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Hand dermatitis affects a significant portion of the population and can be caused by a
variety of endogenous factors (ie, atopy) as well as occupational and environmental
exposures. It is often a chronic problem with high costs to individuals, employers, and
society. This review discusses subtypes of hand dermatitis based on their clinical features
and pathogenesis. It also offers an approach to treatment.
Semin Cutan Med Surg 32:147-157 2013 Frontline Medical Communications
KEYWORDS hand dermatitis, chronic hand dermatitis, irritant contact dermatitis, allergic
contact dermatitis, frictional hand dermatitis, hyperkeratotic dermatitis, psoriasiform hand
dermatitis, nummular dermatitis, atopic dermatitis, vesicular dermatitis, dyshidrotic dermatitis, pompholyx
Nana
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Table 1 Clinical Variants of Hand Dermatitis
Type
Atopic Dermatitis
Allergic Contact Dermatitis
Irritant Contact Dermatitis
Hyperkeratotic/Psoriasiform/
Frictional Dermatitis
Nummular Dermatitis
Pompholyx/Dyshidrotic Eczema
Fiqih
Clinical Presentation
Comments
Fiqih
Fiqih
reaction is possible if the patient has tinea pedis, but a negaconsidered in the differential diagnosis. As with many dermatologic conditions, the patients history gives important
tive KOH scraping from the hand plaques. At that point,
clues (Table 2), which can include a history of atopic dermatreatment of coexisting tinea pedis becomes important in the
titis, asthma, rhinitis, psoriasis, prior patch-testing results,
management of hand dermatophytid.
occupation, hobbies, hand-washing routine, skin care prod- dewi A skin biopsy is done when diagnosis is unclear and other
ucts, other contactants, symptoms, and chronicity of the disdermatologic conditions are considered (Table 3). Histologease.
ically, all subtypes of hand dermatitis will show spongiosis
Taking a bacterial swab culture can help rule out a bactewith mixed inflammatory infiltrate. Vesicular types are more
rial skin infection. Disrupted skin barrier seen in all subtypes
likely to show bigger spongiotic vesicles within epidermis.
of hand dermatitis predisposes to staphylococcal and strepHyperkeratotic/frictional types of hand dermatitis will show
tococcal skin infections. Staphylococcus aureus is the most
psoriasiform epidermal hyperplasia. Periodic acid-Schiff
common culprit; however, cases of methicillin-resistant
(PAS) staining can identify dermatophyte infection if biopsy
Staphylococcus aureus (MRSA) have been seen as well. Pashows psoriasiform spongiotic dermatitis with subcorneal
tients with a history of atopic dermatitis are at highest risk.
neutrophils.
Rarely, the herpes simplex virus can infect eczematous skin
Patch testing is done when allergic contact dermatitis is
of the hands and cause eczema herpeticum. Getting a Tzank
suspected.
smear or a viral swab for a viral culture or polymerase chain
reaction (PCR) is helpful if clinically one sees the scatter of
sharply demarcated small crusty erosions or vesicles.
Atopic Hand Dermatitis
Skin scrapings for a potassium hydroxide (KOH) prepara- dewi
Atopic dermatitis is one of the most common chronic inflamtion or a fungal culture is recommended when feet lesions are
matory skin conditions affecting 8% to 11 % of the United
present. Tinea manus can mimic chronic hand dermatitis. Id
States population.9-11 The pathophysiology of atopic dermatitis is characterized by mutations in the filaggrin gene and a
loss of epidermal barrier function resulting in dry, scaly, inTable 2 Important Aspects of the Patients History When Investigating Hand Dermatitis
flamed, and pruritic skin. It is well known that children with
a history of atopic dermatitis are more likely to develop hand
Patient History
dermatitis as adults.12 The prevalence of hand dermatitis in
Date of onset and progression
atopics is estimated to be around 60% for all ages.13
Associated symptoms such as burning, itching, or pain
Dewi Although there are many clinical presentations of atopic
Occupation and relationship to work (do symptoms
hand dermatitis, the most common distribution is over dorsal
improve on vacation)
hands and dorsal fingers (Figure 1). In a study by Simpson et
Hobbies
al, dorsal hand and volar wrist involvement was seen in most
Skin care products
cases of atopic hand dermatitis (Figure 2). The plaques are
Chemicals, glues, paints, or other materials touching hands
usually scaly, ill-defined, pink, thin, or lichenified (Figure 3).
