The epidemiology of hand eczema in the general population - prevalence and main findings

Global Burden, Incidence and Disability-Adjusted Life-Years for Dermatitis: A Systematic Analysis Combined With Socioeconomic Development Status, 1990-2019

BACKGROUND

Dermatitis is an important global health problem that not only affects social interaction and physical and mental health but also causes economic burden. Health problems or distress caused by dermatitis may be easily overlooked, and relevant epidemiological data are limited. Therefore, a better understanding of the burden of dermatitis is necessary for developing global intervention strategies.

METHODS

All data on dermatitis, including atopic dermatitis (AD), contact dermatitis (CD) and seborrhoeic dermatitis (SD), were obtained from the Global Burden of Disease 2019 (GBD2019) database. The extracted age-standardized incidence rates (ASIR) and disability-adjusted life-years (DALYs) rates (ASDR) data were analysed by stratification, including by sex, country or region, and sociodemographic index (SDI) indicators. Finally, we analysed the correlation between the global burden of dermatitis and socioeconomic development status.

RESULTS

According to the GBD 2019 estimate, the ASIR and ASDR for the three major types of dermatitis in 2019 were 5244.3988 (95% CI 4551.7244-5979.3176) per 100,000 person-years and 131.6711 (95% CI 77.5876-206.8796) per 100,000 person-years. The ASIR and ASDR of atopic dermatitis, contact dermatitis and seborrhoeic dermatitis are: Incidence (95%CI,per 100,000 person-years), 327.91 (312.76-343.67), 3066.04 (2405.38-3755.38), 1850.44 (1706.25- 1993.74); DALYs (95%CI, per 100,000 person-years), 99.69 (53.09-167.43), 28.06 (17.62-41.78), 3.93 (2.24-6.25). In addition, among the three dermatitis types, the greatest burden was associated with AD. According to the ASDR from 1990 to 2019, the burden of dermatitis has exhibited a slow downward trend in recent years. In 2019, the ASIR showed that the USA had the greatest burden, while the ASDR showed that Asian countries (such as Japan, Mongolia, Kazakhstan, and Uzbekistan) and some European countries (France, Estonia) had the greatest burden. According to SDI stratification and the three major dermatitis types, high ASIR and ASDR corresponded to high SDI areas (especially for AD).

CONCLUSION

The burden of dermatitis is related to socioeconomic development status, especially for AD, which is positively correlated with the SDI. The results based on GBD2019 data are valuable for formulating policy, preventing and treating dermatitis and reducing the global burden of dermatitis.

Management of inadequate response and adverse effects to dupilumab in atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by pruritus, skin pain, and sleep disturbances. Currently, dupilumab is the only systemic therapy and biologic medication approved by the United States Food and Drug Administration for moderate-to-severe AD in adults and children. There is a sparsity of literature available on determining treatment failure with dupilumab and the next steps health care providers can take to treat AD. Individual goals and quality of life and not just body surface area should be considered when defining treatment failure. Possible confounding dermatoses also should be ruled out. Early identification of dupilumab-induced adverse events is important. For most patients, dupilumab can be continued while treatment for the adverse event is initiated. Adjusting the frequency of dupilumab dosing also may be considered in some circumstances. Adjuvant therapies, such as methotrexate, azathioprine, mycophenolate mofetil, cyclosporine, or phototherapy can be added but the safety and efficacy of these combination treatments are not known at this time.

Hyperhidrosis Comorbidities and Treatments: A Register-based Study among 511 Subjects

Hyperhidrosis is a dermatological condition that causes psychosocial impairment and has a negative impact on patients’ quality of life. The epidemiology of hyperhidrosis is currently poorly understood. The aim of this study was to analyse comorbidities and treatments in 511 subjects with hyperhidrosis selected from the patient records of Oulu University Hospital. The mean age of patients with local hyperhidrosis was 27.9 years and the majority were female (62.7%). The most common anatomical site of symptoms in the youngest age group was the palms, whereas the axillae were a more common site in advanced age. Depression was a common comorbidity in both local (11.6%) and generalized hyperhidrosis (28.6%). Anxiety affected 12.7% of patients with generalized hyperhidrosis. In 36.8% of the patients with local hyperhidrosis there was a delay in diagnosis of more than 10 years. The most commonly used treatments included topical antiperspirants, iontophoresis and botulin toxin injections.

Low Dose Oral Alitretinoin With Narrowband Ultraviolet B Therapy for Chronic Hand Dermatitis

Background

Chronic hand dermatitis (CHD) is difficult to treat and has high individual and societal burdens. Phototherapy and oral alitretinoin are safe monotherapies for CHD, but their combination has not been assessed.

Objective

To assess the effectiveness and safety of low dose oral alitretinoin combined with phototherapy versus high dose oral alitretinoin for CHD refractory to topical corticosteroids.

Methods

This retrospective study of adult patients with CHD refractory to topical corticosteroid therapy compared low dose oral alitretinoin (10 mg three times weekly) combined with narrowband ultraviolet B therapy (three times weekly; LDA-UVB) to high dose oral alitretinoin (30 mg daily; HDA) for 16 weeks. Outcomes were improvement in disease severity measured by the Physician’s Global Assessment and quality of life measured with the Dermatology Life Quality Index.

Results

The mean age of the study population (n = 64) was 41.25 years and 57.8% were male. Both cohorts experienced improvements in disease severity and quality of life after 16 weeks, however, significantly more participants who received LDA-UVB (n = 21/33, 63.6%) achieved “clear” or “almost clear” assessments compared to those who received HDA (n = 12/31, 38.7%; P < .05). Adverse effects were significantly more prevalent in the HDA group (P < .0001) and included headache, elevated cholesterol, and dry lips.

Conclusions

The combination of low dose oral alitretinoin with narrowband-UVB therapy was more effective and had fewer adverse effects compared to high dose oral alitretinoin for participants with CHD refractory to topical corticosteroid therapy.

Characterization of Residual Facial Dermatitis during Dupilumab Therapy: A Retrospective Chart Review to Delineate the Potential Role of Expanded Series Patch Testing

OBJECTIVE

We sought to determine the incidence of RFDD in patients receiving dupilumab and the rate of resolution of RFDD after expanded series patch testing (ESPT) and allergen avoidance.

