Hand eczema guidelines based on the Danish guidelines for the diagnosis and treatment of hand eczema

Interpretability of the Quality Of Life in Hand Eczema Questionnaire

The Quality Of Life in Hand Eczema Questionnaire (QOLHEQ) is used to measure impairment of health-related quality of life in hand eczema. Here, we prospectively studied the interpretability of international QOLHEQ scores at three time points: baseline, after 1-3 days (T₁), and after 4-12 weeks (T₂). Adult patients with hand eczema completed the QOLHEQ and anchor questions for overall assessment of health-related quality of life impairment. Interpretability of single scores was assessed at baseline by defining severity bands based on agreement with the anchor questions. Smallest detectable change was calculated at T₁. Minimally important change of improvement was calculated at T₂ using three methods: mean cut-off, receiver operating characteristic, and 95% limit. A total of 294 adult patients were included (160 males, mean age 44.9 years). The final proposed severity band of overall QOLHEQ single scores (κ-coefficient of agreement, 0.431) was not at all, 0-10; slightly, 11-39; moderately, 40-61; strongly, 62-86; and very strongly, ≥87. Separate overall severity bands were proposed for males and females and the four subscales of the QOLHEQ. The smallest detectable change in 166 unchanged patients was 18.6 points. The preferred minimally important change, obtained with the receiver operating characteristic method, was 21.5 points. An overall QOLHEQ score of ≥22 is recommended as cut-off for a minimally important, real change.

Efficacy of alitretinoin depending on the concomitant use of topical corticosteroids in chronic hand eczema patients

Alitretinoin is the only systemic agent approved for the treatment of severe chronic hand eczema (CHE) unresponsive to potent topical corticosteroids. Clinical trials have shown the efficacy of oral alitretinoin with topical emollients for CHE treatment, but most studies have failed to reach a therapeutic success rate of 50%. Reasonably, we thought it would be more effective to combine topical corticosteroids with oral alitretinoin, but the concomitant use of topical corticosteroids has not been studied yet. One-hundred and seven Korean patients diagnosed with CHE were recruited. The participants were divided into two groups depending on the concomitant use of topical corticosteroids. Comparative analysis was performed between the combined therapy (alitretinoin and topical corticosteroids) and monotherapy groups (alitretinoin only) by using physician global assessment (PGA), patient's global assessment (PaGA), modified total lesion symptom score (mTLSS), and recurrence rates. The combined therapy group showed a significantly higher treatment success rate than the alitretinoin monotherapy group for all efficacy parameters (PGA: P < 0.001, PaGA: P < 0.001, mTLSS changes: P < 0.001), but there was no significant difference in recurrence rates between the groups (P = 0.266). Combined use of topical corticosteroids is recommended for CHE patients being treated with oral alitretinoin due to clinically rapid and superior effectiveness.

Responsiveness and interpretability of the Hand Eczema Severity Index

Background

The Hand Eczema Severity Index (HECSI) is used to measure the severity of hand eczema. It is unclear what HECSI scores mean and what is the minimally important change (MIC). Furthermore, its responsiveness has not been studied.

Objectives

To study the responsiveness and interpretability of the HECSI.

Methods

This was a prospective study covering two time points: baseline and after 4–12 weeks. Responsiveness was assessed using a criterion approach, with at least one‐step improvement on the ‘Photographic guide for severity of hand eczema’ as the anchor for important improvement. Interpretability of single scores was determined by defining severity bands based on agreement with the anchor. For change scores, the smallest detectable change (SDC) was calculated in patients indicating no change and the MIC was obtained in patients indicating that they had changed using three methods: mean cutoff, receiver operating characteristic (ROC) curve and 95% limit.

Results

In total, 294 patients participated (160 male, mean age 44·9 years). HECSI scores improved or deteriorated in parallel with the anchor. The area under the ROC curve was 0·86 (95% confidence interval 0·81–0·91). The final severity band for single scores had a κ‐coefficient of agreement of 0·694: clear, 0; almost clear, 1–16; moderate, 17–37; severe, 38–116; very severe, ≥ 117. The SDC in 93 unchanged patients was 40·3 points. The obtained MIC values were all smaller than the SDC.

Conclusions

The HECSI has good responsiveness. This study gives meaning to HECSI scores, which can be applied to clinical decision making and the design of clinical trials. We recommend that an improvement of 41 points on the HECSI is regarded as the minimally measurable true change.

