GMS-06-07

Occupational skin diseases: options for multidisciplinarynetworking in preventive medicine

Optionen für eine vernetzte interdisziplinäre Prävention am Beispielberufsbedingter Hautkrankheiten

AbstractOccupational dermatoses (OD) have topped the list of occupationaldiseases in Germany for years. Presently, approximately 16,000 new

Swen Malte John1

OD cases are officially reported to public statutory employers’ liability1 Dept. of Dermatology,Environmental Medicine,

insurance bodies, each year. The disease burden is high not only forindividuals but also for society as a whole. Estimated annual economic Health Theory, University ofcosts in Germany due to sick-leave and lack of productivity due to OD Osnabrück, Osnabrück,

Germanyare more than 1.5 billion euros. Thus, in recent years, various pilot ini-tiatives aiming to improve prevention of occupational skin diseases (ofvarious degrees of severity) have been developed and recently evaluatedin Osnabrück. These activities have been funded by statutory employers’liability insurance schemes.Concepts underpinning these initiatives include multidisciplinary skinprotection teaching programs for various high-risk professions, whichturned out to be pivotal for the success of these projects. A corollary ofthis work is a nationwide multi-step intervention approach currentlyimplemented by the public statutory insurance system. This approachoffers quick preventive help for all levels of severity of OD. These nation-wide activities are accompanied by a national Prevention Campaign:Skin 2007/2008 (Figure 1), which focusesmainly on primary prevention.Despite the high prevalence of OD and its poor prognosis, little is knownabout the molecular mechanisms underlying individual susceptibilityto develop chronic irritant dermatitis. Skin irritation tests are thus farof only limited value. Presently, our institution, in collaboration withAmsterdam universities, focuses on immunogenetic risk factors poten-tially involved in individual susceptibility to OD in order to improve pre-employment counseling and predictive skin testing.For early secondary prevention, the so-called dermatologist’s procedurewas recently up-dated in order to provide more rapid dermatologicalconsultation. Additionally, combined outpatient dermatological andeducational intervention seminars (secondary individual prevention,SIP) are offered to affected employees. We recently demonstrated thesustainability of the SIP approach in hairdressing for periods of up to10 years.For those cases of OD, in which the abovementioned outpatient preven-tion measures are not sufficiently successful, specific interdisciplinaryinpatient preventionmeasures have been developed (tertiary individualprevention, or TIP). TIP represents the ultima ratio within the hierarch-ical prevention concept of the Osnabrück Model. TIP comprises 2–3weeks of inpatient dermatological diagnostics and treatment as wellas intensive health-related pedagogic and psychological counseling.Subsequent to this, 3 consecutive weeks of outpatient treatment aregiven by a local dermatologist. Each patient remains on sick-leave fora total of 6 weeks to allow full barrier recovery. A total of 764 out of1164 (66%) TIP patients treated in our university, followed-up regularlyby a local dermatologist for up to 1 year, were successful in remainingin their respective (risk-) professions as assessed by questionnaire 1year after discharge.

1/17GMS German Medical Science 2008, Vol. 6, ISSN 1612-3174

Research ArticleOPEN ACCESS

Recently obtained SIP and TIP data reveal that there are reliable, evid-ence-based options for multidisciplinary prevention and patient man-agement of OD, using a combined approach by a network of clinics,practices and statutory social insurance bodies. A multicentre study,which aims to further standardize TIP and evaluate sustainability ofprevention in more depth (3-year dermatological follow-up of 1000 ODpatients) is currently being conducted in Germany.

Figure 1: Logo of the Prevention Campaign: Skin (“Healthy Skin Campaign”)Translation: Your skin. The most important 2 m2 of your life. Prevention Cam-paign: Skin, initiated by statutory health and accident insurance institutions

ZusammenfassungHautkrankheiten sind die häufigsten berufsbedingten Erkrankungen,die in bis zu einem Viertel der gemeldeten Verdachtsfälle zu Arbeitsplatz-verlust führen. Die volkswirtschaftlichen Folgekosten durch Produktivi-tätsausfall liegen bei >1,5 Milliarden € jährlich. In Osnabrück werdenseit über 10 Jahren Präventionsmodelle auf allen Ebenen der berufs-dermatologischen Prävention interdisziplinär entwickelt, die in einigenRisikoberufen bereits zu einer erheblichen Senkung der Verdachtsmel-dungen, aber auch der Kosten für die Unfallversicherungsträger (UVT)beitragen konnten.Im Bereich der primären Prävention sind qualifizierte Berufseingangs-beratungen bei Risikoberufen wünschenswert; eine verbesserte Prädik-tion der individuellen Hautempfindlichkeit kann hier hilfreich sein, imübrigen auch für präventive Untersuchungen im Rahmen der Gefahr-stoffverordnung. Hier gibt es neuere Entwicklungen, die auch die Objek-tivierbarkeit einer verbliebenen kutanen Minderbelastbarkeit nach frü-heremBerufsekzembetreffen. Ein besseres Verständnis des komplexenmolekular-genetischen Hintergrundes der chronischen Kontaktderma-titis wird zur Entwicklung gezielterer Präventionsstrategien sowie präzi-serer diagnostischer und therapeutischer Verfahren beitragen.Im Bereich der Sekundärprävention ergab unsere Pilotstudie zumHautarztverfahren im Norddeutschen Raum, die zugleich eine erstesystematischeMaßnahme zur Qualitätssicherung darstellte, eine signi-fikante Verbesserung des Informationsflusses durch eine auf aktuellenErkenntnissen basierende Neukonzeption der Hautarztberichte. Mittler-weile wurde dies neue Hautarztverfahren in beispielhaft kurzer Zeitbundesweit eingeführt.Ergänzend zumHautarztverfahren wurden hier ambulante interdiszipli-näre Beratungsangebote (dermatologisch/edukativ) konzipiert undevaluiert („Sekundäre Individualprävention“ [SIP]), die mittlerweilebundesweit angeboten werden. Die Konsequenz, mit der die Studiener-gebnisse umgesetzt wurden, signalisiert einen Paradigmenwechsel beider gesetzlichen Unfallversicherung im Bezug auf einemöglichst zeitna-he und effiziente Prävention.Hierzu gehört auch, dass in den letzten Jahren die tertiäre Individual-prävention (TIP) nach dem Osnabrücker Modell für Menschen mit


John: Occupational skin diseases: options for multidisciplinary ...

schweren Berufsdermatosen und dem Ziel des Arbeitsplatzerhalteszunehmend an Bedeutung gewinnt; unsere aktuellen Daten zeigen,dass 66% der schwer Erkrankten, die in der Vergangenheit nahezuausnahmslos den Arbeitsplatz verloren hätten, durch die Maßnahmeim Beruf verbleiben konnten. Die Weiterentwicklung dieses interdiszi-plinären und stationär-ambulant vernetzten Heilverfahrens wird jetztim Rahmen einer bundesweiten Multicenterstudie vorangetrieben.Die Berufsgenossenschaft für Gesundheitsdienst undWohlfahrtspflege(BGW) hat von allen UVT den höchsten Anteil Versicherter mit Berufs-dermatosen. Bei der BGW sind die Kosten für berufliche Rehabilitations-maßnahmen bei Hauterkrankungen in den letzten 12 Jahrenmit zuneh-mender Umsetzung der genannten Präventionsmaßnahmen um >60%gesunken: von 35,5 auf 13,3 Mio. € p.a. In gleichem Umfang ist dieHäufigkeit berufsbedingter Hauterkrankungen bei BGW-Versichertenzurückgegangen. Parallel sind die Beiträge der Arbeitgeber für die ge-setzliche Unfallversicherung z.B. in Risikoberufen wie dem Friseurge-werbe um über 60% gesunken; hier ist der sozialpolitisch sensible Be-reich der Lohnnebenkosten unmittelbar berührt. Das sozio-ökonomischePotenzial von Prävention wird hier deutlich: Verbesserungen der Leis-tungen für den Einzelnen und Maßnahmen zum Erhalt der Gesundheitund des Arbeitsplatzes sind bei gleichzeitiger Senkung von Kosten fürdie Solidargemeinschaft erreichbar.Dies ist auch ein Grund, warum die gesetzliche Unfall- und Krankenver-sicherung sowie die Bundesländer die „Präventionskampagne Haut2007–2008“ ins Leben gerufen haben, die für einen bewussterenUmgang mit dem größten Organ des Menschen wirbt. Es handelt sichum das erste trägerübergreifende präventivmedizinische Großprojektin der deutschen Sozialversicherung. Diese Initiative unterstreicht,welches Potenzial man Präventionsmaßnahmen bei Hautkrankheitenund Allergien für die Gesundheitsförderung in Deutschland aktuell bei-misst. Die Kampagne wird durch die Osnabrücker Arbeitsgruppewissen-schaftlich begleitet.Die deutsche Version des Artikels ist verfügbar unterhttp://www.egms.de/en/gms/2008-6/000051.shtml.

