Tertiare Pravention von Berufsdermatosen. Tertiary prevention of occupational skin diseases

[Skin health promotion in the elderly]

BACKGROUND

Skin aging is associated with anatomical and physiological changes. These changes are not pathological; nevertheless, reduced functional skin capacity increases the susceptibility to skin diseases and functional disorders. Especially in old age, the clinical manifestation of skin changes differs greatly between individuals.

PURPOSE

This contribution focuses on a critical reflection of the concept of preventative skin care and skin health promotion in the aged.

RESULTS

Preventive skin care in the aged includes all activities to cleanse and care for the skin which contribute to health promotion and which reduce the probability developing skin disorders or diseases. Preventive skin care in the aged can be classified into primary, secondary, and tertiary prevention, but the empirical evidence supporting individual interventions is heterogeneous.

CONCLUSION

There are no formally developed guidelines or recommendations for basic skin care in the aged. Thus, preventive skin care in the elderly is very likely to be underused.

Tacrolimus ointment in the treatment of occupationally induced chronic hand dermatitis

BACKGROUND

Occupational hand dermatitis (OHD) is a common and often chronic condition. Usage of topical corticosteroids is limited in long-term therapy because of potential side-effects. New treatment options are highly appreciated.

OBJECTIVE

To study efficacy and safety of tacrolimus in patients suffering from OHD.

PATIENTS AND METHODS

In a prospective, open, multicentre study, 29 patients with OHD of predominantly mild-to-moderate severity were treated with tacrolimus ointment (Protopic 0.1%) during a 4-week active treatment period with twice daily application followed by a 2-month optional treatment period. Efficacy was evaluated by the use of a standardized hand eczema score and by clinical severity rating, conducted on all study visits (screening, baseline and weeks 2, 4, 6, and 12). Adverse events were recorded for safety evaluation.

RESULTS

The hand eczema score declined significantly after 2 weeks of treatment compared with baseline and further declined until the end of the study. Finally, 12 (44%) patients were clear of hand eczema. Worsening of the dermatitis occurred in 2 patients (7%). Clinical grading indicated improvement too. Overall tolerability was good.

CONCLUSION

Topical tacrolimus might be an efficacious treatment option for chronic OHD. Blinded and randomized controlled studies are necessary to confirm the results of this pilot study.

Tertiary individual prevention of occupational skin diseases: a decade's experience with recalcitrant occupational dermatitis

OBJECTIVE

If employees are threatened to loose their job due to a severe occupational skin disease (OSD), intensive interdisciplinary measures of tertiary individual prevention (TIP) are required. TIP comprises 2-3-weeks in-patient treatment plus intensive health-pedagogic counseling, and consecutive 3-weeks out-patient treatment by the local dermatologists. Each patient (pt) will stay off work for a total of usually 6 weeks to allow full barrier-recovery.

METHODS

All 1,486 TIP-pts from various high-risk-professions, treated in our institution in the period 1994-2003, were followed up 1 year after the TIP by a standardised questionnaire, which was returned by 1,164 (78%) pts.

RESULTS

Seven hundred and sixty-four (66%) of the responding 1,164 TIP-pts had successfully remained in their (risk-)professions. It could be demonstrated that to remain in the workplace was dependent on the individual motivation to use skin protection (P < 0.001), the provision of skin protection by the employer (P < 0.001), (higher) age of pt (P < 0.001) and the duration of continued out-patient-treatment by the local dermatologist (P < 0.001). However, there were no significant differences concerning the likelihood of successful job-continuation in the various high-risk-professions, e.g. hairdressers, nurses, metal-workers, food handlers, construction-workers.

CONCLUSION

The obtained data from TIP reveal remarkable pertinent options for interdisciplinary pt-management in severe OSD in all risk-professions.

A 7-step consultation plan for health care workers and hairdressers

BACKGROUND

Skin diseases are among the most common occupational disorders in health care workers and hairdressers. Optimal prevention methods make it possible for more individuals to remain active in their profession. We devised a 7-step consultation plan which was employed in a standard fashion and then evaluated.

PATIENTS AND METHODS

264 employees were evaluated in the Education and Support Center of the German Accident Prevention and Insurance Association in the Health and Welfare Services (BGW schu.ber.z Berlin) from 2003 to 2005 in a standardized manner. Included were detailed history, physical examination, skin physiology measurements (transepidermal water loss, corneometry, sebumetry) and then making a diagnosis and therapeutic recommendations.

RESULTS

Within the study group of 264 employees the most frequent diagnosis were toxic-irritant hand eczema (28.4%), allergic contact eczema (19.7%), atopic eczema (15.5%) and irritant contact eczema with atopic diathesis (13.6%). The frequency of contact sensitivity was high in the study group (80.7%). The skin physiological parameters were not remarkably altered and did not differ between individuals with an atopic diathesis versus without an atopic diathesis.

CONCLUSION

This standardized protocol for a "7-step consultation plan"when applied in a standardized manner offers quality-controlled but also individually-adapted support considering dermatological, educational and occupational aspects. Skin physiology parameters did not provide any further information indicating the need of the development of novel techniques to measure skin barrier function.

Osnabrueck hand eczema severity index - a study of the interobserver reliability of a scoring system assessing skin diseases of the hands

An easy-to-use standardized instrument is needed for the clinical assessment of the severity of occupational hand eczema by dermatologists as well as occupational physicians. The Osnabrueck hand eczema severity index (OHSI) was developed for this purpose and the interobserver reliability investigated. The clinical severity was evaluated on the basis of the extension or clinical characteristics of six morphological characteristics. For the validation of the OHSI, hand eczema in 28 patients was investigated independently by one dermatologist and 2 occupational physicians. The agreement between the observers was determined by using kappa values, Kendall's coefficient of concordance, the intraclass correlation coefficient (ICC) and the 95% limits of agreement. The ICC for the total OHSI was 0.80 and the estimated limits of agreement (-3.6 and 3.0) were sufficiently small to expect that ratings according to OHSI performed by independent observers of different medical specialities should produce similar results. It could be demonstrated that the use of the OHSI is simple and practicable. The interobserver reliability for the summary score is good. OHSI seems a reliable tool for assessing the severity of occupational hand eczema.

Rehabilitation von berufsbedingten Hauterkrankungen

The high incidence rates of occupational contact dermatitis, its poor prognosis, and the high social and economic impact of the disease for the affected individuals as well as for the medical insurance companies indicates a need to strive for the target of "rehabilitation instead of retirement". Here, we highlight the need and effectiveness of rehabilitation measures in individuals with work related skin diseases (mainly contact dermatitis and hand eczema). We discuss the measures for secondary individual prevention as well as tertiary prevention, which have been established in our department together with the state medical insurance companies, mainly the Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (BWG: Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Service). The results of the multicentre study "Optimisation and Quality Assessment of Tertiary Prevention of Occupational Dermatoses" are presented and discussed. Both, the secondary as well as tertiary prevention measures have been successful, which has resulted in a decrease in the total annual rehabilitation costs to the BGW. A reason for this success story is the fact that in Germany these organisations are, in contrast to the health insurance companies, responsible for both acute treatment and the rehabilitation.

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.