Hand dermatitis (overview)L30.91

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

A special feature of chronic hand dermatitis is its occupational dermatological relevance (about 52% of all dermatitis of the hands are classified as occupational; see also Occupational skin disease).

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

According to aspects of the acuteness of the "eczema reaction" can be distinguished:

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

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

• Allergic:
• Hand dermatitis, contact dermatitis, allergic (evidence of clinically relevant contact sensitization by type IV and/or type I allergens) or in case of atopic diathesis.
  • Dermatitis, contact dermatitis, allergic (positive patch test as well as contact with the allergen).
  • Protein contact dermatitis.
  • Atopic hand dermatitis (with the minus variants: dermatitis hiemalis/atopic winter feet, pulpitis sicca, dyshidrosis lamellosa sicca).
• Irritative:
• Hand dermatitis, cumulative-toxic contact dermatitis (diagnosis of exclusion in exogenously triggered acute or chronic dermatitis of the hands) often beginning in the interdigital spaces, spreading to the dorsum of the hands; no sensitization; strictly limited to the site of exposure. Cumulative toxic processes are a partial cause of all hand dermatitis in >80% of cases.

Considering the clinical morphology, they can be subdivided as follows:

• Hyperkeratotic (tylotic) hand eczema.
• Hyperkeratotic-rhagadiform hand dermatitis
• Dyshidrotic hand der matitis (vesicular or bullous dermatitis of the palms (and soles) with intraepidermal vesicles or blisters, in prolonged cases also scaling and rhagades)
• Nummular hand dermatitis.

Classification considering localization (not common):

• Back of the hand/back of the foot
• palms/soles
• Finger lateral edges/toe lateral edges
• Fingertip der matitis /toe tip dermatitis /pulpitissicca
• Interdigital folds
• Wrists

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

Hand eczema ranks second among occupational skin diseases in the food industry.

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

In the hairdressing trade, the prevalence (depending on the study) is between 2.0% and 8.5% in the 1st year of training; at the end of the training between 9.8-23.5%. In the metal-working industry there was a cumulative incidence over a period of 2.5 years of about 23%. For cleaning staff, 1-year prevalence was about 46%.

The (chronic, non-specific) hand dermatitis is an exclusion diagnosis, in which other dominant causes are clinically-allergologically excluded. Smokers are significantly more frequently affected than non-smokers.

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

Acute hand eczema is characterised by acute redness, itching, blistering and blistering, depending on the cause and the triggering agent.

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

Both domestic and occupational exposures must be considered. This also includes information on the course of hand eczema during holidays, weekends and periods of incapacity to work.

During the clinical examination, an inspection of the feet as well as the entire integument is necessary in addition to the findings in the hand area.

The standard diagnostics for determining the atopic status should include an orienting prick test with the most frequent inhalation allergens.

Epicutaneous testing is the standard procedure to identify type IV sensitization as a trigger for allergic contact dermatitis. Allergen selection should follow the relevant recommendations and include the selection of exposure-specific allergens.

Mycological exclusion diagnostics are recommended for the initial diagnosis.

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

Psoriasis palmaris: (sharply defined (!), red or white-grey, scaly, sometimes wart-like plaques on the palms of the hands. Typically no spreading to the flexed forearms, no scattering phenomena). Often also infestation of other predilection sites!

Tinea manuum: (usually finely lamellar scaly, itchy plaques, also dyshidrotic blisters or extensive hyperkeratosis; positive mycological evidence is often possible with appropriate efforts).

Lichen planus palmaris: (usually occurring in the context of an exanthematic lichen planus. A flat hyperkeratotic pattern, atypical for the lichen planus, may occur on the palms of the hands; diagnosis extrapalmar).

Hereditary or symptomatic cornification disorder of the palms and soles of the feet ( keratosis palmoplantaris).

Pityriasis rubra pilaris: (always infestation of other skin areas).

Palmo-plantar syphilide (see below Syphilis acquisita): occurring in the context of an exanthematic syphilide; always HV also on other skin areas).

Chronic dermatitis of the hands is often accompanied by nail changes. According to H. Hamm et al:

irregular deformations of the nail plate with dimples, dents, grooves, transverse furrows, roughening of the nail plate, thickening, onycholysis, dyschromas, paronychines (especially in atopic dermatitis of the hands)

