Peter Saitta, DO
Associate Clinical Professor
2
The Classification and Treatment of Hand
Eczema
3Objectives
Period prevalence
Risk factors
Classification systems
Differential diagnosis
First-line therapy options
4Period Prevalence
Prevalence
Number of new cases per time period
Period prevalence
Number of patients with outbreaks during a time
period
Varies 2-10%1-3
5Hand Eczema Risks
STUDY NO AD / NO
IRRITANT WATER
EXPOSURE
AD / NO
IRRITANT WATER
EXPOSURE
AD / IRRITANT
WATER
EXPOSURE
Meding et al. 1990 5-9% 14-23% 34-48%
Nilsson et al. 1986 16% 38% 62-72%
Rystedt et al. 1985 5% 37-50% 60-81%
6
Hand Eczema Risks: Atopic Dermatitis
Atopic dermatitis
Lammintausta et al. 1991
Coenraads et al. 1998
Meding et al. 2000
Meding et al. 2004
Toledo et al. 2008
7
Hand Eczema Risks: Allergic Rhinitis
and Asthma
Allergic rhinitis/asthma increases
risk of hand eczema
But not more than atopic dermatitis4
8
Hand Eczema Risks: Female Gender
Female gender increased risk Coenraads et al. 1983
Kavli et al. 1984
Lantinga et al. 1984
Bryld et al. 2000
Yngveson et al. 2000
Meding et al. 2001
Mortz et al. 2001
Dickel et al. 2002
9
Why Female Gender ?
Meding et al.5
Wet work in 19-29 year-olds
37.5% of women occupationally exposed
18.2% of men
Learbek et al.6
Private exposures
10
Hand Eczema Risks: Occupation
STUDY TYPE OF
STUDY
STUDY
POPULATION
INCIDENCE
(PER 100)
Lantinga et al.
1984
Retrospective General
Population
7.9
Uter et al. 1994 Prospective Hairdressers 152
Smit et al. 1994 Prospective Hairdressers
Nurses
328
145
Brisman et al.
1998
Retrospective Bakers M: 16.7 F:34.4
Uter et al. 1998 Prospective Office workers 41
Funke et al. 2001 Prospective Industrial Factory
Workers
47
11
Hand Eczema Risks: Smoking
Support Risk
Edman et al.
Montnemery et al.
Linneberg et al.
Negative Risk
Lerbeack et al.
Berndt et al.
12Poor Prognosis
ACD7
Delay onset of effective treatment8
Atopic Dermatitis9
Greater area of involved skin10
> 1 year of duration8
13Classification System
Etiology
Morphology
No clear link between morphology and
etiology11
Question the need of morphological
classification system
14
Classification System: Etiology
Irritant contact dermatitis
Allergic contact dermatitis
Atopic dermatitis
80%
Idiopathic
20%
15
Classification System: Etiology
Irritant Contact Dermatitis11
Most common
Wet work
Water
Mechanic / Machinery oils
Detergents
Tight-fitting gloves
Friction
16Wet Work
Wet hands or glove wearing > 2
cumulative hours daily11,12
Greater than 20 hand washes
daily12
17
Classification System: Etiology
Allergic Contact Dermatitis
Way more common in occupational exposures vs. private exposures
(Hobby)11
“Hand eczema that spreads”13
Protein Contact Dermatitis
RARE
Latex
Food proteins
Burning, stinging and itching seconds to minutes after contact14
Systemic Contact Dermatitis
VERY RARE
Specific definition11
Positive patch test
Ingest an oral version
Vesicular hand/foot rash
18
Classification System: Etiology
Atopic dermatitis
Other genetic
Filaggrin null mutations15,16
Twin studies show that MZ twin individuals having a co-
twin with hand eczema had an increased risk of hand
eczema compared with DZ twins6
Atopic dermatitis adjusted
Idiopathic CHE
20%11
19
Classification System: Morphology
Guidelines of the Danish Contact Dermatitis Group
Chronic dry fissured hand eczema
Vesicular hand eczema
