1. health and fitness
2. disease

Hand Dermatitis: Review of
Clinical Features and Treatment Options
Spring Golden, MD, and Tatyana Shaw, MD
Hand dermatitis affects a significant portion of the population and can be caused by a
variety of endogenous factors (ie, atopy) as well as occupational and environmental
exposures. It is often a chronic problem with high costs to individuals, employers, and
society. This review discusses subtypes of hand dermatitis based on their clinical features
and pathogenesis. It also offers an approach to treatment.
Semin Cutan Med Surg 32:147-157 © 2013 Frontline Medical Communications
KEYWORDS hand dermatitis, chronic hand dermatitis, irritant contact dermatitis, allergic
contact dermatitis, frictional hand dermatitis, hyperkeratotic dermatitis, psoriasiform hand
dermatitis, nummular dermatitis, atopic dermatitis, vesicular dermatitis, dyshidrotic dermatitis, pompholyx
H
and dermatitis is one of the most common entities encountered in dermatology, affecting 2%-9% of the general population.1 The quality of life impact is significant, considering that hands play such an important role in social and
occupational settings. Increased severity of hand dermatitis
correlates to decreased quality of life for many patients.2 Furthermore, hand dermatitis is often a chronic debilitating
problem, which lasts on average 10 to15 years from onset.3
Treatment and management of the disease can be frustrating
and costly.
Hand dermatitis is also the most common presentation of
work-related skin diseases. Epidemiological studies have indicated that about 80% of occupational related dermatoses
affect the hands.4 Considering that many of the individuals
do not seek medical care, true prevalence numbers are difficult to obtain and might be even higher. One study found
that of the 63% of kitchen workers affected by hand eczema,
only 35% actually contacted a physician.5 Wet-work environments contribute to higher prevalence of hand dermatitis
in certain occupations, including health care workers, hairdressers, food industry employees, homemakers, and bartenders.6,7 Occupational allergen exposure can lead to the
development of allergic contact hand dermatitis, a subtype of
hand dermatitis. Severe hand dermatitis has been a factor in
workers needing sick leave or switching occupations.
Department of Dermatology, Oregon Health & Science University, Portland.
Disclosures: The authors have completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and none were reported.
Correspondence: Tatyana Shaw, MD, Department of Dermatology, Oregon
Health & Science University, 3303 SW Bond Avenue, CH16D, Portland,
OR 97239-4501. E-mail: [email protected]
1085-5629/13/$-see front matter © 2013 Frontline Medical Communications
DOI: 10.12788/j.sder.0027
This article will review the many clinical variants of
chronic hand dermatitis in hopes of helping clinicians accurately diagnose those conditions as well as provide a treatment algorithm for their management.
Approach to Patient
and Diagnostic Studies
There are many clinical variants of hand dermatitis, subtypes
of which are listed in Table 1. Furthermore, many individuals
will have a hybrid of those clinical entities, making an accurate diagnosis challenging.8
Hand dermatitis is a clinical diagnosis, relying on physical
examination and a patient’s history more so than laboratory
testing. It presents with varying degrees of pruritic and occasionally tender erythematous. The papules and plaques are at
times scaly and crusty, which make them appear to be ill
defined and more sharply demarcated. Vesicles and bullae
are sometimes intermixed with plaques, but can also be the
only morphologic feature present. Acute dermatitis will have
more erythema and a vesicular appearance versus chronic
dermatitis, which is more likely to have hyperkeratotic, lichenified, and fissured plaques. Physical examination of the
hands should include a careful look at the distribution of the
dermatitis (palmar, dorsal, fingers, web spaces, fingernail,
and periungual skin) as well as the extension of dermatitis to
the wrists or forearms. Examination of the feet should be part
of the clinical investigation as some of the variants of hand
dermatitis can have both hand and foot involvement. A complete skin exam is necessary if there are other conditions such
as psoriasis, mycosis fungoides, atopic dermatitis that are
147
S. Golden and T. Shaw
148
Table 1 Clinical Variants of Hand Dermatitis
Type
Atopic Dermatitis
Allergic Contact Dermatitis
Irritant Contact Dermatitis
Hyperkeratotic/Psoriasiform/
Frictional Dermatitis
Nummular Dermatitis
Pompholyx/Dyshidrotic Eczema
Chronic Vesicular Dermatitis
Clinical Presentation
Comments
Plaques on the dorsal hands, fingers and volar wrists
with or without nail changes
Dorsal hand and fingertip involvement that may progress
up forearms
Symmetrical, often involves web spaces extending to
dorsal hands. Plaques under the rings on the fingers
Increased risk of ACD
and ICD
Well defined hyperkeratotic erythematous plaques on
palms with fissuring
Asymmetrical, coin-like lesions on dorsal hands
Intermittent and recurrent bullae on palms or
papulovesicles on sides of fingers. Bland vesicles and
bulla, no erythema
Chronic eruption of vesicles on an erythematous base
Increased risk of ACD
Most common type of
hand dermatitis
Check for tinea pedis
and treat
Abbreviations: ACD, allergic contact dermatitis; ICD, irritant contact dermatitis.
