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 cm². In the following review, important aspects of this new occupational disease will be highlighted and discussed.     

Sozialrechtliche Bewertung UV-induzierter Hauttumoren

The present work deals with insurance and legal issues on the prevention of UV-induced skin tumors. We are convinced that squamous cell carcinoma of the skin fulfils the socio-legally required conditions according to paragraph 9 Abs. 2 SGB VII for approval as an occupational disease. In malignant melanoma evidence also exists for its induction through UV exposure and increased risk for occupational UV exposure, thus, making approval as an occupational disease possible in individual cases. According to the currently available medical knowledge on basal cell carcinoma and malignant melanoma, there is no sufficient basis for the approval of these as occupational disorders. Therefore, significant actions should not only be taken in the context of primary disease prevention, but also within the framework of secondary and tertiary disease prevention in occupational UV exposure.     

Occupational skin diseases

Occupational skin diseases are the most commonly reported notifiable occupational diseases. In Germany, 23 596 out of a total of 71 263 reported occupational diseases in 2010 were classified as occupational skin diseases (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”). Contact dermatitis (allergic, irritant) of the hands is the most common skin disease and atopic skin diathesis is often an important co‐factor. The number of work‐related skin diseases is many times higher than the number of notified occupational dermatoses. This CME article explains the legal framework of occupational diseases, the tasks and obligations of the legal statutory work insurance. Typical allergens and irritants of high risk professions are also presented as are the important steps from diagnosis to compensation. Early prevention of occupational skin diseases is very important to avoid severe chronic hand eczema. Therefore the “dermatologist's report” is crucial. Other occupational dermatoses (outside of BK 5101) are briefly mentioned. In recent years the number of notifications of occupational skin cancer due to occupational UV‐irradiation has increased. According to recent epidemiological findings, there is a significant and consistent positive association between occupational UV‐irradiation and squamous cell carcinoma. Therefore, an important criterion for a new occupational disease is fulfilled.     

Skin cancer induced by natural UV‐radiation as an occupational disease – Requirements for its notification and recognition

In Germany over 2.5 million employees have an increased risk of skin cancer due to their occupational exposure to natural UV‐irradiation. The medical consultation board “Occupational diseases” of the Ministry of Labor and Social affairs has investigated the association between occupational UV‐irradiation and skin cancer risk and recommends to add the following new occupational disease into the appendix1 of the German ordinance on occupational diseases: “Squamous cell carcinoma and multiple actinic keratosis due to natural UV‐irradiation”. In this article we report in the view of the German Society of Occupational and Environmental Dermatology (ABD) and the German Statutory accident insurance (DGUV), whose criteria have to be fulfilled for the notification and recognition of an occupational skin cancer due to natural UV‐irradiation.     

Mechanisms and prevention of UV‐induced melanoma

Melanoma is the deadliest form of skin cancer and its incidence is rising, creating a costly and significant clinical problem. Exposure to ultraviolet (UV) radiation, namely UVA (315‐400 nm) and UVB (280‐315 nm), is a major risk factor for melanoma development. Cumulative UV radiation exposure from sunlight or tanning beds contributes to UV‐induced DNA damage, oxidative stress, and inflammation in the skin. A number of factors, including hair color, skin type, genetic background, location, and history of tanning, determine the skin's response to UV radiation. In melanocytes, dysregulation of this UV radiation response can lead to melanoma. Given the complex origins of melanoma, it is difficult to develop curative therapies and universally effective preventative strategies. Here, we describe and discuss the mechanisms of UV‐induced skin damage responsible for inducing melanomagenesis, and explore options for therapeutic and preventative interventions.     

Rehabilitation von berufsbedingten Hauterkrankungen

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

Running behind a tourist: leisure-related skin cancer prophylaxis

The most important risk factor in the development of skin cancer is exposure to ultraviolet (UV) radiation. Cumulative lifetime UV radiation exposure has been shown to be most important in the pathogenesis of squamous cell carcinoma, whereas intermittent high-dose UV radiation exposure in childhood and adolescence may be more important in the aetiology of basal cell carcinoma and cutaneous malignant melanoma. Using established methodology and best available estimates on UV-related mortality and morbidity, it has been estimated that annually around 1·5?million disability-adjusted life years are lost through excessive exposure to UV radiation. Skin cancer is a significant health problem and its burden is such that it causes the health system more to treat than any other forms of cancer. Prevention is the key action in managing skin cancer at a population level. Investment in prevention programmes such as SunSmart encourages protective behaviours that will reduce the human and financial costs of skin cancer.     