Hyperkeratotic (Tylotic) hand eczema
Interdigital hand eczema
Pulpitis
Nummular hand eczema
Mixed
50.5% demonstrate multiple morphologies17
20
Chronic Dry Fissured Hand Eczema
21
Chronic Dry Fissured Hand Eczema
22
Palmoplantar Psoriasis
Well-Marginated
23
Palmoplantar Psoriasis
Abrupt Wrist Cut-off18
24
Palmoplantar Psoriasis
Micaceous Scale
25
Palmoplantar Psoriasis
Look Elsewhere
Frequency based on location19
1. Generalized Plaque – 49.3%
2. Localized Plaque – 16.9%
3. Guttate – 12.8%
4. Arthropathic – 7.7%
5. Palmoplantar – 7.5%
6. Pustular – 3.1%
7. Other – 2.7%
26
Vesicular Hand Eczema
Intermittent20
Intensely pruritic
Palms/soles, nail, and sides of fingers
Attacks between 1 and 10 months
Two historical descriptions
Pompholyx
Dyshidrosis
27
Vesicular Hand Eczema
Frequency of location20
1. Hands alone – 46.8%
2. Feet alone – 24.1%
3. Hands and feet – 15.6%
4. Nail apparatus – 13.5%
28
Vesicular Hand Eczema
Anatomic Location20 Fungi Positive
Hands 1.2%
Feet 47.8%
Epidermophyton interdigitale 100% of
feet cases
29
Vesicular Hand Eczema
Lane et al.21
25% of any location positive fungal infection
Pitche et al.22
10% of any location positive fungal infection
Guillet et al.23
15.8% of any location with T. rubrum or candida
infection
30
Vesicular Hand Eczema
Always check the feet
Foot involvement is rare
47.8% dermatophyte infection
31
Vesicular Hand Eczema
Dyshidrosiform Pattern
32
33
34
35
Keratolysis Exfoliativa
36
Vesicular Hand Eczema
Dyshidrosiform Pattern
Presence of erythema
Controversial
Progression of lesions24
Early stage
Vesicular
Late stage
Chronic dry fissured presentation
Studded with pinpoint necrotic vesicles
Wet glazed look with pinpoint necrotic vesicles
37
Vesicular Hand Eczema:
Late Stage Dyshidrosiform Pattern
38
Vesicular Hand Eczema: Pompholyx
Very rare
Single episode of palms and
soles
Vesicular and BULLOUS
eruption
39
Vesicular Hand Eczema:
Pompholyx
40
Autoimmune Blistering Disease and
Lymphoma
Dyshidrosiform bullous
pemphigoid
Herpes gestationis
Linear IgA
Lymphoma
41
Palmoplantar Pustulosis
Localized to palms and soles25
1. Soles only 47.36%
2. Palms only 31.57%
3. Both soles and palms 21%
Mildly pruritic
42
43
44
Hyperkeratotic Hand Eczema (Tylotic)
Middle-aged men
NEVER VESICLES
45
Hyperkeratotic Hand Eczema (Tylotic)
46
Palmoplantar Psoriasis
47
Tinea Manuum
48
Interdigital Hand Eczema
Dominant hand
Site for the start of irritant hand
dermatitis26,27
49
Interdigital Hand Eczema
50
Interdigital Hand Eczema
51
Erosio Interdigitale Blastomycetica
52
Scabies
53
54
55
Pulpitis
56
Pulpitis
57
Nummular Hand Eczema
Very rare
Must rule out atopic dermatitis
No elevated IgE or eosinophilia
Nummular Atopic Dermatitis
(Bologna)
58
Nummular Hand Eczema
59Mixed Variety
Any combination of above
60
Problems with Current Classification
Systems good for academic pursuit
Pure clinical pictures are less likely
50.5% demonstrate multiple morphologies17
Morphology changes frequently clinically and
histologically17
No clear link between morphology and
etiology
Johansen et al.28
Cronin et al.29
Diepgen et al.30
61Simplification
Is it an eczematous process?
Acute – vesicles/bullae
Subacute/Chronic – scaling/erythema
62Simplification
IF ACUTE
CHECK THE FEET
CHECK THE FEET
CHECK THE FEET
63Simplification
Hand Eczema
Evaluation Irritant
Do you touch liquids many times a day including
water?
