Hand Eczema Affects 700 million: 13 Dermatologist Treatments for Itchy and Irritated Skin

Atopic-Hands

(edited from the skintherapyletter.com article: New and Existing Therapeutic Options for Hand Eczema)

Hand eczema can be a very frustrating condition. Severe itching, inflammation, dryness, redness and scaling of the skin on the hands are the most typical symptoms. For many people it often runs a chronic, relapsing, and remitting course despite appropriate preventative measures and treatment.5,7,8

Hand eczema affects up to 10% of the population and can have a diverse range of symptoms and underlying causes. A genetic predisposition is believed to play a role in hand eczema in up to 50% of cases.4 The 2 other most important causative factors are contact allergy and irritant exposure. Additional contributory factors include friction, occupation, low humidity, psychological stress, and hyperhidrosis (excessive sweating).5,6 However, for some people, the causes are unknown.5

Learn More About Irritant Contact Dermatitis
Danger in the Beauty Aisle: 19 Ingredients that Cause Allergic Contact Dermatitis

Despite the large scale of the problem, few well-designed, randomized controlled trials evaluating therapies have been carried out. In all hand eczema trials since 1977,3 only 2,142 patients have been enrolled.12 The lack of evidence-based data on therapeutic options for hand eczema has left dermatologists with no clear direction for treating those patients who do not respond to conventional therapy.

This article will review the new and existing treatments that are available for this common dermatologic problem.

Preventative Measures

The first step to preventing flare-ups of hand eczema is to regularly use a moisturizer. Look for moisturizing product that is specially designed for sensitive skin and that is free of fragrances, which may irritate the skin. The regimented use of moisturizers can partially repair and restore the skin barrier and reduce infections and allergic reactions.

One of the most common triggers of hand eczema is water. Frequent hand washing, especially with hot water, can strip the skin of its natural protective oils. Washing with harsh soaps, detergents and solvents can only make the problem worse.

Hand eczema is particularly common in industries involving cleaning, catering, metalwork, hairdressing, healthcare and mechanical work. When engaging in activities where your hands are repeatedly immersed in water, such as washing dishes, wearing rubber gloves can help. However, make sure to use gloves with cotton liners, as direct skin contact with rubber can exacerbate hand eczema.

Contact allergies are responsible for hand eczema in as many as 47% of cases. The best way to accurately find out what’s causing hand eczema is by patch testing.13 Patch testing is an effective way of identifying whether a substance that comes in contact with the skin is causing inflammation or allergic reactions. Common contact allergens that can cause hand eczema include nickel, potassium dichromate, rubber chemicals, and biocides.

The Skinny On Winter Moisturizers
Are You One Of The 350 Million With Dandruff?

Topical Treatments

Corticosteroids
Considered as the first-line therapy in the treatment of hand eczema, several trials have evaluated the effectiveness of mild, moderate, or potent topical corticosteroids for hand eczema.15-17 However, there are no standard recommendations about how these medications should be used.

Corticosteroids work by mimicking the effects of hormones, such as cortisol, that are produced by your adrenal glands. Specifically, they are absorbed into your skin cells and stop those cells from producing chemicals which cause inflammation, allergic reactions when the skin comes into contact with allergens or irritants.

It is important to keep in mind that topical corticosteroids may also be allergens. Consquently, the possibility of a corticosteroid allergy should always be considered before attributing treatment failure to the disease itself.

Immunomodulators
Topical Calcineurin Inhibitors work by blocking the immune system’s inflammatory process, so they reduce inflammation of the affected skin as well the itch and rash associated with eczema. The effectiveness of topical calcineurin inhibitors in the treatment of eczema has been well established; however, their therapeutic role in hand eczema has not been studied in randomized, double-blind, controlled trials.

Topical Tacrolimus
In a study of 29 patients with occupational hand eczema, tacrolimus (Protopic®, Astellas Pharma) was applied twice daily for 4 weeks, followed by a 2 month optional treatment period, which resulted in complete clearance in 44% of patients.19

Pimecrolimus Cream
In a another study, the effectiveness of pimecrolimus cream (Elidel®, Novartis) was evaluated for the treatment of chronic hand eczema.21 294 patients with chronic hand eczema, almost 28% of pimecrolimus-treated patients were clear or almost clear at the end of the study.