1. Conditions framing preventivemedical research in OsnabrückThe following discussion is preceded by a historic and arecent quotation:

“Since both in importance as well as in time, health pre-cedes disease, we ought to consider first how health ispreserved, and then how one may best cure disease.”

Claudius Galenus 129–199 AD

“Our health system, which is thus far predominantlybased on cure, rehabilitation, and nursing, guaranteesquality health care for all citizens. By strengthening pre-vention measures with a prevention law, this system willundergo necessary expansion. It will then further developto serve as amodern health system, in which prevention,cure, rehabilitation, and nursing are all on a par.”

Official draft of the Federal Ministry of Health [andSocial Security] (BMGS) for a prevention law (Standas of December 2004, c.f. Appendix 2, German Fed-eration of the Statutory Accident Insurance Institutions

(HVBG) Newsletter, Prevention-BG 070/2004,20.12.2004, p. 3.)

Both quotations, which are separated by almost two mil-lennia, have similar messages and may well serve asmottoes for the Osnabrück research team; for more than10 years the prevention and rehabilitation of skin dis-eases and environmental allergies has been being re-searched here. Researchers have succeeded in forminga team, which unites dermatologists, occupational healthpractitioners, educators, psychologists and other research-ers in a dynamic interdisciplinary collaboration.Althoughmedicine has beenwidely revered as omnipotentin modern times, it has increasingly had to face its ownlimitations. This also presents an opportunity: If medicineonce again recognizes health protection/prevention asa fundamental part of the discipline, it can in turn regaintrust and become an inherent part of general education,once more [62]. Scientifically documented successeshave elevated preventive medicine into the center stageof political decision-making. The intention of the Germancoalition government to strengthen preventionmeasuresin order to serve as an “individual mainstay of healthcare” [4] is a result of these recent findings.



This encourages us all the more to continue performingprevention research as practiced here, which contributesto quality assurance of prevention measures in terms ofevidence-based prevention. The evaluation of various in-terdisciplinary prevention concepts is being attemptedusing the example of occupational dermatology in a seriesof staged research projects by teams and individuals.Activities are also guided by efforts to implement thesenew findings in medical training and post-graduate edu-cation [8], [32], [33], [34], [36], [39]. It is our aim to cre-ate an integrated system of prevention services that in-terlock and build upon on each other for the benefit ofpeople in high-risk occupational environments.Recently, a breakthrough was made with a new concep-tion of the dermatologist’s procedure, i.e., the “improveddermatological procedure”. Based on the findings of anOsnabrück pilot study in the region of northern Germany,this procedure was introduced nationwide [10], [35].Analogously, inpatientmanagement developed accordingto the so-called OsnabrückModel for people with seriousoccupational skin diseases and allergies are presentlybeing further improved in a nationwide multicentre study[37], [43].It may be asked, how the study of prevention in chronicdiseases – specifically the example of occupational skindiseases – could thrive so well in a university without afaculty of medicine? One answer is that it is preciselybecause of this fact that the preventive approach wasnever in danger of playing second fiddle within the contextof predominantly curative medicine. Indeed, the realiza-tion of research projects could be achieved by a construct-ive collaboration of various disciplines. Accordingly, thispaper should also be understood as a plea for preventionresearch as a concerted effort of the most diverse insti-tutions, which, in this case, encompasses medical (der-matology, occupational medicine) as well as educational(pedagogy, psychology, ergotherapy) and legal (social law)disciplines. The existing social legislation provides anauthoritative legal background against which preventionand health promotion can take place in Germany.Moreover, the long-anticipated comprehensive preventionlaw for all insurance carriers, which is stipulated in thecurrent coalition agreement of the German government,is also timely.To some extent, the Prevention Campaign: Skin (Präven-tionskampagne Haut) was launched January 11, 2007,in anticipation of a prevention law and as a combinedinitiative of public statutory accident and health insuranceschemes. At the same time, this further emphasizes theimportance of the topic of skin diseases and the potentialinherent in prevention existing in this area. Moreover, itis the first case of a major preventative medical projectinvolving all carriers in German social insurance.The campaign receives scientific advice from the Osna-brück research team. Importantly, networking – as prac-ticed in the fields of dermatology, environmental medi-cine, and theory of health in Osnabrück – does not onlyconcern the inner academic circles of university as such.It also includes numerous non-university institutions such

as social insurance carriers, medical practices, and hos-pitals. In this manner, models for interlocking outpatientand inpatient care (referred to as: integrated care) withthe objective of optimizing cooperation between diversehealth care providers with regard to prevention, weredeveloped and successfully implemented [43], [45].By way of example, data of the Professional Associationfor Health Services andWelfare, Hamburg (Berufsgenos-senschaft für Gesundheitsdienst und Wohlfahrtspflege,BGW) illustrate the development of costs for occupationalskin diseases during the past 12 years (Figure 2). Ger-many’s BGW is the public accident insurer with the mostcases of skin disease among its insurant clients. The fig-ure shows the effects of specific, science-based preven-tion measures as tested in collaborations between theBGW and the University of Osnabrück in various modelprojects. The concepts developed and evaluated as aresult are essentially based upon a combination of med-ical consulting and services and of health education toinfluence the behavior of affected persons, which is occu-pation-specific and adapted to individual requirements[55], [72], [83], [85]. These concepts have proven sosuccessful that they have been implemented in themeantime by the BGW and other accident insurers in theform of multidisciplinary outpatient consulting centersand integrated into standard benefits. The BGW’s ex-penditures for occupational rehabilitation measures re-lated to skin diseases were reduced by more than 60%within the period under review since the introduction ofthese measures. At the same time, the frequency of oc-cupational skin diseases among insurants of the BGWdecreased to the same extent. This demonstrates thesocioeconomic potential of prevention: improvements ofbenefits for individuals as well as measures for healthmaintenance and continuation of employment can berealized while reducing the costs for the collective bodyof the insured (Figure 2).

1.1 Successful prevention: the exampleof occupational skin diseases

Chronic occupational contact dermatitis (of irritative, al-lergic, or mixed genesis) is an inflammatory skin diseaseof increasing prevalence. In industrial nations in particu-lar, its socioeconomic and psychosocial relevance is sig-nificant. In Germany, skin disorders continue to be by farthe most common occupational diseases. As they arepersistent and incapacitate individuals to work for lengthyperiods, the economic follow-up costs due to nonworkingtime (sick-leave) and diminishing productivity in businessare considerable. These costs are estimated atmore than1.5 billion euros per annum [5].Through concerted prevention measures, the frequencyof occupational diseases was successfully reduced incertain focal areas over the past years. During the pastdecade, for example, insurers experienced a decline inthe number of reported suspected cases of occupationaldisease in hairdressing (60%) [22], [46], as well as a re-duction of occupational skin and respiratory diseases



Figure 2: Reduction of costs for retraining due to job loss by OD of BGW-insured affected patients in Germany 1994–2006Reduction is related to the implementation of prevention concepts developed in collaboration with the University of Osnabrück,in particular SIP (=secondary individual prevention, multidisciplinary outpatient skin protection counseling) and TIP (=tertiary

individual prevention, multidisciplinary inpatient prevention scheme), which have now been integrated into standard health carenationwide, including all other statutory employers liability insurance bodies.

Accordingly, premiums for statutory occupational accident insurance for BGW-insured businesses decreased (ancillary laborcosts). Source: Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege, BGW, Hamburg, 2007.

caused by latex in health care (>80%), during the sameperiod [1], [2], [3]. While these effects are related to theimpetus generated by the Osnabrück Model they alsodemonstrate the remarkable effectiveness of specific,multidisciplinary prevention measures. The statutory oc-cupational accident insurance system recognized theseresults [29], which, in recent years have enabled us toinitiate – in cooperation with the Study Group for Occupa-tional and Environmental Dermatology (Arbeitsgemein-schaft für Berufs- und Umweltdermatologie, ABD) withinthe German Dermatological Society (Deutsche Dermato-logische Gesellschaft, DDG) – a whole package of meas-ures to significantly improve prevention of occupationalskin diseases on behalf of employees in high-risk occupa-tions. The following discussion gives an account of theseinitiatives.