considered in the differential diagnosis. As with many dermatologic conditions, the patient’s history gives important
clues (Table 2), which can include a history of atopic dermatitis, asthma, rhinitis, psoriasis, prior patch-testing results,
occupation, hobbies, hand-washing routine, skin care products, other contactants, symptoms, and chronicity of the disease.
Taking a bacterial swab culture can help rule out a bacterial skin infection. Disrupted skin barrier seen in all subtypes
of hand dermatitis predisposes to staphylococcal and streptococcal skin infections. Staphylococcus aureus is the most
common culprit; however, cases of methicillin-resistant
Staphylococcus aureus (MRSA) have been seen as well. Patients with a history of atopic dermatitis are at highest risk.
Rarely, the herpes simplex virus can infect eczematous skin
of the hands and cause eczema herpeticum. Getting a Tzank
smear or a viral swab for a viral culture or polymerase chain
reaction (PCR) is helpful if clinically one sees the scatter of
sharply demarcated small crusty erosions or vesicles.
Skin scrapings for a potassium hydroxide (KOH) preparation or a fungal culture is recommended when feet lesions are
present. Tinea manus can mimic chronic hand dermatitis. Id
Table 2 Important Aspects of the Patient’s History When Investigating Hand Dermatitis
Patient History
Date of onset and progression
Associated symptoms such as burning, itching, or pain
Occupation and relationship to work (do symptoms
improve on vacation)
Hobbies
Skin care products
Chemicals, glues, paints, or other materials touching hands
Hand washing regimen
Previous therapies
History of atopic diathesis (childhood or adulthood
eczema, hay fever, asthma)
History of other skin diseases (ie, psoriasis)
Family history of skin diseases and atopy
reaction is possible if the patient has tinea pedis, but a negative KOH scraping from the hand plaques. At that point,
treatment of coexisting tinea pedis becomes important in the
management of hand dermatophytid.
A skin biopsy is done when diagnosis is unclear and other
dermatologic conditions are considered (Table 3). Histologically, all subtypes of hand dermatitis will show spongiosis
with mixed inflammatory infiltrate. Vesicular types are more
likely to show bigger spongiotic vesicles within epidermis.
Hyperkeratotic/frictional types of hand dermatitis will show
psoriasiform epidermal hyperplasia. Periodic acid-Schiff
(PAS) staining can identify dermatophyte infection if biopsy
shows psoriasiform spongiotic dermatitis with subcorneal
neutrophils.
Patch testing is done when allergic contact dermatitis is
suspected.
Atopic Hand Dermatitis
Atopic dermatitis is one of the most common chronic inflammatory skin conditions affecting 8% to 11 % of the United
States population.9-11 The pathophysiology of atopic dermatitis is characterized by mutations in the filaggrin gene and a
loss of epidermal barrier function resulting in dry, scaly, inflamed, and pruritic skin. It is well known that children with
a history of atopic dermatitis are more likely to develop hand
dermatitis as adults.12 The prevalence of hand dermatitis in
atopics is estimated to be around 60% for all ages.13
Although there are many clinical presentations of atopic
hand dermatitis, the most common distribution is over dorsal
hands and dorsal fingers (Figure 1). In a study by Simpson et
al, dorsal hand and volar wrist involvement was seen in most
cases of atopic hand dermatitis (Figure 2). The plaques are
usually scaly, ill-defined, pink, thin, or lichenified (Figure 3).
