Multicentre study ‘rehabilitation of occupational skin diseases -optimization and quality assurance of inpatient management (ROQ)’-results from 12-month follow-up

Programme for prevention of foot dermatoses in patients with work-related skin diseases: Follow-up data of a prospective cohort study (OCCUPES)

BACKGROUND

A programme based on health education has been developed to prevent foot dermatoses (FD) in patients with work-related skin diseases (WRSD).

OBJECTIVE

To evaluate the effectiveness of the programme in a prospective cohort study (OCCUPES).

METHODS

Six and 12 months after completing the programme, follow-up questionnaires were sent to 231 patients with WRSD and FD. Assessments included occupational footwear and foot care, self-reported disease course, and health-related quality of life.

RESULTS

Response to follow-ups was >70%. Wearing functional socks and changing footwear and socks during one work shift increased (all p < 0.001). Complaints about occupational footwear decreased, including sweating and exposure to moisture/wetness. More than 60% reported improved FD while quality of life significantly increased. After 12 months, all foot symptoms were less frequent, including itch (p = 0.009), pain when walking (p = 0.005), pain in rest (p = 0.015) and smell (p = 0.001). The programme received very good ratings by the participants.

CONCLUSIONS

The intervention was effective in improving occupational footwear, foot care and preventive behaviour. It resulted in a reduced burden of FD and should be implemented in the general care of patients with WRSD.

[When protective gloves do not protect-unexpected findings in a dental assistant]

We report on a 38-year-old dental assistant who developed erythema and dryness of the skin of the hands 12 years after she had started the job. After healing for 3 months she developed eczema lesions on the body, especially on the back of the hands, arms, neck, and legs. Contact dermatitis was suspected. We diagnosed atopic dermatitis and allergic contact dermatitis to different thiurames and to three of the seven protective gloves she had worn professionally. Carbamates were identified in those protection gloves. Thus, we assume two skin diseases: atopic hand eczema and atopic dermatitis of the body as well as intermittent contact dermatitis to occupationally relevant contact allergens. By using thiuram- and carbamate-free protective gloves and implementing skin protection and skin care measures, the skin disease has been completely cured to this day.

[Hand eczema or psoriasis: update on the FB 323 study occupational dermatology cohort]

In daily dermatological practice, the distinction between eczema and psoriasis in dermatoses of the hands can be difficult. However, a clear diagnosis is necessary to initiate optimal therapy and management. In recent years, the so-called molecular classifier has been developed for optimized differentiation of eczema and psoriasis. An occupational dermatological cohort has been established at Heidelberg University Hospital since 2020. It is funded by the German Statutory Accident Insurance. The aim is to follow-up patients over 3 years where this new diagnostic method is used and to compare the results with a retrospective occupational dermatological cohort. Recruitment ended in December 2022. The current analysis reports participants' occupational activity, insurance status, disease progression, and number of sick days. A total of 287 patients were included; mean age was 50.4 years and 63.5% (n = 181) were undergoing treatment at the expense of the liable statutory accident insurance at the start of the study. About 50% of the patients worked in health professions, metal industry, or construction. The average duration of occupational dermatosis was 6.5 years. In 38.9% of the patients, the clinical diagnosis had been classified as unclear by the treating dermatologist. By using the molecular classifier, the diagnosis could be clarified in 98% of the cases (eczema vs. psoriasis). The first analyses demonstrate that the molecular classifier contributes to improving therapy by optimizing the diagnosis.