What's already known about this topic?

The Hand Eczema Severity Index (HECSI) is one of the most widely used measurement instruments to measure the severity of hand eczema.

The HECSI has good reliability, but its responsiveness and interpretability have not been studied.

What does this study add?

This study shows good responsiveness of the HECSI.

A severity grading for single scores is proposed.

The smallest detectable change and minimally important change for improvement are determined.

What are the clinical implications of this work?

The obtained values help to interpret HECSI scores in daily practice and clinical studies, and may facilitate researchers in the calculation of sample sizes for clinical trials.

https://www.bjdonline.com/article/

Linked Comment:https://doi.org/10.1111/bjd.18544

https://doi.org/10.1111/bjd.18911 available online

Multispectral imaging of hand eczema

BACKGROUND

Hand eczema is a disease with large variation in clinical presentation and severity. Scoring systems for quantitative severity assessment exist. However, they are observer-dependent. An objective quantitative tool for scoring of hand eczema would improve categorization of hand eczema.

OBJECTIVE

To investigate the usefulness of multispectral imaging in assessing severity of hand eczema with respect to extent and the different morphological features.

METHODS

Patients with hand eczema (n = 60) and healthy controls (n = 28) were included. The severity of hand eczema was assessed by a dermatologist using the Hand Eczema Severity Index (HECSI) and a global assessment (Physician Global Assessment [PGA]). Multispectral imaging of the hand was performed on all patients and controls using the VideometerLab Instrument.

RESULTS

Areas of the morphological elements identified by multispectral imaging were statistically significantly correlated with the PGA scores. Analyzed by Cohen's kappa, a moderate agreement between imaging-based severity assessment and PGA was found. The imaging-based severity assessment was also correlated with HECSI (Spearman rho 0.683, P < .001). Still, the imaging-based algorithm was not capable of differentiating hand eczema patients from controls.

CONCLUSIONS

Multispectral imaging allows quantitative measurements of different skin parameters to be performed. In its present form, multispectral imaging cannot replace the clinical assessment of a dermatologist. However, after refinement, this or similar technologies could prove useful.

Effect of dupilumab on hand eczema in patients with atopic dermatitis: An observational study

Systemic treatment options for chronic hand eczema are limited. Dupilumab is used in atopic dermatitis (AD) but is not licensed for (isolated) hand eczema. In this observational prospective study we aimed to determine the response of hand eczema to dupilumab in patients with AD. Adult patients with hand eczema and AD received dupilumab s.c. at a 600 mg loading dose, followed by 300 mg every 2 weeks. Primary outcome was a minimum improvement of 75% on the Hand Eczema Severity Index after 16 weeks (HECSI-75). Secondary outcomes were severity, measured using the Photographic guide; quality of life improvement as patient-reported outcome, measured using the Dermatology Life Quality Index (DLQI); and AD severity, measured using the Eczema Area and Severity Index (EASI). Forty-seven patients were included (32 males; mean age, 45 years). HECSI-75 was achieved by 28 (60%). Mean HECSI score reduction was 49.2 points (range, 0-164; 95% within-subject confidence interval, 46.4-52.0), which was already significantly decreased after 4 weeks (P < 0.001). DLQI score mean improvement was 8.8 points (standard deviation [SD], 6.0) or 70.0% decrease (SD, 26.4) (P < 0.001). Eighteen patients (38%) were classified as responders on the Photographic guide. There was no difference in response between chronic fissured and recurrent vesicular clinical subtypes. Similar percentages of patients achieving EASI-75 and HECSI-75 were seen after 16 weeks. In conclusion, this study shows a favorable response of hand eczema to dupilumab in patients with AD. This raises the question whether a response will also be seen in isolated hand eczema.

Association Between Topical Corticosteroid Use and Type 2 Diabetes in Two European Population-Based Adult Cohorts

OBJECTIVE

Topical corticosteroids (CSs) are commonly used to treat inflammatory skin conditions including eczema and psoriasis. Although topical CS package inserts describe hyperglycemia and glycosuria as adverse drug reactions, it is unclear whether topical CS use in real life is also associated with an increased risk of type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

Two matched case-control studies and one cohort study were conducted using routinely collected health care data from Denmark and the U.K. A total of 115,218 and 54,944 adults were identified as case subjects with new-onset T2D in the Danish and U.K. case-control study, respectively. For the Danish cohort study, 2,689,473 adults were included. The main exposure was topical CSs, and the outcome was incident T2D.

