Hand eczema
Encyclopedia
Hand eczema presents on the palms and soles, and may sometimes be difficult or impossible to differentiate from atopic dermatitis
Atopic dermatitis
Atopic dermatitis is an inflammatory, chronically relapsing, non-contagious and pruritic skin disorder...

, allergic contact dermatitis
Allergic contact dermatitis
Allergic contact dermatitis is a form of contact dermatitis that is the manifestation of an allergic response caused by contact with a substance....

, and psoriasis
Psoriasis
Psoriasis is an autoimmune disease that appears on the skin. It occurs when the immune system mistakes the skin cells as a pathogen, and sends out faulty signals that speed up the growth cycle of skin cells. Psoriasis is not contagious. However, psoriasis has been linked to an increased risk of...

, which also commonly involve the hands. Even a biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...

 of all these conditions may not result in a definitive diagnosis, as all three conditions may demonstrate spongiosis
Spongiosis
Spongiosis is mainly intercellular edema between the keratinocytes in the epidermis, and is characteristic of eczematous dermatitis, manifested clinically by vesicles, "juicy" papules, and/or lichenification....

 and crusting on the hands.

Non-communicable inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

 of the skin of the hands is referred to as Hand eczema. Hand eczema is widely prevalent (see epidemiology) and, as it is a very visible condition associated with severe itching or pain, has serious consequences for the affected person including a high psychological impact (see symptoms and complaints). Different disease patterns can be identified according to the course of the illness, appearance of symptoms, degree of severity, or catalysts (see causes and types of illness). Prognosis is hard to predict for individual cases of chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...

 hand eczema and usually differs from patient to patient. Successful treatment depends on determining the causes of the condition, obtaining an accurate diagnosis (see diagnosis and sensible examinations, differential diagnoses), sustainable hand protection procedures and an early, extensive, and where appropriate internal treatment (see treatment ).

Epidemiology

Hand eczema is a common condition: study data indicates a one-year prevalence
Prevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...

 of up to 10% in the general population . It is estimated that only 50 - 70% of people affected consult a doctor . The frequency of severe, chronic and recurrent forms of hand eczema is estimated at 5 - 7%. Approx. 2 - 4% of hand eczema patients also report that external (topical) therapy is insufficient . As the most frequent career-related skin illness, chronic hand eczema often leads to unemployment due to an extended inability to work properly. Several factors adversely affect the long-term prognosis, including the development of the condition prior to the 20th birthday, the severity of initial manifestations and eczema during childhood . Women, especially those under 30, are more frequently affected than men. .

Symptoms and complaints

Normally skin inflammation connected with hand eczema is accompanied by blister formation and pronounced itching, but solid calluses and painful tearing
Tearing
Tearing is the act of breaking apart a material by force, without the aid of a cutting tool. A tear in a piece of paper, fabric, or some other similar object may be the result of the intentional effort with one's bare hands, or be accidental...

 may also occur. The quality of life of the affected person is seriously diminished, especially in the case of chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...

 forms of the illness, and psychological impact is often very high. This impact is enhanced by the high visibility of the illness on the hands, which may lead to feelings of shame and fear of rejection.

Causes and types of illness

There are a number of different causes of skin inflammation of the hands , the interplay of which is also significant: environmental factors such as excessive water; contact with allergens or irritants; and genetic disposition . A single catalyst is seldom responsible for the development of hand eczema in patients .

Differences according to catalysts

Three main factors play an essential role in the development of chronic hand eczema: excessive contact with water and irritants (cumulative-toxic stress), contact with allergens, and atopic diathesis, which has a genetic component. Individual hand eczema types are identified and named according to the main catalysts involved, i.e. cumulative-toxic, contact-allergenic, or atopic hand eczema. Activities that are stressful for the skin or involve repeated, excessive contact with water or skin-irritating substances at work or home can cause damage to the skin's protective abilities and increase the chances of inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

. This also applies to prolonged wearing of protective rubber gloves and similar materials, since sweating occurs within these gloves. Disturbance of the skin's protective barrier also facilitates penetration by allergenic substance
Allergen
An allergen is any substance that can cause an allergy. In technical terms, an allergen is a non-parasitic antigen capable of stimulating a type-I hypersensitivity reaction in atopic individuals....

s and promotes the development of contact dermatitis. Contact allergies play a very important role in the development of hand eczema. If the hand is subjected to repeated contact with a substance that leads to an allergy, the skin reacts with signs of inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

. Numerous people affected by hand eczema also experience skin inflammation on their feet. Often, a contact allergy to an ingredient in shoe leather treatment may be the catalyst. Contact allergies in certain types of employment are especially problematic, particularly if the work involves the handling of allergenic materials, e.g. masonry work or hairdressing.