Illness Perceptions of Patients with Occupational Skin Diseases in a Healthcare Centre for Tertiary Prevention: A Cross-Sectional Study

Objectives: To investigate the illness perceptions of patients with occupational skin diseases (OSDs). Design: Cross-sectional study. Setting: Specialised healthcare centre for inpatient and outpatient individual prevention in occupational dermatology in Germany. Participants: A total of 248 patients with hand eczema (55.2% female; average age: 48.5 years, SD: 11.9) were included in the final analyses. Measures: A modified and recently validated version of the 'Revised Illness Perception Questionnaire' (IPQ-R) was used to assess illness perceptions. Severity of skin disease was evaluated with the Patient-Oriented Eczema Measure (POEM), the Osnabrueck Hand Eczema Severity Index (OHSI), and a single, self-reported global item. The Erlangen Atopy Score (EAS) was used for atopy screening. Results: We found strong illness identity, high emotional impact, and long timeline beliefs, meaning that study participants perceive their OSD on the hands as a highly symptomatic, emotionally burdening, and chronic condition. Results suggest that hand eczema has a major impact on how participants manage their own lives, particularly during everyday life and occupational activities. Study participants predominantly identified irritant or sensitising substances and activities at work as well as skin protection regimes as causes of their disease. Conclusions: Healthcare workers should consider the illness perceptions as well as the disease burden of patients with an OSD on the hands in clinical practice. Multi-professional approaches to patient care should be sought. Illness perception in (occupational) dermatological patients should be the subject of further research.

Irritant Contact Dermatitis — a Review

Purpose of Review

Recent Findings

Summary

Documentation of psoriasis in routine care - expert consensus on a German data set

BACKGROUND AND OBJECTIVES

Documenting patient data in psoriasis clinical practice can improve care, but standardized and transparent documentation is rare. The current project aimed to develop a data set for the documentation of psoriasis in daily practice.

MATERIAL AND METHODS

In four online Delphi rounds and one in-person meeting, 27 psoriasis experts allocated variables to a standard, an optimal and an optional data set. Most of the questions were standardized. Open questions were included to allow for the provision of reasons and to enlarge the data sets. Furthermore, in the in-person meeting we considered a) patients' attitudes and b) dermatologists' information on the current usage and acceptability in Germany.

RESULTS

The consensus approach resulted in a data set with 69 variables. The standard data set includes 20, the optimal data set 31 and the optional data set 18 variables. In summary, the data set can mainly be grouped into master data, general status and medical history data, medical history of psoriasis, status of psoriasis, diagnostics and comorbidity, therapies and patient-reported outcomes.

CONCLUSIONS

The consensus recommendation of a standard, an optimal and an optional data set for routine care of psoriasis intends to be a decision-making aid and an orientation for both daily practice and further development of documentation systems.

Occupational contact dermatitis: Return to work using a multidisciplinary clinic model

BACKGROUND

Occupational contact dermatitis often results in work disruption. Return-to-work (RTW) is an important outcome.

OBJECTIVE

The objective of this study was to determine RTW outcomes and factors associated with such outcomes using a multidisciplinary clinic model.

METHODS

Chart abstraction was performed for 194 workers who received RTW assistance over a 6-year period. Elements abstracted included demographic and diagnostic information and information about the RTW program including principles, program components, barriers, and facilitators.

RESULTS

Of the 902 workers seen for dermatologic assessment, 194 received RTW assistance. At initial assessment, 37% were not working because of their skin disease, and at follow-up, 7% were not working because of their skin disease. The RTW plan components included a graduated or trial of RTW, specific recommendations for avoiding exposure, personal protective equipment, skin management, and ongoing skin monitoring. Principles associated with successful RTW included good communication and the availability of modified work and a worker adherence to the plan. Barriers included lack of modified work, unresponsive employers, and ongoing skin problems.

CONCLUSIONS

Specific approaches are important to identify if RTW is to be successful for workers with occupational contact dermatitis.

Contact dermatitis

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

[Pitfalls in occupational dermatology]

Occupational dermatology has become a vibrant and interesting specialty, particularly in recent years. This includes more than hand eczema (HE). The increasing prevalence of atopic dermatitis (AD) has led to an increase of atopic hand eczema which can be worsened in certain occupations. New systemic therapies have improved the range of treatments for HE. The current guideline on hand eczema includes a variety of topical and systemic therapies. Nevertheless, in daily occupational dermatological practice, there are still chronic cases, especially vesicular hand eczema. They can often not be assigned to a clear cause, which is often a problem for those who are affected. In addition, co-factors such as chronic infectious comorbidities and psychological factors/illnesses must be considered. We present challenges in occupational dermatology by reporting special cases.

