Hand dermatitis (overview) L30.91

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Acute eczema of the hands; Acute hand eczema; Chronic dermatitis of the hands; Chronic eczema of the hands; Chronic hand eczema; Hand dermatitis; Hand eczema; Palma eczema; palmar eczema; Subacute hand eczema

Definition
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Frequent, etiopathogenetically heterogeneous, itchy and painful dermatitis of the hands with acute, sub-acute or (frequently) chronic (see below hand dermatitis, chronic) course and varying severity. Hand eczema has a high health economic and socio-medical significance (frequent and possibly long-term incapacity to work).

A special feature of chronic hand eczema is its occupational dermatological relevance (about 52% of hand eczema is classified as occupational; see below occupational skin disease).

Classification
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Hand eczema (eczema of the feet) can be classified according to temporal, etiopathogenic (atopic, contact allergic, irritant) or purely clinical aspects (hyperkeratotic, hyperkeratotic-rhagadiform, dyshidrotic).

According to aspects of the acuteity of the "eczema reaction" can be distinguished:

Taking into account the aetiology (allergic, irritant) the following classification can be made:

Taking into account the clinical morphology can be divided as follows:

Classification according to localization (not usual):

Occurrence/Epidemiology
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Estimates for the 1-year prevalence of hand eczema at occupational exposure in the population vary between 6.7% and 10.6% (see below eczema, contact dermatitis, allergic). A high incidence rate is associated with female sex, contact allergies, atopic eczema and working in humid environments.

Hand eczema ranks second among occupational skin diseases in the food industry.

Evidence of a significant increase in the prevalence of hand eczema among young people/adults at risk of occupational diseases (especially hairdressers, bakers, florists, tilers, electroplating workers, dental technicians, machinists, workers in the metal industry, workers in health professions, etc.) during their training periods.

In the hairdressing trade, the prevalence (depending on the study) is between 2.0% and 8.5% in the 1st year of training; at the end of the training between 9.8-23.5%. In the metal-working industry there was a cumulative incidence over a period of 2.5 years of about 23%. For cleaning staff, 1-year prevalence was about 46%.

Etiopathogenesis
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The (chronic, non-specific) hand dermatitis is an exclusion diagnosis, in which other dominant causes are clinically-allergologically excluded. Smokers are significantly more frequently affected than non-smokers.

Localization
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The back of the hand, palms, side edges of the fingers, fingertips, webbed skin and wrists are particularly affected.

Clinical features
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Clinical signs and symptoms of chronic hand eczema include erythema, edema, vesicle formation, hyperkeratosis, fissures, rhagades, itching and pain.

Acute hand eczema is characterised by acute redness, itching, blistering and blistering, depending on the cause and the triggering agent.

Histology
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S.u. Eczema.

Diagnosis
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The medical history of patients with hand eczema should include specific exposures (including leisure time, domestic and occupational stress, medication, nicotine and other noxious agents), the course of time and the patient's own allergological history, taking into account the Erlangen atopy score.

Both domestic and occupational exposures must be considered. This also includes information on the course of hand eczema during holidays, weekends and periods of incapacity to work.

During the clinical examination, an inspection of the feet as well as the entire integument is necessary in addition to the findings in the hand area.

The standard diagnostics for determining the atopic status should include an orienting prick test with the most frequent inhalation allergens.

Epicutaneous testing is the standard procedure to identify type IV sensitization as a trigger for allergic contact dermatitis. Allergen selection should follow the relevant recommendations and include the selection of exposure-specific allergens.

Mycological exclusion diagnostics are recommended for the initial diagnosis.

If the clinical picture indicates the presence of psoriasis, histological confirmation of the diagnosis should be sought, as this is essential for long-term therapy planning.

Differential diagnosis
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Psoriasis palmaris: (sharply defined (!), red or white-grey, scaly, sometimes wart-like plaques on the palms of the hands. Typically no spreading to the flexed forearms, no scattering phenomena). Often also infestation of other predilection sites!

Tinea manuum: (usually finely lamellar scaly, itchy plaques, also dyshidrotic blisters or extensive hyperkeratosis; positive mycological evidence is often possible with appropriate efforts).

Lichen planus palmaris: (usually occurring in the context of an exanthematic lichen planus. A flat hyperkeratotic pattern, atypical for the lichen planus, may occur on the palms of the hands; diagnosis extrapalmar).

Hereditary or symptomatic cornification disorder of the palms and soles of the feet ( keratosis palmoplantaris).

Pityriasis rubra pilaris: (always infestation of other skin areas).

