Hand eczema classification: a cross-sectional, multicentre study of the aetiology and morphology of hand eczema

Inflammatory plasma signature of chronic hand eczema: Associations with aetiological and clinical subtypes

BACKGROUND

Chronic hand eczema (CHE) is a highly prevalent, heterogeneous, skin disease that encompasses different aetiological and clinical subtypes. Severe CHE without atopic dermatitis has been associated with systemic inflammation; yet it remains unknown if specific CHE subtypes leave distinct, systemic, molecular signatures.

OBJECTIVES

To characterize the inflammatory plasma signature of different aetiological and clinical CHE subtypes.

METHODS

We assessed expression levels of 266 inflammatory and cardiovascular disease risk plasma proteins as well as filaggrin gene mutation status in 51 well-characterized CHE patients without concomitant atopic dermatitis and 40 healthy controls. Plasma protein expression was compared between aetiological and clinical CHE subgroups and controls both overall and according to clinical CHE severity. Correlation analyses for biomarkers, clinical and self-reported variables were performed.

RESULTS

Very severe, chronic allergic contact dermatitis (ACD) on the hands was associated with a mixed Type 1/Type 2 systemic immune activation as compared with controls. Circulating levels of Type 1/Type 2 inflammatory biomarkers correlated positively with clinical disease severity among CHE patients with ACD. No biomarkers were found, that could discriminate between aetiological subtypes, for example, between ACD and irritant contact dermatitis. Hyperkeratotic CHE showed a distinct, non-atopic dermatitis-like, systemic footprint with upregulation of markers associated with Type 1 inflammation and tumour necrosis factor alpha, but not Type 2 inflammation. Increased levels of CCL19 and CXCL9/10 could discriminate hyperkeratotic CHE from both vesicular and chronic fissured CHE, whereas no difference was found between the latter two subtypes.

CONCLUSION

Profiling of systemic biomarkers showed potential for identifying certain CHE subtypes. Peripheral blood levels of inflammatory biomarkers were associated and correlated with the clinical disease severity of chronic ACD on the hands, underlining that this is a systemic disease. We question whether hyperkeratotic CHE should be classified as eczema.

Chronic hand eczema: A prevalent disease in the general population associated with reduced quality of life and poor overall health measures

BACKGROUND

The impact of hand eczema (HE) on Health-Related Quality of Life (HRQoL) has only been sparsely studied in a general population setting, and never by use of the disease specific Quality Of Life in Hand eczema Questionnaire (QOLHEQ).

OBJECTIVES

To examine the HRQoL of unselected individuals with HE using the QOLHEQ. Further, to provide prevalence estimates of severe and chronic HE (CHE), and to contrast overall health related outcomes between individuals with and without HE.

METHODS

In this nationwide, cross-sectional study a questionnaire covering questions on HE related outcomes, and overall health was sent to a random sample of 100 000 Danish adults via a secure digital mailbox, linked to their unique civil registration numbers. Data on demographic characteristics were retrieved from the civil registration system. Individuals reporting HE, further answered the QOLHEQ and other disease specific questions.

RESULTS

The response rate was 42.7% (n = 42 691). Total estimates of lifetime, 1-year and point prevalences of HE were 24.4%, 13.3% and 5.8%. Of individuals reporting a 1-year prevalence, 35.1% reported moderate-severe disease and 82.6% CHE. Individuals with HE were more likely to report less good or poor overall health, and sick leave (any reason), compared to those without. In the 2176 (92.5%) with current HE who completed the QOLHEQ, median QOLHEQ scores corresponded to a moderate impairment of the symptoms and treatment and prevention domains and a slight impairment overall and for the emotions and functioning domains. Factors that were strongly associated with moderate to severe HRQoL impairment included severe, chronic and occupational HE as well as female sex.

CONCLUSIONS

HE is highly prevalent, bears a considerable burden on society and significantly affects the lives of impacted individuals. Our findings indicate a necessity for targeted prevention aimed at high-risk groups, and support and treatment for those most affected.

Programme for prevention of foot dermatoses in patients with work-related skin diseases: Baseline data and first results of a prospective cohort study (OCCUPES)

BACKGROUND

Programmes for prevention of hand dermatoses in patients with work-related skin diseases (WRSD) are well established. Similar interventions for foot dermatoses (FD) are widely missing.

OBJECTIVE

To evaluate the effectiveness of a programme for prevention of FD based on health education in patients with WRSD while investigating the impact and possible causative factors of FD.

METHODS

In a prospective cohort study (OCCUPES), 231 patients with WRSD and FD participating in the programme were recruited. The skin was examined and questionnaires were completed, including assessment of footwear, FD severity, symptoms and health-related quality of life.