Overview on vitamin D and sunbed use

Vitamin D seems to be associated with a protective effect in a vast range of diseases, including cardiovascular, autoimmune and oncologic conditions. Since ultraviolet (UV) B light is the most important prerequisite for the cutaneous synthesis of vitamin D, sunbeds are able to increase serum vitamin D levels, although only transiently in most cases. In this scenario, the artificial tanning industry relentlessly tries to promote the use of sunbeds as a ‘safe’ therapeutic measure to achieve an adequate serum vitamin D status. The World Health Organization classified UV‐emitting tanning devices, as well as the whole UV spectrum, as group‐1 carcinogens, as they significantly increase the risk of melanoma and non‐melanoma skin cancer. In case of vitamin D deficiency or insufficiency, the current risk‐benefit ratio is therefore in favour of vitamin D supplementation instead of sunbed use. Artificial tanning devices should never be considered as an option to achieve an appropriate vitamin D status. Their supposedly beneficial effects, vastly publicised by the artificial tanning industry, are not worth the carcinogenic risk associated with sunbed use.     

How to run an effective and efficient dermato‐oncology unit: a Dutch approach

The worldwide incidence of skin cancer (especially non‐melanoma skin cancer) has risen dramatically over the last decades. Skin cancer, including pre‐malignant lesions, is becoming a chronic disease. Adjustments in skin cancer health care need to be made. A disease management system for skin cancer is mandatory in order to avoid waiting lists and insure adequate treatment quality with ever growing numbers of patients requiring treatment. At the Catharina Hospital Eindhoven adjustments are being made on several levels of the dermato‐oncology unit in collaboration with Eindhoven University of Technology. The model combines technological improvements, training health care workers, training of general practitioners and prevention of skin cancer. We discuss our ideas and clinical experiences with managing a dermato‐oncology unit.     

Paediatric melanoma

Paediatric melanoma, although rare, is the most common skin cancer in children. Our current knowledge on paediatric melanoma incidence trends is expanding, as several studies have addressed this issue with conflicting results. Known risk factors for paediatric melanoma include family history of melanoma, a previous history of malignancy, large congenital nevi, numerous melanocytic nevi, sunburns, increased UV exposure and a sun‐sensitive phenotype. In younger children, melanoma more often presents with atypical features, such as a changing, amelanotic or uniformly coloured, often bleeding lesion, not fulfilling in most cases the conventional ABCDE criteria. The major differential diagnoses are melanocytic nevi, proliferative nodules in congenital nevi and atypical Spitz tumours. Moreover, in the younger age group non‐Caucasian children are over‐represented, tumours tend to be thicker and lymph nodes are often involved. Despite the frequent diagnosis at an advanced stage, the overall survival is fair in paediatric melanoma. Specific guidelines for management of melanoma in children do not exist, and most often the disease is treated similarly to melanoma in adults.     

Epidemiology of cutaneous melanoma and non-melanoma skin cancer in Schleswig-Holstein, Germany: incidence, clinical subtypes, tumour stages and localization (epidemiology of skin cancer)

