The impact of stigmatization of psoriasis, atopic dermatitis and mastocytosis in different areas of life-A qualitative interview study.

Background: Stereotypes and false assumptions about chronic and visible skin diseases can determine the behaviour towards affected individuals and result in stigmatization or discrimination. Objective: The aim of this study was to analyze the perceived disease-related stigmatization of individuals with psoriasis, atopic dermatitis (AD) or mastocytosis. The study also aims to broaden people-centred knowledge of the effects of stigmatization in different areas of life, namely in everyday life, at work, in sports and in relationships. Methods: Qualitative in-depth semi-structured interviews were conducted among individuals with either psoriasis, AD or mastocytosis. Participants were recruited via self-help networks and were asked to express their experience of stigmatization in different areas of life. All interviews were audio recorded, transcribed verbatim and evaluated based on Mayring's content analysis. Results: In total, 24 individuals aged 19-79 years and living in Germany were included in the study-eight for each disease. Stigmatization was experienced in all three diseases in all mentioned areas of life as well as in interaction with medical professionals. Self-exclusion, negative self-perception and negative behaviour of others were the most frequent experiences with stigmatization. Conclusion: Stigmatization, both internal and external, is an important factor contributing to the mental burden of people with chronic skin diseases. More research is needed to gain deeper insight into stigmatization and its psychological burden in various contexts to enhance people-centred care in chronic skin diseases.

Addictions in patients with atopic dermatitis: a cross-sectional pilot study in Germany.

BACKGROUND: Atopic dermatitis (AD) is the most common chronic inflammatory skin disease worldwide and displays many atopic, but also non-atopic comorbidities. Among the latter, mental health disorders such as depression have been extensively studied. However, data on addictions are still rare. OBJECTIVES: The aim of this study was to assess the prevalence of different kinds of addictions in adult AD patients using a single-centre approach. METHODS: This non-interventional cross-sectional study was performed from 03/2020 to 05/2020 at the Department of Dermatology of a large German university hospital. Participants with a diagnosis of AD confirmed by a dermatologist answered questions about disease severity (patient-oriented eczema measure, POEM), quality of life (Dermatology Life Quality Index, DLQI) and smoking habits. They were screened for problematic alcohol consumption, drug abuse, internet addiction and pathological gambling using internationally established and validated questionnaires. RESULTS: 157 patients (56.1% female; mean age of 49.9 ± 20.4) with an average POEM of 13.7 ± 7.5 and DLQI of 6.1 ± 5.4 were evaluated. 14.1% were identified as regular smokers, 12.1% screened positive for alcohol dependency, 6.4% for drug use disorders, 4.5% for Internet addiction and 3.2% for pathological gambling. Co-occurrences of different addictions were observed, and a positive correlation was noted between DLQI scores and smoking. CONCLUSIONS: In summary, this study hints at elevated positive screening rates for problematic alcohol consumption, drug use disorders, Internet addiction and problem gambling compared with the general population. Screening routinely for addictions may improve patient-centred health care of AD patients.

Atopic dermatitis: disease characteristics and comorbidities in smoking and non-smoking patients from the TREATgermany registry.

