Cost of illness from occupational hand eczema in Germany

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1 Contact Dermatitis Original Article COD Contact Dermatitis Cost of illness from occupational hand eczema in Germany Thomas L. Diepgen 1, Reginald Scheidt 1, Elke Weisshaar 1,SwenM.John 2 and Klaus Hieke 3 1 Department of Clinical Social Medicine, Occupational and Environmental Dermatology, University Hospital Heidelberg, Heidelberg, Germany, 2 Department of Dermatology, Environmental Medicine, University of Osnabrück, Osnabrück, Germany, and 3 Oxford Outcomes Ltd, Oxford OX20JJ, UK doi: /cod Summary Background. There is little knowledge about the costs of occupational hand eczema. Objectives. To estimate the societal costs of patients with occupational hand eczema in Germany. Methods. Resource use during the past year, disease severity and quality of life [Dermatology Life Quality Index (DLQI)] were gathered for patients with occupational hand eczema before they entered a special rehabilitation programme. Costs were calculated from the societal perspective. The analysis focused on all patients and the severity groups no signs/mild (group A) and moderate to severe (group B). Results. One hundred and fifty-one patients were analysed, with a mean age of 44.9 years and a mean DLQI score of 10.9; 64.9% were male. Sickness absence was recorded for 62.9% of all patients (76.4 days on average in the last 12 months). Annual societal costs were 8799 per patient. Indirect costs represented 70% of total costs. Quality of life (DLQI) was statistically different across both severity groups (group A, 7.9; group B, 12.9), but direct treatment costs were not ( 2705 versus 2610, respectively). There was a trend towards higher indirect costs in patients in severity group B (group A, 5120; group B, 6796). Conclusion. The annual societal costs of patients with occupational hand eczema in this study are high, and similar to those for severe psoriasis and atopic dermatitis. Key words: diseases. contact dermatitis; costs; economics; hand eczema; occupational skin Skin disease, mainly contact dermatitis, is the commonest occupational disease in many countries (1, 2). A recent review showed an incidence of hand eczema of 5.5 cases/1000 person-years. High incidence rates were associated with female sex, contact allergy, atopic Correspondence: Professor Dr Thomas L. Diepgen, Department of Clinical Social Medicine, Occupational and Environmental Dermatology, Thibautstr. 3, Heidelberg, Germany. Tel: ; Fax thomas.diepgen@med.uni-heidelberg.de Conflicts of interest: T. L. Diepgen has received lecture and consultancy fees from Basilea Pharmaceutica International Ltd, R. Scheidt and E. Weisshaar declare no conflict of interest, S. M. John declares no conflict of interest, and K. Hieke has received consultancy fees from Basilea Pharmaceutica International Ltd. Funding: This study was supported by a research grant from Basilea Pharmaceutica International Ltd, Basel, Switzerland. Accepted for publication 14 November 2012 dermatitis, and wet work (3). A Danish study showed that 44% of patients with hand eczema had consulted a dermatologist (4). Within 10 different European dermatology departments, 51.7% of all cases had hand eczema related to work (5). A few recent studies have described the productivity loss resulting from occupational hand eczema, but without quantifying the associated costs. A Danish survey showed that this occupational disease leads to prolonged sick leave in 19.9% of patients and job loss in 23% over the course of a year, with severity being a major risk factor (6). In a Swedish 12-year follow-up study, 82% of occupational skin disease patients (mainly hand eczema) reported having changed their work situation because of their condition, and 48% had been on sick leave for at least one period of 7 days. Finally, for 15% of the patients, the occupational skin disease resulted in exclusion from Contact Dermatitis, 69,

2 the labour market through unemployment or disability pension (2). In a follow-up study of 605 Finnish workers with occupational hand eczema, 7 14 years after the initial diagnosis 54% had changed work task or job, 34% had changed occupation, 20% had retrained to a new occupation, 25% had lost their job, and only 8% had experienced no change at work (7). There is little information about the costs of chronic hand eczema (8), and more specifically of occupational hand eczema. The objective of this study was to assess the societal costs (direct and indirect costs) of occupational hand eczema in the year before patients entered a special rehabilitation programme. In addition, the severity of hand eczema and the impairment of quality of life (QoL) were investigated. Patients and Methods Patients Patients were recruited in one specialized hand eczema clinic (University Clinic Heidelberg) in Germany (between April 2006 and April 2007). In order to be eligible for the