Evaluation Atopic
Did you have childhood eczema, allergies or asthma?
Allergic
What do you do for work?
64
Additional Work Up: Patches
Standard Series
Toledo et al.
Linberg et al.
Menne et al.
Worker’s
Compensation
Irritant contact
dermatitis31-33
21% with positive
patch test34
30% relevant
Nickel (100%)
ACD worse prognosis7
65Treatment
#1 Treatment is the same
#2 Blow them up
Faster clearance at disease onset lowers risk of chronicity43
#3 And then juice em up
Systemic and topical steroids35
One episode – 38.4%
Intermittent non-cyclic – 30.8%
Intermittent cyclic-28.5%
Chronic – 2.3%
Patients perceive systemic agents as powerful
#4 Don’t stop treatment if it gets better
66Treatment
#5 Shake their hands
#6 What worked before, may not work again
#7 It gets better with time
Period prevalence decreases with aging
78% of subjects claimed improvement of
symptoms over 15 years36
67
Study Years to Follow-Up Persistence
Agrup et al. 2 years 72%
Burrows et al. 10-13 years 79%
Reichenberger et al. 15 years 46%
Fregert et al. 3 years 68%
Gooskes et al. 15 years 55%
Lammintausta et al. 5 years 34%
Driessen et al. 5 years 50%
Keczkes et al. 15 years 69%
Latinga et al. 3 years 59%
Rystedt et al. 3 years 83%
Pryce et al. 2 years 75%
Chia et al. 1 year 28%
Wall et al. 10 years 55%
Halbert et al 10 years 76%
Rosen et al 5 years 66%
Nethercott et al. 2 years 37%
Susitaival et al. 12 years 44%
68
Treatment: Hand Care Instructions
Decrease number of washes daily
(Brancaccio)
“Your hands are broken, if your leg was
broken would you still walk on it”
Alcohol based disinfectants are less
irritating to the skin than soap and water26
Apply emollient within 2-3 minutes of wash24
Greasy as possible
Fragrance free
Apply as many times during day as you
like
69Treatment: Gloves
Use gloves when wet work or dirty work
Latex or vinyl
Tight-fitting
Cotton liner
Change when damp
70
First-Line: Topical Steroids
Which one should I use?17
Potent 65.5%
Moderate 30.53%
Superpotent 2.3%
Mild 1.67%
How often and for how long?11
Once daily dosing equal efficacy as twice daily
Two-week intervals
Even switching in the same class can prove to be
beneficial (Holland)
71
Alternatives to Topical Steroids
Tacrolimus 0.1% vs. mometasone furoate37
50% improvement in both groups
Pimecrolimus vs. mometasone furoate38
Did not reach statistical significance
Used in combination with steroids
Clear (Cohen)
1st week: ¾ Steroid Ointment ¼ Tacrolimus
2nd week: ½ Steroid ointment ½ Tacrolimus
3rd week: ¼ Steroid ointment ¾ Tacrolimus
4th week: ALL Tacrolimus
5th-on: ALL Tacrolimus Fri, Sat, Sun
72
First-Line: Systemic Steroids
First Blow
Prednisone 40-60mg daily initial dose and taper
between 3-4 weeks39
Intramuscular Kenalog 40-80mg40
Limit 4 shots per year (Wolverton)
Second Blow
Prednisolone 30mg daily for 3 days at onset of
eruptions41
Prednisone 40-60mg x 1 dose on day 1 of the
eruption23
73
Routine Intramuscular Steroid
A Comparison on the Efficacy, Relapse Rate and Side
Effects among Three Modalities of Systemic
Corticosteroid Therapy for Alopecia Areata57
Triamcinolone acetonide 40mg monthly x 6
Then 40mg every 6 weeks x 18 months
Total treatment duration = 24 months (2 years)
Total of TEN 40mg injections annually
74
Routine Intramuscular Steroid
A Comparison on the Efficacy, Relapse Rate and Side
Effects among Three Modalities of Systemic
Corticosteroid Therapy for Alopecia Areata57
56 subjects IM Triamcinolone acetonide arm (29 in
prednisolone)
16 dysmenorrhea (vs 3)
3 abdominal pain (vs 1)
1 worsening acne (vs 0)