Severe and chronic eczema qualifies as one of the most frequent occupational illnesses. Patients should therefore be referred to an occupational-dermatological specialist as soon as possible. Patients with a history of neurodermitis, hay fever, or allergic asthma often develop hand eczema. These sicknesses reflect the individual's particular susceptibility or genetic predisposition to react over-sensitively to various environmental influences. This is described as atopy or atopy diathesis. Atopic diathesis is frequently accompanied by genetically conditioned problems with the skin's protective barriers, which causes a weakening of the skin's resistance against irritating substances and moisture, as well as easier penetration by allergens, which may lead to the development of contact allergies.

Differences according to prevailing signs of skin illness (morphology)

The clinical appearance of various subtypes of hand eczema differs. The term dyshidrotic
Dyshidrosis
Dyshidrosis is a skin condition that is characterized by small blisters on the hands or feet...

hand eczema is used to describe formations that mainly exhibit pronounced, itching blister formations, while callus and tear formations typically indicate hyperkeratotic fissured hand eczema.

Differences according to degree of severity and course

Independent of the triggering cause or the prevailing signs of skin illness, the selection and planning of treatment options is important, since different types of illness also differ in terms of their degree of severity and the course of the illness. While light hand eczema heals relatively quickly following dermatological therapy and patient participation, more pronounced hand eczema may persist over several weeks. Severe hand eczema is characterised by consistent or recurring, extended inflammation of the skin that severely affects the patient. Hand eczema is described as chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...

 if it lasts at least 3 months in spite of dermatological treatment or if it recurs at least twice within a period of 12 months (relapsed)
Relapse
Relapse, in relation to drug misuse, is resuming the use of a drug or a dependent substance after one or more periods of abstinence. The term is a landmark feature of both substance dependence and substance abuse, which are learned behaviors, and is maintained by neuronal adaptations that mediate...

 . Severe and chronic patterns of hand eczema are often resilient to treatment, making the condition extremely stressful for those affected.

Diagnosis and sensible examinations, differential diagnoses

During diagnosis it is important to determine the type of hand eczema and plan specific treatment accordingly. An additional diagnosis of allergies will indicate whether contact allergies or atopy diathesis are the cause of the hand eczema. Discussion concerning frequency of contact with water, irritants, and allergens in private and professional environments will also help evaluate individual stresses on the patient's skin. The hands may also exhibit various other skin illnesses and potential fungal infection
Mycosis
A mycosis is a fungal infection of animals, including humans. Mycoses are common, and a variety of environmental and physiological conditions can contribute to the development of fungal diseases...

 or psoriasis
Psoriasis
Psoriasis is an autoimmune disease that appears on the skin. It occurs when the immune system mistakes the skin cells as a pathogen, and sends out faulty signals that speed up the growth cycle of skin cells. Psoriasis is not contagious. However, psoriasis has been linked to an increased risk of...

 must be ruled out. Usually, taking the patient’s personal history into account will help provide an accurate diagnosis.

Treatment

Hand eczema is a complex condition and treatment should only be administered by a dermatologist with specialist knowledge. For any patient and their dermatologist, treatment of hand eczema may be very costly. Treatment should follow certain basic principles, and chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...

 and severe cases of hand eczema in particular require complex treatment concepts. Besides skin care, hand protection, and external (topical) applications with preparations containing effective ingredients or light therapy, an internal (systemic) therapy may be considered Warshaw EM, et al.:Therapeutic options for chronic hand dermatitis. Dermatol Ther 2004; 17(3): 240–50. PMID 15186370.

Avoidance of catalysts, basic procedures, and skin protection

First of all, catalysts for the development of chronic hand eczema, such as skin-irritating damage, excessive contact with water or proven allergenic substances, must be strictly removed and avoided. Treatment of every type of hand eczema and degree of severity must include sustainable replenishment of the natural oils and moisture contained in the skin with creams and salves free of fragrances and preservatives; this is an essential basic step. In addition, protection procedures developed especially for the individual's skin stresses must be applied, e.g. use of cotton or hypoallergenic plastic gloves. Depending on the individual's own needs, these procedures should continue after the hand eczema heals, since they will also have a preventative effect.

