(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
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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.
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.
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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.
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.
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
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
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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 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 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.
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.
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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.
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.
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