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Hand Eczema

What is Hand Eczema (Dermatitis)

Eczema, also called dermatitis. 'Hand dermatitis' is a broad term for any type of eczema that develops on the hands. Hand dermatitis often has unique causes, commonly job-related and can require specific testing and treatments.

How Common is Hand Dermatitis?

- An estimated 2% to 10% of the general population is affected by hand dermatitis.

- 20% to 35% of all dermatitis affects the hands.

- 9% to 35% of all occupational disease and up to 80% or more of all occupational contact dermatitis. Five occupations were responsible for more than 60% of these cases:

- 1-Housekeeper, 2-Bricklayer, 3-Worker in metallurgic or mechanical industry, 4-Hairdresser, 5-Health care worker

- higher than average risk include: janitors and housecleaners, florists, bakers, bartenders, caterers, cooks, and agricultural workers.

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Hand Eczema

Risk Factors for Hand Eczema - Dermatitis

Medical condition-a history of atopic disease (atopic dermatitis, asthma, or hay fever) increases the risk

Occupation -"Wet work" -hand washing, using chemicals and solvents can play a role.

Stress-cmay worsen all types of eczema

Environment-low humidity and cold weather strips skin of moisture which increases risk of developing some types of hand dermatitis. Alternately, sometimes heat and high humidity play a role. Perspiration under gloves can contribute to hand dermatitis

What Else Can Look Like Dermatitis

PSORIASIS

Well demarcated scaly plaques, with scales which may not be silvery.

Psoriasis affecting the hands is most prominent over pressure points

Usually relative lack of itching

Often psoriasis elsewhere on body

Nails may show features of psoriasis: pits, oil spots, subungual hyperkeratosis, splinter hemorrhages, onycholysis (lifting up of distal nail).

Lichen Planus must be also considered

Causes of Hand Dermatitis

There is usually no one clear-cut cause. Many conditions can present with hand dermatitis. Often several conditions can co-exist.

Irritant contact dermatitis (80%)

Repeat water exposure is probably the most important irritant.

Frequent or prolonged exposure repetitive insults water, soaps, detergents, cleansers, solvents, degreasers, lubricants, oils, coolants, unidentified, food products, fiberglass dust, metals, plastics, resins, and mechanical trauma inhibiting repair of the epidermal barrier

A brief exposure to strong irritant such as battery acid is also a caus.

SIGNS AND SYMPTOMS INCLUDE:

Usually symmetrical and affects dorsal fingertips and webspaces.

Dry, chapped skin. With repeat exposures, areas of itchy, red, scaly, swollen skin

Skin may burn or sting with contact to everyday items.

If exposure to irritants persists, skin can crack, scale, and become very dry.

Blisters are very uncommon and open areas may develop later forming crusts and scales

Allergic contact dermatitis (20%)

Common allergens include nickel, Balsam of Peru (added to fragrances, foods, skin care products), fragrance, and preservatives.

Occupational allergens may include topical antibacterials, metallic salts (eg, chromate, nickel), organic dyes, plants, plastic resins, and rubber additives, and others.

Usually develops a few hours after allergen touches the skin

SIGNS AND SYMPTOMS INCLUDE:

In acute phase-usually vesicles or small blisters with itchy, swollen, red skin.

In later phases skin can become dry with crusts, scales, and fissures

Overtime if exposure to allergen persists skin can darken and become thick and leathery.

Distribution commonly dorsal hands, particularly fingers.

Atopic dermatitis

Adults with atopic dermatitis usually have involvement of the hands and or eyelids

SIGNS AND SYMPTOMS INCLUDE:

Intense itchiness; acute skin lesions are erythematous papules with excoriations, vesicles, and serous exudates. Chronic phase characterized by thickened skin, accentuated skin markings (lichenification), and fibrotic papules.

Hyperkeratotic

Characterized by hyperkeratosis. In contrast to other types of vesicular palmoplantar eczema, vesicles do not dominate clinical picture. May resemble psoriasis. More common in middle age to elderly men.

Vesicular palmoplantar dermatitis is a term sometimes used to encompass the following 4 types of hand dermatitis.

Diagnosis of Hand Dermatitis

Without proper diagnosis and treatment, hand dermatitis can persist and become chronic. It can often become disabling because it affects one's ability to perform at work and home. Additionally, hand dermatitis may interfere with sleep, cause emotional discomfort, and negatively affect interpersonal interactions.
Some studies suggest that early diagnosis may be important in preventing chronicity.

Approach

A thorough history and physical examination is essential in helping to deduce the possible cause(s) of hand dermatitis. Is the patient atopic. Especially important is an occupational and social history. It is often challenging to distinguish irritant contact from allergic contact dermatitis. 

The important aspects of the history and physical exam include:

1. DERMATITIS SPECIFIC HISTORY

- Patient's description of dermatitis and symptoms

- Temporal associations (waxings/wanings)

- Relationship of dermatitis to work, effect of vacations and travel

- Change in pattern or behavior of dermatitis

- Previous and current therapies by physician and patient

- Dermatitis at sites other than hands

- Chemicals, detergents, medicaments, lubricants, cleansers, frictional contacts, and type of gloves encountered at work, home, or in hobbies

- Frequency of hand washing, type of soap and lotions

- Personal care products including nail polish

2. OCCUPATIONAL HISTORY

Does patient think present dermatitis linked to occupation?

