REVIEW ARTICLE Hand dermatitis/eczema: Current management strategy Virendra N. SEHGAL, 1 Govind SRIVASTAVA, 2 Ashok K. AGGARWAL, 2 Alpna D. SHARMA 2 1 Dermato-Venereology (Skin ⁄ VD) Center, Sehgal Nursing Home, Panchwati, Delhi, and 2 Skin institute and School of Dermatology, Greater Kailash, New Delhi, India ABSTRACT Ever since its inception a couple of centuries ago, hand dermatitis ⁄ eczema has been in the reckoning. Idiosyncra- sies continued to loom large thereafter, till it acquired its appropriate position. Dermatitis ⁄ eczema are synonymous, often used to indicate a polymorphic pattern of the inflammation of the skin, characterized by pruritus, erythema and vesiculation. A spectrum delineated into acute sub-acute and chronic dermatitis of the hands. Pompholyx, recurrent focal palmer peeling, ring, wear and tear and fingertip eczema, apron, discoid eczema, chronic acral der- matitis, gut and patchy papulosquamous eczema are its clinical variants. Occupational dermatitis ⁄ eczema may be contributory. Etiological definitions are clinched by detailed history of exogenous and endogenous factors. However, scientific confirmation of the entity is through patch testing by using available antigens. Key words: hand dermatitis ⁄ eczema: clinical classification, occupational dermatitis ⁄ eczema. INTRODUCTION Hands are an integral part of our life from execution of day-to-day activities to earning a livelihood. They are also of great aesthetic and cosmetic value. The hands when diseased or incapable of work, become a seri- ous disability, responsible for loss of manpower and large scale loss of national productivity. Besides, it causes individual psychosocial trauma and affects quality of life. Hand dermatitis (HD) ⁄ eczema is mainly confined to the hands. Dermatitis ⁄ eczema are often used synon- ymously to indicate a polymorphic pattern of the inflammation of the skin, characterized by pruritus, erythema and vesiculation. Hand eczema is a fre- quently encountered problem, affecting individuals from all walks of life, involved in different fields of work. In the absence of required care and therapy, it may turn into a chronic, distressing disease largely influencing an individual’s daily life. Both endogenous and exogenous factors may contribute to the devel- opment of HD ⁄ eczema. Endogenous factors refer to conditions like atopic dermatitis, hyperkeratotic pal- mer dermatitis and the like, while exogenous factors include both systemic and topical irritants, allergens, inhalants, ingestants and infections. In situations where an inflammatory response of the skin occurs following exposure to exogenous substance ⁄ allergen ⁄ irritant, it is designated as con- tact dermatitis. Also, irritant and ⁄ or allergic contact dermatitis, phototoxic and photo-allergic contact der- matitis, an immediate type of contact reaction, are also included in the category. Contact dermatitis is an alarming problem all over the world. Whole popula- tion studies and examinations of random samples of people have put its incidence at 1.5–6%, whereas in an occupational environment contact dermatitis accounts for approximately 90% of dermatoses. 1,2 In Correspondence: Virendra N. Sehgal, M.D., FNASc, FAMS, FRAS, A-6 Panchwati, Delhi 110 033, India. Email: [email protected]Received 17 September 2009; accepted 1 November 2009. doi: 10.1111/j.1346-8138.2010.00845.x Journal of Dermatology 2010; 37: 593–610 Ó 2010 Japanese Dermatological Association 593
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REVIEW ARTICLE
Hand dermatitis/eczema: Current managementstrategy
Virendra N. SEHGAL,1 Govind SRIVASTAVA,2 Ashok K. AGGARWAL,2
Alpna D. SHARMA2
1Dermato-Venereology (Skin ⁄ VD) Center, Sehgal Nursing Home, Panchwati, Delhi, and 2Skin institute and School of Dermatology,
Greater Kailash, New Delhi, India
ABSTRACT
Ever since its inception a couple of centuries ago, hand dermatitis ⁄ eczema has been in the reckoning. Idiosyncra-
sies continued to loom large thereafter, till it acquired its appropriate position. Dermatitis ⁄ eczema are synonymous,
often used to indicate a polymorphic pattern of the inflammation of the skin, characterized by pruritus, erythema
and vesiculation. A spectrum delineated into acute sub-acute and chronic dermatitis of the hands. Pompholyx,
recurrent focal palmer peeling, ring, wear and tear and fingertip eczema, apron, discoid eczema, chronic acral der-
matitis, gut and patchy papulosquamous eczema are its clinical variants. Occupational dermatitis ⁄eczema may be
contributory. Etiological definitions are clinched by detailed history of exogenous and endogenous factors. However,
scientific confirmation of the entity is through patch testing by using available antigens.
