Dermatological procedures

Reporting and diagnostic procedure for the early detection of occupational skin diseases. In practice, the procedure is of central importance for the secondary prevention of occupational dermatoses. The dermatologist procedure is initiated if there is a possibility of a skin disease developing, recurring or worsening as a result of an occupational activity (see also occupational skin disease).

The dermatologist procedure enables the dermatologist to:

• Recommend so-called § 3 BeKV measures
• Suggest concrete improvements to working conditions
• Review of workplace conditions via the technical supervisory service of the employers' liability insurance association and, if necessary, optimization of occupational safety options.

There are also opportunities to initiate specific skin protection measures. As part of the dermatologist's report, outpatient and, if necessary, inpatient treatment can be suggested.

• This is a procedure for the early detection of work-related skin diseases, which all statutory accident insurance institutions have signed up to. The legal basis is anchored in 1st paragraph § 3 BKV.
  • § Section 3 BKV is defined as follows: If an insured person is at risk of developing, recovering or aggravating an occupational disease, the insurance institution must take all appropriate measures to counteract this risk.

The dermatologist procedure has a two-stage structure: the patient can be referred to a dermatologist by any doctor. The dermatologist will then prepare a dermatologist's report in which he informs the insurance carrier of the findings and his conclusions. § 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 to a dermatologist if there is a possibility that a skin disease may develop, recur or worsen as a result of an occupational activity within the meaning of the Ordinance on Occupational Diseases (see below: Occupational disease of the skin). The dermatologist shall examine the insured person. He shall immediately submit a dermatologist's report in accordance with form F 6050 to the accident insurance institution and send copies to the attending physician and the health insurance fund. The doctor must use form F 2900 ÜV for the presentation to the dermatologist.

§ 42 Obligation to re-present: If necessary for diagnostic reasons, the dermatologist may monitor the course of the disease by re-presenting the insured person. He must immediately prepare the dermatologist's report in accordance with form F 6050 for the accident insurance institution and send copies to the attending physician and the health insurance fund.

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

The dermatologist's procedure is used for the early detection of occupational dermatoses and triggers prophylactic measures. It is intended to prevent an occupational dermatosis from becoming an occupational disease.

Dermatologist's report: The central instrument in the dermatologist's procedure is the dermatologist's report. This is the first time the accident insurance institution learns of the existence of a skin disease in an insured person and can take prophylactic action as part of §3 measures. Billing can be carried out via the accident insurer without special authorization or treatment order.

BK notification: Medical notification of an occupational disease ("green notification") is made if there is reasonable suspicion of an occupational disease. In the case of dermatoses that do not fall under item 5101 BeKV, there is a reasonable suspicion if an occupational condition can be assumed; in the case of diseases under item 5101, only if the formal legal criteria for an occupational disease are also considered to be fulfilled. The BK notification inevitably initiates a BK assessment procedure!

Determination procedure: Includes preliminary examinations by the accident insurance institution (treatment reports, information from the insured person, employer and health insurance fund, workplace analysis by the Technical Supervisory Service) and concludes with a correlation report. This can take 1-2 years.

The employers' liability insurance association as cost bearer: After the treatment costs have been covered (written notification), usually for a limited period of time, liquidation takes place via the accident insurance institution. Unless otherwise stated in the treatment order, the amounts for general medical treatment apply. Special medical treatment is only provided if specified in the order. The scale of fees of the accident insurance institutions applies (see: Butz-Leufting: BG-GOÄ; Kepnerdruck Druckereiverlag GmbH, Eppingen).

Therapeutics, cotton gloves, skin protection products (see below skin protection products, industrial), skin cleansing products (see below skin cleansing products, industrial), skin care products, bath oils etc. may be prescribed. Protective gloves are generally not covered (employer!), prescription (vinyl gloves) only if expressly approved! Prescriptions are issued on a health insurance prescription (mark UV in the prescription header, state the name and location of the BG, file number of the BG; free prescription). BG prescriptions run outside the drug budget!

Occupational eczema in the consultation: Prepare a dermatologist's report as quickly as possible and apply for skin protection measures. If necessary, certify incapacity for work in order to assess the progression of the skin disease and establish eligibility for testing. As a rule, approval is given after 4-8 weeks, if the accident insurance institution does not respond, a new dermatologist's report or consultation with the responsible case officer. Unfortunately, some employers' liability insurance associations are very restrictive. After approval, start skin protection measures and regular treatment report with recommendation for further cost coverage. It is important that the patient attends regular check-ups! In the event of recurrences, further dermatologist reports may be required.