Guidelines for the Diagnosis, Treatment, and Prevention of Hand Eczema

Hand eczema is a common condition associated with significantly impaired quality of life and high social and occupational costs. Managing hand eczema is particularly challenging for primary care and occupational health physicians as the condition has varying causes and both disease progression and response to treatment are difficult to predict. Early diagnosis and appropriate protective measures are essential to prevent progression to chronic eczema, which is much more difficult to treat. Appropriate referral to a specialist and opportune evaluation of the need for sick leave are crucial to the good management of these patients. These guidelines cover the diagnosis, prevention, and treatment of chronic hand eczema and highlight the role that primary care and occupational health physicians can play in the early management of this disease.

Occupational dermatoses in the Brazilian South region recorded in a reporting system (2007 to 2016)

Background

Occupational dermatoses must be mandatorily reported in Brazil.

Objective

To characterize the reporting of occupational dermatoses in the Brazilian South region, and describe the profile of the involved workers.

Method

Retrospective and descriptive study of 396 cases of occupational dermatoses reported from 2007 through 2016 via the Information System for Notifiable Diseases.

Results

3.6 and 2.2 cases / 10,000 workers / year were of men and women, respectively. The highest incidence of occupational dermatoses corresponded to age range 50 to 64 years old, 1.8 cases / 10,000 workers / year, and to maintenance and repair workers, 3.6 cases / 10,000 workers / year. Most cases involved whites (77%) and workers not having completed elementary school (37.6%). Patch testing was only performed for 11.4% of cases.

Conclusion

Reinforcing measures to promote the use of personal protective equipment is necessary, as well as to improve reporting and sensitize professionals to perform accurate reports in official systems.

Effectiveness of secondary prevention in metalworkers with work-related skin diseases and comparison with participants of a tertiary prevention program: A prospective cohort study

BACKGROUND

In Germany, a multistep approach has been established to prevent work-related skin diseases (WRSDs).

OBJECTIVES

To evaluate the effect of a secondary individual prevention program (SIP) in metalworkers with WRSD and to compare their characteristics with those of participants of a tertiary individual prevention program (TIP).

PATIENTS AND METHODS

In a prospective cohort study, metalworkers with WRSD of the hands participating either in the SIP (n = 114) or in the TIP (n = 83) were recruited. At baseline and at the respective follow-up 8-12 weeks after the SIP or at dismissal from the TIP (3-4 weeks later), questionnaires were completed and the severity of WRSD was assessed. Saliva samples were collected for assessment of filaggrin (FLG) mutations and an explorative genome-wide association study (GWAS).

RESULTS

Ninety-three SIP patients (81.6%) attended the follow-up. Disease severity was significantly reduced, and knowledge and protective behavior were significantly improved compared to baseline. Significant differences between SIP and TIP patients were found regarding duration and severity of symptoms, work absenteeism, tobacco smoking, and presence of atopic dermatitis, but not regarding FLG mutations and by GWAS.

CONCLUSIONS

The SIP was effective in metalworkers with WRSDs. Individual factors may influence the course of the disease and the need for the TIP.

Quality of life measurement in occupational skin diseases. Position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Occupational Skin Disease

The European Academy of Dermatology and Venereology (EADV) has started the 'Healthy Skin @ Work' campaign aimed to raise awareness among the public and EU authorities on the frequency and impact of occupational skin diseases (OSDs). The EADV Task Forces (TFs) on Quality of Life and Patient Oriented Outcomes (QoL/PO) and on OSD present their mutual position statement on QoL assessment in OSDs. The EADV TFs recommend the use of the DLQI as a dermatology-specific instrument and SF-36 as a generic instrument in health-related (HR) QoL studies on OSDs. The OSD-specific questionnaire, LIOD, is not recommended for general use in its present form because of its three months recall period. The EADV TFs discourage the use of non-validated and of non-validated modifications of previously validated HRQoL instruments. The EADV TFs wish to encourage research into: the HRQoL impact of OSDs other than occupational contact dermatitis and hand eczema; comparisons between the effects of different treatments and other interventions on HRQoL in OSDs; and into the HRQoL impairment of patients with OSDs from different countries, and with different provoking factors, to predict if the results of successful therapeutic and educational interventions may be generalized across countries and between occupations.

