It is a common group of acute and chronic eczematous disorders that affect the dorsal and palmar aspects of the hand.
Hand dermatitis is also known as hand eczema and is a common condition seen in the primary care setting.
Occupational exposures and frequent hand washing often lead to symptoms that are irritating and can cause discomfort.
Irritant dermatitis, atopic dermatitis of the hand, and contact dermatitis of the hand account for at least 70% of all diagnoses.
A unifying feature in most cases is an underlying disruption in the stratum corneum, disrupting its barrier function.
Who gets hand dermatitis?
Hand dermatitis is common (especially in young adult women) and accounts for 20–35% of all dermatitis. It can occur at any age, even during childhood.
It is particularly common in people with a history of atopic eczema.
Hand dermatitis is particularly common in the cleaning, catering, metalworking, hairdressing, healthcare, housework, painting, and mechanical industries.
This is primarily due to contact with irritants, but specific contact allergies can contribute.
Risk factors for hand dermatitis include the use of latex gloves, chemical exposure, and frequent hand washing .
Health professionals, machinists, housekeepers, and estheticians are examples of people who are at higher risk of developing symptoms.
Other predictive factors include a history of childhood eczema and female gender.
Causes of dermatitis on the hands
Hand dermatitis is often the result of a combination of causes, including:
- Genetic and unknown factors (constitutional dermatitis of the hand).
- Injuries (contact irritant dermatitis).
- Immune reactions (allergic contact dermatitis).
- Hand dermatitis is frequently caused or aggravated by work, when it is known as occupational dermatitis.
These damage the external stratum corneum, eliminating lipids and altering the skin’s barrier function. The loss of water and inflammation lead to a further deterioration of the barrier function.
Symptoms of hand dermatitis
General symptoms often include irritation and discomfort that, in many cases, significantly interfere with normal daily activities related to home or work.
It is estimated that between 5% and 7% of patients with hand dermatitis are characterized by chronic or severe symptoms and between 2% and 4% of severe cases are refractory to traditional topical treatment.
The management of refractory cases presents a significant challenge to the primary care provider and may require a referral.
Hand dermatitis can affect the backs of the hands, the palms of the hands, or both. It can be very itchy, often burning, and sometimes painful.
The phases of dermatitis are:
Acute dermatitis of the hands presents with:
- Red macules.
Features of chronic hand dermatitis include:
There are various causes and clinical presentations of hand dermatitis.
The stratum corneum is essential to form a barrier against the external environment and prevent water loss. This superficial layer contains epithelial cells embedded in a lipid bilayer of ceramides, fatty acids and cholesterol with a water content between 20% and 35%.
Almost all forms of hand dermatitis involve an alteration in the stratum corneum that is generally followed, but in some cases is preceded by a local inflammatory response.
In simple terms, the appearance of in the stratum corneum leads to the activation of inflammatory cells.
Inflammatory activity and transepidermal water losses lead to dryness, cracking, and inflammation. The lipids of the stratum corneum are mostly water soluble and exposure to water from “wet work” can remove additional lipids.
This explains the paradox regarding water drying hands and the need to use emollients as a form of treatment.
The drying effect of additional water can best be imagined when you think of cracks and hard, dry soil in a desert that is present after the evaporation of rainwater.
The loss of water from the stratum corneum causes cracks, fissures and a further deterioration of its barrier function.
Disruption of the lipid layer in irritant hand dermatitis occurs when exposed to detergents, soaps, and other chemicals or irritants.
The inflammation results from an irritant that is strong enough or that is in contact with the skin long enough to erode the barrier. Repeated or severe exposures extend to the deeper layers of the skin and endothelium.
This, in turn, can turn into a vicious cycle of chronic and / or serious illness. Underlying deficiencies within the major components of the lipid barrier that allow for water loss are present in individuals with atopic dermatitis.
These deficiencies lead to water loss, a weakened barrier, and a lower threshold for the activation of inflammation. As a result, patients have dry skin and an increased vulnerability to various triggers, including irritants and allergens.
The mechanism in contact dermatitis is different from that observed for irritant or atopic dermatitis. Contact dermatitis involves a delayed type IV hypersensitivity reaction.
Induction occurs when allergens penetrate the skin and are processed by Langerhans cells.
The allergens then conjugate with carrier proteins to form antigens. Conjugated antigens migrate to the lymph nodes, where sensitization occurs.
Within 12 to 48 hours after re-exposure, lymphokines are released by memory T cells and produce an inflammatory response.
Understanding each patient’s disease pattern and any exacerbating factors is essential for effective diagnosis and management. Diagnostic considerations are based on the history and physical examination.