RESULTS

Topical CS was significantly associated with T2D in the Danish (adjusted odds ratio [OR] 1.25 [95% CI 1.23-1.28]) and U.K. (adjusted OR 1.27 [95% CI 1.23-1.31]) case-control studies. Individuals who were exposed to topical CSs had significantly increased risk of incident T2D (adjusted hazard ratio 1.27 [95% CI 1.26-1.29]). We observed significant dose-response relationships between T2D and increasing potency of topical CSs in the two Danish studies. The results were consistent across all sensitivity analyses.

CONCLUSIONS

We found a positive association between topical CS prescribing and incident T2D in Danish and U.K. adult populations. Clinicians should be cognizant of possible diabetogenic effects of potent topical CSs.

Interventions for hand eczema

BACKGROUND

Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema.

OBJECTIVES

To assess the effects of topical and systemic interventions for hand eczema in adults and children.

SEARCH METHODS

We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were participant- and investigator-rated good/excellent control of symptoms, and adverse events.

MAIN RESULTS

We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow-up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head-to-head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty-two studies were industry-funded.Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons.Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant-rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator-rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty.When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator-rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant-rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty.Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator-rated symptom control when compared to local narrow-band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant-rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow-band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty.Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator-rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant-rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well-tolerated application site burning/itching.A within-participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator- or participant-rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment.Evidence from these studies was rated as moderate certainty.Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator-rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant-rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty.Alitretinoin 10 mg improves investigator-rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant-rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate-certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high-certainty evidence). Outcomes were assessed between 48 and 72 weeks.

AUTHORS' CONCLUSIONS

Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating.Well-designed and well-reported, long-term (more than three months), head-to-head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established.The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments.

Sociodemographic and clinical profile of patients with occupational contact dermatitis seen at a work-related dermatology service, 2000 - 2014

BACKGROUND

Occupational dermatoses are common, especially contact dermatitis. Epidemiological studies on these dermatoses are scarce in Brazil and they are necessary as part of the public policy to protect workers' health.

OBJECTIVES

To identify sociodemographic and clinical profile of patients with occupational contact dermatitis seen between 2000 and 2014 at an occupational dermatology service.

METHODS

It is a cross-sectional and retrospective study, based on information obtained from the service's database.

RESULTS

Of 560 patients with conclusive patch test, 289 (46.9%) presented occupational dermatoses and 213 occupational contact dermatitis with predominance of the allergic type in relation to the irritative type (149:64 respectively). The odds of occupational dermatoses were higher among men and lower among patients aged 50 years or older and with higher level of education. Regarding the possibility of presenting occupational allergic contact dermatitis, only the gender variable was statistically significant. The professions most seen were cleaners, construction workers, painters, mechanics/metallurgists and cooks. The commonest allergens were nickel sulfate, potassium dichromate, cobalt chloride, carba-mix and formaldehyde.

STUDY LIMITATIONS

The main limitations of this study are the fact that it was carried out in a tertiary service of occupational dermatoses and the lack of access to some allergens outside the patch test baseline series.

CONCLUSIONS

It was possible to identify the sociodemographic and clinical profile of patients with suspected occupational contact dermatitis seen at the Service, beyond the professional groups and allergens related to a high risk of occupational contact dermatitis in this population.

Using Patch Testing to Improve Therapeutic Outcome in the Treatment of Hand Eczema in Vietnamese Patients

BACKGROUND:

Hand eczema is a common chronic and relapsing skin disease with various clinical features. Hand eczema aetiology can be allergic contact dermatitis (ACD), irritant contact dermatitis (ICD), atopic dermatitis (AD) and unknown or combination causes. If the causative agents are not detected treatment of hand eczema will be a failure. A patch test can be useful to detect causative agents in suspected allergic contact hand eczema. Then patients will avoid contacting them. This results in the improvement of hand eczema. In Vietnam, patch test has not been used before, so we conduct this study.

AIM:

To identify causative allergens by using patch test with 28 standard allergens in consecutive patients.

