Hand dermatitis

Author: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, 1997.


What is hand dermatitis?

Hand dermatitis is a common group of acute and chronic eczematous disorders that affect the dorsal and palmar aspects of the hand.

Hand dermatitis is also known as hand eczema.

Who gets hand dermatitis?

Hand dermatitis is common (especially in young adult females) and accounts for 20–35% of all dermatitis. It may occur at any age, including during childhood. It is particularly prevalent in people with a history of atopic eczema.

Hand dermatitis is particularly common in industries involving cleaning, catering, metalwork, hairdressing, healthcare, housework, painting and mechanical work. This is mainly due to the contact with irritants, but specific contact allergies can contribute.

What causes hand dermatitis?

Hand dermatitis often results from a combination of causes, including:

Hand dermatitis is frequently caused or aggravated by work, when it is known as occupational dermatitis.

Irritants include water, detergents, solvents, acids, alkalis, cold, heat and friction. These damage the outer stratum corneum, removing lipids and disturbing the skin’s barrier function. Water loss and inflammation lead to further impairment of barrier function.

Contact allergy is a delayed hypersensitivity reaction with elicitation and memory phases involving T lymphocytes and release of cytokines.

What are the clinical features of hand dermatitis?

Hand dermatitis may affect the backs of the hands, the palms or both. It can be very itchy, often burns, and is sometimes painful. It has acute, relapsing and chronic phases.

Acute hand dermatitis presents with:

  • Red macules, papules and plaques
  • Swelling
  • Blistering and weeping
  • Fissuring.

Features of chronic hand dermatitis include:

  • Dryness and scale
  • Lichenification.

There are various causes and clinical presentations of hand dermatitis.

Atopic hand dermatitis

Atopic hand dermatitis depends on constitutional weakness of the skin barrier function and is triggered by contact with irritants. It may affect one or both dorsal hands and palms. It may manifest as a discoid pattern of eczema. Patients may also have eczema in other sites including feet, hands, flexures.

Nummular dermatitis

Nummular dermatitis or discoid eczema tends to affect the dorsal surfaces of the hands and fingers as circumscribed plaques. Other sites of the body may or may not be affected.

Vesicular hand dermatitis

Vesicular hand dermatitis is also known as pompholyx, cheiropompholyx and dyshidrotic eczema. Intensely itchy crops of skin-coloured blisters arise on the palms and the sides of the hands and fingers. Similar symptoms often affect the feet. It is likely this form of dermatitis is triggered by emotional stresses via sweating (hyperhidrosis).

Chronic relapsing vesiculosquamous dermatitis

Chronic relapsing vesiculosquamous dermatitis is a common pattern of palmar and finger dermatitis, in which episodes of acute vesicular dermatitis are followed by chronic scaling and fissuring.

Hyperkeratotic hand dermatitis

Hyperkeratotic hand dermatitis is a chronic, dry, non-inflammatory palmar dermatitis. It can appear similar to palmar psoriasis, but is less red and less well circumscribed.

Fingertip dermatitis

Fingertip dermatitis can be isolated to one or several fingers.

Irritant contact dermatitis

The hands are the most common site for irritant contact dermatitis, and is often due to wet work and repeated exposure to low-grade irritants. The finger-webs are the first place to be affected, but inflammation can extend to fingers, the backs of the hands and the wrists. Irritant contact dermatitis often spares the palms.

  • Acute irritant dermatitis is due to injury by potent irritants such as acids and alkalis, often in an occupational setting.
  • Repeated exposure to low-grade irritants such as water, soaps, and detergents leads to chronic cumulative irritant dermatitis.

Allergic contact dermatitis

Allergic contact dermatitis may be difficult to distinguish from constitutional forms of hand dermatitis and irritant contact dermatitis. There are about 30 common allergens and innumerable uncommon or rare ones. Common allergens include nickel, fragrances, rubber accelerators (in gloves) and p-phenylenediamine (permanent hair-dye). Clues to contact allergy depend on the allergen, but may include:

  • Periodic flare-ups associated with certain tasks or places hours to days earlier
  • Irregular, asymmetrical distribution of rash
  • Sharp border to the rash (eg, at wrist corresponding with cuff of rubber glove).
Hand dermatitis

See more images of hand dermatitis ...

Complications of hand dermatitis

  • Bacterial infection (staphylococci and/or streptococci) can result in pustules, crusting and pain.
  • Dermatitis at the ends of the fingers may result in deformed nails.
  • Dermatitis can spread to affect other sites, particularly the forearms and feet.

How is hand dermatitis diagnosed?

Hand dermatitis is usually straightforward to diagnose and classify by history and examination, considering:

  • Acute, relapsing or chronic course
  • Past history of skin disease
  • Dermatitis on other sites.

Differential diagnosis includes:

  • Contact urticaria — for example, to latex gloves (immediate redness, itching and swelling that resolves within an hour)
  • Protein contact dermatitis, most often affecting caterers (combination of urticaria and dermatitis induced by reactions to meat)
  • Psoriasis (symmetrical, well circumscribed, red, scaly plaques)
  • Tinea manuum (unlilateral or asymmetrical, peripheral scale).

Patients with chronic hand dermatitis may have patch tests to detect contact allergens.

Patch tests in patients with hand dermatitis

What is the treatment for hand dermatitis?

Patients with all forms of hand dermatitis should be most particular to:

  • Minimise contact with irritants — even water
  • Use non-soap cleanser when washing hands, rinse carefully, and ensure hands are completely dry afterwards
  • Completely avoid touching allergens that have been identified by patch testing
  • Wear task-appropriate protective gloves
  • Apply thick emollients before work/school and reapply after washing or when the skin dries out (this may be 10–20 times in a day).

Vinyl gloves are less likely than rubber gloves to cause allergic reactions.

  • They must be scrupulously clean and should have no holes.
  • They should not be worn for long periods.
  • Sweating under the gloves aggravates dermatitis.
  • Lined gloves or inner cotton gloves improve comfort.

Topical steroids reduce inflammation.

  • Use a potent topical steroid on dermatitis on the backs of the hands and an ultrapotent topical steroid on palms.
  • Cream formulation is usually best for vesicular hand dermatitis, and ointment for chronic dermatitis.
  • They should be applied to areas of active dermatitis once or twice daily for several weeks, then discontinued or frequency/potency reduced.
  • Short-term occlusion increases potency and is warranted if standard applications have not been effective.

Secondary infection may require oral antibiotic, usually flucloxacillin.

Severe acute flares of hand dermatitis are treated with prednisone (systemic steroids) for 2–4 weeks.

Chronic intractable hand dermatitis may be treated with secondline agents such as azathioprine, methotrexate, ciclosporin, alitretinoin or phototherapy.

How can hand dermatitis be prevented?

Contact irritant hand dermatitis can be prevented by careful protective measures and active treatment. It is very important that people with atopic dermatitis (eczema) are made aware of the risk of hand dermatitis, particularly when considering occupation.

What is the outlook for hand dermatitis?

With careful management, hand dermatitis usually recovers completely. A few days off work may be helpful. When occupational dermatitis is severe, it may not be possible to work for weeks or months. Occasionally a change of occupation is necessary.

 

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