Dermatological procedures

Notification and diagnostic procedures for the early detection of occupational skin diseases. In practice, the procedure is of central importance for the secondary prevention of occupational dermatoses. The dermatological procedure is initiated if there is a possibility that a skin disease develops, revives or worsens as a result of occupational activity (see also occupational skin disease).

The dermatological procedure enables the dermatologist:

• recommendation of so-called § 3 BeKV measures
• proposals for concrete improvements in working conditions
• Review of workplace conditions via the technical supervisory service of the employers' liability insurance association and, if necessary, optimisation of occupational safety measures.

There are also possibilities to initiate concrete skin protection measures. Within the scope of the dermatologist's report outpatient and, if necessary, inpatient treatment methods can be suggested.

• This is a procedure for the early detection of occupational skin diseases to which all statutory accident insurance institutions have subscribed. The legal foundation is anchored in the 1st paragraph § 3 BKV.
  • § 3 BKV is defined as follows: If an insured person is at risk of developing, resurrecting or aggravating an occupational disease, the insurer has to counteract this risk by all appropriate means.

The dermatological procedure is structured in two steps: The assignment of the patient to a dermatologist is possible by any doctor. The dermatologist will then issue the so-called dermatologist's report, in which he will inform the insurance company of the findings and his conclusion. § Section 43 of the medical contract specifies the contractual obligation for each doctor.

Procedure: Every doctor is obliged to immediately present an insured person with pathological skin changes, where there is a possibility that a skin disease may arise, revive or worsen as a result of an occupational activity in the sense of the Ordinance on Occupational Diseases (see below occupational skin disease), to a dermatologist. The dermatologist will examine the insured person. He immediately submits a dermatologist's report according to form F 6050 to the accident insurance institution and sends copies to the treating physician and the health insurance company. The doctor must use form F 2900 ÜV for presentation to the dermatologist.

§ 42 Dermatologist's obligation to present the insured person again: If necessary for diagnostic reasons, the dermatologist may monitor the course of the disease by presenting the insured person again. The dermatologist must immediately prepare the dermatologist's report according to form F 6050 to the accident insurance institution and send copies to the treating physician and the health insurance company.

§ 43 Skin tests: The dermatologist is entitled to carry out tests which are necessary to clarify the causal relationship between the skin disease and the occupational activity. Tests shall be limited to the extent necessary for the dermatologist's report. Any further tests require the consent of the accident insurance institution.

The dermatological procedure serves the early detection of occupational dermatoses and triggers prophylactic measures. It shall prevent that an occupational dermatosis becomes an occupational disease.

Dermatologist's report: The central instrument in the dermatological procedure is the dermatologist's report. It is the first time the UV-carrier learns about the presence of a skin disease in an insured person and can take prophylactic measures within the scope of §3 measures. The bill can be settled via the accident insurer without special approval or treatment contract.

BK notification: Medical notification of an occupational disease ("green notification") is made if there is a justified suspicion of an occupational disease. In case of dermatoses which are not covered by number 5101 BeKV, the justified suspicion exists if an occupational condition is to be assumed, in case of illnesses according to number 5101 only if the formal legal criteria of an occupational illness are also to be regarded as fulfilled. The BK notification inevitably initiates a BK determination procedure!

Determination procedure: Includes preliminary examinations by the accident insurance institution (treatment reports, information from the insured, employer and health insurance company, workplace analysis by the technical supervisory service) and concludes with a contextual expert opinion. This can take 1-2 years.

The employer's liability insurance association as the cost carrier: After the treatment costs have been paid (written notification), usually for a limited period of time, the UV carrier is liquidated. Unless otherwise stated in the treatment contract, the amounts for general treatment apply. Special medical treatment is only provided if indicated in the contract. The scale of fees of the accident insurance institutions applies (see: Butz-Leufting: BG-GOÄ; Kepnerdruck Druckereiverlag GmbH, Eppingen).

Therapeutics, cotton gloves, skin protection preparations (see below skin protection preparations, industrial), skin cleansing agents (see below skin cleansing agents, industrial), skin care preparations, bath oils etc. may be prescribed. Protective gloves are usually not covered (employer!), regulation (vinyl gloves) only if expressly approved! Recipes are made on a cash prescription (mark UV in the prescription header, state name and seat of the BG, file number of the BG; prescription free of charge). BG prescriptions are outside the drug budget!

Occupational eczema in consultation hours: prepare a dermatologist report as quickly as possible and apply for skin protection measures. If necessary, certify incapacity to work in order to assess the course of the skin disease and establish testability. As a rule, consent is given after 4-8 weeks, if the UV carrier does not react, a new dermatologist's report or consultation with the responsible person. Some professional associations are unfortunately very restrictive. After approval, the skin protection measures are started and regular treatment report with recommendation of further cost absorption. It is important that the patient is regularly presented to the doctor again! In case of recurrences, possibly submit further dermatologist reports.

Incapacity to work: Costs of incapacity to work during ongoing §3 measures are borne by the UV carrier, but the health insurance company will make advance payment: Usual AU certificate with health insurance head, tick the work accident, under Diagnosis: §3 measures covered by BG, file number. Periods of incapacity to work can be important to prove occupational relevance and are an important criterion for the assessor. As a rule, no serious skin disease or compulsion to refrain from the damaging activity is recognised without AU! Even repeated recidivism can usually only be proven by the time spent in an occupational injury (occupational injury/healing/work/recidivism).

