Occupational skin diseases: options for multidisciplinary networking in preventive medicine

Occupational dermatoses (OD) have topped the list of occupational diseases in Germany for years. Presently, approximately 16,000 new OD cases are officially reported to public statutory employers' liability insurance bodies, each year. The disease burden is high not only for individuals but also for society as a whole. Estimated annual economic costs in Germany due to sick-leave and lack of productivity due to OD are more than 1.5 billion euros. Thus, in recent years, various pilot initiatives aiming to improve prevention of occupational skin diseases (of various degrees of severity) have been developed and recently evaluated in Osnabrück. These activities have been funded by statutory employers' liability insurance schemes. Concepts underpinning these initiatives include multidisciplinary skin protection teaching programs for various high-risk professions, which turned out to be pivotal for the success of these projects. A corollary of this work is a nationwide multi-step intervention approach currently implemented by the public statutory insurance system. This approach offers 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 (Fig. 1)), which focuses mainly on primary prevention. Despite the high prevalence of OD and its poor prognosis, little is known about the molecular mechanisms underlying individual susceptibility to develop chronic irritant dermatitis. Skin irritation tests are thus far of only limited value. Presently, our institution, in collaboration with Amsterdam universities, focuses on immunogenetic risk factors potentially 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 procedure was recently up-dated in order to provide more rapid dermatological consultation. Additionally, combined outpatient dermatological and educational intervention seminars (secondary individual prevention, SIP) are offered to affected employees. We recently demonstrated the sustainability of the SIP approach in hairdressing for periods of up to 10 years. For those cases of OD, in which the abovementioned outpatient prevention measures are not sufficiently successful, specific interdisciplinary inpatient prevention measures have been developed (tertiary individual prevention, or TIP). TIP represents the ultima ratio within the hierarchical prevention concept of the Osnabrück Model. TIP comprises 2-3 weeks of inpatient dermatological diagnostics and treatment as well as intensive health-related pedagogic and psychological counseling. Subsequent to this, 3 consecutive weeks of outpatient treatment are given by a local dermatologist. Each patient remains on sick-leave for a total of 6 weeks to allow full barrier recovery. A total of 764 out of 1164 (66%) TIP patients treated in our university, followed-up regularly by a local dermatologist for up to 1 year, were successful in remaining in their respective (risk-) professions as assessed by questionnaire 1 year after discharge. Recently obtained SIP and TIP data reveal that there are reliable, evidence-based options for multidisciplinary prevention and patient management 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 of prevention in more depth (3-year dermatological follow-up of 1000 OD patients) is currently being conducted in Germany.