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Leskur D, Bročić I, Mićanović M, Lozić M, Rušić D, Perišin AŠ, Maleš I, Modun D, Bukić J. Introducing the model of repeated exposure of skin to antiseptics: Randomised pilot trial. Contact Dermatitis 2024; 90:585-593. [PMID: 38417425 DOI: 10.1111/cod.14532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/01/2024]
Abstract
INTRODUCTION Intensified hand hygiene measures were recommended for preventing the spread of SARS-CoV-2. However, these measures can lead to skin damage and the development of hand eczema, particularly among health professionals. OBJECTIVES This pilot study aimed to evaluate the effects of repeated antiseptic use on healthy skin under controlled conditions and to assess the emollient use. METHODS Twelve healthy volunteers (nine females, age = 22.3 ± 2.8 years (mean ± SD), Fitzpatrick phototypes II and III) with no skin diseases were recruited. Antiseptic was applied daily for 3 weeks on the volar sides of forearms. Emollient cream was also applied daily. Skin assessments were performed using non-invasive methods (transepidermal water loss-TEWL, skin hydration, erythema and melanin content). RESULTS Prolonged antiseptic use increased TEWL, decreased hydration and elevated erythema and melanin levels. Emollient cream significantly reduced TEWL and improved hydration on antiseptic-treated sites, and also enhanced hydration on intact skin. CONCLUSIONS Prolonged use of antiseptics can have adverse effects on the skin, including barrier disruption and inflammation. Emollient showed promise in improving skin hydration and reducing the damage caused by antiseptics. Further research with a larger sample is needed to confirm these findings and assess emollient efficacy during frequent antiseptic use.
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Affiliation(s)
- Dario Leskur
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Ivana Bročić
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Mislav Mićanović
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Mirela Lozić
- Department of Medical Chemistry and Biochemistry, University of Split School of Medicine, Split, Croatia
| | - Doris Rušić
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Ana Šešelja Perišin
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Ivanka Maleš
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Darko Modun
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Josipa Bukić
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
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Wang Y, Vizely K, Li CY, Shen K, Shakeri A, Khosravi R, Smith JR, Alteza EAII, Zhao Y, Radisic M. Biomaterials for immunomodulation in wound healing. Regen Biomater 2024; 11:rbae032. [PMID: 38779347 PMCID: PMC11110865 DOI: 10.1093/rb/rbae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 05/25/2024] Open
Abstract
The substantial economic impact of non-healing wounds, scarring, and burns stemming from skin injuries is evident, resulting in a financial burden on both patients and the healthcare system. This review paper provides an overview of the skin's vital role in guarding against various environmental challenges as the body's largest protective organ and associated developments in biomaterials for wound healing. We first introduce the composition of skin tissue and the intricate processes of wound healing, with special attention to the crucial role of immunomodulation in both acute and chronic wounds. This highlights how the imbalance in the immune response, particularly in chronic wounds associated with underlying health conditions such as diabetes and immunosuppression, hinders normal healing stages. Then, this review distinguishes between traditional wound-healing strategies that create an optimal microenvironment and recent peptide-based biomaterials that modulate cellular processes and immune responses to facilitate wound closure. Additionally, we highlight the importance of considering the stages of wounds in the healing process. By integrating advanced materials engineering with an in-depth understanding of wound biology, this approach holds promise for reshaping the field of wound management and ultimately offering improved outcomes for patients with acute and chronic wounds.