matitis is related to a disturbed barrier function, and
an increased epidermal cell turnover leading to liche-
nification, whereas an acute ICD is more of an inflam-
matory reaction caused by release of mediators and
cytokines like tumor necrosis factor-a, interleukin (IL)-
1, IL-6, IL-8, c-interferon (IFN-c), IL-2 and granulocyte
monocyte-colony stimulating factor.51
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Hand dermatitis ⁄ eczema
Allergic contact dermatitis
Allergic contact dermatitis is a delayed hypersensitiv-
ity reaction mediated by T cells. Under ordinary con-
ditions, exposure to contact allergens sets in motion
two competing mechanisms, the one mediated by
effecter T-lymphocytes leading to a state of hyper-
sensitivity that becomes clinically manifest as an
eczematous skin reaction, while the other is mediated
by regulatory T cells leading to a relative or complete
tolerance of allergen. The balance between effecter
and suppressor cells is determined by the state of
reactivity of the skin.
Antigenicity is accomplished by the conjugation of
the small molecules with autologous proteins present
on the skin. Most of these proteins are the cell mem-
brane proteins.
It is not possible for T-lymphocytes to interact
directly with the contact antigen even when they pos-
ses the appropriate surface receptors for that anti-
gen. The antigen must first be processed and then be
presented in a suitable form in which it associates
with major histocompatibility complex class II mole-
cules, coded in the human leukocyte antigen-differ-
entiation region (HLA-DR) genes present in dendritic
cells, Langerhans cells (LC) or antigen-presenting
cells. Epidermal LC have properties that make them
particularly suitable for this function. Epicutaneously
applied allergen molecules attach with their antigen-
presenting cells within 6 h.52 Within 24 h of antigen
application, LC migrate to regional lymph nodes
where they present the antigen to the compatible
T-lymphocytes within the lymph nodes. Certain
T-lymphocytes like CD4+ and CD45 RA+ become
physically apposed to the LC, thus facilitating the
transfer of antigen. Ever since the role of LC in skin
immunity was established it has been investigated
extensively.53–55 Recent data deriving from trans-
genic animals that are deficient in LC have begun to
challenge the dogma that there is a universal require-
ment for these cells in the development of skin sensi-
tization. Accordingly, relationships between LC
mobilization, draining lymph node activation, and skin
sensitization using immunomodulators agonistic for a
family of sphingosine-1-phosphate (S1P) receptors
have been highlighted in a recent commentary.56
Many mediators or cytokines are released by this
apposition, namely, IL-1 by antigen-presenting cells
and IL-2 by T-lymphocytes.57 Other cytokines that
are important at this stage are IL-6, transforming
growth factor-b and IL-12. The cytokines cause
clonal proliferation of antigen-specific T-helper 1,
CD4+ lymphocytes which might be capable of
responding to a particular antigen when future
exposure occurs.
The cellular response seem to be based on an
increased frequency of T cells with a given specificity
throughout the body of a sensitized individual, and
takes 7–10 days before there are sufficient numbers
of T-lymphocytes to cause contact dermatitis. On
subsequent exposure, antigen-presenting cells and
specific T cells meet locally, leading to cytokine pro-
duction within the skin, thus leading to development
of an erythematous reaction, which reaches a maxi-
mum in 18–48 h.
Cytokines that play a major role in the development
of allergic contact dermatitis are those with a major
stimulatory effect on other lymphocytes (MIP-1b, IL-2,
IFN-c), on mononuclear phagocytes (chemotactic
factor, migration inhibitory factor, IFN-a) and on mast
cells and vasculature (skin reactive factor, IFN-c).
CLINICAL CLASSIFICATION
The etiological classification of HD has already been
described (vide supra). However, no single classifica-
tion of hand eczema is completely satisfactory. A sim-
ple method is to classify it according to the stage of
eczema:
1 Acute: clinical features range from erythema, chap-
ping to a florid dermatitis with edema, inflammation,
vesiculation, pain, exudation, bullae formation and
tissue necrosis.
2 Subacute: milder, characterized by erythema, pap-
ules and crusting.
3 Chronic: lichenification characterized by thickening
of the skin, exaggerated skin marking, scaling and
pigmentation.
The preceding classification is easy to comprehend
and facilitates treatment approach.