Incapacity for work: Costs of incapacity for work during ongoing §3 measures are borne by the accident insurance institution, but the health insurance company pays in advance: Usual certificate of incapacity for work with health insurance company header, mark work accident, under diagnosis: §3 measures taken over by BG, file number. Periods of incapacity for 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 recognized without sick leave! Repeated relapses can usually only be proven by time off work (sick leave/healing/work/recurrence).

Abandonment of the harmful activity: If no satisfactory result can be achieved with the feasible prophylactic measures, if it is not justifiable to continue the harmful activity and if abandonment of the harmful activity is indicated, the BK report is filed. If the patient cannot change to a suitable job within the company and the job has to be given up, incapacity for work is certified until an occupational rehabilitation measure (e.g. retraining) takes place. This also applies to people who have already been made redundant, as sickness benefit is higher than unemployment benefit and the assessment procedure can take longer (this procedure is backed up by a social court decision, as there are generally not a significant number of suitable jobs available on the labor market. Presentation to the rehabilitation counselor at the employment office in order to initiate a vocational rehabilitation measure as quickly as possible. The employment office will make advance payments; once the BG has recognized its responsibility, the costs assumed will be reimbursed. This also applies to the higher injury benefit paid to the retrainee. At the beginning of the rehabilitation program, the patient is "written back to health".

The doctor as rehabilitation consultant: Whether a patient should be permanently taken out of work (his occupation) depends on the course, severity and prognosis of the skin disease, but also on social criteria. This is where the dermatologist is needed as a rehabilitation consultant. The same applies to competent advice regarding a BG decision. Complaints yes or no - the sole recommendation to give up your job is unprofessional and can cause financial damage. To help you make the right decision, here are the various protection and support measures offered by the accident insurance institutions:

• Retraining in a suitable occupation (usually a dry occupation): Applies to younger people affected - there is often a permanent reduction in earnings, as retraining is usually in a lower-paid occupation.
• Transitional benefit (according to §3 para. 2) to compensate for reduced earnings: After retraining, in the event of unemployment, permanent incapacity to work or if the person concerned has taken up a lower-paid job. The aim is to achieve a gradual acclimatization to the lower earnings (graduated over 5 years in steps of one fifth).
• Integration assistance: If the person concerned looks for a job on the labor market, full financing of the job during the training period, usually for 6 months.
• Occupational disease pension: Irrespective of the earnings situation, from a reduction in earning capacity of 20%.
• Depending on the situation, this results in various solutions to be favored (if internal implementation is not possible):
  • Apprentice: If possible, complete training, then retrain.
  • Affected person relatively young, retrainable and still employable on the labor market: retraining.
  • Unable to retrain due to age, difficult to place, retirement or early retirement age cannot be reached within 5 years: take up another job with temporary protection (transitional benefit). If the person concerned will not tolerate a later reduction in earnings, attempt to keep them in work (accepting occasional periods of sick leave) until pension can be reached in 5 years.
  • Advanced age, pension in sight: giving up work: unemployment benefit and transitional benefit, then retirement.
  • It can also be decisive whether further financial resources can be expected: occupational illness pension, private occupational disability insurance.
  • In the case of self-employed persons, only the complete transfer of the business (e.g. sale) is generally recognized as the cessation of all harmful activities. Changes of activity within the company are often not accepted by the accident insurance institution, as it is assumed that the employee occasionally "lends a hand".

• 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 no. 3101 and 3102) and diseases of the respiratory tract including rhinitis (e.g. BK no. 4301, 4302).

If there is a real suspicion of an existing occupational disease, no dermatologist procedure is initiated but a "Medical report of suspected occupational disease" according to form text F6000. Form 6000 is also used if you want to report an occupational disease without a dermatologist procedure. In this case, the patient's consent is not required.

All necessary forms for the dermatologist procedure or a notification of suspected occupational disease can be found online at: www.dguv.de/formtexte/aerzte/index.jsp.

If the patient cannot name the accident insurance company responsible, the report will be sent to the accident insurance company whose responsibility 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