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Affiliation(s)
- Ying Wang
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
- Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4 Canada
| | - Katrina Vizely
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada
| | - Chen Yu Li
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada
| | - Karen Shen
- Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4 Canada
| | - Amid Shakeri
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
- Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4 Canada
| | - Ramak Khosravi
- Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4 Canada
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - James Ryan Smith
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | | | - Yimu Zhao
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
- Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4 Canada
| | - Milica Radisic
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
- Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4 Canada
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada
- Terrence Donnelly Centre for Cellular & Biomolecular Research, University of Toronto, Toronto, ON M5S 3E1, Canada
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Gill C, Fischer AK, Dicke K, Teigelake B, Brans R, Skudlik C, John SM, Symanzik C. Teledermatological Follow-Up Consultations in Individual Prevention of Occupational Dermatoses: A Monocentric Feasibility Study on Quality and Satisfaction by Patients and Physicians. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6127. [PMID: 37372714 DOI: 10.3390/ijerph20126127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
Teledermatology has become very popular, and not only due to the SARS-CoV-2 pandemic. Patients with occupational skin diseases (OSDs) could also benefit from teledermatology services as part of their follow-up care, but the opportunities and challenges for patients and dermatologists, especially regarding quality and satisfaction, need exploration. In this single-center feasibility study, 215 patients taking part in a tertiary prevention program for OSD were invited to participate. After obtaining consent, a follow-up video consultation appointment with the center's dermatologists was made. Quality and satisfaction with the consultations were evaluated by fully standardized online questionnaires filled in by the patients and dermatologists. A total of 68 teledermatological follow-up consultations were conducted by 10 dermatologists on 42 patients. Half of the dermatologists (50.0%) and 87.6% of the patients were satisfied with the video consultations. However, the lack of physical examination seems to be a problem, especially from the physicians' point of view (75.8%). A total of 66.1% of the dermatologists and 87.5% of the patients saw video consultations as useful supplements to face-to-face consultations. The results of our feasibility study indicate general satisfaction of patients and physicians with teledermatological sessions in occupational dermatology, especially as a useful supplement to face-to-face consultation.
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Affiliation(s)
- Carina Gill
- Department of Dermatology, Institute for Health Research and Education, Environmental Medicine and Health Theory, University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
| | - Ann-Kristin Fischer
- Department of Dermatology, Institute for Health Research and Education, Environmental Medicine and Health Theory, University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
| | - Katja Dicke
- Department of Dermatology, Institute for Health Research and Education, Environmental Medicine and Health Theory, University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
| | - Björn Teigelake
- Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (BGW), Gesundheitscampus-Süd 29, 44801 Bochum, Germany
| | - Richard Brans
- Department of Dermatology, Institute for Health Research and Education, Environmental Medicine and Health Theory, University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Lower Saxony Institute of Occupational Dermatology at the University of Osnabrück, 49076 Osnabrück, Germany
| | - Christoph Skudlik
- Department of Dermatology, Institute for Health Research and Education, Environmental Medicine and Health Theory, University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Lower Saxony Institute of Occupational Dermatology at the University of Osnabrück, 49076 Osnabrück, Germany
| | - Swen Malte John
- Department of Dermatology, Institute for Health Research and Education, Environmental Medicine and Health Theory, University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Lower Saxony Institute of Occupational Dermatology at the University of Osnabrück, 49076 Osnabrück, Germany
| | - Cara Symanzik
- Department of Dermatology, Institute for Health Research and Education, Environmental Medicine and Health Theory, University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrück, Am Finkenhügel 7a, 49076 Osnabrück, Germany
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Symanzik C, Skudlik C, John SM. Acceptance of skin products in healthcare workers: an empirical investigation. Occup Med (Lond) 2023; 73:29-32. [PMID: 35641115 PMCID: PMC9384166 DOI: 10.1093/occmed/kqac046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Healthcare workers (HCWs) are at high risk of developing hand eczema (HE). This can be exacerbated by hygiene measures related to the coronavirus disease (COVID-19). Using mild skin cleansers and emollients or moisturizers is central in the prevention of HE-especially with increased COVID-19 hygiene regimes. AIMS This study aimed to assess parameters important for the acceptance of a skincare concept in HCWs. METHODS In this proof-of-concept user trial, HCWs were provided ad libitum with hand wash oil and hand cream during the 6-month period, when occupationally acquired COVID-19 infections among HCWs were peaking in Germany and then surveyed about acceptance of the products using questionnaires. RESULTS Of 135 HCWs, 115 (85%) responded. Skin tolerance of the hand wash oil and the hand cream was rated very good by 63% and 52% of the 115 participants, respectively. Of the 115 participants, 58% and 57% were very satisfied with the hand wash oil and the hand cream, respectively. CONCLUSIONS Acceptance of skin cleansing and skincare products in HCWs seems influenced by parameters such as self-assessed skin tolerance and self-reported overall satisfaction. It must be assumed that products are only used as recommended if they are well-accepted. Employers might survey employees about acceptance of products using the parameters identified to adjust concepts if necessary to sustainably contribute to the prevention of HE.