Papules or vesicles can be present as well. Chronic volar wrist
involvement can result in permanent hypopigmentation or
depigmentation of the area. Nail changes such as loss of the
cuticle, thickening/inflammation of the nail folds, or irregular
ridging can occur. In addition to pruritus, painful fissures
Hand dermatitis
149
Table 3 Chronic Hand Dermatitis Mimickers
Condition
Psoriasis
Dermatophyte infections
Scabies
Lichen planus
Dermatomyositis
Pitaryasis rubra pilaris
Mycosis Fungoides
Differentiating Factors
Well demarcated, erythematous, scaly plaques in characteristic for psoriasis distribution
(scalp, concha, extensor surfaces, gluteal cleft, umbilicus).
Nails with pitting, oil spots, distal onycholysis.
Palmoplantar pustulosis.
One hand, two feet involvement.
Burrows and erythematous papules in web spaces and volar wrists, lateral fingers.
Sharply demarcated, violaceous, flat topped scaly, polygonal papules and plaques.
Other typical for lichen planus locations, such as oral mucosa, wrists, ankles, nails.
Erythematous to violaceous plaques over DIP, PIP, MCP joints. May have dilated
capillaries in nail folds and ragged cuticles.
Hyperkeratotic yellow diffuse keratoderma/plaques. Confluent erythematous scaly
plaques with follicular accentuation over the body. Islands of spared normal skin.
Confluent erythematous hyperkeratotic plaques over the palms and soles.
Abbreviations: DIP, distal interphalangeal joint; MCP, metacarpal phalanges joint; PIP, proximal interphalangeal joint.
Allergic contact dermatitis is a Type IV delayed hypersensitivity response that is elicited when an allergen comes into
direct contact with the skin. Development of dermatitis is
usually delayed by a few days from the time of allergen exposure. This is in contrast to a Type I immediate hypersensitivity reaction, which is seen in urticaria where contact with
an allergen results in hives within minutes to hours of exposure.
The clinical presentation of allergic contact hand dermatitis can include itching, stinging, burning, and pain. Patients
may also develop vesicles, bullae, erythematous papules,
weeping, and crusting. Fingertips, nail folds, and dorsal
hands are most commonly involved. However, any part of
the hand can be affected. Clinicians should be suspicious of
an allergic contact dermatitis if there is a change in the patient’s chronic pattern of dermatitis and if there is spread
from the patient’s palms to either the dorsal hands or forearms.
Often, irritant contact dermatitis predates development of
allergic contact dermatitis. Frequent water exposure helps
sensitization to contact allergens. In occupations where wetwork is combined with exposure to such allergens, allergic
contact dermatitis is more common. For instance, one study
of hand dermatitis in hairdressers in Bangkok reported relevant positive patch-test reactions in 75% of those cases. Reactions to paraphenylenediamine, nickel, and fragrance mix
were the most frequent causative allergens among those hairdressers.14 Similarly, in health care workers, frequent handwashing and preceding irritant contact hand dermatitis are
Figure 1 Atopic hand dermatitis with dorsal hand and periungual
disease distribution. Courtesy of Eric Simpson, MD.
Figure 2 Atopic hand dermatitis with volar wrist involvement. Courtesy of Eric Simpson, MD.
within hyperkeratotic lichenified plaques cause a lot of distress in those patients. Water exposure was the most frequently cited exacerbating factor for flares of atopic hand
dermatitis.9
Individuals with atopic dermatitis are more likely to develop both allergic and irritant contact dermatitis given their
innate impaired barrier function. Therefore, it is important to
consider all 3 of these causes of hand eczema in a patient with
a history of atopy.
Contact Hand Dermatitis
Allergic Contact Dermatitis
S. Golden and T. Shaw
150
Table 4 Allergens that Frequently Cause Allergic Contact
Hand Dermatitis*
Allergens
Rubber Allergens
Thiuram
Carba Mix
Fragrances
Fragrance Mix
Balsam of Peru
Figure 3 Atopic hand dermatitis in an infant with dorsal hand involvement and nummular plaques on the ankles. Courtesy of Eric
Simpson, MD.
risk factors for the development of allergic contact dermatitis
to gloves (Figure 4). Any type of hand dermatitis or history of
atopy can be a risk factor for acquiring allergen sensitization.15-18
The most common allergens causing allergic contact hand
dermatitis (Table 4 and Figure 5) are nickel (hand tools,
jewelry), rubber accelerators (gloves), neomycin (topical antibiotics), chromate (leather), and preservatives (skin care
products).15,19,20
Diagnosis of an allergic contact dermatitis is aided by patch
testing. Detailed exposure history from work, home, and
hobby environments gives important clues and guides the
selection of appropriate patch tests. Patch tests are applied to
the patient’s back for 48 hours under occlusion. The patch
tests are then read at 48 hours and at 5-7 days. A positive
reaction is attained when there is a fixed area of erythema that
is either blistered or elevated. Patients can also do a Repeat
Open Application Test (ROAT) to their own products by
applying them twice daily on the inner forearm for up to a
Figure 4 Allergic contact hand dermatitis in a typical glove allergen
distribution. Courtesy of Patricia Norris, MD.
