Hand eczema

Dermatitis of the hands, dermatitis of the feet, palmoplantar dermatitis, palmar dermatitis, plantar dermatitis, hand eczema, foot eczema, eczema of the hands, eczema of the feet, chronic hand dermatitis, chronic foot dermatitis, chronic hand eczema, palmoplantar eczema, tylotic eczema, hyperkeratotic eczema, rhagadiform eczema, irritative-toxic eczema, cumulative-irritative eczema, cumulative-toxic eczema, palmar eczema, plantar eczema.

Inflammation of the acral skin, which can occur acutely (called dermatitis) or chronically (then called eczema). Very frequent clinical picture. Multiple aetiologies, further stratified in the various classifications.

• Incidence: 5/1000/year
• 1-year prevalence: approx. 10% of the population
• 1-10% of the working population suffers from severe hand eczema

Division according to severity

• Mild hand eczema: Heals quickly
• Moderate: persists for weeks despite therapy
• Severe hand eczema: Extensive permanent or recurrent skin changes of significant disease value

Classification according to duration

• Acute: < 3 months
• Chronic recurrent:
  • ≥ 3 months despite therapy and prevention or
  • 2 recurrences within 12 months

Division according to aetiology

• Subtoxic-irritant hand eczema
• Allergic hand eczema
• Atopic hand eczema

Division according to morph

• Hyperkeratotic-rhagadiform hand eczema
• Hyperkeratotic hand eczema
• Dyshidrotic hand eczema

Special form: fingertip eczema

• Depending on subtype

• Cumulative toxic(-irritative) hand eczema:
  • ↑ Exposure to moisture, working with toxic and sub-toxic substances (this includes water)

• Contact allergic hand eczema:
  • Contact with type IV allergens that trigger contact allergy in the person. Mostly occupational context

• Atopic hand eczema:
  • Atopia in self or family history

Depending on the subtype.

• Anamnesis with regard to aetiologically significant factors (atopy, contact allergies, hyperhidrosis, psychological stressors, psoriasis, aggravating factors, hobbies, domestic stress, as well as previous therapy and prevention)
• Mycology (according to guidelines, tinea manuum should be ruled out in all hand eczema)
• Atopia screening
  • History
  • Family history
  • Clinical signs of atopy (Diepgen's atopy score can help if unclear)
  • Laboratory: total IgE, sx-1, fx-5, phadiatop
  • If necessary, prick test
• Epicutaneous testing, do not forget photopatch if useful
• Biopsy (performed far too little, but it is very useful diagnostically and can also exclude palmoplantar psoriasis molecularly)

Contact allergic genesis: Not infrequently manifested first on the backs of the hands or feet, since the skin is thinner here.

• Superinfection, impetiginisation
• Gram-negative forefoot infection
• Poor entry (rhagades) for erysipelas

• Wear gloves when cleaning (especially with harsh cleaning products) and when in contact with water
• Change gloves several times if necessary
• Otherwise, avoid wearing gloves (exposure to moisture)
• Remoisturise several times a day
• Avoid all type I & IV allergens!

Basic therapy (therapy level 1)

• Therapy of the underlying disease
• For contact allergic aetiology
• Nicotine abstinence
• Elevation of the affected extremities
• Psychiatric consultation may be discussed if psychogenic triggers are suspected. We advise against the use of psychotropic drugs (e.g.: opipramol or sedatives) without consulting a psychologist or psychiatrist
• It is uncertain whether a nickel- or chromium-free diet (in case of contact sensitisation to it) is effective

Skin care

• Remoisturising hand cream, ideally with urea (5%) or other water-retaining substances (lactate) as well as glycerine
• For dyshidrosis, hand care products with aluminium to suppress moisture make sense
• Synthetic detergents with a refatting function
• Adstringentia/Antiphlogistika-Lsg. (for hand baths)
• Black tea hand baths

Rhagades

• 2-Octylcyanoacrylate adhesives result in immediate pain relief. 2 people to glue, disinfect with aqueous solution before gluing. Water activates the adhesive, i.e. the adhesive then holds even better
• Good adhesive fabric tapes are suitable for stabilising weak points for up to weeks

Topical therapy (therapy level 2)

• Mometasone fuorate or clobetasol propionate cream / ointment
• Topical calcineurin inhibitors (tacrolimus / pimecrolimus)
• Polyvidone iodine- wound ointment / solution / ointment gauze
• Triclosan skin wash lotion
• Acute, weeping stage: rather moist topicals, greasy ones do not adhere
• Chronic stage: fatty topicals as these are occlusive and retain moisture in the skin
• Moist dressings with NaCl 0.9% solution for ↑ eruption pressure
• In hyperhidrosis, tap water iontophoresis
• In case of impetiginisation: fucidic acid

UV therapy (therapy level 3)

• UVBnb or cream PUVA therapy

Systemic therapy (therapy level 4)

• Prednisone p.o. 40-60 mg 1x tgl. for a few days
• Alitretinoin 30mg t.gl.
• In case of impetiginisation: Cefuroxime p.o. 500 mg 2x tgl. for a few days

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2. Grattan CEH, Carmichael AJ, Foulds IS. Comparison of topical PUVA with UVA for chronic vesicular hand eczema. Br J Dermatol 1989;121:28-9.
3. Meding B, Swanbeck G. Occupational hand eczema in an industrial city. Contact Dermatitis 1990;22:13-23.
4. Nakagawa T, Nakashima K, Takaiwa T, Negayama K. Trichosporon cutaneum (Trichosporon asahii ) infection mimicking hand eczema in a patient with leukemia. Journal of the American Academy of Dermatology 2000;42:929-31.
5. Wollina U, Karamfilov T. Adjuvant botulinum toxin A in dyshidrotic hand eczema: a controlled prospective pilot study with left-right comparison. Journal of the European Academy of Dermatology and Venereology 2002;16:40-2.
6. Ruzicka T, Lynde CW, Jemec GBE, et al. Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicentre trial. Br J Dermatol 2008;158:808-17.
7. Molin S, Vollmer S, Weiss EH, Ruzicka T, Prinz JC. Filaggrin mutations may confer susceptibility to chronic hand eczema characterized by combined allergic and irritant contact dermatitis. British Journal of Dermatology 2009;161:801-7.