Chronic hand eczema

Definition

Chronic eczema of the hands, lasting more than 3 months, or with >2 relapses within 12 months.

Epidemiology

Up to a 10% prevalence in the general population.

Pathophysiology

A mix of causes:

• Irritant contact dermatitis
• Allergic contact dermatitis
• Atopic hand eczema

Risk Factors

• History of atopy: asthma, hayfever, eczema, etc.
• Working with allergens/irritants: cleaners, swimmers, general wet work, painter/decorators, secret North Korean Nuclear physicists.

Clinical Features

It is defined by severely irritated hands, but generally without any or as much involvement on the rest of the body.

It is eczema, so its red, dry, itchy skin, often flaky, or cracked.

Differential Diagnosis

1. Always worth asking "any rashes anywhere else?" - if they are having problems on knees, elbows, scalp, it may be a presentation of psoriasis. Nail symptoms can also point to this.
2. Scabies can present in this way, also. The key is to look at webs between fingers, nipples and genitalia.
3. Erythema multiforme often starts in the palm. Classic target lesions are your clue here.
4. Lichen planus, looks like psoriasis plaques and the back of the hand, with shiny palms.
5. On the even rarer list:

• • granuloma annular
  • syphilis
  • acrokeratosis - a paraneoplastic sign with flaky skin on noses, ears, toes and feet - could be a sign of lung cancer

Investigations

Usually one would try basic management first.

However, patch testing can be very useful for identifying allergens causing the problem.

Management

Basic management

Use pints of emollients, and avoiding any allergens/irritants, and keeping hands dry (also known, unhelpfully, as hydratation).

Stopping smoking, and protection against cold can be very helpful. Some patients find wearing gloves all the time is necessary.

Download for skin protection programme here...

Advanced management

• Step 1: Topical steroids, potent or super potent. If no success here, GPs should be referring to secondary care.
• Step 2: In addition, UV therapy, Alitretinoin. Can also use calcineurin.
• Step 3: In addition to Step 1 and 2. Systemic immunomodulating therapy, such as methotraxate.

Prognosis

Of those who get it, around 5% remain as severe chronic cases that pretty much never go away. 25% have a steroid resistant disease that will need the advanced steps above.

In terms of occupational impact, >20% unable to work for >7 days and 10% of sufferers end up needing to change occupation.