RESULTS

The baseline and some early results are presented. A work-related causation of FD was likely in 60 patients (26.0%) with irritant contact dermatitis being the most frequent diagnosis. Work-related FD were associated with male sex (p = 0.012), sweating in footwear (p = 0.004) and wearing of safety footwear (p = 0.013). FD were often long-lasting with a high degree of work-absenteeism, quality of life impairment, itch and pain, particularly in work-related FD.

CONCLUSIONS

Interventions are needed to reduce the burden of FD in patients with WRSD. The programme addresses current shortcomings in prevention of FD. A long-term evaluation of its effectiveness follows.

S2k-Leitlinie Diagnostik, Prävention und Therapie des Handekzems: S2k guideline diagnosis, prevention and therapy of hand eczema

Die S2k‐Leitlinie „Diagnostik, Prävention und Therapie des Handekzems (HE)“ gibt auf der Grundlage eines evidenz‐ und konsensbasierten Ansatzes konkrete Handlungsanweisungen und Empfehlungen für die Diagnostik, Prävention und Therapie des HE. Die Leitlinie wurde auf der Grundlage der deutschen Leitlinie „Management von Handekzemen“ aus dem Jahr 2009 und der aktuellen Leitlinie der European Society of Contact Dermatitis (ESCD) „Guidelines for diagnosis, prevention and treatment of hand eczema“ aus dem Jahr 2022 erstellt. Allgemeines Ziel der Leitlinie ist es, Dermatologen und Allergologen in der Praxis und Klinik eine akzeptierte, evidenzbasierte Entscheidungshilfe für die Auswahl sowie Durchführung einer geeigneten und suffizienten Therapie für Patienten mit Handekzemen zur Verfügung zu stellen. Die Leitlinie basiert auf zwei Cochrane‐Reviews zu therapeutischen und präventiven Interventionen beim HE. Die übrigen Kapitel wurden überwiegend basierend auf nicht systematischen Literaturrecherchen durch die Expertengruppe erarbeitet und konsentiert. Die Expertenkommission bestand aus Mitgliedern von allergologischen und berufsdermatologischen Fachgesellschaften und Arbeitsgruppen, einer Patientenvertretung und Methodikern. Im Rahmen einer Konsensuskonferenz am 15.09.2022 wurden die Vorschläge für die Empfehlungen und Kernaussagen unter Verwendung eines nominalen Gruppenprozesses konsentiert. Der strukturierte Konsensfindungsprozess wurde professionell moderiert. Die vorliegende Leitlinie hat eine Gültigkeit bis zum 22.02.2028.

S2k guideline diagnosis, prevention, and therapy of hand eczema

The consensus-based guideline "Diagnosis, prevention, and treatment of hand eczema (HE)" provides concrete instructions and recommendations for diagnosis, prevention, and therapy of HE based on an evidence- and consensus-based approach. The guideline was created based on the German guideline "Management von Handekzemen" from 2009 and the current guideline of the European Society of Contact Dermatitis (ESCD) "Guidelines for diagnosis, prevention, and treatment of hand eczema" from 2022. The general goal of the guideline is to provide dermatologists and allergologists in practice and clinics with an accepted, evidence-based decision-making tool for selecting and conducting suitable and sufficient therapy for patients with hand eczema. The guideline is based on two Cochrane reviews of therapeutic and preventive interventions for HE. The remaining chapters were mainly developed and consented based on non-systematic literature research by the expert group. The expert group consisted of members of allergological and occupational dermatological professional associations and working groups, a patient representative, and methodologists. The proposals for recommendations and key statements were consented by using a nominal group process during a consensus conference on September 15, 2022. The structured consensus-building process was professionally moderated. This guideline is valid until February 22, 2028.

Prevalence and Characteristics of Itch and Pain in Patients Suffering from Chronic Hand Eczema

BACKGROUND

Hand eczema (HE) is a frequent chronic inflammatory dermatosis. Itch and pain are considered two of the most common and burdensome symptoms of the disease. Yet, the data related to these symptoms are still limited. The aim of this study was to evaluate characteristics of itch and pain in adults suffering from HE.

METHODS

The study group comprised 100 adult HE patients. An original questionnaire designed by the authors was used to survey the patients. It included questions regarding demographic characteristics such as the duration of the disease, exacerbation count, past diagnostics and treatment, as well as atopic predispositions. Additionally, the itch and pain intensity (numerical rating scale-NRS) during '3 days prior to the study' and the 'entire disease' period was implemented. The clinical assessment of the disease severity was performed according to two specific measurement instruments: Investigator Global Assessment for Chronic Hand Eczema (IGA-CHE) scale and Hand Eczema Severity Index (HECSI). To assess patient quality of life (QoL), the DLQI tool was used and to determine the level of stigmatization and for its impact on patients' life the 6-Item Stigmatization Scale (6-ISS) was employed.