METHODS:

A group of 300 HE patients from the National Hospital of Dermatology and Venereology (NHDV) in Vietnam were enrolled in this study. They were divided into 4 groups-ACD, ICD, AD and unknown aetiology. The patient was patch tested with 28 standard allergens to identify the causative agents.

RESULTS:

Among the 300 HE enrolled patients, ACD accounted for 72.7%, AD and ICD had the same rate of 12.7%. 39.3% of the patients had a positive patch test. Reaction to nickel sulfate was the most common (10.3%), followed by potassium dichromate (9.7%), cobalt (4%) and fragrance mix (3.1%). About one-third of the cases had relevant clinical reactions correlated with the contact agents and clinical history. Males reacted to cement, thiuram mix and formaldehyde more than females, while females reacted to a nickel more than males.

CONCLUSIONS:

Hand eczema has variable clinical features and diverse aetiology. ACD is an important cause of hand eczema that can be managed with a patch test to detect causative allergens. Nearly 40% of HE cases had positive patch test. Relevant patch test reactions were seen in one-third of the patients. We propose using patch test detect causative agents in suspected allergic contact hand eczema. Then patients will avoid contacting them. This results in the improvement of hand eczema.

Study protocol: efficacy of oral alitretinoin versus oral cyclosporine A in patients with severe recurrent vesicular hand eczema (ALICsA): a randomised prospective open-label trial with blinded outcome assessment

INTRODUCTION

Systemic treatment with alitretinoin is registered for all clinical types of severe chronic hand eczema. However, it is especially effective in the hyperkeratotic subtype and less effective in non-hyperkeratotic forms. Cyclosporine A (cyclosporine) is prescribed for hand eczema in daily practice as well. It has shown to be particularly effective in patients with vesicular hand eczema. The primary objective of this study is to compare efficacy of alitretinoin and cyclosporine in the treatment of severe recurrent vesicular hand eczema.

METHODS AND ANALYSIS

This is an investigator-initiated randomised prospective open-label trial with blinded outcome assessment. Severity assessments and laboratory measurements will be conducted corresponding to daily practice. The study population will consist of 72 adult patients (age 18-75 years) with severe recurrent vesicular hand eczema. Patients are treated with either (group I) alitretinoin 30 mg once daily or (group II) cyclosporine with a starting dose of 5 mg/kg/day and a decrease in dosage after 8 weeks to 3-3.5 mg/kg/day. The treatment period is 24 weeks for both drugs. Primary endpoint for efficacy is response to treatment, defined as an improvement of ≥2 steps on a Physician Global Assessment, using a validated Photoguide, after 24 weeks of treatment. Secondary endpoints are improvement of Hand Eczema Severity Index, Quality of Life in Hand Eczema Questionnaire and a Patient Global Assessment. Adverse events and time to response will be registered. Furthermore, cost-utility, quality-adjusted life years and cost-effectiveness will be assessed with the EQ-5D-5L questionnaire while monitoring costs.

ETHICS AND DISSEMINATION

This protocol was reviewed and approved by the Medical Ethical Review Board of the University Medical Centre Groningen (reference METc 2015/375). The study will be conducted according to the principles of the Declaration of Helsinki, in accordance with the Dutch Medical Research Involving Human Subjects Act.

TRIAL REGISTRATION NUMBER

NCT03026946; Pre-results.

Presenteeism in a Dutch hand eczema population-a cross-sectional survey

BACKGROUND

Presenteeism (attending work despite complaints and ill health, which should prompt rest and absence) has been overlooked in the field of hand eczema.

OBJECTIVES

To examine the 1-year prevalence of presenteeism related to hand eczema in a population of hand eczema patients who visited a tertiary referral centre. Secondary objectives: to identify intrinsic/extrinsic reasons for presenteeism and to evaluate associated factors.

METHODS

This was a cross-sectional questionnaire study. Presenteeism was defined as "going to work despite feeling you should have taken sick leave because of hand eczema". Respondents answered questions about socio-demographic factors, clinical features, occupational characteristics, and hand eczema related to occupational exposure.

RESULTS

Forty-one per cent (141/346) of patients who had both worked and had hand eczema during the past 12 months reported presenteeism. The most often reported reasons were: "Because I do not want to give in to my impairment/weakness" (46%) and "Because I enjoy my work" (40%). Presenteeism was associated with: mean hand eczema severity; absenteeism because of hand eczema; improvement of hand eczema when away from work; and high-risk occupations.

