N.K. Veien, MD, PhD1 and T. Menné, MD, PhD2
1Dermatology Clinic, Aalborg, Denmark
2Department of Dermatology, University of Copenhagen, Gentofte Hospital, Copenhagen, Denmark
Hand eczema is a common skin disease that tends to become chronic and may interfere with many types of work. Emollients have been shown to be useful in reducing eczema activity and in the primary prevention of hand eczema. Protection of the hands is very important for the prevention of hand eczema and is a fundamental aspect of the treatment of hand eczema. Although topical corticosteroids are the mainstay of treatment, few studies of their rational use, efficacy and side-effects have been conducted. A combination of tacrolimus and topical corticosteroids may reduce the risk of steroid-associated side effects. Systemic treatment with immunosuppressants such as cyclosporine and methotrexate show promising results, and acitretin may suppress keratotic hand eczema. Botulinum toxin has been used with success in the treatment of dyshidrotic hand eczema. PUVA is effective as a systemic treatment. Bath-PUVA treatment, UVB and Grenz rays can also suppress hand eczema.
Key Words: hand eczema, corticosteroids, cyclosporine, emollients, PUVA, botulinum toxin, Grenz rays
Hand eczema is both a common and an important skin disease. A point prevalence of 5.4% was found in a population-based study of Swedish adults.1 In this study, twice as many women as men had hand eczema. This condition tends to become chronic. The mean duration among the patients in a study conducted by Meding and Swanbeck was 11.6 years2.
There is no generally accepted classification of hand eczema. A 3-step classification is proposed:
- An etiological diagnosis where possible. The most common etiological groups seen in Meding and Swanbeck’s study were allergic contact dermatitis (19%), irritant contact dermatitis (35%) and atopic dermatitis (22%). Fifteen percent had unclassified eczema, and a few had nummular hand eczema, hyperkeratotic hand eczema, or pompholyx.
- Adiagnosis based on the morphology of the dermatitis.
- Identification of the dynamics of the dermatitis.
A controlled, intervention study in which 107 student auxiliary nurses participated in an educational program to prevent skin problems during the first 10 weeks of practical
training showed promising results.3
In a prospective, randomized controlled intervention study, Held, et al4 allocated 207 persons employed in “wet work” occupations to an intervention program, while 168 persons not enrolled in the program served as controls. The intervention program consisted of oral and written instructions on skin care. After 5 months, the level of information on skin care was significantly higher and behavior with regard to skin protection significantly improved in the intervention group compared to the control group. In the intervention group there was a significant reduction in the number of employees with skin problems. The results of other studies support the contention that protection of the hands, including the use of emollients, is of utmost importance for the prevention and treatment of hand eczema.5,6
Topical corticosteroids are the mainstay of treatment of hand eczema. General guidelines for the use of topical corticosteroids are given in the Journal of the American Academy of Dermatology.7 The thick stratum corneum – particularly on the palms, palmar aspects of the fingers and around the nails – necessitates the use of rather potent preparations to achieve sufficient suppression of hand eczema. It is important to instruct patients not to rub off excess corticosteroid on the dorsum of the hands if there is no dermatitis there. The skin on the dorsum of the hands is prone to atrophy, and topical steroids increase this risk.
Hand eczema tends to become chronic, resulting in the development of hyperkeratosis and fissures. Ointments occlude and hydrate the skin and are generally better suited for the treatment of hand eczema than creams. Although it may be impractical to use ointments during the workday, they can be used at bedtime. Topical corticosteroids should be used on affected areas of the hands every day for 1-2 months and then tapered to intermittent use for several months.
There is a paucity of well-controlled studies of the treatment of hand eczema with topical corticosteroids.
Möller, et al.8 compared long-term, intermittent maintenance treatment of chronic hand eczema with a very potent corticosteroid (clobetasol propionate) and a moderately potent preparation (flupredniden acetate). Sixty-one patients were treated for 1-3 weeks with clobetasol propionate, and the dermatitis of 90% of these patients cleared. In a subsequent double-blind, right-left part of the study, clobetasol propionate and predniden acetate were compared. Fifty-five of the patients were treated for a mean of 138 days. There were no relapses of dermatitis during the treatment period for 70% of those treated with clobetasol propionate and for 30% of those treated with flupredniden acetate.
In a prospective, open, randomized trial, 120 patients with chronic hand eczema were treated with one daily application of mometasone furoate fatty cream for up to 9 weeks or until the dermatitis cleared.9 The dermatitis of 106 patients cleared, and they were then randomized to long-term maintenance treatment with mometasone furoate fatty cream to be applied either a) on Sunday, Tuesday and Thursday or b) on Saturday and Sunday or c) to the application of an emollient and no further use of steroid cream. During the 30-week maintenance period, the actively treated patients showed significantly better results than the placebo group. The most effective maintenance schedule was treatment 3 times a week. A few actively treated patients developed slight evidence of atrophy, but for others, initial evidence of atrophy gradually disappeared. The treatment schedule outlined in this study was therefore considered to be safe.
Schnopp, et al10 conducted a 4-week, right-left, randomized, prospective, observer-blinded study of 16 patients with dyshidrotic palmar eczema. Treatment consisted of either 0.1% tacrolimus ointment or 0.1% mometasone furoate ointment. Mometasone furoate was shown to be slightly more effective than tacrolimus. The authors speculated that rotational therapy with tacrolimus and mometasone furoate might be effective and have none of the side-effects seen after monotherapy with topical corticosteroids.