METHODS

This is a retrospective chart review of 80 patients with atopic dermatitis who were evaluated for RFDD after treatment with dupilumab. Expanded series patch testing findings and response to allergen avoidance were assessed in the subset of patients with RFDD who subsequently underwent ESPT while continuing to receive dupilumab.

RESULTS

Forty-nine patients (61.3%) experienced facial dermatitis before initiating dupilumab. Thirty-five patients (43.8%) experienced RFDD after starting dupilumab. Of the 14 patients with RFDD who received ESPT, 92.9% had 1 or more relevant positive patch test results, with 50% of such patients being mostly to completely clear of facial dermatitis after allergen avoidance. Importantly, 50.6% of the positive reactions to allergens were not included on the North American Contact Dermatitis Group Core 80.

CONCLUSIONS

Many patients with RFDD benefit from patch testing and subsequent allergen avoidance. Expanded series patch testing should be offered to patients who experience RFDD after beginning dupilumab therapy to ensure that such patients have eliminated any exogenous component of their dermatitis, such as concomitant allergic contact dermatitis.

Prevalence and Severity of Hand Eczema in the Dutch General Population: A Cross-sectional, Questionnaire Study within the Lifelines Cohort Study

Data on chronic hand eczema and severity of hand eczema in the general population is scarce. In this cross-sectional study, a questionnaire was sent to 135,950 Lifelines Cohort Study participants, in order to investigate the prevalence and severity of hand eczema in the Dutch general population. In total, 57,798 subjects were included. The lifetime prevalence of hand eczema was 15.0% (95% confidence interval 14.7-15.3), the 1-year prevalence 7.3% (95% confidence interval 7.1-7.6), and the self-reported physician-diagnosed prevalence 6.1% (95% confidence interval 5.9-6.3). The 1-year prevalence of chronic hand eczema was 4.7% (95% confidence interval 4.5-4.9). The majority (56.9%) of the subjects with hand eczema had almost clear at worst ever and the prevalence of severe to very severe hand eczema at worst ever in the general population was 1.9% (95% confidence interval 1.8-2.1). Future epidemiological studies in the general population should include data about chronic hand eczema and severity of hand eczema, as this can provide perspective on the burden of hand eczema.

Causes of irritant contact dermatitis after occupational skin exposure: a systematic review

PURPOSE

Irritant contact dermatitis (ICD) is a major cause of occupational disease. The aim was to review the relation between exposure to occupational irritants and ICD and the prognosis of ICD.

METHODS

Through a systematic search, 1516 titles were identified, and 48 studies were included in the systematic review.

RESULTS

We found that the evidence for an association between ICD and occupational irritants was strong for wet work, moderate for detergents and non-alcoholic disinfectants, and strong for a combination. The highest quality studies provided limited evidence for an association with use of occlusive gloves without other exposures and moderate evidence with simultaneous exposure to other wet work irritants. The evidence for an association between minor ICD and exposure to metalworking fluids was moderate. Regarding mechanical exposures, the literature was scarce and the evidence limited. We found that the prognosis for complete healing of ICD is poor, but improves after decrease of exposure through change of occupation or work tasks. There was no substantial evidence for an influence of gender, age, or household exposures. Inclusion of atopic dermatitis in the analysis did not alter the risk of ICD. Studies were at risk of bias, mainly due to selection and misclassification of exposure and outcome. This may have attenuated the results.

CONCLUSION

This review reports strong evidence for an association between ICD and a combination of exposure to wet work and non-alcoholic disinfectants, moderate for metalworking fluids, limited for mechanical and glove exposure, and a strong evidence for a poor prognosis of ICD.

Skin Microbiome in Patients with Hand Eczema and Healthy Controls: A Three-week Prospective Study

The pathogenesis of chronic hand eczema remains unclear. Insights into the skin microbiome in hand eczema and its potential relevance to disease severity may help to elucidate the underlying mechanisms of hand eczema. The aim of this study was to characterize the microbiome in patients with hand eczema and healthy controls. A 5-visit prospective study was conducted over a period of 3 weeks. At each visit, bacterial swabs were taken from the hands of patients with hand eczema and controls. The microbiome was examined using DNA extraction and 16S rRNA amplicon sequencing (V3–V4 regions). Fifty patients with hand eczema and 50 controls were included (follow-up rate=100%). The baseline bacterial α-diversity was reduced on the hands of patients with hand eczema compared with controls (effect size=–0.31; 95% confidence interval (95% CI) –0.50; –0.11; p = 0.003). The dysbiosis on the patients’ hands was stable over the study period, was associated with disease severity, and was characterized by reduced bacterial diversity and different bacterial community compositions.

Dermatology for the internist: optimal diagnosis and management of atopic dermatitis

Internists are front-line health care providers that commonly provide the first encounter to patients for dermatological conditions, especially atopic dermatitis (AD). Internists need to be comfortable with managing mild-moderate AD in their practices. Criteria and guidelines established in dermatology literature are available to help the general practitioner diagnose and treat AD. AD is a systemic disease associated with multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions. Environmental factors may play a role in the development or worsening of AD; however, there is currently no strong evidence to guide specific population- or clinic-based interventions for their avoidance. While food allergies are common in AD patients, the role of food allergens as an exacerbating factor for AD is controversial. Before starting any dietary modifications, careful evaluation should be performed by an allergist. If the patient is not well-controlled despite adequate topical therapies or is experiencing severe/worsening disease, early referral to dermatology is warranted to rule out confounding diagnoses and/or escalation to systemic therapies. Finally, it is important to recognise the racial disparities present in AD and address these when formulating treatment plans.Key messages:Confounding dermatoses, either instead of or in addition to AD, should be considered in treatment-refractory AD, and the appropriate workup may be initiated while awaiting dermatology referral.AD patients have multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions.

Lifetime prevalence and determinants of hand eczema in an adolescent population in Germany: 15-year follow-up of the LISA cohort study

BACKGROUND

Hand eczema is a common inflammatory skin disorder in both adolescence and adulthood.

OBJECTIVES

We sought to assess the lifetime prevalence of hand eczema and associated exogenous and endogenous risk factors among adolescents in Germany.