study, patients needed to have occupational hand eczema that had been diagnosed, treated and reported by a dermatologist using a special report (Hautarztbericht). The provider of the patients occupational health insurance [statutory work insurance: Berufsgenossenschaften (BG)] confirmed the diagnosis of occupational chronic skin disease, and then referred the patients to our department to participate in a specific interdisciplinary inpatient rehabilitation measure, known as tertiary individual prevention. Tertiary individual prevention comprises 3 weeks of inpatient treatment, including intensive health education and counselling, and consecutive outpatient treatment by the local dermatologist. Most patients included in such programmes are at risk of losing their ability to continue their current work activities. Data collection This study collected data on current patient status and resource use in the 12 months prior to inclusion in the rehabilitation programme. The primary source for resource use information comprised comprehensive and high-quality medical records covering medical history, and diagnostic and therapeutic procedures. Additionally, a 1-hr structured interview with each patient was performed to provide information on their occupational status and out-of-pocket expenses. The current clinical status was assessed by dermatological examination at the time when the patient entered the study. The severity of hand eczema was assessed by an easy-to-use physician assessment (1 = no signs; 2 = mild; 3 = moderate; 4 = severe) and by the Osnabrück Hand Eczema Severity Index (OHSI) score (9), which evaluates six morphological signs (erythema, scaling, papules, vesicles, infiltration, and fissuring). Additionally, QoL was evaluated with the 10-item Dermatology Life Quality Index (DLQI) questionnaire (10). According to the physician assessment at the time of the dermatological examination, two severity groups were established: severity group A (no signs/mild) and severity group B (moderate to severe). Cost analysis The analysis was performed from a societal perspective, covering both medical care (direct) and productivity loss (indirect) costs. First, costs of medical care were calculated by use of the appropriate tariffs (Table 1) relevant for the statutory work insurance (BGs). Second, productivity loss (indirect costs) was calculated by use of the human capital approach (each day off work is valued according to the average income of a working day) (Table 1) (11). The medical records provided key information regarding resource use. Nevertheless, a number of assumptions needed to be made concerning the exact quantification of resource utilization for the purpose of the cost analysis: Physician visits: whether visits to general practitioners (primary care physicians) or dermatologists occurred in the last 12 months was recorded, but not the actual frequencies. For the present analysis, frequencies of one visit for general practitioners and 12 visits for dermatologists were assumed. These patients typically had to visit a dermatologist once a month for the special report (Hautarztbericht) requested by the statutory work insurance provider (BGs). Drug use: only ranges were recorded. The lowest point in a given range was used as a point estimate (e.g. drug x, one to three times per week = once weekly in the analysis). Furthermore, a usage of 2 g was assumed for each application of topical steroids, tacrolimus, and pimecrolimus. For emollients, the frequency of application was not recorded; an annual use of 500 g was assumed for the purpose of this analysis. Psoralen + ultraviolet (UV)A (PUVA)/UVB therapy: three treatments per week were assumed. If treatment duration was not recorded, it was assumed to be 10 weeks (standard practice in Germany). If information on frequency of usage was missing, the lowest possible frequency was assumed. If data 100 Contact Dermatitis, 69,

3 Table 1. Sources of unit costs information Cost item Source Prescription drugs Rote Liste, Gelbe Liste Pharmindex (January/February 2008) Non-prescription creams Price lists of online pharmacies, e.g. Online pharmacy Zur Rose : Online pharmacy medpex : Pqoo5ACFSjlXgoduAdmqg Online portal onmeda : (January/February 2008) Physician visits UV-GOÄ (2008); 1, 6 Diagnostic tests UV-GOÄ (2008) Patch tests (70): 380, 381, 382 Prick tests (25): 385, 386 Scratch tests (10): 388 Intracutaneous tests (20): 390 Mycological diagnostic (4): 4711, 4716 Allergy tests (6): 3572 Alkali resistance tests (2): 760 Histology, excision (1): 744, 4800 UV treatment UV-GOÄ (2008) PUVA: 565 UVA: 567 Outpatient rehabilitation DGUV, Department of Statistics on Occupational Diseases (M Butz, pers. comm. 2006) data Inpatient rehabilitation DGUV, Department of Statistics on Occupational Diseases (M Butz, pers. comm. 2006) data) Sick leave per day Human capital approach; average annual income (2007) as calculated by German Pension