Postgraduate Medicine

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Hand dermatitis

Ken Landow

To cite this article: Ken Landow (1998) Hand dermatitis, Postgraduate Medicine, 103:1, 141-152,
DOI: 10.3810/pgm.1998.01.276

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 DERMATOLOGY SERIES

Hand dermatitis
The perennial scourge

Ken Landow, MD

PREVIEW none seems more likely to predict

Hand dermatitis strikes nearly everyone at least occasionally, especially hand eczema in adulthood than
with allergic reactions to natural rubber latex becoming increasingly com- either severe acral atopic der-
mon. Given the difficulties of diagnosis and treatment, protection and pre- matitis before age 15 or general-
vention are vital. If irritants are not avoided, hand dermatitis may persist ized dermatitis during childhood.
for years-even decades-and necessitate a change in the patient's em- A persistent eczematous eruption
ployment, recreational activities, or both. on the body and dry, itchy skin
further compound the risk. More
than 90% of people with all of
these risk factors experience
and dermatitis, or eczema, pounds hamper efforts to provide problems when they engage in

H continues to perplex even

the most astute clinician.
Time-honored principles, so use-
ful in separating allergic from irri-
tant eruptions on the torso and
extremities, fail to provide even
the most rudimentary clues to di-
agnosis. While physicians cor-
rectly advise discontinuing expo-
sure to potentially exacerbating
chemicals, irritants, and cleansers,
we also regularly fail to consider
the patient's lifestyle, occupation,
and social circumstances when
offering advice. As a result,
hand dermatitis often becomes
chronic and spreads to involve
adjacent skin. Even when a spe-
cific allergen appears culpable,
self-medication, excoriation,
and irritation from other corn-
First in a series of articles on dermatology
coordinated by the author.
relief. Adding to the sense of
frustration, hand eczema accounts
for up to a third of all occupation-
related diseases and often leads
to discomfort, absenteeism, un-
employment, and even litigation.
Prevalence and risk factors
Scarcely anyone escapes at least
a fleeting interlude with hand
eczema. According to one recent
survey, nearly 1 in 9 adults expe-
rience this condition during any
given year, with as many as 1 in
20 having the problem at any
given moment. Surveys routinely
suggest a marked female predomi-
nance: the female-male ratio
ranges from greater than 5:1 with
all~!_gic reactions to 2:1 or 3:1
with the more commonly occur-
ring irritant and atopic condi-
tions.'
Among predisposing factors,
"wet work," while only 13% of
otherwise healthy individuals are
similarly affected. Neither a fam-
ily history of atopy nor a personal
history of either asthma or aller-
gic rhinitis appears to be a risk
factor. Susceptibility is greatest
among younger people and those
in frequent contact with poten-
tial irritants, such as water, deter-
gents, dust, dirt, and a variety of
chemicals. 2 Seasonal variation
occurs, most notably increased
prevalence during the winter
months with exacerbation during
exposure to cold, relatively dry
outdoor air. Improper choice of
protective creams and gloves may
further worsen the situation. 3
Classification
Hand eczema can be classified into
a number of subtypes (table 1).
While the exact frequency of each
continued

