HAND DERMATITIS

By Gary M. White, MD

Irritant Hand Dermatitis


Hand dermatitis (HD) is an eczematous condition of the hands. It may because by a variety of factors including atopic dermatitis, and irritant or allergic contact dermatitis. In general, this page focuses on irritant hand dermatitis. See also pompholyx, allergic contact dermatitis of the hands, , and hyperkeratotic eczema.

Clinical

Red, scaly, eczematous areas occur on the fingers and hands. The classic patient is someone who washes his/her hands frequently (e.g., a parent who changes many diapers or a homemaker, mechanic, etc.). Tiny tapioca-like vesicles may be seen along the sides of the fingers. This morphology is called pompholyx. Excessive water contact aggravates the condition. Asking healthcare workers to wash their hands more has lead to an increase in the incidence of irritant hand dermatitis in the UK [Br J Dermatol 2015 Feb 05--EPub Ahead of Print].

Wet Work

Wet work, defined as skin in liquids or gloves for more than 2 hours per day puts patients at high risk for HD. The classic professions associated with wet work are bakers, hairdressers, dental assistants, kitchen workers, butchers, doctors, nurses, dentists, veterinarians and laboratory technicians. Hair dressers may develop allergy to glyceryl monothioglycolate and ammonium persulfate. Cement workers commonly develop a hand dermatitis.

Treatment

A hand dermatitis handout is available. Inquiry should be made about the patient's occupation, hobbies, and activities about the house. Does the patient swim often? Excessive exposure to the cold, water, or chemicals can precipitate a hand dermatitis. Allergic contact dermatitis should always be considered. Instruct the patient to use gloves any time his/her hands are in water, e.g., washing dishes, cleaning, etc. Have the patient apply a heavy cream (e.g., Eucerin cream or Neutrogena hand cream) or vaseline to the hands multiple times per day, especially after the hands have been wet. A night-time soak can be very beneficial. The patient may apply a potent topical steroid initially, followed by milder steroids or vaseline. For rough but dry work like gardening, leather or other protective gloves are recommended. Lotions are not nearly as effective as creams/ointments as they are composed primarily of water. For significant redness and inflammation, give a Class I or II topical steroid ointment QD-BID. If all these fail, add cephalexin 250-500 mg QID for 7-10 days.

For painful fissures, a topical antibacterial ointment covered by a bandage and left on overnight is very effective. Alternatively, super glue (e.g., Krazy glue) may be recommended (see the "Fissures" section of the hand dermatitis handout). Topical 5% lidocaine ointment can be helpful for itching.

Treatment-Resistant Hand Dermatitis

Hand dermatitis may be a chronic condition. This is more likely if there is a history of atopic dermatitis, eczema at other sites, and/or onset before 20 years of age.

For persistent hand dermatitis, patch testing should be done to exclude allergic contact dermatitis. For example, a blinded provocation trial showed that the majority of patients with hand eczema and nickel allergy experienced a flare after stacking coins for 4 hours.

At times, azathioprine, mycophenolate mofetil, or methotrexate may be needed. Oral alitretinoin has been used [Arch Dermatol. 2004;140(12):1453-1459] and is approved in the UK as Toctino (usual starting dose 30 mg/day). For flares, IM triamcinolone e.g. 40-60 mg may be helpful. Allergy to ingested substances, e.g., nickel, can cause a vesicular hand dermatitis. See systemic contact dermatitis.

Apremilast has been reported effective in chronic hand dermatitis in case reports [JAAD 2017;77;177].

UVB, PUVA and Excimer Laser

Hand/foot UVB, PUVA or Excimer laser can be very effective. It is often considered as second line therapy in patients who fail topical steroids. The main disadvantage to these therapies is the patient has to come into the office several times a week. The excimer laser can be highly effective for severe dyshidrotic eczema of the hands.

In one retrospective review [Int J Dermatol 2016;55:e447-53] of 30 patients with recalcitrant CHFE (19 with hand involvement, four with foot involvement, and seven with both) treated twice weekly with excimer laser (308 nm) single wavelength ultraviolet (UV)B radiation , improvements in clinical scores included a 69% reduction in average physician's global assessment (PGA) scores (from 2.77 at baseline to 0.87 after treatment, P < 0.0001). Only mild sunburn-like reactions were observed.

Additional Pictures

Irritant Hand Dermatitis Irritant Hand Dermatitis

Irritant Hand Dermatitis

Scabies as shown here may mimic a hand dermatitis.
Irritant Hand Dermatitis Irritant Hand Dermatitis

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