Hand dermatitis (overview) L30.91

Frequent, etiopathogenetically heterogeneous, itchy and painful dermatitis of the hands with acute, subacute or (frequently) chronic (see below hand dermatitis, chronic) course and varying degrees of severity. Hand eczema has a high health economic and socio-medical significance with frequent and possibly long-lasting incapacity to work.

A special feature of chronic hand dermatitis in particular is its occupational dermatological relevance (around 52% of all dermatitis of the hands is classified as work-related; see also occupational skin disease below).

Hand eczema (foot eczema) can be classified according to temporal, etiopathogenetic (atopic, contact allergic, irritant), or purely clinical aspects (hyperkeratotic, hyperkeratotic-rhagadiform, dyshidrotic).

Based on the severity of the “eczema reaction,” the following distinctions can be made:

• Acute hand dermatitis (dyshidrotic hand eczema, pompholyx)
• Subacute hand eczema
• Chronic hand eczema

Taking etiology (allergic, irritant) into account, the following classification can be made:

Allergic:

• Hand eczema, contact eczema, allergic (evidence of clinically relevant contact sensitization to Type IV and/or Type I allergens) or in cases of atopic diathesis.
  • Dermatitis, contact dermatitis, allergic (positive patch test and contact with the allergen)
  • Protein contact dermatitis
  • Atopic hand dermatitis ( including the following subtypes:dermatitis hiemalis/atopic winter feet, pulpitis sicca, dyshidrosis lamellosa sicca)

Irritant:

• Hand dermatitis, cumulative-toxic contact dermatitis (diagnosis of exclusion in cases of exogenously triggered, acute or chronic dermatitis of the hands), often beginning between the fingers and spreading to the backs of the hands; no sensitization; strictly limited to the site of exposure. Cumulative-toxic processes are a contributing factor in > 80% of all cases of hand dermatitis.

Taking the clinical morphology into account, the following subdivisions can be made:

• Hyperkeratotic (tylotic) hand eczema
• Hyperkeratotic-rhagadic hand dermatitis
• Dyshidrotic hand dermatitis(vesicular or bullous dermatitis of the palms (and soles) with intraepidermal vesicles or bullae; with prolonged duration, also scaling and rhagades)
• Nummular hand dermatitis

Classification based on location (not commonly used):

• Back of the hand/back of the foot
• Palms/soles
• Sides of the fingers/sides of the toes
• Fingertip dermatitis/toetipdermatitis/pulpitis sicca
• Interdigital folds
• Wrists

Estimates for the 1-year prevalence of hand eczema due to occupational exposure in the population vary between 6.7% and 10.6% (see below eczema, contact eczema, allergic). A high incidence rate is associated with female gender, contact allergies, atopic eczema and working in a humid environment.

Hand eczema is the second most common occupational skin disease in the food industry.

Evidence of a significant increase in prevalence among young people/adults at risk of occupational diseases (especially hairdressers, bakers, florists, tilers, electroplaters, dental technicians, machinists, workers in the metal industry, employees in healthcare professions, etc.) during their training phases.

In the hairdressing trade, the prevalence (depending on the study) is between 2.0 % and 8.5 % in the first year of training and between 9.8 % and 23.5 % at the end of training. In the metalworking industry, a cumulative incidence of around 23% was found over a period of 2.5 years. The 1-year prevalence among cleaning staff was around 46%.

(Chronic, nonspecific) hand dermatitis is a diagnosis of exclusion, in which other predominant causes have been ruled out clinically and allergologically. Smokers are affected significantly more often than nonsmokers. 

The back of the hand, palms, edges of the fingers, fingertips, webbed fingers and wrists are mainly affected.

Clinical signs and symptoms of chronic hand eczema include, among others, erythema, edema, vesicle formation, hyperkeratosis, fissures, rhagades, itching, and pain.

Acute hand eczema is characterized, depending on the cause and triggering agent, by sudden onset of redness, itching, and the formation of vesicles and blisters.

S. u. Eczema.

The medical history of patients with hand eczema should include specific exposures (including leisure time, domestic and occupational stress, medication intake, nicotine and other noxious substances), the course over time and the patient's own allergological history, taking into account the Erlangen Atopy Score.

Both domestic and occupational exposures must be taken into account. This also includes information on the course of hand eczema during vacation, weekends and periods of incapacity for work.

During the clinical examination, an inspection of the feet and the entire integument is necessary in addition to the findings in the area of the hands.

Standard diagnostics to determine the atopy status should include an indicative prick test with the most common inhalation allergens.