VOL 103/ NO 1/ JANUARY 1998/ POSTGRADUATE MEDICINE I HAND DERMATITIS 141

 Hand dermatitis, continued

condition varies according to

the particular population under
study, the three most common Diagnosis of primary Irritant dermatitis may seem
are irritant, allergic, and atopic straightforward, but its morphologic features regularly fail
dermatitisY (For a discussion of to differentiate lt from allergic dermatitis.
atopic dermatitis, see my article
beginning on page 101 of the
March 1997 issue.) The popular are found upon clinical examina-
assumption that morphologic fea- tion: involvement of the dorsal
tures of the eruption may assist in aspect of fingers and hands (44%),
differentiating between allergic palmar aspect of fingers and hands
and irritant reactions is, unfortu- (15%), fingers only (19%), and
nately, erroneous. This concept, whole hand (22%). 6 However,
so useful with other kinds of der- much variation occurs. For exam-
matitis, lacks validity in relation ple, whereas irritant reactions
to hand eczema. often target the fingers and dorsal
Four general reaction patterns aspect of the hands, the palms
may demonstrate marked involve-
ment in at least 40% of cases.
Taille 1 Cl.1ssrtrcatron ot llanrl
Similarly, allergies that tradition-
llermatrtrs lJy suiJtypP
ally have been linked to the dor-
sum of the hands actually are rel-
Subtype Frequency
atively nondiscriminatory in
(%)
their diffuse involvement. 6
Other cutaneous abnormalities
Irritant dermatitis 21-35
may be confused with hand
eczema (figure 1). Among the
Allergic dermatitis 19-33
conditions to be mindful of are
malignant states and infectious,
Atopic dermatitis 18-36
papulosquamous, pustular, and
bullous disorders (table 2).
Pompholyx 5
(dyshidrosis)
Irritant dermatitis
Neurodermatitis 1-5
Variously referred to as dishpan
hands, housewives' eczema, or
Hyperkeratotic 2
detergent hands, primary irritant
dermatitis
dermatitis represents the most
common eruption to involve the
Nummular eczema
hands (figure 2). It often com-
mences during the cold winter
Id reaction <1
months or at times of low relative
humidity. Long-term, repeated
exposure to irritating chemicals
is more important than the pre-
cise nature of the agent involved;
even compounds of relatively low
irritancy may cause problems
with sufficiently prolonged con-
tact. Excessive palmar perspira-
tion further heightens the risk.
Indeed, simple hand washing
with "gentle" soaps remains a ma-
jor precipitant, especially among
young women in the months fol-
lowing the birth of a child.
As assaults from washing, ex-
posure to dehydrating chemicals,
and repeated injury cause the
stratum corneum to lose its abil-
ity to function as a protective
barrier, the likelihood of prob-
lems increases. At first, mild dry-
ness and chapping of the skin de-
velop, often with slight erythema
manifested principally about the
knuckles and fingertip. pads. With
ongoing injury, cracks and fissures
appear along with mild swelling.
Ultimately, the skin becomes
eczematous and may demonstrate
oozing and crusting. Throughout
the process, the patient perceives
a general itchiness of the involved
cutaneous surface and responds
by scratching, which further ex-
acerbates the condition and may
continued

142 HAND DERMATITIS I VOL 103/ NO 1/ JANUARY 1998/ POSTGRADUATE MEDICINE

 Hand dermatitis, continued

result in infection, ulceration, Figure 1. Conditions that

and various secondary changes. may mimic hand darma·
Among the often-implicated tltls. a. Hand of a patient
with systemic lupus ery-
factors are water, wet work, deter-
thematosus. b. Gottron's
gents, cleaning agents, hand papulas over the knuck·
cleansers, abrasives, and cutting las In a patient with dar·
oils. While the term "housewives' matomyosltls. c. Palmar
eczema" remains in vogue, the lesions of erythema mu I·
same disorder commonly strikes tlforma. d. Vesicular
lesions of hand-foot-and·
bartenders, dishwashers, wait-
mouth disease. a. Typl·
ers, nurses, dental hygienists, cal fixed drug eruption.
cooks, garage mechanics, plumb-
ers, hairdressers, and others
who experience sufficient provo-
cation.

Diagnosis
Diagnosis of primary irritant der-
matitis may seem straightforward,
but unfortunately, its morpho-
logic features regularly fail to dif-
ferentiate it from allergic derma-
titis. In fact, the two conditions
sometimes occur simultaneously
in the same patient. Neither
patch testing nor the radioaller-
gosorbent test (RAST) offers
reliable diagnostic insights;
while positive tests regularly
lack relevance, negative tests
cannot exclude an allergic
component of an untested com-
pound.7

Management
Regardless of the exact precipi-
tant, certain management tech-
niques are universally warranted.
None is more essential than pro-
tection. However, patients may
not comply with dictums regard-
ing washing less often. Specific
continued

VOL 1031 NO 1 I JANUARY 19981 POSTGRAOUATE MEDICINE I HAND DERMATITIS 145

 Hand dermatitis, continued

Figure 2. Primary Irritant

Taille 2. Dlffelentlal dlaqnost1c dermatitis from exces-
COilSH!era!IOilS lllfi<JIH1 [if'llllilli!IS
sive washing.