The initial history should consider occupation, history of atopic dermatitis, and hand washing activities or exposure to other irritants. Symptoms vary depending on the type of hand dermatitis.
Acute symptoms in hand contact dermatitis, for example, typically consist of blisters with overlapping crying and scabs along with intense itching.
Subacute changes often include erythema and scaling, which can lead to lichenification, fissuring, and thickening of the skin as the condition becomes chronic.
The distribution and morphology of the lesions must be considered, but no distribution is classic for any specific type of dermatitis. However, in some cases, an area of inflammation may correspond exactly to a region that is exposed to an allergen or irritant.
Between 20% and 35% of all dermatitis affects the hands, and in many cases it also affects other parts of the body. Therefore, it is important to inquire about skin lesions elsewhere to identify possible systemic dermatoses such as psoriasis.
Hand dermatitis is often a chronic disease that is difficult to manage.
Patch testing for allergens and evaluation of skin scrapings on potassium hydroxide for hyphae along with fungal and bacterial cultures may be necessary for correct diagnosis.
A large study in 1990 found that the most common types of hand eczema were irritant contact dermatitis (35%), followed by atopic hand dermatitis (22%) and allergic contact dermatitis (19%).
The remaining diagnostic considerations are largely based on morphology and include, but are not limited to:
- Eccema numular.
- Hyperkeratotic dermatitis.
Other potential causes for hand dermatitis that are not reviewed in this article include, but are not limited to:
- Identification reactions.
- Chronic vesicular dermatitis of the hand.
Irritant contact dermatitis
This is the most common type of hand dermatitis and results from exposure of the skin to exogenous substances that erode, irritate, or damage the stratum corneum.
Symptoms can occur in anyone and typically include burning, itching, and tenderness at the site of exposure to an irritant. The palms, despite having a thicker stratum corneum, are frequently involved.
The involvement of finger networks extending to the dorsal and ventral surfaces may also suggest this diagnosis.
Atopic dermatitis of the hand
Atopic patients have a 13.5 times higher risk of developing occupational dermatoses than non-atopic patients, and represent a special category at high risk for both allergic and irritant responses.
Clues to diagnosis may include dermatitis of the hand at an early age and dry, itchy skin often seen during the adult life of the patient. Symptoms tend to develop on the backs of the hands and fingers and can spread to the wrist.
Contact dermatitis, sometimes called allergic contact dermatitis, is a delayed-type hypersensitivity in which the generation of memory T cells to an antigen will reproducibly generate an inflammatory response in the event of antigen rejection.
Substances with high potential for sensitization include nickel, rubber blend (an additive used in rubber products), fragrance blend, topical antibiotics, and potassium dichromate, along with other preservatives.
These products contain low molecular weight lipophilic compounds that penetrate the skin.
Occupational hazards that should alert a physician to allergic contact dermatitis include exposure to any of these substances, as well as frequent use of latex gloves.
This can be an especially obvious consideration if there is an identifiable exposure to an object along with a well-defined associated area of dermatitis.
The intensity of the inflammation depends on the concentration of the antigen and the degree of sensitivity.
Allergic contact dermatitis can favor the fingertips, folds, and dorsal hands. Treatment should be aimed at the identification and avoidance of allergens, as well as the control of inflammation.
Dermatitis numular de la mano
Nummular dermatitis of the hands is of unknown cause and presents with circular areas of redness, scaling, and erythema usually seen on the back of the hands. Symptoms can also be present in the extremities.
The inflammation is often subacute or chronic and may appear psoriatic. Once present, the size of the lesions does not usually change.
The term pompholyx is often used interchangeably with dyshidrotic eczema; this reflects the finding that sweat volume was higher in patients with pompholyx. Pompholyx is the symmetrical development of vesicles on the lateral aspect of the fingers preceded by itching.
Symptoms can also be present on the palms of the hands and can also affect the feet and toes and lead to nail dystrophy. The vesicles usually last about 2 to 4 weeks before resolving, and then recur at variable intervals.
Hyperkeratotic dermatitis is a chronic disease consisting of adherent, symmetrical scales on the palmar surface. It is more common in middle-aged men. The cause is usually not identifiable, but may be the result of an allergy or chronic irritation.
The clinical course is usually chronic and stable, and treatment should resemble that used for other forms of chronic hand dermatitis.
Gram-positive bacteria and / or fungal infections should be considered in chronic cases and in cases that do not respond to conventional treatment.
In cases where infection is suspected, culture of vesicular or pustular lesions may be necessary, along with gentle scraping of lesions for potassium hydroxide preparation to evaluate fungal elements.