METHODS

This was a cross-sectional study embedded into a prospective population-based birth cohort in four regions of Germany, which recruited healthy neonates born between November 1997 and January 1999. We included 1736 participants who had completed the 15-year follow-up from birth cohort and 84.6% (1468/1736) had clearly reported whether they have ever had hand eczema. All the data were based on questionnaires and blood tests (immunoglobulin E). Multivariable logistic regression analysis was used to examine endogenous and exogenous factors in relation to the lifetime prevalence of hand eczema among adolescents.

RESULTS

One thousand four hundred and sixty-eight adolescents (715 girls, 48.7%) were included in the final analysis. The lifetime prevalence of hand eczema among adolescents at the age of 15 was 10.4% (95% confidence interval [CI]: 8.9%-12.1%), with a significantly higher lifetime prevalence among girls than boys (12.7% vs. 8.2%, P = 0.005). Multivariable logistic regression analysis indicated statistically significant associations between the lifetime prevalence of hand eczema and having ever been diagnosed with atopic dermatitis (aOR = 1.8, 95% CI: 1.1-2.8) or having ever had dry skin (aOR = 1.9, 95% CI: 1.1-3.1), respectively. No statistically significant independent associations were found between asthma, hay fever, allergy-related clinical symptoms, immunoglobulin E positivity and other exogenous factors in relation to hand eczema.

CONCLUSION

Our study fills a research gap on the epidemiological burden of hand eczema among adolescents. One out of ten ever suffered from hand eczema until age 15 years indicating that hand eczema constitutes a significant burden in paediatric populations. The role of atopic dermatitis in hand eczema reinforces previous findings. Exogenous risk factors warrant further investigation.

The History of Surfactants and Review of Their Allergic and Irritant Properties

Surfactants, many of which are used as detergents, can be found in many common household items, such as shampoos, conditioners, soaps, and cosmetics. One should recognize the multitude of surfactants that are used in today's products to identify any potential allergic contact dermatitis (ACD) or irritant contact dermatitis (ICD). Given their abundance in everyday products, it is understandable that many cases of occupational contact dermatitis that arise can be attributed to surfactants. The products most connected with ACD are cocamidopropyl betaine, oleamidopropyl dimethylamine, decyl glucoside, 3-dimethylaminopropylamine, amidoamine, and cocamide diethanolamine. Similarly, the most common surfactant-related causes of ICD are sodium lauryl sulfate and benzalkonium chloride. It is important for dermatologists to identify the causes and differentiate between the two, to adjust treatments and products accordingly. Here, the most frequently used surfactants, as well as their correlation between ACD and ICD, will be reviewed.

Allergens in Hand, Foot, and Hand-Foot Eczema: An Intercomparison by Patch Testing

Background:

Hand eczema (HE), foot eczema (FE), and hand–foot eczema (HFE) manifest on exposure to various agents in day-to-day life or in occupations or both.

Objectives:

The objectives of this study were to identify pattern of allergens causing HE, FE, and HFE and to identify multiple and concurrent contact allergies.

Materials and Methods:

A study was conducted from October 2013 to August 2015 which included 190 patients. Patch test was performed for 78.94% of patients (n = 150). The statistical tests used were descriptive, Cramer's V, and Chi-square tests.

Results:

The most commonly affected group was HFE (55.8%) followed by HE (22.1%) and FE (22.1%). Allergens showed positivity either singly 56.3% (n = 67) or in combination 43.69% (n = 52). Nickel (41.79%) was the most common allergen in all the three groups followed by potassium dichromate. Late reactions (after day 7) were observed in 17.64% of patients (n = 21). Nickel was observed in 42.85% (n = 9) and paraphenylenediamine was observed in 28.57% of patients (n = 6) with P values of <0.001 and 0.050, respectively. Multiple contact allergies were seen in 44% of patients (n = 52). Concurrent reactions (55.8% [n = 29]), polysensitization (34.6% [n = 18]), and mixed reactions (9.6% [n = 5]) (P value of <0.001) were observed.

Conclusion:

Significant multiple contact allergies including concurrent reactions with nickel sulfate, potassium dichromate, cobalt chloride, and polysensitization were observed. No significant differences in allergen pattern were observed in HE, FE, and HFE.

Recommendation:

Day 7 reading is recommended in HFE.

A self-report questionnaire to detect hand dermatitis in nurses

BACKGROUND

Hand dermatitis is highly prevalent among nurses due to their frequent exposure to wet work. Providing cost-effective dermatological health surveillance for this occupational group presents a challenge to health service providers.

AIMS

To ascertain the predictive value of nurses' self-assessment of whether they had current hand dermatitis using a screening questionnaire when compared with the assessment made by a dermatologist of the nurses' hand photographs.

METHODS

We conducted a cross-sectional study comparing the self-report decision made by student and intensive care nurses using a single hand dermatitis screening question with the clinical assessment of their hand photographs made by dermatologists using a standardized photographic guide.

RESULTS

We analysed data collected at study baseline (n = 1599). The results showed that the screening question had a high negative predictive value (91%; 95% CI 89-93), but a low positive predictive value (39%; 95% CI 34-45). It demonstrated acceptable accuracy in distinguishing those with and without the disease (area under the receiver operator curve = 0.7) and had a high specificity (86%; 95% CI 84-88) but a sensitivity of only 52% (95% CI 46-59) in identifying hand dermatitis.

CONCLUSIONS

We found that nurses were able to accurately self-assess themselves as not having any signs of hand dermatitis. By contrast, they were less able to accurately self-assess positive cases suggesting under-recognition of early disease. We propose that a questionnaire containing a single hand dermatitis screening question should be considered as a tool for screening out clear cases as part of a workplace health surveillance programme for detecting hand dermatitis.