CONCLUSIONS

In this study, presenteeism was common and predominantly observed in patients with more severe hand eczema and occupational exposure. The most frequently reported reasons for presenteeism were of an intrinsic nature.

Efficacy and Safety of Alitretinoin for Chronic Hand Eczema in Korean Patients

Background

Chronic hand eczema (CHE) tends to be refractory to conventional therapy. Previous clinical trials have found that a 24-week treatment course of oral alitretinoin is effective and well tolerated for CHE treatment.

Objective

The aim of this study was to investigate the efficacy and safety of oral alitretinoin in Korean CHE patients.

Methods

A total of 27 patients with moderate to severe CHE took 30 mg of alitretinoin daily for 12 weeks. The primary efficacy parameter was the physician's global assessment (PGA). The response was defined as a patient being "clear" or "almost clear" of disease. The secondary efficacy parameters were the modified total lesion symptom score (mTLSS) and the patients' global assessment (PaGA). All adverse events and laboratory abnormalities were recorded during the treatment period.

Results

Alitretinoin led to CHE symptom improvement in 44.4% of patients. The PGA, mTLSS, and PaGA scores correlated well with each other. Reported adverse events were typical retinoid class effects and headache was the most common.

Conclusion

Taking 30 mg of oral alitretinoin daily for 12 weeks was found to be effective in treating Korean patients with CHE, compared with the 24 week-treatment shown in previous studies.

Guidelines for diagnosis, prevention and treatment of hand eczema

The guidelines aim to provide advice on the management of hand eczema (HE), using an evidence- and consensus-based approach. The guidelines consider a systematic Cochrane review on interventions for HE, which is based on a systematic search of the published literature (including hand-searching). In addition to the evidence- and consensus-based recommendation on the treatment of HE, the guidelines cover mainly consensus-based diagnostic aspects and preventive measures (primary and secondary prevention). Treatment recommendations include non-pharmacological interventions, topical, physical and systemic treatments. Topical corticosteroids are recommended as first line treatment in the management of HE, however continuous long-term treatment beyond six weeks only when necessary and under careful me-dical supervision. Alitretinoin is recommended as a second line treatment (relative to topical corticosteroids) for patients with severe chronic HE. Randomized control trials (RCT) are missing for other used systemic treatments and comparison of systemic drugs in “head-to-head” RCTs are needed.The guidelines development group is a working group of the European Society of Contact Dermatitis (ESCD) and has carefully tried to reconcile opposite views, define current optimal practice and provide specific recommendations, and meetings have been chaired by a professional moderator of the AWMF (Arbeitsgemeinschaft der Wis-senschaftlichen Medizinischen Fachgesellschaften; Association of the Scientific Medi-cal Societies in Germany).No financial support was given by any medical company. The guidelines are expected to be valid until December 2017 at the latest.

Successful treatment of refractory chronic hand eczema with calcipotriol/betamethasone ointment: A report of three cases

Chronic hand eczema (CHE) is a common skin disorder with frequent relapses, and its treatment comprises a challenge due to its uncertain etiology. In particular, certain cases of CHE exhibiting severe keratinization have a very poor response to various treatments. The Daivobet ointment, a complex product comprising calcipotriol and betamethasone, has been successfully used for the treatment of patients with plaque-type psoriasis for ~10 years; however, there are few reports on the effect of the ointment on other skin disorders of abnormal keratinization, such as eczema. The present study reported 3 cases of refractory hyperkeratotic eczema of the hand that did not respond to several treatments, but responded well to topical Daivobet treatment.

Hand dermatitis: a review of clinical features, prevention and treatment

Hand dermatitis is a socially significant health problem. This review provides a discussion on the clinical features and patterns as well as the differential diagnosis of hand dermatitis, because these are essential for proper diagnosis in clinical practice. The morphology, however, is poorly related to the etiology in chronic cases. In all cases of chronic hand dermatitis, a full diagnostic examination should be undertaken and the etiology should be clarified and addressed in the treatment concept, instead of just moving directly from a morphological diagnosis to therapy. Preventive measures should be included in the treatment concept according to etiology. A stepwise approach for escalating therapy is advised, including basic topical therapy, topical corticosteroids, calcineurin inhibitors, as well as phototherapy and systemic therapy with corticosteroids, alitretinoin, cyclosporine, methotrexate, azathioprine, and others.

