Programme for prevention of foot dermatoses in patients with work‐related skin diseases: Follow‐up data of a prospective cohort study (OCCUPES)

A programme based on health education has been developed to prevent foot dermatoses (FD) in patients with work‐related skin diseases (WRSD).


| INTRODUCTION
Foot dermatoses (FD) are frequent in patients with work-related skin diseases (WRSD) and mainly consist of foot eczema, but also include other FD such as fungal infections or plantar psoriasis. 1Even though they are often accompanying diseases of non-occupational origin, they can be work-related due to insufficient protection of occupational footwear against skin hazards at work (e.g., wetness) or the occupational footwear itself resulting in irritant or allergic contact dermatitis, skin infections or worsening of endogenous dermatoses. 1,2e most common work-related FD is considered irritant contact dermatitis of the feet caused by sweating in footwear, particularly in safety footwear. 1r hand eczema, which is the most common WRSD, prevention measures based on health education are widely recommended to prevent progress or relapse of the disease. 3In contrast to the wellestablished programmes focusing on hand dermatoses in patients with WRSD, 4,5 similar programmes specifically addressing prevention of FD have been missing.As described in detail before, 6 we have therefore developed a programme for prevention of FD in patients with WRSD.As part of the multi-step intervention approach funded by the statutory accident insurance institutions in Germany, 4,7,8 this programme is provided in our department during the inpatient/outpatient tertiary individual prevention programme (TIP) 7,9 or in an outpatient setting, either embedded in the regular outpatient skin protection seminar as part of the secondary individual prevention programme (SIP) 7 or as a separate outpatient individual counselling (FD-SIP). 6The programme consists of a face-to-face training on prevention of FD based on health education, individual selection of appropriate occupational footwear and matching socks as well as counselling by a dermatologist experienced in WRSD. 6 evaluate the effectiveness of this programme over time, a prospective cohort study (OCCUPES) was conducted.The baseline data of the 231 recruited patients with WRSD and FD participating in the programme have been published before. 6A work-related causation of FD was likely in 60 patients (26.0%) and was significantly associated with male sex, wearing safety footwear and sweating in footwear.FD were often long-lasting with a high degree of work-absenteeism, decreased quality of life, and debilitating symptoms such as itch and pain, particularly in work-related FD. 6 We here present the results of the follow-ups 6 and 12 months after completing the programme on prevention of FD.

| Intervention and study population
The intervention including the training on prevention of FD and the characteristics of the study population at baseline have been described in detail before. 6Briefly, 231 patients (70.6% males) with WRSD suffering from FD were consecutively recruited on a voluntary basis after obtaining informed written consent while taking part in the programme at the Institute for Interdisciplinary Dermatologic Prevention and Rehabilitation (iDerm) at the Osnabrück University, Germany, between January 2016 and December 2019.The training was provided either during the TIP or the SIP or during a separate outpatient individual counselling (FD-SIP). 6ntrols were not recruited for ethical and legal reasons. 10The study protocol was approved by the ethics committee at the Osnabrück University.

| Study design
An uncontrolled prospective cohort study was conducted.As presented before, 6 basic sociodemographic data were collected by structured interviews and a full skin examination was performed by a dermatologist in all patients at baseline (T1), whereas only in the TIP patients, a second examination was done shortly before dismissal from the inpatient phase (T2).The severity of FD at baseline was assessed using the Osnabrueck Foot Eczema Severity Index (OFSI). 6e aetiology of FD was based on the final diagnoses made by the dermatologists.As described before, a combination of different aetiological components was possible.A history or current clinical signs of flexural eczema were recorded at baseline and an Erlangen atopy score ≥ 10 was defined as atopic skin diathesis. 11per-based questionnaires in accordance with the questionnaires used for the structured interviews at baseline 6 were sent to all participants both 6 months (T3) and 12 months (T4) after the intervention (pre/post design) collecting self-reported information on continuance of work, work absenteeism, occupational strain (e.g., occlusion effects, exposure to skin hazards), current occupational footwear, individual skin protection behaviour, course of the disease and treatment.
Health-related quality of life was assessed with the Dermatology Life Quality Index (DLQI). 12The DLQI has a score range from 0 to 30 with higher scores indicating a stronger impairment of the quality of life.The patients were asked to focus on impairments related to the FD when filling out the DLQI questionnaire.In addition, at both time points (T3, T4), two visual analogue scales (VAS) were used to assess the intensity of itch and pain caused by the FD within the past 24 h as described before. 6

