TSx-Cover

Hand Dermatitis

Key Points

  • Hand dermatitis may be difficult to treat due to the thickened skin surface of the hands and the frequent exposure of the hands to irritants and potentially exacerbating factors.
  • Hand dermatitis can range from an acute, extremely pruritic or painful eruption, characterized by deep-seated vesicles (dyshidrotic eczema, pompholyx), to the chronic hand dermatitis commonly seen in those in at-risk occupations.
  • The therapeutic strategy is to eliminate any external cause and to control the cutaneous inflammation. Management is typically through topically applied medications. For severe cases, systemic immunosuppression may be necessary.
  • All patients with hand dermatitis, independent of the clinical type, have reduced tolerance to irritants. Avoidance of irritants, including wetness, and frequent use of moisturizers are important.

Introduction

Inflammatory processes may involve the dorsal or palmar surfaces of the hands. Dorsal hand dermatitis is managed as is dermatitis elsewhere on the body; however, given the thickened skin surface of the hands and the frequent exposure of the hands to irritants and potentially exacerbating factors, hand dermatitis can be difficult to treat. This discussion is restricted to dermatitis based primarily on the palmar surface.

Hand dermatitis can range from an acute, extremely pruritic or painful eruption, characterized by deep-seated vesicles (dyshidrotic eczema, pompholyx), to the chronic hand dermatitis commonly seen in those in at-risk occupations. For therapeutic purposes, hand dermatitis can be classified into vesiculobullous types (acute and chronic) and hyperkeratotic hand dermatitis (no vesicles in any phase of the eruption). Both types may also be marked by edema, fissures, nummular plaques, and erosions. Persons who are predisposed with atopic dermatitis are at particular risk to develop hand dermatitis. Workers in certain industries, such as hairdressing, may be at increased risk and may affect quality of life as well as ability to work; in one study, between 0.7 and 1.5 cases per 1000 employees were affected by a hand dermatitis. The therapeutic strategy is to eliminate any external cause and to control the cutaneous inflammation. Management is typically through topically applied medications. For severe cases, systemic immunosuppression may be necessary.

All patients with hand dermatitis, independent of the clinical type, have reduced tolerance to irritants. The most common irritants are soap and water. Hand protection for all manual tasks, wet or dry, prevents exacerbations. Especially important is the use of vinyl gloves when doing any wet work. Moisturizing the hands regularly is critical in controlling most cases of hand dermatitis. Nightly application of a heavy moisturizer is strongly recommended.

There is an important differential diagnosis of hand dermatitis, including: atopic dermatitis involving the hand, tinea (superficial dermatophyte infection), allergic contact dermatitis, psoriasis, lichen planus, scabies, herpes simplex, pityriasis rubra pilaris, and cutaneous lymphoma. A skin biopsy and/or patch testing should be considered in treatment-refractory cases.

Initial Evaluation

Differential diagnosis

Allergic contact dermatitis of the hand

Tinea manuum

Palmoplantar keratoderma of psoriasis

Treatment

First-line therapy: The first-line therapy for hand dermatitis is to stop any offending agents. The mainstay of treatment is the use of topical medications in conjunction with frequent use of moisturizers. The approach to the management of hand dermatitis differs on the clinical presentation; the therapeutic strategy for vesiculobullous hand dermatitis and hyperkeratotic hand dermatitis are discussed separately below.

Vesiculobullous hand dermatitis

First steps

  • A superpotent or high-potency topical steroid cream such as clobetasol propionate 0.05% or fluocinonide 0.05% cream should be applied once or twice daily. Occlusion overnight with vinyl gloves may enhance efficacy.
  • For pruritus, diphenhydramine 25-50 mg, hydroxyzine 25-75 mg, or doxepin 10-75 mg nightly may be used. Sedation should be anticipated.

Ancillary steps

Acetic acid soaks (one tablet or packet in one cup of cool tap water) for 15 minutes twice daily will dry lesions, relieve itching, and reduce likelihood of secondary infection.

Subsequent steps

  • In mild cases, topical tacrolimus 0.1% ointment (such as Protopic) may be beneficial.
  • Systemic steroids may be used for a short period of time (one week) for acute flares. Systemic steroids should not be used for the chronic management of hand dermatitis unless no other alternative exists.
  • Phototherapy (UVB or UVA1) or photochemotherapy (PUVA), oral or by soak, administered with a hand and foot unit, can be very effective. This modality takes several weeks to produce improvement and is available only in selected dermatologists’ offices. In limited studies, PUVA was superior to UVB in the treatment of hand dermatitis; however, other studies have not shown that one light modality is more effective.
  • Patch testing by a dermatologist should be considered in any patient with chronic vesiculobullous hand dermatitis. Although 50% or fewer of patients will have relevant positives, those positive patients may have considerable improvement with avoidance of the relevant allergens. Patch testing should be guided by a thorough review of the patient’s exposures, including hobbies and occupational history.
  • In severe refractory cases, cyclosporine A, mycophenolate mofetil, or alitretinoin may be necessary.

Chronic hyperkeratotic hand dermatitis

First steps

Apply a high-potency or superpotent topical, fluorinated steroid ointment such as clobetasol propionate 0.05% or fluocinonide 0.05% ointment once or twice daily. once or twice daily, with nightly occlusion to enhance efficacy.

