Hand Eczema/Dyshidrotic Dermatitis
Wednesday, January 14, 2009
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
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
Vesiculobullous Hand Eczema
- A superpotent or high-potency topical steroid cream should be
applied once or twice daily. Occlusion overnight with vinyl gloves
may enhance efficacy.
- For pruritus, diphenhydramine 25-50 mg, hydroxyzine 25-75 mg,
or doxepin 10-75 mg nightly may be used. Sedation should be
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.
- In mild cases, topical tacrolimus 0.1% ointment may be
- 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
- 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.
- 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
- 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
- In severe refractory cases, cyclosporine A 3-5 mg/kg/day, or
mycophenolate mofetil 2 gm/day may be considered.
- Severe chronic hand eczema remains one condition in which
superficial radiotherapy (Grenz ray) may still be indicated.
- In nickel patch test-positive patients, disulfiram (200 mg/day
for 8 weeks) may be considered.
- 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
Apply a high-potency or superpotent topical, fluorinated steroid
ointment once or twice daily, with nightly occlusion to
- 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.
- 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.
- 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.
- Patients with severe, recalcitrant hand eczema may be treated
with soak or oral PUVA, UVB, or UVA-1 phototherapy. PUVA is most
- 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.
- 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.
- 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.
- 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.
- 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
- Patients taking sedating antihistamines should be warned about
operating motor vehicles or other tasks requiring fine motor
- Neither UVB phototherapy nor PUVA is curative for hand eczema.
Long-term skin care therapy is required to maintain
- Smoking reduces the efficacy of phototherapy in the treatment
of hand eczema.