Vesicular hand eczema transcriptome analysis provides insights into its pathophysiology

Hand eczema is a common inflammatory skin condition of the hands whose pathogenesis is largely unknown. More insight and knowledge of the disease on a more fundamental level might lead to a better understanding of the biological processes involved, which could provide possible new treatment strategies. We aimed to profile the transcriptome of lesional palmar epidermal skin of patients suffering from vesicular hand eczema using RNA‐sequencing. RNA‐sequencing was performed to identify differentially expressed genes in lesional vs. non‐lesional palmar epidermal skin from a group of patients with vesicular hand eczema compared to healthy controls. Comprehensive real‐time quantitative PCR analyses and immunohistochemistry were used for validation of candidate genes and protein profiles for vesicular hand eczema. Overall, a significant and high expression of genes/proteins involved in keratinocyte host defense and inflammation was found in lesional skin. Furthermore, we detected several molecules, both up or downregulated in lesional skin, which are involved in epidermal differentiation. Immune signalling genes were found to be upregulated in lesional skin, albeit with relatively low expression levels. Non‐lesional patient skin showed no significant differences compared to healthy control skin. Lesional vesicular hand eczema skin shows a distinct expression profile compared to non‐lesional skin and healthy control skin. Notably, the overall results indicate a large overlap between vesicular hand eczema and earlier reported atopic dermatitis lesional transcriptome profiles, which suggests that treatments for atopic dermatitis could also be effective in (vesicular) hand eczema.

2020 Korean Consensus Guidelines for Diagnosis and Treatment of Chronic Hand Eczema

Background

Hand eczema refers to eczema located on the hands, regardless of its etiology or morphology. Despite its high prevalence and significant impact on patients' quality of life, treatment is frequently challenging because of its heterogeneity, chronic and recurrent course, and lack of well-organized randomized controlled trials of the various treatment options.

Objective

These consensus guidelines aim to provide evidence-based recommendations on the diagnosis and management of hand eczema to improve patient care by helping physicians make more efficient and transparent decisions.

Methods

A modified Delphi method, comprising two rounds of email questionnaires with face-to-face meetings in between, was adopted for the consensus process that took place between February and September 2020. Forty experts in the field of skin allergy and contact dermatitis were invited to participate in the expert panel.

Results

Consensus was reached for the domains of classification, diagnostic evaluation, and treatment; and a therapeutic ladder to manage chronic hand eczema was developed.

Conclusion

These are the first consensus guidelines for chronic hand eczema in the Asian population, which will help standardize care and assist clinical decision-making in the diagnosis and treatment of chronic hand eczema.

Frequency of hand eczema in the elderly: Cross-sectional findings from the German AugUR study

BACKGROUND

Hand eczema (HE) is a chronic inflammatory skin disease caused by a genetic predisposition and environmental exposures. There is a lack of population-based studies on skin diseases in the elderly.

OBJECTIVES

Our aim was to estimate the frequency of HE in the elderly to determine its burden of disease in this particular population.

METHODS

We analyzed data from the research platform AugUR, a study on chronic diseases in the elderly (n = 1133, ages 70-95 years, mean age 77.6, 45.1% women). Raw frequencies were estimated using self-reports on physician-diagnosed HE from a standardized personal interview. Frequencies were standardized to the Bavarian population weighted by gender and 5-year age-groups.

RESULTS

In our sample 2.7% (95% confidence interval [CI] 1.6-4.3) of the paticipants reported to ever have been diagnosed with HE. Among those 57% were male. After standardization, the frequency was estimated at 2.8% (95% CI 1.9-3.9). There were no differences between male and female participants.

CONCLUSIONS

Compared to other studies on lifetime frequency of HE, our estimates seem to be remarkably lower. More in-depth studies with validated diagnoses are warranted to precisely estimate the burden of HE in the elderly.

Treatment with alitretinoin in patients taking part in a tertiary individual prevention program for work-related skin diseases

BACKGROUND

Patients taking part in a tertiary individual prevention program (TIP) for work-related skin diseases frequently have chronic hand eczema (HE) for which alitretinoin is a treatment option.

OBJECTIVE

To investigate treatment with alitretinoin before and during the TIP and related factors.

METHODS

Data of 1614 patients taking part in the TIP between January 2015 and December 2019 were analyzed retrospectively.

RESULTS

Three hundred forty-eight patients (21.6%) reported treatment with alitretinoin prior to the TIP showing an increase over time, particularly in men. In 45 patients (2.8%), alitretinoin treatment was initiated during the TIP. Treatment with alitretinoin was significantly less common among female than male patients, both prior to (P < .001) and during the TIP (P = .015). Female patients who had received alitretinoin in the past were significantly older than the other female patients (P < .001). Among patients treated with alitretinoin prior to the TIP, women had a significantly higher disease severity at admission than men (P = .007).

CONCLUSIONS

About twenty percent of patients reported treatment with alitretinoin prior to the TIP. The data indicate that treatment of female TIP patients with alitretinoin is less frequent than among male patients and depends on age and disease severity.

A clinician's guide to cutaneous T-cell lymphoma presenting as recalcitrant eczematous dermatitis in adults

Cutaneous T-cell lymphoma (CTCL) encompasses a group of low-grade, non-Hodgkin lymphoma, including mycosis fungoides and Sézary syndrome. Diagnosis of CTCL can be challenging given the prolonged, gradual onset and shared characteristics with many benign inflammatory skin diseases. In this case series, we describe four unique cases of patients with chronic, recalcitrant eczematous dermatitis who presented for a patch-test consultation and were ultimately diagnosed with CTCL. In particular, we highlight clinical pearls to aid in distinguishing CTCL from inflammatory dermatoses and describe the diagnostic strategy to help dermatologists arrive at the diagnosis of CTCL at earlier stages of the disease.

The (new) occupational disease no. 5101: "Severe or recurrent skin diseases"

Occupational dermatoses are among the most common occupational diseases, with BK 5101 accounting for the largest proportion. Historically, the latter was also the most frequently reported group of occupational diseases within the working age population. More than 80,000 suspected cases of occupational diseases were notified in 2019, of which 19,883 related to BK 5101. In Germany, work-related hand eczema accounts for 90 % of all BK 5101 diseases, and consists mainly of contact eczema. Especially young people working in the hairdressing sector, health care, metal, food or construction industries belong to the high-risk group. Diagnosis, therapy and prevention of BK 5101 play an important role, since advanced skin diseases are usually accompanied by a poor prognosis and long periods of inability to work, which can have considerable socio-economic consequences. On January 1^st , 2021, with the "Seventh Act amending the Fourth Book of the German Social Code (SGB) and other Laws", an amendment to the Occupational Diseases Law came into force, with which the obligation to cease work was abolished, thereby fulfilling a decades-long requirement for recognition of BK 5101. As of this year, only the "severe or repeated recurrences" of a skin disease remain as a criterion for the occurrence of an insured event, which will likely result in an increased number of notifications and acknowledged cases of occupational skin diseases.