Ancillary steps

  • Many patients suffer disease exacerbations from excessive exposure to hot water and harsh detergents. Use of cool water, mild soaps, adequate protection, and an emollient hand cream is critical to prevent relapses in these patients.
  • Patients with recalcitrant and/or recurrent disease often benefit from concurrent therapy with a cosmetically acceptable tar preparation. Ten to 20% LCD in petrolatum can be compounded. Up to one month of twice daily therapy may be required to detect improvement. The use of tar makes the dermatitis less dependent on steroids and, hence, less likely to relapse. In addition, tar minimizes the possible side effects from topical steroids.
  • In patients with significant hyperkeratosis, topical lactic acid 5-12% or urea 10-40% preparations may be added to the above treatment. These will reduce the scale and enhance the penetration of the active agents.

Subsequent steps

  • Patients with severe recalcitrant hand dermatitis may be treated with soak or oral PUVA, UVB, or UVA-1 phototherapy. PUVA may be most effective.
  • In severe refractory cases, cyclosporine A, mycophenolate mofetil, or alitretinoin may be necessary.
  • Patch testing is much less likely to be positive in patients with hyperkeratotic than vesiculobullous hand dermatitis; however, it should be considered when the clinical pattern or occupational history is strongly suggestive for a contactant.

Pitfalls

  • Check patients with acute dyshidrotic dermatitis for inflammatory tinea pedis or active stasis dermatitis (SD). ID reactions (auto sensitization) from these two conditions can mimic dyshidrotic dermatitis. Occasionally, an allergic contact dermatitis, restricted to the palms, will mimic chronic hand dermatitis. In suspected allergic contact dermatitis, patch testing may be required to detect the responsible allergen.
  • Though potent topical corticosteroids are first-line therapy, these may cause skin atrophy with prolonged use. Daily use of corticosteroids for up to a month should be tapered down to use two or three times a week for maintenance therapy.
  • Both acute and chronic hand dermatitis can become secondarily infected, usually with S. aureus. The presence of honey-colored crusts should alert one to this complication, which can exacerbate the pruritus. In these patients, a bacterial culture should be acquired, and cephalexin or dicloxacillin 250-500 mg 4 times daily for 7-10 days is almost always curative.
  • Both acute and chronic hand dermatitis tend to relapse and/or persist for years. A preventive program, consisting of antihistamines, protective gloves, cool water washing, mild soaps, and frequent application of emollients is necessary for long-term control.
  • Patients taking sedating antihistamines should be warned about operating motor vehicles or other tasks requiring fine motor skills.
  • Neither UVB phototherapy nor PUVA is curative for hand dermatitis. Long-term skin care therapy is required to maintain remissions.
  • Smoking reduces the efficacy of phototherapy in the treatment of hand dermatitis.

When to refer to a dermatologist

  • When the diagnosis of hand dermatitis is not clear, or when an underlying cause is suspected.
  • For treatment-refractory hand dermatitis, including those requiring phototherapy or systemic immunosuppression.
  • For patch testing as a part of the diagnostic evaluation of hand dermatitis.

Clinical Case

Case 1

  • 44-year-old healthy male
  • No significant past medical history
  • Review of systems is noncontributory
  • Job history notable for work at a printing press
  • No hobbies with chemical exposures
  • Presents for management of 18 months history of a hyperkeratotic eruption on bilateral palms; the feet are not affected
  • Currently using topical triamcinolone 0.1% ointment daily and emollient lotion with partial benefit

Initial evaluation

  • Healthy appearing male
  • Bilateral hands with hyperkeratotic erythematous plaques with fissures present at the fingertips
  • Diagnosis: hand dermatitis
  • Recommend patch testing
  • Soaks in tap water for 10 minutes twice daily followed by application of clobetasol 0.05% ointment
  • Gentle skin care recommended: use of gentle hand soaps, frequent use of lipid-rich emollients, avoidance of wet work (such as dishwashing and other housework) without gloves
  • Follow-up in 2 weeks

Two-week follow-up evaluation

  • Partial improvement
  • Patch testing (including for chemicals involved in printing process) does not reveal any clear triggers
  • Recommend ongoing twice daily soaks and clobetasol ointment
  • Follow-up in 2 weeks

Follow-up evaluation

  • Minimal interval improvement
  • Recommend limited use of clobetasol ointment (use three days a week) alternating with 20% LCD tar in petrolatum
  • Follow-up in 6 weeks (still not resolved -> soak PUVA is initiated)

References

Coenraads PJ (2012) Hand eczema, NEJM, 367: 1829-1837.

Bissonnette R et al (2010) Redefining treatment options for chronic hand eczema, JEADV, 24 (Suppl.3): 1-20.

Dirschka T et al (2008) An open-label study assessing the safety and efficacy of alitretinoin in patients with severe chronic hand eczema unresponsive to topical corticosteroids, Clin Exp Derm, 36: 149-154.

English J et al (2009) Consensus statement on the management of chronic hand eczema, Clin Exp Derm, 34: 761-769.

English JSC, Wootton CI (2012) Recent advances in the management of hand dermatitis: Does alitretinoin work?, Clinics in Derm, 29: 273-277.

Ruzicka T et al (2008) Efficacy and safety of oral alitretinoin in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicenter trial, BJD, 138: 808-817.