BACKGROUND: Atopic dermatitis (AD) is a chronic inflammatory skin disease with a multifactorial genesis including genetic predispositions and environmental risk and trigger factors. One of the latter possibly is smoking, indicated by an increased prevalence of AD in adults and children that are actively or passively exposed to cigarette smoke. OBJECTIVES: In this study, AD characteristics and its atopic comorbidities are compared in smoking and non-smoking AD patients. METHODS: TREATgermany is a non-interventional clinical registry which includes patients with moderate to severe AD in Germany. Baseline data of patients included in TREATgermany from inception in June 2016 to April 2020 in 39 sites across Germany was analysed comparing AD disease characteristics and comorbidities in smokers vs. non-smokers. RESULTS: Of 921 patients, 908 (male: 58.7%) with a mean age of 41.9 ± 14.4 reported their smoking status. The objective Scoring of Atopic Dermatitis (oSCORAD) did not differ between smokers (n = 352; 38.8%) and non-smokers, however, lesions' intensity of oozing/crusts and excoriations as well as patient global assessment scores (PGA) of AD severity were higher in smoking as opposed to non-smoking patients. Smokers reported a lower number of weeks with well-controlled AD and more severe pruritus than non-smokers. Total IgE levels were more elevated in smokers and they displayed a younger age at the initial diagnosis of bronchial asthma. After adjustment for potential confounders, the increased intensity of oozing/crusts, the reduced number of weeks with well-controlled AD and the greater pruritus remained different in smokers compared to non-smokers. In addition, smoking patients with adult-onset AD showed a 2.5 times higher chance of involvement of the feet. CONCLUSIONS: German registry data indicate that AD patients who smoke have a higher disease burden with a different distribution pattern of lesions in adult-onset AD.

Can crowdsourced data help to optimize atopic dermatitis treatment? Comparing web search data and environmental data in Germany.

BACKGROUND: Atopic dermatitis (AD) is one of the most common chronic skin diseases worldwide, showing various manifestations and having a severe impact on quality of life. As previous studies demonstrated, internet search analysis can help identify public interest in diseases and possible influencing factors on search behavior. OBJECTIVE: To identify AD-related topics of interest in Germany using internet search volume. METHODS: Google Ads Keyword Planner was used to identify AD-related search terms including their search volume in Germany on a national level as well as in 16 selected cities from January 2016 to December 2019. Identified keywords were qualitatively analyzed, and temporal trends as well as the influence of seasonal and environmental factors on search volume were assessed. RESULTS: Overall, 1222 AD-related search terms with a search volume of 8 842 360 searches were identified. An increase from 2016 to 2019 and seasonal peaks from January to April of each year were observed. Nationwide, the search volume correlated with mean monthly temperature and sun duration. With increasing temperature and sun duration, a significant decrease in search queries was observed. The most populated cities showed the lowest number of searches per 100 000 inhabitants (Berlin, Hamburg, and Munich). In the eight categories formed (comorbidities, general, influential factors, localization, stage of life, symptoms/severity, therapy/information, and questions on AD), the highest proportion of search queries were assigned to the category "therapy/information" in most cities. In this category, a focus on the topics of "alternative medicine" and "home remedies" could be observed. CONCLUSION: The overall high and increasing search volume indicates a high interest in AD-related topics, especially regarding treatment and disease education. Information provided by internet search volume analyses can optimize AD therapy and patient-centered care by providing insight into patient needs and predicting potential climatic trigger factors.

Skin cancer risk and shade: comparing the risk of foresters with other outdoor workers.

BACKGROUND: Keratinocyte carcinoma (KC) is an increasingly important public health problem with an especially high prevalence in outdoor workers. In contrast to other occupations, foresters spend most of their outdoor time under the shade of trees. OBJECTIVES: We aimed to compare the unique sun exposure patterns and sun protection behaviour of foresters with those of other outdoor workers and their relation to the KC risk. METHODS: In July 2018, a cross-sectional study was conducted at an international forestry fair using a questionnaire about health awareness and skin cancer screening by dermatologists to assess the prevalence of KC. RESULTS: A total of 591 participants (78.7% male; mean age 46.8 ± 16.2 years) including 193 foresters were enrolled. Of all foresters, 72% experienced sunburns (solar erythema) within the past year and 50% of them experienced the worst sunburn during work. Foresters were most likely to often/always wear protective clothes (29.0%) but were least likely to often/always avoid midday sun (23.8%) and stay in the shade (31.1%). Having an outdoor profession or spending hours outside for leisure was negatively associated with sun protection. Skin examination revealed an overall KC prevalence of 16.7%, with 16.5% of foresters being affected. CONCLUSION: Despite being protected by trees, the risk of KC for foresters is comparable to that of other professional groups. Shade alone may not provide sufficient protection. Additional sun protection measures are necessary.