Given the chronic nature of hand eczema, topical calcineurin inhibitors may provide the greatest benefit as a maintenance therapy between flares, which is akin to that adopted for the treatment of atopic dermatitis. Based on the information derived from a small number of studies, their use appears to be limited to treatment of non-hyperkeratotic (non-thickening of skin) hand eczema.20-22

Alcohol Is Abusive To Your Skin, Find Out Why
Chocolate And Sex Causes Acne

 

Phototherapy

Phototherapy is one of the most effective treatments for hand eczema.

Ultraviolet B (UVB)
Narrowband UVB is now the most common form of phototherapy used to treat skin diseases. It has shown clinical effectiveness in the treatment of psoriasis and eczema.24 “Narrow-band” refers to a specific wavelength of ultraviolet (UV) radiation that is exposed to the skin.

The safety and effectiveness of narrow band UVB therapy for the treatment of chronic hand eczema was evaluated in a study of 15 patients who had failed conventional topical therapy.25 Patients who were treated with narrow band UVB 3 times weekly for 9 weeks. Patients were assessed every 3 weeks during the treatment period and then evaluated 10 weeks following the last treatment. All of the 12 subjects who completed the trial showed improvement.

Both broad band and narrow band UVB appear to be as effective as topical/bath psoralen + UVA (PUVA) therapy in the treatment of chronic hand dermatitis.26 However, the risks of phototoxicity and dyspigmentation associated with local PUVA therapy make UVB therapy a preferable choice for first-time treatment.

PUVA
PUVA is utilized by first treating the hands with a cream that contains an ingredient that causes the skin to become light-sensitive, then the hands are then irradiated with ultraviolet A light (UV-A).  Several studies have reported benefits from both topical and systemic PUVA therapy for chronic hand dermatitis.27-29 PUVA may be the phototherapy of choice for hyperkeratotic hand eczema given the ability for the UVA’s longer wavelengths to penetrate deeper into the skin.

UVA-1
UVA-1 therapy has been established as an effective treatment of atopic dermatitis in several clinical trials.31,32 UVA-1 was first reported to be beneficial for dyshidrotic hand eczema in an uncontrolled trial of 12 patients.33 Subjects received daily treatment with local UVA-1 irradiation for 3 weeks. Conditions for 10 out of 12 patients were judged to be cleared or almost cleared at the end of the treatment course and patients remained relapse free during a 3 month follow-up period.

Ionizing Radiation

Grenz Rays / Radiotherapy
The inflammatory cells operative in eczema are highly sensitive to radiation.34 Grenz rays and superficial radiotherapy were popular treatments for chronic severe hand eczema 20-30 years ago. However, their association with a greater risk of cancer has resulted in these treatments falling out of favor. Superficial radiation therapy appears to provide greater benefit than Grenz ray therapy and this is likely because of its deeper penetration into the skin. As a result of non-standardized treatment protocols, it is difficult to critically compare studies and reach valid conclusions about these forms of treatment.35-39

External Beam Megavoltage Therapy
In a recent case report, low dose external beam megavoltage therapy resulted in complete clearance and a prolonged remission of severe treatment resistant dyshidrotic hand eczema in a 41 year-old woman.40 These results are impressive and a reminder that ionizing radiation, an often forgotten intervention for this disease, may be helpful for stubborn cases.

Dermatologist Evaluation of 17 Cosmeceuticals – Which Help Aging Skin and Which Don’t
Have An Itch That Won’t Go Away? A Dermatologist’s Guide to Pruritus Treatment

Systemic Treatments

Immunosuppressive Therapy
Systemic immunosuppressive therapy may be considered for those cases of hand eczema that are not responsive to topical steroids and phototherapy. Systemic medications such as glucocorticoids and cyclosporine are generally effective in managing acute flare-ups, however, they are not practical over the long-term. While 1 study demonstrated eczema remission in 74% of patients 1 year after a 6-week course of cyclosporine,41 other studies have shown high relapse rates within weeks of drug discontinuation.42,43

Medications such as methotrexate and mycophenolate mofetil (CellCept®, Roche Laboratories) may be more promising for long-term control of severe hand eczema.