Job title, job description, regular and occasional chemical exposures and sources

Employer, location of employment, time at current job, previous occupations

Description of work when rash began

Other workers affected?

3. SPECIFIC OCCUPATION EXPOSURES

Construction worker-sensitized to chromium from cement exposure

Hair dresser-allergic to paraphenylenediamine (dyes), cocamidopropyl betaine (surfactant-detergent), or glycerol monothioglycolate (permanent wave and straightening solutions)

Treatment of Hand Dermatitis (Hand Eczema)

1.Behavoral Treatment of Hand Eczema

Where possible, avoid or minimize wet-work,

Avoid excessive sweating and dry conditions which are sometimes triggers

Avoid scratching which worsens the condition and may cause cracks allowing bacteria to enter leading to infection. Sometimes applying cold compress to area reduces itch. Keep fingernails short.

Avoid the substance(s) causing the irritation or allergy. Avoiding all substances can be very difficult-if not impossible-especially if these substances are encountered at work. Using barrier cream, wearing gloves, and practicing glove hygiene is often helpful.

Avoid harsh or scented soaps. Soapless cleansers may be best to use such as cetaphil, spectro jel, spectro derm, lipikar syndet

Minimize contact with fruit juices, fruits, vegetables, raw meat while preparing food

Protect hands by using cotton gloves as liner under vinyl gloves

Shampoo hair while wearing vinyl gloves, if possible

Take off rings before wet-work or hand washing

Use emollients frequently to help restore normal skin barrier function. A thin smear of a thick barrier cream should be applied to all affected areas before work, and reapplied after washing and whenever the skin dries out. Some moisturizers without allergens include: Vasoline, Cliniderm moisturizer

Stress management-stress triggers flare-ups in many people so reducing stress may be beneficial.

2.Topical Therapy for Hand Eczema

Topical Steroids

Topical steroids are used to reduce inflammation and remain a mainstay of therapy.

Ointments are more effective and have fewer preservatives and additives than creams.The final decision about the base used should be taken after input from the patient

The thick stratum corneum especially palms, palmar aspects of fingers, and around nails often necessitates use of rather potent preparations such as clobetasol propionate 0.05% ointment for a few weeks only

If the response is unexpectedly slow consider corticosteroids allergy.

Cross-reactions between groups of corticosteroids and flares with systemic steroids may also complicate therapy.

Topical steroids should be used on affected areas twice per day until condition improves, then taper to intermittent use for maintaince.

Salicylic acid, LCD

Salicylic acid, LCD tar are sometimes prescribed for hyperkeratotic areas

3.Phototherapy (Light) as Hand Eczema Treatment

Narrow-band UVB light and PUVA are helpful for their local immunosuppressive effect.

4. Systemic Treatment of Hand Eczema

AntihistaminesAntihistamines can be used to help itch. Common antihistamines include:

Atarax,

Benadryl

Reactine

Antibiotics

Sometimes needed if infection develops

Most infections are caused by staph and so Keflex (Cephalexin) 500mg QID x 7 days is commonly prescribed

Oral corticosteroids (Prednisone)

May be effective in a short course for recurrent pomphylx and dyshidrotic hand dermatitis.

Treatment does of 0.5-1mg/kg or 20-40mg prednisone tapered over several weeks can be effective.

Warning about side effects of prednisone mst always be given.

Oral Immunosuppressants

Cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil are occasionally used for treatment-resistant chronic hand dermatitis. None of these medicines have received regulatory approval to treat hand dermatitis and more research is necessary in order to confirm their safety and effectiveness in treating this condition. Because these agents have the potential to cause significant side-effects, their use must be strictly monitored by a physician and regular laboratory tests are necessary while undergoing therapy.

Cyclosporine has been reported to be effective in atopic dermatitis, pompholyx, and psoriasis. Its effectiveness has been demonstrated in two small studies in hand dermatitis with a dosage of 3 mg/kg. The use of cyclosporine requires careful monitoring. Serious side-effects include kidney dysfunction, increased blood pressure, and increased risk of infections and various cancers.

Methotrexate has been reported to improve hand dermatitis in several case reports. Side-effects include nausea, vomiting, and diarrhea. Long-term use can lead to liver cirrhosis, pulmonary fibrosis (lung scarring), and pancytopenia (lowering of all blood cell counts).

Azathioprine has been reported to improve atopic dermatitis and pompholyx, but there is very limited research studying its benefits for hand dermatitis. Use of this drug requires careful monitoring as it can cause a serious lowering of the white blood cell count.

Mycophenolate mofetil (MMF) may be considered for use in chronic hand dermatitis when patients do not respond to other therapies. There is concern over MMF's teratogenic potential and long-term use may increase cancer risk.

Retinoids

9-cis retinoic acid (alitretinoin) (Toctino®) is a new oral retinoid that is currently approved for use in Europe. Research has demonstrated significant clinical improvement in patients with chronic hand eczema, especially for the variant known as hyperkeratotic dermatitis.

Side-effects include headache, flushing.

Strict pregnancy prevention is required 1 month before, during, and for 1 month after treatment with alitretinoin for women of child bearing potential due to the teratogenicity of the product.

                                                                              Source: www.handeczema.com