Preservatives
Methylchloroisothiazolinone
Methylisothiazolinone
Quaternium-15
Formaldehyde and releasers
Antibiotics
Neomycin sulfate
Bacitracin
Metal
Nickel
Potassium dichromate
Source
Gloves
Occupation: healthcare,
hairdressers
Skin care products,
cosmetics, hair
products
Skin care products,
cosmetics, lubricants,
household products
Topical antibiotics
Costume jewelry, keys,
coins, buttons, tools
Tanned leather gloves
*These allergens are a sampling of common allergens found to
cause allergic contact hand dermatitis and by no means an exhaustive list of contact dermatitis allergens.
week to see if a response is elicited. A diagnosis of allergic
contact dermatitis is made when a patient has a positive
patch-test reaction and a relevant exposure to the allergen in
question.
Irritant Contact Dermatitis
Irritant contact dermatitis is one of the most common variants of hand dermatitis comprising approximately 80% of all
contact hand dermatitis.15 Irritant contact hand dermatitis is
caused by repetitive exposure to mechanical and chemical
irritants such as water, soap, solvents, oils, friction, and
trauma. Irritants can cause the release of inflammatory cytokines, decrease in surface lipids, and denature epidermal keratinocytes, all of which lead to decreased barrier function and
a decrease in epidermal water content.15,16,21
The most common cause of irritant hand dermatitis is
hand washing where the wet-to-dry cycle disrupts the epidermal barrier. Irritant contact dermatitis usually appears
within 3 months of the first exposure to wet work. Those
individuals with an already compromised epidermal barrier,
such as those with atopic dermatitis, are more susceptible to
irritant hand dermatitis.15,22 Furthermore, irritant contact
hand dermatitis may lead to the development of an allergic
contact dermatitis. The disruption of the epidermal barrier
leads to enhanced susceptibility for allergen sensitization, as
discussed in the previous section.
Clinically, irritant contact dermatitis presents with xerosis,
scaly erythematous plaques, fissuring, and lichenification. It
commonly involves web spaces and can extend to the dorsal
and ventral surface of the hand and fingers (Figure 6). Vesicles do not typically form. Pruritus can be mild; however,
Hand dermatitis
151
Figure 6 Irritant contact hand dermatitis in a hospital worker. Web
spaces are often involved when wet-work is an exacerbating factor.
Courtesy of Susan Tofte, NP.
Figure 5 Allergic contact dermatitis to surgical gloves. (A) Lichenified
plaques over the radial portion of the dorsal hand near the thumb is a
very typical distribution for allergic contact dermatitis to gloves. (B)
Patch-testing results. Relevant positive patch tests to rubber accelerators (thiuram and carba mix) and 2 types of surgical gloves used by the
patient at work. Both sets of gloves contained rubber products.
stinging, burning and pain are frequently reported symptoms.
Both irritant and allergic contact dermatitis have a predilection for certain occupations. They are found to be more
common in hospital workers, construction laborers, food industry workers, janitorial workers, machinists/mechanics,
and beauticians (Figure 7).
Hyperkeratotic Hand Dermatitis
Hyperkeratotic or psoriasiform hand dermatitis comprises
approximately 2% of hand dermatitis.17 The cause of this
dermatitis is unknown; however, patients will often have a
Figure 7 (A, B) Irritant contact hand dermatitis in a barista. Only the
patient’s right thumb was repetitively exposed to water as she made
coffee drinks at work. Courtesy of Susan Tofte, NP.
S. Golden and T. Shaw
152
Figure 9 Frictional hand dermatitis. Courtesy of Eric Simpson, MD.
Figure 8 Psoriasis mimicking hyperkeratotic hand dermatitis. Courtesy of Patricia Norris, MD.
history of manual labor. It is more common in men 40-60
years of age.
This hand dermatitis is defined as symmetric hyperkeratosis of the palms that is well demarcated without involvement
of the wrists. Cracking and fissuring of the palms often causes
pain. This form of dermatitis also lacks vesicles. Itching can
be minimal. In some cases, there may be foot involvement.
