Rehabilitation, dermatological

Medical (dermatological) rehabilitation is understood to mean the restoration of physical and/or mental functions, the reduction of disease-related deficits to improve social participation with physiotherapeutic, dietary and occupational therapy measures as well as clinical psychology and instructions for self-management. These complex measures can be carried out both on an outpatient and inpatient basis.

Benefits for dermatological rehabilitation can be granted in accordance with § 9 + 15 SGB VI if the insured person's earning capacity is considerably endangered or reduced due to a dermatological disease and if the insured person's performance or participation is considerably endangered or a reduction in earning capacity ( MdE) can be averted by the benefits or, in the case of reduced earning capacity, this can be significantly improved or restored or its significant deterioration averted by the benefits (§ 10 para. 1 SGB VI; so-called personal requirements). For other cost units see: Note(s)

According to the applicable rehabilitation guidelines and the "Guidelines on the need for rehabilitation for skin diseases", dermatological rehabilitation is still indicated if there is a need for rehabilitation. This is the case if a comprehensive, curative treatment by a dermatologist/venereologist required for the individual rehabilitant is not sufficient in the case of a health-related impending or already manifest impairment of participation, if the skin disease extends over a larger body surface and/or is localized in the visible body area, there is a severe form of skin disease progression following hospital treatment, for which there is a special need for rehabilitation, an optimal therapeutic effect can only be achieved through the holistic, interdisciplinary concept of rehabilitation and there is a positive rehabilitation prognosis (e.g. long-term recurrence-free treatment).e.g. long-term recurrence-free interval) (see fast-track treatment).

The rehabilitation of skin patients with co-occurring mental illnesses has been introduced as Behavioral Medicine-Oriented Rehabilitation (VOR) in the German Pension Insurance (DRV) since 2023.

In particular, the severity of the clinical manifestations, the frequency of recurrence of the chronic skin disease despite adequate therapy (e.g. multiple exacerbations requiring inpatient treatment) and the presence of risk factors must be taken into account. As a rule, benefits for dermatological rehabilitation are not provided by the REHA cost bearer before four years have elapsed following the provision of such or similar benefits for rehabilitation. However, this does not apply if premature benefits are urgently required for health reasons (§ 12 Para. 2 SGB VI). Rehabilitation is indicated, for example, for the following dermatological/allergological diseases:

• Allergic rhinoconjunctivitis
• Allergic bronchial asthma
• Follow-up treatment (AHB) for malignant skin tumors (e.g. malignant melanoma, spinocellular carcinoma, basal cell carcinoma, etc.) and malignant systemic diseases of the skin (e.g. T-cell lymphomas, mycosis fungoides, etc.)
• Atopic dermatitis, endogenous eczema, neurodermatitis
• Autoimmunological blistering diseases (e.g. pemphigus vulgaris, bullous pemphigoid)
• Chronic itchy dermatoses (e.g. diseases of the prurigo group)
• Chronic diseases of the lymphatic system(lymphoedema)
• Chronic contact eczema
• Chronic urticaria
• Chronic wounds
• Dematoses that are characterized by particular resistance to therapy and have already been treated for a long time without success
• Hand and foot eczema
• Dermatological manifestations of chronic venous insufficiency (CVI), arterial occlusive disease (AVD)
• Erythroderma
• Genetically caused large-area skin diseases (e.g. epidermolysis bullosa group, ichthyoses).
• Large scars, e.g. as a result of burns or operations
• Perioral dermatitis
• Psoriasis vulgaris
• Tuberculosis cutis
• Collagenoses
• Withdrawal from glucocorticoids
• Lichen planus
• Lichen simplex chronicus
• Cutaneous T-/B-cell lymphomas
• Parapsoriasis
• Prevention of allergies
• Rosacea .

Due to the complexity of the problem of the "chronic skin patient", a very differentiated and individualized rehabilitation concept is required. Just like the inpatient form, outpatient dermatological rehabilitation is based on a holistic rehabilitation concept including a socio-medical assessment and includes a comprehensive, rehabilitation-specific, interdisciplinary range of therapies. This consists of physical, individually tailored physical measures such as ointment therapy, UV radiation, therapeutic baths, etc., disease-centered drug therapy, psychological, ecotrophological, social and educational components.