5 adrenocortical impairment (vs 2)
Both groups resolved in 2 months without
steroid taper
75
Routine Intramuscular Steroid
Twelve-year clinico-therapeutic experience in pemphigus: a
retrospective study of 54 cases58
Intramuscular triamcinolone acetonide was given in cases
of poor compliance
80mg IM on day 0, 4, 7, 28
40mg IM every for weeks x 6 doses
Total duration of treatment = 6 months
Total of TEN injections
1 subject with weight gain
1 subject with cushingnoid features
Resolved within 4 months without steroid taper
76
Routine Intramuscular Steroid
Triamcinolone acetonide: a new management of
noncompliance in nephrotic children59
8 monthly doses of IM Triamcinolone
acetonide 2mg/kg Each month dose decreased by 10-20%
Total duration of treatment = 8 months
Total of EIGHT injection
All subjects had decreased longitudinal
growth
Normalized
77
Treatment: If infected
S. aureus
Systemic antibiotics superior to topicals24
78
Treatment: If Hyperhidrosis
Botulinum toxin A42
– Left versus right study
– Vesicular hand dermatitis only
– 100 units plus topical steroids
Botulinum toxin43
– Left versus right study
– Vesicular hand dermatitis only
– 162 units of botox but no steroids
79
Ultraviolet Light
UVA >>> NBUVB >>> UVB52
– Apoptosis of lymphocytes through reactive oxygen species and FAS ligand
– Increase in IL-10 inhibition of interferon –gamma.
Efficacy PUVA53,54
– Systemic = Topical = Bath
– Bath with least side effect
• Decreased UVA doses due to uniform absorption
• Phototoxicity risk disappears after 2 hours
– Sunblock and gloves
– High dose UVA-1
• Max single dose of 130J/cm2
• Cumulative dose 1720J/cm2
• As effective as cream puva52
Reduction in pruritus in first week55
80
Other Systemics
Azathioprine 100-150mg daily44
Methotrexate 15-25mg weekly45
Mycophenolate mofetil 2g/day46
Cyclosporine 2.5mg/kg/day47
Etanercept 25mg twice weekly48
81
Alitretinoin (9-cis-retinoic acid)
Approved Europe
– Indicated for chronic hand eczema refractory to
topical and systemic steroids
– Not for vesicular hand dermatitis
Panagonist RXR, RAR
Retinoid Adverse Events
– Headache, mucocutaneous dryness, elevated liver
enzymes, elevated blood lipid levels,
teratogenicity
No combination studies
82
Alitretinoin (9-cis-retinoic acid)
Alitretinoin 30mg daily49
– Median time to clear hands is 12 weeks
Placebo, Alitretinoin 10mg, 20mg, 40mg daily
doses for 12 weeks50
– 70% reduction in 50%
Alitretinoin 10mg, 30mg daily for 24 weeks51
– 100% reduction in 48%
– More response with 30mg
83
Summary
Period prevalence
2-10%
Risk factors
Atopic dermatitis, allergic rhinitis/asthma, occupation, wet
irritant exposure
Classification systems
Etiology and morphology
Not practical day-to-day clinic
Differential Diagnosis
Check the feet
First-line therapy options
Blow em up and then juice em up
84
1. Kavli et al. Hand dermatoses in Tromso. Contact Dermatitis. 1984;10:174-177.
2. Coenraads P et al. Prevalence of eczema and other dermatoses of the hands and arms in the Netherlands. Association with age and occupation. Clin Exp Dermatol.
1983;9:495-503.
3. Goh et al. Occupational dermatoses in Singapore. Contact Dermatitis. 1984;11:288-293.
4. Meding et al. Hand eczema in Swedish adults – changes in prevalence between 1983-1996.
5. Meding B etl a. Incidence of Hand Eczema – a population based retrospective study. J Invest Deramtol. 122;873-877.2004.
6. Lerbeak et al. Incidence of hand eczema in a population-based twin cohort: genetic and environmental risk factors. Br J Dermatol.2007;552-557.