Epicutaneous testing is the standard procedure for identifying type IV sensitizations as triggers of allergic contact dermatitis. Allergen selection should be based on the relevant recommendations and include the selection of exposure-specific allergens.

During the initial diagnosis, a mycological exclusion diagnosis is recommended.

If the clinical picture indicates the presence of psoriasis, histological confirmation of the diagnosis should be sought, as this is essential for long-term treatment planning.

Palmar psoriasis: sharply demarcated (!), red or white-gray, scaly, and sometimes wart-like plaques on the palms; typically does not extend to the flexor surfaces of the forearms, and does not spread to other areas; other predilection sites are also frequently affected!

Tinea manuum: usually fine-lamellar, scaly, itchy plaques; may also present as dyshidrotic vesicles or extensive hyperkeratosis (A positive mycological diagnosis is often achievable with appropriate testing.)

Lichen planus palmaris (see Lichen planus below): usually part of exanthematouslichen planus; on the palms, a diffuse hyperkeratotic pattern atypical of lichen planus may occur; diagnosis made on extrapalmar areas

Hereditary or symptomatic keratinization disorder of the palms and soles (palmoplantar keratosis).

Pityriasis rubra pilaris: a palmary involvement pattern resembling a glove, always accompanied by involvement of other skin areas

Palmo-plantar syphilides (see below:Syphilis acquisita): occurring as part of exanthematous syphilides; circumscribed brownish plaques (smooth, non-eczematous surfaces); always accompanied by skin lesions on other areas of the skin as well. Exclusion through specific syphilis diagnostics.

Chronic hand eczema is often accompanied by dystrophic nail changes. According to H. Hamm et al., these include:

Irregular deformities of the nail plate, including pits, dents, ridges, transverse grooves, roughening of the nail plate, thickening, onycholysis, dyschromia, and paronychia (especially in cases of atopic dermatitis of the hands).

The relevance assessment of identified type IV allergens is very important and if occupational triggers are identified, a review of the workplace and the possibility of replacing substances should be considered. Since allergic contact dermatitis can only be healed by consistently avoiding the triggering substances, patients must be fully informed about the type of contact allergens and their occurrence. If ingredients of topical products have been identified as contact allergens, allergen-oriented advice on skin protection and skin care measures is essential.

Rehabilitation as part of a measure to ensure employability (especially in the case of customer contact, industrial dermatoses, etc.). If necessary, skin protection training or, in the case of psychological involvement: behavioral medicine-oriented rehabilitation (VOR).

The same recommendations also apply to foot eczema (see: Notes).

• Treatment is guided by the classification, clinical presentation, and severity of hand eczema. Mild cases of hand eczema should be treated quickly, effectively, and consistently to prevent the condition from becoming chronic. Chronic hand eczema is difficult to treat and requires comprehensive management.
• When treating hand eczema, the general principles of stage-appropriate eczema therapy must be observed, as well as the etiology (atopic, allergic, irritant), the acuity (acute vs. chronic eczema), the morphology (redness, scaling, lichenification, vesicles, hyperkeratosis, rhagades, etc.), and the location (back of the hand, spaces between the fingers, palms) of the skin manifestations. A prerequisite for successful treatment is the identification and avoidance of causative exogenous factors (e.g., allergens, irritants).
• The treatment of hand eczema follows a stepwise approach:
  • Basic therapy: Consistent moisturization of the skin with products that are as free as possible of preservatives and fragrances; treat the acute stage with compresses, lotions, or creams; the subacute stage with ointments; and the chronic stage with rich ointments. Nourishing, moisturizing topical preparations with a gentle base (e.g., Linola Fett N, Asche Basis Ointment, Excipial Almond Oil Ointment) or the use of a moisturizing, mild hand cream.
  • Keratolytics: salicylic acid (up to 20%) and urea (5–10%), especially for chronic hand eczema, particularly the hyperkeratotic-rhagadiform type. Caution! Excessive or incorrect dosing, occlusion, or concurrent exposure to irritants may lead to skin irritation, redness, and a burning sensation. If necessary, use a well-tolerated base with 2–10% urea added (e.g., Basodexan ointment/rich cream, Excipial U Lipolotio, Linola Urea Cream, Nubral Cream).
  • Glucocorticosteroids: The potency of the corticosteroid used and the duration of therapy depend on the severity of the hand eczema and its location. Always combine with a moisturizing, steroid-free topical treatment. Systemic corticosteroids should be used only in special cases. Do not use topical corticosteroids for an extended period. It is better to use sufficiently potent corticosteroids for a short period during an acute flare-up and then taper them off as quickly as possible.

