Chapter 147. Hand Eczema

An Asian American physician presents with dry scaling on her hands. Frequent hand washing makes it worse and it sometimes cracks. She has allergic rhinitis and she had more widespread atopic dermatitis in her youth. This is a case of chronic atopic hand dermatitis (Figure 147-1). The treatment suggested was use of Cetaphil (or equivalent nonsoap cleanser) instead of soap and water. She was directed to soak her hands 3 to 5 minutes in warm water every night, apply triamcinolone 0.1% ointment, and cover with cotton gloves overnight. Her hands cleared 90% with this treatment and she was pleased with the results.

Hand eczema refers to a wide spectrum of inflammatory skin diseases of the hands, including atopic dermatitis, contact dermatitis, pompholyx, and dyshidrotic eczema.

Hand dermatitis, pompholyx, dyshidrotic eczema, vesicular palmoplantar eczema. Although some people use pompholyx and dyshidrotic eczema synonymously, others reserve pompholyx for hand eczema with vesicles and bullae on the palms and dyshidrotic eczema for conditions with smaller vesicles between the fingers and toes.

• The prevalence of hand dermatitis is estimated at approximately 2% to 8.9% in the general population.1

• There are many clinical variants of hand dermatitis and a number of different classification schemas. Here is one accepted classification scheme:

  1. Contact (i.e., allergic and irritant) (Figure 147-2).

  2. Hyperkeratotic (i.e., psoriasiform) (Figure 147-3).

  3. Frictional (Figure 147-4).

  4. Nummular (Figure 147-5).

  5. Atopic (Figure 147-6).

  6. Pompholyx (i.e., dyshidrosis) (Figures 147-7 and 147-8).

  7. Chronic vesicular hand dermatitis.1 (Figure 147-9)

• Another way of looking at hand dermatitis is to break it down into three categories:2

  1. Endogenous—Atopic, psoriasis, pompholyx, dyshidrotic (we do not include psoriasis as a type of hand eczema in this chapter).

  2. Exogenous—Allergic and irritant contact dermatitis.

  3. Infectious—Tinea, Candida, and/or superimposed S. aureus (Figure 147-10).

• Most contact dermatitis of the hands is secondary to irritants such as soap, water, solvents, and other chemicals.
• Allergic contact dermatitis (ACD) is a type IV, delayed-type, cell-mediated, hypersensitivity reaction.
• The nine most frequent allergens related to hand contact dermatitis were identified by patch testing from 1994 to 2004.3 These are quaternium-15 (16.5%), formaldehyde (13.0%), nickel sulfate (12.2%), fragrance mix (11.3%), thiuram mix (10.2%), balsam of Peru (9.6%), carba mix (7.8%), neomycin sulfate (7.7%), and bacitracin (7.4%).3
• Rubber allergens were commonly associated with occupation. One third of patients with ACD had identifiable relevant irritants.3
• Most common allergens are preservatives, metals, fragrances, topical antibiotics, or rubber additives.3

Clinical Features1

Contact (i.e., allergic and irritant) (Figure 147-2).

• Symptoms include burning, stinging, itching, and tenderness at the site of exposure to the irritant or allergen.1
• Acute signs include papules, vesicles, bullae, and edema.
• Weeping and crusting can occur with or without superinfection.
• Chronic signs include plaques with fissuring, hyperpigmentation, and/or lichenification.
• Irritant contact dermatitis may predispose to ACD.

Hyperkeratotic (i.e., psoriasiform) (Figure 147-3).

• Symmetric hyperkeratotic plaques.
• May be localized to the proximal or middle part of the palms.
• Painful fissures are common.

Frictional (Figure 147-4).

• Mechanical factors, often from work, such as trauma, friction, pressure, and vibration, induce skin changes with erythema and scale.
• “Wear-and-tear dermatitis.”1
• Can be caused by contact with paper and fabrics.

Nummular (Figure 147-5).