Palmo-plantar syphilide (see below Syphilis acquisita): occurring in the context of an exanthematic syphilide; always HV also on other skin areas).

Complication(s)
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Chronic dermatitis of the hands is often accompanied by nail changes. According to H. Hamm et al:

irregular deformations of the nail plate with dimples, dents, grooves, transverse furrows, roughening of the nail plate, thickening, onycholysis, dyschromas, paronychines (especially in atopic dermatitis of the hands)

General therapy
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The relevance assessment of identified Type IV allergens is very important and if occupational triggers are identified, a workplace review and the possibility of substance substitution should be considered. Since allergic contact eczema can only be healed by consistently avoiding the triggering substances, patients must be fully informed about the type of contact allergens and their occurrence. If ingredients of external agents have been identified as contact allergens, allergen-oriented advice on skin protection and skin care measures is indispensable.

External therapy
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  • The therapy is based on the systematics, clinic and severity of the hand eczema. Mild hand eczema should be treated quickly, effectively and consistently in order to counteract chronification. Chronic hand eczema is difficult to treat and requires complex management.
  • When treating hand eczema, the general therapeutic principles of stage-appropriate eczema therapy must be observed, as well as the aetiology (atopic, allergic, irritant), the acute (acute vs. chronic eczema), the morph (redness, scaling, lichenification, blisters, hyperkeratosis, rhagades, etc.) and the localisation (back of the hand, interdigital spaces, palms) of the skin symptoms. A prerequisite for successful therapy is the recognition and avoidance of causative exogenous factors (e.g. allergens, irritants).
  • The therapy of hand eczema follows a step-by-step concept:
    • Basic therapy: Consistent re-fattening of the skin with preparations that are as free of preservatives and fragrances as possible, treatment with compresses, lotions or creams in the acute stage, with ointments in the subacute stage and with fatty ointments in the chronic stage. Nourishing moisturizing topicals in a compatible basis (e.g. Linola Fett N, Asche Base Ointment, Excipial Almond Oil Ointment) or the application of a greasing, blanching hand cream.
    • Keratolytics: salicylic acid (up to 20%) and urea (5-10%), especially in chronic, especially hyperkeratotic-rhagadiform hand eczema. Caution! Excessive or incorrect dosage, occlusion or simultaneous irritant exposures may cause skin irritation, redness and burning. If necessary, use a well tolerated base with an addition of 2-10% urea (e.g. Basodexan ointment/fat cream, Excipial U Lipolotio, Linola Urea cream, Nubral cream).
    • Glucocorticosteroids: The potency of the corticosteroid used and the duration of therapy depend on the severity of the hand eczema and its localisation. Always in combination with moisturising steroid-free local therapy. Systemic corticosteroids only in special cases. Do not use topical corticosteroids for a long period of time. It is better to use sufficiently strong corticosteroids for a short period of time in acute attacks and then to eliminate them as quickly as possible.
    • Acute vesicular to bullous stage (weeping): Short-term glucocorticoids of medium to strong potency in low-fat bases, hydrophilic creams or solutions such as 0.1% triamcinolone cream R259, 0.25% prednicarbate (e.g. Dermatop cream), 0.1% mometasone (e.g. Ecural fat cream/solution) or 0.05% clobetasol (e.g. Dermoxin cream). If necessary, moist compresses (NaCl) several times a day, in case of superinfection with antiseptic additives such as quinolinol (e.g. Chinosol 1:1000), R042 or potassium permanganate (light pink); Cave! possible sensitization against disinfectants! In the vesicular stage also moist with glucocorticoid such as 1% hydrocortisone in lipophilic base R120, a dressing moistened on top or a cotton glove. If resistant to therapy, topical glucocorticoids with short-term occlusion.
    • In the vesicular stage also fat-damp with glucocorticoidxterna such as 1% hydrocortisone in lipophilic basis, bandage moistened over it or possibly cotton glove. If resistant to therapy, topical glucocorticoids with intermittent occlusion (use 2 times/day for 2 hours).
    • Late crusty or squamous stage: Hydrophilic creams for skin regeneration (e.g. DAC base cream, Amciderm base cream, Ash base cream, Dermatop base cream). If necessary also with "wound healing additives" like dexpanthenol (e.g. R064, Bepanthen Lotio). Local PUVA therapy can be helpful, initially 4 times/week, maintenance therapy 2 times/week.
    • Topical calcineurin inhibitors: Can be used to treat atopic hand eczema.
    • Other local therapy: In superinfected eczema, e.g. clioquinol (vioform), chlorhexidine, etc.), antiseptic additives such as quinolinol (e.g. quinosol 1:1000) or potassium permanganate (light pink). Cave! Possible sensitization against disinfectants!
    • In case of subacute to chronic eczema tar-containing preparations (e.g. Liquor carbonis detergens 5-10%), ichthyol or tumenol 5-10%, in case of hyperkeratotic-rhagadiform hand eczema cignolin (dithranol).
    • Tap water iontophoresis: Tap water iontophoresis is the treatment of choice for existing hyperhidrosis and dyshidrotic hand eczema.