However, an anatomical classification is useful in
defining the etiology of HD. A morphological classifi-
cation of hand eczema is often suggested. Although
most cases are of a patchy vesiculosquamous nature
without any special characteristics, one-third of cases
present particular patterns that deserve recognition
and are outlined below.
598 � 2010 Japanese Dermatological Association
V.N. Sehgal et al.
Pompholyx
Pompholyx is a frequent deep-seated vesicular erup-
tion of idiopathic ⁄unknown origin affecting the palm
and soles recognized as palmoplantar pompholyx.58
It has been assumed to be a disturbance of sweat
gland function. Pompholyx is of the hands (cheiro-
pompholyx) (Figs 2,3) and of the soles (podopompho-
lyx). It accounts for 5–20% of all cases of hand
eczema.20,32
The role of sweat glands is disputed, although dis-
tribution of lesions corresponds to emotionally acti-
vated palmoplantar sweating and hot weather.
However, hyperhidrosis is not a constant feature.
Role of atopy may be significant. Lodi et al.58 found
personal and family history of atopy in 50% of their
patients as compared to 12% controls. Primary irri-
tants may cause pompholyx, for example in metal
workers exposed to soluble oils.59 Contact allergens
known to cause pompholyx are primin, isopropyl para
phenylene diamine, benzisothiazol ones, dichro-
mates, perfumes, fragrances, balsam and even nickel
sulfate. It was found that many nickel-sensitive
patients presented with this pattern of hand eczema
and produced flares on ingesting oral nickel sulfate.60
Chromium61 and cobalt have also been implicated,
and dermatophyte infection is another factor causing
‘‘id’’ reaction in the form of symmetrical vesicular
eruption. Aspirin ingestion, oral contraceptives and
regular smoking also increase the risk of pompholyx.
Clinically, an episode of pompholyx is character-
ized by sudden onset of crops of clear vesicles, which
appear deep-seated and sago-like. There is no ery-
thema, but a sensation of heat and prickling of the
palms may precede the attacks. Vesicles may
become confluent and present as large bullae. Reso-
lution with desquamation occurs in 2–3 weeks.
Rubbing and inappropriate treatment may produce
secondary eczematous changes. Nails can be
involved. The attacks can occur at intervals of
3–4 weeks for months or years; and there may also
be a pattern of summer aggravation.
Recurrent focal palmer peeling
This condition is probably a mild form of pompholyx,
presenting with small areas of superficial, white
(a)
(b)
Figure 2. (a,b) Hand dermatitis ⁄eczema: pompholyx show-ing multiple vesicles on the thenar eminence of the palmsextending to dorsa of the hands.
Figure 3. Hand dermatitis ⁄eczema: pompholyx keratoticscaly lesions of the hands.
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Hand dermatitis ⁄ eczema
desquamation on the sides of fingers and on palms
or on feet, mainly during summer months. There are
usually no vesicles, but some patients may subse-
quently develop true pompholyx. The condition is rel-
atively asymptomatic.
Hyperkeratotic palmer/tylotic eczema
Hyperkeratotic palmer ⁄ tylotic eczema is a distinct
form with highly irritable, scaly fissured, hyperkera-
totic patches on the palms and palmer surfaces of
fingers (Fig. 4), seen frequently in men of middle age.
Etiology is unknown, and patch tests are usually neg-
ative. However, in an Indian study of 230 patients
who were patch tested, contact sensitivity was
detected in 130, mainly by vegetables (garlic, onion),
followed by detergents, metals, rubber, leather, plas-
tic, fertilizers and drugs.62
Ring eczema
In ring eczema, an irritable patch of eczema begins
under a ring and typically spreads to involve the adja-
cent side of the middle finger and adjacent area of
the palm. This characteristic pattern commonly
affects young women, more so after marriage or
childbirth. However, as may be commonly thought,
these patients do not show sensitivity to gold, copper
and rarely to white gold alloys. Nickel, cobalt and
chromium sensitivity are found on patch testing, but
this type of hand eczema is primarily by concentra-
tions of soap and detergents beneath rings, with
micro-trauma or friction also playing a role. Ring der-
matitis has also been described as a clinical presen-
tation of fragrance sensitization.63 The dermatitis
remains confined or may occasionally show discoid
patches elsewhere or a diffuse vesicular eczema.
Wear and tear/asteatotic dermatitis/eczema/
housewives’ dermatitis/dry palmer eczema/
dermatitis palmeris sicca
This variant is due to a combined effect of asteatosis,
exposure to mild irritants and trauma. It is commonly
seen in housewives and cleaners who frequently
immerse their hands in water and detergents.