• Nummular hand dermatitis (also called discoid hand dermatitis).
• Tiny papules, papulovesicles, or “coin-shaped” eczematous plaques.
• Dorsal hands and distal fingers are often involved.

Atopic

• Patients with childhood atopic dermatitis are predisposed to develop hand dermatitis as adults (Figure 147-6).
• There is no characteristic pattern and it can occur on any part of the hand.
• Extension to or involvement of the wrist is common (Figure 147-11).

Pompholyx (i.e., dyshidrosis, dyshidrotic eczema).

• Has recurrent crops of papules, vesicles, and bullae on the lateral aspects of the fingers, as well as the palms and soles, on a background of nonerythematous skin (Figures 147-7 and 147-8).
• These are described as tapioca vesicles as they look like the small spheres in tapioca. The vesicles open and the skin then peels (mild desquamation).
• There may be pruritus or pain.
• Although some use the names pompholyx and dyshidrotic eczema interchangeably, others only use the name pompholyx to describe an explosive onset of large bullae, usually on the palms (Figure 147-8) and dyshidrotic eczema to mainly describe chronic small tapioca vesicles on the sides of the fingers (Figure 147-7).
• Both conditions may last 2 to 3 weeks and resolve, leaving normal skin, only to recur again at varying intervals.
• Both conditions are idiopathic and closely related, if not identical.
• Symptoms may be associated with exogenous factors (e.g., nickel or hot weather) or endogenous factors (e.g., atopy or stress).

Chronic vesicular hand dermatitis (Figure 147-9).

• Chronic vesicles that are mostly palmar and pruritic.
• Differentiated from pompholyx by a more chronic course and the presence of vesicles with an erythematous base.
• The soles of the feet may also be involved.
• Poorly responsive to treatments.
• In one series, 55% of patients with this type of hand dermatitis were found to have positive patch test results.4

Typical Distribution

Of course, hand dermatitis is on the hands, but both hands and feet can be involved in dyshidrotic eczema and chronic vesicular hand dermatitis.

Laboratory Studies

Scraping and using microscopy with KOH (with or without a fungal stain) to look for dermatophytes is helpful (see Chapter 135, Fungal Overview).

Patch testing can be crucial to the diagnosis and treatment of hand eczema. Patch testing is described in detail in the previous chapter (Chapter 146, Contact Dermatitis). The patient in Figure 147-8 had severe pompholyx worsening with topical steroids. Patch testing showed she was allergic to topical steroids (Figure 147-12). Her hands finally cleared with oral cyclosporine and avoidance of all topical and oral steroids.

• Tinea manus is often found as part of the two-foot, one-hand syndrome in which both feet have scaling tinea pedis and one hand has scale as well (Figure 147-13) (see Chapter 135, Fungal Overview, and Chapter 140, Tinea Pedis).
• Candida can be seen in between the fingers with erythema and scale over the fingers and hand (Figure 147-10) (see Chapter 136, Candidiasis).
• Psoriasis often involves the hand. It can present with plaques on the dorsum of hand and over the knuckles of the fingers or on the palm of the hand. Palmoplantar psoriasis will involve the hands and feet (see Chapter 152, Psoriasis).
• Knuckle pads are thickening of the skin over the knuckles. These can be accompanied by hyperpigmentation.

• Lifestyle modifying factors, as listed in Table 147-1, are essential.
• Avoid irritants and “wet work” at home and at work as much as possible. SOR C
• Wear protective gloves when working with known allergens or potentially irritating substances such as solvents, soaps, and detergents.5,6 SOR A
• Use cotton liners under the gloves for both comfort and the absorption of sweat. Wearing cotton glove liners can prevent the development of an impaired skin barrier function caused by prolonged wearing of occlusive gloves.5,6 SOR B

There is insufficient evidence to promote the use of barrier creams to protect against contact with irritants.5,6 SOR A