Malignant states
Actinic keratoses
Bowenoid keratoses
Radiation dermatitis

Infectious disorders
Herpes simplex
Hand-foot-and-mouth disease
Mosaic warts
Scabies
guidance and direction from the while cooking meals and giving
Tinea manus
physician can improve this situa- children a bath. A rubber band at
tion. the wrist "seals" the outer rubber
Papulosquamous disorders
For instance, simply directing glove to prevent water from
Psoriasis
the patient to wear gloves gener- reaching the hands. Objections
Pityriasis rubra pilaris
ally does not produce the desired from patients that their dexterity
Lichen planus
outcome. Instead, the patient suffers may be countered with the
Reiter's syndrome
should be specifically advised to observation that surgeons wear
Secondary syphilis
wear thin cotton gloves, available gloves during the most techno-
Fungal infections
from hobby or photography stores, logically delicate procedures.
underneath rubber or vinyl gloves. Hand washing may be accom-
Pustular disorders
Several pairs of cotton gloves plished by use of soapless emul-
Pustular psoriasis
should be kept ready, since per- sions, such as Cetaphil or Aquanil
Acrodermatitis continua
spiration and damage to the outer Cleanser. These are applied to
Pustular bacterid of Andrews
glove often necessitate changing dry skin and simply toweled off.
them. Because perspiration may While recent questions regarding
Bullous disorders
worsen the problem even among the efficacy of such cleansers may
Erythema multiforme
those wearing gloves, patients be well founded, they direct at-
Epidermolysis bullosa
may be further instructed to use tention away from the main issue:
Phytophotodermatitis
long-handled cleaning utensils to the trauma of repeated cycles
minimize contact of the gloved of washing and drying with soap
Miscellaneous
hand with hot water. and water. Actually, soap addi-
Obsessive-compulsive disorder
Gloves are appropriate not tives such as vitamin E, deodor-
Frictional dermatitis
only for wet work but also as pro- ants, dyes, antiseptics, rosins, per-
tection during dry, dusty, or dirty fumes, and lanolin may be the
activities. Protective covering re- primary culprits, rather than the
mains necessary during personal soap itself. 8
hygiene tasks, including sham- Topical corticosteroids remain
pooing and showering, as well as the bulwark of therapy, but ap-

146 HAND DERMATITIS I VOL 103/ NO 1/ JANUARY 1998/ POSTGRADUATE MEDICINE

propriate injunctions against ap,
plying potent agents too often
or over too long a time are wise.
For most patients, use of a mild
to moderately strong steroid
cream or ointment is adequate.
Use of ultrahigh,potency prod,
ucts (augmented betamethasone
dipropionate [Diprolene], clobe,
tasol propionate [Temovate],
halobetasol propionate [Ultra,
vate]} should be limited to no
more than several weeks, after
which more traditional and prob,
ably somewhat less harmful agents
(hydrocortisone, triamcinolone
acetonide, fluocinonide) gener,
ally suffice.
Especially during the cooler
months, emollients aid in pre,
venting hand eczema. Relatively
heavy compounds, such as
Eucerin, Lubriderm, Aquaphor
Natural Healing, and Vaseline,
and those containing urea, lactic
acid, and alpha,hydroxy acids are
preferable to the more popular,
highly advertised, but lighter mois,
turizers. According to some, the
amount of time necessary to dis,
solve the compound into the skin
directly correlates with the likeli,
hood of benefits. For more chronic
disease with lichenification, tar
products, psoralen plus ultravio,
let A, and even intralesional in,
jections of corticosteroids may be
appropriate. Protective creams,
once popular, are now used less
often. They generally lack effi,
cacy and may actually worsen
some forms of hand eczema. 3
VOL 103/ NO 1/ JANUARY 1998/ POSTGRADUATE MEDICINE I HAND DERMATITIS
Without physician diligence
Table 3. Common causes of
and patient compliance, irritant
allerg1c contact dermat1t1s
dermatitis of the hand may per,
sist for years.
Nickel
Jewelry
Allergic dermatitis
Clips
Handles
Manifestations of allergic contact
Zippers
dermatitis often mimic those of
Knobs
irritant eruptions; indeed, they
Scissors
often supervene and worsen an
Coins
already existent dermatitis.
Among the most commonly im,
Chromates
plicated compounds are nickel,
Cement
chromates, and rubber (table 3). 8•10
Leather goods
While true allergic reactions
Matches
may result in a characteristic well,
demarcated rash, by the time a
Rubber
patient presents to a physician,
Finger cots
the eruption pattern usually
Gloves
makes morphologic diagnosis im,
Rubber bands
possible. When allergic dermati,
Adhesive tape
tis is suspected, patch tests may
Adhesive bandages
help establish a specific etiologic
diagnosis. Far too often, though,
Roslns
patients who undergo patch test,
Newsprint
ing react to a variety of chemi,
Printing ink
cals that may have little or noth,
Tissues
ing to do with the particular skin
Towels
eruption under consideration.
Copy paper
For this reason, indiscriminate
Boxes
patch testing is counterproduc,
Adhesives
tive. Thorough history taking
Soldering flux
coupled with directed testing,
however, may offer clues to the
underlying disease mechanism.
Protection, avoidance, and ap, Latex allergy
propriate intervention, following Recently, considerable attention
the principles already delineated, has been focused on allergy to
allow relatively rapid improve, natural rubber latex gloves. Long
ment in most cases of allergic used as a physical barrier against
dermatitis. hand dermatitis, these gloves may
continued
147