Quality of life, anxiety, depression, social anxiety and avoidance in patients with chronic hand eczema

BACKGROUND

Previous studies have demonstrated that chronic hand eczema (CHE) causes negative effects on psychological status of patients. However, presence of social anxiety and avoidance has not been investigated in CHE patients. In this descriptive and prospective study, we aimed to examine the psychosocial dimensions of CHE in a more detailed manner.

METHODS

70 patients with CHE and 70 controls were participated in the study. The quality of life (QoL) was assessed with the World Health Organization QoL Questionnaire-Short Form (WHOQoL-BREF); anxiety and depression were evaluated with the Hospital Anxiety and Depression Scale (HADS); and social anxiety and avoidance were evaluated with the Liebowitz Social Anxiety Scale (LSAS).

RESULTS

The physical and environmental subscale scores of the WHOQoL-BREF were significantly lower (P<0.001, P=0.041); whereas HADS-total (P=0.019), HADSanxiety (P=0.014), LSAS-total (P=0.025), LSAS-anxiety (P=0.037) and LSASavoidance (P=0,029) scores were significantly higher in CHE patients compared to controls. The physical (r=-0.260, p=0.002) and social (r=0.204, p=0.016) domains of the WHOQoL-BREF scale negatively correlated with the severity of eczema, while the psychological (r=-0.363, p=0.002) and environmental (r=-0.456, p<0.001) domains negatively correlated with the extent of eczema. HADS-total (r=0.284, p=0.017) and HADS-depression (r=0.311, p=0.009) also showed positive correlations with the extent of the CHE.

CONCLUSIONS

Considering that impairment in QoL may be associated with psychosocial morbidity, it is important to develop strategies to recognize and treat those psychiatric comorbidities in patients with CHE.

Hand eczema and temporal variation of Staphylococcus aureus clonal complexes: A prospective observational study

BACKGROUND

Hand eczema (HE) is frequently associated with Staphylococcus aureus; however, its role in the pathogenesis of HE is poorly understood.

OBJECTIVE

To investigate the temporal variation in S aureus subtypes, ie, clonal complex (CC) types, on the hands and relate it to S aureus colonization in the nose and severity in a cohort of HE patients.

METHODS

S aureus from the hands and nose of 50 adult HE patients and 50 controls was prospectively identified at 5 visits over 3 weeks.

RESULTS

S aureus was identified on the hands of 23 (46%) patients at 2 or more visits and on the hands of 1 control once. Of the HE patients with S aureus colonization, 78% had the same S aureus CC type over time. Twenty-one patients had the same S aureus CC type on the hands and in the nose. Persistent colonization was strongly related to an increased disease severity.

LIMITATIONS

A relatively small S aureus culture-positive population.

CONCLUSION

The temporal stability of S aureus CC type and high occurrence of the identical subtypes on the hands and in the nose imply that S aureus colonization in patients with HE is of a more permanent nature. Taken together with the finding that persistent colonization and HE severity are clearly related, our results indicate that S aureus may contribute to the perpetuating course of HE.

Handekzem – Gleiche Therapie für alle Formen?

Es gibt nicht einen einzigen Typ des chronischen Handekzems (CHE) – weder morphologisch noch immunologisch. Schutz und Präventionsmaßnahmen können für alle Typen des CHE definiert werden. Die Therapie muss passen und zielgerichtet sein. Einige Therapien können jedoch für alle Typen des Handekzems angeboten werden wie topische Kortikosteroide, Calcineurinantagonisten, UV-Therapie und Alitretinoin, ggf. auch Dupilumab, was in größeren Studien untersucht werden sollte. Die Wahrnehmung des Handekzems sollte gerade in Zeiten der Irritation durch Desinfektion der Hände erhöht werden, damit Prävention und frühzeitige Therapie erfolgen können.

Clinical Pattern and Patch Test Profile of Hand Eczema in Hospital Employees in a Tertiary Care Hospital of North India

Introduction:

Health care workers form an important occupational group with a high risk of hand eczema. All health care professionals are exposed to a variety of allergens and irritants which can cause hand dermatitis, resulting in significant morbidity.

Aims and Objectives:

To assess the clinical profile of hand eczema in hospital employees, to perform patch test in relevant cases and to find out the most common sensitizers in them.

Materials and Methods:

This was a cross-sectional, hospital-based study in which the staff was screened for features of hand eczema and patch testing was done in the suspected cases of allergic contact dermatitis.

Results:

Out of 340 employees screened, 46 employees (13.5%) suffered from hand eczema. The most common type was wear and tear dermatitis accounting for 17 (36.9%) cases, followed by discoid eczema, pompholyx, focal palmar peeling, finger-tip eczema, hyperkeratotic eczema, ring eczema, and unspecified types. Patch testing was positive in 15 (32.6%) cases. The most common allergen was paraphenylene diamine, followed by fragrance mix, nitrofurazone, mercaptobenzothiazole, potassium bichromate, black rubber mix, and thiuram mix. A statistically significant association (0.001) was found with an underlying history of atopy.

Conclusion:

Hand eczema is a commonly encountered dermatological complaint in many hospital employees. Proper counseling, work, up, patch testing, and treatment can mitigate the symptoms in such employees.

Nomenclature and clinical phenotypes of atopic dermatitis

Atopic dermatitis is a heterogeneous disease and resists classification. In this review, we discuss atopic dermatitis nomenclature and identify morphologic phenotypes, which will facilitate correct diagnoses and development of treatment strategies. We support using the term 'atopic dermatitis' rather than eczema, because it describes the allergic background and inflammation ('itis') as drivers of the disease. Atopic dermatitis has many morphologic manifestations that vary by topographic area affected, age, or race and require consideration in differential diagnosis. Different phenotypes based on morphology and topographic location, ethnicity, and age are discussed. A better-defined phenotype identification for atopic dermatitis will facilitate earlier and correct diagnosis of this complex condition and inform selection of the most appropriate treatment choice in an era in which targeted therapies may generate more individualized patient care.

The cardiovascular safety of oral alitretinoin: a population-based cohort study involving 19 513 patients exposed to oral alitretinoin

BACKGROUND

Oral alitretinoin is a retinoid used for severe chronic hand eczema. Although caution is recommended for patients with uncontrolled dyslipidaemia or cardiovascular risk factors, the actual atherothrombotic risk has not been investigated thus far.

