Related Therapeutic strategies

Herpes simplex virus (HSV) occurs in 2 common locations: orofacial (usually due to HSV-1) and genital (usually due to HSV-2).

Read more

Seborrheic dermatitis can be limited to the scalp, but it also can involve the face and any hairy or intertriginous area and rarely can even progress to a generalized erythroderma.

Read more

Chancroid

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The diagnosis of chancroid is usually clinical, although improved culture techniques allow isolation of the causative organism H. ducreyi. The therapeutic strategy is to eliminate the pathogenic microorganism.

Read more

Therapeutic Strategies

Hand Eczema/Dyshidrotic Dermatitis

Timothy Berger Bruce Wintroub

Wednesday, January 14, 2009

Overview

Inflammatory processes may involve the dorsal or palmar surfaces of the hands. Dorsal hand dermatitis is managed as is dermatitis elsewhere on the body. This discussion is restricted to dermatitis based primarily on the palmar surface. Hand eczema can range from an acute, extremely pruritic or painful eruption, characterized by minute, "tapioca" vesicles (dyshidrotic eczema, pompholyx), to the chronic hand eczema commonly seen in those in at-risk occupations. For therapeutic purposes, hand eczema can be classified into vesiculobullous types (acute and chronic) and hyperkeratotic hand eczema (no vesicles in any phase of the eruption). Persons who are predisposed to atopic dermatitis are at particular risk of developing hand eczema.  The therapeutic strategy is to eliminate any external cause and to control the cutaneous inflammatory reaction.

General Principles

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

Vesiculobullous Hand Eczema

First Steps

  1. A superpotent or high-potency topical steroid cream should be applied once or twice daily. Occlusion overnight with vinyl gloves may enhance efficacy.
  2. For pruritus, diphenhydramine 25-50 mg, hydroxyzine 25-75 mg, or doxepin 10-75 mg nightly may be used. Sedation should be anticipated.


Ancillary Steps

Domeboro soaks (l tablet or packet/pt cool tap water) for 15 minutes twice daily will dry lesions, relieve itching, and reduce likelihood of secondary infection.

Subsequent Steps

  1. In mild cases, topical tacrolimus 0.1% ointment may be beneficial.
  2. Systemic steroids may be used for acute flares. Prednisone starting at 40-60 mg daily and tapered over no more than 1 to 2 months is recommended. Systemic steroids should not be used for the chronic management of hand eczema unless no other alternative exists.
  3. Phototherapy (UVB or UVA1) or photochemotherapy (PUVA), oral or by soak, administered with a hand and foot unit, can be very effective. This modality takes several weeks to produce improvement and is available only in selected dermatologists' offices.
  4. Bexarotene gel 1% with or without a topical steroid, if tolerated, at twice to three times daily can improve hand eczema. Local side effects of chronic topical steroids can be avoided with this strategy.
  5. Patch testing should be considered in any patient with chronic vesiculobullous hand eczema. Although 50% or fewer of patients will have relevant positives, those positive patients may have considerable improvement with avoidance of the relevant allergens.
  6. In severe refractory cases, cyclosporine A 3-5 mg/kg/day, or mycophenolate mofetil 2 gm/day may be considered.
  7. Severe chronic hand eczema remains one condition in which superficial radiotherapy (Grenz ray) may still be indicated.
  8. In nickel patch test-positive patients, disulfiram (200 mg/day for 8 weeks) may be considered.
  9. In patients with hyperhidrosis and vesiculobullous hand eczema, botulinum toxin A injections to the palms will control both the hyperhidrosis and the eczema. The eczema will return with the sweating, but remissions average 7-12 months.


Chronic Hyperkeratotic Hand Eczema

First Steps

Apply a high-potency or superpotent topical, fluorinated steroid ointment once or twice daily, with nightly occlusion to enhance efficacy. 

Ancillary Steps

  1. Many patients suffer disease exacerbations from excessive exposure to hot water and harsh detergents. Hence, use of cool water, mild soaps, adequate protection, and an emollient hand cream is critical to prevent relapses in these patients.
  2. Patients with recalcitrant and/or recurrent disease often benefit from concurrent therapy with a cosmetically acceptable tar preparation. A total of 10-20% LCD in petrolatum can be compounded. Up to 1 month of twice-daily 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.
  3. 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 Steps

  1. Patients with severe, recalcitrant hand eczema may be treated with soak or oral PUVA, UVB, or UVA-1 phototherapy. PUVA is most effective.
  2. In severe refractory cases, cyclosporine A 3-5 mg/kg, mycophenolate mofetil 2 gm/day, or methotrexate 10-25 mg once weekly, may be considered.
  3. Patch testing is much less likely to be positive in patients with hyperkeratotic than vesiculobullous hand eczema; however, it should be considered when the clinical pattern is strongly suggestive for a contactant.


Pitfalls

  1. Check patients with acute dyshidrotic eczema for inflammatory tinea pedis or active stasis dermatitis (SD). ID reactions (auto-sensitization) from these two conditions can mimic dyshidrotic eczema. Occasionally, an allergic contact dermatitis, restricted to the palms, will mimic chronic hand eczema. In suspected allergic contact dermatitis, patch testing may be required to detect the responsible allergen.
  2. Both acute and chronic hand eczema can become secondarily infected, usually with Staphylococcus  aureus. The presence of honey-colored crusts indicates this complication, which can exacerbate the pruritus. In these patients, cephalexin or dicloxacillin 250-500 mg 4 times daily for 7-10 days is almost always curative.
  3. Both acute and chronic hand eczema tend to relapse and/or persist for years. A preventive program, consisting of antihistamines, protective gloves, cool water washing, mild soaps, and frequent application of emollients is necessary for long-term control.
  4. Patients taking sedating antihistamines should be warned about operating motor vehicles or other tasks requiring fine motor skills.
  5. Neither UVB phototherapy nor PUVA is curative for hand eczema. Long-term skin care therapy is required to maintain remissions.
  6. Smoking reduces the efficacy of phototherapy in the treatment of hand eczema.

Back to Therapeutic Strategies

CONTENT PROVIDED BY:
Derm101.com Logo

Disclaimer: The material above has been prepared by Derm101.com. It has not been reviewed by the DermQuest Editorial Board for its accuracy or reliability. Reference to any products, service, or other information does not constitute or imply endorsement, sponsorship, or recommendation by members of the Editorial Board.