Figure 3. a. Microvasic·
ular eruption of pom·
pholyx. b. More severe
eruption of pompholyx.
actually precipitate a variety of
problems. Since the 1930s, gloves
made of rubber, derived from the
sap {latex) of the commercially
grown tree Hevea brasiliensis, have
been associated with delayed sen-
sitivity reactions. To ensure a
durable final product, manufac-
turers add to the latex a wide ar-
ray of chemicals, including thiu-
rams, carbamates, and pigments.
Ken Landow, MD
Or Landow is clinical professor of dermatology,
University of Southern California School of
Medicine, Los Angeles, and is in private prac·
tice of dermatology in Las Vegas.
Correspondence: Ken Landow, MD, 1820 E
Desert Inn Rd, Las Vegas, NV 89109. E·mail:
drlandow®anv .net.
148
Hand dermatitis, continued
In fact, up to 200 different com-
pounds may be necessary to pro-
vide the desired characteristics.
Other commonly used agents in-
clude antioxidants, vulcanizers,
accelerators, retarders, promoters,
and mold releasers. 11
Until 1979, the standard erup-
tion caused by rubber gloves con-
sisted of a well-demarcated rash
ending at the wrists and present-
ing as swelling, erythema, vesicu-
lation, and pruritus. Most likely
as a result of changes in the rub-
ber production process, a new
syndrome of contact urticaria
emerged in 1979. The incidence
of the new syndrome now ex-
ceeds that of the original type IV
immunologic reactions. The cur-
HAND DERMATITIS I VOL103/ NO 1/ JANUARY 1998/ POSTGRADUATE MEDICINE
rent problem presents as urticaria
developing within 30 to 60 min-
utes after donning the gloves and
overwhelmingly involves health-
care workers and other individu-
als with frequent exposure to nat-
ural rubber. This immediate
IgE-mediated eruption emanates
from a protein relatively loosely
bound to the rubber. When the
glove is pulled on, the protein be-
comes aerosolized along with the
powder that is used to make the
gloves slide on easily. As a result,
patients experience not only ur-
ticarial and eczematous skin reac-
tions, but other common com-
plaints, such as conjunctivitis,
allergic rhinitis, facial edema,
asthma, generalized urticaria, and
even anaphylaxis. 12
Once a patient is sensitized
to natural rubber latex gloves,
exposure to balloons, rubber
bands, barium enema kits, toys,
rubber nipples, pacifiers, con-
doms, stethoscope tubing, adhe-
sive bandages, and examining
gloves worn by others may result
in potentially disastrous compli-
cations.13 This situation, origi-
nally recognized by European al-
lergists and only more recently
by American and Canadian ex-
perts, is now widespread. By most
estimates, up to one in nine
healthcare workers may be aller-
gic to these products. A recent
review 13 suggests that a lag time
(often measured in years) exists
between development of this
type of immediate rubber allergy
continued

