about 1.7 million estimated AK cases in Germany. In 2011, AK accounted for 8.3% of the hundred most frequently treated dermatological outpatient diagnoses. The proportion of AK cases has risen almost continuously over the last 10 years, compared to other dermatological conditions. Estimated annual number of AK cases documented by dermatologists in Germany is about 1.7 million. CONCLUSIONS: Actinic keratosis is a frequent condition in higher age groups and more prevalent in men; a relevant need for health care is evident. Predictors and risk factors for AK are easy to identify in the population, which could also help to detect groups with special need for preventive measures.

A new instrument for the assessment of patient-defined benefit in the treatment of allergic rhinitis.

BACKGROUND: Allergic rhinitis (AR) is a common disease that affects health-related quality of life (HRQoL). Current and future health policy demands the assessment of patient-relevant treatment benefit for evaluation of treatments. METHODS: We developed, validated and tested a standardized instrument for the assessment of patient-relevant needs and benefits in AR. In an open survey of patients with AR, 100 need and benefit items were generated. The items were condensed to a 25-item list by an expert panel. On this list, patient rates the personal importance of 25 treatment needs on a scale ranging from 'not at all' to 'very' before treatment (Patient Needs Questionnaire, PNQ). At the end of the treatment, patient rates the extent, to which these needs were achieved by treatment from 'did not help at all' to 'helped a lot' (Patient Benefit Questionnaire). The patient benefit index (PBI) is computed to provide a global weighted benefit parameter. This disease-specific instrument was validated in n = 104 patients with AR. RESULTS: The PBI-AR showed good acceptability and feasibility in clinical routine. Reduction in nose and eye symptoms was rated most important. The PBI amounted to 2.2 (PBI ranges from 0 = 'no benefit' to 4 = 'maximum benefit'). Reliability of the PNQ was high (Cronbach's alpha = 0.9).The PBI was significantly correlated with relevant external validation criteria, such as patient satisfaction (R = 0.54) and HRQoL (R = 0.26). CONCLUSION: The PBI-AR is a feasible, reliable and valid instrument for the standardized assessment of patient-relevant benefits in the treatment of AR.

The Euromelanoma skin cancer prevention campaign in Europe: characteristics and results of 2009 and 2010.

BACKGROUND: Euromelanoma is a skin cancer education and prevention campaign that started in 1999 in Belgium as 'Melanoma day'. Since 2000, it is active in a large and growing number of European countries under the name Euromelanoma. OBJECTIVE: To evaluate results of Euromelanoma in 2009 and 2010 in 20 countries, describing characteristics of screenees, rates of clinically suspicious lesions for skin cancer and detection rates of melanomas. METHODS: Euromelanoma questionnaires were used by 20 countries providing their data in a standardized database (Belgium, Croatia, Cyprus, Czech Republic, FYRO Macedonia, Germany, Greece, Hungary, Italy, Lithuania, Luxembourg, Malta, Moldavia, Portugal, Serbia, Slovenia, Spain, Sweden, Switzerland and Ukraine). RESULTS: In total, 59,858 subjects were screened in 20 countries. Most screenees were female (64%), median ages were 43 (female) and 46 (male) and 33% had phototype I or II. The suspicion rates ranged from 1.1% to 19.4% for melanoma (average 2.8%), from 0.0% to 10.7% for basal cell carcinoma (average 3.1%) and from 0.0% to 1.8% for squamous cell carcinoma (average 0.4%). The overall positive predictive value of countries where (estimation of) positive predictive value could be determined was 13.0%, melanoma detection rates varied from 0.1% to 1.9%. Dermoscopy was used in 78% of examinations with clinically suspected melanoma; full body skin examination was performed in 72% of the screenees. CONCLUSION: Although the population screened during Euromelanoma was relatively young, high rates of clinically suspected melanoma were found. The efficacy of Euromelanoma could be improved by targeting high-risk populations and by better use of dermoscopy and full body skin examination.

The German National Program on Psoriasis Health Care 2005-2015: results and experiences.