[Prevention of hand eczema]

Apart from endogenous factors, hand eczema is often caused by irritant or allergic contact dermatitis related to occupational or non-occupational exposure to skin hazards. This enables several complementary approaches on the level of primary, secondary and tertiary prevention. A high priority is set on identification and subsequent reduction or elimination of causative exposures. Important preventive approaches include legal regulations, technical and organizational measures as well as correct use of adequate personal protective equipment (e.g. protective gloves). Interventions based on health education are conducted to improve individual protective behaviour. Even though evidence-based proof of effectiveness is limited, preventive measures are considered of particular importance for avoidance of occupational hand eczema and its adverse sequelae. Therefore, a complex, step-wise approach to occupational skin diseases has been established in Germany. In recent years, the positive impact of secondary and tertiary preventive measures of this approach has been demonstrated.

Interdisciplinary and multiprofessional outpatient secondary individual prevention of work-related skin diseases in the metalworking industry: 1-year follow-up of a patient cohort

Background

In Germany, work-related skin diseases are predominant within the spectrum of reported occupational diseases. Metal workers are among the high-risk professions. Offering effective prevention programs to affected patients is of utmost importance to avoid deterioration of the disease and job loss. We conducted a 1-year follow-up in patients who participated in a multidisciplinary, complex outpatient prevention program representing a standard procedure of patient care by the respective statutory accident insurance.

Methods

The multi-component prevention program consists of multiprofessional individual patient counseling, a structured skin protection seminar in a group, as well as workplace visits and on-site counseling in terms of appropriate skin protection (e.g. gloves). An observational study with a 1-year follow-up and four measurements (T1-T4, longitudinal pre/post-test design) including dermatological examinations and standardized written questionnaires was conducted between 2013 and 2016 to assess changes over time regarding job loss and disease severity.

Results

Data from 94 patients (87 male, mean age: 45.4 years) were included in the analysis. One year after the skin protection seminar (T4), 83 patients (88.3%) remained in their original professional metalworking activity and four patients (4.3%) had given up their profession because of their skin disease. At baseline (T1), irritant contact dermatitis of the hands was the most frequent diagnosis (80.7%). Methods for self-reported disease severity showed good correlation with the clinical gold standard at T1 and T2 (dermatological examination with the Osnabrück Hand Eczema Severity Index / OHSI), and a significant decrease of the self-reported disease severity was found over time from T1 to T4 (p < 0.001). Further results indicate an improved self-perceived disease control and an overall satisfaction with the prevention program.

Conclusions

The results of this observational study demonstrate that the comprehensive prevention program positively influences the course of work-related skin diseases, increases the possibility to continue working in a “high-risk” profession and improves the disease management of metal workers. In the long term, the prevention program may lead to cost savings by preventing high therapy costs or professional retraining.

Electronic supplementary material

The online version of this article (10.1186/s12895-018-0080-2) contains supplementary material, which is available to authorized users.

Skin Protection Seminars to Prevent Occupational Skin Diseases: Results of a Prospective Longitudinal Study in Apprentices of High-risk Professions

BACKGROUND

Occupational skin diseases (OSDs) are frequent in professions with exposure to skin hazards. Thus, a health educational intervention for apprentices of high-risk professions was conducted. It was the aim of this study to gain insight into possible effects of this intervention.

METHODS

A one-time skin protection seminar was conducted in 140 apprentices of health-related and non-health-related professions [trained cohort (TC)]. In addition, 134 apprentices of the same occupations were monitored [untrained cohort (UTC)]. The OSD-specific knowledge and the skin condition of the hands were assessed at baseline (T0), after the seminar (T1), and after 6 (T2) and 12 months (T3).