  • Delgocitinib: In adults with moderate-to-severe chronic hand eczema for whom topical glucocorticosteroids are not sufficiently effective or are not appropriate, delgocitinib 20 mg/g cream (Anzupgo®; a topical Pan-JAK inhibitor) may be used. Apply twice daily at approximately 12-hour intervals to the affected areas of the hands and wrists until symptoms are completely or nearly completely resolved. If symptoms recur, treatment may be resumed. If no improvement is observed after 12 weeks of continuous treatment, therapy should be discontinued (LEO Pharma GmbH 2025; Bissonnette R et al. 2024).

  • Acute vesicular to bullous stage (weeping): Short-term use of moderate- to high-potency glucocorticoids in low-fat bases, hydrophilic creams, or solutions such as triamcinolone cream 0.1%R259, prednicarbate cream 0.25% (e.g., Dermatop Cream), mometasone 0.1% (e.g., Ecural ointment/solution), or clobetasol cream 0.05% (e.g., Dermoxin cream). If necessary, apply moist compresses (NaCl) several times a day; in cases of superinfection, use antiseptic additives such as quinolinol (e.g., Chinosol 1:1000), R042, or potassium permanganate (light pink); Caution! Possible sensitization to disinfectants! In the vesicular stage, also apply a greasy-moist dressing with a glucocorticoid, such as 1% hydrocortisone in a lipophilic base R120, covered with a moistened dressing or, if necessary, a cotton glove. If the condition is resistant to treatment, use topical glucocorticoids with short-term occlusion.
  • In the vesicular stage, also use a moist ointment with topical glucocorticoids such as 1% hydrocortisone in a lipophilic base, covered with a moistened dressing or, if necessary, a cotton glove. If the condition is resistant to treatment, use topical glucocorticoids with intermittent occlusion (twice daily for 2 hours).
  • Late crusted or squamous stage: Hydrophilic creams to promote skin regeneration (e.g., Basiscreme [DAC], Amciderm Basis Cream, Asche Basis Cream, Dermatop Basis Cream). If necessary, also use products with “wound-healing additives” such as dexpanthenol (e.g., R064, Bepanthen Lotion). Local PUVA therapy may be helpful, initially 4 times per week, followed by maintenance therapy 2 times per week.
  • Topical calcineurin inhibitors: can be used to treat atopic hand eczema.
  • Other topical treatments: For superinfected eczema, e.g., clioquinol (Vioform), chlorhexidine, etc.; antiseptic additives such as quinolinol (e.g., Chinosol 1:1000) or potassium permanganate (light pink). Caution! Possible sensitization to disinfectants!
  • For subacute to chronic eczema, tar-containing preparations (e.g., Liquor carbonis detergens 5–10%), Ichthyol or Tumenol 5–10%; for hyperkeratotic-rhagadiform hand eczema, Cignolin (dithranol).
  • Tap water iontophoresis: In cases of existing hyperhidrosis and dyshidrosiform hand eczema, tap water iontophoresis is the treatment of choice.

Cream or bath PUVA therapy: Particularly effective for chronic hand eczema. Initially 4x/week, maintenance therapy 2x/week.

Note! A combination of topical calcineurin inhibitors and UV therapy is not recommended.

Rules of conduct for hand eczema:

• Avoid harsh cleaning agents for the hands (e.g. hand washing pastes) at work, in baby care or in the household.
• Avoid or wear protective gloves when handling water (e.g. when washing up) or for contact with aggressive substances (e.g. fruit, lemons, uncooked potatoes, tomatoes, aggressive cleaning agents, organic solvents, polishes, stain removers).
• In case of prolonged wet work with perspiration in the protective gloves: change gloves several times with a short break to dry off and put on cotton gloves.
• Do not wear rings when doing housework.
• Protect hands from the cold in winter and apply a particularly moisturizing cream.

The term "hand eczema" is initially only topographically descriptive. Like other topographically defined forms of eczema (e.g. eyelid eczema, anal eczema, lip eczema), it is justified by the clinical characteristics and the high socio-economic significance of these forms of eczema. The annual costs of chronic, occupational hand eczema are estimated at around EUR 9,000 per year (approximately the costs of moderate psoriasis vulgaris).

In principle, all the remarks made for hand eczema also apply to "foot eczema", which is not explicitly mentioned here.

Therapy costs: In a larger study, the average direct annual therapy costs for chronic hand eczema amounted to 1,742 euros per patient, the indirect (economic) costs to 386 euros,

The annual costs for chronic occupational hand eczema are estimated at around 9,000 euros per year (approximately the costs for moderate psoriasis vulgaris).

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