RESULTS

Within the period of 3 days prior to the examination, itch was reported by 81.0% of patients (n = 81), whereas 53.0% (n = 53) of them experienced pain. Both symptoms were reported more frequently in females (itch: p = 0.022; pain: p = 0.033). When sexes were compared, females reached higher scores in both IGA-CHE and HECSI. Itch and pain intensity correlated positively with disease severity. The intensity of itch and pain significantly influences HE patients' QoL. A positive correlation between the 6-ISS score and the intensity of itch in the 'last 3 days' period was revealed (r = 0.221; p = 0.027).

CONCLUSIONS

Itch and pain are common symptoms in HE patients, significantly contributing to the feeling of stigmatization. Providing characteristics of itch and pain may improve HE management. Symptom-decreasing treatment would definitely have a positive influence on patients' well-being.

Topical and systemic JAK inhibitors in hand eczema - a narrative review

INTRODUCTION

Hand eczema is a chronic inflammatory skin disease characterized by significant prevalence and impact on patients' Quality of Life (QoL). Because of its complex and diverse clinical picture, HE management requires patient-specific treatment which may constitute a challenge. First described in the 1990s, Janus kinase inhibitors (JAK inhibitors) state a group of modern therapeuticals, which exhibit good bioavailability and are well tolerated by patients in both - topical and systemic - routes of administration. They are an immunomodulating small molecules, impacting JAKs' enzymatic activity.

AREAS COVERED

This review provides a summary of available data concerning JAK inhibitors' use in HE patients, regarding also clinical trials for the HE treatment.

EXPERT OPINION

Recent studies are introducing JAK inhibitors as an alternative for other topical and systemic therapies in HE patients. Treatment targeting specific immune pathways enables precise management and extends range of potential therapeutic options. Despite early promising results, future studies need to evaluate JAK inhibitors' safety, potential risks and benefits resulting from the treatment, as well as impact of the therapy on patients' QoL.

Quick Treatment of Very Severe Refractory Hand and Foot Eczema with Dupilumab: A Case Report and Literature Review

Previously case reports showed dupilumab may benefit for hand eczema treatment, but relatively comprehensive assessments are lacking. A 45-year-old male with multiple severe vesicles, bullae and pustule on the palmar aspects of both hand and foot diagnosed dyshidrotic eczema by pathology was treated with dupilumab at an initial dose of 600 mg subcutaneously, followed by 300 mg every 2 weeks. The physician's assessment of the patient revealed an excellent response to the treatment with dupilumab; the lesions and symptoms achieved dramatic improvement on the third day, and at 6 weeks, the hands and feet became completely normal without relapse in the past 1.5 years of discontinuation. Systematic literature searches were performed, and 6 case reports, 5 case series, 2 prospective observational studies and 1 retrospective review with a total of 150 patients were identified to describing the evaluation of efficacy and safety of dupilumab treatment for hand and foot eczema. Dupilumab appears to be safe and well tolerated with clinical benefit in recalcitrant hand and foot eczema. Larger randomized controlled trials using validated outcome measures and detailed hand eczema type and population classification are needed before dupilumab can be applied in clinical settings.

Economic Burden of Chronic Hand Eczema: A Review

There has been no extensive synthesis of studies evaluating the cost of chronic hand eczema (CHE). This review evaluated the societal costs, healthcare resource utilisation, missed work time and job loss due to CHE. MEDLINE and 16 other databases and websites were searched in October 2020 for studies meeting prespecified inclusion criteria. Studies conducted in Europe, Australia, New Zealand or the Americas were included. Two reviewers independently assessed titles and abstracts, and full-text papers published in English between 2000 and 2020, for relevance. Data extraction was carried out by one reviewer and checked by a second reviewer. All data were based on costs between 2001 and 2013 but have been inflated to 2020 prices and converted to US dollars and Euros. A total of 30 studies (reported in 33 publications) were included in the synthesis. Mean total societal costs per year per patient ranged from $2549 (€1813) to $10,883 (€7738). Pharmacological therapy was, on average, $28.34 (€20.15) per month in Italy and $36.49 (€25.94) per month for emollients in Switzerland. Yearly treatment costs were $599.05 (€425.92) for drugs, including topical corticosteroids, topical calcineurin inhibitors, other topical treatments and oral treatments, and $178.40 for emollients, in Germany. CHE was associated with hospitalisation costs ranging from $81.86 (€58.20) per patient per month (US) to $105.04 (€74.68) per patient per month (Italy) and $639.59 (€454.75) per year (Germany). Up to 57% of patients took sick leave and up to 25% reported job loss/job change due to CHE. This review confirms the significant cost burden of CHE. Given the paucity of studies estimating the monetary costs of absenteeism, presenteeism and job loss associated with CHE, current mean societal costs are likely underestimated. Uncontrolled disease may also lead to increased costs to patients and society.