7. Cahill et al. The prognosis of occupational contact dermatitis in 2004. Contact Dermatitis. 2004;51:219-226.
8. Veien N et al. Hand eczema:causes, course, and prognosis. Contact Dermatitis. 2008;58:330-4.
9. Toledo et al. Patch testing in children with hand eczema. Contact Dermatitis. 65;213-219.
10.Meding B et al. Fifteen-year follow-up of hand eczema: predictive factors. J Invest Dermatol. 2005;124:893-7.
11. Menne T et al. Hand eczema guidelines based on the Danish guidelines for the diagnosis and treatment of hand eczema. Contact Dermatitis 65;3-12.
12. Coenraads P et al. Risk for hand eczema in employees with past or present atopic dermatitis. Ach Occup Environ Health. 1998;71:7-13.
13. Molin et al. Diagnosing chronic hand eczema by an algorithm: a tool for classification in clinical practice. Clin and Exp Dermatol. 36;595-601.
14. Janssens V et al. Protein contact dermatitis: myth or reality? Br J Dermatol. 1995; 132:1-6.
15.Thyssen J et al. Filaggrin null mutations increase the risk and persistence of hand eczema in subjects with atopic dermatitis: results from a general population study. Br J
Dermatol. 2010;115-120.
16.Molin S et al. Filaggrin mutations may confer susceptibility to chronic allergic and irritant hand dermatitis. Br J Deramtol. 2009;801-7.
17.Apfelbacher C et al. CARPE: a registry project of the German Dermatological Society for the characterization and care of chronic hand eczema. JDDG;2011:682-688.
18. Kumar et al. Palmoplantar lesions in psoriasis: a study of 3065 patients. Acta Derm Venerol. 82;192-195.
19. Sampogna et al. Prevalence of symptoms experienced by patients with different clinical types of psoriasis. Br J Dermatol. 2004;151:594-599.
20. Tibor B et al. Pompholyx on the hands and feet. Its etiology, pathogenesis, and specific vaccine therapy. Mycopath et Mycol applicata. 1974;53:25-44.
21. Lane et al. Dermatoses of the hands. JAMA. 128;987-993.
22. Guillet M et al. A-year causative study of pomphylox in 120 patients. Arch Dermatol. 2007;143:12:1504-8.
23. Storrs et al. Acute and recurrent vesicular hand dermatitis not pompholyx or dyshidrosis. Arch Dmeratol. 2007;143-5.
24. Brady M et al. Hands and feet that blister and peel: dyshidrosis. J Ped Health Care. 1993;7:37-8.
25. Brunasso A et al. Can we really separate plamoplantar pustulosis from psoriasis? JEADV 2010;24:611-624.
26.Kampf G et al. Prevention of irritant contact dermatitis among health care workers by using evidence-based hand hygience practices: a review. Ind health. 2007;645-652.
27.Schwanitz H et al. Interdigital dermatitis; sentinel skin damage in hairdressers. Br J Dermatol. 2000;1011-1012.
28. Johansen et al. Classification of hand eczema: clinical and etiological types. Based on the guideline of the Danish Contact Dermatitis Group. Contact Dermatitis. 65;13-21.
29. Cronin E. Clinical pattern of hand eczema in women. Contact Dermatitis. 1985;13:153-161.
30. Diepgen T etl al. European Environmental contact dermatitis research group. Hand eczema multicentre study of the etiology and morphology of hand eczema. Br J Dermatol.
2009;160:353-358.
31. Veien N et al. Hand eczema: causes, course and prognosis 1. Contact Dermatitis 2008;58:330-334.
32. Lantinga H et al. Prevalence, incidence and course of eczema on the hands and forearms in a sample of the general population. Contact Dermatitis. 1984;10:135-139.
33. Agner T. Hand eczema. Contact Dermatitis. 4th edition. Forsch PI. Berlin. Springer. 2006;pp335-344.
34. Beattie PE et al. Which dhildren should we patch test? Clin Exp Dermatol 2006;32:6-11.
35. Apfelbacher C et al. Occurrence and prognosis of hand eczema in the care industry: results from the PACO follow-up study (PACO II). Contact Dermatitis. 2008;58:322-329.