RESULTS

The OSD-specific knowledge increased in all cohorts from T0 to T3, but we found a significantly higher knowledge in the TC at T2 (p < 0.001, t = 3.6, df = 196, 95% confidence interval = 0.9, 3.3) and T3 (p < 0.001, t = 3.8, df = 196, 95% confidence interval = 1.0, 3.2) compared to the UTC. Our results indicated a better skin condition of the hands in the TC of the health-related professions but not in the non-health-related professions.

CONCLUSION

The study indicates that an educational intervention may positively influence the disease-specific knowledge and the prevalence of OSD in apprentices. However, definite conclusions cannot be drawn because of the heterogeneous study cohorts and the study design. Future research should aim at tailoring primary prevention to specific target groups, e.g., in view of the duration and frequency of skin protection education, different professions, and gender-specific prevention approaches.

New developments in occupational dermatology

Occupational skin diseases according to BK No. 5101 - "severe or recurrent skin diseases which have forced the person to discontinue all occupational activities that caused or could cause the development, worsening, or recurrence of the disease" - is the most commonly reported notifiable occupational diseases in Germany. Following the optimization of measures of primary, secondary, and tertiary prevention, today most individuals affected are able to continue their profession. With the revision of the German ordinance on occupational diseases (BKV) in January 2015, skin cancer caused by UV irradiation was added to the list of occupational diseases. The new occupational disease (BK) 5103 is defined as "squamous cell carcinoma or multiple actinic keratoses of the skin caused by natural UV irradiation". In this context, "multiple" signifies the occurrence of either more than five individual actinic keratosis lesions over the course of 12 months or the presence of field cancerization of > 4 cm(2) . In the following review, important aspects of this new occupational disease will be highlighted and discussed.

Colonisation with methicillin-resistant Staphylococcus aureus and associated factors among nurses with occupational skin diseases

OBJECTIVES

To evaluate the prevalence of colonisation with methicillin-resistant Staphylococcus aureus (MRSA), associated factors and the effectiveness of decolonisation procedures among nurses with occupational skin diseases (OSD).

METHODS

In a retrospective cohort study, the medical records of 319 nurses from Germany who were screened consecutively for MRSA when participating in a tertiary individual prevention programme (TIP) for severe OSD between July 2009 and December 2014 were evaluated.

RESULTS

90.3% of nurses with severe OSD suffered from hand eczema. 43 were colonised with MRSA on admission (13.5%), mainly in the nose (n=35, 81.4%). However, the hands were affected in more than half of the MRSA carriers (n=24, 55.8%). Risk factors for MRSA colonisation were atopic skin diathesis (OR 2.01, 95% CI 1.03 to 3.92, p=0.049) and presence of atopic dermatitis on other body parts than the hands (OR 4.33, 95% CI 2.23 to 8.43, p<0.001). Hand eczema was significantly more severe in MRSA carriers than in non-carriers (OR 1.23, 95% CI 1.10 to 1.37, p<0.001) and showed a higher prevalence of vesicles, erosions or fissures. MRSA eradication was successful in 67.4% after the first attempt.

CONCLUSIONS

Nurses with OSD have a twofold to threefold higher prevalence of MRSA colonisation than what has been reported for point-prevalence screenings among healthcare workers in Germany. Atopic skin diathesis, atopic dermatitis and severe hand eczema are the main risk factors. Thus, prevention and treatment of OSD could be important elements in reduction of colonisation with MRSA among nurses and transmission to others.

Occupational skin diseases from 1997 to 2004 at the Department of Dermatology, University Hospital of Northern Norway (UNN): an investigation into the course and treatment of occupational skin disease 10-15 years after first consultations with a dermatologist

Objectives

We investigate the impact of occupational skin disease consultations among outpatients at the Dermatological Department, University Hospital, Northern Norway.