• The therapy is based on the systematics, clinic and severity of the hand eczema. Mild hand eczema should be treated quickly, effectively and consistently in order to counteract chronification. Chronic hand eczema is difficult to treat and requires complex management.
• When treating hand eczema, the general therapeutic principles of stage-appropriate eczema therapy must be observed, as well as the aetiology (atopic, allergic, irritant), the acute (acute vs. chronic eczema), the morph (redness, scaling, lichenification, blisters, hyperkeratosis, rhagades, etc.) and the localisation (back of the hand, interdigital spaces, palms) of the skin symptoms. A prerequisite for successful therapy is the recognition and avoidance of causative exogenous factors (e.g. allergens, irritants).
• The therapy of hand eczema follows a step-by-step concept:
• Basic therapy: Consistent re-fattening of the skin with preparations that are as free of preservatives and fragrances as possible, treatment with compresses, lotions or creams in the acute stage, with ointments in the subacute stage and with fatty ointments in the chronic stage. Nourishing moisturizing topicals in a compatible basis (e.g. Linola Fett N, Asche Base Ointment, Excipial Almond Oil Ointment) or the application of a greasing, blanching hand cream.
• Keratolytics: salicylic acid (up to 20%) and urea (5-10%), especially in chronic, especially hyperkeratotic-rhagadiform hand eczema. Caution! Excessive or incorrect dosage, occlusion or simultaneous irritant exposures may cause skin irritation, redness and burning. If necessary, use a well tolerated base with an addition of 2-10% urea (e.g. Basodexan ointment/fat 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 localisation. Always in combination with moisturising steroid-free local therapy. Systemic corticosteroids only in special cases. Do not use topical corticosteroids for a long period of time. It is better to use sufficiently strong corticosteroids for a short period of time in acute attacks and then to eliminate them as quickly as possible.
• Acute vesicular to bullous stage (weeping): Short-term glucocorticoids of medium to strong potency in low-fat bases, hydrophilic creams or solutions such as 0.1% triamcinolone cream R259, 0.25% prednicarbate (e.g. Dermatop cream), 0.1% mometasone (e.g. Ecural fat cream/solution) or 0.05% clobetasol (e.g. Dermoxin cream). If necessary, moist compresses (NaCl) several times a day, in case of superinfection with antiseptic additives such as quinolinol (e.g. Chinosol 1:1000), R042 or potassium permanganate (light pink); Cave! possible sensitization against disinfectants! In the vesicular stage also moist with glucocorticoid such as 1% hydrocortisone in lipophilic base R120, a dressing moistened on top or a cotton glove. If resistant to therapy, topical glucocorticoids with short-term occlusion.
• In the vesicular stage also fat-damp with glucocorticoidxterna such as 1% hydrocortisone in lipophilic basis, bandage moistened over it or possibly cotton glove. If resistant to therapy, topical glucocorticoids with intermittent occlusion (use 2 times/day for 2 hours).
• Late crusty or squamous stage: Hydrophilic creams for skin regeneration (e.g. DAC base cream, Amciderm base cream, Ash base cream, Dermatop base cream). If necessary also with "wound healing additives" like dexpanthenol (e.g. R064, Bepanthen Lotio). Local PUVA therapy can be helpful, initially 4 times/week, maintenance therapy 2 times/week.
• Topical calcineurin inhibitors: Can be used to treat atopic hand eczema.
• Other local therapy: In superinfected eczema, e.g. clioquinol (vioform), chlorhexidine, etc.), antiseptic additives such as quinolinol (e.g. quinosol 1:1000) or potassium permanganate (light pink). Cave! Possible sensitization against disinfectants!
• In case of subacute to chronic eczema tar-containing preparations (e.g. Liquor carbonis detergens 5-10%), ichthyol or tumenol 5-10%, in case of hyperkeratotic-rhagadiform hand eczema cignolin (dithranol).
• Tap water iontophoresis: Tap water iontophoresis is the treatment of choice for existing hyperhidrosis and dyshidrotic hand eczema.

Remember! A combination of topical calcineurin inhibitors with UV therapy is not recommended.

• Avoid the use of harsh cleaning agents for 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 rinsing) or for contact with pungent substances (e.g. fruit, lemons, uncooked potatoes, tomatoes, strong cleaning agents, organic solvents, polishes, stain removers).
• For longer damp work with sweat formation in the protective gloves, change the gloves several times with a short work break to dry them off and put cotton gloves under.
• Do not wear rings when doing housework.
• Protect hands from the cold in winter and apply special moisturising cream.

The term "hand eczema" is first of all only topographically significant. It is justified, like other topographically defined eczema forms (e.g. eyelid eczema, anal eczema, labial eczema), by the clinical features and the high socio-economic importance of these eczema forms. The annual costs for chronic, occupational hand eczema are estimated at about 9,000 Euro / year (about the costs for moderately severe psoriasis vulgaris).

In principle, all statements made for hand eczema also apply to "foot eczema", which is not explicitly listed here.

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

The annual costs for chronic occupational hand eczema are estimated at about 9,000 Euro/year (about the costs for moderately severe psoriasis vulgaris).

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