Sometimes it is difficult to differentiate it from psoriasis (Figure 8). Absence of other clinical features of psoriasis or psoriatic arthritis is a helpful distinguishing factor.
Histologically one will see hyperkeratosis, parakeratosis,
acanthosis, and some spongiosis, which is otherwise known
as psoriasiform dermatitis. The course of this hand dermatitis
tends to be chronic and often resistant to treatment.
Frictional Hand Dermatitis
Frictional hand dermatitis is caused by the “wear and tear” of
repetitive mechanical forces. These mechanical forces include friction, pressure, trauma, and vibration. This dermatitis may take years to develop depending on the extent and
duration of those mechanical insults on the hands. Repetitive
friction causes hyperkeratotic plaques and occasionally
bullous lesions if the related force is of high enough intensity.
This type of hand dermatitis is not pruritic or vesicular.
Work-related frictional hand dermatitis has been reported by
those who handle money, carbonate copy paper, bus tickets,
artificial fur, panty hoses, carpeting material, and computer
mice.23,24 There is overlap between frictional hand dermatitis
and hyperkeratotic/psoriasiform dermatitis. In fact, they may
be the same entity (Figure 9).
Plaques are often asymmetric and can reoccur in different
places on the hand. Patients may also have nummular
plaques elsewhere on the body.
Vesicular Hand
Dermatitis and Dyshidrotic
Hand Dermatitis/Pompholyx
Pompholyx (acute dyshidrotic hand dermatitis) has intermittent and episodic recurrences of vesicles and bullae that typically last 2 to 3 weeks before resolving (Figure 11). Between
episodes, patients have normal appearing skin. Sometimes
pompholyx presents with large tender bulla without surrounding erythema on the palms. More frequently, collections of very itchy small papulovesicles on the sides of the
fingers are seen (Figure 12). Secondary bacterial infections
can occur. Dermatophyte infection and an id reaction to a
dermatophyte elsewhere on the skin can present similarly.
Therefore, it is important to check the patient’s feet and do
potassium chloride scrapings to rule out a fungal infection.
Some studies have suggested that a nickel allergy may be
associated with pompholyx. In these studies, patients who
were allergic to nickel ingested nickel orally and had reacti-
Nummular Hand Dermatitis
Nummular hand dermatitis does not have any specific age or
gender demographics. It is characterized by papules, vesicles,
and coined shaped eczematous plaques, which appear more
frequently on the dorsal hands and distal fingers (Figure 10).
Figure 10 Nummular hand dermatitis.
Hand dermatitis
Figure 11 Acute dyshidrotic hand dermatitis. Courtesy of Patricia
Norris, MD.
vation of their dermatitis. However, the quantities of nickel
ingested in these studies were much higher than their typical
dietary value. Other studies have not found a relationship
with the ingestion of nickel causing worsening hand findings.17
Chronic vesicular hand dermatitis is a distinct clinical entity from pompholyx as it often lacks the episodic timing and
presents with more erythematous appearing vesicles. We see
the chronic appearance of pruritic vesicles on the palms
and/or on the fingertips. In some patients feet are also involved.
Treatment
Basic Principles: Good Hand Care
The treatment of all subtypes of hand dermatitis is similar. All
treatment starts with attempts to restore skin barrier function
and avoidance of exacerbating factors. A recent trial of hospital workers with hand eczema showed improvement in the
patient’s dermatitis when education and counseling about
proper skin care was provided.25 Skin care products in the
form of thick creams, ointments, or petrolatum products are
important in helping to restore the skin’s protective barrier.26
Frequent reapplication, especially after hand washing, is key.
Avoidance of common irritants and skin care products with
an alcohol or water base helps to avoid further water evaporation and drying of the hands. Creams should also be fragrance-free and contain as few preservatives as possible to
avoid allergens that may result in an allergic contact dermatitis. It is also very important to cut down on wet work,
especially in occupations involving repetitive wet-to-dry cycles. Some of the hand sanitizers on the market are less irritating than the typical hand washing routine. Protective
clothing and changing work flow/environment can help to
avoid contact with allergens and irritants. Thin cotton gloves
under occlusive gloves are recommended. However, some
allergens can pass through the gloves. For instance, acrylate
monomers, which are used in dentistry, penetrate rubber
(latex and neoprene) and vinyl gloves.
