SEARCH

SEARCH BY CITATION

Summary

  1. Top of page
  2. Summary
  3. UV-induced non-melanocytic skin cancer as an occupational disease
  4. Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer
  5. Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments
  6. Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure
  7. Summary
  8. Conflict of interest
  9. References

Invasive squamous cell carcinoma (SCC) as a “quasi occupational disease” according to §9 Section 2 of the German Social Code Book (SGB) VII typically develops on chronically UV-damaged skin from actinic keratoses. After the Medical Scientific Committee of the Federal Ministry of Labor and Social Affairs has confirmed the legal criteria for acknowledging UV-induced SCC as an occupational disease, it is expected that the condition will be added to the official list of occupational diseases issued by the Federal Government in the near future. The Social Accident Insurance is required by law (§3 Occupational Disease Regulation) to prevent these tumors by all appropriate means“. There are excellent therapeutic and preventive measures for the management of actinic keratoses to avoid the development of SCC. The Dermatologist's Procedure“ according to §§ 41–43 of the agreement between the Social Accident Insurance and the Federal Medical Association was established in Germany in 1972 to take preventive measures in insured persons with skin lesions possibly developing into an occupational disease, or worsening it, or leading to a recurrence of it This procedure proved to be very successful in the prevention of severe and/or recurring skin diseases forcing a worker to leave his job. On the basis of this agreement, the Social Accident Insurance has the instruments to independently provide preventive measures for the new occupational skin disease SCC induced by natural UV light according to §9 Section 2 of the German Social Code Book (SGB) VII.


UV-induced non-melanocytic skin cancer as an occupational disease

  1. Top of page
  2. Summary
  3. UV-induced non-melanocytic skin cancer as an occupational disease
  4. Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer
  5. Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments
  6. Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure
  7. Summary
  8. Conflict of interest
  9. References

The carcinogenic effect of UV radiation is well known; it is classified as a carcinogen by the WHO [1]. The biologic mechanisms of UV-induced skin carcinogenesis via direct and indirect DNA changes and UV-induced immunosuppression are also well documented [2-4]. Squamous cell carcinoma (SCC) of the skin develops primarily form actinic keratoses (SCC in situ), for which cumulative UV exposure is a major risk factor [5].

As the mechanisms of damage from natural light are identical for occupational and nonoccupational UV exposure, recent studies on occupationally-related skin cancers have focused on epidemiological aspects. The available epidemiological studies on occupational causes of cutaneous SCC were systematically evaluated by Schmitt et al. [6, 7] who concluded that SCC and actinic keratoses in outdoor workers should be considered occupational diseases. Additional work-related UV exposure of 40 % doubles the risk of SCC and therefore confirms an relationship to work [8]. On the other hand, the relation between outdoor work and basal cell carcinoma (BCC) is less clear. A significant positive association between occupational UV exposure and BCC was reported in 5 studies, while 11 studies did not find a significant association [6]. Therefore, the relationship between occupational UV exposure and BCC is still open to discussion [9], and further epidemiological studies are being prepared.

After the Scientific Committee for Occupational Medicine of the Federal Ministry of Labor and Social Affairs confirmed that UV-related non-melanocytic skin cancer can be considered as an occupational disease, it is expected that it will included in the official list of occupational diseases in the near future.

Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer

  1. Top of page
  2. Summary
  3. UV-induced non-melanocytic skin cancer as an occupational disease
  4. Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer
  5. Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments
  6. Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure
  7. Summary
  8. Conflict of interest
  9. References

The current state of therapy for actinic keratoses, SCC and BCC is shown in the AWMF guidelines of the Working Group Dermatologic Oncology (ADO) of the German Society of Dermatology (DDG) [10-12]. The measures mentioned below have certainly different levels of evidence than the guidelines, which should be consulted when questions arise.

Since cutaneous SCC is locally destructive but does not frequently metastasize, the therapeutic measures are primarily surgical. Complete excision with histopathological control of the resection margin is the therapy of choice [11]. If surgical removal is not possible, radiation therapy, possibly in combination with chemo/immunotherapy, is indicated. In the case of highly malignant tumors, prophylactic lymph node dissection may be useful; therapeutic lymph node dissection is performed if lymph node metastases are clinically suspected. In the case of distant metastases, a variety of immunotherapy/polychemotherapy schemes can be used in addition to surgical or radiation for the primary tumor [11].