Abandonment of the harmful activity: If no satisfactory result can be achieved with the prophylactic measures that can be carried out, if the patient cannot be held responsible for his or her whereabouts and if the abandonment of the harmful activity is indicated, the BK report is filed. If the patient cannot change to a suitable workplace within the company and the activity has to be given up, incapacity to work is certified until a vocational rehabilitation measure (e.g. retraining) is taken. This then also applies to persons who have already given notice, since sickness benefit is assessed at a higher rate than unemployment benefit and the assessment procedure can take longer (this procedure is secured by a social court decision, since suitable jobs are usually not available in significant numbers on the labour market. Presentation to the rehabilitation counsellor at the employment office in order to initiate a vocational rehabilitation measure as quickly as possible. The employment office makes an advance payment, and after the BG has recognized the competence, the costs incurred are reimbursed. This also applies to the higher injury benefit paid to the retrained person. At the beginning of the rehabilitation measure the patient is written "healthy" again.

The physician as rehabilitation consultant: Whether a patient should be permanently removed from the profession (his activity) depends on the course, severity and prognosis of the skin disease, but also on social criteria. Here the dermatologist is in demand as a rehabilitation consultant. The same applies to a competent consultation regarding a BG decision. Complaints yes or no - the sole recommendation to give up the profession is unprofessional and can cause financial damage. In order to be able to make the right decision, the following is a list of the various insurance and support measures offered by the accident insurance institutions:

• Retraining in a suitable occupation (usually a dry occupation): Applies to younger people - often there is a loss of earnings in the long term, as they are usually retrained in a less well-paid occupation.
• Transitional benefit (according to §3 Abs. 2) to compensate for reduced earnings: after retraining, in case of unemployment, permanent incapacity to work or if the person concerned has taken up a lower-paid job. The aim is to gradually become accustomed to the lower earnings (graduated over 5 years in steps of five).
• Integration aid: if the person concerned is looking for a job on the labour market, full financing of the job during the familiarisation period, usually for 6 months.
• Occupational disease pension: independent of the earning situation, from a 20% reduction in earning capacity.
• Depending on the situation, this results in different solutions to be favoured (if internal implementation is not possible):
  • Apprentice: If possible, have training completed, then retrain.
  • Relatively young, retrainable and still employable on the labour market: retraining.
  • Unable to retrain because of age, difficult to place, unable to reach retirement or early retirement age within 5 years: take up another job with temporary protection (transitional benefit). If the person concerned does not tolerate a later reduction in earnings, try to keep him or her in the job (accepting occasional periods of unemployment) until retirement age can be reached in 5 years.
  • Advanced age, retirement in sight: cessation of activity: unemployment benefit and transitional benefit, then retirement.
  • The question of whether further financial resources can be expected can also have a decisive effect: occupational disease pension, private occupational disability insurance.
  • In the case of self-employed persons, as a rule, only the complete transfer of the business (e.g. sale) is recognised as the cessation of all damaging activities. Changes of activity within the company are often not accepted by the UV carrier, as occasional "helping hands" are assumed.

• Topical basic therapy:
• Hydration of the skin
• Emollients
• Avoidance or reduction of trigger factors
• Initiation of skin protection measures
• Stage 1 (mild hand eczema):
• antipruriginous and antiseptic agents
• topical glucocorticosteroids (short-term or intermittent)
• topical calcineurin inhibitors
• Iontophoresis
• Stage 2 (moderately severe and severe hand eczema; in addition to measures of stage 1):
• highly potent topical glucocorticosteroids
• UV Therapy
• Alitretinoin
• Stage 3 (persistent or chronically recurring hand eczema; in addition to measures of stage 1 and stage 2):
• systemic immunomodulating therapy
• Alitretinoin
• systemic glucocorticosteroids
• Ciclosporin

• The dermatologist procedure does not cover: skin cancer (e.g. BK No. 5102), infectious skin diseases (e.g. BK Nos. 3101 and 3102) and diseases of the respiratory tract including rhinitis (e.g. BK Nos. 4301, 4302).
• If there is a real suspicion of an existing occupational disease, no dermatologist procedure is initiated but a "Medical report in case of suspicion of an occupational disease" according to form text F6000. Form 6000 is also used if a report of an occupational disease is to be made without a dermatologist's procedure. In this case, the patient's consent is not required.
• All the necessary forms for the dermatologist's procedure or a report of a suspected occupational disease can be found online at: www.dguv.de/formtexte/aerzte/index.jsp.
• If the patient cannot name his competent accident insurance, the report will be sent to the accident insurance whose competence is assumed. A list of all accident insurers can be found at: http://www.dguv.de/Inhalt/BGuUK/index.jsp

1. Diepgen TL et al (2009) Management of hand eczema - Guideline - LCD 10-digit: L20. L23. L24. L25. L30. J Dtsch Dermatol Ges 7:S1-S16
2. John SM (2003) Procedure for the early detection of occupational skin diseases (dermatologist procedure) In: Schwanitz HJ, Wehrmann W, Brandenburg S, John SM (Hrsg) Gutachten Dermatologie, Steinkopf Verlag, Darmstadt, pp. 33-59