Management of Chronic Hand Eczema

Management of hand eczema is complex because of the broad range of different pathogeneses, courses, and prognoses. Furthermore, the efficacy of most available treatments is not well established and the more severe forms can have a major impact on the patient's quality of life. Patient education, preventive measures, and the use of emollients are the mainstays in the management of hand eczema. High-potency topical corticosteroids are the treatment of choice, with calcineurin inhibitors used for maintenance. Phototherapy or systemic treatments are indicated in patients who do not respond to topical treatments. Switching from topical treatments should not be delayed to avoid sensitizations, time off work, and a negative impact on quality of life. Alitretinoin is the only oral treatment approved for use in chronic hand eczema.

Clinical profile and quality of life of patients with occupational contact dermatitis from New Delhi, India

BACKGROUND

Data regarding occupational contact dermatitis (OCD) and its effect on quality of life (QOL) in India are limited.

OBJECTIVES/AIMS

To evaluate patients with OCD and record the outcome of treatment.

PATIENTS/MATERIALS/METHODS

All patients with OCD were evaluated for severity of disease (by the use of physician global assessment) and its effect on QOL (by use of the Dermatology Life Quality Index) questionnaire) at the first visit and after 3 months of treatment.

RESULTS

Among 117 patients with OCD, hand eczema was present in 81.2%. Positive patch test reactions were found in 76%. The most common allergens were Parthenium hysterophorus and potassium dichromate. The most frequent diagnosis was occupational allergic contact dermatitis (OACD) (57%), caused by farming and construction work, followed by occupational irritant contact dermatitis (OICD) (24%), caused by wet work. Severe psychosocial distress was recorded in 62.5% of patients. After 3 months of treatment, 83% improved significantly, and 54% had improvement in QOL.

CONCLUSIONS

Farmers were most frequently affected, followed by construction workers and housewives. OACD was found at a higher frequency than OICD. The most frequent allergens were Parthenium hysterophorus in farmers, potassium dichromate in construction workers, and vegetables in housewives. OCD has a significant impact on QOL. Patch testing, in addition to standard treatment, improves the outcome considerably.

Systemic antihistamines--a common outside the guidelines therapeutic strategy in hand eczema management

BACKGROUND

Hand eczema (HE) is the most common skin disease affecting hands. Although the current treatment guidelines do not recommend use of systemic antihistamines as routine therapy, they seem to be widely used by physicians handling with this problem.

OBJECTIVE

The aim of the study was to investigate the attitude to prescribe systemic antihistamines in HE.

MATERIAL AND METHODS

A 10-item questionnaire was distributed among physicians participating in regional dermatological conferences. 127 valid questionnaires were analysed.

RESULTS

A total of 127 physicians participated in the survey. 124 (97.6%) responders prescribe antihistamines in HE and 16 (12.6%) subjects declared routine use of oral antihistamines in the HE management. Significantly more dermatologists than other specialists used antihistamines in the treatment of HE accompanying atopic dermatitis (77.8% vs. 54.5%, P < 0.01) and dermatologists significantly more commonly used antihistamines in HE due to their anti-inflammatory properties (40.3% vs. 20.0%, P = 0.02). Regarding the type of eczema, antihistamines were prescribed most frequently in acute allergic HE (n = 92, 72.4%) and in HE accompanying atopic dermatitis (n = 86, 67.7%).

CONCLUSIONS

Despite the lack of the large, randomized, controlled studies on the effectiveness of the systemic antihistamines in the treatment of HE, this type of therapy seems to be prevalently used among the physicians.

Occupational irritant contact dermatitis diagnosed by analysis of contact irritants and allergens in the work environment

BACKGROUND

Irritant contact dermatitis (ICD) is a common diagnosis in patients with occupational contact dermatitis (OCD). Studies are lacking on the usefulness of material safety data sheets (MSDSs) in making the diagnosis of ICD.

OBJECTIVE

To characterize irritant exposures leading to the diagnosis of occupational ICD (OICD), and to evaluate the occurrence of concomitant exposures to contact allergens.

METHODS

We included 316 patients with suspected occupational hand dermatitis, referred to the Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Denmark during January 2010-August 2011, in a programme consisting of a clinical examination, exposure assessment, and extensive patch/prick testing.