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Affiliation(s)
- C Symanzik
- Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at Osnabrück University, Osnabrück, Germany
| | - C Skudlik
- Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at Osnabrück University, Osnabrück, Germany
| | - S M John
- Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, Osnabrück, Germany
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at Osnabrück University, Osnabrück, Germany
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Gina M, Wichert K, Pieper B, Behrens T, Brüning T, Fartasch M. Irritative potential of different washing procedures used for heavy-duty soiling: Short and intense or longer and mild? Contact Dermatitis 2023; 88:363-371. [PMID: 36727255 DOI: 10.1111/cod.14282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/22/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND To prevent irritant contact eczema even in occupational fields with heavy-duty soiling, it is generally recommended to use 'mild' hand cleansers (mild detergent without grits, MC). On the other hand, since grit-containing cleansers (GC) show a higher washing power that minimizes washing time, their usage is generally preferred in specific occupational fields. OBJECTIVES To compare whether a shorter, intense washing period might cause less skin damage than a longer washing period with an MC. METHODS Differences in cleaning time were first verified in a pilot study using standardized model dirt. In the main study, the forearms of 35 healthy volunteers were washed with three standardized procedures over a period of 3 days, either using 2 min of MC with/without hand brush or 1-min GC. Clinical scoring, transepidermal water loss (TEWL), corneometry, colourimetry and scaliness/roughness (Visioscan) were used to evaluate the epidermal barrier, topography and irritation. RESULTS The pre-study showed that washing time doubled when using MC vs. GC. Using GC resulted in stronger barrier disruption, even after a shorter washing period - median ΔT4-T1 TEWL 0.96 g/m2 /h vs. 4.91 g/m2 /h respectively, p < 0.0001. The most harmful procedure for the skin was the additional application of a hand brush (18.86 g/m2 /h). CONCLUSIONS Short-time washing with GC damages the skin barrier more significantly in comparison to a longer application of an MC. When washing with MC, the strongest irritant reaction occurred when accompanied with hand brushing.
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Affiliation(s)
- Michal Gina
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA), Institute of the Ruhr University Bochum, Bochum, Germany
| | - Katharina Wichert
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA), Institute of the Ruhr University Bochum, Bochum, Germany
| | - Birgit Pieper
- German Social Accident Insurance - Institution for the Woodworking and Metalworking Industries (BGHM), Dortmund, Germany
| | - Thomas Behrens
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA), Institute of the Ruhr University Bochum, Bochum, Germany
| | - Thomas Brüning
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA), Institute of the Ruhr University Bochum, Bochum, Germany
| | - Manigé Fartasch
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA), Institute of the Ruhr University Bochum, Bochum, Germany
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Symanzik C, Stasielowicz L, Brans R, Skudlik C, John SM. Prevention of occupational hand eczema in healthcare workers during the COVID-19 pandemic: a controlled intervention study. Contact Dermatitis 2022; 87:500-510. [PMID: 35989622 PMCID: PMC9538141 DOI: 10.1111/cod.14206] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/03/2022] [Accepted: 08/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Occupational hand eczema (HE) is common among healthcare workers (HCWs) and has - in some regions of the world - increased during the COVID-19 pandemic due to related hygiene measures. OBJECTIVES To evaluate the efficacy of an intervention for HE prevention in HCWs during the pandemic. METHODS A prospective, controlled, unblinded interventional trial was conducted in 302 HCWs. The intervention group (IG) (n = 135) received online-based health education and free access to hand cleansing and hand care products. The control group (CG) (n = 167) did not receive any intervention within the study. At baseline (T0), after three (T1) and six (T2) months, participants completed standardised questionnaires. The Osnabrueck Hand Eczema Severity Index (OHSI) was assessed at T0 and T2. RESULTS During the observation period, there were no new HE cases in the IG (n = 115) and 12 cases (8.8%) in the CG (n = 136). OHSI values at T2 were lower in the IG (b = -1.44, P < 0.001). Daily use of emollients was higher at work (b = 1.73, P < 0.001) and at home (b = 1.62, P < 0.001) in the IG at T2. CONCLUSIONS The intervention was effective in HE prevention and improving skin care behaviour during the COVID-19 pandemic. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Cara Symanzik
- Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, Osnabrück, Germany.,Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at Osnabrück University, Osnabrück, Germany
| | | | - Richard Brans
- Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, Osnabrück, Germany.,Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at Osnabrück University, Osnabrück, Germany
| | - Christoph Skudlik
- Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, Osnabrück, Germany.,Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at Osnabrück University, Osnabrück, Germany
| | - Swen M John
- Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, Osnabrück, Germany.,Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at Osnabrück University, Osnabrück, Germany
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Symanzik C, Weinert P, Babić Ž, Hallmann S, Havmose MS, Johansen JD, Kezic S, Macan M, Macan J, Strahwald J, Turk R, van der Molen HF, John SM, Uter W. Skin Toxicity of Selected Hair Cosmetic Ingredients: A Review Focusing on Hairdressers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:7588. [PMID: 35805241 PMCID: PMC9265752 DOI: 10.3390/ijerph19137588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/06/2022] [Accepted: 06/18/2022] [Indexed: 12/04/2022]
Abstract
The safety assessment of cosmetics considers the exposure of a 'common consumer', not the occupational exposure of hairdressers. This review aims to compile and appraise evidence regarding the skin toxicity of cysteamine hydrochloride (cysteamine HCl; CAS no. 156-57-0), polyvinylpyrrolidone (PVP; CAS no. 9003-39-8), PVP copolymers (CAS no. 28211-18-9), sodium laureth sulfate (SLES; CAS no. 9004-82-4), cocamide diethanolamine (cocamide DEA; CAS no. 68603-42-9), and cocamidopropyl betaine (CAPB; CAS no. 61789-40-0). A total of 298 articles were identified, of which 70 were included. Meta-analysis revealed that hairdressers have a 1.7-fold increased risk of developing a contact allergy to CAPB compared to controls who are not hairdressers. Hairdressers might have a higher risk of acquiring quantum sensitization against cysteamine HCl compared to a consumer because of their job responsibilities. Regarding cocamide DEA, the irritant potential of this surfactant should not be overlooked. Original articles for PVP, PVP copolymers, and SLES are lacking. This systematic review indicates that the current standards do not effectively address the occupational risks associated with hairdressers' usage of hair cosmetics. The considerable irritant and/or allergenic potential of substances used in hair cosmetics should prompt a reassessment of current risk assessment practices.
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Affiliation(s)
- Cara Symanzik
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) and Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, 49076 Osnabrueck, Germany; (P.W.); (S.M.J.)
| | - Patricia Weinert
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) and Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, 49076 Osnabrueck, Germany; (P.W.); (S.M.J.)
| | - Željka Babić
- Institute for Medical Research and Occupational Health, HR 10001 Zagreb, Croatia; (Ž.B.); (M.M.); (J.M.); (R.T.)
| | - Sarah Hallmann
- Department of Medical Informatics, Biometry and Epidemiology, University of Erlangen, 91054 Erlangen, Germany; (S.H.); (J.S.); (W.U.)
| | - Martin Stibius Havmose
- National Allergy Research Centre, Department of Skin and Allergy, University of Copenhagen, Gentofte Hospital, 2900 Copenhagen, Denmark; (M.S.H.); (J.D.J.)
| | - Jeanne Duus Johansen
- National Allergy Research Centre, Department of Skin and Allergy, University of Copenhagen, Gentofte Hospital, 2900 Copenhagen, Denmark; (M.S.H.); (J.D.J.)
| | - Sanja Kezic
- Amsterdam UMC, Department of Public and Occupational Health, Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.K.); (H.F.v.d.M.)
| | - Marija Macan
- Institute for Medical Research and Occupational Health, HR 10001 Zagreb, Croatia; (Ž.B.); (M.M.); (J.M.); (R.T.)
| | - Jelena Macan
- Institute for Medical Research and Occupational Health, HR 10001 Zagreb, Croatia; (Ž.B.); (M.M.); (J.M.); (R.T.)
| | - Julia Strahwald
- Department of Medical Informatics, Biometry and Epidemiology, University of Erlangen, 91054 Erlangen, Germany; (S.H.); (J.S.); (W.U.)
| | - Rajka Turk
- Institute for Medical Research and Occupational Health, HR 10001 Zagreb, Croatia; (Ž.B.); (M.M.); (J.M.); (R.T.)
| | - Henk F. van der Molen
- Amsterdam UMC, Department of Public and Occupational Health, Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.K.); (H.F.v.d.M.)
| | - Swen Malte John
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) and Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück University, 49076 Osnabrueck, Germany; (P.W.); (S.M.J.)
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, University of Erlangen, 91054 Erlangen, Germany; (S.H.); (J.S.); (W.U.)
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