OBJECTIVES

To detect any excess of atherothrombotic events among patients exposed to alitretinoin, during treatment or in the 2 years following initiation.

METHODS

Using the French Health Insurance database, we compared the number of patients who had an atherothrombotic event (coronary artery disease, ischaemic stroke or peripheral artery disease requiring revascularization) in the population exposed to oral alitretinoin vs. the general population of the same age, sex and baseline cardiovascular risk, using standardized morbidity ratios (SMRs).

RESULTS

Between 2009 and 2017, 19 513 patients were exposed to oral alitretinoin in France. Sixty-four (0·3%) patients had an atherothrombotic event while on alitretinoin. Patients receiving alitretinoin experienced no more atherothrombotic events than the general population: patients without cardiovascular risk factors or previous atherothrombotic events had a SMR of 0·65 [95% confidence interval (CI) 0·26-1·34] during alitretinoin treatment, and 1·21 (95% CI 0·90-1·59) in the 2 years following initiation; patients with cardiovascular risk factors or previous atherothrombotic events had a SMR of 0·82 (95% CI 0·60-1·08) during alitretinoin treatment and 0·95 (95% CI 0·82-1·09) in the 2 years following initiation. Taken separately, SMRs for each outcome did not increase either.

CONCLUSIONS

These data from an exhaustive nationwide population-based study do not support an increase in the incidence of atherothrombotic events with alitretinoin use, regardless of the baseline cardiovascular risk of the patient.

Topical 0.05% clobetasol cream in the treatment of chronic hand eczema: A protocol for systematic review and meta-analysis

BACKGROUND

Chronic hand eczema (CHE) is a recurrent, frequently disabling skin condition that requires daily skin care to prevent transepidermal water loss, posing a significant burden of society and economy. In recent years, topical 0.05% clobetasol cream is widely used for the treatment of CHE for its efficacy, tolerability and safety. Whereas, no systematic review and meta-analysis has been updated up to now. Therefore, this work aims to assess the effectiveness and safety of topical 0.05% clobetasol cream in patients with CHE.

METHODS

Study on topical 0.05% clobetasol cream for CHE will be searched from their inception to December, 2020 with the language restrictions of English and Chinese in 8 databases (PubMed, Cochrane Library, Embase, the web of science, VIP, CNKI, CBM, and WAN FANG). According to the heterogeneity test, a fixed or random-effect model will be used to synthesize data. The primary outcome is the proportion of patients achieving more than 75% reduction in signs and symptoms according to the Hand Eczema Severity Index (HECSI). The secondary outcomes include: scored for 4 different characteristics of the lesions (redness, scaling, lichenification, and pruritus), QoL questionnaire, adverse events, and recurrence events. STATA 13.0 and Review Manager software 5.3 will be used for analysis and synthesis. Two or more reviewers will independently conduct the selection of studies, data extraction, and data analysis.

RESULTS

The results of the study expect to provide a high-quality, evidence-based recommendation on topical 0.05% clobetasol cream in the treatment of CHE for clinicians.

CONCLUSION

The study will provide scientific and useful evidence for better use of topical 0.05% clobetasol cream in treating CHE.

ETHICS AND DISSEMINATION

This study is a protocol for an overview of SRs/MAs that did not involve individual data. Thus, ethical approval is not required.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/SPHVZ.

New evidence on the minimal important change (MIC) for the Hand Eczema Severity Index (HECSI)

BACKGROUND

How changes in hand eczema (HE) severity correlate with the single scores on the Hand Eczema Severity Index (HECSI) is sparsely investigated and particularly needed in clinical trials.

OBJECTIVES

To find the minimal important change (MIC) for HECSI based on patient's and physician's assessments using different methods.

METHODS

In this prospective follow-up study, three different anchors were used: two anchor questions for patients and physician, respectively, and the Physician Global Assessment (PGA) with a photographic guide. MIC was estimated by mean change in patients with a one-step increase to anchor-questions, receiver-operating characteristic (ROC) plot, and smallest detectable change (SDC).

RESULTS

One hundred fifty-two patients with HE (63.8% female) were included at baseline (89% completed follow-up). The mean change, ROC cutoff, and SDC values were 7.1, 4.5, 21.4 (patient-rating), 8.2, 4.5, 8.3 (physician-rating), and 16.6, 6.5, 27.1 points (PGA), respectively. SDC stratified by baseline severity was 2.9 and 11 points for mild and moderate-severe HE (physician-rating), respectively.

CONCLUSION

Identification of the MIC for the HECSI is important in relation to evaluation of treatment, intervention, and sample-size calculations. An improvement of 8.3 points on the HECSI is recommended as the MIC. MIC values may differ according to baseline severity, and this variation should be clarified in future studies.

Prevalence, incidence, and severity of hand eczema in the general population - A systematic review and meta-analysis

Accurate assessments of the burden of hand eczema (HE) in the general population are important for public awareness and intervention. The aim of this systematic review and meta-analysis was to provide updated estimates of prevalence and incidence, alongside additional epidemiological endpoints on HE in the general population. PubMed, Embase and Web of Science were searched for studies reporting the prevalence and/or incidence of HE in the general population. Proportion meta-analyses were performed to calculate pooled estimates of prevalence, incidence, severity, and the proportion of individuals with HE and a history of atopic dermatitis. Sixty-six studies were included in the quantitative analysis encompassing 568 100 individuals. The pooled estimates for lifetime, 1-year, and point prevalence were 14.5% (95% confidence interval [CI]: 12.6-16.5), 9.1% (95% CI: 8.4-9.8) and 4.0% (95% CI: 2.6-5.7), respectively. The pooled incidence rate of HE was 7.3 cases/1000 person-years (95% CI: 5.4-9.5). The occurrence of HE was 1.5-2 times higher in females than males. More than one third suffered from moderate/severe disease and around one third had a history of atopic dermatitis. HE was a recurrent, long-lasting disease with an average age at onset of the early- to mid-twenties. In conclusion; HE is a highly prevalent disease in the general population and carries a significant risk of long-term or chronic disease.