Botulinum Toxin (BOTOX)
Hyperhidrosis (excessive sweating) has been reported to be an aggravating factor in dyshidrotic (blistering) hand eczema in nearly 40% of cases.48 As such, botulinum toxin – type A (BTX-A), which is an approved treatment for hyperhidrosis, has been explored as an off-label treatment for dyshidrotic eczema.49 In an open study of 10 patients with dyshidrotic hand eczema treated with BTX-A, 7 of 10 patients experienced good or very good improvement in their eczema at 6 weeks.50 Sweating was more likely to be an aggravating factor to the eczema in responders to this formulation.

Retinoids
Systemic retinoids, including etretinate (Tigason®, Hoffmann-La Roche) and acitretin (Soriatane®, Stiefel), have shown some benefit in the treatment of hand eczema.34,46 Studies in the past have focused on their treatment of hyperkeratotic (thickening of the skin) eczema.

Hand eczema is a highly prevalent disorder, which in many patients is chronic, debilitating, and associated with impaired quality of life. Lifestyle management, the use of emollients, avoidance of allergens, and topical corticosteroids are effective and sufficient treatments for some patients, but many require additional intervention. The best way to manage these patients is unclear based on the current level of evidence. A standardized, universally accepted classification system of hand eczema and larger scale, well-designed, randomized trials are necessary prerequisites to achieve optimal and successful management of this skin disorder.

1. Warshaw E, Lee G, Storrs FJ. Hand dermatitis: a review of clinical features, therapeutic options, and long-term outcomes. Am J Contact Dermat 14(3):119-37 (2003 Sep).

2. Magina S, Barros MA, Ferreira JA, et al. Atopy, nickel sensitivity, occupation, and clinical patterns in different types of hand dermatitis. Am J Contact Dermat 14(2):63-8 (2003 Jun).

3. Diepgen TL, Agner T, Aberer W, et al. Management of chronic hand eczema. Contact Dermatitis 57(4):203-10 (2007 Oct).

4. Coenraads PJ, Diepgen TL. Risk of hand eczema in employees with past or present atopic dermatitis. Int Arch Occup Environ Health 71(1):7-13 (1998 Feb).

5. Veien NK, Hattel T, Laurberg G. Hand eczema: causes, course, and prognosis I. Contact Dermatitis 58(6):330-4 (2008 Jun).

6. Lerbaek A, Kyvik KO, Ravn H, et al. Clinical characteristics and consequences of hand eczema – an 8-year follow-up study of a population-based twin cohort. Contact Dermatitis 58(4):210-6 (2008 Apr).

7. Veien NK, Hattel T, Laurberg G. Hand eczema: causes, course, and prognosis II. Contact Dermatits 58(6):335-9 (2008 Jun).

8. Meding B, Wrangsjö K, Järvholm B. Fifteen-year follow-up of hand eczema: persistence and consequences. Br J Dermatol 152(5):975-98 (2005 May).

9. Niemeier V, Nippesen M, Kupfer J, et al. Psychological factors associated with hand dermatoses: which subgroup needs additional psychological care? Br J Dermatol 146(6):1031-7 (2002 Jun).

10. Cvetkovski RS, Zachariae R, Jensen H, et al. Quality of life and depression in a population of occupational hand eczema patients. Contact Dermatitis 54(2):106-11 (2006 Feb).

11. Agner T, Andersen KE, Brandao FM, et al. Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. Contact Dermatitis 59(1):43-7 (2008 Jul).

12. Van Coevorden AM, Coenraads PJ, Svensson A, et al. Overview of studies of treatment for hand eczema – the EDEN hand eczema survey. Br J Dermatol 151(2):446-51 (2004 Aug).

13. Li WF, Wang J. Contact hypersensitivity in hand dermatitis. Contact Dermatitis 47(4):206-9 (2002 Oct).

14. Lerbaek A, Kyvik KO, Menné T, et al. Retesting with the TRUE Test in a population-based twin cohort with hand eczema – allergies and persistence in an 8-year follow-up study. Contact Dermatitis 57(4):248-52 (2007 Oct).