Fund (Deutsche Rentenversicherung), CD/durchschnittseinkommen.html divided by 230 working days Out-of-pocket expenses Patients DGUV, German statutory accident insurance (Deutsche Gesetzliche Unfallversicherung); UV, ultraviolet; UV-GOÄ, physician s fee tariffs for DGUV (Unfallversicherungsträger-Gebührenordnung für Ärzte); numbers relate to tariff codes. on resource utilization were missing, it was assumed to be zero if not specified otherwise. Therefore, overall, a conservative approach to handling missing data was used. Statistical analysis Data were analysed with descriptive statistics [means, 95% confidence intervals (CIs)]. Analyses were performed for the complete cohort of patients and by severity degree, that is, no signs/mild (severity group A) versus moderate to severe (severity group B). For the comparison of continuous measurements (age, OSHI score, DLQI scores, and costs) across the two severity groups, the Mann Whitney U-test was applied. Results Sample description Data on 161 patients with occupational hand eczema entering a special rehabilitation programme to prevent or improve occupational disability were consecutively collected. Eight patients were excluded because of missing data, and 2 because their final diagnosis was psoriasis and not hand eczema. Therefore, the further analysis is based on 151 patients with occupational hand eczema. A total of 58 patients were in severity group A (no signs/mild) and 93 in group B (moderate to severe). It should be noted that only 2 patients were in the no signs state and 15 patients were in the severe state. Hence, the vast majority of patients in group A had disease of mild severity, whereas group B was composed mainly of patients with disease of moderate severity. The mean age of patients at the time of the assessment was 44.9 years, and 64.9% were male. There were no statistical demographic differences between the two severity groups (A and B): the mean age was 43.6 versus 45.8 years, and the proportion of male patients was 65.5% versus 64.5%, respectively (Table 2). The mean OSHI score was 5.1, and the mean DLQI score was 10.9, the latter indicating a large impact on the patient s life [according to Hongbo et al. (12)]. The vast majority of patients ( 75%) reported DLQI scores Contact Dermatitis, 69,

4 Table 2. Patient characteristics at enrolment (N = 151) All patients (n = 151) Severity A (no signs/mild) (n = 58) Severity B (moderateto severe) (n = 93) Male sex (%) 97 (64.9) 38 (65.5) 60 (64.5) Mean age at enrolment (years) OSHI a (95% CI) 5.1 ( ) 2.9 ( ) 6.5 ( ) DLQI b (95% CI) 10.9 ( ) 7.9 ( ) 12.9 ( ) CI, confidence interval; DLQI, Dermatology Life Quality Index; OSHI, Osnabrück Hand Eczema Severity Index; PUVA, psoralen + ultraviolet A treatment. a OSHI score: 0 (best) to 18 (worst). b DLQI score: 0 (best) to 30 (worst); a DLQI score above 10 indicates a very large or extremely large effect on the patient s life (12). p < that are associated with a moderate, very large or even extremely large impact on the patient s life (Fig. 1). For patients with no, mild, moderate and severe hand eczema, the mean DLQI scores were 11.0, 7.9, 12.0, and 17.3, respectively. Hence, the QoL for most patients with no signs or mild disease was also considerably impaired (see also Fig. 2). Additionally, in all severity groups, differences in OSHI score and QoL according to the DLQI were statistically significant between the two severity groups, with higher scores being observed in group B (both p<0.001; Table 2). Resource utilization and sickness absences Most patients had visited a dermatologist in the previous year, but only a minority (17.2%) had contacted general practitioners. The patients had been treated with topical DLQI No signs (n=2) Mild (n=56) Moderate (n=76) Severe (n=17) Fig. 2. Quality of life [Dermatology Life Quality Index (DLQI) scores] by physician assessment (n = 151). steroids (78.2% of all patients), cream or bath PUVA (39.7%), topical calcineurin inhibitors (17.9%) and systemic steroids (15.2%) in the last 12 months. A considerable proportion of patients (25.9%) had attended an inpatient rehabilitation programme in the previous year. Some 62.9% of patients reported at least one sickness absence day because of their skin disease in the previous year: 55.2% in severity group A, and 67.7% in group B. For patients with at least one sickness absence in the previous year, the average number of days lost was 76.4 days, and 11.5% reported extremely long sickness absences (6 months or longer) (Fig. 3). At enrolment in the study, 33.8% of all patients were currently on sick leave. Details on resource utilization and sick leave are shown in Table % 11.0% 19.7% Extremely large effect on my life (21 30) Very large effect on my life (11 20) Moderate effect on my life (6 10) 35.8% A small effect on my life (2 5) No effect at all (0 1) 27.7% Fig. 1. Distribution of Dermatology Life Quality Index (DLQI) scores according to the classification by Hongbo et al. (12) (n = 151). 102 Contact Dermatitis, 69,

