Diagnosis is based on clinical presentation and the identification of irritants.
The structure of atopic skin predisposes the person to irritant contact dermatitis.
Must be treated effectively in the early phase to prevent the condition becoming chronic.
Aetiology
A chemical (rarely physical) irritant can injure the skin and cause an inflammatory reaction if the exposure is strong enough and sufficiently prolonged.
Most common causative agents: detergents and solvents, hand disinfectants, wet working conditions (water, hands overheating inside protective gloves), processing of foodstuffs (raw vegetables, for example)
High-risk occupations: kitchen work, cleaners, health care staff, hairdressers etc.
Symptoms
Hand dermatitis (picture 1) is often the presenting symptom, starting in between the fingers (picture 2) and the back of the hand spreading only later on to the palm.
Dermatitis occurring in palms of the hands and soles of the feet suggests some other cause than irritant contact dermatitis (endogenous eczema, psoriasis).
Investigations
The diagnosis of irritant contact dermatitis is based on clinical presentation and the identification of irritant agents.
The patient's history is used to identify exposure to irritants and the effect that avoiding exposure (e.g. holidays) has on the condition.
Review of work tasks and any irritation factors in them; also in hobbies
IgE-mediated sensitisation has no direct causal relationship with irritant contact dermatitis. The structure of atopic skin (personal history of atopic dermatitis) predisposes the person to irritant contact dermatitis.
Additional investigations are important in the differential diagnosis of prolonged hand dermatitis Diagnostic Tests in Dermatology: patch testing, skin prick tests (protein contact dermatitis, e.g. foodstuffs, latex), fungal samples (for microscopy and culture), skin biopsy.
Treatment
Reduction or avoidance of the irritant factor
Appropriate hand protection (use of protective gloves with cotton gloves underneath)
Regular use of basic topical ointments Emollients and Moisturisers for Eczema (national legislation applies as to whether the patient may have these reimbursed)
The patient should refrain from the use of soap; emollients (soap substitutes) to be used in place of soap to wash hands.
Moderately potent to potent glucocorticoid creams once or twice daily until the rash has healed for at least 2-6 weeks as appropriate to the severity of the condition.
A follow-up visit should be arranged after the initial treatment if the dermatitis is not healed.
Maintenance therapy with a glucocorticoid cream is often needed (only after the dermatitis has healed) in order to prevent a recurrence, twice a week for 1-3 months.
Especially on atopic skin, tacrolimus cream may also be of benefit, e.g. twice daily for 1-3 months.
If the patient's employment is associated with hand irritation, sick leave should be allocated for the length of time it takes for the dermatitis to resolve, unless work conditions can be changed (light duties), even if only temporarily.
If occupational hand dermatitis is suspected, a follow-up appointment should always be arranged towards the end of the sick leave (has the dermatities healed or clearly abated during the sick leave?).
Specialist consultation
In cases where irritant dermatitis has not resolved within 3 months despite appropriate and regular topical treatment, a referral to a dermatologist is recommended for consultation and patch testing in order to exclude allergic contact dermatitis.
References
Agner T, Aalto-Korte K, Andersen KE, et al. Classification of hand eczema. J Eur Acad Dermatol Venereol 2015;29(12):2417-22. [PubMed]
Bauer A, Rönsch H, Elsner P, et al. Interventions for preventing occupational irritant hand dermatitis. Cochrane Database Syst Rev 2018;(4):CD004414. [PubMed].