| Statistics
Statistical analyses were conducted with SPSS Version 25.0 (IBM Corp., Armonk, NY, USA).Descriptive statistics report means and standard deviations (SD) for continuous variables, and (relative) frequencies for categorical variables.As not all questions in the questionnaires were answered by all respondents, the reference total number of patients differs depending on the respective item.In the drop out analysis, differences of continuous variables were assessed using the unpaired t-test and differences of categorical variables using the Pearson's chi-squared (χ 2 ) test.Fisher's exact test was applied if at least one expected value under independence was lower than 5. Differences between baseline (T1) and follow-ups after 6 months (T3) and 12 months (T4) were calculated with the paired t-test for continuous variables and the McNemar test for categorical variables.Differences were considered significant if the p-value was less than 0.05. the follow-up after 6 months (T3).Of these, 163 (94.2%) had continued working in the same profession in the meantime (since T1).The remaining 10 patients had either left the profession (n = 5) or had been on sick leave for ≥180 days (n = 5).After 12 months (T4), 166 (71.9%) patients took part in the follow-up and of these, 146 (88.0%) had continued working in the same profession in the past 6 months (since T3).Ten patients had left the profession and 10 patients had been on sick leave for ≥180 days prior to T4.

| Response rate and job continuation
Common reasons for leaving the profession prior to T3 or T4 were the WRSD, retirement or job cuts.

| Characteristics of study populations
The characteristics of the study populations at T3 and T4 compared to baseline are presented in Table 1.There were no major differences between these populations and the baseline cohort and also not between the whole cohorts at T3 and T4 and the respective subgroups of those who had continued working in the same profession in the 6 months prior to each follow-up.The majority of participants were male with a mean age of 48-49 years and a mean duration of working in the current profession of about 20 years at T1.The biggest cohorts came from the metal industry, the construction industry and the healthcare sector.About one quarter of patients had current or a history of flexural eczema and a little bit less had an atopic skin diathesis based on the Erlangen Atopy Score at baseline.About half of the patients were current tobacco smokers.
Drop-out analyses comparing the baseline data of the parameters presented in Table 1 (and additionally the OFSI and the DLQI at T1) for those who took part and those who did not take part in the respective follow-up revealed no major differences (complete data not shown).The only significant differences were that those who did not take part in the follow-ups were younger than those who participated (mean age at T3: 43.8 vs. 48.6 years, mean age at T4: 45.5 vs. 48.2years) and that there was a higher share of warehouse workers among those lost to follow-up than among the participants at T4 (12.3% vs. 3.6%).

| Occupational footwear
The characteristics of occupational footwear at T3 and T4 compared to baseline are presented for patients who reported at the respective follow-ups that they had worked in the previous 6 months in the same profession as during recruitment and had not been on sick-leave for ≥180 days in the meantime and were thus, able to exert the recommendations at work (Tables 2 and 3).Of those for whom a different type of occupational footwear had been selected at T1, 54.2% and 71.1% reported to have replaced the footwear at T3 and T4, respectively.As before, the majority of patients (still around 70%) reported to wear safety footwear.Compared to baseline, wearing special work shoes had significantly increased while correspondingly wearing ordinary shoes at work significantly decreased at both time points.The self-reported average daily duration of wearing the footwear at work was still about 8 h, but had significantly decreased at T4 compared to T1 (7.98 ± 1.91 h vs. 8.47 ± 1.65 h).At both time points, the share of those wearing socks with a high cotton content inside their occupational footwear had significantly decreased from 78.4% to 43.8% at T3 and from 77.1% to 44.4% at T4 while the share of those wearing functional socks made of breathable, moisture-wicking material had significantly increased from 8.0% to 59.3% at T3 and from 9.0% to 58.3% at T4. Having left profession (n=10) due to:

| Foot dermatoses
In Tables 4 and 5, data on FD at T3 and T4 compared to baseline are presented for both all patients and the subgroup of patients who reported at the respective follow-ups that they had worked in the previous 6 months in the same profession as during recruitment and had not been on sick-leave for ≥180 days in the meantime.Focusing on the latter group, improvement of FD compared to baseline was reported by 64% and 61.7% at T3 and T4, respectively.Healing of FD was indicated by around 20% at both follow-ups.All foot symptoms were less frequently reported at T3 than at baseline with significant changes for pain when walking (36.8% vs. 52.8%)and smell (12.3% vs. 23.9%).At T4, all foot symptoms were significantly less frequently reported than at baseline, specifically itch (57.6% vs. 70.1%),pain when walking (38.9% vs. 54.2%),pain in rest (13.9% vs. 25.0%), and smell (10.4% vs. 24.3%).The mean intensities of itch or pain in the previous 24 h based on the VAS at T3 were not significantly different from the values at baseline.At T4, the mean itch intensity had significantly decreased compared to baseline (mean ± standard deviation (SD): 2.50 ± 2.82 vs. 3.11 ± 2.91).Moreover, the DLQI both at T3 and T4 was significantly lower than at baseline.In addition, FD-related work absenteeism in the previous 6 months decreased from T3 (mean ± SD: 5.5 ± 16.3 days) to T4 (mean ± SD: 3.3 ± 12.0 days) (Table 1).
At T3 and T4, about 70% of all patients and the subgroup who had worked in the previous 6 months in the same profession as during recruitment and had not been on sick-leave for ≥180 days in the meantime reported to have used emollients in the past 6 months, which was significantly more than those reporting to have used them in the 12 months before baseline (Tables S1 and S2).Moreover, at both time points there was a significant higher number of patients reporting to have applied topical antiperspirants and at T3, the self-reported use of topical antimycotics was more frequent than at baseline.Only a few patients reported to have received systemic treatment of their skin disease in the previous 6 months, both at T3 and T4.The question about systemic treatment of the skin disease was not limited to treatments initiated because of the FD, but included also those initiated because of skin diseases at other sites, for example, hand dermatoses.

| Rating of the prevention programme
Overall, the programme for prevention of FD received very good ratings by the participants both at T3 and T4.In the following, those who gave the answers ('Yes' and 'Yes, very much') were combined for each question.More than 80% felt well-informed about skin protection measures, that they had received good advice and considered the given recommendations helpful.Around 80% agreed that it was worth taking part and that they had discovered important risk factors.
65%-70% indicated that it was possible to implement the recommendations and that they are coping better with their disease, with rising numbers from T3 to T4 (Table S3).

