Chapter 153: Hand Eczema

PATIENT STORY

An Asian American physician presents with dry scaling on her hands. Frequent handwashing 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 153-1). Her physician recommended she use Cetaphil (or equivalent non-soap cleanser) instead of soap and water for handwashing. Triamcinolone 0.1% ointment was prescribed for use twice daily, including use of cotton gloves overnight over the ointment. Her hands improved greatly with this treatment, and she was pleased with the results.

INTRODUCTION

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

SYNONYMS

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.

EPIDEMIOLOGY

• The prevalence of hand dermatitis is estimated at approximately 2% to 8.9% in the general population, with only a fraction of adults with hand eczema seeking medical care.^1,2

ETIOLOGY AND PATHOPHYSIOLOGY

• 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 153-2).

  2. Hyperkeratotic (i.e., psoriasiform) (Figure 153-3).

  3. Frictional (Figure 153-4).

  4. Nummular (Figure 153-5).

  5. Atopic (Figure 153-6).

  6. Pompholyx (i.e., dyshidrosis) (Figures 153-7 and 153-8).

  7. Chronic vesicular hand dermatitis¹ (Figure 153-9).

• Another way of looking at hand dermatitis is to break it down into three categories³:

  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 Staphylococcus aureus (Figure 153-10).

• 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 2004.⁴ 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%).⁴

• Rubber allergens were commonly associated with occupation. One third of patients ...