Dr John English explains how effective treatment of hand eczema depends on accurate diagnosis, accessible testing, and prompt treatment
I n the UK, hand eczema or dermatitis (both terms are synonymous) in its mildest forms is very common. At least 10% of the general population will experience hand eczema at some stage.1 Often, however, people with hand eczema will just put up with it, as in many occupations (e.g. hairdressing, healthcare work, and metal work2) it is regarded as ‘part of the job’ and people fear losing their jobs because of it. The more severe forms are less common but can be very disabling for the individuals affected. Early intervention and prevention programmes can help to stop the condition progressing to severe chronic hand eczema.
ESCD guidance on diagnosis, prevention, and treatment of hand eczema
In 2014, a working group of the European Society of Contact Dermatitis published guidance on diagnosis, prevention, and treatment of hand eczema.2 This evidence- and consensus-based guidance is also available as a Guidelines summary3
Diagnosis and history
There are two main categories of hand eczema:
- exogenous (irritant or allergic) and
- endogenous (cause not known).
Often there is a mix of both. Irritant contact dermatitis (ICD) is very common and is due to too much (over-) exposure to irritants, for example, from frequent hand- or hair-washing by healthcare professionals or hairdressers.
Allergic contact dermatitis (ACD) often develops in the context of ICD as the damaged skin barrier allows allergens to pass through it and sensitisation of the immune system to occur. Endogenous factors, such as atopy and filaggrin polymorphisms (genetically weak skin barrier function), make affected individuals more susceptible to barrier-function breakdown and consequent ACD. The commonest allergens to cause ACD in chronic hand eczema are:
- rubber glove additives
- preservatives, biocides, and fragrance in cosmetics and toiletries.
Not every skin condition of the hands is hand eczema. Any inflammatory skin condition (e.g. psoriasis, lichen planus, granuloma annulare, etc) can affect the hands so making a correct diagnosis is important as the management may be very different according to the condition. For example, fungus infection of the hand is very treatable and curable with oral antifungal agents. Patients with psoriasis of the palms do not respond very well to potent topical steroids. If the skin condition is non-eczematous, the rest of the skin should be examined.
Detailed exposure history
The history should be taken by guided interview and include discussion of specific exposures (at work and home) that may relate to the clinical features (see Guidelines summary for more detail on what to include).2
Past or family history of eczema, asthma, and hay fever
A history of atopy increases the chance of developing ICD.4
It is not possible to make the diagnosis from the clinical pattern of hand eczema; for this reason, patch testing for potential allergy is recommended in all patients with chronic (>3 months) hand eczema.
Prevention should be encouraged in the workplace: wet work is a particular risk factor for hand eczema and primary prevention is recommended; secondary prevention strategies should be undertaken when eczema is already present on the hand.2,3 Education and skin protection strategies should be developed and implemented.
Treatment recommendations in the ESCD guideline include non-pharmacological interventions, and topical, physical, and systemic treatments. It is recommended that acute hand eczema is treated quickly and vigorously to avoid the development of chronic hand eczema.2,3
Lifestyle changes involving avoidance of identified allergens and reduction in exposure to irritants are recommended in all patients, and a skin protection programme should be tailored to individual needs.2,3 These motivate and empower individuals to take responsibility for their own health.2
Regular use of topical emollients is strongly recommended to help primary and secondary prevention. Adherence is important and patient education may be necessary.
Short-term (up to 6 weeks) use of topical corticosteroids will usually be very helpful. Longer-term use can cause the skin barrier to function adversely.
Alitretinoin is the only licensed medication for adults with chronic hand eczema that is unresponsive to treatment with potent topical corticosteroids,2 and is often very effective.
Systemic immunosuppressants, such as ciclosporin, are often used in severe hand eczema when phototherapy or alitretinoin has failed; however, they are much more toxic than the above-mentioned treatments.
Phototherapy for chronic hand eczema usually takes the form of topical application of methoxyP soralen followed by exposure to long wave UV light A—giving the name PUVA. A course involves twice-weekly visits to the dermatology department for 3 months.