Study design

From 1997 until 2004, 386 patients with occupational skin disease were examined and given advice on skin care, skin disease treatment, skin protection in further work, and on the legal rights of patients with this disease. Ten to fifteen years later, we wanted to look at these patients in terms of their work situation, the current status of their disease, the help they received from the labour offices, and their subjective quality of life.

Material and methods

In the autumn of 2011 until the spring of 2012, a number of the patients examined in the period from 1997 to 2004 were selected and sent a questionnaire, which they were asked to answer and return, regarding their work situation and the progress and current status of their occupational disease.

Results

A total of 153 (77%) patients answered the questionnaire; 71% of these patients were still in work, and further 15% had old-age retired, 13% were working until then; 16% had retired early because of disability; 54% had changed jobs because of their occupational skin disease; 86% of the patients indicated that the skin disease had improved since our previous investigation.

Conclusions

Our investigation into patients with occupational skin disease documented that the majority of patients who had received professional dermatological consultation and intervention offers were still in the labour market and had good control of their skin disease 10–15 years later. We discovered that 71% of the patients were still employed. 13% had remained in work until they became old age pensioners. Only 16% dropped out of work because of disability. These high percentages may indicate that our intervention has contributed positively to patients’ work conditions and the course of their skin disease.

Recent Trends in Occupational Contact Dermatitis

Occupational contact dermatitis (OCD) remains prevalent among workers and impacts quality of life and workability. The purpose of this review is to summarize the recent advances in occupational contact dermatitis as well as potential hazardous agents in the workplaces causing OCD. The review covers new developments in the epidemiology, etiology, diagnosis, and management of occupational contact dermatitis. This article also provides updated information on the prevalence of work-related skin symptoms and on new contact allergens among working population. It is emphasized that in the context of prevention of OCD, special attention should be focused on the identified high-risk occupational groups, especially healthcare workers and hairdressers starting with the apprentices. Current approaches include working out the standards and guidelines to improve the education, knowledge, diagnosis, and management of OCD based on a multidisciplinary team of medical specialists and an employer.

Management of Chronic Hand Eczema

Management of hand eczema is complex because of the broad range of different pathogeneses, courses, and prognoses. Furthermore, the efficacy of most available treatments is not well established and the more severe forms can have a major impact on the patient's quality of life. Patient education, preventive measures, and the use of emollients are the mainstays in the management of hand eczema. High-potency topical corticosteroids are the treatment of choice, with calcineurin inhibitors used for maintenance. Phototherapy or systemic treatments are indicated in patients who do not respond to topical treatments. Switching from topical treatments should not be delayed to avoid sensitizations, time off work, and a negative impact on quality of life. Alitretinoin is the only oral treatment approved for use in chronic hand eczema.

Individual prevention courses for occupational skin diseases: changes in and relationships between proximal and distal outcomes

BACKGROUND

To treat people with occupational contact dermatitis, the German Accident Prevention and Insurance Association in the Health and Welfare Services offers 2-day individual prevention (IP) seminars.

OBJECTIVES

We investigated whether there are short-term and medium-term changes in proximal (e.g. behaviour) and distal (e.g. symptoms) outcomes after an IP seminar, whether changes in proximal outcomes are associated with changes in distal outcomes, and whether subgroups can be identified that benefit in particular.

PATIENTS/MATERIALS/METHODS

In a prospective study, 502 participants of 85 IP courses completed the health education impact questionnaire (heiQ™) and skin symptom questionnaire (Skindex-29) at the start of the course, immediately thereafter, and after 6 months. Change was assessed according to standardized effect size. Regression techniques were used to analyse associations between proximal and distal outcomes.

RESULTS

After 6 months, participants showed improved self-management skills and preventive behaviour, and less fear of job loss, disease-related symptoms, and emotional distress. Significant associations between proximal and distal outcomes were found. Participants who felt more limited by their skin disease showed greater effects.

CONCLUSIONS

The results are consistent with the assumption that IP courses provide a range of benefits for people with occupational contact dermatitis. Changes in distal outcomes may be influenced by changes in proximal outcomes.