A Comparison of the Effect of Topical Preparation of Sambucus ebulus L. and Hydrocortisone on Hand Eczema: A Double-Blind Randomized Controlled Trial

Objectives: Corticosteroids as the main treatment of hand eczema can cause major side effects. This study compared the effect of topical preparation of Sambucus ebulus L. leaves and hydrocortisone on the severity of hand eczema. Design: Ninety-four patients with hand eczema aging 18-60 years were recruited in two groups (S. ebulus vs. hydrocortisone). Interventions: The patients used topical medications twice a day and were followed for 4 weeks. The observations were made at the first visit, and also second and fourth weeks of the study. Outcome measures: The primary outcomes were changes in the severity of hand eczema (hand eczema severity index [HECSI]) and life quality (dermatology life quality index [DLQI]). Secondary outcomes were the rate of healing and the severity of itching. Results: Thirty-eight patients in hydrocortisone and 43 in S. ebulus fulfilled all phases of the follow-up. In both groups, the HECSI, itching scores decreased over time without any significant difference between the groups (p = 0.49, 0.57, respectively). The DLQI scores were significantly better in the S. ebulus group (p = 0.02) after 4 weeks of medication. There was no significant difference between the healing rates of the two groups (p = 0.33). Conclusions: Topical use of S. ebulus can be as effective as that of hydrocortisone when it comes to reducing the severity of hand eczema.

Guidelines for the Diagnosis, Treatment, and Prevention of Hand Eczema

Hand eczema is a common condition associated with significantly impaired quality of life and high social and occupational costs. Managing hand eczema is particularly challenging for primary care and occupational health physicians as the condition has varying causes and both disease progression and response to treatment are difficult to predict. Early diagnosis and appropriate protective measures are essential to prevent progression to chronic eczema, which is much more difficult to treat. Appropriate referral to a specialist and opportune evaluation of the need for sick leave are crucial to the good management of these patients. These guidelines cover the diagnosis, prevention, and treatment of chronic hand eczema and highlight the role that primary care and occupational health physicians can play in the early management of this disease.

Drugs for the Treatment of Chronic Hand Eczema: Successes and Key Challenges

Chronic hand eczema (CHE) is a common and burdensome inflammatory skin condition seen in up to 10% of the population, more often in high-risk occupational workers. Topical therapeutics comprise the standard of care, but up to 65% of cases do not resolve after treatment, and moderate-to-severe cases are often resistant to topical therapeutics and require systemic options instead. To date, there are no systemic therapeutics approved to treat CHE in the United States, but several drugs are under investigation as potential treatments for CHE. The primary focus of this review is on the novel therapeutics, topical and systemic, that are under investigation in recently completed or currently ongoing trials. This review also briefly outlines the existing treatments utilized for CHE, often with limited success or extensive adverse effects. CHE represents a major challenge for physicians and patients alike, and efforts to improve the minimally invasive diagnostic tools and treatment paradigms are ongoing. In the near future, CHE patients may benefit from new topical and systemic therapeutics that specifically target abnormally expressed immune markers.

Beneficial Effects of Paraffin Bath Therapy as Additional Treatment of Chronic Hand Eczema: A Randomized, Single-Blind, Active-Controlled, Parallel-Group Study

Objective: Chronic hand eczema (CHE) is a common inflammatory skin disease with a major psychological and socioeconomic impacts on patients' quality of life (QoL) and work ability. To the best of knowledge, this study is the first randomized-controlled trial conducted to evaluate the effect of paraffin bath therapy in management of hand eczema and its related symptoms. Design: This study was a parallel-group, active-control, randomized clinical trial with measures at pretreatment, 6th week, and 12th week of treatment. Settings: The study took place at the Outpatient Clinic of Faculty of Physical Therapy, Cairo University, and some licensed rehabilitation centers in Cairo for a 1-year period. Subjects: Sixty patients with moderate to severe CHE were randomly assigned into two groups of equal number; the paraffin bath therapy group and the control group. Interventions: The paraffin group received paraffin bath therapy for 5 days a week for 12 weeks, in addition to the routine skin care program, while the control group only received the routine skin care program. Outcome measures: SCORing Atopic Dermatitis (SCORAD) was used to assess the severity of atopic dermatitis and dermatology life quality index (DLQI) to assess the effect of CHE on quality of patients' life. All measurements were obtained before, at the 6th week, and at the 12th week of treatment. Results: Marked improvement in the severity of the disease symptoms was observed, reflected by a highly decrease in objective SCORAD score in the paraffin group over time more than the control group. The percentage of reduction was 28.6% in paraffin group versus 0.41% in control group. Subjective item score (itching and sleepiness) was reduced in the paraffin group more than the control group with a percentage of improvement (47% and 5.5%), respectively. Regarding QoL measure, there were highly positive changes in DLQI in paraffin group more than the control group. The percentage of improvement was 60% in paraffin group and 3.8% in control group. Conclusions: Paraffin bath therapy applied for a 12-week duration seems to be effective, both in reducing severity of eczema symptoms and improving QoL in patients with CHE.

Degree of employment, sick leave, and costs following notification of occupational contact dermatitis-A register-based study

BACKGROUND

Occupational contact dermatitis (OCD) is the most commonly recognized occupational disease in Denmark.

OBJECTIVES

To examine the impact of recognized OCD on degree of employment, sick leave, unemployment, and job change.

METHODS

Data on all recognized individuals with OCD notified in Denmark between 2010 and 2015 (n = 8940) were linked to information on social transfer payments in the years before and after notification. The number of weeks on unemployment benefits or sick leave and the degree of employment during the 2 years prior to notification was compared with the 2 years following notification.

RESULTS

The degree of employment decreased on average 8.9 work-hours/month, corresponding to an average annual loss of income per worker of approximately €1570. The average number of weeks that workers were receiving unemployment benefits and paid long-term sick leave rose by 2.5 and 3.4 weeks, respectively, corresponding to an average additional annual cost per worker of approximately €420 and €770, respectively. Longer case-processing time was significantly associated with lower degree of employment and higher levels of unemployment and sick leave.

CONCLUSIONS

OCD has a significant negative impact on employment and economics, thus highlighting the need for a national, strategic action plan for effective prevention of OCD.

How irritant are n-propanol and isopropanol? - A systematic review

BACKGROUND

The use of alcoholic-based hand rubs (ABHRs) is an important tool for hand hygiene, especially in times of the COVID-19 pandemic. Possible irritant effects of ABHR may prevent their use by persons at risk of infection.

