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Case Note

Case Note: Hyperkeratotic Eruption on the Hands

History

A 44-year-old healthy male, with no significant past medical history, presents for management of hyperkeratotic eruption on bilateral palms.

Initial evaluation

  • Healthy-appearing male
  • No significant past medical history
  • Review of systems non-contributory
  • Presents for management of 18 months' history of hyperkeratotic erythematous plaques on bilateral palms, with fissures present at the fingertips
    • Feet or nails not affected so fungal infection unlikely
  • No hobbies with chemical exposures
  • Job history notable for work at a printing press
  • Currently using topical triamcinolone 0.1% ointment daily and emollient lotion with partial benefit
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Enter your diagnosis

Diagnosis

  • A diagnosis of hand dermatitis is rendered

Initial Treatment

  • Recommendations:
    • Patch testing
    • Soak hands in tap water for 10 minutes twice daily, followed by application of clobetasol 0.05% ointment
    • Gentle skin care
      • Use of gentle hand soaps, frequent use of lipid-rich emollients, avoidance of wet work (such as dishwashing and other housework) without gloves
  • Follow-up in 2 weeks

Follow-up evaluation strategy

2-week follow-up evaluation:

  • Partial improvement
  • Patch testing (including for chemicals involved in printing process) does not reveal any clear triggers
  • Ongoing twice-daily soaks and clobetasol ointment recommended
  • Follow-up in a further 2 weeks 

Subsequent 2-week follow-up evaluation:

  • Minimal interval improvement
  • Recommend limited use of clobetasol ointment (use 3 days a week) alternating with 20% liquor carbonis detergens (LCD) tar in petrolatum
  • Follow-up in 6 weeks reveals symptoms still not resolved. Soak (psoralen + ultraviolet A) PUVA is initiated 

Further recommendations:

  • Many patients suffer disease exacerbations from excessive exposure to hot water and harsh detergents. Use of cool water, mild soaps, adequate protection and an emollient hand cream is critical to prevent relapses in these patients
  • With regards to the 20% LCD tar in petrolatum initiated in the present case note; this treatment may benefit patients with refractory and/or recurrent disease. Up to 1 month of twice-daily 10-20% LCD in petrolatum therapy may be required to detect improvement. The use of tar makes the dermatitis less dependent on steroids and, hence, less likely to relapse. In addition, tar minimizes the possible side effects from topical steroids
  • In patients with significant hyperkeratosis, topical lactic acid 5-12% or urea 10-40% preparations may be added to the above treatment. These will reduce the scale and enhance the penetration of the active agents 

Subsequent treatment steps:

  • Patients with severe recalcitrant hand dermatitis may be treated with soak or oral PUVA (as finally initiated in the present case note), topical PUVA, UVB or UVA-1 phototherapy. PUVA may be most effective
  • In severe refractory cases, cyclosporine A 3-5 mg/kg, mycophenolate mofetil 2 grams/day or methotrexate 10-25 mg once weekly may be considered. Alitretinoin may also be a highly effective therapeutic option for refractory disease

General discussion

Hand dermatitis can range from an acute, extremely pruritic or painful eruption, characterized by deep-seated vesicles (dyshidrotic eczema, pompholyx), to the chronic hand dermatitis commonly seen in those in at-risk occupations. For therapeutic purposes, hand dermatitis can be classified into vesiculobullous types (acute and chronic) and hyperkeratotic hand dermatitis (no vesicles in any phase of the eruption). Both types may also be marked by edema, fissures, nummular plaques and erosions. Individuals who are predisposed with atopic dermatitis are at particular risk to develop hand dermatitis. Workers in certain industries, such as hairdressing, may be at increased risk and may affect quality of life as well as ability to work; in one study, between 0.7 and 1.5 cases per 1000 employees were affected by hand dermatitis. The therapeutic strategy is to eliminate any external cause and to control the cutaneous inflammation. Management is typically through topically applied medications. For severe cases, systemic immunosuppression may be necessary. 

All patients with hand dermatitis, independent of the clinical type, have reduced tolerance to irritants. The most common irritants are soap and water. Hand protection for all manual tasks, wet or dry, prevents exacerbations. Especially important is the use of vinyl gloves when doing any wet work. Moisturizing the hands regularly is critical in controlling most cases of hand dermatitis. Nightly application of a heavy moisturizer is strongly recommended. 

There is an important differential diagnosis of hand dermatitis, including: atopic dermatitis, tinea (superficial dermatophyte infection), allergic contact dermatitis, psoriasis, lichen planus, scabies, herpes simplex, pityriasis rubra pilaris and cutaneous lymphoma. A skin biopsy and/or patch testing should be considered in treatment-refractory cases. 

Further reading

Coenraads PJ. Hand eczema. N Engl J Med 2012;367:1829-37. 

Bissonnette R, et al. Redefining treatment options for chronic hand eczema. Eur Acad Dermatol Venereol 2010;24 (Suppl 3):1-20. 

Dirschka T, et al. An open-label study assessing the safety and efficacy of alitretinoin in patients with severe chronic hand eczema unresponsive to topical corticosteroids. Clin Exp Dermatol 2008;36:149-54. 

English J, et al. Consensus statement on the management of chronic hand eczema. Clin Exp Dermatol 2009;34:761-9. 

English JSC, Wootton CI. Recent advances in the management of hand dermatitis: Does alitretinoin work? Clin Dermatol 2012;29:273-7. 

Ruzicka T, et al. Efficacy and safety of oral alitretinoin in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicenter trial. Br J Dermatol 2008;138:808-17.

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