[Health care of chronic inflammatory skin diseases : Do affected individuals seek dermatological care?] / Versorgung von chronisch entzündlichen Hauterkrankungen : Gehen Betroffene zum niedergelassenen Dermatologen?

BACKGROUND: Psoriasis, atopic eczema and urticaria are chronic inflammatory skin diseases that are often associated with an impairment of affected individuals and their families. Despite constant progress in therapy of these diseases, affected people often do not consult an office-based dermatologist. OBJECTIVES: The aim of this study was to estimate which proportion of affected individuals with severe forms of these diseases receive treatment by an office-based dermatologist in Bavaria. MATERIALS AND METHODS: All dermatologists listed in the database of the Bavarian Association of Panel Doctors (KVB; Kassenärztliche Vereinigung Bayern; n = 499) were invited to participate in a paper-based cross-sectional study. The stated number of patients by each dermatologist were set in relation with the literature-based 1­year prevalence, as well as data on population and data of the KVB. Estimations were based on three approaches (conservative, medium, and progressive estimation method). RESULTS: Overall, 137 dermatologists participated (38.7% women; mean age: 53.2 ± 8.5 years). Conservative estimation indicated that 56.5% of individuals with moderate to severe psoriasis, 57.3% of individuals with moderate to severe atopic eczema and 71.9% of those suffering from chronic spontaneous urticaria are not seen by an office-based dermatologist. CONCLUSION: Many affected individuals seem not to seek an office-based dermatologist when affected by a severe skin condition. Thus, further and more precise studies to identify, address and minimize barriers to optimal patient care are needed.

Atopic eczema: burden of disease and individual suffering - results from a large EU study in adults.

BACKGROUND: Atopic eczema (AE, atopic dermatitis) is one of the most common non-communicable inflammatory skin diseases affecting 1-5% of the adult population in Europe with marked impairment in quality of life. In spite of great progress in understanding the pathophysiology of disturbed skin barrier and immune deviation, AE still represents a problem in daily clinical practice. Furthermore, the true impact of AE on individual suffering is often not recognized. OBJECTIVES: With a large European study, we wanted to provide insights into the actual suffering and individual burden of disease in adult patients with AE. METHODS: A total of 1189 adult patients (18-87 years, 56% female) with moderate to severe AE were recruited in nine European countries by dermatologists or allergists together with the help of patient organizations. A computer-assisted telephone interview was performed by experienced interviewers between October 2017 and March 2018. The following instruments were used to assess severity or measure quality of life: Patient-Oriented Eczema Measure (POEM), Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS-D) and a newly developed Atopic Eczema Score of Emotional Consequences (AESEC). Patients were also asked to self-assess the severity of their disease. RESULTS: Despite current treatment, 45% of participants still had actual moderate to very severe AE in POEM. Due to their skin disease, 57% missed at least 1 day of work in the preceding year. DLQI showed moderate to extremely large impairment in 55%. According to HADS-D, 10% scored on or above the threshold of eight points with signs of depressive symptoms. Assessed with AESEC, 57% were emotionally burdened with feelings such as 'trying to hide the eczema', 'feeling guilty about eczema', having 'problems with intimacy' and more. Of persons actually suffering from severe AE, 88% stated that their AE at least partly compromised their ability to face life. CONCLUSIONS: This real-life study shows that adults with a moderate to severe form of AE are suffering more than what would be deemed acceptable. There is a need for increased awareness of this problem among healthcare professionals, policymakers and the general public to support research in the development of new and more effective treatments and provide access to better and affordable health care for affected patients.

'Try to make good hay in the shade - it won't work!' A qualitative interview study on the perspectives of Bavarian farmers regarding primary prevention of skin cancer.