15. Veien NK, Olholm Larsen P, Thestrup-Pedersen K, et al. Long-term, intermittent treatment of chronic hand eczema with mometasone furoate. Br J Dermatol 140(5):882-6 (1999 May).

16. Uggeldahl PE, Kero M, Ulshagen K, et al. Comparative effects of desonide cream 0.1% and 0.05% in patients with hand eczema. Curr Ther Res 40:969-73 (1986).

17. Gupta AK, Shear NH, Lester RS, et al. Betamethasone dipropionate polyacrylic film-forming lotion in the treatment of hand dermatitis. Int J Dermatol 32(11):828-9 (1993 Nov).

18. Gutman AB, Kligman AM, Sciacca J, et al. Soak and Smear: a standard technique revisited. Arch Dermatol 141(12):1556-9 (2005 Dec).

19. Schliemann S, Kelterer D, Bauer A, et al. Tacrolimus ointment in the treatment of occupationally induced chronic hand dermatitis. Contact Dermatitis 58(5):299-306 (2008 May).

20. Schnopp C, Remling R, Möhrenschlager M, et al. Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: a randomized, observer-blinded trial. J Am Acad Dermatol 46(1):73-7 (2002 Jan).

21. Belsito DV, Fowler JF Jr, Marks JG Jr, et al. Pimecrolimus cream 1%: a potential new treatment for chronic hand dermatitis. Cutis 73(1):31-8 (2004 Jan).

22. Thaci D, Steinmeyer K, Ebelin ME, et al. Occlusive treatment of chronic hand dermatitis with pimecrolimus cream 1% results in low systemic exposure, is well tolerated, safe, and effective. An open study. Dermatology 207(1):37-42 (2003).

23. Hanifin JM, Stevens V, Sheth P, et al. Novel treatment of chronic severe hand dermatitis with bexarotene gel. Br J Dermatol 150(3):545-53 (2004 Mar).

24. Ibbotson SH, Bilsland D, Cox NH, et al. An update and guidance on narrowband ultraviolet B phototherapy: a British photodermatology group workshop report. Br J Dermatol 151(2):283-97 (2004 Aug).

25. Sezer E, Etikan I. Local narrowband UVB phototherapy vs. local PUVA in the treatment of chronic hand eczema. Photodermatol Photoimmunol Photomed 23(1):10-4 (2007 Feb).

26. Simons JR, Bohnen IJ, van der Valk PG. A left-right comparison of UVB phototherapy and topical photochemotherapy in bilateral chronic hand dermatitis after 6 weeks’ treatment. Clin Exp Dermatol 22(1):7-10 (1997 Jan).

27. Schempp CM, Müller H, Czech W, et al. Treatment of chronic palmoplantar eczema with local bath-PUVA therapy. J Am Acad Dermatol 36(5 Pt 1):733-7 (1997 May).

28. Morison WL, Parrish JA, Fitzpatrick TB. Oral methoxsalen photochemotherapy of recalcitrant dermatoses of the palms and soles. Br J Dermatol 99(3):293-302 (1978 Sep).

29. van Coevorden AM, Kamphof WG, van Sonderen E, et al. Comparison of oral psoralen-UV-A with a portable tanning unit at home vs hospital-administered bath psoralen-UV-A in patients with chronic hand eczema: an open-label randomized controlled trial of efficacy. Arch Dermatol 140(12):1463-6 (2004 Dec).

30. Hawk JL, Grice PL. The Efficacy of localized PUVA therapy for chronic hand and foot dermatoses. Clin Exp Dermatol 19(6):479-82 (1994 Nov).

31. Abeck D, Schmidt T, Fesq H, et al. Long-term efficacy of medium-dose UVA1 phototherapy in atopic dermatitis. J Am Acad Dermatol 42(2 Pt 1):254-7 (2000 Feb).

32. Krutmann J, Czech W, Diepgen T, et al. High-dose UVA1 therapy in the treatment of patients with atopic dermatitis. J Am Acad Dermatol 26(2 Pt 1):225-30 (1992 Feb).

33. Schmidt T, Abeck D, Boeck K, et al. UVA-1 Irradiation is effective in treatment of chronic vesicular dyshidrotic hand eczema. Acta Derm Venereol 78(4):318-9 (1998 Jul).