In 2005, the first national psoriasis survey in Germany revealed large deficits in health care particularly in patients with moderate to severe disease. The consecutive goal was to improve health care for psoriasis countrywide. For this, a large-scale national program was initiated starting with a comprehensive analysis of structures and processes of care for psoriasis. Patient burden, economic impact and barriers to care were systematically analyzed. In order to optimize routine care, a S3 guideline, a set of outcomes measures and treatment goals, were developed. Implementation was enforced by the German Psoriasis Networks (PsoNet) connecting the most dedicated dermatologists. The annual National Conference on Health Care in Psoriasis established in 2009 consented National Health Care Goals in Psoriasis 2010-2015 and defined a set of quality indicators, which are monitored on a regular basis. Currently 28 regional networks including more than 800 dermatologists are active. Between 2005 and 2014 7 out of 8 quality indicators have markedly improved, and regional disparities were resolved. e.g., mean PASI (Psoriasis Area Severity Index) dropped from 11.4 to 8.1 and DLQI (Dermatology Life Quality Index) from 8.6 to 5.9. A decade of experience indicates that a coordinated nationwide psoriasis program based on goal orientation can contribute to better quality of care and optimized outcomes.

Comparative removal of pyrimidine dimers from human epidermal keratinocytes in vivo and in vitro.

We have compared the kinetics for repair of UV-induced cyclobutane pyrimidine dimers in the DNA of keratinocytes in human skin and in cell culture. A small area of the buttocks of volunteers was exposed to UVB-irradiation and biopsies were taken at various time intervals. Epidermal keratinocytes in culture from the same subjects were exposed to UVC with doses chosen to elicit comparable yields of dimers in cellular DNA. The initial density of pyrimidine dimers and the kinetics of their removal were assessed utilizing the dimer-specific T4 endonuclease V and sedimentation of the unlabeled DNA through alkaline sucrose gradients. The position of DNA in the gradients was determined using a monoclonal antibody against random sequences of single-stranded DNA in a sensitive immunoassay. The initial dimer frequency was 3.9-6.7 per 10(8) daltons DNA. About 40% of the dimers were removed within 1 h, 70% in 6 h, and 90% in 24 h for both in vivo and in vitro samples. The early rapid removal phase may represent preferential repair of actively transcribed genes. Our findings reaffirm the usefulness and applicability of cell culture systems to model in vivo repair phenomena. The use of monoclonal antibodies to detect single-stranded DNA in alkaline sucrose gradients may be of value in a variety of studies involving human tissues in which it is not possible to use radioactive labeling of the DNA for the analysis.

Metabolism of arachidonic acid by human epidermal cells depends upon maturational stage.

Synthesis of 12- and/or 15-HETE by human epidermal cells was investigated after separating basal cells from suprabasal epidermal cell layers. We found that the main metabolite of 3H-arachidonic acid (3H-AA), formed by freshly prepared upper epidermal layers (stratum granulosum and spinosum), upon RP-HPLC co-eluted with authentic 3H-12-HETE. A 3H-15-HETE co-eluting peak selectively occurred in chromatograms obtained from supernatants of fractions containing basal cells. Supernatants of freshly prepared suspensions rich in basal keratinocytes appeared to contain 3H-15-HETE as their main 3H-AA metabolite, by far exceeding the recovered amounts of 3H-12-HETE. Moreover, keratinocytes cultured for 1 week or longer were found to produce predominantly a 3H-AA metabolite co-eluting with 3H-15-HETE. In supernatants of cultured cells, little if any 3H-12-HETE was detectable. Cultured human skin fibroblasts were not found to produce relevant amounts of HETE. Genuine tissue rich in basal cells, i.e., cells of hair follicles, were found to form twice as much 3H-15-HETE as 3H-12-HETE (3H-15-HETE/3H-12-HETE-ratio = 1.9 +/- 0.8; n = 7). Apparently, different epidermal layers are able to produce a characteristic pattern of 3H-AA metabolites. 3H-15-HETE generation seems to be a marker for proliferating keratinocytes, whereas 3H-12-HETE formation appears to be typical for differentiating suprabasal epidermal cells. Our results may explain the heretofore varying patterns of AA-metabolites by keratinocytes reported in the literature.

Effect of neuropeptides present in skin on the proliferation of human peripheral blood mononuclear cells and T cells.