BACKGROUND: Extensive exposure to solar ultraviolet radiation (UVR) is the main risk factor for keratinocyte carcinoma (KC), making outdoor workers, including farmers, a high-risk population for KC. The use of sun protection is crucial for KC prevention but is not typically implemented by outdoor workers during their daily tasks. OBJECTIVES: To explore the attitudes of Bavarian farmers regarding sun-protective measures in their daily work and to understand perceived barriers and unmet needs. METHODS: Farmers were recruited through the Bavarian Farmers Association in Bavaria, Southern Germany. Qualitative semi structured interviews were conducted with participants between December 2017 and March 2018. Interviews were recorded, transcribed verbatim and analysed using qualitative content analysis. RESULTS: Twenty farmers (11 women, nine men; nine aged 18-30 years, 11 aged > 60 years) participated. Knowledge and awareness of UVR exposure and KC, perceived individual barriers to implementing sun-protective measures, individual experiences and farm life-specific circumstances emerged as key areas influencing the perspectives of farmers regarding the primary prevention of KC. Female farmers tended to take a more positive stance on sun protection, whereas male farmers showed a lower overall interest. CONCLUSIONS: Knowledge and awareness of KC and UVR exposure is very limited in Bavarian farmers with serious perceived barriers due to the demands of daily agricultural work. Further qualitative studies are needed to identify intervention options that can increase skin cancer awareness and that can successfully overcome real barriers to implementing sun protection.

Skin diseases are more common than we think: screening results of an unreferred population at the Munich Oktoberfest.

BACKGROUND: Skin diseases are ranked as the fourth most common cause of human illness, resulting in an enormous non-fatal burden. Despite this, many affected people do not consult a physician. Accordingly, the actual skin disease burden might be even higher since reported prevalence rates are typically based on secondary data that exclude individuals who do not seek medical care. OBJECTIVE: The aim of the study was to investigate the prevalence of skin diseases in an unreferred population in a real-life setting. METHODS: A cross-sectional study of 9 days duration was performed in 2016 at the 'Bavarian Central Agricultural Festival', which is part of the Munich Oktoberfest. As part of a public health check-up, screening examinations were performed randomly on participating visitors. All participants were 18 years or older and provided written informed consent. RESULTS: A total of 2701 individuals (53.5% women, 46.2% men; mean age 51.9 ± 15.3 years) participated in the study. At least one skin abnormality was observed in 1662 of the participants (64.5%). The most common diagnoses were actinic keratosis (26.6%), rosacea (25.5%) and eczema (11.7%). Skin diseases increased with age and were more frequent in men (72.3%) than in women (58.0%). Clinical examinations showed that nearly two-thirds of the affected participants were unaware of their abnormal skin findings. CONCLUSION: Skin diseases might be more common than previously estimated based on the secondary data of some sub-populations. Further information and awareness campaigns are needed to improve people's knowledge and reduce the global burden associated with skin diseases.

Primary and secondary prevention of skin cancer in mountain guides: attitude and motivation for or against participation.

BACKGROUND: Outdoor professionals such as mountain guides are at a substantial risk of developing non-melanoma skin cancer (NMSC) due to solar ultraviolet radiation (UVR) exposure. Despite major recent primary prevention efforts, studies on secondary skin cancer prevention efforts are limited and corresponding data on outdoor workers scarce. OBJECTIVE: To assess the sun protective behaviour and individual motivations for or against skin cancer screening examinations in the German mountain guide population to aid in the development of effective awareness and prevention strategies. METHODS: A cross-sectional study among all registered mountain guides in Germany was conducted using a 35-item online questionnaire on primary and secondary prevention of NMSC as well as perceived barriers for prevention. RESULTS: A total of 145 mountain guides participated in the study in January 2017. Of these, 86.2% reported using sunscreen often or always, 62.1% with a sun protection factor (SPF) of 30-50% and 60.7% had undergone dermatological examination by a medical professional. The most common reasons for using secondary prevention efforts were hope of an early diagnosis (77.3%), fear of skin cancer (73.9%) and the intention to be aware of one's own health (70.5%). The main reasons for not doing so were absence of conspicuous skin conditions (63.2%) and feeling healthy (59.6%). CONCLUSION: Awareness of prevention strategies recommended by the scientific community is low among affected occupationally high-risk mountain guide populations. Understanding the specific needs of this high-risk group is essential for the development of sustainable awareness and prevention strategies.

