Guidelines for diagnosis, prevention and treatment of hand eczema

European Society of Contact Dermatitis


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Introduction

  • Hand eczema (HE) is associated with many different aetiologies and morphologies. Severity may range from very mild to severe and the course from acute to chronic, resulting in prolonged disability
  • Eczema and dermatitis are used as synonyms, both terms are used interchangeably
  • Acute and subacute HE can be defined as eczema, localised to the hands, that lasts for less than 3 months and does not occur more than once per year. A subjective sensation of burning and itching is present in most cases
  • Chronic HE refers to an eczematous process that lasts for more than 3 months or relapses twice or more often per year. Scaling and fissures are found in most cases
  • HE may be located anywhere on the hands and wrists. Involvement of a large area at onset of the disease indicates a bad prognosis. Patch testing should be performed irrespective of location

Aetiology

  • Irritant HE:
    • develops as a result of prolonged or repeated exposure to primary irritants
    • depends on the duration and intensity of exposure to the potentially responsible agent(s)
  • Allergic HE:
    • caused by a delayed-type reaction (type IV reaction) as an immunological response to contact with an allergen in a sensitised individual
    • diagnosis is confirmed when there is a positive patch test reaction to a topical allergen or a cross-reacting allergen, and a relevant current exposure to this allergen
  • Protein contact dermatitis:
    • rare, distinct form of allergic or irritant HE caused by IgE-mediated mechanisms, or non-immunological mechanisms
    • characterised by an initial urticarial phase followed by eczema
    • most common triggers are latex and food allergens
    • diagnosis is based on exposure to proteins and a positive prick test, or proven specific IgE, to suspected items
  • Atopic HE:
    • occurs in individuals with previous or current atopic dermatitis with no documented exposure likely to cause irritant contact dermatitis
  • Pompholyx:
    • is a recurrent HE with vesicular eruption
    • no relevant contact allergy and no documented irritant exposure likely to cause dermatitis
    • characterised by isolated vesicles on the palms of the hands
    • can also affect the sides of the fingers, and be accompanied by erythema of variable intensity and severe pruritus
    • recurrences may be triggered by:
      • stress
      • systemic contact dermatitis
      • dust mites
      • fungus infections elsewhere
  • Hyperkeratotic HE:
    • chronic eczema with hyperkeratosis in palmar hands, or pulpitis, and no vesicles or pustules, also called hyperkeratotic dermatitis of the palmar hands
    • no documented exposure to the involved skin areas likely to cause irritant exposure is present
    • typically presents as sharply demarcated circumscribed hyperkeratotic and fissured lesions in the middle of the palms, and absence of vesicular lesions
    • causative factors of hyperkeratotic HE are still poorly understood

Flowchart on the various causes of HE*

Flowchart on the various causes of HE

Diagnosis

  • The history should be taken by guided interview and include a search for specific exposures related to the clinical features. This should include:
    • pattern of dermatitis
    • duration of dermatitis
    • exacerbations and remissions including relationship to work
    • the patient’s own suspicions
    • use of and response to skin care products and medicaments
    • the use of gloves
    • number of hand washings
    • hobbies and leisure activities
    • housework
    • occupational exposures
  • Information on previously documented allergies and test procedures should be collected, together with information about atopic status, including previous atopic dermatitis

Physical examination

  • Apart from assessing the hands, the clinical examination should include an inspection of the entire skin, especially the feet. Palmar psoriasis is an important differential diagnosis to hyperkeratotic dermatitis of the palms. A careful inspection of clinical signs of dermatophytosis has always to be included

Investigations

  • Multiple diagnostic procedures may be needed in each individual case. These include:
    • diagnostic patch tests
    • skin prick tests
    • exposure assessment
    • microbial tests and cutaneous biopsies

