Irritant Hand Dermatitis

Irritant hand dermatitis is a non immunological inflammatory skin reaction from repeated exposure to water, soaps, detergents, solvents, friction and occlusion. It is the commonest form of occupational skin disease.

• High risk jobs: healthcare, cleaning, catering, hairdressing, mechanics, construction, farming, domestic work.
• Atopic dermatitis markedly increases susceptibility.
• Wet work for more than 2 hours daily or hand washing more than 20 times daily increases risk.

Dryness, redness, scaling, fissuring and burning or stinging of the web spaces, backs of hands and fingers, with painful cracks; vesicles and bullae occur in acute irritant reactions.

• Improves on holidays and worsens at work.
• Differential diagnosis: allergic contact dermatitis (rubber, nickel, fragrance, preservatives), atopic hand eczema, dyshidrotic eczema, psoriasis, tinea manuum, scabies, hyperkeratotic eczema, lichen planus, protein contact dermatitis.
• Complications: chronic fissured painful hands, secondary bacterial infection, nail dystrophy, sensitisation to contact allergens, occupational disability and job loss.

Clinical, based on history and distribution.

• Patch testing to exclude allergic contact dermatitis in chronic or non responding disease.
• KOH scraping and culture to exclude tinea; swab if infected.
• Detailed occupational and household exposure history and, if suspected, latex and food prick testing.

Remove exposure, protect the barrier and use short courses of topical steroid.

• Supportive: minimise wet work, wear gloves for wet work and chemicals (cotton lined nitrile or vinyl gloves, not latex powdered gloves; remove gloves intermittently), lukewarm water, soap substitutes, dry hands thoroughly, apply emollient or barrier cream after every wash and at night, avoid rings during work, workplace modification or job redeployment.
• Pharmacological: mometasone furoate 0.1 percent or betamethasone valerate 0.1 percent ointment once daily for 2 to 4 weeks, then taper to twice weekly; clobetasol propionate 0.05 percent ointment for 1 to 2 weeks for severe thickened dermatitis; tacrolimus 0.1 percent ointment twice daily as steroid sparing therapy. Short course of oral prednisolone 0.5 mg/kg daily for 7 to 10 days for severe acute flare. Chronic refractory disease: alitretinoin 10 to 30 mg daily for up to 24 weeks under specialist care, or methotrexate 7.5 to 15 mg weekly. Flucloxacillin 500 mg four times daily for 7 days for secondary infection.
• Procedures: narrowband UVB or hand PUVA phototherapy for chronic disease.
• Special groups: pregnancy, emollients and topical steroids only, absolutely avoid alitretinoin and methotrexate; children, emollients and mild steroids, avoid prolonged wet exposure; atopic individuals, education on career choice; HIV, treat infection and dermatitis together.
• Red flags: severe fissuring with infection, vesiculation suggesting allergic contact dermatitis, no improvement in 4 to 6 weeks, spreading to forearms and face, nail damage.
• Follow-up: review at 2 to 4 weeks, then 3 monthly if chronic; refer to a dermatologist or occupational health physician for refractory disease and patch testing.