2. Primary preventionPrimary prevention represents a focus of applied occupa-tional health education [70], [85]. The function of primaryprevention is to avert occupational dermatoses (OD) bymeans of providing information and training for skin-protective behavior (referred to as: behavioral prevention),of ensuring skin-protective working environments in ac-cordancewith the respective regulations (cf. environment-al prevention, in: Technical Rules for Hazardous Sub-stances, German Hazardous Materials Ordinance/Tech-nische Regeln Gefahrstoffe, Gefahrstoffverordnung) aswell as of offering consultation regarding individual skinsensitivity.

The question, however, as to what constitutes increasedindividual skin sensitivity and how it can be reliably diag-nosed, remains unsolved. This question becomes evenmore important with Germany’s current Hazardous Ma-terials Ordinance (Gefahrstoffverordnung), effectiveJanuary 1, 2005. For the first time, the ordinance stipu-lates compulsory occupational health examinations foremployees who perform wet work for at least 4 hours perday. Wet work represents the most decisive factor in thegenesis of OD; wearing protective gloves that are occlu-sive also qualifies as wet work in this context. Therefore,it can be assumed that several million German employeesmeet the conditions stipulated in the HazardousMaterialsOrdinance and should therefore take part in such occu-pational health examination and consultation in future,subject to law [54]. As of yet, it has not been decided,how and on the basis of which criteria the examinationsshall be conducted.The identification of persons with sensitive skin is alsoparticularly urgent; studies consistently show that theirshare within the general population as well as amongpeople in humid working environments is increasing [16],[22]. The high number of atopics is particularly noteworthyin this respect. More than half of patients with OD fall inthe category of persons with a predisposition to highlysensitive skin and mucosa as well as with a tendency todevelop atopic diseases (e.g., atopic dermatitis, hay feveror pollinosis, allergic asthma). In these cases, a focusedpre-employment consultation concerning up-to-datemethods of skin protection to be used from the first dayof exposure to wet work would be part of essential primaryprevention.



Another important aspect, especially for atopics, is theinfluence exerted by commonwaterproof protective gloveson skin irritation due to occlusion effects. In Osnabrück,we have been collecting information on positive experi-ences with protective gloves made from various semiper-meable membranes, for some time. On the one hand,they minimize the accumulation of humidity and thesubsequent measurable barrier impairment caused byocclusion (transepidermal water loss, TEWL) [82], andon the other hand, they foster barrier regeneration ofdamaged skin to a remarkable extent [11]. These gloveshave gained a high degree of user acceptance, however,the lack of resistance to chemicals remains problematic.

2.1 Individual skin sensitivity: fromprediction to prevention

2.1.1 Definition and diagnostics

The term “sensitive skin” has not been precisely definedin dermatology. Nevertheless, it is commonly used andismost frequently understood as increased skin reactivityto irritative noxa. However, objectifying suspected casesof increased skin sensitivity remains problematic. Ingeneral, various skin provocation tests using irritants areapplied, but a universally accepted ”gold standard” is stilllacking.It is now scientifically proven that cutaneous responsive-ness to irritants in some patients is significantly morepronounced than that in the majority of human subjects.Themain reason for this is probably a genetic disposition,which is not necessarily related to atopy [24], [25], [26].According to recent findings, there are very different, in-dividual reaction patterns to irritant stimuli that range ona broad spectrum between the extremes of tolerance andhyperirritability. High cutaneous tolerance to irritants aswell as hyperirritability, seem to occur primarily and sec-ondarily (developed after prolonged exposure). For ex-ample, the adaptation phenomena observed inhairdressing that results in the development of tolerancepost-exposure, is termed hardening [84]. Uter describedcases of apprentice hairdressers who developed handeczema early in their careers, which healed later in pro-fessional life and ultimately led to remarkable resilience.This effect, in some cases, occurred even in the absenceof skin protection [76]. Themechanisms that bring abouthardening are as yet unknown. Unfortunately, this phe-nomenon can only be observed in a minority of exposedpersons in high-risk occupations.Daily occupational dermatological practice shows thatthe opposite phenomenon also exists. That is, even afterthe healing of severe hand eczema due to intense expos-ure to humidity, affected persons maintain to exhibit in-creased skin sensitivity when exposed to everydaystresses. Potential pathogenetic mechanisms of this –normally subclinical – secondary hyperirritability are un-known. This is also related to the fact that a generallyaccepted verification procedure for (primary and second-ary) cutaneous hyperirritability is still missing. Discussions

are controversial as to whether current procedures canshed light on constitutional characteristics or whetherthey only provide a picture of skin reactivity at a givenmoment in time [24].Although a diagnostic gold standard is lacking, occupa-tional dermatologists are frequently expected to specifythe extent of an individual’s skin sensitivity. This appliesnot only to pre-employment consultation (and examina-tions based on the Hazardous Materials Ordinance).Among other things, the dermatological expert has toquantify subsequently reduced skin endurance for theassessment of the reduction in the ability to work. Medico-legal evaluations such as these have far-reaching con-sequences for affected persons, not least of which aredecisions concerning pension payments drawn on them.While allergological diagnostics is established and nation-al as well as international professional societies havedeveloped authoritative standards for the implementationand interpretation of related tests [7], [59], [78], this isnot the case for skin irritability diagnostics. Nevertheless,there are concrete efforts to standardize the routine useof sodium hydroxide (NaOH) and sodium lauryl sulfate(SLS) asmodel irritants, of which NaOH shall be discussedin the following. In order to assess the changes in thebarrier function of skin caused by the tests, modern bio-physical measuring methods are employed [49].

2.1.2 NaOH provocation tests (alkali-resistancetests)

Themost common functional test in occupational derma-tology in the German-speaking area is the alkali-resist-ance test according to Burckhardt 1947 [15]. The test,during which diluted NaOH solution is applied on the skinunder occlusion, has been modified by Burckhardt andhis co-workers repeatedly [13], [14], [56]. Most of themodifications concerned test duration, concentration ofthe solution, and recording test results. Today, challengewith 0.5 M NaOH for three 10-minute periods under su-pervised clinical observation is implemented most fre-quently. We were able to demonstrate, however, that awide variety of modifications to the NaOH test are per-formed by practicing occupational dermatologists, mostlywith reference to Burckhardt [49]. The lack of standard-ized procedures may be one of the reasons why the rel-evance of this test is considered very differently by occu-pational dermatologists [38], [49].In general, challenge with NaOH aims at determining in-dividual sensitivity of the skin barrier to alkaline sub-stances, to which we are frequently exposed in privateand professional life. NaOH also seems especially suitableas a model irritant in occupational dermatology becausewet work is one of the main causes of irritativedermatoses. Typically, wet work is defined as a minimumof 2 hours of regular daily contact with (aqueous) liquidsor of wearing humidity-impermeable gloves (cf. TechnicalRegulation for Hazardous Materials (Technische Regelnfür Gefahrstoffe, TRGS) 401 of June 2008 and the validHazardousMaterials Ordinance of January 2005). Simply



Figure 3: Test procedure for the swift modified alkali resistance test (SMART) as presently practiced by the “Task force onAssessment and Evaluation of Irritant Skin Damages” of the ABD

Test site: medial forearm, ventral. The same procedure is performed for the differential irritation test (DIT), when the SMART iscarried out in parallel on the back of the hand corresponding to chirality and the contralateral forearm. TEWL = transepidermal

waterloss. Clinical and biophysical readings are to be conducted 10 min after the second provocation phase.

by the diluting effect of humidity on the skin, wet workcauses an increase in the pH of physiologically acidic skin(approx. pH 5.5) after depletion of its buffer systems,hence resulting in alkalinization. Thus, wet work-inducedalkalinization of the skin surface is simulated by NaOHchallenge. Recent studies increasingly demonstrate theimportance of an acidic skin pH for homoeostasis of theskin barrier. An acidic milieu is particularly essential forthe complex architecture of epidermal lipid layers, whichare instrumental for the functional integrity of the stratumcorneum [27].In Osnabrück, we have made use of these findings todevelop new therapies. As we were able to show, rinsingwith CO2-impregnated water favorably influences thehealing of eczema and has a protective effect for eczemain the case of experimentally induced irritation [12].

