Hand dermatitis (or eczema) may be classified as being of constitutional, contact or mixed origin. It may or may not be associated with dermatitis at other sites.
Occupational factors may be important, and having hand dermatitis may prevent the patient from working. Hand dermatitis is particularly common in industries involving cleaning, catering, metalwork, hairdressing, healthcare and mechanical work.
Hand dermatitis may affect palms, dorsum or both. Often it starts as a mild intermittent complaint, but it can become increasingly severe and persistent. It can present acutely (with blisters and oedema) or persist as a chronic condition characterised by dry skin and fissures.
Mostly hand dermatitis is bilateral and fairly symmetrical, but some forms of contact dermatitis may be unilateral or asymmetrical, tending to favour the dominant hand.
Atopic dermatitis Atopics may develop non-specific hand dermatitis at any age. They are also more prone to contact irritant dermatitis than non-atopics because of defective skin barrier function. Various clinical patterns may arise.
Pompholyx Pompholyx, also known as dyshidrotic or vesicular palmar eczema, refers to acute, chronic or relapsing blistering of the fingers, palms and/or soles. Crops of irritable deep-seated vesicles are followed by scaling and fissuring of the affected areas and may be complicated by Staphylococcus aureus infection. Sweating in response to emotional stress or heat may precipitate vesicles in some individuals. Pompholyx sometimes presents as an id reaction to tinea pedis (‘one foot, two hands’ syndrome) or as an expression of contact dermatitis to nickel.
Nummular dermatitis Nummular dermatitis may affect any site including the hands, resulting in round or oval, dry or exudative plaques; surrounding skin may appear entirely normal. Contact factors may or may not play a part as affected plaques can arise in areas of skin that have been injured in some way. In most cases, typical nummular (discoid) plaques are found elsewhere, particularly the forearms and lower legs.
Contact irritant dermatitis
The most common occupational factor leading to dermatitis is frequent immersion of the hands in water especially in combination with detergents and solvents. These injure surface keratinocytes reducing the effectiveness of the stratum corneum as a barrier. Friction and repetitive injury also damage the skin. Irritants result in much more damage once dermatitis has become established; a few minutes carelessness can result in a flare-up that can last for several months.
Contact allergic dermatitis
Specific immunological hypersensitivity can result in immediate or delayed reactions.
Immediate contact urticaria is most frequently caused by latex gloves; itchy weals last for about 20 minutes. Other causes include paraphenylenediamine (permanent hair dye), fragrances, plants and fish. Contact urticaria is usually localised but can rarely precipitate generalised anaphylaxis.
Allergic contact dermatitis is delayed for hours to days after the contact has occurred, so it can be difficult to identify the cause. There are a huge number of items that can cause allergic contact dermatitis, including nickel and other metals, fragrances, rubber accelerators, hair dye, adhesives and preservatives.
Once a specific allergy has been identified and confirmed by patch testing, contact with the causative material must be strictly avoided long term to clear up the dermatitis and to prevent its recurrence.
Nail dystrophy Nails are involved when hand dermatitis affects the distal phalanx, particularly when the dermatitis is predominantly palmar but sometimes when it is dorsal. Chronic paronychia may be a variant of dermatitis especially when culture negative for candida.
Skin swabs for Staphylococcus aureus are sometimes required if antibiotic treatment is not proving effective in apparently infected hand dermatitis.
Skin scrapings for microscopy and fungal culture may be necessary to rule out dermatophyte infection.
Patch testing should be carried out in chronic cases or if there is suspicion of specific contact allergy.
Hand dermatitis is most commonly confused with the following skin disorders:
Many other inflammatory skin diseases may also affect hands.
Management of hand dermatitis involves:
With careful management, hand dermatitis usually recovers completely. It may be necessary to discontinue work for days, weeks or months; compensation from ACC sometimes applies. Occasionally a change of occupation is necessary.
Describe the aetiology and management of hand dermatitis in nurses.
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