[New dermatologist's procedure. Research plans for improving secondary prevention of occupational dermatoses]

[The "dermatologist's procedure" after the abolition of the obligation to refrain from risky work activities in occupational disease law]

Die Berufskrankheit (BK) Haut Nr. 5101 war bisher definiert als „schwere oder wiederholt rückfällige Hauterkrankungen, die zur Unterlassung aller Tätigkeiten gezwungen haben, die für die Entstehung, die Verschlimmerung oder das Wiederaufleben der Krankheit ursächlich waren oder sein können“. In einer weitreichenden Reform des Berufskrankheitenrechts, die zum 01.01.2021 in Kraft trat, hat der Gesetzgeber beschlossen, den „Unterlassungszwang“ als Voraussetzung für die Anerkennung einer Berufskrankheit abzuschaffen. Dieser Unterlassungszwang sollte mit dem 1972 eingeführten Hautarztverfahren und den dort etablierten Präventionsinstrumenten (dermatologische Behandlung, Sanierung des Arbeitsplatzes, Hautschutzmaßnahmen, gesundheitspädagogische Maßnahmen) verhindert werden, was in einem Großteil der Fälle auch gelang. Während die Abschaffung des Unterlassungszwangs die Anerkennung von schweren oder wiederholt rückfälligen Hauterkrankungen als Berufskrankheiten erleichtert, wird das Hautarztverfahren jedoch weiterhin Bedeutung behalten für die beruflichen Hauterkrankungen, insbesondere Handekzeme, die primär nicht die Kriterien der Schwere und/oder der wiederholten Rückfälligkeit erfüllen und die durch geeignete Behandlungs- und Präventionsmaßnahmen beherrscht werden können. Um bei einer BK-Anzeige wegen der Schwere oder wiederholten Rückfälligkeit einer Hauterkrankung Verzögerungen in der Sekundärprävention zu vermeiden, sollte gleichzeitig über einen Hautarztbericht zur BK-Anzeige der Unfallversicherungsträger die für zeitnahe Präventionsmaßnahmen und einen dermatologischen Behandlungsauftrag erforderlichen Informationen erhalten. Ein Anhaltspunkt für die Schwere könnte der Erfolg oder der Misserfolg des Hautarztverfahrens sein.

[Quality management in occupational dermatology]

BACKGROUND

Health care of patients with occupational dermatitis (OD) in the sense of suspected "BK 5101" is carried out in Germany within the optimized dermatologist's procedure and the "dermal intervention" (formerly: hierarchical multistep intervention approach) of the statutory accident insurance (UVT), respectively.

OBJECTIVES AND METHODS

Dermatologists and UVT administrators are obliged to improve OD patient care by continuous quality management measures. Essential quality management elements include the research projects EVA_Haut and VVH, the clearing procedure of the Task Force on Occupational and Environmental Dermatology (ABD), training of dermatologists to receive the CME certificate "Occupational Dermatology (ABD)", the establishment of processing standards for administrators and optimized dermatologist's report forms (based on the results of all the above steps taken).

RESULTS

It was shown that the optimized dermatologist's procedure and "dermal intervention" are established in Germany. Also, the available preventive and therapeutic measures for OD patients are effective. Despite the increase of cases with suspected OD, the number of cases in which a career change was required is almost constant (3 %); at the same time the percentage of notified cases which, as a result, are covered within the dermatologist's procedure by the UVT is rising (86 %). The measures recently taken have continuously increased quality of health care in occupational dermatology.

Secondary prevention of occupational dermatoses: first systematic evaluation of optimized dermatologist's procedure and hierarchical multi-step intervention

BACKGROUND

In 2011, 25,056 notifications of suspected occupational dermatitis (OD) were submitted to the statutory accident insurance (UVT), predominant by dermatologist's reports. Parallel to the introduction of the improved dermatologist's procedure, the hierarchical multi-step intervention approach to OD was launched within the UVT. It is aimed at ensuring that patients with OD can be allocated to preventive dermatological interventions quickly and appropriately according to the severity of their OD. From 2007-2010, the quality of dermatological interventions as well as the corresponding administrative procedures were evaluated in a unique research project supported by the German Social Accident Insurance.

PATIENTS AND METHODS

About 10 % (n = 1 600) of notified cases with suspected OD in 2007 in Germany were analyzed in a random quota sample by occupational dermatologists and administrations. Follow-up was 12 months. If a dermatologist's procedure was initiated after the initial notification, patients' and dermatologists' opinions were obtained by questionnaires.

RESULTS

More than 85 % of the OD notifications were submitted by dermatologists and only 1.6 % by occupational physicians. In 88 %, the dermatologist's report was used. Yet, there is room for optimizing procedures: e.g., the clinical and/or occupational relevance of type IV allergies was assessed only in 36.5 % of patients. Job loss due to OD occurred less often if suitable preventive and/or therapeutic strategies (e.g., skin protection seminars) were implemented by the UVT (p = 0.001). Preventive and therapeutic strategies were initiated more often when the dermatologist's report was conclusive, a central element is the outpatient care by a dermatologist.

CONCLUSIONS

The research project shows that the quality of dermatological intervention, as well as administrative procedures, can be optimized. Early intervention with suitable preventive and therapeutic strategies in patients with OD should be aimed at, as this is crucial for the outcome of OD.

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.

[Rehabilitation for occupational dermatoses. Outpatient and inpatient measures]

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.

Pravention und Regeneration epidermaler Barrierestorungen bei Berufsdermatosen. Prevention and regeneration of barrier disturbances in occupational dermatology

Over the past 10 years primary, secondary and tertiary prevention of occupational skin disorders has been shown to be successful, documented with appropriate statistical methods. Interventional strategies are the main features of secondary and tertiary prevention, now well-established in occupational dermatology. Primary prevention is best accomplished by health education measures, both in the form on individual counseling and seminars. This overview reviews the scientific background of hand eczema with respect to barrier damage and repair and then considers the options for individualized and focused prevention. Special anatomical features of the interdigital space and palms, as well as functional disorders, such as palmar hyperhidrosis, are discussed. The importance of barrier regeneration is considered in light of the role of an acid pH, the epidermal calcium gradient and aspects of percutaneous absorption. The effects of anti-oxidants are considered, and new bioengineering methods which rely on physiologic measuring techniques are reviewed.