153
studies are lacking, open-label studies have shown a benefit
with topical steroids. In an open-label study done by Veien et
al, mometasone fumarate was used freely by participants for
up to 9 weeks and 75% of the patients were found to be clear
by 6 weeks. In a follow-up study, individuals were randomized to use either mometasone 2 days per week, 3 days per
week, or use emollients alone freely. Individuals in both steroid treatment arms showed a longer recurrence-free rate,
83% in the 3 times per week group, and 67% in the twice
weekly group using steroids. Only 26% of the individuals
using only an emollient benefited.27 The American Academy
of Dermatology recommends that potent topical steroids be
used on the hands twice daily for up to a month and then
tapered down to 2 to 3 times per week for maintenance.28
Occlusion of the topical steroid with cotton gloves aides in
intensifying the therapeutic effect. Ointment vehicles of topical therapy are preferred over cream-based formulations as
they contain less water and preservatives.
If long-term topical treatment is needed, then calcineurin
inhibitors such as tacrolimus or pimecrolimus can be used
daily for maintenance therapy. Unlike topical steroids, these
therapies do not cause skin atrophy or telangietasias. Pimecrolimus was studied in 2 large randomized controlled clinical trials and found to be more efficacious in treating hand
dermatitis when used twice daily with overnight occlusion
compared to using just a vehicle cream alone.29 Similarly,
smaller studies have shown twice daily application of tacrolimus to be more beneficial than vehicle cream alone in both
clinical improvement and patient subjective views of improvement.30,31
Light and Radiation Therapy
Phototherapy is a second-line treatment for chronic hand
dermatitis. Both psoralen in conjunction with ultraviolet A
(PUVA) and ultraviolet B (UVB) light therapy have been studied. In a study done by Rosen et al, treatment with PUVA was
compared to UVB in 2 separate study groups and within the
same patient by applying each therapy to different hands.
Topical Therapy
A potent topical steroid is the initial prescribed treatment of
choice for hand dermatitis. Although randomized clinical
Figure 12 Small vesicles on the lateral aspects of fingers is typically
seen in dyshidrotic hand dermatitis. Courtesy of Eric Simpson, MD.
154
Both forms of phototherapy were effective in improving the
hand dermatitis; however PUVA treatment was found to be
more effective.32 Other studies have shown equal efficacy.33 If
there is inadequate response when considering irritant effects
with PUVA-soak therapy or side effects of oral psoralen intake, our recommendation is to start with narrow band UVB
and progress to PUVA.
Grenz ray is a type of superficial ionizing radiation that has
been used to treat hand dermatitis. A double-blind study by
Fairris et al showed that using superficial x-ray radiotherapy
in conjunction with topical steroids was more effective in
treating hand dermatitis compared to topical therapy alone.34
Grenz ray has also been reported to be beneficial in recalcitrant frictional hand dermatitis.35 Treatment using Grenz ray
typically involves 6 treatments of 200 to 400 rads spaced
every 1 to 3 weeks. This is followed by a 6-month break in
treatment. Grenz ray is a safe therapeutic option as the rays
are almost entirely absorbed in the upper 3 mm of the dermis.36 However, it is recommended that individuals not exceed more than 5,000 rads in a lifetime.
Systemic Therapy
For acute or recurrent vesicular hand dermatitis, systemic
glucocorticoids can be helpful if started at the onset of symptoms and only used for up to 3 to 5 days.17 For some patients,
it is the only way they are able to halt a pompholyx flare
quickly. Allergic contact dermatitis and atopic hand dermatitis may also benefit from systemic steroids if the dermatitis
is severe. However, systemic glucocorticoids should not be
used for long-term treatment of any form of hand dermatitis
due to the many long-term side effects. Among the effects are
cataracts, glaucoma, hyperglycemia, osteoporosis, and suppression of the hypothalamic-pituitary-adrenal access.
Oral retinoids have been studied and proven to be efficacious in controlling hand dermatitis, especially the hyperkeratotic/psoriasiform or frictional variants. Both alitretinoin
and acitretin improved chronic hand eczema. However, alitretinoin is only approved for hand eczema in Europe and
Canada. In one study, 40% of patients taking 30 mg of alitretinoin daily were clear and 24% of patients taking 10 mg
were clear.37,38 Retinoids are a great third-line treatment for
chronic hand dermatitis given their good safety profile and
less frequent lab monitoring compared to immunomodulating medications. The main side effects of retinoids include
xerosis, increase in lipid levels, and teratogenicity. Therefore
individuals of child-bearing age need to be carefully monitored with pregnancy tests and counseled about the side effects. Acitretin is not recommended for women of child-bearing age as currently there is a recommendation to avoid
pregnancy for 3 years after discontinuation of acitretin therapy.