5 1 30 days 45.8% days 18.8% days 17.7% days 6.3% days 11.5% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Patients Fig. 3. Duration of sickness absence in the past year (for patients with sickness absences) (n = 96). Table 3. Resource utilization by occupational hand eczema patients in the last 12 months (n = 151) Table 4. Annual per patient cost of occupational hand eczema (n = 151) All patients (n = 151) Severity A (no signs/mild) (n = 58) Severity B (moderate to severe) (n = 93) All patients (n = 151) Severity A (no signs/mild) (n = 58) Severity B (moderate to severe) (n = 93) At least 1 day lost from work because of skin disease (%) Mean days lost (if at least day lost) (days) Inpatient rehabilitation (%) At least one general practitioner visit (%) At least one dermatologist visit (%) Topical steroids (%) Systemic steroids (%) Topical calcineurin inhibitors (%) Bath PUVA (%) Cream PUVA (%) PUVA, psoralen + ultraviolet A treatment. All data refer to the 12 months preceding the assessment. Cost The annual societal costs amounted, on average, to 8799 (95% CI ) per patient (Table 4). Indirect costs, that is, costs associated with the actual number of days lost from work, constituted the dominant cost factor for patients with occupational hand eczema, accounting for 70% of total costs. Within the remaining direct costs, inpatient rehabilitation was by far the most important cost driver (13%), followed by outpatient services (8%), which also include the costs of PUVA/UVB therapy. All other costs were of minor Indirect costs (productivity loss), mean (95% CI) Direct costs (medical care costs), mean (95% CI) Total societal costs, mean (95% CI) CI, confidence interval ( ) 2646 ( ) 8799 ( ) 5120 ( ) 2705 ( ) 7825 ( ) 6796 ( ) 2610 ( ) 9406 ( ) importance, each contributing 3% to overall costs (Fig. 4). The cost differences between the two severity groups did not reach statistical significance (p = 0.297). However, there was a trend towards higher indirect costs in severity group B (+32%), but direct costs were essentially identical. This observation reflects the similarity in treatment patterns for the two groups. The difference in the use of systemic steroids (8.6% versus 19.3%) had no impact on total direct costs, owing to the low cost of this drug category. Discussion In this study, the societal costs associated with occupational hand eczema amounted to 8799 per Contact Dermatitis, 69,

6 12.8% Inpatient rehabilitation 7.9% 3.0% 2.4% 2.3% 1.7% Outpatient services Diagnostics Out-of-pocket Complementary therapies 69.9% Drugs Indirect costs (productivity loss) Fig. 4. Relative importance of cost components in occupational hand eczema patients (n = 151). patient. Most of these costs were attributable to productivity losses. This shows the impact of hand eczema on work productivity. There was no substantial difference in the costs generated in the preceding 12 months between patients with low and high disease severity at their assessment visit. However, the severity assessed at the time of the visit represents a snapshot. Furthermore, for some patients, work-induced hand eczema may have improved recently, owing to a long (ongoing) sickness absence period. Therefore, the disease activity over the preceding 12 months may not necessarily have differed between the treatment groups. Also, the inclusion criterion for referral to our special rehabilitation programme was the occurrence of severe occupational chronic hand eczema. The disease of referred patients had not been sufficiently controlled within the last year, and no clearance of eczema had been achieved for almost all patients. Conversely, the QoL differed significantly between the two groups [DLQI scores: group A, 7.9 (95% CI ); group B, 12.9 (95% CI ); p<0.001]. It should, however, be noted that in group A (no signs/mild) the QoL impairment was already quite high, showing that the disease was also insufficiently controlled in these patients. To conclude, disease severity, although impacting on patients QoL, had little influence on treatment patterns and costs. Indirect costs, which constituted by far the most important cost factor, tended to increase with severity. To our knowledge, only one study (13, 14) has looked at the costs of occupational chronic hand eczema in a similar way to our study. This Spanish study estimated, within a decision analytic model, the costs of severe, chronic hand eczema from the perspective of an employer s mutual insurance company (EMIC). Information on resource use for medical treatments was gathered from dermatologists and occupational physicians. The costs related to the different types of disability were derived from 156 patients from one of the main EMICs in Spain. The majority (98.6%) of the costs were related to indirect costs (productivity loss resulting from disability). The average indirect