External treatment

External treatment should be oriented primarily according to the prevailing signs of illness. In the case of blister forming, drying treatments such as hand baths containing synthetic tannins or oily-moist preparations may hinder itching. If callus development exhibiting tear formation is present, the focus should be on softening the skin with preparations containing urea
Urea
Urea or carbamide is an organic compound with the chemical formula CO2. The molecule has two —NH2 groups joined by a carbonyl functional group....

 or salicylic acid
Salicylic acid
Salicylic acid is a monohydroxybenzoic acid, a type of phenolic acid and a beta hydroxy acid. This colorless crystalline organic acid is widely used in organic synthesis and functions as a plant hormone. It is derived from the metabolism of salicin...

. In order to reduce inflammation, creams and salves containing cortisone
Glucocorticoid
Glucocorticoids are a class of steroid hormones that bind to the glucocorticoid receptor , which is present in almost every vertebrate animal cell...

 are often very effective. However, severe and chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...

 cases seldom respond sufficiently and require long periods of treatment which can increase the risk of side effects occurring. In individual cases, and especially in case of atopic hand eczema, the dermatologist may prefer to use cortisone-free, anti-inflammatory creams or salves, which include so-called "calcineurin inhibitors" tacrolimus
Tacrolimus
Tacrolimus is an immunosuppressive drug that is mainly used after allogeneic organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection...

 or pimecrolimus
Pimecrolimus
Pimecrolimus is an immunomodulating agent used in the treatment of atopic dermatitis . It is currently available as a topical cream, once marketed by Novartis under the trade name Elidel.-Pharmacology:Pimecrolimus is an ascomycin macrolactam derivative...

.

Phototherapy

Phototherapy can be effective in the treatment of chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...

 hand eczema. However, not all dermatologists or dermatology clinics offer this form of therapy, and it involves extended periods of treatment for the patient. A period of four to six weeks should involve 3 - 4 radiation sessions. The most frequently applied form of light therapy is PUVA
PUVA
PUVA is a psoralen + UVA treatment for eczema, psoriasis, graft-versus-host disease and vitiligo, and mycosis fungoides. The psoralen is applied or taken orally to sensitize the skin, then the skin is exposed to UVA. Long term use has been associated with higher rates of skin cancer.Psoralens are...

 therapy. This first treats the hands with a cream that contains an ingredient that causes the skin to become light-sensitive, the hands are then irradiated with ultraviolet A light  (UV-A). After two days of treatment, a pause of one day must occur. Due to possible risks such as premature skin aging or chronic light damage caused to the skin, photptherapy cannot be considered for the long term.

Systemic treatment

Besides skin care, skin protection, and an external treatment, severe and chronic
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...

 cases of hand eczema often also require systemic treatment. Various preparations are available for this. For acute, severe episodes exhibiting blister formation, internal cortisone preparations, sometimes in combination with certain antibiotics, may be helpful in the short term. The active agent ciclosporin
Ciclosporin
Ciclosporin , cyclosporine , cyclosporin , or cyclosporin A is an immunosuppressant drug widely used in post-allogeneic organ transplant to reduce the activity of the immune system, and therefore the risk of organ rejection...

, which is approved for treatment of severely pronounced neurodermitis, may also be used for severe, atopic hand eczema. Other substances that suppress the immune system
Immune system
An immune system is a system of biological structures and processes within an organism that protects against disease by identifying and killing pathogens and tumor cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own...

 have also shown effectiveness in some cases. However, these substances are not approved for hand eczema.

In the last couple of years an internal medicine has been approved for the first time for the treatment of chronic hand eczema . This involves a derivative of vitamin A
Retinoid
The retinoids are a class of chemical compounds that are related chemically to vitamin A. Retinoids are used in medicine, primarily due to the way they regulate epithelial cell growth....

, called alitretinoin, which is also naturally present in the human body. Alitretinoin can be used to treat all forms of severe chronic hand eczema which have not reacted to external cortisone preparations. The effectiveness of this form of treatment has been tested extensively in clinical study programs and proven prior to its approval . The trial results showed that two thirds of patients did not suffer a recurrence 6 months after application of the medication, and that re-treatment is effective if hand eczema reoccurs . The duration of alitretinoin treatment is 3 to 6 months. During treatment and one month prior to beginning and one month after completion, women of childbearing-age must use contraceptives and also test for pregnancy each month since, as with all derivatives of vitamin A, the substance involved is teratogenic. Side effects mainly include temporary headaches during the initial days of treatment, as well as a possible increase in blood fat and cholesterol
Cholesterol
Cholesterol is a complex isoprenoid. Specifically, it is a waxy steroid of fat that is produced in the liver or intestines. It is used to produce hormones and cell membranes and is transported in the blood plasma of all mammals. It is an essential structural component of mammalian cell membranes...

 values. Regular laboratory tests of blood values are recommended to monitor this.

See also

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