Access to rehabilitation in dermatology takes the form of

- follow-up treatment (AHB)/rehabilitation (AR), which takes place within 2 weeks after completion of (surgical) therapy in an AHB clinic, e.g. in the case of invasive skin tumors;

- on the other hand, as a fast-track treatment (EHV) for chronic inflammatory skin diseases after an acute stay, which has been possible at the expense of the DRV since 2000;

- or as part of individual tertiary prevention in the case of occupational accident insurance association dermatology procedures at the expense of the statutory accident insurance provider;

- and, since 2023, as behavioral medicine-oriented rehabilitation (VOR) over 4 weeks at the expense of the DRV for psoriasis or neurodermatitis with concomitant mental illness.

The decision as to whether inpatient or outpatient dermatological rehabilitation is carried out for a rehabilitant depends on:

• the extent of the damage
• Impairment of activities
• (impending) impairment of participation
• the extent of the medical risk
• social environment and the legitimate wishes of the rehabilitant (consideration of personal/family and religious/ideological needs and circumstances) as well as the availability of an outpatient or inpatient facility that meets the quality criteria.
• Indication/medical requirements/activities: as a result of the above-mentioned injuries and their effects, activities may be impaired:
  • in behaviour in personal and social activities (e.g. acceptance of the illness, self-image, problems of stigmatization, skills in dealing with the illness, compensation strategies, self-endangerment, role in the family, motivation and drive at work)
  • in self-care (e.g. household, cleaning, shopping, nutrition, personal hygiene, clothing) in locomotion, mobility and dexterity (e.g. manual skills, prolonged walking, climbing stairs, fast walking, use of public transport, travel)
  • situational (e.g. physical resilience in work, leisure and everyday life in terms of weight, endurance, certain body positions such as standing for long periods, damp environments, extreme cold/heat, sunlight, environmental toxins).
  • Participation: As a result of the above-mentioned damage and impairment of activities, participation may be impaired in the following different areas:
    • Physical independence (e.g. need for aids)
    • Adaptation of the environment
    • Need for help from other people
    • Personal assistance or care
    • Dependence on outside help
    • Limited independence or self-care in everyday life
    • Mobility (e.g. restrictions in movement in the personal environment, in the neighborhood, in the community, in long-distance areas, when traveling)
    • Employment in the professional field with regard to commuting to and from work, workplace conditions (e.g. occupational exposure to skin allergens and noxious substances), work organization, qualifications (training, further education and training)
    • Household management in leisure time
    • mental resilience
    • social integration/reintegration (e.g. establishing and maintaining social relationships)
    • economic independence.
  • Context factors: The so-called context factors represent the entire background of a person's life. They include all environmental and personal factors that are important for a person's health. The context factors interact with all components of the ICF (body functions and body structures, activities and participation). Context factors can have a positive, supportive influence (support factors) on all components of functional health and thus on the course of rehabilitation. It is therefore important to recognize these as early as possible and to use their rehabilitation-promoting effect (resource concept of rehabilitation).

Rehabilitation goals: The goals of medical rehabilitation are to avert, eliminate, reduce, prevent the worsening of or mitigate the consequences of impending or already manifest impairments to participation in working life and life in society by introducing the necessary rehabilitation measures at an early stage. The aim of rehabilitation is to (re)enable the rehabilitated person to carry out gainful employment and/or certain activities of daily living in the manner and to the extent that is considered "normal" for this person (typical for his/her personal life context).

Objectives in this sense for working life are, for example, the restoration and maintenance of earning capacity Planning of workplace adaptation Maintaining the workplace Planning and initiation of measures for (further) participation in working life.

Goals for activities of daily living: e.g. organization of the home environment, adaptation of living space, help in finding coping strategies, guidance on health-conscious nutrition and motivation to change lifestyle, including reduction of negative contextual factors, initiation of adaptation to sports and leisure activities.

Rehabilitation goals related to body functions and body structures: The goals are to avert, eliminate, reduce, prevent the worsening or mitigate the consequences of damage to the entire skin organ, taking into account the diagnoses, in particular with regard to clinical appearance, itching, infections, movement restrictions and contractures. The focus here is on the long-term improvement or stabilization of the skin condition and, if necessary, other manifestations.

