Occupational Hand Eczema

Occupational hand eczema is eczema of the hands caused or worsened by work, usually from irritants, wet work and, in a minority, contact allergens. It is the commonest occupational skin disease.

Epidemiology. One year prevalence of hand eczema is about 10% in the general population. Work related hand eczema is most frequent in healthcare, cleaning, hairdressing, food handling, metalwork and construction.

Wet work. Hands wet or in occlusive gloves for more than 2 hours daily, or hand washing 20 or more times daily, is the usual exposure threshold.

Classification. Irritant contact dermatitis (about 80% of cases), allergic contact dermatitis, atopic hand eczema, protein contact dermatitis and hyperkeratotic forms. Chronic disease means over 3 months or 2 or more relapses in 12 months.

Prognosis. A large fraction have chronic disease with job loss or career change. Early diagnosis and workplace change improve the outlook.

Pathophysiology.

Water, detergents and solvents disrupt the stratum corneum lipids and release keratinocyte cytokines, producing inflammation. Filaggrin loss-of-function and atopy lower the threshold.

In allergic disease, haptens penetrate the damaged barrier and cause type IV hypersensitivity. Protein contact dermatitis involves type I reactions to food or latex proteins.

• Dryness, erythema, scaling, fissures, lichenification and itching of the hands, most often on the dorsum, finger webs and palms.
• Vesicles in pompholyx like forms.
• Nail dystrophy and pain from fissures; reduced hand function.

Red flags.

• Weeping, crusting or pustules (secondary bacterial infection).
• Grouped punched out erosions with fever (eczema herpeticum).
• Rapid spread, systemic upset or erythroderma.

• Work and exposure history, wet work time, glove use, products and effect of holidays.
• Severity scoring with a validated hand eczema index.
• Patch testing with a baseline series plus occupational allergens for chronic, atypical or work related disease; read at day 2 and day 4 or later.
• Prick tests or specific IgE for protein contact dermatitis.
• Skin swabs for infection; skin scrapings with potassium hydroxide microscopy and culture for fungus; biopsy when diagnosis is unclear.

Differential diagnosis. Palmoplantar psoriasis, tinea manuum, pompholyx, scabies, contact urticaria, lichen planus, hyperkeratotic eczema, drug eruption, cutaneous T cell lymphoma.

• Reduce wet work, use appropriate gloves (nitrile, with cotton liners for short use), change gloves when damp, and use soap substitutes.
• Emollient applied liberally at least twice daily and after each handwash, long term.
• Clobetasol propionate 0.05% ointment topically to affected skin once or twice daily for up to 2 weeks, maximum 50 g weekly. Monitor skin atrophy, striae, telangiectasia and infection. Avoid on the face, flexures and genitals and on infected skin; use the lowest potency that works in pregnancy and avoid in children.
• Face and flexures: hydrocortisone 1% cream topically once or twice daily for up to 7 days; do not exceed 2 weeks on the face. Monitor for atrophy and periorificial dermatitis.
• Chronic severe disease: alitretinoin 30 mg orally once daily with a main meal for 12 to 24 weeks (reduce to 10 mg daily if 30 mg is not tolerated). Maximum 30 mg daily. Monitor fasting lipids, liver enzymes and thyroid function before treatment, at 1 month and then every 3 months; assess mood and headache. Contraindicated in pregnancy and breastfeeding (a pregnancy prevention programme with effective contraception from 1 month before to 1 month after treatment is required), liver disease, severe renal impairment, uncontrolled hyperlipidaemia and with tetracyclines.
• Refractory disease: narrowband UVB or topical psoralen with UVA phototherapy 2 to 3 times each week. Short course ciclosporin 2.5 mg/kg daily orally in 2 divided doses, increased by 0.5 to 1 mg/kg after 2 weeks to a maximum of 5 mg/kg daily, for 3 to 6 months. Monitor blood pressure and creatinine (twice before starting, then every 2 weeks for 3 months, then monthly), potassium, magnesium, lipids and liver enzymes. Reduce dose by 25 to 50% if creatinine rises by more than 30% from baseline on 2 readings, and stop if it persists. Avoid in uncontrolled hypertension, renal impairment, malignancy and with live vaccines; check interactions (macrolides, azole antifungals, statins, NSAIDs).
• Secondary bacterial infection: flucloxacillin 500 mg orally four times daily for 7 days, maximum 1 g four times daily in severe infection. Monitor liver function if therapy exceeds 14 days. Reduce dose when eGFR is under 10; avoid in penicillin allergy or prior flucloxacillin related jaundice. For penicillin allergy use clarithromycin 500 mg orally twice daily for 7 days, maximum 1 g daily; halve the dose when eGFR is under 30; monitor QTc and check interactions (statins, warfarin).
• Eczema herpeticum: start aciclovir without waiting for confirmation, 5 mg/kg intravenously every 8 hours, increased to 10 mg/kg for severe or immunocompromised patients, for 7 to 10 days. Maximum 10 mg/kg each dose. Monitor creatinine and hydration. Extend the interval when eGFR is under 50 (every 12 hours at 25 to 50 mL/min; every 24 hours at 10 to 25 mL/min). Needs hospital care and ophthalmology review for periocular disease.
• Prednisolone 40 mg orally once daily in the morning for 5 days, then 20 mg for 5 days, then 10 mg for 5 days, then stop, for a severe acute flare. Maximum 40 mg daily. Monitor glucose, blood pressure and mood. Caution in diabetes, peptic ulcer and infection; acceptable in pregnancy when needed; no renal adjustment.

Monitoring. Review at 4 to 6 weeks, then every 3 months; reassess severity and workplace exposure at each visit.

Referral and escalation. Dermatology for chronic, severe or unclear disease and for patch testing; occupational physician for workplace and job change; urgent referral for suspected eczema herpeticum; notification and compensation where required.

Special groups. Pregnancy: avoid alitretinoin, ciclosporin and phototherapy with psoralen. Children and older adults: avoid high potency steroids for long periods.