Oral immunomodulating medications have also been tried
in the treatment of hand dermatitis. They are considered
when topical therapy or phototherapy fails. Support for the
use of immunomodulating drugs comes primarily from studies in atopic dermatitis.39 Cyclosporine is one medication
known to suppress T-lymphocytes. In particular, atopic der-
S. Golden and T. Shaw
matitis patients may show great benefit from starting this
medication. One double-blinded randomized trial of 41 patients showed that 50% of individuals given oral cyclosporine
at a dose of 3 mg/kg/day improved compared to 32% of
individuals given topical corticosteroids after 6 weeks.40 Another trial of 41 patients after 1 year on oral cyclosporine (3
mg/kg/day) showed between a 50%-79% improvement depending on the type of hand dermatitis.41 In severe cases,
cyclosporine doses of 5 mg/kg/day for 3 months can be helpful in halting a significant flare while allowing the patient to
bridge to a different long-term therapy. However, cyclosporine is not a good long-term medication due to its side effects
of nephrotoxicity, hepatotoxicity, and hypertension. Cyclosporine can be used to induce clearance or improvement of a
patient’s hand dermatitis as the patient transitions to a more
long-term therapy.
Mycophenolate mofetil, azatihoprine, and methotrexate
are immunomodulating medications that have been used for
chronic hand dermatitis. Mycophenolate mofetil inhibits the
synthesis of guanosine nucleotides needed for lymphocyte
proliferation. There are a few case reports of individuals with
dyshidrotic eczema having clearing with mycophenolate
mofetil therapy. One patient with a 4-year history of recalcitrant disease that was previously treated with corticosteroids,
iontophoresis, and phototherapy was placed on 3 g/day of
mycophenolate mofetil and had complete clearance of his
disease within 4 weeks. The dose was then reduced gradually
over a 1-year period without recurrence of dermatitis. Typical doses of mycophenolate mofetil are between 2 to 3 grams
per day.42,43 Methotrexate is another medication that can be
used for hand dermatitis and works by inhibiting dihydrofolate reductase, which is an enzyme important in cell proliferation. In one study, low-dose methotrexate (12.5 to 22.5 mg
per week) was given to 5 patients with recalcitrant pompholyx and all patients showed partial or complete remission of
their disease while on methotrexate.44 Azathioprine, which
works by inhibiting ribonucleic and deoxyribonucleic acid
synthesis, has been reported to help atopic dermatitis, allergic contact dermatitis, and pompholyx. Participants in these
studies were given daily doses between 100 mg and 150 mg
daily. The effects were seen typically between the 4th and 6th
week of treatment.45 With all of these immunomodulating
medications, frequent lab draws are necessary to evaluate for
hepatotoxicity, nephrotoxicity, and bone marrow suppression.
Literature on the use of antitumor necrosis factor-␣
treatments is lacking. Given their anti-inflammatory potential and beneficial use in conditions such as psoriasis,
Bechet’s disease, and pyoderma gangrenosum, the existing
literature may have some efficacy in treating hand dermatitis. There is one case study of a patient with a 6-year
history of recalcitrant pompholyx who was treated with
etanercept. She was placed on twice weekly 25 mg etanercept subcutaneous injections and, after 4 months, had
reached remission. However, she suffered a flare and her
dose was doubled to 50 mg twice weekly. Unfortunately,
this increase in dosage did not benefit her and treatment
with etanercept was discontinued.46 More studies are
Hand dermatitis
155
Table 5 Treatment Options
Medication
Topical steroids
Dosing
Lab Monitoring
Twice daily for 1 month
then decrease to 2-3
times per week
Twice daily
None
Two to three times
weekly slowly
increasing treatment
each visit
Six treatments of 200-400
rad every 1-3 weeks,
max lifetime dose 500010,000 rads
20-60 mg per day for 3-4
days
None
Oral retinoids (Acitretin
and Alitretinoin)
Acitretin – 10-50 mg per
day
Alitretinoin – 10-30 mg
per day
Cyclosporine
3 mg/kg/day
Pregnancy test, CBC, LFTs,
renal function, fasting
lipid panel monthly for 3-6
months then every 3
months
Blood pressure, CBC, renal