Accordingly, the horny layer of the skin gets dam-
aged, the skin over the palms becomes dry, appears
crisscrossed with superficial cracks and loses its nor-
mal pliability. There may be associated dryness and
chapping of skin over dorsa of knuckle joints. Exuda-
tion and weeping are not usually seen. The condition
is usually bilateral (Fig. 5).
Fingertip eczema
As the name suggests, fingertip eczema is a condi-
tion that characteristically involves the palmer sur-
face of the tips of some or all of the fingers. Skin is
dry, cracked and glazed and breaks down into
painful fissures (Fig. 6). It usually remains localized.
Two clinical patterns have been described. The first
type involves most or all of the dominant hand, par-
ticularly thumb and forefinger, and worsens in win-
ter. It is most likely more of a cumulative irritant
dermatitis due to degreasing agents and to trauma.
The second pattern involves preferentially the
thumb, forefinger and the third finger of one hand
and is usually occupational. It may be irritant or
allergic, seen with colophony, formaldehyde, tulip
bulbs41 or certain vegetables like onion and garlic
held in the fingers. Patch tests are relevant in the
second pattern.
Apron eczema
Apron eczema is a type of hand eczema that involves
the proximal palmer aspect of two or more adjacent
fingers and the contiguous palmer skin over the
metacarpophalangeal joints, thus resembling an
apron. Rarely, it is caused by contact allergens, but
may reflect the effect of irritants. It is more common
in women and is largely endogenous.64Figure 4. Hand dermatitis ⁄eczema: hyperkeratotic palmer ⁄tylotic eczema and hyperkeratosis of the palms.
600 � 2010 Japanese Dermatological Association
V.N. Sehgal et al.
Discoid eczema
Discoid eczema is characterized by circular and ⁄or
oval plaques of eczema with a clearly demarcated
edge and normal intervening skin. The plaques usu-
ally recur at the same site. Both sexes are equally
affected. Various possibilities regarding its etiology
include an atopic diasthesis,65,66 role of infection,
local physical and chemical trauma, sensitivity to spe-
cific allergens and emotional stress. Role of contact
allergens was shown in a study on 48 patients with
discoid eczema of whom eight had hand eczema. A
high percentage of these showed clinically-relevant
positive patch tests with rubber, chemicals and met-
als as the common allergens.67 In an Indian study on
50 patients with discoid eczema, patch testing analy-
sis showed a positive reaction to allergens in 56%,
with potassium dichromate as the most common
allergen (20%), followed by nickel (16%), cobalt chlo-
ride and fragrances (12% each).68 Discoid eczema
may be recognized in three different patterns:
(i) hands and forearms; (ii) limbs and trunk; and (iii) dry
discoid eczema.
Discoid eczema of the hands affects the dorsa of
the hands or the backs or the sides of individual fin-
gers. It often develops as a single plaque, occurring
at the site of a burn or local chemical ⁄ irritant reaction.
Secondary lesions may occur on the hands, fingers
or forearms. In the acute phase, lesions are dull red,
oozy, crusted and go on to become less vesicular
and more scaly as they progress, with a central clear-
ing and peripheral extension.
Chronic acral dermatitis
Chronic acral dermatitis is a distinctive syndrome
affecting middle-aged patients, and is characterized
by pruritic, hyperkeratotic papulovesicular eczema of
(a) (b) (c)
Figure 5. (a,b) Hand dermatitis ⁄eczema: housewives’ dermatitis. (c) Skin over the palms is dry, criss-crossed and hassuperficial cracks.
(a)
(b)
Figure 6. (a,b) Hand dermatitis ⁄eczema: fingertip dermatitis.Dry, cracked, glazed skin, breaking down into painful ero-sions, affecting the palmer surface of the fingers.
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Hand dermatitis ⁄ eczema
the hands and the feet. It is associated with grossly
elevated immunoglobulin (Ig)E levels without any per-
sonal or family history of atopy.
Gut/slaughterhouse eczema.
Gut ⁄slaughterhouse eczema is seen as a transient
vesicular eczema which begins from the webs of the
fingers and spreads to the sides. Each episode may
be mild and may clear spontaneously but recurs at
regular intervals. This specifically affects workers
engaged in evisceration of carcasses of animals in
Figure 7. (a,b) Hand dermatitis ⁄eczema: erythema, indura-tions erosions pigmentations, with prominent skin marking,affecting dorsal and palmer surface of the hands.
602 � 2010 Japanese Dermatological Association
V.N. Sehgal et al.
gardening, automobile repairs and domestic work.
Various irritants and sensitizers implicated are rubber,
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