Treatment of dermatitis on the hands
Therapy must be individualized for the patient and must address both the acute and chronic aspects of dermatitis. Regardless of the type of hand dermatitis, restoration of the epidermal barrier is essential.
Avoiding irritants, hand washing or other “wet work” and the use of emollients will help restore the normal skin barrier, regardless of the type of hand dermatitis.
Regular use of emollients and barrier creams has been shown to protect against drying and chemical irritation.
Simple petroleum-based emollients are generally as effective as emollients containing skin-related lipids, although several studies suggest that topical mixtures of key stratum corneum lipids, including ceramides, can accelerate barrier repair.
Adequate hydration of the skin is also extremely important for prevention in patients with chronic diseases, even when symptoms are well controlled. Emollients are best used immediately after bathing to “lock in” moisture.
Skin protection programs that recommend protective gloves (vinyl or cotton) and mild soaps to use when washing has been used to reduce irritating symptoms.
Identification and avoidance
Patch testing is important for the identification of potential contact allergens.
Certain individuals may need to change jobs if symptoms are severe and allergens are difficult to avoid on the job.
Topical corticosteroids are often used as first-line agents to control inflammation. In general, ointments are more effective and contain fewer preservatives than creams or gels.
Some authors advocate the “soak and smear” technique in which medium to high potency steroids are applied after complete hydration of the hands with an emollient.
Urea may also be helpful in increasing the topical absorption of steroids, especially in chronic and lichenified cases.
However, acute inflammation may not benefit from topical steroids, as the cream or ointment may have a difficult time penetrating the vesicles. Subacute inflammation requires group III to IV steroids for control.
Chronic inflammation requires topical group I steroids without occlusion or topical group II to V steroids with occlusion for 1 to 3 weeks until the inflammation subsides.
The occlusion is best done with a plastic bag wrapped around the hand after applying the topical corticosteroid to an area that has been cleaned with mild soap and water.
Continued use of medium strength topical steroids for more than 3 to 4 weeks is discouraged due to possible side effects including atrophy and telangiectasia.
Tachyphylaxis is also more likely with continued use and may require a change in treatment.
Treatment of infections
Antistapilcoccal antibiotics, such as cephalexin or dicloxacillin, are an effective treatment when indicated by clinical signs and symptoms. Methicillin-resistant Staphylococcus aureus, if present, will require a change in antibiotic coverage.
For outpatient therapy for community-acquired methicillin-resistant S. aureus skin and soft tissue infections, trimethoprim-sulfamethoxazole or doxycycline should be considered.
A sensitive bacterial culture should be obtained to guide therapy, aid in treatment failures, and document resistance patterns in the local population.
Topical or oral antifungal medications should also be used as appropriate, depending on the results of the skin scraping and subsequent potassium hydroxide preparation.
Agents such as tacrolimus and pimecrolimus are topical substances that inhibit the release of inflammatory cytokines.
Unlike topical steroids, these agents do not cause dermal atrophy or telangiectasia, and may be useful for treatment in sensitive areas and for chronic skin conditions.
Pimecrolimus is thought to be more effective than tacrolimus for mild to moderate chronic hand dermatitis.
The most prominent side effects are usually burning and itching at the application site, and systemic absorption and immunosuppression are negligible.
The response to these agents is slower than that of topical steroids. However, both tacrolimus and pimecrolimus have black block warnings for rare malignancies, including skin and lymphoma, although causal relationships have not been established.
Oral immunosuppressive medications, such as azathioprine or methotrexate, should be reserved for severe cases and should be administered by physicians with extensive experience and knowledge of both the disease and the medications.
Systemic steroids may be helpful in severe cases and may also be helpful in short bursts for treating acute vesicular symptoms or recurrent pompholyx.
Possible side effects, such as cataracts, hyperglycemia, and osteoporosis, make oral steroids an unwanted option for chronic or indiscriminate use.
Oral histamine antagonists block endogenous histamine release and may relieve itching. This modality may be more useful in patients with allergic hand dermatitis. H1 receptor antagonists are the drugs of choice.
Ultraviolet radiation therapy
Ultraviolet A radiation with or without psoralens has been used with at least moderate efficacy to treat all types of resistant hand dermatitis. Ultraviolet radiation leads to local immunosuppression and reduces inflammation.
Ultraviolet B radiation has been found to be equal to or slightly less effective than ultraviolet A radiation. Other treatment considerations
Other available treatments include local steroid injections for resistant cases. Botulinum injections and iontophoresis have been shown to be somewhat effective for pompholyx.
In hyperkeratotic hand dermatitis, topical retinoids may be helpful because they normalize the maturation of epidermal cells.