METHODS

This systematic review is based on a PubMed search of articles published between January 2000 and September 2019 in English and German, and a manual search, related to the irritation potential of alcohol-based disinfectants restricted to n-propanol (1-propanol) and its structural isomer isopropanol (isopropyl alcohol, 2-propanol).

RESULTS

The majority of the included studies show a low irritation potential of n-propanol alone. However, recent studies provide evidence for significant barrier damage effects of repeated exposure to 60% n-propanol in healthy, as well as atopic skin in vivo. The synergistic response of combined irritants, (ie, a combination of n-propanol or isopropanol with detergents such as sodium lauryl sulfate) is greater, compared with a quantitatively identical application of the same irritant alone.

CONCLUSION

While recent studies indicate a higher risk of skin irritation for n-propanol and isopropanol than reported in the past, this risk still seems to be lower than that for frequent handwashing with detergents, as recommended by some to prevent COVID-19 infections.

Gender and occupational allergy: Report from the task force of the EAACI Environmental and Occupational Allergy Interest Group

Women's work has traditionally been considered less hazardous to health in comparison with men's work. The increased women's participation in the workforce has led to an increased attention to women's working conditions. Women and men are unequally represented in individual professions or sectors (horizontal segregation), with women also under-represented in leadership positions (vertical segregation). The selection of specific occupations can result in differences between types and levels of occupational exposures among women and men and can affect prevalence of occupational allergy. Gender distribution of work-related asthma appears to vary across countries without clear global difference. Occupational rhinitis tends to be higher in women, although is not clear if this is related to a sex/gender effect or to differences in work exposure. Women are more likely to have occupational contact dermatitis, mainly due to wet work. No clear effects of gender on rates of hypersensitivity pneumonitis have been shown. Besides variation in exposures, physical and physiological characteristics, different behaviours and health consciousness have an impact on the occupational health hazards of women and men. Occupational allergy health promotion strategies need to consider approaches for women and men adjusted by gender, and legislative actions similarly could be implemented in a more gender-sensitive way.

Chronic Hand Eczema Guidelines From an Expert Panel of the International Eczema Council

Background

Assessment of chronic hand eczema (CHE) is complex and warrants standardization.

Objective

We sought to guide clinicians on the assessment of CHE.

Methods

An electronic questionnaire regarding the diagnosis and assessment of CHE was completed by councilors (n=45) of the International Eczema Council, an international group of clinicians and researchers with expertise in CHE. The survey consisted of 52 statements for consensus.

Results

Overall, nine statements (17.3%) had strong, twenty-three (44.2%) moderate, 12 (23.1%) low, and 8 (15.4%) very low levels of agreement. Five statements had considerable disagreement, including the value of conducting a skin biopsy (62.2% disagreement), investigating for possible type 1 reactions (60.0%), conducting a fungal culture (44.4%), finding no history of relevant allergens and/or irritants (31.1%) in most or all cases, and performing patch testing irrespective of lesion location and morphology (28.9%). Agreement was generally highest among respondents from Europe (28.6–77.8% agreement), followed by Asia (7.1%–35.7% agreement), North America (0%–35.5% agreement), and other (0%–13.3% agreement).

Conclusions

There were substantial differences of agreement, suggesting there are many knowledge and/or practice gaps with respect to CHE. Future research is needed to inform evidence-based and/or consensus guidelines for CHE.

Colonization with Staphylococcus aureus in patients with hand eczema: Prevalence and association with severity, atopic dermatitis, subtype and nasal colonization

BACKGROUND

While Staphylococcus aureus (S. aureus) colonization has been thoroughly studied in atopic dermatitis (AD), where S. aureus is related to flares and considered a trigger factor, S. aureus colonization in hand eczema (HE) has only been sparsely studied.

OBJECTIVES

To examine the 1-week prevalence of S. aureus colonization in HE patients, and its association with severity, HE subtype, AD, and nasal S. aureus colonization compared with healthy controls.

METHODS

In a case-control study of 50 adult HE patients and 50 healthy controls, bacterial swabs from lesional skin (patients only), non-lesional skin (dorsal hand), and the nasal cavity were sampled for culturing of S. aureus on days 1, 3, 5 and 8. Participants were characterized by demographics, AD, HE subtype, filaggrin gene mutation status, and HE severity.

RESULTS

Twenty-seven HE patients (54%) were colonized with S. aureus on the hand compared to one control (2%) (P < .01). Nasal S. aureus colonization was found in 72% of patients and 22% of controls (P < .01). For patients, S. aureus colonization on the hands was associated with an atopic HE subtype and HE severity (P = .01 and P < .01, respectively).

CONCLUSIONS

Both hand and nasal S. aureus colonization were highly prevalent among HE-patients and may have an impact on the persistence of HE.

Protocol for the development of a core domain set for hand eczema trials

BACKGROUND

Clinical hand eczema trials measure a variety of outcome domains to determine the success of interventions. This considerably limits the comparability and overall confidence in the study results, and thereby the strength of recommendations for clinical practice.

OBJECTIVES

The Hand Eczema Core Outcome Set (HECOS) initiative aims to develop a core outcome set (COS) for the standardized evaluation of interventions in future hand eczema trials and reviews. This COS will define the minimum that should be measured and reported in controlled and randomized-controlled trials of therapeutic hand eczema interventions. The objective of this protocol is to specify the methods to develop a core domain set.

METHODS

In Phase 1, a list of candidate domains will be derived from a systematic literature review concerning previously measured outcomes in hand eczema trials, from qualitative patient interviews and from expert interviews. In Phase 2, a consensus study about core domains will be conducted by an online 3-round Delphi survey and a face-to-face meeting, applying predefined consensus criteria. HECOS involves hand eczema and methods experts as well as patients and further stakeholders with an interest in the initiative.

OUTLOOK

When a set of core domains has been defined, HECOS is going to identify appropriate outcome measurement instruments in a development process that will be detailed in another protocol. The COS will considerably enhance the methodological quality, comparability and usefulness of hand eczema trials for clinical decision-making and the development of new therapeutic options for hand eczema, and also reduce the effort of planning, conducting, and reporting individual hand eczema studies, reviews and meta-analyses.