Systemic corticosteroid treatment in doses of 20-40mg prednisolone tapered over several weeks is a very effective treatment of hand eczema. For acute, vesicular eruptions, the same dose may be used for just a few days at a time. There are, however, no good clinical studies of this treatment.
A comparison of the treatment of severe chronic hand eczema with either systemic cyclosporine 3mg/kg/day or topical betamethasone dipropionate cream showed the two treatments to be equally effective in a randomized, doubleblind, cross-over study of 41 patients treated for 6 weeks. The relapse rate was approximately 50% in both groups 2 weeks after discontinuation of treatment.11 In an open, long-term follow-up study of patients with chronic hand eczema treated with cyclosporine 3mg/kg/day for 6 weeks, 21 of 27 patients were still in remission one year after the cessation of treatment.12
A case report of the treatment of 5 patients with recalcitrant palmoplantar pompholyx with methotrexate described the treatment as promising and suggested a steroid-sparing effect.13
In a single-blind, placebo-controlled study, 29 patients with hyperkeratotic dermatitis of the palms were either treated with 30mg acitretin per day or given a placebo for 8 weeks. After 4 weeks, there was a statistically significant reduction of symptoms in the treated group compared with the placebo group. This difference was maintained at 8 weeks.14
Thirty-eight patients with chronic hand eczema were treated with oral 9-cis-retinoic acid in an open study.15 Twenty-one (55%) showed good response.
Veien, et al.16 treated patients with atopic hand eczema with 300mg ranitidine twice daily for 4 months in a doubleblind, placebo-controlled trial. Thirty-eight of 47 patients completed the trial. Although there was a statistically significant difference in favor of ranitidine for certain of the criteria used to determine the severity, there was no statistically significant difference between ranitidine and placebo for the sum of the factors measured.
In an open study of 10 patients with dyshidrotic hand eczema, 10 patients were treated with intradermal injections of a mean of 162U botulinum toxin in 72 sites in one palm. The other palm was the control. Using a visual analog scale, it was shown that itching decreased by 39% in the treated palm and increased by 52% in the untreated palm. The dermatitis of 7 of the 10 patients improved on the treated palm. Six of these 7 had increased sweating of the palms during the summer months. There is no mention of the duration of the effect of this treatment.17
Various forms of irradiation have been used to treat hand eczema. Sjövall and Christensen treated 26 patients 4-5 times per week for 10 weeks in an open trial with a UVB
source.18 The eczema of 18 of 26 patients showed marked improvement. Rosén, et al19 carried out a prospective, randomized study of 35 patients with chronic hand eczema. The patients were treated on one hand with either UV-B or oral PUVA, and the other hand served as a control. Treatment was carried out 3 times a week for a maximum of 3 months. PUVA was more effective than UV-B. The difference was evident after 3 weeks and persisted throughout the study. The dermatitis cleared on all 14 of the hands treated with PUVA.
In a right-left comparison of UVB and bath-PUVA given for 6 weeks to 13 patients with symmetrical chronic hand dermatitis, both treatments proved moderately effective. The authors suggested that starting with UVB might give fewer side effects.20
In open studies, bath-PUVA has been shown to have a promising effect in patients with dyshidrotic hand eczema.21
Twenty-four patients with symmetrical, chronic hand eczema participated in a double-blind study of Grenz ray therapy. One of the hands of each patient was treated with 3 Gray 10kV once/week for 6 weeks. At follow-up consultations 5 and 10 weeks after the initiation of treatment, Grenz ray treatment was seen to be significantly better than placebo for all the features studied.22
Iontophoresis treatment intended to reduce palmar sweating may also reduce the severity of hand eczema.23
Treatment results are summarized in Table 1.
|Diagnosis||No. of Treatment Patients||Type of Study||Duration of Study||Results|
|Chronic hand eczema||155||Double-blind, right-left||Mean 138 days||70% relapse-free after clobetasol|
30% relapse-free after flupredniden
|106||Open, prospective, randomized||30 weeks||83% relapse-free if treated 3 times/week|
68% relapse-free if treated twice/ week
|38||Open||55% had good response|
|35||Prospective, randomized, right-left||3 months||PUVA more effective than UVB|
|24||Double-blind treatment of either right or left hand||6 weeks||Grenz rays more effective than placebo|
|Severe chronic hand eczema||41||Randomized, double-blind, cross-over||6 weeks||Equal effectiveness|
|Dyshidrotic hand eczema||16||Prospective, randomized, right-left, observer-blind||4 weeks||Mometasome more effective than tacrolimus|
|10||Open||One treatment||7 or 10 improved|
|20||One hand||Statistically significant decrease of itching and vesicle formation|
|Hyperkeratotic palmar dermatitis||29||Single-blind, placebo- controlled||8 weeks||Acitretin statistically significantly more effective than placebo|
|Atopic hand eczema||47||Double-blind, placebo- controlled||4 months||Ranitidine marginally better than placebo|
Table 1: Summary of treatment results.
A careful history, detailed exposure assessment and patch testing with standard series and allergens from the patients’ environment are pivotal for the successful teratment of hand eczema. It is of crucial importance to instruct the patients in the basic treatment using emollients and ointments. Instruction on the proper cleansing of the skin as well as skin protection is also paramount. Topical steroids are the mainstay of the pharmacological treatment of hand eczema. With regard to efficacy and safety, treatment with mometasone furoate is best documented. Systemic treatment with prednisolone or immunosuppressants or physical treatment methods, such as UV-light or Grenz rays may be indicated if treatment with topical steroids fails to suppress the hand eczema.