2.1.3 Current NaOH provocation tests inoccupational dermatology

2.1.3.1 Swift modified alkali resistance test (SMART)

Burckhardt’s alkali resistance test results in superficialnecrosis in 1% of cases (colliquative necrosis) [75]. Nat-urally, this refers to persons with sensitive skin in particu-lar, as they are overrepresented in collectives treated byoccupational dermatologists.Therefore, a less invasive swift modified alkali resistancetest (SMART) was developed in Osnabrück. It employsup-to-date biophysical diagnostics (measurement ofTEWL) and 0.5 M NaOH exposure for only two 10-minuteperiods as well as a drying and observation intervalbetween sessions. The test was clinically evaluated in572 personswith a history of examination by occupationaldermatologists, and standardized (test site: forearm) [49](Figure 3). Challenge with 0.9% sodium chloride (NaCl)served as a control. The test allowed identification ofgenotypic characteristics (atopic skin disposition) in the

studied cohort, both clinically and biophysically. Thus,SMART appears to be helpful in identifying increasedconstitutional risks within the context of occupationaldermatologic issues, while reducing invasiveness andtime expenditure and improving validity as compared toconventional procedures [38], [48].

2.1.3.2 Differential irritation test (DIT)

Subsequently, SMART was applied in a trial to assesssecondary irritant skin changes (secondary hyperirritabil-ity). For purpose of comparison, the test was carried outsynchronously on two parts of the body. One part wascontinuously exposed to occupation-related irritants ofthe subject’s past (back of the hand), while the other partwas not (ventral forearm). On the basis of a pilot studyinvolving a control group (31 subjects) and a group withhealed occupational eczema (48 subjects), a differentialirritation test (DIT) was developed [24], [44], [49].Normally, the skin on the back of the hand is very robust.Normal persons show no reactivity to the SMART in thisarea. However, a subcohort of approximately 10% ofstudied patients, which previously suffered from occupa-tional hand eczema (healed at time of testing), exhibitedprima facie, a seemingly paradoxical phenomenon: skinreactions on the back of the hand were stronger thanthose on the forearm. A reversal in the normal hierarchyof skin reactivity was observed in this subcohort in a skinarea which was previously exposed to occupational skinhazards and affected by eczema. This result points tosecondary hyperirritability in terms of acquired reducedskin endurance. In persons with normal skin, such aparadoxical pattern of findings is not encountered. In themeantime, the phenomenon of an inverse hierarchy ofskin sensitivity, expressed in acquired hypersensitivity ofthe back of the hand, was confirmed in another sample.In this study, the phenomenon was observed in 49 of554 former wet workers with healed eczema [38], [44].



Thus, there is evidence that the proposed test is of socio-medical relevance (i.e., extent of the reduction in earningcapacity [9]; prognostic outcome, for example, concerningthe prospects of success of preventive measures). Thusfar, DIT is the first methodological approach to objectifysubclinically reduced endurance of the skin of the handsfollowing an earlier case of occupational eczema (healedat time of testing).

2.1.4 Standardization of irritability diagnosticsin occupational dermatology

In light of the incidence and relevance of irritant skindamages, it is unfortunate that the standardization ofskin irritability diagnostics in occupational dermatologyremains incomplete. Therefore, the Study Group for Oc-cupational and Environmental Dermatology (ABD) in theGerman Dermatological Society (DDG) set up a task forcein 2001 under the name “Assessment and Evaluation ofIrritant Skin Damages”, with the following members: Dr.G. Bartel, Aachen; Dr. A. Degenhardt, Bremen; PD Dr. R.Brehler, Münster; Prof. Dr. M. Fartasch, Bochum, Prof.Dr. P.J. Frosch, Dortmund; Prof Dr. S. M. John (Chair),Osnabrück; Dr. Dr. M. Haufs, Bochum; Dr. P. Kleesz,Mannheim; PD Dr. V. Mahler, Erlangen; Dr. H.-G. Mane-gold, Bielefeld; Dr. I. Schindera, Völklingen; Dr. N. Siz-mann, Nürnberg; Dr. K.-H. Tiedemann, Schwäbisch-Gmünd; Dr. E. Wagner, Berlin; PD Dr. E. Weisshaar,Heidelberg; Prof. Dr. M. Worm, Berlin. This task force aimsto establish a consensus for occupational dermatologicdiagnostics based on existing scientific findings. Atpresent, a multicentre study on the SMART/DIT is beingconducted. Moreover, a black list of test procedures thatare proven unsuitable for routine occupational dermato-logic examinations has been compiled, in order to avoidunnecessary stress for patients examined [31].

2.1.4.1 Outlook: specific prevention using immunologicor immunogenetic prediction

The causes of individual skin sensitivity and correspond-ing risk of contracting irritant contact dermatitis due toexposure during wet work are incompletely understood.However, an imbalance of pro- and anti-inflammatory cy-tokines seems to play a decisive role in this respect. Inaddition, several studies suggest the importance of oxid-ative stress due to reactive oxygen species (ROS) resultingfrom external influences on the skin as well as the import-ance of structural proteins, e.g., filaggrin, for epidermalbarrier function [20], [30], [57], [74]. The coding genesrelevant for the production of inflammation mediatorsand filaggrin have proven to be polymorphic. Test proced-ures developed only recently allow for exploring the im-munological properties of the stratum corneum barrierby means of tape-stripping [17], [58]. A number of cluessuggest that the identification of immunologicalmessen-gers in the uppermost cell layers will permit a causal ex-planation of the phenomena observed in relation to skinirritation tests, and thus mark a departure from the

sphere of mere empiricism. Should this prove correct, itwould then be possible in future to dispense with skin ir-ritation tests such as the alkali resistance test, and todirectly derive predictive conclusions from the observedpatterns of immunologicalmessengers or immunogeneticfindings [50]. Persons with sensitive skin could be advisedat an early stage and subjected to appropriate preventionmeasures. An immunogenetic method for identifying indi-vidual risk factors in chronic occupational eczema ispresently under development at Osnabrück in a jointproject with the University of Amsterdam [18], [19], [20].Needless to say, serious problems regarding provisionsfor protection of privacy will accompany such options forspecific prevention measures employing more and moreprecise immunogenetic prediction methods. This issueremains to be solved. However, this is a general problemthat future prevention efforts in dispositional diseaseswill be confronted with, in light of increasing technologicaladvances in genome research [61].

3. Secondary preventionSecondary prevention measures are indicated when oc-cupational skin reactions already exist. Secondary preven-tion requires accuratemedical diagnostics, psychologicalunderstanding, and an improvement of working conditions[65], [81]. In collaboration with the University of Osna-brück, the BGW introduced effective early-stagemeasuresin the form of outpatient skin protection seminars forpatients in the initial stages of disease development (so-called secondary individual prevention=SIP seminars).These measures were conceived as complementary tooutpatient treatment in dermatological practices. In themeantime, other accident insurers have adopted theseconcepts, or developed analogous models. It becameconsistently apparent that such low threshold preventionmeasures are essential for successful secondary preven-tion of OD [6], [36], [42], [55], [63], [69], [79], [80].The question of how accident insurers are informed thatan insured employee has developed an occupational skindisease is of central importance. To this end, the so-calleddermatologist’s report (Hautarztbericht) was introducedin most federal states in 1972 (as of 1996 for all states).Thus, the dermatologist’s report and the dermatologist’sprocedure, instituted subsequently as required, occupya prominent position in the field of OD-prevention [36],[47], [51]. Drawing on the results of a pilot study conduct-ed by the University of Osnabrück in the Northern Germanregion, the dermatologist’s procedure was recently com-pletely revised and up-dated on the basis of currentfindings in prevention research [35], [47]. This study wassupported by the German Federation of the StatutoryAccident Insurance Institutions (Hauptverband der gewerb-lichen Berufsgenossenschaften, HVBG). It was realizedin collaboration with the Federation of the Statutory Acci-dent Insurance Institutions in Northwestern Germany(LandesverbandNordwestdeutschland der gewerblichenBerufsgenossenschaften), the Statutory Accident Insur-



Figure 4: Course of outpatient treatment according to ABD guidelines on the improved dermatologist’s procedure,first published October 2006 [42]

These guidelines were recently incorporated in the regulations for quality assurance as well as in guidelines of the DDG [40],[41]. As a rule, treatment should immediately be assigned to the dermatologist, in order to render prompt and optimal carepossible for persons with occupational dermatoses. A duly completed dermatologist’s report (form “initiation of prevention”,F6050), which facilitates rapid administrative decisions is a precondition for the assignment of treatment. Company medical

officers should be involved in the procedure from the outset, if possible. During outpatient treatment, a progress report (F6052)should normally be made bimonthly. If applicable, this should be complemented by further reports by the concerned company

medical officer.