Hand washing regimen
Previous therapies
Papules or vesicles can be present as well. Chronic volar wrist
History of atopic diathesis (childhood or adulthood
involvement can result in permanent hypopigmentation or
eczema, hay fever, asthma)
depigmentation of the area. Nail changes such as loss of the
History of other skin diseases (ie, psoriasis)
cuticle, thickening/inflammation of the nail folds, or irregular
Family history of skin diseases and atopy
ridging can occur. In addition to pruritus, painful fissures
Hand dermatitis
149
Dewi
Condition
Psoriasis
Dermatophyte infections
Scabies
Lichen planus
Dermatomyositis
Pitaryasis rubra pilaris
Mycosis Fungoides
Differentiating Factors
Well demarcated, erythematous, scaly plaques in characteristic for psoriasis distribution
(scalp, concha, extensor surfaces, gluteal cleft, umbilicus).
Nails with pitting, oil spots, distal onycholysis.
Palmoplantar pustulosis.
One hand, two feet involvement.
Burrows and erythematous papules in web spaces and volar wrists, lateral fingers.
Sharply demarcated, violaceous, flat topped scaly, polygonal papules and plaques.
Other typical for lichen planus locations, such as oral mucosa, wrists, ankles, nails.
Erythematous to violaceous plaques over DIP, PIP, MCP joints. May have dilated
capillaries in nail folds and ragged cuticles.
Hyperkeratotic yellow diffuse keratoderma/plaques. Confluent erythematous scaly
plaques with follicular accentuation over the body. Islands of spared normal skin.
Confluent erythematous hyperkeratotic plaques over the palms and soles.
Abbreviations: DIP, distal interphalangeal joint; MCP, metacarpal phalanges joint; PIP, proximal interphalangeal joint.
within hyperkeratotic lichenified plaques cause a lot of distress in those patients. Water exposure was the most frequently cited exacerbating factor for flares of atopic hand
dermatitis.9
Dewi Individuals with atopic dermatitis are more likely to develop both allergic and irritant contact dermatitis given their
innate impaired barrier function. Therefore, it is important to
consider all 3 of these causes of hand eczema in a patient with
a history of atopy.
Allergic contact dermatitis is a Type IV delayed hypersensitivity response that is elicited when an allergen comes into
direct contact with the skin. Development of dermatitis is
usually delayed by a few days from the time of allergen exposure. This is in contrast to a Type I immediate hypersensitivity reaction, which is seen in urticaria where contact with
an allergen results in hives within minutes to hours of exposure.
Figure 2 Atopic hand dermatitis with volar wrist involvement. Courtesy of Eric Simpson, MD.
Airin
airin
Foto
dicopas
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Figure 3 Atopic hand dermatitis in an infant with dorsal hand involvement and nummular plaques on the ankles. Courtesy of Eric
Simpson, MD.
Preservatives
Methylchloroisothiazolinone
Methylisothiazolinone
Quaternium-15
Formaldehyde and releasers
Antibiotics
Neomycin sulfate
Bacitracin
Metal
Nickel
Potassium dichromate
Source
Gloves
Occupation: healthcare,
hairdressers
Skin care products,
cosmetics, hair
products
Skin care products,
cosmetics, lubricants,
household products
Topical antibiotics
Hand dermatitis
151
152
Vesicular Hand
Dermatitis and Dyshidrotic nisa
Hand Dermatitis/Pompholyx
Pompholyx (acute dyshidrotic hand dermatitis) has intermittent and episodic recurrences of vesicles and bullae that typically last 2 to 3 weeks before resolving (Figure 11). Between
episodes, patients have normal appearing skin. Sometimes
pompholyx presents with large tender bulla without surrounding erythema on the palms. More frequently, collections of very itchy small papulovesicles on the sides of the
fingers are seen (Figure 12). Secondary bacterial infections
can occur. Dermatophyte infection and an id reaction to a
dermatophyte elsewhere on the skin can present similarly.
Therefore, it is important to check the patients feet and do
potassium chloride scrapings to rule out a fungal infection.
Some studies have suggested that a nickel allergy may be
associated with pompholyx. In these studies, patients who
were allergic to nickel ingested nickel orally and had reacti-
Hand dermatitis
nisa
nisa
Treatment
nisa Basic Principles: Good Hand Care
The treatment of all subtypes of hand dermatitis is similar. All
treatment starts with attempts to restore skin barrier function
and avoidance of exacerbating factors. A recent trial of hospital workers with hand eczema showed improvement in the
patients dermatitis when education and counseling about
proper skin care was provided.25 Skin care products in the
form of thick creams, ointments, or petrolatum products are
important in helping to restore the skins protective barrier.26
Frequent reapplication, especially after hand washing, is key.