and recognition of the cause.
Medical, occupational, and legal
implications are numerous. One
example serves to point up the
gravity of the situation: By 1992,
Food and Drug Administration
(FDA) files contained reports of
at least 15 deaths related to ana-
phylactic reactions to rubber in
barium enema preparation kits. 12
Diagnosis of latex allergy must
be confirmed by prick or scratch
tests performed in facilities geared
to handle anaphylactic reactions.
Reliance on RAST testing is un-
wise, since at least 50% of aller-
gic patients may be reassured by
false-negative reports.
Together, the FDA and the
American Society for Testing and
Materials are currently develop-
ing standards for manufacturers
who seek to label their gloves as
hypoallergenic. The best choice
for those concerned about poten-
tial problems but who require the
impervious barrier of latex rubber
is a powder-free glove that is low
in both residual accelerators and
extractable latex proteins. For pa-
tients who are already sensitized
to latex, inhaling of powder car-
rying latex proteins may have
potentially lethal ramifications,
even without direct glove con-
tact.12'14 Other options include
Tactyl-1, Royal Shield Vinylite,
Elastyren, and Neutraderm 4-H. 14
While vinyl gloves may be an ac-
ceptable substitute, they are not
impervious to certain chemicals,
including the methyl methacry-
VOL 103/ NO 1/ JANUARY 1998/ POSTGRADUATE MEDICINE I HAND DERMATITIS
Hand dermatitis, continued
By 1992, FDA files contained reports of at least
15 deaths related to anaphylactic reactions to rubber
in barium enema preparation kits.
lates widely used in orthopedics
and neurosurgery.
Pompholyx
One of the most frustrating of
all hand eruptions for both pa-
tient and physician appears as
tiny clear vesicles under the sur-
face of the skin (figure 3 ). They
develop around the medial and
lateral aspects of the fingers and
on the central palm, with fre-
quent extension to the thenar
and hypothenar eminences.
Described in 1873 as dyshidrosis,
this eruption lacks any clinical or
histologic evidence of involve-
ment of the eccrine sweat appara-
tus." For this reason, the term
"pompholyx" (bubble) is more
appropriate.
The bilaterally symmetric
eruption may be heralded by ei-
ther itching or burning for sev-
eral hours before making its clini-
cal debut. The small (1- to 2-mm)
clear vesicles lack any trace of
erythema at their outset. How-
ever, with repeated or prolonged
bouts or after patients "unroof"
the vesicles by scratching, in-
flammation and occasionally
infection may supervene.
Now considered by most to be
a nonspecific reaction pattern,
pompholyx targets women twice
as often as men. It peaks in inci-
dence between the ages of 20
and 40 and may be associated
with a variety of positive, albeit
noncontributory, patch tests. A
considerable minority of patients
with pompholyx test positive to
nickel, cobalt, chromate, and bal-
sam of Peru. According to some
investigators, patients whose
diets are free of these chemicals
are rewarded by marked improve-
ment in the dermatitis. 16 But this
long-held notion probably repre-
sents nothing more than testi-
mony to the vagaries of the con-
dition's clinical manifestations.
At present, most experts be-
lieve this dermatitis represents a
reaction to stress or emotional
turmoil for which the exact neu-
rotransmitters remain unknown.
It may occur more often in pa-
tients prone to atopic dermatitis
and must be differentiated from
the less common id reaction.
This latter condition causes a
similar eruption but occurs in as-
sociation with an acute inflam-
matory fungal infection of the
feet or with stasis dermatitis.
Treatment remains unsatisfac-
tory. Fortunately, the condition's
continued
151

