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AlexanderSalava

Hand Dermatitis

Essentials

  • Hand dermatitis may be related to an eczematous condition, skin infection or other skin disease.
  • Diagnosis is based on the patient's history and physical examination.
  • The most common cause is irritant contact dermatitis, in which case additional investigations are only needed should the condition persist.
  • A sufficiently long and effective topical therapy (total treatment time often 2-3 months) at the initial phase will prevent the condition becoming chronic.

Aetiology

  • Exogenous
  • Endogenous
    • Atopic dermatitis with hand dermatitis Investigation of Atopy
    • Chronic vesicular or hyperkeratotic eczema (dermatitis) on the palms and soles (synonyms include acute palmoplantar eczema, dyshidrotic eczema, pompholyx, eczema infectiosum)
  • Many skin diseases are associated with rash that also involves the hands (rash usually also on other body areas): psoriasis Psoriasis, lichen planus Lichen Planus etc.
  • Palmoplantar pustulosis causes pustules on the palms of the hands (pictures 2 3) or the soles of the feet. The aetiology remains unclear.
  • Other possible causes
    • Tinea manuum (picture 4): rash often unilateral, also affects the feet and toenails Dermatomycoses
    • Scabies Scabies
    • Bacterial infection associated with vesicle formation (e.g. group A Streptococcus)
    • Hand, foot and mouth disease Enterovirus Infections (1-2 weeks after an enteroviral infection)
    • Peeling of the skin at the fingertips and palms after scarlet fever or streptococcal tonsillitis
    • Herpes simplex (e.g. on a fingertip; picture 5)
    • Syphilis Syphilis: a rare cause of macular hand dermatitis

Examining the patient

Clinical history

  • Is there a personal history of atopy or a family history of any skin diseases (e.g. psoriasis)?
  • Is the patient exposed to factors that may irritate the hands at work, e.g. wet working conditions? Has the patient been off work due to the dermatitis? How does the condition react to time off and how quickly?
    • If no improvement occurs within 1-2 weeks and dermatitis is also present on the soles of the feet, it is not likely that the patient has occupational dermatitis.

Physical examination

  • The examination of a patient with hand dermatitis must also include the examination of his/her feet.
  • Bear in mind the sites of predilection for psoriasis: scalp, nails, knees and forearms.
  • An immunologic reaction in tinea pedis may trigger a mycid reaction (id reaction) where vesicles develop on the hands, but tinea is only found on the feet.

Investigations

  • Fungal samples (for microscopy and culture) to exclude tinea
  • Patch testing if allergic contact dermatitis is suspected
  • A skin biopsy is rarely indicated to diagnose other skin disease (a biopsy is usually taken from a skin area other than the hands).

Chronic dermatitis

  • Hand dermatitis may become chronic and persist despite the original aetiology (pictures 6 7).
  • The possibility of allergic contact dermatitis (e.g. an occupational allergen) should be considered.
  • Chronic dermatitis in the nail fold and chronic paronychia may disturb nail growth (picture 8) and lead to the development of ”washboard nails” (pictures 9 10).

Treatment

  • The definitive treatment of hand dermatitis is directed against the cause of the disease and must include the avoidance of irritant agents.

Topical treatment

  • Sufficiently long and effective treatment at the initial phase will prevent the condition becoming chronic. The most common cause of chronic hand dermatitis is insufficient topical glucocorticoid treatment at the initial phase.
  • Moderately potent to potent glucocorticoid creams once or twice daily until the skin has healed, for 2-6 weeks as appropriate to the severity of dermatitis. A follow-up appointment is indicated if the condition has not totally resolved.
  • If clear improvement is observed at the follow-up appointment, the glucocorticoid cream can be continued until the dermatitis is totally resolved (total treatment time 2-3 months).
  • 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.
  • Tacrolimus cream may also be of benefit, especially in patients with atopy.

Systemic treatment

  • Antimicrobials are very rarely needed in hand dermatitis. If the rash is clearly infected (picture 6, a systemic antimicrobial may be indicated, e.g. cephalexin 500 mg three times daily for 7-10 days.
    • Alternative antimicrobials and their doses are the same as those used in impetigo Impetigo and other Pyoderma.
    • Antimicrobials are not the first-line treatment in hand dermatitis, and they do not replace topical treatment.
  • Systemic glucocorticoids may be considered as short term treatment in a severe acute phase, for example prednisolone 20-40 mg once daily for 1-2 weeks.
    • Particularly effective against acute vesicular hand dermatitis. In chronic hand dermatitis they should be used in exceptional cases only.

Other measures

  • Hand protection is of paramount importance. Cotton gloves can be worn under protective gloves.
  • Information regarding appropriate occupational hand protection should be consulted.
  • In exogenous dermatitis, an attempt should be made to remove the cause (allergens and irritant agents).
  • Advice should always also be given on hand protection and how to use basic topical ointments and soap substitutes.
  • Where irritants are encountered at the workplace, sick leave should be prescribed for the length of time it takes for the dermatitis to resolve.
  • If occupational hand dermatitis is suspected, a follow-up appointment should always be arranged towards the end of the sick leave so that the state of the skin can be documented.

Specialist consultation

  • In cases where 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.
  • The first consideration in cases of prolonged hand dermatitis is the possibility of exogenous dermatitis with a cause that can be eliminated.
  • Patch testing can be repeated later on if necessary, and task allocation may need to be addressed at the workplace.
  • A dermatologist may, if indicated, commence local light treatment (PUVA-cream) or systemic immunosuppressive (methotrexate, cyclosporine) or retinoid (acitretin, alitretinoin) medication.

References

  • Diepgen TL, Andersen KE, Chosidow O et al. Guidelines for diagnosis, prevention and treatment of hand eczema. J Dtsch Dermatol Ges 2015;13(1):e1-22. [PubMed]
  • Antonov D, Schliemann S, Elsner P. Hand dermatitis: a review of clinical features, prevention and treatment. Am J Clin Dermatol 2015;16(4):257-70. [PubMed]
  • Agner T, Aalto-Korte K, Andersen KE et al. Classification of hand eczema. J Eur Acad Dermatol Venereol 2015;29(12):2417-22. [PubMed]
  • Christoffers WA, Coenraads PJ, Svensson Å et al. Interventions for hand eczema. Cochrane Database Syst Rev 2019;(4):CD004055. [PubMed]
  • Lampel HP, Powell HB. Occupational and Hand Dermatitis: a Practical Approach. Clin Rev Allergy Immunol 2019;56(1):60-71. [PubMed]
  • Elsner P, Agner T. Hand eczema: treatment. J Eur Acad Dermatol Venereol 2020;34 Suppl 1():13-21. [PubMed]