BACKGROUND: Population-based figures on skin cancer are essential for a realistic assessment of the personal disease burden, prevention modes and the need for caring. The Robert Koch Institute in Germany estimates the incidence of melanoma skin cancer as seven cases in 100 000 persons (age-standardized by the European standard rate). Population-based studies presumably show higher incidence rates of 10-16 cases in 100 000 persons. Few data exist for non-melanoma skin cancer (NMSC) as this is not systematically registered in Germany. OBJECTIVES: To present the first population-based results from the Schleswig-Holstein (Germany) Cancer Registry on incidence, stage distribution, clinical types and localization of skin cancer and to compare the results with other studies. METHODS: The Cancer Registry of the Bundesland Schleswig-Holstein with 3500 registering institutions, 100 of which are dermatological institutions, investigates all notifiable incident cancer cases according to international standards. From the recorded data all melanoma and NMSC cases were identified and evaluated. RESULTS: Between 1998 and 2001, 1784 malignant melanoma (MM) and 12 956 NMSC cases underwent diagnostic and analytical evaluation. For MM, age-standardized incidence rates were 12.3 and 14.8 in 100 000 men and women, respectively, and the mean age of men was greater than that of women (56.6 vs. 54.9 years, P < 0.05). Superficial spreading melanoma was the most frequent clinical type (39.1%). The tumours were predominantly located on the trunk in men (46.8%) in contrast to leg and hip in women (39.5%). For NMSC, the age-standardized incidence rates were 100.2 and 72.6 in 100 000 men and women, respectively. More than 80% of all tumours were basal cell carcinoma. CONCLUSIONS: The first population-based data from Schleswig-Holstein on the characteristics (age, sex, histological subtypes, localization and stage) of skin tumours agree well with the existing literature and may thus be regarded as representative. However, markedly higher incidences for MM and NMSC in the north of Germany compared with other parts of the country were observed. As the incidence rates from the north of Germany fit well into the European geographical pattern, we assume no regional increase. Therefore, the official German estimates on cutaneous tumours may largely depend on regional factors and may not be regarded as representative for all regions in Germany.     

Outdoor activities in childhood: a protective factor for cutaneous melanoma? Results of a case–control study in 271 matched pairs

BACKGROUND: A matched case-control study was performed in Munich, Germany, in 1996-97 to evaluate the risk of cutaneous melanoma due to ultraviolet (UV) exposure behaviour in Southern Bavaria, Germany. OBJECTIVES: Patients with cutaneous melanoma and controls were investigated by two physicians using a standardized questionnaire to identify risk factors for the development of melanoma, such as professional and leisure sun exposure behaviour. In each person, a total body examination was performed to detect benign skin alterations, phenotypic characteristics and precursor lesions for skin cancer. PATIENTS/METHODS: A total of 271 melanoma patients and 271 controls were individually matched for residence, age and gender. A multiple conditional logistic regression analysis was performed. RESULTS: Of 56 factors, those risk factors with a strong effect on the development of melanoma were: the existence of melanoma in first degree relatives, solar lentigo, actinic keratosis, actinic cheilitis, skin phototype, immediate skin reaction to UV light at the start of the outdoor season, sunburn in childhood and sun exposure during holidays in sunny areas 20 years before melanoma was diagnosed; outdoor activities in childhood were found to be protective. CONCLUSIONS: Sunburn in childhood and increased sun exposure during annual holidays in sunny areas should be avoided. In contrast, outdoor activities in childhood, including soccer and gardening, should be encouraged because they are associated with a lower risk of melanoma formation.     

Development of a targeted risk‐group model for skin cancer screening based on more than 100 000 total skin examinations

Background Skin cancer screening aims to detect potentially metastasizing skin cancers at an early and surgically curable stage. This may take the form of mass screening, as currently occurs in Germany, or of targeted screening of those at greatest risk. Objective To develop a model to identify patients at high risk of developing skin cancer who would benefit from regular skin cancer screening. Methods This was an open prospective point‐prevalence study of consecutive patients presenting to dermatologists for a total skin check. Demographic and skin cancer risk factors were recorded and, for the first time, histology of skin lesions was documented. Results were analysed by univariate and multivariate analyses and, after logistic regression with stepwise forward selection, a risk‐group model was developed. Results The results of 108 281 total skin examinations were available for analysis. 142 definite melanomas, 108 severely dysplastic naevi/cannot‐exclude‐melanoma, 491 basal cell carcinomas (BCC) and 93 squamous cell carcinomas (SCC) were excised. A risk model was developed for melanoma and SCC based on mathematical e‐functions. The model had >92% sensitivity for melanoma and SCC and an overall 67.24% specificity for melanoma, SCC and BCC. This targeted risk model identified one‐third of the study population as being at risk for the development of melanoma and SCC. Conclusions Using the risk calculator developed from this study, targeted screening of the identified at‐risk population reduces the numbers needed to be screened regularly by 50%, yet has better sensitivity for melanoma and similar sensitivity for SCC compared to the current mass screening programme in Germany.     