Rehabilitation goals related to activities: The goals are to avert, eliminate, reduce, prevent the worsening or mitigate the consequences of an increase in the impairment of activities, especially in behavior (e.g. in the family, at work, in leisure time, in motivation and in crises) in self-care (e.g. in hygienic activities).(e.g. hygiene) in locomotion and mobility in coping with the disease, e.g. reduction of anxiety and depression, coping with chronic pain, itching and stress, promotion of compliance, in optimizing coping with the disease.)

Rehabilitation goals related to participation: The goals are to avert, eliminate or reduce imminent or already manifest impairments of participation, to prevent their increase or to mitigate their consequences, in particular in physical independence (with regard to self-care), mobility (getting around in the environment), employment (training, gainful employment, household management, leisure), mental stability, social integration and economic independence (with regard to securing a livelihood). Rehabilitation goals related to contextual factors The nature and extent of the functional problem can be exacerbated or reduced by contextual factors (environmental factors and personal factors), so that these must be taken into account when determining the rehabilitation goals. This may require workplace inspections, home inspections and discussions with the employer or caregivers with the aim of adapting the environmental conditions to the remaining impairments of the rehabilitant's activities (adaptation).

Driven by the realization that sustainable behavioral modification is hardly possible only through repeated applications/training in a 3 to 4 week setting, rehabilitation aftercare measures (RENA) were introduced by DRV and GKV shortly before the corona pandemic (2019), which are only now belatedly moving into the awareness of care.

In the 1st year after rehabilitation, the DRV (subject to a positive employment prognosis) and the GKV (for certain indications, which are often comorbidities of skin diseases [diabetes, obesity...]) finance the following aftercare measures for up to 12 months:

ACCESS ONLY VIA THE DRV:

- T-RENA=training-therapeutic rehabilitation aftercare

- Tele-RENA (e.g. Caspar Health)=digital individual T-RENA

-I-RENA=intensive rehabilitation aftercare with two or more modules

-Psy-RENA=psychosomatic rehabilitation aftercare

ACCESS VIA THE GKV:

Rehabilitation sports, functional training, physiotherapy, weight training in the fitness center

PATHS TO REHABILITATION:

Applications for rehabilitation benefits are made by completing form 60 (available from the health insurance funds).

Employed persons and pupils/students are generally rehabilitated at the expense of the DRV. This is based on §§ 9 + 15 SGB VI. The attending physician fills out form S0051 (for adults) or G0612 (children/adolescents).
Industrial workers who may have been referred by the DRV can apply for a Tertiary Individual Prevention Measure (TIP) via the statutory accident insurance (BG, DGUV) in accordance with §§ 27 SGB VII + § 42 SGB IX.

Privately insured persons without a DRV account should contact their health insurance company

Civil servants should contact their benefits office

Further information on dermatological rehabilitation can be found on the website of the"Arbeitsgemeinschaft Rehabilitation in dermatology".

1. Elsner J, Weyergraf A (2007) Indication and application for dermatologic rehabilitation. JDDG 5 (Suppl2) 52
2. Framework recommendations for outpatient dermatological rehabilitation, dated January 22, 2004. Federal Working Group for Rehabilitation II special section.
3. Buhles,N, E,A; L,H; S,S; T,A; W,J: Interdisciplinary S1-LL: Inpatient dermatologic rehabilitation. AWMF register no.: 013-083, on 3.12.2024
4. Buhles, Norbert (2020). Outpatient follow-up care after dermato-oncologic rehabilitation. German Dermatol.: 414 - 418 .
5. Schmitter, J; Buhles, N; (2014) Quo vadis? Rehabilitation for atonic dermatitis. SKIN (02), 72-76
6. Buhles,N, Spindler,T, (2023) Wisdom from the White Paper-Chapter 4.14: Rehabilitation in allergology. Allergo J (32/2), 16-24
7. Lantzsch, H; B,N, (2014) Rehabilitation in psoriasis: Quo vadis? Act. Dermatolog.(40), 223-230