Prevention

  • Groups at high risk of HE include hairdressers, healthcare workers, metal workers
  • Primary prevention is recommended to decrease the incidence of HE. Exposure to wet work is a particular risk factor for development of HE, and preventive efforts (e.g. wearing gloves) should aim at reducing wet exposure
  • Secondary prevention strategies are indicated when eczema is already present on the hands. The objective is to spot early skin changes in order to rapidly implement corrective measures. Skin protection education and training are an important part of secondary prevention

Treatment

General principles

  • Successful therapy requires identification and avoidance of causal exogenous factors (e.g. allergens, irritants)
  • Acute HE should be treated quickly and consequently to avoid the development of chronic HE
  • Chronic HE is difficult to treat and requires complex management strategies, taking into account etiology, morphological features, and site of the lesions

Non-pharmacological

  • Lifestyle change is recommended for all patients. This involves avoidance of identified allergens and irritants, substituting alternatives where possible, use of hand protection, and avoiding wet work and mechanical irritation
  • A skin protection programme should be tailored to individual need; this should include education about HE with the aim of giving the patient realistic expectations of treatment outcomes, as HE is not always curable
  • Management should include not only the patient but also the family too, taking into account psychological issues, occupation, and the history of the condition and its treatment

Topical emollients

  • Should be recommended when there is an impaired skin barrier function, and used prophylactically after working hours.
  • Adherence to treatment is important, and this may be optimised when patients chose an emollient that they like to use. Patient education on the use of emollients (when, how, which one to choose) may be necessary

Topical corticosteroids

  • First-line treatment in the management of HE
  • Very effective in the short term, but they inhibit repair of the stratum corneum, cause skin atrophy, and interfere with recovery in the long term
  • Continuous long-term treatment beyond 6 weeks be performed only when necessary and under careful medical supervision

Topical calcineurin inhibitors

  • Topical calcineurin inhibitors may be considered for HE patients with long-term need for treatment, although evidence for their efficacy is limited
  • This is an off-label treatment except for patients with HE on an atopic basis

Photo-therapy

  • Can be used in adult patients with chronic HE refractory to first-line treatment (relative to topical corticosteroids)
  • Long-term use of photo-therapy may increase the risk of skin malignancy

Systemic corticosteroids

  • Can be used briefly to treat acute severe HE (generally for a maximum of 3 weeks)
  • Chronic use is not recommended due to potentially serious long-term side-effects

Alitretinoin

  • Approved for use in treating severe, chronic HE that does not respond, or responds inadequately, to topical corticosteroids
  • Pregnancy prevention 1 month before, during, and for 1 month after cessation of treatment, is required in women of child-bearing potential

Cyclosporine

  • May be considered for HE patients with long-term need for treatment if first-and second-line therapy has been insufficient or contra-indicated
  • This is an off-label treatment except for patients with HE on an atopic basis

Other systemic treatments

  • Azathioprine may be considered for HE patients; especially those with atopic HE, with long-term need for treatment if first-and second-line therapy has been insufficient or contra-indicated:
    • no evidence identified on efficacy
    • doctors and patients need to be aware that this is an off-label treatment
  • Methotrexate may be considered for HE patients; especially those with atopic HE, with long-term need for treatment if first-and second-line therapy has been insufficient or contra-indicated:
    • no evidence identified on efficacy
    • doctors and patients need to be aware that this is an off-label treatment
  • Acitretin may be considered for hyperkeratotic eczema of the palm, if first- and second-line therapy has been insufficient or contra-indicated:
    • doctors and patients need to be aware that this is an off-label treatment
    • there is low evidence for the efficacy of acitretin
  • Antihistamines are not recommended for treatment of HE. No evidence identified on efficacy

References

full guideline available from…
onlinelibrary.wiley.com/doi/10.1111/ddg.12510_1/abstract

Diepgen T, Andersen K, Chosidow O et al. Guidelines for diagnosis, prevention and treatment of hand eczema. J Dtsch Dermatol Ges 2015; 13 (1): e1-e22.


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