Hand Eczema

Hand eczema is inflammation of the skin of the hands with erythema, scaling, vesicles, fissures and lichenification, and it is chronic when it lasts more than 3 months or relapses at least twice in a year. It is a common cause of work disability.

One year prevalence is about 10% and lifetime prevalence about 15%. Women are affected more often than men, and risk is highest in healthcare, hairdressing, food handling, cleaning, metalwork and construction.

Subtypes are irritant, allergic contact, atopic, hyperkeratotic, vesicular (dyshidrotic) and nummular. Causes frequently overlap. Risk factors include atopic dermatitis, filaggrin loss-of-function variants, repeated wet work, and contact allergy to rubber chemicals, metals, fragrance, preservatives and plant allergens.

Pathophysiology.

Repeated exposure to water, detergents and solvents removes lipids and damages the stratum corneum. Allergens then enter and trigger type IV hypersensitivity, while atopic skin shows a helper T-cell type 2 bias. Inflammation and a damaged barrier sustain one another.

• Erythema, scale and dryness, with painful fissures over the finger joints, finger pulps and palms.
• Vesicles on the sides of the fingers and palms, and hyperkeratotic fissured plaques on the palms.
• Chronic lichenification, nail changes (ridging, pitting) and paronychia.
• Pain, loss of dexterity, sleep disruption and impaired work and social function.

Red flags.

• Fever or spreading erythema from secondary bacterial infection, or grouped painful vesicles suggesting herpes simplex.
• A unilateral, scaly asymmetrical eruption, suggesting tinea manuum.
• Hyperkeratotic plaques with atypical scale, suggesting psoriasis or mycosis fungoides.

• Detailed history of occupation, hobbies, wet work, glove use, atopy and family history, and a record of improvement away from work.
• Fungal scraping for potassium hydroxide microscopy and culture, especially in unilateral or scaly disease, and a swab for bacteria.
• Patch testing with the baseline series plus occupational and personal products, with interpretation of relevance.
• Prick tests or specific IgE for immediate reactions, for example to latex or food proteins.
• Skin biopsy if the diagnosis is unclear. Use a validated severity score to monitor treatment response.

Differential diagnosis. Psoriasis, tinea manuum, scabies, palmoplantar pustulosis, pityriasis rubra pilaris, keratoderma, lichen planus and mycosis fungoides.

General.

• Avoid irritants and identified allergens. Wash with lukewarm water and soap substitutes, dry carefully, and apply emollients after each hand wash and at night.
• Protect with cotton liners under nitrile or vinyl gloves, limited to short periods, and remove rings before wet work.

Topical.

• Potent corticosteroid (betamethasone valerate 0.1% or mometasone furoate 0.1%) once daily for 2 to 4 weeks, then twice weekly proactive maintenance on previously affected skin.
• Very potent corticosteroid (clobetasol propionate 0.05%) once daily for up to 2 weeks for hyperkeratotic or fissured disease, with occlusion or hydrocolloid dressings for fissures.
• Tacrolimus 0.1% ointment twice daily as a steroid sparing agent. Delgocitinib 20 mg/g cream twice daily is licensed in some regions for moderate to severe chronic hand eczema.

Phototherapy and systemic treatment.

• Narrowband ultraviolet B, or psoralen with ultraviolet A, two to three times weekly.
• Alitretinoin 30 mg daily for 12 to 24 weeks (10 mg daily if not tolerated) for severe disease unresponsive to potent topical treatment. It is teratogenic. Monitor lipids, thyroid function and mood, and arrange strict contraception.
• Methotrexate 7.5 to 15 mg once weekly (maximum 25 mg) with folic acid 5 mg weekly, ciclosporin 2.5 to 5 mg/kg/day in two divided doses, or azathioprine 1 to 3 mg/kg/day after thiopurine methyltransferase testing.
• Short prednisolone 0.5 mg/kg/day (usually 30 to 40 mg) for 5 to 7 days for severe flares only.

Monitoring. Review at 4 weeks and 12 weeks, with severity score and quality of life. Check ciclosporin blood pressure and creatinine, methotrexate full blood count, liver tests and renal function.

Referral and escalation. Refer for diagnosis, patch testing, occupational advice and failure of potent topical treatment after 4 to 6 weeks.

Special groups. Alitretinoin and methotrexate must not be used in pregnancy, and reliable contraception is needed in both sexes where applicable. In children use lower potency steroids and tacrolimus 0.03%.