Living with xeroderma pigmentosum: comprehensive photoprotection for highly photosensitive patients

Xeroderma pigmentosum (XP) is a rare autosomal recessive disease of deoxyribonucleic acid (DNA) repair with ultraviolet (UV) radiation sensitivity and a 10 000‐fold increased risk of skin cancer. Symptoms include: freckle‐like pigmentation in sun‐exposed skin before age 2 years, severe burns after minimal sun exposure (50% of patients) and damage to exposed surfaces of the eyes with loss of vision and ocular cancer. About 25% of patients develop a progressive neurodegeneration. The combination of an inherited inability to repair UV‐induced DNA damage and environmental exposure to UV must occur for cutaneous and ocular symptoms to develop. There is no cure for XP, but many of its manifestations may be reduced or prevented through consistent UV protection; thus XP serves as a model for sun protection of patients with marked photosenstivity. Sun protective clothing including hats, sunglasses and face shields, sun screen lotions and avoidance of environmental sources of UV are cornerstones of prevention of skin and eye damage and cancer. Although XP is a serious disease with the potential for limitation of life expectancy, XP patients can live active lives while at the same time avoiding UV.     

Lymphoma‐associated skin cancer: incidence,natural history,and clinical management

The link between immunosuppression and skin cancer has been well described. The two most common situations involving immunosuppression‐associated skin cancer are solid organ transplantation and non‐Hodgkin lymphoma (NHL), including chronic lymphocytic leukemia (CLL). Patients with lymphoma are more likely to have development of a secondary malignancy, with skin cancer being the most common. The most common types of skin cancer in patients with NHL/CLL include melanoma, squamous cell carcinoma, basal cell carcinoma, and Merkel cell carcinoma. Many skin cancers demonstrate increased aggressiveness in patients with NHL/CLL and are associated with higher recurrence rates, increased regional metastasis, and death secondary to skin cancer metastases. This review delineates the current research regarding the relationship between NHL/CLL and cutaneous malignancy. Immunosuppressed patients with skin cancer should be treated promptly and aggressively to decrease recurrence and metastases. Regular skin self‐examinations, dermatologic examinations, sun‐protective habits, and education may prove beneficial in this high‐risk patient population.     

Nationwide hospitalization costs of skin melanoma and non-melanoma skin cancer in Germany

Introduction Non‐melanoma skin cancer (NMSC), in contrast to skin melanoma (MEL), is considered a negligible health problem because mortality of NMSC is low. The aim of this study was to provide insights into the burden of NMSC and MEL by analysing nationwide skin cancer hospitalization data and data from a dermatologist panel of Germany. We wanted to estimate hospitalization costs due to skin cancer in Germany. Material and methods We analysed the most recent nationwide hospitalization data from 2003 and estimated hospitalization costs due to MEL and NMSC. We estimated the annual number of private dermatologist practice visits in Germany due to skin cancer. Results In 2003, 20 455 melanoma‐related and 41 929 NMSC‐related hospitalizations occurred in Germany. Age‐standardized hospitalization rates for NMSC were 2.5‐fold and 1.8‐fold higher among men and women than the rates for MEL, respectively. The age‐specific proportions of hospitalizations for NMSC in relation to all cancer‐related hospitalizations increased within the age range of 65 years and more. Among people aged 90 years and more, 14% of all cancer‐related hospitalizations were due to NMSC. Estimated annual hospitalization costs for MEL were €50 to 60 million, and those for NMSC were €105 to 130 million. The estimated number of private dermatologist practice visits in Germany 2003 is considerably higher for NMSC than MEL Conclusions Analyses of hospitalizations data and data from private dermatologists give NMSC higher public health relevance than can be obtained from consideration of death statistics.     