Radiation therapy
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Cream or bath PUVA therapy: Especially effective for chronic hand eczema. Initial 4 times/week, maintenance therapy 2 times/week.

Remember! A combination of topical calcineurin inhibitors with UV therapy is not recommended.

Internal therapy
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In severe chronic hand eczema, the use of alitretinoin (Toctino) at a dosage of 10-30 mg/day p.o. is justified.

Prophylaxis
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Rules of conduct for hand eczema:
  • Avoid the use of harsh cleaning agents for hands (e.g. hand washing pastes) at work, in baby care or in the household.
  • Avoid or wear protective gloves when handling water (e.g. when rinsing) or for contact with pungent substances (e.g. fruit, lemons, uncooked potatoes, tomatoes, strong cleaning agents, organic solvents, polishes, stain removers).
  • For longer damp work with sweat formation in the protective gloves, change the gloves several times with a short work break to dry them off and put cotton gloves under.
  • Do not wear rings when doing housework.
  • Protect hands from the cold in winter and apply special moisturising cream.

Note(s)
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The term "hand eczema" is first of all only topographically significant. It is justified, like other topographically defined eczema forms (e.g. eyelid eczema, anal eczema, labial eczema), by the clinical features and the high socio-economic importance of these eczema forms. The annual costs for chronic, occupational hand eczema are estimated at about 9,000 Euro / year (about the costs for moderately severe psoriasis vulgaris).

In principle, all statements made for hand eczema also apply to "foot eczema", which is not explicitly listed here.

Therapy costs: In a larger study of chronic hand eczema, the average direct annual therapy costs per patient amounted to 1,742 Euros, the indirect (economic) costs to 386 Euros,

The annual costs for chronic occupational hand eczema are estimated at about 9,000 Euro/year (about the costs for moderately severe psoriasis vulgaris).

Literature
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  1. Augustin M et al (2011) Healthcare costs in patients with chronic hand eczema in Germany. Abstract CD 46th DDG-Conference, FV11/04
  2. Bryld LE et al (2003) Risk factors influencing the development of hand eczema in a population-based twin sample. Br J Dermatol 149: 1214-1220
  3. DiepgenTL (2008) Chronic hand eczema. dermatologist 59: 683-689
  4. Diepgen T et al (1999) The epidemiology of occupational contact dermatitis. Int Arch Occup Environ Health 72: 496-506
  5. Grattan CE et al (1991) Comparison of topical PUVA with UV-A for chronic vesicular hand eczema. Acta Derm Venereol 71: 118-122
  6. Hamm H et al (2018) Diseases of the nails. In: Braun-Falco`s Dermatology, Venerology Allergology G. Plewig et al. (Hrsg) Springer Verlag S 1400
  7. Heydorn S et al (2003) Fragrance allergy in patients with hand eczema - a clinical study. Contact dermatitis 48: 317-323
  8. Lehucher-Michel MP et al (2000) Dyshidrotic eczema and occupation: a descriptive study. Contact Dermatitis 43: 200-205
  9. Molin S, Ruzicka T (2008) Alitretinoin. dermatologist 59: 703-709
  10. Schäfer T (2003) Epidemiology of occupational hand eczema Allergology 26: 369-376
  11. Schnopp C (2002) Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: a randomized, observer-blinded trial. J Am Acad Dermatol 46: 73-77
  12. Skoet R et al (2003) Contact dermatitis and quality of life: a structured review of the literature. Br J Dermatol 149: 452-456
  13. Stambaugh MD et al (2000) Complete remission of refractory dyshidrotic eczema with the use of radiation therapy. Cutis 65: 211-214
  14. Uter W (1998) Prevalence and incidence of hand dermatitis in hairdressings apprentices: results of the POSH-study. Int Arch Occup Environment Health 71: 487-492
  15. Veien NK, Menne T (2003) Treatment of hand eczema. Skin Therapy Lett 8: 4-7

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Last updated on: 29.10.2020