Subtypes of Hand Dermatitis

Contact Dermatitis of the Hands:

This can be either an irritant contact dermatitis or an allergic contact dermatitis. The clinical appearances sometimes overlap and some individuals with allergic dermatitis may also have the super-imposed irritant.

Irritant Dermatitis Of The Hands:

This condition is usually multi-factorial. It is caused by recurrent exposure to irritants such as soaps, detergents, solvents, bleach, wet vegetables and raw meat. This may start with small erythematous itchy patches. Occasionally there are small blisters although these are more common in allergic reactions. The skin can react to the inflammation by forming scales. Fissures can then develop and these can be quite painful. The majority of individuals who have irritant dermatitis (75% of all cases of hand dermatitis) will produce this through contact with detergents, cleansers, water, metals, food or rubber.

Allergic Contact Dermatitis Of The Hands:

This is usually more acute and more inflammatory that irritant dermatitis. It more commonly occurs on the backs of the fingers, web spaces and wrists. The irritant dermatitis seems to occur more often on the palmar aspects. In the acute phase of an allergic reaction there are usually vesicles or small blisters associated with swelling of the skin. This is related to exposure and is a true allergic reaction.

In the chronic phase there is usually thickening of the skin with scaling and fissuring. Patch testing is essential in cases of recurrent hand dermatitis. A number of studies have shown that a large number of those with chronic hand dermatitis are allergic to Nickel. Avoidance of contact with the metal nickel in cosmetic jewelry, ear rings ,belt buckles, coins is necessary. Nickel is also found in our diets. High nickel content is found in food cooked in stainless steel utensils, shellfish, tea, chocolate, asparagus, beans, mushrooms, onions, maize, spinach, tomatoes, peas, pears, rhubarb, baking powder, almonds, lettuce, oatmeal, pineapples, prunes, multigrain breads and soy alfalfa sprouts.

This is a difficult list to avoid but for those with troublesome dermatitis with positive patch tests to nickel this may be necessary to try. Latex allergy is frequent in healthcare workers especially if they are atopic. Those allergic to latex can have a cross allergy with avocados, bananas, kiwi and spinach.

For those allergic to nickel, cobalt, fragrances, epoxy resins and balsam of Peru rubber gloves may not protect much as these allergens can penetrate the gloves. Vinyl gloves offer more protection.

Dyshidrotic Eczema:

This condition is also known as pompholyx. The lesions are small blisters or vesicles that occur on the palm and on the sides of the fingers. This episode usually occurs abruptly. The blisters are extremely itchy and usually appear in crops and last for one or two weeks. As the swelling and blisters subside scaling and fissures usually occur. It is more common in women and the course is somewhat unpredictable.

It is interesting that 75% of those with pompholyx are smokers, 50% are atopic, and 20% have allergies to nickel. It is always worth patch testing these individuals as allergic reactions to chrome, perfumes, rubber, colophony, preservatives and plants have also been noted.

Hyperkeratotic Dermatitis:

This condition is more common in men. The skin usually does not blister. There are dry, scaly, thickened patches and it is not usually itchy. The cracking and fissuring may be uncomfortable and painful. This condition may last for years. Patch test results are usually negative.

Treatment:
In terms of treatment of hand dermatitis general hand care involves minimizing irritants and keeping the skin hydrated.

Dyshidrotic Eczema (Pompholyx):

Potent topical steroids are required to settle this reaction. Occasionally one resorts to systemic steroids. Moisturizing is important. Identifying fungus on the feet is necessary as there is sometimes an ID reaction. This means dermatitis develops on the hand as a reaction to the fungus infection on the feet.

In resistant cases both topical and systemic PUVA is required. Short courses of systemic steroids, methotrexate and cyclosporine have occasionally been used in very disabling circumstances. The treatment for this usually involves the avoidance of irritants and aggressive use of moisturizers and barrier creams. Preparations including salicylic acid and tar can be of some benefit. In severe cases oral retinoids have been utilized.

In the differential diagnosis one must always consider allergic dermatitis. Patch testing is a must in persistent dermatitis of the hands. Pustular psoriasis can sometimes mimic dermatitis.

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