Because of the risk of recurrence and metastasis and the occurrence of independent secondary tumors on chronically UV-damaged skin, regular follow-up is required in patients with cutaneous SCC. Low-risk tumors should be followed up at six-month intervals up to the 5th postoperative year [11]. Tumors with a high risk of metastasis, including those in patients with immunosuppression, organ transplantation and having multiple tumors, require regular re-evaluation every three months in the first two years, preferably with lymph node sonography; thereafter, half-yearly controls up to the 5th year are suggested [11]. As SCC typically develops on massively UV-damaged skin from actinic keratoses, treatment of actinic keratoses is an effective prevention of SCC.

The recommended treatments for actinic keratosis can be divided into therapies for single or few lesions, including surgical methods (curettage/excision, shave biopsy), cryotherapy and laser therapy, and “field therapies” for major areas affected by actinic keratoses (field cancerization) such as chemical peeling or photodynamic therapy. Topical measures such as 5-fluoruracil, diclofenac, imiquimod and recently ingenol mebutate can be used for single lesions, as well as for the treatment of broad areas, where systemic retinoids may also play a role. A therapeutic algorithm was described in a recent review [13].

When actinic keratoses have been successfully treated, the patients should have regular dermatological follow-up at least once a year. High-risk patients (immunosuppression, especially light-sensitive skin) may need more frequent controls.

Suitable measures for prevention of recurrence or new occurrence of actinic keratoses are those which are also established as primary prevention measures for occupational skin cancer. Consequent UV protection according to the guidelines of the DDG [14] includes:

  • ▸ Avoidance of midday sun and technical measures
  • ▸ Sun-protective clothing
  • ▸ Application of suitable sunscreens

Controlled studies have shown that the occurrence of actinic keratosis was significantly reduced by use of sunscreens both in the general population [15] and in high-risk patients [16]. However, sunscreens are often used wrongly or at too low doses [17]. Innovative practice-oriented training concepts are required in analogy to the secondary prevention measures for occupational disease BK 5101 [18], but undesired side-effects such as vitamin D deficiency, possibly requiring monitoring of 25OH vitamin D levels) have to be considered [19]. Preventive therapeutic measures for field cancerized skin, e.g., photodynamic therapy (PDT) or other topicals, are additional possible options that require further prospective controlled studies [20].

Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments

  1. Top of page
  2. Summary
  3. UV-induced non-melanocytic skin cancer as an occupational disease
  4. Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer
  5. Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments
  6. Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure
  7. Summary
  8. Conflict of interest
  9. References

Health prevention is a top priority task for the insurers; as early as 1925 the first Occupational Disease Regulation (BKVO/BKV) contained a discretionary clause in paragraph 6. If occurrence, recurrence or deterioration of an occupational disease (BK) was to be feared, the insurers granted a transitory pension up to 50% of the full pension as long as the insured person abstained from dangerous activities [21, 22]. According to paragraph 5 of the third BKVO of 1936 this discretionary clause was changed into a direct provision; in case of an occupational disease the insurers had to grant a transitory pension to compensate for financial disadvantages [23, 24].

Occupational skin cancer has been included in the BKVO since 1925. Under number 7 the first BKVO of 1925 contained the occupational disease „skin cancer caused by soot, paraffin, tar, anthracene, pitch and related substances“[21, 22]. Number 13 of the second BKVO related to „chronic and chronic-recurrent skin diseases caused by soot, paraffin, tar, anthracene, pitch and related substances“[25, 26]. While the first BKVO permitted insurance coverage only for skin cancer, the regulatory authority intended to also include precursors of skin cancer by formulating „chronic and chronic recurrent skin diseases” [25, 26]. The administrative practice of the accident insurers undermined this intention by literal construction of BK number 13 which denied responsibility for early treatment of precancerous lesions. The third BKVO therefore specified BK number 13 as follows: „Skin cancer or lesions susceptible to skin cancer development…“[23, 24]. The official statement of reasons for the third BKVO said: „It seemed necessary to separately list skin cancer and precancerous lesions because the interpretation of insurance coverage given in number 15 for chronic eczematous and inflammatory skin diseases shall not apply. It is the aim of this regulation that exactly these diseases obtain insurance coverage as early as possible and without any restrictions“. BK number 15 related to the current BK number 5101. The standard comments of the Ministry of Labor at that time explained the reasons for necessary changes of BK number 13 unmistakably as follows: „A special position is purposely given to skin cancer and cutaneous lesions susceptible to cancer development by soot, paraffin, pitch or similar substances, namely because affected persons are at increased risk. Quick intervention is required; therefore, the regulation supports insurance coverage for this group of occupational skin diseases without the mandatory restrictions for other skin diseases. For the same considerations, skin diseases related to X-ray exposure and radioactive agents take an equally special position“[27, 28].