RESULTS

OCD was diagnosed in 228 patients. Of these patients, 118 were diagnosed with OICD. The main irritant exposures identified were wet work (n = 64), gloves (n = 45), mechanical traumas (n = 19), and oils (n = 15). Exposure to specific irritant chemicals was found in 9 patients, and was identified from MSDSs/ingredients labelling in 8 of these patients. Review of MSDSs and ingredients labelling showed that 41 patients were exposed to 41 moderate to potent contact allergens, and 18 patients were exposed to 25 weak workplace contact allergens.

CONCLUSION

In the present study, the systematic exposure assessment did not reveal any new irritants. MSDSs have a limited role in the investigation of ICD.

The combined diagnosis of allergic and irritant contact dermatitis in a retrospective cohort of 1000 consecutive patients with occupational contact dermatitis

BACKGROUND

The diagnosis of combined allergic and irritant contact dermatitis is an accepted subdiagnosis for hand dermatitis, and it is often considered in a patient with contact dermatitis, a positive and relevant patch test result, and wet work exposure. We therefore hypothesize that it is arbitrary for wet work exposure to be taken into consideration in a patient with newly diagnosed relevant contact allergy. Furthermore, an overestimation of the diagnosis will probably occur if the criteria for wet work exposure are applied correctly, as many occupations have an element of wet work.

OBJECTIVES

To find the statistically expected number of combined allergic and irritant contact dermatitis cases in 1000 patients, and to evaluate the diagnostic criteria for the diagnosis.

METHODS

One thousand consecutive patients with occupational contact dermatitis from a hospital unit in Denmark were assessed.

RESULTS

The expected number of cases with the diagnosis of combined allergic and irritant contact dermatitis was 0.33%, as compared with the observed number of 6.4%. Females occupied in wet occupations were often diagnosed with combined allergic and irritant contact dermatitis (p < 0.005).

CONCLUSION

The diagnosis of combined allergic and irritant contact dermatitis should be used critically to avoid misclassification, and possible criteria for the diagnosis are proposed.

Occupational contact dermatitis in blue-collar workers: results from a multicentre study from the Danish Contact Dermatitis Group (2003-2012)

BACKGROUND

Blue-collar workers have a high risk of occupational contact dermatitis, but epidemiological studies are scarce.

OBJECTIVES

To investigate allergic contact dermatitis in blue-collar workers with dermatitis registered by the Danish Contact Dermatitis Group.

METHODS

A retrospective analysis of patch test data from 1471 blue-collar workers and 1471 matched controls tested between 2003 and 2012 was performed. A logistic regression was used to test for associations.

RESULTS

The blue-collar workers often had occupational hand dermatitis (p < 0.001). Atopic dermatitis was less commonly observed among blue-collar workers (19.6%) than among controls (23.9%) (p = 0.005). Allergens with a statistically significant association with the occupational group of blue-collar workers were epoxy resins, methyldibromo glutaronitrile, 2-bromo-2-nitro-1,3-propanediol, potassium dichromate, and methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI). The following occupations were additionally identified as risk factors for contact sensitization to MCI/MI and MI, epoxy resins, and potassium dichromate, respectively: painting, construction work, and tile setting/terrazzo work.

CONCLUSION

Contact allergy is a major problem among blue-collar workers. The data indicate a healthy worker effect among blue-collar workers diagnosed with dermatitis, as blue-collar workers were diagnosed significantly less often with atopic dermatitis than were controls.

[Management of chronic hand eczema]

The management of hand eczema, more readily called chronic hand dermatitis, is complex. This heaviness is related not only to the disease itself by its different clinical forms but also the multiplicity and diversity of etiological factors, triggering / maintaining or aggravating factors. The repeated therapeutic failures are ransom of incorrect information about the disease and its environment, a lack of clarity in the prescription and duration of treatment in general too short. The reference treatment is high potency topical steroids with or without occlusion for 4-8 weeks followed by alitretinoin 30 mg / day for at least 3-6 months with a monthly lipid and liver monitoring and mandatory monthly pregnancy test in women of childbearing. Associated measures and patient education are the cornerstones of successful treatment. Other alternative treatments such as phototherapy, methotrexate, cyclosporin, mycophenolate mofetil etc. can be considered in case of resistance or for clearing followed by topical treatments.