ance Institution for the Construction Industry Hannover(BG-Bau Hannover), the Professional Association forHealth Services andWelfare Delmenhorst (BGWDelmen-horst), the Statutory Accident Insurance Institution forthe Metal Industry Hannover (Metall-BG Hannover, cf.Acknowlegments), and dermatologists practicing in theNorthern German regionwho filed dermatologist’s reportson persons insured with the mentioned accident insur-ance institutions during the period of the study.In an unprecedented shortness of time, results of theOsnabrück pilot study were implemented by accident in-surers, so that the “improved dermatologist’s report”could be introduced nationwide as early as January 1st,2006 [10], [42]. The improved dermatologist’s reportemphasizes, among other things, an accurate assessmentof harmful impacts and, in particular, a definitive state-ment regarding required preventive (therapeutic and skinprotection) measures. For the purposes of optimal earlyintervention, rapidmedical treatment following completionof the report and documentation of progress at close in-tervals are now required as a rule. In October 2006,guidelines for implementing the dermatologist’s proced-ure were formulated by the Study Group for Occupationaland Environmental Dermatology (ABD), for the first time[42]. These guidelines were recently added to existingguidelines and recommendations of the German Derma-tological Society (DDG) [40], [41] (Figure 4). As a con-

sequence, the dermatologist’s procedure has clearly de-veloped beyond the scope of its originally described ob-jectives; today it encompasses the complete spectrumof occupational dermatologic interventions, includingcontinuous dermatological monitoring and therapy forOD-patients. Hopefully, this will contribute to a furtherincrease in the use of the dermatologist’s procedure asa central instrument in the prevention of OD [21], [36],[51].In parallel with the newly developed dermatologist’s pro-cedure, insurance administrations have introduced theso-called multi-step approach to skin conditions (Stufen-verfahren Haut) [23], which complements the preventionconcept underlying the improved dermatologist’s report.Experiences of the Osnabrück research teamwere furtherincorporated, once again. In future, multi-step preventionmeasures shall be initiated by the insurance administra-tions in a more systematic manner and earlier than pre-viously done. In doing so, rapid enforcement of an insuredperson’s legal claim to preventionmeasures for purposesof preserving employment shall be guaranteed. Withinthis concept, the improved dermatologist’s report is ofcentral importance, because it facilitates a rapid decisionbased on the operational criteria given in the report. Ob-viously, for this purpose, the report forms have to be dulycompleted by the submitting dermatologists [10].



The efficiency of the newly conceived prevention meas-ures will be put to test by the Prevention Campaign: Skin2007/2008 (slogan: “The 2 most important squaremeters of your life”) , during which an increase in reportssubmitted is expected. Success of the Prevention Cam-paign: Skin will be evidenced if affected persons areconvinced to draw on the legal prevention benefits towhich they are entitled, at significantly earlier stages ofdisease. In this respect, estimates of the significantnumber of unreported cases of occupational skin diseaseexcluded from official statistics should be kept in mind.Epidemiological field studies in occupational high-riskenvironments suggest that the extent of underreportingmay be 50- to 100-fold higher than currently documented[22], [46], [60].The operational efficiency of early prevention is presentlybeing analyzed in a research project by the GermanStatutory Accident Insurance (Deutsche Gesetzliche Un-fallversicherung, DGUV) at the University of Osnabrück(Quality Assurance and Evaluation of the Improved Der-matologist’s Procedure and the Multi-Step InterventionApproach to Skin Conditions (412.02:411.43-FB 130-EVA_Haut)). In this study, a random quota sample includ-ing 20% of all improved dermatologist’s procedures con-ducted in Germany are examined with respect to the im-plementation of the dermatologist’s procedure bymedicaldoctors, the implementation of procedures of the multi-step intervention approach to skin conditions by insuranceadministrations, and the interactions of involved institu-tions, while differentiating severity and course of the skindisease (1-year follow-up).

4. Tertiary prevention according tothe Osnabrück ModelOccupational skin diseases represent a substantial ex-pense factor for statutory accident insurances. Amongall occupational diseases, they result in highest expendit-ures for insurants receiving occupational rehabilitationbenefits (referred to as:measures supporting participationin professional life), per year. Among statutory accidentinsurance institutions, 60% of all beneficiaries of rehabil-itation measures were insured persons with OD. At thesame time, approximately 60% of all expenses for occu-pational rehabilitation were dedicated to this purpose[47]. Due to present economic conditions, expendituresfor occupational rehabilitation (e.g., 2004: 62.5 millionEuro for skin diseases) frequently do not achieve theirstated objectives as claimants do not succeed in reinte-grating into the employment market. On the one hand,this emphasizes the need for specific, early secondaryprevention of OD, and on the other hand, the need to alsocreate options to help affected individuals, where OD hasalready advanced to a severe, recalcitrant course in orderto secure a professional future.Severe occupational skin diseases that interfere with thecontinuation of occupational activity are frequent. In ad-dition to follow-up costs incurred by the collective body

of the insured, the significant degree of personal sufferingcaused by these diseases as well as the serious psycho-social consequences they entail for affected persons,must be considered in particular. These considerationsshould be made, namely, in the context of actual place-ment opportunities available during career shifting [45].In Osnabrück, for more than 10 years we have gainedexperience with a model of quality-assured tertiary indi-vidual prevention (TIP), which combines all available op-tions in the form of comprehensivemultidisciplinary inter-vention for persons with severe OD, according to state-of-the-art scientific knowledge in the field (OsnabrückModel, Figure 5 [45], [65], [66], [67], [69], [70], [71],[72], [73], [81]).The intensified measures of TIP are indicated, when thecessation of the harmful occupation, or the developmentof an occupational skin disease according to GermanOccupational Disease Ordinance Nr. 5101 (Berufskrank-heitenverordnung) is imminent. TIP, according to theOsnabrück Model, combines in an inpatient phase of upto 3 weeks of dermatological consultation and therapyand health-related pedagogic and psychological motiva-tion training with the objective of bringing about a funda-mental change in skin protection behavior at the work-place (i.e., behavioral and – where possible – environ-mental prevention [45], [64], [68], [72], [81]). Comple-mentary to these measures, the following preventionmeasures are also offered: ergotherapeutic exercises totest adequate skin protection methods in a simulationmodel of the workplace, counseling by the casemanagerof the accident insurance institution, and – wheneverpossible – involvement of the companymedical officer/oc-cupational physician. Subsequently, local dermatologistsfollow-up cases at close intervals, i.e., outpatient treat-ment covered by accident insurance institutions (BG-Heilverfahren; Figure 5).Indications for TIP are predominantly chronic, toxic degen-erative or allergic contact eczema, and occupationalatopic hand eczema. Other OD, such as severe therapy-resistant occupationally triggered psoriasis palmaris arealso included. Moreover, the spectrum of indication isbroadened by the (if necessary, repeated) treatment ofolder employees undergoing outpatient therapy refractoryhand eczema, to stabilize skin conditions to the greatestextent possible (referred to as: refresher TIP).From October 1994 to March 2007, more than 2,500patients underwent TIP measures in Osnabrück. In thecourse of a recently conducted long-term evaluation ofthemeasures employed (collectives 10/1994–09/2003),it was shown that in a follow-up of the Osnabrück cohort,1 year after initiation of TIP, 66% of participants withsevere hand eczema remained active in their respectiveoccupations. In the past, these patients would have lostgainful employment, almost without exception (Figure 6)[71], [73]. The continuation of employment was found tobe unrelated to type of risk occupation practiced (i.e.,metalwork, construction, health care, hairdressing, foodprocessing, cleaning), but was contingent upon the ageof patients at the time of receiving TIP (Figure 7). Accumu-



Figure 5: Flow chart of TIP according to the OsnabrückModel, uponwhich the presentmulticentre study of the German StatutoryAccident Insurance (DGUV) is based: modified inpatient treatment and integrated consecutive outpatient care by the referring

dermatologist at patient’s place of residenceOverall period of abstention from work is approx. 6 weeks, to allow for complete regeneration of the skin barrier after severe

damage [43], [71], [73].