natural history generally allows
remission before patients tire of
their medical therapy. Topical
corticosteroids and oral antihis,
tamines, together with the full
complement of dermatologic po,
tions, seem to have little effect.
Educating patients about stress
management may be the most
helpful intervention.
A related condition, previously
referred to as keratolysis exfolia,
tiva but now renamed recurrent
focal palmar peeling, represents an
asymptomatic curiosity. Mild, dis,
crete areas of scaling ( 1 to 2 mm
in diameter) develop, centered
around focally normal skin. The
eruption lacks any erythematous
component, does not vesiculate,
and fails to produce any symp,
toms. Its cause remains mysteri,
ous, but it may be mistaken for
an occupational dermatitis or
healing pompholyx. While the
condition seems to be quite prev,
alent in the community, most af,
fected persons fail to seek med,
ical care. Benign neglect remains
the only treatment optionY
Summary
Hand eczema continues to be,
devil both patients and physi,
cians. While appropriate and ju,
dicious intervention minimizes
aggravation, discomfort, and
inconvenience, recurrences are
frequent. Treatment with corti,
costeroids is often effective for ir,
ritant dermatitis. Efforts to avoid
the irritant, protect the hands,
152
Hand dermatitis, continued
and use emollients are vital in
preventing recurrence. Protec,
tion and avoidance are also the
key techniques to teach patients
with allergic dermatitis. In the
case of pompholyx, experts now
believe the condition is caused
by stress or emotional turmoil,
so the most helpful intervention
may be patient education about
stress management.
Recognizing the role of irritants
encountered at work, at home,
References
1. Meding B. Epidemiology of hand eczema
in an industrial city. Acta Derm Venereal
1990; 153(Suppl): 1-43
2. Woolner D, Soltani K. Management of
hand dermatitis. Compr Ther 1994;20(7):
422-6
3. Schluter-Wigger W, Elsner P. Efficacy
of 4 commercially available protective
creams in the repetitive irritation test
(RIT). Contact Dermatitis 1996;34(4):
278-83
4. Diepgen TL, Fartasch M. General
aspects of risk factors in hand eczema. In:
Menne T, Maibach HI, eds. Hand eczema.
Boca Raton: CRC Press, 1994:141-56
5. Meding B. Epidemiology of hand eczema.
In: Menne, Maibach, eds,• pp 157-64
6. Cronin E. Hand eczema. In: Rycroft RJ,
Menne T, Frosch PJ, et al. Textbook of
contact dermatitis. New York: Springer-
Verlag, 1992:207-18
7. Epstein E. Hand dermatitis: practical
management and current concepts. J Am
Acad Dermatol1984;10(3):395-424
8. Rietschel RL, Fowler JF. Hand derma-
titis due to contactants: special considera-
tions. In: Rietschel RL, Fowler JF, eds.
Fisher's contact dermatitis. 4th ed. Balti-
more: Williams & Wilkins, 1995:330-57
9. Farm G. Contact allergy to colophony
and hand eczema: a follow-up study of
patients with previously diagnosed contact
HAND DERMATITIS I VOL 103/ NO 1/ JANUARY 1998/ POSTGRADUATE MEDICINE
and in the recreational setting of,
fers physicians the opportunity to
intervene preemptively. When
patients avoid unnecessary expo,
sure and protect the skin against
climatic instability, the toll ex,
acted by hand eczema can be dra,
matically reduced. RN
Earn credit on this article.
See CME Quiz.
allergy to colophony. Contact Dermatitis
1996;34(2):93-100
10. Karlberg AT, Gafvert E, Liden C.
Environmentally friendly paper may in-
crease risk of hand eczema in rosin-sensitive
persons. JAm Acad Dermatol1995;33(3):
427-32
11. Hamann CP, Kick SA. Allergies asso-
ciated with medical gloves: manufacturing
issues. Dermatol Clin 1994;12(3):547-59
12. Taylor JS, Praditsuwan P. Latex al-
lergy: review of 44 cases including outcome
and frequent association with allergic hand
eczema. Arch Dermatol1996;132(3):265-71
13. Hunt LW, Fransway AF, Reed CE,
et al. An epidemic of occupational allergy
to latex involving health care workers.
J Occup Environ Med 1995;37(10):1204-9
14. Field EA. Hypoallergenic gloves. lnt
Dent J 1995;45(6):339-46
15. Clark RA, Hopkins TT. The other
eczemas. In: Moschella SL, Hurley HJ, eds.
Dermatology. 3d ed. Philadelphia: Saunders,
1992:493-8
16. Veien NK, Menne T. Acute and
recurrent vesicular hand dermatitis
(pompholyx). In: Menne, Maibach, eds,•
pp57-73
17. Lee YC, Rycroft RJ, White IR, et al.
Recurrent focal palmar peeling. Australas J
Dermatol1996;37(3):143-4