34. Thestrup-Pedersen K, Andersen KE, Menné T, et al. Treatment of hyperkeratotic dermatitis of the palms (eczema keratoticum) with oral acitretin: a single-blind placebo-controlled study. Acta Derm Venereol 81(5):353-5 (2001 Oct-Nov).

35. Cartwright PH, Rowell NR. Comparison of Grenz rays versus placebo in the treatment of chronic hand eczema. Br J Dermatol 117(1):73-6 (1987 Jul).

36. Lindelöf B, Wrangsjö K, Lidén S. A double-blind study of Grenz ray therapy in chronic eczema of the hands. Br J Dermatol 117(1):77-80 (1987 Jul).

37. Fairris GM, Jones DH, Mack DP, et al. Conventional superficial X-ray versus Grenz ray therapy in the treatment of constitutional eczema of the hands. Br J Dermatol 112(3):339-41 (1985 Mar).

38. Fairris GM, Mack DP, Rowell NR. Superficial X-ray therapy in the treatment of constitutional eczema of the hands. Br J Dermatol 111(4):445-9 (1984 Oct).

39. King CM, Chalmers RJ. A double-blind study of superficial radiotherapy in chronic palmar eczema. Br J Dermatol 111(4):451-4 (1984 Oct).

40. Stambaugh MD, DeNittis AS, Wallner PE, et al. Complete remission of refractory dyshidrotic eczema with the use of radiation therapy. Cutis 65(4): 211-4 (2000 Apr).

41. Granlund H, Erkko P, Reitamo S. Long-term follow-up of eczema patients treated with cyclosporine. Acta Derm Venereol (Stockh) 78(1):40-3 (1998 Jan).

42. Granlund H, Erkko P, Eriksson E, et al. Comparison of cyclosporine and topical betamethasone-17, 21-dipropionate in the treatment of severe chronic hand eczema. Acta Derm Venereol 76(5):371-6 (1996 Sep).

43. Petersen CS, Menné T. Cyclosporine A responsive chronic severe vesicular hand eczema. Acta Derm Venereol 72(6):436-7 (1992 Nov).

44. Egan CA, Rallis TM, Meadows KP, et al. Low-dose oral methotrexate treatment for recalcitrant palmoplantar pompholyx. J Am Acad Dermatol 40(4):612-4 (1999 Apr).

45. Pickenäcker A, Luger TA, Schwartz T. Dyshidrotic eczema treated with mycophenolate mofetil. Arch Dermatol 134(3): 378-9 (1998 Mar).

46. Deschamps P, Leroy D, Pedailles S, et al. Keratoderma climactericum (Haxthausen’s disease): clinical signs, laboratory findings and etretinate treatment in 10 patients. Dermatologica 172(5):258-62 (1986).

47. Bollag W, Ott F. Successful treatment of chronic hand eczema with oral 9-cis-retinoic acid. Dermatology 199(4):308-12 (1999).

48. Lodi A, Betti R, Chiarelli G, et al. Epidemiological, clinical and allergological observations on pompholyx. Contact Dermatitis 26(1):17-21 (1992 Jan).

49. Solish N, Bertucci V, Dansereau A, et al. A comprehensive approach to the recognition, diagnosis and severity-based treatment of focal hyperhidrosis. Recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg 33(8):908-23 (Aug 2007).

50. Swartling C, Naver H, Lindberg M, et al. Treatment of dyshidrotic hand dermatitis with intradermal botulinum toxin. J Am Acad Dermatol 47(5):667-71 (2002 Nov).

51. Wollina U, Karamfilov T. Adjuvant botulinum toxin A in dyshidrotic hand eczema: a controlled prospective pilot study with left–right comparison. J Eur Acad Dermatol Venereol 16(1):40-2 (2002 Jan).

52. Holzle E, Alberti N. Long-term efficacy and side effects of tap water iontophoresis of palmoplantar hyperhidrosis – the usefulness of home therapy. Dermatologica 175(3):126-35 (1987).

53. Odia S, Vocks E, Rakoski J, et al. Successful treatment of dyshidrotic hand eczema using tap water iontophoresis with pulsed direct current. Acta Derm Venereol 76(6):472-4 (1996 Nov).