costs per patient of the EMIC were 3459 for patients with partial disability (sick leave of up to 3 months), 9961 for patients with partial permanent disability (sick leave of up to 24 months), and for patients with total permanent disability in their current profession. The latter group permanent disability was the most important cost driver (67.6% of total costs), although only 18% were estimated to reach this type of disability (13, 14). The indirect cost in our study ( 6152 per patient) is located between the first two groups in the Spanish study. This may be attributed to the fact that our study included patients who entered a programme that should prevent exclusion from the workforce, whereas the Spanish study included a number of patients with permanent disability. It is also interesting to compare the results of the present analysis with a recent cost-of-illness study by Augustin et al. (15), which included 223 non-occupational chronic hand eczema patients who were covered by the statutory health insurance in Germany, which covers 90% of the population. This insurance does not cover occupational diseases. The annual total costs were considerably lower, at 2128 per patient on average. The large difference can mainly be explained by much lower indirect costs ( 386), because of less sick leave. Furthermore, the study also included patients with milder disease (average DLQI score of 6.7 versus 10.9 in the present study). However, it should be noted that the study also identified 104 Contact Dermatitis, 69,

7 patient groups with significant costs [e.g. patients with Physician Global Assessment severe ( 3205) or patients with hospitalization ( 8407)] (15). The costs of occupational hand eczema in our study are estimated to be at least as high as the costs of atopic dermatitis or moderate to severe psoriasis in Germany. Gieler et al. (16) estimated the costs of atopic dermatitis at a German dermatological clinic, based on a selection of 148 patients with chronic atopic dermatitis (aged years). The total annual cost per patient was estimated to be Rathjen et al. (17) estimated the total annual costs for 204 German children with moderate to severe atopic to amount to 4421 per patient. Also in Germany, Schöffski et al. (18) estimated the total annual costs of illness generated during the previous 12 months in 184 patients with moderate to severe psoriasis before biologics became available. QoL was also assessed by the use of DLQI. The total annual costs amounted to 6709 per patient, and QoL was highly impaired (mean DLQI score of 10.6). The impacts on costs and QoL in the most severe psoriasis subgroup (most severe skin symptoms, highest hospitalization rate, and largest loss of productivity) were total annual costs of 8831 per patient and a mean DLQI score of Interestingly, this was similar to our findings in patients with moderate to severe disease (group B), who had annual costs of 9406 per patient and a mean DLQI score of Although our study was based on reliable, comprehensive medical records and patient information, not all data relevant for a complete economic analysis were available. Some data were estimated by using assumptions, as explained above. These assumptions have been conservative in general (that is, if information on resource use was missing, it was assumed to be zero, or frequencies of dermatologist visits were based on the minimum required number of visits by the BGs), making an under-estimate of costs more likely than an over-estimate. Overall, the major cost drivers, indirect costs and inpatient rehabilitation, were not based on these assumptions (Fig. 4). Furthermore, we recognize that, although some information was not available and was therefore ignored for the purpose of this analysis, it could have been important for a complete view on the societal costs of occupational hand eczema. Most importantly, indirect costs were restricted to costs resulting from work absenteeism. The costs of early retirement, work disability, and retraining, estimated at between and per patient in Germany (19) for re-training alone, were not included. Conversely, there may be some overlap between patient out-of-pocket expenses and costs of complementary therapies, as the latter are not covered routinely by the BG. As a consequence, some double-counting may have occurred. However, given the low share of both out-ofpocket expenses and costs of complementary therapies, this is unlikely to have had a significant impact on overall costs. We are aware that our study was based on selected patients, and that the estimates for the costs of occupational hand eczema may differ from those in other settings. This study was based on patients with occupational hand eczema that had not been sufficiently managed in the past year. We included a cohort of 161 consecutive patients who were referred to us between April 2006 and April In comparison with other studies (3), a relatively high