36. Meding et al. Fifteen-year follow up of hand eczema: persistence and cosequences. Br J Dermatol. 2005;152:975-980.
37. Schnopp C et al. Topical tacrolimus and mometasone furoate in treatment of dyshidrotic palmar eczema: a randomized, observer-blinded trial. J Am Acad Dermatol.
2002;46:73-7.
85
38. Belsito D et al. Multicenter Investigator group: pimecrolimus cream 1%: a potential new treatment for chronic hand dermatitis. Cutis. 2004;73(1):31-8.
39.Wollin U et al. Pharmacotherapy of pompholyx. Exper Opin Pharmaother 2004;5(7)1517-22.
40.Boettget et al. Increased vagal modulation in atopic dermatitis. J Dermatol Sci 2009;53(1):55-9.
41. Veien N. Acute and recurrent vesicular hand dermatitis. Dermatol Clin. 2009;337-353.
42. Wollina et al. Adjuvant botulinum toxin A in dyshidrotic hand eczema: controlled prospective pilot study with left-right comparison. J Eur Acad Dermatol Venereol 2002;16:40-2.
43.Bansal C et al. Novel cutaneous uses for botulinum toxin type A. J Cosmet Dermtol. 2006;5(3):268-72.
44. Sceerri L et al. Azathioprine in dermatological practice: an overview with special emphasis on its use in non-bullous inflammatory dermatoses. Adv Exp Med Biol
1999;455:343-8.
45.Egan et al. Low-dose oral methotrexate treatment for recalcitrant palmoplantar pompholyx. J am Acd Dmeratol. 1999;40(4)612-14.
46. Pickenacker A et al. Dyshidrotic eczema treated with mycophenolate mofetil. Arch Dermatol. 1998;134(3):378-9.
47. Reitamo S et al. Cyclosporin A in the treatment of chronic dermatitis of the hands. Br J Dermatol. 1994;130(1):75-8.
48. Ogden S. Recalcitrant hand pomphylox; variable response to etanercept. Cli and Exp Dermatol. 31; 129-156.
49. Bissonnette R et al. Successful retreatment with alitretinoin in patients with relapsed chronic hand eczema. Br J Dermatol. 2010;162:420-26.
50. Ruzicka et al. Oral alitretinoin (9-cis-retinoic acid) therapy for chronic hand eczema dermatitis in patient refractory to stand therapy: results of a randomized, double-blind,
placebo-controlled, multicenter trial. Arch Dermatol. 2004;140(12):1453-9.
51. Ruzicka et al. Efficacy and safety of oral alitretinoin (9-cis-retinoic acid_ in patients with severe chronic hand eczema refractory to topical coriticosteroids: restuls of a
randomized double blind, placebo controlled, multicentre trial. Br j Dermatol. 2008;158:808-817.
52. Krutman J. Phototherapy for atopic dermatitis. Clin Exp Deramtol. 2000;25(7):552-8.
53.Grattan C et al. Comparison of topical PUVA with UVA for chronic vesicular hand eczema. Acta Derm Venerol. 1991;71:118-22.
54.Petering H et al. Comparison of locatlized high-dose UVA2 versus topical cream psorlenUVA for treatment of chronic vesicular dyshidrotic eczema. J Am Acad Dermatol.
2004;68-72.
55. UVA1 Irradiation is effective in ttreatment of chronic vesicular dyshidrotic hand eczema. Acta Derm Venerol
56. ansen G. Grenz rays:adequate or antiquated? J Deramtol Surg Oncol 1978;4:627-9.
57. Kurosawa M et al. A comparison of the Efficacy, relapse rate, and side effects among three modalities of systemic corticosteroid therapy for alopecia areata. Der.
2006;212:361-365.
58. Mahajan V et al. Twelve year clinico-therapeutic experience in pemphigus: a retrospective study of 54 cases. In J of Derm. 2005;44:821-827.
59. Ulinknski T et al. Triamcinolone acetonide: a new management of noncompliance in nephortic children. Prediatr Nephrol. 2005;20:759-762.