function, LFTs, Mg, K,
Uric acid, fasting lipids at
baseline, every 2 weeks
for 1-2 months and then
monthly
Mycophenolate mofetil
2 to 3 grams per day
Methotrexate
12.5 to 22.5 mg per week
with daily folic acid
supplementation
Azathioprine
50-150 mg per day
Topical calcineurin
inhibitors
PUVA or narrow band
UVB
Grenz ray
Oral prednisone
None
Side Effects
Atrophy,
telangiectasias,
acne/rosacea, striae
Skin malignancies,
lymphoma
Skin malignancies,
headaches, nausea
None
Skin malignancies
Consider checking glucose
levels especially in
diabetic patients,
long-term use will need
bone density evaluations
Cataracts, glaucoma,
hyperglycemia,
osteoporosis, and
suppression of the
hypothalamicpituitary-adrenal
access
Xerosis, increase in
lipid levels,
hepatotoxicity, and
teratogenicity
Pregnancy test, CBC, CMP,
Hepatitis B and Hepatitis
C, PPD at baseline, then
CBC and CMP every 2-4
weeks during dose
escalation and then every
3 months when dose
stable*
CBC, CMP, urinalysis at
baseline, 1-2 weeks after
initiation, then monthly for
1-2 months then every 3
months
Thiopurine
methyltransferase at
baseline, CBC, CMP,
pregnancy test, urinalysis,
and PPD at baseline,
every 2 weeks for 2
months then every 3
months
Hyperlipidemia,
hypertension,
hepatotoxicity,
nephrotoxicity,
hyperkalemia,
hyperuricemia,
hypomagnesemia
GI symptoms,
opportunistic
infections, bone
marrow suppression
Hepatotoxicity, bone
marrow suppression,
pulmonary fibrosis/
pneumonitis,
carcinogenesis, oral
ulcers, GI upset
GI upset, bone marrow
suppression,
hepatotoxicity,
increased risk of
infections,
carcinogenicity
*Mycophenolate mofetil prescription now requires registration with the Mycophenolate REMS. Physicians are required to educate patients
about the teratogenicity of the medication. Reproductive age females must have a pregnancy test before initiating the drug, 8-10 days after the
initial pregnancy test and monthly while on the drug. Patients must also use contraception while taking mycophenolate and for 6 weeks after
discontinuation of the drug. All pregnancies during treatment must be reported to the Mycophenolate Pregnancy Registry.
Abbreviations: CBC, complete blood count; CMP, comprehensive metabolic panel; GI, gastrointestinal; K, potassium; LFT, liver function tests;
Mg, magnesium; PPD, purified protein derivative tuberculin test; PUVA, psoralen ultraviolet A; UVB, ultraviolet B.
S. Golden and T. Shaw
156
therefore needed to assess whether treatment with antitumor necrosis factor-␣ medications would be helpful.
Finally, patients with hand dermatitis should also be assessed for bacterial infections and, if present, should be
treated with either systemic or topical antibiotics.
Treatment options, dosing, monitoring and side effects are
listed in Table 5.47
Conclusion
Chronic hand dermatitis is commonly encountered in the
practice of dermatology. Numerous types of chronic hand
dermatitis exist, including atopic dermatitis, allergic contact
dermatitis, irritant contact dermatitis, hyperkeratotic/psoriasiform dermatitis, frictional dermatitis, chronic vesicular
dermatitis, and dyshidrotic dermatitis/pompholyx. Hand
dermatitis is often a combination of these entities and therefore may prove to be a diagnostic challenge. This paper highlights the clinical distinctions between the various forms of
hand dermatitis to help clinicians establish accurate diagnoses and differentiate hand dermatitis from other primary dermatology conditions. Treatment of hand dermatitis starts
with helping to repair the skin barrier with proper hand-care
hygiene. Avoiding wet and dry cycles as well as moisturizing
is of utmost importance. First-line prescription therapy involves using potent topical steroids and often a topical calcineurin inhibitor as maintenance therapy. Light therapy,
either PUVA or narrow band UVB, and Grenz ray therapy are
considerations for hand dermatitis that failed topical treatment. Finally, oral retinoids or immunomodulating medications can be used as they are helpful in many inflammatory
skin disorders. Physicians must work together with patients
to find a treatment option that best suits the patient as studies
have shown that chronic hand dermatitis can negatively impact one’s quality of life.
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