| DISCUSSION
The SIP and TIP are well-established for patients with work-related hand dermatoses in Germany.Prospective cohort studies have shown that they lead to improvement in protective behaviour, a decrease in disease severity, improvement in quality of life and enable most patients to continue working in their high-risk profession. 7In contrast, prospective cohort studies in patients with FD are rare.Limited evidence is available that health education about foot care is effective in prevention of foot ulcerations in patients with diabetes mellitus. 13,14 the best of our knowledge, no other studies have addressed the   prevention of FD at work.Only a few had left the profession or had been on long-term sick leave afterwards.Therefore, exclusion of these patients in the sub-analyses did not result in major differences.A majority reported improvements and around 20% reported healing of FD at both follow-ups indicating sustained reduction of the disease burden.In line with this, all FD-related, self-reported symptoms were less frequent after 1 year, including itch, pain when walking, pain in rest and smell.In addition, the intensity of itch had significantly decreased compared to baseline.Similarly, the health-related quality of life was significantly better at both follow-ups showing a sustained improvement.The mean DLQI value decreased from 10.0 at baseline 6 to 6.5 after 12 months.This was comparable to a previous prospective multicentre study comprising 1788 TIP patients with primarily hand dermatoses, in which the mean DLQI value at admission was 10.4 15 and decreased to 5.5 in those taking part in a follow-up after 12 months (n = 1409). 16Moreover, in line with the improved skin condition, FD-related work absenteeism substantially decreased in the present study.
The data revealed a delayed implementation of recommendations in terms of changes in occupational footwear which may also explain  additionally increased indicating that improvements of wearing comfort were still possible by selecting different footwear.This may have decreased skin irritation caused by pressure and friction related to too tight or too loose footwear. 17Sweating was the most frequent complaint about occupational footwear which had been affirmed by two thirds of patients at baseline and was particularly common in those wearing safety footwear. 6The resulting moist occlusive environment within footwear may induce skin irritation and favours skin infections. 18Accordingly, irritant contact dermatitis of the feet related to sweating in footwear was the most common diagnosis in patients with work-related FD at baseline. 6Therefore, several strategies to reduce extensive and prolonged exposure to moisture related to sweating in footwear were compiled during the intervention.In line with these recommendations, significantly more patients reported at follow-ups to have a second pair of shoes/boots at work and to change their potentially moist footwear and socks during one work shift.For most occupations, footwear equipped with breathable and moisturewicking materials is available and was also preferred in the individual recommendations.This type of footwear should be worn in combination with matching functional socks made of breathable, moisturewicking material to enable efficient evaporation of sweat built within footwear to the outside. 6At baseline, most patients wore not matching socks with a high cotton content which rather trap moisture.
Therefore, in a high number of patients a different type of socks, mainly functional socks, had been selected.Accordingly, significantly more patients at follow-ups reported to wear functional socks with their occupational footwear while significantly less reported to use socks with a high cotton content.The implementation of these T A B L E 5 Characteristics of foot dermatoses at baseline and after 12 months (T4).

Figure 1
Figure 1 presents a flow-chart of the study cohort over time.Of the 231 patients recruited at baseline, 173 (74.9%) took part in n=1) Work absenteeism ≥ 180 days (n=10) T3 After 6 months T4 After 12 months Loss to follow-up (n=65) Loss to follow-up (n=58) F I G U R E 1 Flow chart of the study cohort.T A B L E 1 Characteristics of study populations at baseline (T1), 6 months (T3) and 12 months (T4) after completion of the programme on prevention of foot dermatoses.
Note: A: All participants.B: Participants who continued working in the same profession in the past 6 months.Abbreviations: FD, foot dermatoses; SD, standard deviation.
effectiveness of interventions based on health education to preventFD in patients with WRSD.Most of the patients in our study had continued working in the same profession after the intervention and had thus, the chance to exert the individual recommendations for T A B L E 2 Characteristics of occupational footwear, including socks, and wearing behaviour of patients participating in follow-up after 6 months (T3) and comparison with baseline data (T1).

T A B L E 3
Characteristics of occupational footwear, including socks, and wearing behaviour of patients participating in follow-up after 12 months (T4) and comparison with baseline data (T1).
Significant differences are presented in bold.A: All participants.B: Participants who continued working in the same profession in the past 6 months.Abbreviations: DLQI, Dermatology Life Quality Index; SD, standard deviation; VAS (Visual Analogue Scale).a McNemar.b t test (paired).† More than one answer possible.
Note: Presented are the results of the participants who continued working in the same profession in the past 6 months.Significant differences are presented in bold.
a McNemar test.b t-test (paired).† More than one answer possible.
Note: Presented are the results of the participants who continued working in the same profession in the past 6 months.Significant differences are presented in bold.
a McNemar test.b t-test (paired).† Note: Significant differences are presented in bold.A: All participants.B: Participants who continued working in the same profession in the past 6 months.Abbreviations: DLQI, Dermatology Life Quality Index; SD, standard deviation; VAS (Visual Analogue Scale).a McNemar test.b t-test (paired).† More than one answer possible.