Avoidance of common irritants and skin care products with
an alcohol or water base helps to avoid further water evaporation and drying of the hands. Creams should also be fragrance-free and contain as few preservatives as possible to
avoid allergens that may result in an allergic contact dermatitis. It is also very important to cut down on wet work,
especially in occupations involving repetitive wet-to-dry cycles. Some of the hand sanitizers on the market are less irritating than the typical hand washing routine. Protective
clothing and changing work flow/environment can help to
avoid contact with allergens and irritants. Thin cotton gloves
under occlusive gloves are recommended. However, some
allergens can pass through the gloves. For instance, acrylate
monomers, which are used in dentistry, penetrate rubber
(latex and neoprene) and vinyl gloves.
153
studies are lacking, open-label studies have shown a benefit
with topical steroids. In an open-label study done by Veien et
al, mometasone fumarate was used freely by participants for
up to 9 weeks and 75% of the patients were found to be clear
by 6 weeks. In a follow-up study, individuals were randomized to use either mometasone 2 days per week, 3 days per
week, or use emollients alone freely. Individuals in both steroid treatment arms showed a longer recurrence-free rate,
83% in the 3 times per week group, and 67% in the twice
weekly group using steroids. Only 26% of the individuals
using only an emollient benefited.27 The American Academy
of Dermatology recommends that potent topical steroids be
used on the hands twice daily for up to a month and then
tapered down to 2 to 3 times per week for maintenance.28
Occlusion of the topical steroid with cotton gloves aides in
intensifying the therapeutic effect. Ointment vehicles of topical therapy are preferred over cream-based formulations as
they contain less water and preservatives.
If long-term topical treatment is needed, then calcineurin
inhibitors such as tacrolimus or pimecrolimus can be used
daily for maintenance therapy. Unlike topical steroids, these
therapies do not cause skin atrophy or telangietasias. Pimecrolimus was studied in 2 large randomized controlled clinical trials and found to be more efficacious in treating hand
dermatitis when used twice daily with overnight occlusion
compared to using just a vehicle cream alone.29 Similarly,
smaller studies have shown twice daily application of tacrolimus to be more beneficial than vehicle cream alone in both
clinical improvement and patient subjective views of improvement.30,31
154
Hand dermatitis
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155
Dosing
Lab Monitoring
None
None
Cyclosporine
3 mg/kg/day
Mycophenolate mofetil
Methotrexate
Azathioprine
Topical calcineurin
inhibitors
PUVA or narrow band
UVB
Grenz ray
Oral prednisone
None
Side Effects
Atrophy,
telangiectasias,
acne/rosacea, striae
Skin malignancies,
lymphoma
Skin malignancies,
headaches, nausea
None
Skin malignancies
Cataracts, glaucoma,
hyperglycemia,
osteoporosis, and
suppression of the
hypothalamicpituitary-adrenal
access
Xerosis, increase in
lipid levels,
hepatotoxicity, and
teratogenicity
Hyperlipidemia,
hypertension,
hepatotoxicity,
nephrotoxicity,
hyperkalemia,
hyperuricemia,
hypomagnesemia
GI symptoms,
opportunistic
infections, bone
marrow suppression
Hepatotoxicity, bone
marrow suppression,
pulmonary fibrosis/
pneumonitis,
carcinogenesis, oral
ulcers, GI upset
GI upset, bone marrow
suppression,
hepatotoxicity,
increased risk of
infections,
carcinogenicity
*Mycophenolate mofetil prescription now requires registration with the Mycophenolate REMS. Physicians are required to educate patients
about the teratogenicity of the medication. Reproductive age females must have a pregnancy test before initiating the drug, 8-10 days after the
initial pregnancy test and monthly while on the drug. Patients must also use contraception while taking mycophenolate and for 6 weeks after
discontinuation of the drug. All pregnancies during treatment must be reported to the Mycophenolate Pregnancy Registry.
Abbreviations: CBC, complete blood count; CMP, comprehensive metabolic panel; GI, gastrointestinal; K, potassium; LFT, liver function tests;
Mg, magnesium; PPD, purified protein derivative tuberculin test; PUVA, psoralen ultraviolet A; UVB, ultraviolet B.
156
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therefore needed to assess whether treatment with antitumor necrosis factor- medications would be helpful.
Finally, patients with hand dermatitis should also be assessed for bacterial infections and, if present, should be
treated with either systemic or topical antibiotics.
Treatment options, dosing, monitoring and side effects are
listed in Table 5.47
Conclusion
jiwo
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