Applying conditioning creams after work can improve skin condition in workers with damaged skin on the hands.6 SOR A

• Avoid latex gloves because of a high risk of latex allergy among patients with hand dermatitis. SOR C
• Frequent and liberal use of emollients can help restore normal skin-barrier function. Simple, inexpensive, petrolatum-based emollients were found to be equally as effective as an emollient containing skin-related lipids in a 2-month study of 30 patients with mild to moderate hand dermatitis.7 SOR B
• For patients with very dry skin that is not irritated by water, it may help to soak hands 3 to 5 minutes in warm water at night, apply triamcinolone 0.1% ointment, and cover with cotton gloves overnight. The cotton gloves may be used repeatedly even though they will soak up some of the ointment. SOR C
• Do not wash hands with soap. Use Cetaphil, a nonsoap cleanser. SOR C

See Table 147-2 for a summary of the recommended therapeutic agents for different types of hand dermatitis.

Topical Agents

• Topical steroids are first-line agents for inflammatory hand dermatitis. Ointments are considered more effective and contain fewer preservatives and additives than creams. Some patients will prefer a cream vehicle, so that patient preference should be considered in prescribing topical steroids. It is better to have a patient use a cream than not use an ointment.
• Start with 0.1% triamcinolone ointment bid as it is inexpensive and effective. SOR C Cut back on use when possible to avoid skin atrophy, striae, and telangiectasias.
• Topical calcineurin inhibitors, tacrolimus and pimecrolimus, are effective in the treatment of atopic and other allergic types of hand dermatitis.8,9 SOR B Skin burning or an unpleasant sensation of warmth is reported by approximately 50% of patients using topical tacrolimus and 10% with pimecrolimus.10

Phototherapy and Ionizing Radiation

• Psoralen and UVA irradiation (PUVA) has been used to treat patients with all forms of hand dermatitis.10 SOR C
• Grenz rays (ionizing radiation with ultra-soft X-rays or Bucky rays) usually requires 200 to 400 rad (2 to 4 Grays or Gy) every 1 to 3 weeks for up to a total of 6 treatments, followed by a 6-month hiatus.10 SOR C

Systemic Steroids and Immunomodulators

• Oral prednisone may be used to treat the most severe and recalcitrant case of hand dermatitis. Pulse dosing of 40 to 60 mg daily for 3 to 4 days may be valuable.10 For atopic dermatitis of the hands, an injection of 40 mg triamcinolone acetonide is another option when topical meds are not fully working. SOR C
• Cyclosporine is a potent immunomodulating agent used to treat severe and recalcitrant cases of atopic dermatitis and hand dermatitis. In a systematic review, cyclosporin consistently decreased the severity of atopic dermatitis. The decrease in disease severity was greater at 2 weeks with dosages greater than or equal to 4 mg/kg. After 6 to 8 weeks the relative effectiveness was 55%.11 For patients with severe functional problems this can be a great relief (Figure 147-8). Unfortunately, relapse rates are high after discontinuation of the cyclosporine.10 SOR B
• Mycophenolate mofetil and methotrexate have been reported to be beneficial in case reports.10 SOR C
• Alitretinoin (9-cis-retinoic acid) is an effective treatment for severe chronic hand eczema.12 SOR B Like all systemic retinoids it is teratogenic and requires careful monitoring. This medication is not yet available in the United States, but is being used in Canada and the United Kingdom.

• See Table 147-1.

Patients with chronic hand dermatitis are often desperately looking for help and often appreciate frequent follow-up until the dermatitis is controlled. Patch testing requires three visits within a 1-week period.

Patient Resources

• DermNet New Zealand—http://www.dermnetnz.org/dermatitis/hand-dermatitis.html.

Provider Resources

• Dyshidrotic eczema—http://emedicine.medscape.com/article/1122527.
• Vesicular Palmoplantar Eczema—http://emedicine.medscape.com/article/1124613.