Figure 6: Employment continuation 1 year after TIP measures have been employed in different high-risk occupations(cohort 10/1994–09/2003) [71], [73]

It can be shown that the comparatively low success rate in hairdressing does not result from an occupation-specific, but from anage-specific effect (i.e., a preponderance of younger age groups among the cohort of counseled hairdressers; among these age

groups, the risk of career shifting is higher. Cf. Figure 7). Ntotal=1164



Figure 7: Age-dependent risk of job loss by OD among affected patients, 1 year after completion of TIP measures(cohort 10/1994–09/2003)

Logistic regression adjusted for implementation of advised preventionmeasures, supply of skin protectionmaterials by employers,and implementation of outpatient medical treatment. 1 =minimal risk of job loss. In the <20-year-old age group, the risk of career

change due to severe hand eczema is 5-fold higher than in the 40- to 50-year-old age group [71], [73]. Ntotal=1163

lation of life experience and professional experience acton increasing individual motivation to employ consistentskin protection at the workplace, and this in turn in-creases the probability of employment continuation. Thus,TIP measures prove particularly successful in the caseof patients over 30 years of age, i.e., persons whoseprofessional alternatives in the current employmentmarket are limited (even if occupational retraining iscompleted with outstanding results) [71]. This observationemphasizes the sociopolitical dimension of TIPmeasures.An earlier evaluation of the 2002 patient collective(N=274) showed that 91% of cases were primary occupa-tional contact eczema of the hands, while in 75% ofcases, primary irritant hand eczema (i.e., partly irritantinduced atopic eczema), was diagnosed [70]. Overall,clinically relevant Type IV sensitization was observed in42% of cases, predominantly as secondarily acquired al-lergic contact eczema. Clinically relevant sensitizationswere most frequent in hairdressing with 66% of casesrepresented.The use of topical glucocorticosteroids coupled with ab-stention from allergens or noxa is indicated in cases ofacute contact eczema. However, recently it has becomeincreasingly apparent that adverse affects on epidermalbarrier function are related to the regular use of glucocor-ticosteroids [28], [52], [53], [77]. Therefore, concomitantwetwork- exposure and continuous glucocorticosteroidtherapy are called into question. It was found that 90%of patients with chronic OD in our collective had a historyof treatment with topical glucocorticosteroids, which wasadministered on a long-term daily regular bases in nearly40% of cases. Due to adverse effects of long-term therapywith topical glucocorticosteroids on the epidermal barrier,

which are induced by various pathomechanisms, TIP aimsat steroid-free therapy to the greatest possible extent. Tothis end, among other treatments, like calcineurin-antag-onists, classic dermatological externa such as shale oilin a disease stage-specific base, tannins and antiseptics,baths and irradiation such as local PUVA therapy (PUVAbath or cream therapy), as well as tap water iontophoresisfor hyperhidrosis, are variously used. In total, at the timeof discharge, complete freedom from dermatolgicalsymptoms or significant amelioration was observed in84% of participants. In order to attain a complete regen-eration of barrier function, it is necessary to allow for atleast a total of 6 weeks of exposure abstinence aftersevere skin damage to the skin [49].Affected persons, who are successfully convinced of thesignificance of preventionmeasures during TIP, frequentlycreate a multiplier effect among other employees of anenterprise, even though they are not yet recipients ofsuch prevention measures.This demonstrates that inpa-tient (and outpatient) prevention projects, which featurea setting-based approach, have an outreach effect onpopulation strata in which health-conscious behavior isnot a priority. It has become increasingly apparent thatmany affected persons confront the subject of (skin)health for the first time during these measures, andsubsequently prove to be remarkably impressionable interms of greater empowerment and increased personalresponsibility. In this respect, it should be borne in mindthat skin diseases are not to trifle with as commonlythought. In fact, the persistence of insufficiently treatedchronic dermatoses frequently lead to permanent adverseimpacts on future life prospects, also in social terms.Protracted phases of inability to work caused by eczema



all too frequently entail a decline into precarious employ-ment relationships or even worse, long-term unemploy-ment, which is followed by a significant loss of incomeand loss of what contributes to a person’s central identityin life.One of the decisive factors in TIP is the consistent andseamless continuation of initiatedmedical and preventiveefforts. Subsequent outpatient treatment, which iscovered for by the concerned accident insurance institu-tion and administered by the patient’s dermatologist, isalways indicated and an essential component of TIPmeasures. Thus, it is a welcome fact that locally practicingdermatologists largely perceive TIP as an important addi-tion to the spectrum of treatments offered in their prac-tices.Therefore, TIP exemplarily demonstrates options for effi-cient integrated care of patients (inpatient phase/outpa-tient treatment by the local dermatologist) [43]. It repre-sents an essential move towards multi-step diseasemanagement in occupational dermatology. Its prospectsfor success appear to be particularly good within the ex-tensive prevention mandate defined by Article 3 of theGerman Ordinance on Occupational Diseases (Berufs-krankheitenverordnung, BKV; referred to as: by all ad-equate means). That is, dermatological diagnostics andtreatment, which are defined according to disease stage,serve the interests of each patient and may proceed – inclinics and practices – without budgetary restrictions.

4.1 Nationwide multicentre study ontertiary individual prevention

Quality assurance of TIP’s further development appearsto be an important task in future. Emphasis will be placedon the integrative character of prevention concepts, whichwill combinemultidisciplinarymeasures to ensure a closeintegration of outpatient and inpatient treatment in termsof seamless care and patient counseling. It is in this waythat TIP currently differs from classic inpatient rehabilita-tion measures for OD that are largely monodisciplinaryin nature. Moreover, these are insufficiently united withnecessary therapeutic and workplace-related measures.Analogous to this, there are no verifiable, authoritativequality standards for inpatient rehabilitation of OD. In thecase of TIP, networked models as proposed by statutoryhealth insurances [referred to as: integrated care, in Art-icle 140 et seq. of the Social Code, Book V (Sozialgesetz-buch V)] can be realized. The central coordinating tasksof the “gate-keepers” as provided for in the concept ofintegrated care are performed by occupational diseaseadministrators (BK-Sachbearbeiter), which manage re-lated procedures. The administrator should turn to localdermatologists or, if applicable, to company medical of-ficers for advice. The improved dermatologist’s procedurewas created as a universal interactive information plat-form.Accordingly, a nationwide multicentre research projectof head organizations of statutory accident insurance in-stitutions is presently being conducted to further develop

multidisciplinary, inpatient–outpatient, networked treat-ment procedures, termedMedical-Occupational Rehabili-tation Procedure for Skin Diseases – Improvement andQuality Assurance of Treatment (Medizinisch-beruflichesRehabilitationsverfahren Haut – Optimierung und Quali-tätssicherung des Heilverfahrens; ROQ). The insurancestaff responsible for collaborating in this study was com-prehensively informed regarding study objectives. Thestudy itself was decisively supported by nationwide kick-off events. Recruitment has taken place since November2005. Project supervision rests with the University ofOsnabrück and the University of Heidelberg (Prof. Dr. T.L. Diepgen). Other participating study centers include theClinics for Occupational Diseases in Bad Reichenhall andFalkenstein, the latter in collaboration with the UniversityDermatological Clinic Jena (Prof. Dr. P. Elsner). The studyis conducted as a prospective, controlled cohort studyexamining 1000 patients with severe OD. In addition tofurther quality assurance, the assessment of transferab-ility to other centers and sustainability of the interventionis of particular importance. Studied patients in this cohortwill receive regular dermatological follow-up examinationsfor 3 years. Herein, the issues of employment continu-ation, satisfaction at the workplace, and quality of life arerecorded in particular, as well as disease history. A decis-ive operation manual and regular training of all centercare-takers (“train the trainer”) ensure a uniform mul-tidisciplinary approach based on the current state ofknowledge in all participating clinics. Upon discharge, thedesignated treating dermatologist (and the accident in-surance institution) receives comprehensive informationon the prevention concept which has been developedtogether with the affected individual. Moreover, a stand-ardized procedure on the occasion of discharge from in-patient treatment is established. Patients receive, at theexpense of the accident insurance institution, a so-calledstarter-set which includes individually assessed, profes-sion-specific skin protection materials, to provide for im-plementation of improved skin protection from the outset.