Thus it is historically confirmed that the insurers at that time did not convincingly put the legal order into practice according to paragraph 3, which required legal clarification. On the occasion of the 4th BKVO in 1946, Kölsch, one of the most important occupational physicians in Germany at that time, commented on BK number 13 as follows: „There is definitely an obligation to register fully developed skin cancer. Precancerous conditions should be notified, and occupational change or preventive treatment come into question“[29].

Up to the time of the 4th BKVO in 1943 the regulatory authority considered cessation of damaging activities for prevention of occupational diseases that would require transitory payment as a last resort. With paragraph 5 of the 4th BKVO medical treatment for prevention of occupational diseases was „legally“ introduced as a discretionary (desired) measure [30]. In the 7th BKVO of 1968 discretionary measures for prevention and rehabilitation were changed to mandatory measures effective July 1, 1968 [31]. The new version „by all appropriate means the accident insurer has to … “ does not specifically mention medical treatment but substantially overlaps with the granting of such. For the insurer is obliged to prevent the development of occupational diseases „by all appropriate means“ through measures of prevention and rehabilitation and to eliminate or ameliorate their sequelae. From that time on medical treatment of occupational diseases was established as a legal obligation, and the restrictive practice of the insurers with respect to preventive treatment of imminent occupational diseases was no longer tolerated.

Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure

  1. Top of page
  2. Summary
  3. UV-induced non-melanocytic skin cancer as an occupational disease
  4. Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer
  5. Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments
  6. Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure
  7. Summary
  8. Conflict of interest
  9. References

Medical treatment of occupational diseases can currently only can be provided on specific order of the responsible insurer.

For historical reasons, there is no automatic approach to therapy for occupational diseases as is the case for work-related and travel accidents, where the medical referee decides at the first examination that the accident insurer is responsible for initiation of medical treatment. Based on the medical report of suspicion, the insurer usually initiates a declaratory procedure and then decides whether the occupational disease is recognized as an insured event. This procedure is very complex and time-consuming; in most cases it takes several years. Legally this brings disadvantages to the insured person, their health insurance, the treating dermatologist and finally the accident insurers themselves. The insured person has to pay prescription charges and does not receive modern treatment such as PDT at the expense of the health insurance, because therapy is performed according to the rigid efficacy principles of paragraph 12 Social Code Book (SGB) V.

Despite the medical report of suspicion, the health insurance usually pays further diagnosis and therapy until the insured event is acknowledged as an occupational disease. The dermatologist performs treatment at the expense of the health insurance until treatment is ordered by the accident insurer. A retrospective conversion of health insurance treatment to occupational insurance treatment is legally not permitted and technically impossible. In addition, targeted individual preventive measures and early therapy according to paragraph 3 BKV remain unexploited.

The basic obligation of the accident insurer to support prevention and the high priority of granting preventive treatment for precancerous skin lesions according to paragraph 3 BKV unconditionally apply to the problem of non-melanocytic skin cancer induced by natural UV light according to paragraph 9 section 2 SGB VII. Provided that the regulatory authority publishes scientific rationales of the Committee for Occupational Medicine in the foreseeable future, cutaneous precancerous lesions, most specifically actinic keratoses, should be listed as a new occupational disease. This would be clear call to take action for systematic protective measures and early treatment according to paragraph 3.

The Social Accident Insurance and dermatologists have the needed mechanisms to solve the contractural problems rapidly and effectively. The Dermatologist's Procedure has existed for more than forty years (1972) on the legal basis of paragraph 9 section 6 No. 1 SGB VII in conjunction with paragraph 3 BKV. This procedure was developed in close cooperation between dermatologists and the Occupational Accident Insurance.

The regulation under paragraph 9 section 6 No. 1 SGB VII („With the consent of the Bundesrat, the Federal Government enacts a statutory ordinance concerning (1) requirements, kind and extent of insurance coverage for prevention of occurrence, recurrence or deterioration of occupational diseases…“) is the enabling act for regulation of preventive efforts in occupational diseases. It specifies the principle of paragraph 14 SGB VII (obligation of the accident insurer to prevent by all appropriate means).