Challenges to primary care
The main challenges in primary care are as follows:
- practitioners who are managing patients with work-related chronic hand eczema rely on the cooperation of employers, which is not always forthcoming especially from small-to-medium-sized enterprises. The Health and Safety Executive can always provide guidance and support in this situation6
- alitretinoin has been assessed by NICE and Technology Appraisal 177 has been published on its use;5 however, alitretinoin can only be prescribed by dermatologists or physicians experienced in using oral retinoids, owing to its potential toxicity and teratogenicity.5 These practitioners therefore have to prescribe alitretinoin, monitor the patient’s progress, and implement pregnancy prevention programmes in women of child-bearing potential5
- due to severe shortages of dermatologists in the UK, there are unfortunately often long waits (around 2–3 months) for patch testing.
How well is hand eczema managed in primary care?
Hand eczema can be very difficult to manage in any healthcare setting as the causes of the eczema are not always easily avoided (for example, frequent hand-washing and glove usage in a healthcare setting), and most patients do not want to lose their job. Even in the home, patients will have daily exposure to irritants, for example personal care and household cleaning products.
Having poor access to specialist dermatological services is a particular problem—throughout the British Isles—in managing a patient with severe chronic hand eczema.
Hand eczema can be very disabling and is often chronic. Better management can greatly improve the patient’s quality of life.
- Take a detailed exposure history to potential irritants/allergens, to include both work and home
- is there a past or family history of eczema, asthma, and hay fever
- Prevention should be encouraged in the workplace
- Education and skin protection strategies should be developed and implemented
- Refer the patient for patch testing if the hand eczema lasts more than 3 months
- Regular use of emollients is strongly recommended to help primary and secondary prevention
- Short-term use of topical steroids will usually be very helpful:
- longer term use can adversely affect the skin barrier function
- Alitretinoin is the only licensed medication for chronic hand eczema and is often very effective
- PUVA or systemic immunosuppressants are often used in severe hand eczema
PUVA=methoxyPsoralen followed by UV light A
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- Hand eczema can be a particularly difficult problem for GPs to manage, especially when it is work-related
- GPs should consider referring people with probable work-related hand eczema to occupational health services and using the new national service if the employer does not have one
- Local clinical guidelines should identify cost-effective products for use in hand eczema and list appropriate quantities for clinicians to prescribe:
- these guidelines should also identify triggers for referral to a specialist and for allergy testing, and commissioners should ensure that these services are available
- In areas where there is a shortage of specialist dermatologists, commissioners could work with specialists to commission specialist nurse or GP with a Special Interest roles and ensure that they are supported by dermatologists
Read the Guidelines summary of the ESCD Guidelines for diagnosis, prevention and treatment of hand eczema for more information on hand eczema
- Thyssen J, Johansen J, Linneberg A et al. The epidemiology of hand eczema in the general population—prevalence and main findings. Contact Dermatitis 2010; 62 (2): 75–87.
- Diepgen T, Andersen K, Chosidow O et al. Guidelines for diagnosis, prevention and treatment of hand eczema—short version. J Dtsch Dermatol Ges 2015; 13: 77–84. Available at: onlinelibrary.wiley.com/doi/10.1111/ddg.12510/epdf
- Diepgen T, Andersen K, Chosidow O et al. Guidelines for diagnosis, prevention and treatment of hand eczema. In: Hayeem N, Editor. Guidelines—summarising clinical guidelines for primary care. Chesham: MGP Ltd, March 2016; 58: 333–336. Available at: www. guidelines.co.uk/skin_escd_he (accessed 6 April 2016).
- Hogan D. Allergic contact dermatitis clinical presentation. Available at: emedicine.medscape.com/article/1049216-clinical (accessed 6 April 2015).
- NICE. Alitretinoin for the treatment of severe chronic hand eczema. Technology Appraisal Guidance 177. NICE, 2009. Available at: www.nice.org.uk/ta177
- Health and Safety Executive website. www.hse.gov.uk (accessed 6 April 2016).