4.2 Perspectives

The proven collaboration of researchers with locallypracticing dermatologists was crucial to the success ofthe Osnabrück Model. Thus, fundamental requirementsformulated by the German Advisory Council on the Assess-ment of Developments in the Health Care System(Sachverständigenrat für das Gesundheitswesen) in 2001(referred to by the council as: close interlocking of outpa-tient and inpatient medical care) were met exemplarilyin terms of introducing improved patient care. Thegathered data support the concept that dermatology inthe future should orient itself towards prevention evenmore so than previously [43].In light of the proven success of TIP, classic unidimension-al inpatient treatments for severe OD should no longerbe implemented. This has been stated in the Multi-stepApproach to Skin Conditions (See internal workflow ofaccident insurance institutions for handling “skin disease



cases”, cf. paragraph 2). In this context, the benefit ac-crued for the collective body of the insured by timely andsystematic preventionmeasures in cases of OD has beenemphasized for the first time [23], [67]. Considering thefrequently short period of time between the first reportof occupational skin disease and the discontinuation ofemployment [47], it represents a welcome innovation foraffected patients. This also indicates a departure from apredominantly curative approach and an orientation to-wards a preventive system. In fact, this was frequentlycalled for recently by head organizations of statutory ac-cident insurance institutions [29], and is in accordancewith the current coalition agreement [4]. The text of thecoalition agreement refers to the importance of preven-tion, particularly in the light of demographic change.However, occupational aspects are not mentioned in theagreement. Nevertheless, increasing weekly workinghours and prolonging of working life span suggest thatthe number of OD cases will also rise. Contrary to popularassumption, female skin is no more sensitive than maleskin, but skin sensitivity increases with age for both sexes.This further emphasizes the future significance of efficientdermatological intervention instruments, up to and includ-ing networked and integrated TIP. It is hoped that themulti-step prevention concepts presented herein mayalso support preventive medical approaches in otherdisciplines.

List of abbreviationsCO2: carbon dioxideDIT: differential irritation testNaCl: sodium chlorideNaOH: sodium hydroxideOD: occupational dermatosesPUVA: psoralen plus UVAROS: reactive oxygen speciesSIP: secondary individual preventionSLS: sodium lauryl sulfateSMART: swift modified alkali resistance testTEWL: transepidermal water lossTIP: tertiary individual prevention

Notes

Conflict of interest

The author declares no competing interests.

Acknowledgments

I wish to thank A. Axt-Hammermeister and K.-H. Hage-mann (LVBG Nordwestdeutschland), W. Römer, G. Kocy-Rensing (NMBG Hannover), H. Goepfert (Bau-BG Hanno-ver) and H. Middendorf, F. Jäger, E. Rakus and K. Rojahn(BGW Delmenhorst), without the help of which this pub-lication would not have been possible. Further, I wish to

thank the Steering Committee (Chairperson O. Blome, E.Rogosky, U. Pällmann, HVBG; A. Axt-Hammermeister, K.-H. Hagemann, LVBG; H. Goepfert, Bau-BG; Prof. Dr. St.Brandenburg, BGW; W. Römer, NMBG; W. Wehrmann, I.Schindera, BVDD) and the Research Working Group:Chairperson W. Wehrmann, B. Melnik, NY. Schürer andX. Skudlik. For support in conducting and analyzing thestudy, I thank I. Tully, M. Prues and H. Dickel. For biomet-rical measurements I am grateful to O. Kuss (Martin-Luther-Universität Halle-Wittenberg). And finally, I amthankful to H. P. Francks, (BGMS Mainz) who updatedthe forms of the improved dermatologist’s report on thebasis of study results and various legal provisions, withenduring patience.

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27. Hachem J, Crumrine D, Fluhr J, Brown BE, Feingold KR, Elias PM.pH directly regulates epidermal permeability barrier homeostasis,and stratum corneum integrity/cohesion. J Invest Dermatol.2003;121(2):345-53. DOI: 10.1046/j.1523-1747.2003.12365.x

28. Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. Adverse effects oftopical glucocorticosteroids. J Am Acad Dermatol. 2006;54(1):1-15; quiz 16-18. DOI: 10.1016/j.jaad.2005.01.010

29. Hinne K, Wolff H. Wir haben keinen Grund, uns zu verstecken.Arbeit und Gesundheit. Z Sich Gesund Arb. 2005;(1):16-17.

30. Hüffmeier U, Traupe H, Oji V, Lascorz J, Ständer M, Lohmann J,Wendler J, Burkhardt H, Reis A. Loss-of-function variants of thefilaggrin gene are not major susceptibility factors for psoriasisvulgaris or psoriatic arthritis in German patients. J InvestDermatol. 2007;127(6):1367-70. Epub 2007 Jan 25. DOI:10.1038/sj.jid.5700720

31. John SM, Bartel G, Brehler R, Degenhardt A, Fluhr J, Frosch PJ,Haufs MG, Khrenova L, Kleesz P, Kügler K, Manegold HG,Schindera I, Sizmann N, Soost S, Tiedemann KH, Wagner E,Worm M. Negativliste: Hautirritabilitäts- undHautfunktionsdiagnostik zur Erfassung und Bewertung irritativerHautschäden. ABD-Arbeitsgruppe "Erfassung und Bewertungirritativer Hautschäden". Dermatol Beruf Umwelt/Occup EnvironDermatol. 2006;54:108-11.

32. John SM, Blome O, Brandenburg S, Diepgen T, Elsner P,WehrmannW. Zertifizierung: "Berufsdermatologie (ABD)": NeuesSeminar-Curriculum 2006 der Arbeitsgemeinschaft für Berufs-und Umweltdermatologie. [Certificate: occupational dermatology(ABD). New curriculum 2006 of the CME-seminars of the task-force of occupational and environmental dermatology]. J DtschDermatol Ges. 2007;5:135-44

33. John SM, Blome O, Brandenburg S, WehrmannW, Schwanitz HJ.Der zertifizierte Gutachter: Curriculum der Gutachterseminareder ABD. In: Schwanitz HJ, Wehrmann W, Brandenburg S, JohnSM, Hrsg. Gutachten Dermatologie. Darmstadt: Steinkopff Verlag;2003. p. 97-103.

34. John SM, Blome O, Brandenburg S, WehrmannW, Schwanitz HJ.Qualitätssicherung in der berufsdermatologischenBegutachtung:Curriculum der Gutachterseminare der ABD in Zusammenarbeitmit dem HVBG und dem Berufsverband. Dermatol BerufUmwelt/Occup Environ Dermatol. 2001;49:13-8.

35. John SM, BlomeO, Rogosky E, Axt-Hammermeister A, HagemannKH, Kuss O, Skudlik C, Dickel H. Optimiertes Hautarztverfahren:Ergebnisse einer Pilotstudie im Norddeutschen Raum. DermatolBeruf Umwelt/Occup Environ Dermatol. 2006;54(3):90-100.

36. John SM, Diepgen TL, Elsner P, Köllner A, Richter G, Rothe A,Schindera I, Stary A, Wehrmann W, Schwanitz HJ. Vier JahreQualitätssicherung im Hautarztverfahren: Bericht aus derClearingstelle der ABD. J Dtsch Dermatol Ges. 2004;2:717-21.

37. John SM, Elsner P, Kotschy-Lang N, Raab W, Diepgen TL.Integrierte Versorgung und Disease-Management in derBerufsdermatologie? Start einer Multizenterstudie zurOptimierung des Heilverfahrens. Dermatol Beruf Umwelt/OccupEnviron Dermatol. 2005;53:135 (abstract).

38. John SM, Schwanitz HJ. Functional skin testing: the SMART-procedures. In: Chew AL, Maibach HI, editors. Irritant Dermatitis.Berlin, Heidelberg, New York: Springer Verlag; 2006. p. 211-21.

39. John SM, Schwanitz HJ. Qualitätssicherung imHautarztverfahren:Bericht aus der Clearingstelle der ABD. In: Hauptverband dergewerblichen Berufsgenossenschaften, Hrsg. Berichtsband überdas Berufsgenossenschaftliche Forumam29.03.2001 anläßlichder 6. Tagung der Arbeitsgemeinschaft für Berufs- undUmweltdermatologie (ABD e.V.). St. Augustin: HVBG; 2004. p.34-45.

40. John SM, Skudlik C, RömerW, BlomeO, Brandenburg S, DiepgenTL, Harwerth A, Köllner A, Pohrt U, Rogosky E, Schindera I, StaryA, Worm M. Empfehlung: Hautarztverfahren. J Dtsch DermatolGes. 2007;5:1146-8.

41. John SM, Skudlik C, RömerW, BlomeO, Brandenburg S, DiepgenTL, Harwerth A, Köllner A, Pohrt U, Rogosky E, Schindera I, StaryA, Worm M. Hautarztverfahren [K32]. In: Korting H, Callies R,Reusch M, Schlaeger M, Sterry W, Hrsg. DermatologischeQualitätssicherung. Leitlinien und Empfehlungen. 5. Auflage.Berlin: BW Wissenschaftsverlag; 2007. p. 957-9.