Ultraviolet radiation and skin cancer

Skin cancer is the most common type of cancer in fair-skinned populations in many parts of the world. The incidence, morbidity and mortality rates of skin cancers are increasing and, therefore, pose a significant public health concern. Ultraviolet radiation (UVR) is the major etiologic agent in the development of skin cancers. UVR causes DNA damage and genetic mutations, which subsequently lead to skin cancer. A clearer understanding of UVR is crucial in the prevention of skin cancer. This article reviews UVR, its damaging effects on the skin and its relationship to UV immunosuppression and skin cancer. Several factors influence the amount of UVR reaching the earth's surface, including ozone depletion, UV light elevation, latitude, altitude, and weather conditions. The current treatment modalities utilizing UVR (i.e. phototherapy) can also predispose to skin cancers. Unnecessary exposure to the sun and artificial UVR (tanning lamps) are important personal attributable risks. This article aims to provide a comprehensive overview of skin cancer with an emphasis on carefully evaluated statistics, the epidemiology of UVR-induced skin cancers, incidence rates, risk factors, and preventative behaviors & strategies, including personal behavioral modifications and public educational initiatives.     

Epidemiologie von chronischen Lichtschäden

Whereas in Australia the high incidence of UV‐induced skin cancer and chronic UV‐damage is epidemiologically well proved, comparable figures in Europe and particularly in Germany are missing. Presumably, the prevalence and incidence of actinic keratoses, basal cell carcinoma and squamous cell carcinoma are significantly underestimated. The importance of chronic skin damage is discussed in accordance with new epidemiologic studies recently published in international journals. Since the percentage of older people is increasing in Germany the therapeutic importance of UV‐damage and its relevance for preventive medicine will be of increasing importance in the next years.     

Occupational skin cancer induced by ultraviolet radiation and its prevention

Skin cancer is by far the most common kind of cancer diagnosed in many western countries and ultraviolet radiation is the most important risk factor for cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). Although employees at several workplaces are exposed to increased levels of UV radiation, skin cancer due to long-term intense occupational exposure to UV radiation is often not considered as occupational disease. The actually available evidence in the epidemiological literature clearly indicates that occupational UV radiation exposure is a substantial and robust risk factor for the development of cutaneous SCC and also clearly shows a significant risk for developing BCC. There is enough scientific evidence that outdoor workers have an increased risk of developing work-related occupational skin cancer due to natural UV radiation exposure and adequate prevention strategies must be implemented. The three measures which are successful and of particular importance in the prevention of nonmelanoma skin cancer in outdoor workers are changes in behaviour regarding awareness of health and disease resulting from exposure to natural UV radiation, protection from direct UV radiation by wearing suitable clothing, and regular and correct use of appropriate sunscreens.     

Tertiäre Prävention von Berufsdermatosen

Background: Inpatient tertiary prevention of occupational skin diseases is indicated when the employee is threatened with loosing their job. Earlier studies have shown that with intensive tertiary preventive measures, 2/3 of such individuals can continue their jobs long‐term. Data on the effectiveness of tertiary prevention for various occupational groups has not been previously available. Patients and Methods: The outcome of all participants treated in the year 2002 was analyzed according to occupational groups with respect to diagnosis, medical intervention prior and during the inpatient period. Results: In 91 % of 296 cases contact dermatitis of the hands was diagnosed (75 % primary irritant contact dermatitis (37 % chronic irritant contact dermatitis, 38 % irritated atopic hand eczema, 16 % allergic contact dermatitis). Clinically relevant Type IV‐delayed hypersensitivity (allergic contact dermatitis) reactions were identified in 42 % of cases; in most cases, the delayed hypersensitivity followed irritant contact dermatitis. In more than 83 % of cases, a complete or nearly complete remission was achieved. Clinical relevant Type IV sensitization was most frequent in hairdressers (66 %). Cleaning and housekeeping personnel most frequently used corticosteroids on a regular basis (60 %) and most often experienced corticosteroid withdrawal (53 %) and atrophy of the skin of the hands (23 %). Conclusion: The data from studies on the tertiary prevention of occupational skin diseases reveal strategies for the optimization of outpatient care indicate specific occupational risk factors. The variance between professions may reflect differing approaches to secondary prevention.