Different outdoor professions have different risks - a cross-sectional study comparing non-melanoma skin cancer risk among farmers, gardeners and mountain guides.

BACKGROUND: One of the main risk factors for non-melanoma skin cancer (NMSC), the most common cancer worldwide, is solar ultraviolet radiation (UVR). This has led to the recognition of NMSC as occupational disease for outdoor workers in several countries. However, outdoor professions are a very heterogeneous group with diverse daily activities and associated UVR exposure. OBJECTIVE: To compare the prevalence of NMSC and associated risk behaviour in different outdoor professions. METHODS: Cross-sectional study among outdoor workers (farmers, gardeners, mountain guides) and indoor workers (office employees) as control group using a paper-based questionnaire on UVR exposure and protective behaviour followed by a skin examination by a dermatologist. RESULTS: A total of 563 participants (46.9% women, 46.9 ± 13.8 years) consisting of 348 outdoor workers (38.8% farmer, 35.3% gardener, 25.9% mountain guides) and 215 indoor workers were included in the study between March and September 2017. NMSC incl. actinic keratosis was diagnosed in 33.3% of mountain guides, 27.4% of farmers, 19.5% of gardeners and in 5.6% of indoor workers. Significant differences were seen between the outdoor professions with mountain guides at highest risk compared to farmers (OR = 2.6, 95% CI = 1.2-5.7). Substantial differences between the professions were also seen in skin cancer screening attendance rates (indoor worker 61.4%, mountain guides 57.8%, farmers 31.9%, gardeners 27.6%), daily UVR exposure during work and protective behaviour such as sunscreen use during work. CONCLUSION: Different outdoor professions have significant different risks for NMSC and show different risk behaviour. Tailoring prevention efforts to different professions based on their individual needs could be the key to lower the global burden of (occupational) NMSC.

Guideline-compliant prescription of biologicals and possible barriers in dermatological practices in Bavaria.

INTRODUCTION: Psoriasis and urticaria are chronic inflammatory skin diseases, which account for a substantial socioeconomic burden and severely affect patients' quality of life. According to the respective German guidelines, biologicals can be used for the treatment of severe forms of these diseases. However, only a minority of patients receive this advised treatment. OBJECTIVE: To analyse the prescription of biologicals according to the German national guidelines for psoriasis and chronic spontaneous urticaria and to assess possible barriers to prescription. MATERIALS AND METHODS: Cross-sectional, questionnaire-based study including all Bavarian dermatologists based in private practices. Linear and logistic regression models were used to identify significant influencing factors on the perception of possible barriers. RESULTS: Between January 2017 and February 2017, a total of 137 (of 499) dermatologists participated. Of all patients with moderate to severe psoriasis and chronic spontaneous urticaria, participating dermatologists indicated treating 14.2% and 6.9% with biologicals, respectively. The most prevalent barriers to prescription were the high cost of the therapy, the low reimbursement and the fear of recourse. Analysis showed that age, years spent working in a dermatological hospital and the number of patients treated with moderate to severe psoriasis affect the perception of many barriers. Furthermore, age and barriers related to physician factors and external factors were identified as modifiers to the prescription scheme of dermatologists. CONCLUSIONS: The role of clinical education and the importance of external and economic barriers in comparison with medical barriers have to be emphasised. Guideline-compliant use of biologicals has to be optimised. Further research is needed to ascertain not only a barrier pattern for Bavaria but also for wider settings. Actions based on this for psoriasis are needed to achieve the goal of the WHO Global Psoriasis Report to strengthen the role of patient-centred care and improve the quality of life of affected patients. Analogue, this applies also for urticaria.