42. John SM, Skudlik C, RömerW, BlomeO, Brandenburg S, DiepgenTL, Harwerth A, Köllner A, Pohrt U, Rogosky E, Schindera I, StaryA, WormM. Leitlinie Hautarztverfahren der Arbeitsgemeinschaftfür Berufs- und Umweltdermatologie (ABD). Dermatol in BerufUmwelt/Occup Dermatol Environ. 2006;54:101-3.

43. John SM, Skudlik C. Neue Versorgungsformen in derDermatologie: Vernetzte stationär-ambulante Prävention vonschwerenBerufsdermatosen - Eckpunkte für eine funktionierendeintegrierte Versorgung in Klinik und Praxis. [New forms ofmanagement in dermatology. Integrated in-patient-out-patientprevention of severe occupational dermatoses: cornerstones foran effective integrated management in clinics and practices].Gesundheitswesen. 2006;68:769-74.

44. John SM, Uter W. Meteorological influence on NaOH irritationvaries with body site. Arch Derm Res. 2005;296(7):320-6.

45. John SM. Chancen und Grenzen der stationären Prävention vonBerufsdermatosen. In: Berufsgenossenschaft der keramischenund Glas-Industrie, Hrsg. Berufsbedingte Haut- und obstruktiveAtemwegserkrankungen. Arbeitsmedizinisches Kolloquium BadReichenhall 2005. Heidelberg: Dr. Curt Haefner-Verlag; 2006.p. 19-32.

46. John SM. Epidemiologie berufsbedingter Hauterkrankungen. In:Schwanitz HJ, Wehrmann W, Brandenburg S, John SM, Hrsg.Gutachten Dermatologie. Darmstadt: Steinkopff-Verlag; 2003.p. 3-16.

47. John SM. Hautarztverfahren: Universelle Plattform für diedermatologische Frühintervention. In: Szliska S, Brandenburg S,John SM, Hrsg. Berufsdermatosen. 2. Aufl. MünchenDeisenhofen: Dustri Verlag Dr. Karl Feistle; 2006. p. 517-46.

48. John SM. Hautirritabilitätstests. In: Szliska C, Brandenburg S,John SM, Hrsg. Berufsdermatosen. 2. Aufl. MünchenDeisenhofen: Dustri Verlag Dr. Karl Feistle; 2006. p. 581-9.

49. John SM. Klinische und experimentelle Untersuchungen zurDiagnostik in der Berufsdermatologie. Konzeption einerwissenschaftlich begründeten Qualitätssicherung in dersozialmedizinischen Begutachtung. Studien zur Prävention inAllergologie, Berufs- und Umweltdermatologie (ABU), Bd. 4.Osnabrück: Universitätsverlag Osnabrück; 2001.

50. John SM. Objectifying primary and acquired sensitive skin. In:Berardesca E, Fluhr J, Maibach HI, editors. Sensitive skinsyndrome. New York: Taylor & Francis; 2006. p. 129-47.

51. John SM. Verfahren zur Früherfassung beruflich bedingterHautkrankheiten (Hautarztverfahren). In: Schwanitz HJ,Wehrmann W, Brandenburg S, John SM, Hrsg. GutachtenDermatologie. Darmstadt: Steinkopff Verlag; 2003. p. 33-59.

52. Kao JS, Fluhr JW, Man MQ, Fowler AJ, Hachem JP, Crumrine D,Ahn SK, Brown BE, Elias PM, Feingold KR. Short-TermGlucocorticoid Treatment Compromises Both Permeability BarrierHomeostasis and Stratum Corneum Integrity: Inhibition ofEpidermal Lipid Synthesis Accounts for Functional Abnormalities.J Invest Dermatol. 2003;120(3):456-64. DOI: 10.1046/j.1523-1747.2003.12053.x

53. Kolbe L, Kligman AM, Schreiner V, Stoudemayer T. Corticosteroid-induced atrophy and barrier impairment measured by non-invasive methods in human skin. Skin Res Technol. 2001;7:73-7. DOI: 10.1034/j.1600-0846.2001.70203.x

54. Kütting B, Diepgen T, Schmid K, Drexler H. Überlegungen zunotwendigen Konsequenzen für arbeitsmedizinischeVorsorgeuntersuchungen durch die Novellierung derGefahrstoffverordnung amBeispiel der Vorsorgeuntersuchungenfür Hauterkrankungen und obstruktive Atemwegserkrankungen.Arbeitsmed Sozialmed Umweltmed. 2005;40:308-12.

55. Lachapelle JM, Wigger-Alberti W, Bomann A, Mellström GA,Wulfhorst B, Bock M, Skudlik C, John SM, Perrenoud D, GogniatT, Olmstead W, Held E, Agner T. Prevention and Therapy. In:Frosch PJ, Menné T, Lepoittevin JP, editors. Contact Dermatitis.Berlin, Heidelberg: Springer; 2006. p. 831-67.

56. Locher G. Permeabilitätsprüfung der Haut Ekzemkranker undHautgesunder für den neuen Indikator Nitrazingelb "Geigy",Modizifierung der Alkaliresistenzprobe, pH-Verlauf in der Tiefedes stratum corneum. Dermatologica. 1962;124:159-82.

57. McLean WH, Hull PR. Breach delivery: increased solute uptakepoints to a defective skin barrier in atopic dermatitis. J InvestDermatol. 2007;127:8-10. DOI: 10.1038/sj.jid.5700609

58. Perkins MA, Osterhues MA, Farage MA, Robinson MK. Anoninvasive method to assess skin irritation and compromisedskin conditions using simple tape adsorption of molecularmarkers of inflammation. Skin Res Technol. 2001;7(4):227-37.DOI: 10.1034/j.1600-0846.2001.70405.x

59. Przybilla B, Schnuch A, Aberer W, Agathos J, Brasch J, Frosch PJ,Fuchs T, Richter G. Durchführung des Epikutantests mitKontaktallergenen. In: Korting HC, Callies R, ReuschM, SchlaegerM, Sterry W, Hrsg. Dermatologische Qualitätssicherung. Leitlinienund Empfehlungen. Germering: Zuckschwerdt Verlag; 2003. p.307-12.

60. Riehl U. Interventionsstudie zur Prävention vonHauterkrankungen bei Auszubildenden des Friseurhandwerks.Studien zur Prävention in Allergologie, Berufs- undUmweltdermatologie (ABU), Bd. 3. Osnabrück: UniversitätsverlagRasch; 2001

61. Schultze J. Paradigmenwechsel: Von der Prävention zurPrädiktion. In: Michna H, Oberender P, Schultze J, Wolf J, Hrsg."... und ein langes gesundes Leben". Prävention auf demPrüfstand: Wieviel organisierte Gesundheit - wievielEigenverantwortung? II. Interdisziplinärer Kongress JungeNaturwissenschaft und Praxis; 8.-9. Juni 2006; Köln. Köln: HansMartin Schleyer-Stiftung; 2006. p. 53-9.

62. Schwanitz HJ, Batzdorfer L, John SM. Forschungsbericht 1987-2002 ("Halbzeit"). Studien zur Prävention in Allergologie, Berufs-und Umweltdermatologie (ABU), Bd. 6. Göttingen: V&R Unipress;2003.

63. Schwanitz HJ, John SM. Untersuchungen zur Nachhaltigkeit desOsnabrücker Hautschutzmodells bei Friseuren und Altenpflegern.In: BGN, Hrsg. 10. Erfurter Tage. Prävention von arbeitsbedingtenGesundheitsgefahren und Erkrankungen. Leipzig : Monade;2004. p. 334-40.

64. Schwanitz HJ, Riehl U, Schlesinger T, BockM, Skudlik C, WulfhorstB. Skin care management: educational aspects. Int Arch OccupEnviron Health. 2003;76(5):374-81. DOI: 10.1007/s00420-002-0428-z

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Corresponding author:Prof. Dr. Swen Malte JohnFachgebiet Dermatologie, Umweltmedizin,Gesundheitstheorie, Universität Osnabrück, Sedanstr.115 (Station D1), 49069 Osnabrück, Deutschland, Tel:0541-969-2357, Fax: [email protected]

Please cite asJohn SM. Occupational skin diseases: options for multidisciplinarynetworking in preventive medicine. GMS Ger Med Sci. 2008;6:Doc07.

This article is freely available fromhttp://www.egms.de/en/gms/2008-6/000052.shtml

Received: 2008-07-28Published: 2008-10-27

Copyright©2008 John. This is an Open Access article distributed under the termsof the Creative Commons Attribution License(http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). Youare free: to Share — to copy, distribute and transmit the work, providedthe original author and source are credited.



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