Hand Eczema
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Direct answer
Hand eczema is a chronic or recurrent dermatitis of the hands, classified as irritant contact, allergic contact or atopic, and several types often coexist. Irritant contact dermatitis is the commonest type and follows repeated exposure to water, soaps and detergents, a pattern called wet work. Management follows a stepwise plan that begins with avoidance, emollients and potent topical steroids, and escalates to phototherapy or systemic agents for severe chronic disease.
What you must remember
- Irritant contact: the commonest type, caused by water, soaps, detergents, solvents and friction, with dryness, fissuring and scaling on the fingers and palms.
- Allergic contact: delayed hypersensitivity to nickel, cobalt, fragrances, preservatives and rubber accelerators such as thiurams, confirmed by patch testing.
- Atopic: occurs in people with atopy, often with a personal or family history of atopic dermatitis, and may involve the dorsa of the hands and fingers.
- Pattern variants: pompholyx, chronic palmar hyperkeratotic and fissured eczema, and periungual disease are patterns that can occur with any cause.
- Risk factors: wet work for more than about two hours a day, healthcare, cleaning, catering and hairdressing jobs, atopy and previous hand eczema.
- Patch testing: essential for recurrent, occupational or unexplained hand eczema, so that allergens can be avoided.
- Escalation: oral alitretinoin (where available) for severe chronic hand eczema that resists potent steroids; ciclosporin, methotrexate or dupilumab in selected patients, following local guidance.
A stepwise management plan
Chronic hand eczema is managed in layers, beginning with the cause and ending with systemic therapy for disease that resists everything else. The steps below follow standard practice in dermatology and occupational health.
- Classify the type: decide whether irritant, allergic or atopic disease predominates, using the exposure history, the pattern and the response to avoidance.
- Stop the exposure: reduce wet work where possible, wear cotton-lined gloves under nitrile or vinyl gloves, and avoid any contact allergen identified on patch testing.
- Use emollients: apply fragrance-free emollients several times a day and after every hand wash to restore the barrier.
- Prescribe topical steroids: use a potent steroid in courses for flares, stepping down to a milder preparation once the flare settles.
- Consider phototherapy: narrowband UVB or PUVA is used for chronic disease that resists topical treatment, with the long-term risks of PUVA in mind.
- Add systemic therapy: alitretinoin is used for severe chronic disease, with contraception required, since it is contraindicated in pregnancy.
Each step should be reviewed at intervals, and the response to avoidance guides further decisions. Occupational hand eczema also has medico-legal implications, so documenting exposures and advice is valuable.
Where the exam tries to catch you
Hand eczema questions test the classification, the role of patch testing and the safety of alitretinoin.
- Trap: calling all hand eczema allergic and ordering only patch tests Correct: irritant contact dermatitis is the commonest type, and patch testing is useful when allergy is suspected.
- Trap: treating chronic hand eczema with topical steroids alone Correct: emollients, avoidance and phototherapy or systemic agents are needed for refractory disease.
- Trap: prescribing alitretinoin to a woman who may become pregnant Correct: alitretinoin is teratogenic and contraindicated in pregnancy, so effective contraception is required.
- Trap: forgetting to ask about wet work Correct: prolonged water and detergent exposure is the main occupational trigger, so the history must cover it.
Frequently asked questions
Which type of hand eczema is the commonest?
Irritant contact dermatitis is the commonest type of hand eczema, caused by water, soaps, detergents and friction. It is especially common in healthcare workers, cleaners, caterers and hairdressers. Avoidance of wet work and regular emollients are the core measures.
When is patch testing indicated in hand eczema?
Patch testing is indicated when hand eczema is recurrent, chronic or occupational, or when allergy is suspected from the history. Common allergens include nickel, cobalt, fragrances, preservatives and rubber chemicals. A positive result guides avoidance advice for the patient.
What is wet work in hand eczema?
Wet work is occupational exposure to water, detergents and moist hands over long periods, commonly taken as more than about two hours a day. It is a major risk factor for irritant hand eczema. Protective gloves and barrier creams are standard preventive measures.
Which drug treats severe chronic hand eczema?
Alitretinoin, an oral retinoid, is used for severe chronic hand eczema that has not responded to potent topical steroids. It is teratogenic and contraindicated in pregnancy, so effective contraception is required during treatment. Phototherapy and other systemic agents are considered when it is unsuitable.