Since the 7th BKVO of 1968 paragraph 3 section 1 sentence 1 is formulated as follows [31]: „If insured persons are at risk of developing an occupational disease that may recur or deteriorate, the accident insurers have to counteract this danger by all appropriate means“.

The regulation is targeted at prevention of danger to health prior to the occurrence of an insured event [32]. Paragraph 3 section 1 demands early intervention of the accident insurer; however, since 1925 there have been no legislative or regulatory notification criteria for paragraph 3, so as to inform the accident insurers of the “imminent occupational disease” and enable them to take action. Only after considering these legal conditions was it possible for the partners of the Social Accident Insurance and the Association of Statutory Health Physicians to contractually regulate the Dermatologist's Procedure.

Effective July 1, 1972, the Dermatologist's Procedure was included in the agreement between physicians and occupational insurance association. In their official journal the Federation of Institutions for Statutory Accident Insurance and Prevention (HVBG) pointed out that the newly introduced Dermatologist's Procedure was applicable to all skin diseases listed in the 7th BKVO of June 20, 1968, which was valid that time, thus also including skin cancer due to polyaromatic hydrocarbons (BK number 5102) or ionizing radiation (BK number 2402) [33]. The Dermatologist's Procedure was the result of intense cooperative efforts of dermatologists and accident insurers, who had already worked together successfully for more than 50 years. Siegfried Borelli rendered great service by examining a large number of patients with occupational skin diseases. As early as 1971 he called for dermatological accident insurance consultants in cases of occupational skin diseases [34]. Unfortunately, this reasonable demand has been left unconsidered for more than forty years. Even after passage of the law for structural reform in health care in 1989, giving responsibility to the social accident insurance for treatment of occupational diseases from the first day on, this legislative demand was ignored. In 1999 the Dermatologist's Procedure was optimized by the Federation of Institutions for Statutory Accident Insurance and Prevention (HVBG) and this was successfully updated in cooperation with dermatology under consideration of prevention research findings [35]. The initial early recognition procedure introduced in 1972 thus developed into an early intervention procedure using efficient preventive and therapeutic measures.

The legal basis of the Dermatologist's Procedure is paragraph 3 BKV. As the law does not provide for coverage (and also medical treatment) prior to the occurrence of an insured event, the Dermatologist's Procedure could only be contractually agreed between physicians and the central associations of the accident insurers. Therefore the insured person must agree to the procedure, because otherwise the reporting physician is not authorized to transmit personal data to the accident insurer. There is no legal obligation to notify; a distinction has to be made between suspicion report according to paragraph 202 SGB VII and a dermatologist report according to paragraph 41 section 2 of the scale of medical fees. According to paragraph 41 section 1 (obligation to see a dermatologist) „each physician is obliged to refer insured persons immediately to a dermatologist if they have suspicious skin lesions that might lead to development, recurrence or deterioration of a disease resulting from occupational activity“.

This principally applies to all skin diseases listed as occupational diseases. For example, within the Dermatologist's Procedure skin cancer according to BK numbers 1108 (arsenic), 2402 (ionizing radiation) or 5102 (polyaromatic hydrocarbons) can definitely be notified by a dermatological report. Already in 1972 the contractual partners fully agreed that the Dermatologist's Procedure should be applicable for all skin diseases according to the BKV. This is clearly shown in the text of paragraph 41 section 1 of the scale of medical fees.

The Dermatologist's Procedure is currently only employed for number 5101 of the BKV, for which there is only one protocol note. In fact, the Dermatologist's Procedure is based on Borelli's extensive research which only included skin diseases as per BK number 5101 [34].

Irrespective of whether the contractual content „skin disease due to occupational activity in accordance with BKV“ can be limited to one occupational disease by a simple protocol note and that other agreements can be reached by the contractual partners, there is urgent need for action. According to current scientific knowledge early recognition and targeted specialized therapy of non-melanocytic skin cancer offer excellent chances of recovery [36]. Against this background it is a high priority task for the occupational accident insurers to focus on early diagnosis and therapy of occupational non-melanocytic skin cancer and to provide the necessary instruments and contractual framework in cooperation with dermatology within the scope of the Dermatologist's Procedure to address UV-induced skin cancer.