The release of neuropeptides, such as substance P (SP) and somatostatin (SOM), from primary sensory nerve fibers has been implicated in the modulation of local immune responses in surface tissues, such as the skin, the pulmonary airways, and the gastrointestinal mucosa. We have investigated the influence of six neuropeptides substance P (SP), somatostatin (SOM), substance K (SK), vasoactive intestinal peptide (VIP), bombesin (BOM), and adrenocorticotropic hormone (ACTH) on the proliferation of resting and partially stimulated human peripheral blood mononuclear leukocytes (PBMLs) and T lymphocytes. Neuropeptides in concentrations from 10(-7) to 10(-12) M were added to either resting or partially stimulated cells [interleukin-2 (IL-2), concanavalin A (Con A), and phytohemagglutinin (PHA)]. Cellular proliferation was assessed by incorporation of 3H-thymidine after 72 h. With the exception of SP, no significant effect of any of these neuropeptides on 3H-thymidine incorporation was found. In resting cells, 10(-9) MSP elicits an 80...maximal increase of 3H-thymidine incorporation, whereas no statistically significant effect on partially stimulated leukocytes was found. These results contradict a previous report on a significant mitogenic effect of SP on partially stimulated T cells. Considering the very minimal effect of SP on resting cells and, particularly, the absence of an effect on partially stimulated cells, we would question a significant modulatory role for SP and the five other neuropeptides in the proliferation of immunocompetent cells in skin.

Preferential binding of monocytes and Leu 2+ T lymphocytes to interferon-gamma treated cultured skin endothelial cells and keratinocytes.

Recombinant gamma interferon (r-IFN-gamma) increases the adherence of peripheral blood mononuclear leukocytes (PBMLs) to cultured keratinocytes and cutaneous microvascular endothelial cells (MECs). To determine which specific type of PBMLs bound to these r-IFN-gamma treated cells, we performed immunophenotyping on the adherent PBMLs. The adherent PBMLs were detached from the r-IFN-gamma treated keratinocytes and MECs by adding EDTA, and collected by cytocentrifugation, followed by immunocytochemical staining using a panel of monoclonal antibodies. Our results reveal that the relative adherent population of PBMLs was composed of approximately 60%-70% monocytes and 18%-24% Leu 2+ T lymphocytes (T-cytotoxic/suppressor) which preferentially bound to r-IFN-gamma treated keratinocytes and MECs. There was some lesser binding by Leu 3 + lymphocytes (T-helper/inducer); approximately 8%, and no binding of B lymphocytes. Since r-IFN-gamma also induced HLA-DR expression in keratinocytes and MECs, these in vitro data suggest that r-IFN-gamma may play an important role in the immunobiology of diverse skin diseases such as graft vs host disease, lichen planus, and other inflammatory dermatoses, because the keratinocytes express HLA-DR and the predominant T-cell subset in the epidermis is Leu 2 + (over the Leu 3 + T cell) in all of these conditions. These results represent a direct attempt to explain in situ immunophenotypic mononuclear leukocyte subset distribution patterns by using r-IFN-gamma and purified cultured cells such as keratinocytes and MECs. We propose that IFN-gamma, by both increasing the adherence of PBMLs, and promoting selective binding of monocytes and Leu 2 + T lymphocytes to both keratinocytes and MECs, may be important in regulating PBML localization and recirculation in the skin.

Leukotriene B4 enhances adherence of human polymorphonuclear leukocytes to dermal microvascular endothelial cells in vitro.

Adherence of polymorphonuclear leukocytes (PMNs) to endothelial cells (ECs) is a crucial step in the diapedesis of inflammatory cells to the site of inflammation. We have demonstrated that leukotriene B4 (LTB4), a metabolite of the arachidonic acid cascade, and N-formyl-L-methionyl-L-leucyl-L-phenylalanine (FMLP) significantly enhance the binding of human PMNs to selected populations of human dermal microvascular endothelial cells (MECs) in vitro. MECs were isolated from the vascular-rich portion of foreskins of newborns. MECs were grown in Iscove's modified Dulbecco's media with 2% prepartum serum and 8% newborn calf serum on 1% gelatin-coated plastic dishes. PMNs isolated from five human donors were added to the culture dishes for varying time intervals (usually 30 min) in the presence and absence of the chemotactic stimuli LTB4 and FMLP. Addition of PMNs to MECs in the absence of chemotactic stimuli results in "baseline" binding to the MEC monolayer. About one in every 150 ECs binds more than five PMNs. These selected ECs are randomly distributed throughout the monolayer. LTB4 from 10(-10) to 10(-7) M increases the number of MECs which selectively bind PMNs by 260% at 10(-7) M. FMLP also increases adherence in qualitatively and quantitatively similar fashion. These data support a role for LTB4 in the mediation of adherence of neutrophils to dermal MECs. In contrast to other endothelial cells from the large blood vessels, such as from umbilical veins or calf thoracic aortae, PMNs bind only to selected MECs in culture, even when stimulated with LTB4 or FMLP.(ABSTRACT TRUNCATED AT 250 WORDS)