proportion of patients were male, which might be influenced by the occupations of the patient seen in our clinic. Our cost calculations reflect the situation in the catchment area of a specialized clinic in Germany, which may not be representative of other European countries (e.g. because of differences in patient management). The first data on the management of chronic hand eczema in Germany from the registry project of the German Dermatological Society for the characterization and care of chronic hand eczema (CARPE) indicate that patients in the present study have received similar treatments as chronic hand eczema patients in Germany [e.g. proportion of patients with UV therapy, 39.7% (present study) versus 38.3% (CARPE); topical calcineurin inhibitors, 17.9% versus 31.9%; and hospitalization, 25.9% versus 30.4%] (20). Despite these caveats, this study shows the importance of occupational hand eczema with regard to the magnitude of the economic burden for individuals, health insurance providers, and society. In conclusion, occupational hand eczema has a huge economic impact, as it leads to both significant productivity loss and medical care costs. Acknowledgements T. L. Diepgen, E. Weisshaar and S. M. John designed the study protocol of the specific interdisciplinary inpatient rehabilitation measure, known as tertiary individual prevention. R. Scheidt and K. Hieke performed the data management and analyses. All authors listed participated in study conduct, data analysis and interpretation, and publication manuscript generation and review. Contact Dermatitis, 69,

8 References 1 Diepgen T L. Occupational skin-disease data in Europe. Int Arch Occup Environ Health 2003: 76: Meding B, Lantto R, Lindahl G, Wrangsjö K, Bengtsson B. Occupational skin disease in Sweden a 12-year follow-up. Contact Dermatitis 2005: 53: Thyssen J P, Johansen J D, Linneberg A, Menné T. The epidemiology of hand eczema in the general population prevalence and main findings. Contact Dermatitis 2010: 62: Hald M, Berg N D, Elberling J, Johansen J D. Medical consultations in relation to severity of hand eczema in the general population. Br J Dermatol 2008: 158: Agner T, Andersen K E, Brandao F M et al. Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. Contact Dermatitis 2008: 59: Cvetkovski R S, Rothman K J, Olsen J, Mathiesen B, Iversen L, Johansen J D, Agner T. Relation between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema. Br J Dermatol 2005: 152: Mälkönen T, Alanko K, Jolanki R, Luukkonen R, Aalto-Korte K, Lauerma A, Susitaival P. Long-term follow-up study of occupational hand eczema. Br J Dermatol 2010: 163: VeienNK,HattelT,LaurbergG.Hand eczema: causes, course, and prognosis II. Contact Dermatitis 2008: 58: Skudlik C, Dulon M, Pohrt U, Appl K C, John S M, Nienhaus A. Osnabrueck hand eczema severity index a study of the interobserver reliability of a scoring system assessing skin diseases of the hands. Contact Dermatitis 2006: 55: Finlay A Y, Khan G K. Dermatology Life Quality Index (DLQI) a simple practical measure for routine clinical use. Clin Exp Dermatol 1994: 19: Gray A M, Clarke P M, Wolstenholme J L, Wordsworth S. Applied Methods of Cost-effectiveness Analysis in Health Care: Oxford, Oxford University Press, Hongbo Y, Thomas C L, Harrison M A, Salek M S, Finlay A Y. Translating the science of quality of life into practice: what do dermatology life quality index scores mean? J Invest Dermatol 2005: 125: Mascaro J M, Querol I, Lindner L, Prior M, Oliver J, Halbach R P. Costs of patients with occupational severe chronic hand eczema refractory to topical corticosteroids for employer s mutual insurance companies in Spain. Value Health 2009: 12: A453 A Mascaro J M, Querol I, Lindner L, Prior M, Oliver J, Halbach R P. Impacto De La Introducción De Alitretinoína Oral En Los Costes Del Eczema De Las ManosSevero De OrigenProfesionalDesde La Perspectiva De Las Mutuas De Accidentes De Trabajo Y EnfermedadesProfesionales En España. RevSocEspMedSegurTrab2010: 5: Augustin M, Kuessner D, Purwins S, Hieke K, Posthumus J, Diepgen T L. Cost-of-illness of patients with chronic hand eczema in routine care: results from a multicentre study in Germany. Br J Dermatol 2011: 165: Gieler U, Hohmann M, Niemeier V, Kupfer J. Cost evaluation in atopic eczema. J Dermatol Treat 1999: 10: S15 S Rathjen D, Thiele K, Staab D, Helberger C. Die Geschätzten Kosten von Neurodermitis bei Kindern. ZGesundh 2000: 8: Schöffski O, Augustin M, Prinz J, Rauner K, Schubert E, Sohn S, Reich K. Costs and quality of life in patients with moderate to severe plaque-type psoriasis in Germany: a multi-center study. J Dtsch Dermatol Ges 2007: 5: Diepgen T L. The costs of skin disease. Eur J Dermatol 2006: 16: Apfelbacher C J, Akst W, Molin S et al. CARPE: a registry project of the German Dermatological Society (DDG) for the characterization and care of chronic hand eczema. J Dtsch Dermatol Ges 2011: 9: Contact Dermatitis, 69,