Summary

  1. Top of page
  2. Summary
  3. UV-induced non-melanocytic skin cancer as an occupational disease
  4. Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer
  5. Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments
  6. Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure
  7. Summary
  8. Conflict of interest
  9. References

It is biologically and epidemiologically confirmed that occupational exposure to natural UV light can induce cutaneous SCC and its precursors, actinic keratoses. The medical guidelines of the German Dermatology Society (treatment of actinic keratosis, BCC, SCC) provides evidence-based scientific experience data on the diagnosis, therapy, treatment algorithms, follow-up and prevention, which guarantee a high standard of care. Once „UVinduced skin cancer“ has been included in the list of occupational diseases after publication of scientific rationales, the Social Accident Insurance will be required to take action for a systematic nationwide § 3 procedure. The legal situation according to SGB VII, BKV and scale of medical fees offers the accident insurers an optimal possibility to prevent occupational non-melanocytic skin cancer by all available means through early recognition and treatment within the Dermatologist's Procedure. There is no doubt about the legal obligation of the accident insurers according to paragraph 3 BKV to take all measures of individual prevention in case of occupational non-melanocytic skin cancer according to paragraph 9 section 2 SGB VII. For more than four decades the Dermatologist's Procedure has been the scope for realization of secondary individual prevention of UV-related occupational skin cancer.

