The Management of Hand Eczema
Some physicians believe that hand eczema is rather common; many studies show that 5 percent of the U.S. population with European ancestry have an overt case of this disorder and at least another 10 percent of the population have clinical symptoms, even though their symptoms may not be obvious in a physical exam. Patients with the less obvious form of the disorder may have only subjective finders.
What Does It Look Like?
Anyone can diagnose the most obvious cases of hand dermatitis—bright red, scaly, eczematous skin with cracks and fissures that bleed. If the plaques are hyperkeratotic, sharply marginated and involve the mid palm, the problem may actually be psoriasis, which affects approximately 3 percent of the Caucasian population. It is the more subtle cases that are harder to diagnose. There may be little or no erythema, especially on the more heavily pigmented individual. The scaling may be so mild that magnification is required to reveal it. And there may be no clinical signs at all, only the subjective observation by patients that their hands are incredibly sensitive, sting and burn easily, and are generally “uncomfortable.”
What Are the Causes?
There are two general categories of hand dermatitis—endogenous and exogenous. The endogenous form is found in the approximately one-third of the population that is atopic—those people with allergies, asthma, and edema. Their eczema can be triggered by substances other than those that come into contact with their hands. Unfortunately, however, their hand eczema can be made worse by exogenous factors as well. Exogenous factors include those to which one has an allergic reaction and those factors that cause an irritant (but not allergic) dermatitis.
Allergic contact dermatitis occurs in 10 to 15 percent of the population and is caused by delayed hypersensitivity, which typically takes 24 to 96 hours to develop. Allergic contact hand dermatitis can be caused by a number of substances, including plants, foods, fragrances, clothing, dyes, rubber, solvents, metals, chemicals such as formaldehyde, and many more. Diagnosis of allergic contact hand eczema requires patch testing. “Level one” patch testing is done by many dermatologists in their offices. This includes testing for the approximately 20 most common substances responsible for contact dermatitis. Testing that includes the more unusual substances usually requires referral to a tertiary-care dermatology center.
The second type of allergy is contact urticaria. The latex protein enters the skin and causes an immediate reaction mediated by immunoglobulin E. This is the case with a person who puts on a pair of latex gloves and rapidly feels stinging and burning and quickly develops dermatitis. (It is also the case with a person who blows up a latex balloon and has immediate facial swelling and angioedema.) Contact urticaria is known to afflict 5 to 8 percent of health care workers who extensively use latex gloves.
Irritant contact dermatitis is almost ubiquitous, and almost everyone will experience it sometime in their lifetime. Any exposure to water (by washing dishes, for example) can cause the disorder. Exposure to other chemicals in either the workplace or at home can also be responsible. A full-blown case of debilitating hand eczema will not develop in everyone, but irritation will be obvious to most people at some times. Much less common causes of hand dermatitis include tinea (ringworm), which requires a KOH preparation for diagnosis. Psoriasis and other skin disorders are easily diagnosed by concomitant skin findings.
What Solutions Are Available?
Prevention of the problem is, of course, the best solution. Patients should avoid the substances or situations that cause or exacerbate the hand dermatitis. And they should be gentle with their skin by using only mild soaps to wash their hands and by washing with cool water. (Hot water will not kill bacteria and will dry out the skin more than cool water.) Protection is another important approach, primarily by using gloves. Many different kinds of gloves are now available and can be selected according to a patient’s occupation and individual needs. Studies in the past five years have clearly shown that when nurses are provided with appropriate protective products, the frequency of irritant contact dermatitis will decrease.
Historically, topical corticosteroids have been the mainstay of treatment for hand eczema. However, their chronic use may lead to tachyphylaxis and skin atrophy. Often they are not as efficacious for irritant contact dermatitis as for other skin diseases, such as psoriasis, and many people develop allergies to the topical steroids. In tertiary-care settings, about 4 to 5 percent of patients are allergic to topical corticosteroids, meaning that 1 in 20 patients will get better simply by stopping their use. Corticosteroid-sparing alternatives are now available and are used increasingly to prevent rebound flaring after initial treatment with topical steroids.
Some barrier creams protect the skin against certain irritants that can cause contact dermatitis. They actually can help block uptake of the allergen by the skin, thereby preventing the allergic contact dermatitis. Unlike topical corticosteroids, which require a prescription and can have adverse side effects, barrier creams are available without a prescription and can be used indefinitely.