References

  1. Top of page
  2. Summary
  3. UV-induced non-melanocytic skin cancer as an occupational disease
  4. Guideline-directed treatment and prevention of UV-related occupational non-melanocytic skin cancer
  5. Prevention of occupational skin cancer as a task of the Social Accident Insurance: Historical developments
  6. Prevention of UV-induced occupational skin cancer as a task of the Social Accident Insurance: Possibilities within the scope of the Dermatologist's Procedure
  7. Summary
  8. Conflict of interest
  9. References
  • 1
    IARC monographs on the evaluation of carcinogenic risks to humans. Solar and ultraviolet radiation. IARC Monogr Eval Carcinog Risks Hum 1992; 55: 1316.
  • 2
    Ikehata H, Ono T. The mechanisms of UV mutagenesis. J Radiat Res 2011; 52: 11525.
  • 3
    Sage E, Girard PM, Francesconi S. Unravelling UVA-induced mutagenesis. Photochem Photobiol Sci 2012, 11: 7480.
  • 4
    Rangwala S, Tsai KY. Roles of the immune system in skin cancer. Br J Dermatol 2011; 165: 95365.
  • 5
    Glogau RG. The risk of progression to invasive disease. J Am Acad Dermatol 2000; 42: 234.
  • 6
    Schmitt J, Diepgen T, Bauer A. Occupational exposure to non-artificial UV-light and non-melanocytic skin cancer − a systematic review concerning a new occupational disease. J Dtsch Dermatol Ges 2010; 8: 25063.
  • 7
    Schmitt J, Seidler A, Diepgen TL et al. Occupational ultraviolet light exposure increases the risk for the development of cutaneous squamous cell carcinoma: a systematic review and meta-analysis. Br J Dermatol 2011; 164: 291307.
  • 8
    H. Drexler, T. L. Diepgen, J. Schmitt et al. Arbeitsbedingte UV-Exposition und Malignome der Haut. Überlegungen zu einer neuen Berufskrankheit: UV-induzierter Hautkrebs. Dermatologie in Beruf und Umwelt 2012; 60: 4855.
  • 9
    Diepgen TL, Bernhard-Klimt C, Blome O et al. Bamberger Merkblatt: Begutachtungsempfehlungen für die Begutachtung von Haut und Hautkrebserkrankungen Teil II: Hautkrebs. Dermatologie in Beruf und Umwelt 2009; 57: 317.
  • 10
    Breuninger H, Sebastian G, Schwipper V et al. Deutsche Leitlinie: Basalzellkarzinom. In: Deutsche Leitlinie: Basalzellkarzinom. Stuttgart, New York: Thieme; 2005: 111.
  • 11
    Breuninger H, Sebastian G, Kortmann RD et al. [Brief guidelines: squamous cell carcinoma of the skin, lip and eyelids]. J Dtsch Dermatol Ges 2006, 4: 2602.
  • 12
    Stockfleth E, Terhorst D, Hauschild A et al. Leitlinie Aktinische Keratosen. J Dtsch Dermatol Ges 2012; 10(Suppl 7) : 123.
  • 13
    Manousaridis I, Leverkus M. Malignant epithelial tumors: Part II. Therapy and prevention. J Dtsch Dermatol Ges 2013, 11: 927.
  • 14
    Elsner P, Holzle E, Diepgen T et al. Recommendation: daily sun protection in the prevention of chronic UV-induced skin damage. J Dtsch Dermatol Ges 2007, 5: 16673.
  • 15
    Darlington S, Williams G, Neale R et al. A randomized controlled trial to assess sunscreen application and beta carotene supplementation in the prevention of solar keratoses. Arch Dermatol 2003, 139: 4515.
  • 16
    Ulrich C, Jürgensen JS, Degen A et al. Prevention of non-melanoma skin cancer in organ transplant patients by regular use of a sunscreen: a 24 months, prospective, case-control study. Br J Dermatol 2009; 161(Suppl 3): 7884.
  • 17
    Kim SM, Oh BH, Lee YW et al. The relation between the amount of sunscreen applied and the sun protection factor in Asian skin. J Am Acad Dermatol 2010, 62: 21822.
  • 18
    Armstrong AW, Idriss NZ, Kim RH. Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: a randomized controlled trial. Patient Educ Couns 2011, 83: 2737.
  • 19
    Holick MF, Binkley NC, Bischoff-Ferrari HA et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011, 96: 191130.
  • 20
    Apalla Z, Sotiriou E, Chovarda E et al. Skin cancer: preventive photodynamic therapy in patients with face and scalp cancerization. A randomized placebo-controlled study. Br J Dermatol 2010, 162: 1715.
  • 21
    § 6 der 1. Berufskrankheiten-Verordnung (1.BKVO) vom 12. Mai 1925. Reichsgesetzblatt I. 69.
  • 22
    Curschmann F, Krohn J. Die Ausdehnung der Unfallversicherung auf Berufskrankheiten. Die Ausdehnung der Unfallversicherung auf Berufskrankheiten. Kommentar zur RVO und zur 1. BKVO. Carl Heymanns Verlag, Berlin, 1926: 109 pp.
  • 23
    Bauer M, Engel, H, Koelsch F et al. Dritte Verordnung über die Ausdehnung der Unfallversichung auf die Berufskrankheiten. G. Thieme, Leipzig, 1936.
  • 24
    BKVO über die Ausdehnung der Unfallversicherung auf Berufskrankheiten. Reichsgesetzblatt I. 1936; 117.
  • 25
    BKVO vom 11.2.1929. Reichsgesetzblatt I. 1929; 27.
  • 26
    Bauer M, Engel H, Koelsch F, Krohn J. Die Ausdehnung der Unfallversicherung auf Berufskrankheiten durch die 2. BKVO. Berlin SW 61: Verlag von Reimar Hobbing, 1929.
  • 27
    Amtliche Nachrichten für Reichsversicherung Nr. 12, S. IV 353. Reichsarbeitsblatt 1936; Nr. 36, IV
  • 28
    Martineck. Arbeit und Gesundheit. Sozialmedizinische Schriftenreihe aus dem Gebiete des Reichs- und Preußischen Arbeitsministeriums. 1937: 332.
  • 29
    Koelsch F. Die meldepflichtigen Berufskrankheiten. Die meldepflichtigen Berufskrankheiten. Verlag Urban und Schwarzenberg, Berlin-München, 1946: 45.
  • 30
    BKVO vom 29.1.1943. BGBL I 1943: 85.
  • 31
    BKVO vom 20.6.1968. BGBL I 1968: 721.
  • 32
    Blome O, John SM. Das Hautarztverfahren. Die BG 2007; 1: 2731.
  • 33
    Noeske H. Verfahren zur Früherkennung berufsbedingter Hauterkrankungen (Hautarztverfahren). Die BG. 1972; 7: 2637.
  • 34
    Borelli S, Düngemann H. Beiträge zur Rehabilitation von chronisch Hautkranken und Allergikern. Beiträge zur Rehabilitation von chronisch Hautkranken und Allergikern. Schriftenreihe der Bayerischen Landesärztekammer 1972: 5 and 45.
  • 35
    Dickel H, John SM, Kuss O, Schwanitz HJ. [New Dermatologist's Procedure. Research plans for improving secondary prevention of occupational dermatoses]. Hautarzt 2004; 55: 1021.
  • 36
    Garbe C. Früherkennung und Primärprävention von Hautkrebs. Der Onkologe 2008; 14: 156163.