Irritant Contact Dermatitis — a Review

Purpose of Review

Recent Findings

Summary

Comparison of ALitretinoin with PUVA as the first-line treatment in patients with severe chronic HAnd eczema (ALPHA): study protocol for a randomised controlled trial

INTRODUCTION

Hand eczema (HE) is one of the most common skin disorders and an important cause for morbidity and occupational disability. The 1-year prevalence of HE is estimated to be up to 10% and it is estimated that 5%-7% of those develop severe chronic HE. However, current clinical evidence is not compelling enough to guide clinical practice. In a survey among 194 UK dermatologists the most frequent first choice approaches were psoralen combined with ultraviolet A (UVA) treatment (PUVA), oral steroids and alitretinoin (AL). When asked which strategy was most efficient for long-term outcome 20% of clinicians indicated they did not know; 43% of clinicians reported AL and 30% reported PUVA.

METHODS AND ANALYSIS

ALPHA is a multicentre, open, prospective, two-arm parallel group, randomised controlled trial comparing PUVA and AL with a planned sample size re-estimation. Between 500 and 780 participants will be randomised on a 1:1 basis. The physician's global assessment (PGA) will direct treatment after randomisation, non-responders will be treated according to usual clinical practice; providing valuable pilot data on second line therapeutic approaches to inform future trials.Assessments will be conducted up to 52 weeks post randomisation. The primary outcome measure is the Hand Eczema Severity Index at 12 weeks. Secondary outcome measures include modified Total Lesion Symptom Score, PGA, time to relapse, patient reported outcome measures and DNA extraction and assessment of genetic variants. A substudy on molecular inflammatory mediators will provide information on subgroup specific treatment responses. Photographs will be taken and HE severity assessed by a central review panel.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Leeds West Research Ethics Committee (14/YH/1259).Trial results will be disseminated at relevant clinical conferences and societies, published in peer-reviewed journals and through relevant patient groups.

TRIAL REGISTRATION NUMBER

ISRCTN80206075.

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.

Alitretinoin for the treatment of severe chronic eczema of the hands

INTRODUCTION

Chronic hand eczema (CHE) is a frequent skin disorder affecting up to 10% of the population and strongly reduces Quality of Life (QoL). The first-line therapeutic strategies for the management of CHE include a change of lifestyle, an education program for the skin and the application of specific emollients. Topical corticosteroids or calcineurin inhibitors are the most used anti-inflammatory drugs. However, up to 65% of patients require systemic options. Alitretinoin, a retinoid structurally related to vitamin A, is the first systemic treatment approved in the European Union (EU) for severe CHE refractory to potent topical corticosteroids.

AREAS COVERED

This review summarizes the available data on the pharmacokinetics, pharmacodynamics, efficacy, and safety profile of oral alitretinoin for the treatment of CHE.

EXPERT OPINION

Alitretinoin can be considered as a valid therapeutic option for the treatment of CHE in patients not responding to ordinary treatments. Clinical trials and real-life experiences showed that it acts effectively on both objective and subjective clinical signs, resulting in a significant improvement in QoL of patients. As for other retinoids, caution should be taken in patients with certain chronic diseases (hepatopathies, kidney failure, hyperlipidemia, thyroid dysfunction) or childbearing potential women.

Diagnosis and Management of Dermatitis, Including Atopic, Contact, and Hand Eczemas

This is a comprehensive and current guide for the diagnosis, differential diagnosis, treatment, and management of eczematous dermatitis, with a focus on atopic dermatitis, irritant and allergic contact dermatitis, hand dermatitis including recurrent vesicular and hyperkeratotic types, asteatotic dermatitis, and nummular or discoid dermatitis. Diagnostic options highlighted are clinical history, physical examination, and patch testing. Therapeutic options highlighted are moisturizers, topical corticosteroids, topical calcineurin inhibitors, crisaborole, phototherapy, and systemic medications including biologics.

Contact dermatitis

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

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.

DECISA Project (DErmatology Clinics in Italy: Survey on Alitretinoin): A real-life retrospective cohort multicenter study on 438 subjects with chronic hand eczema

Alitretinoin is the only systemic agent approved to treat moderate-severe chronic hand eczema (CHE) unresponsive to potent topical corticosteroids. No nationwide Italian data regarding real-life efficacy, safety, and tolerability of treatment are available. The DECISA project (DErmatology Clinics in Italy: Survey on Alitretinoin) retrospectively examined data from a registry including 15 Dermatology Clinics authorized to prescription of alitretinoin for CHE patients. Disease severity was assessed at baseline, and after 3 and 6 months of treatment, using the 5-point Physician Global Assessment (PGA) and the modified Total Lesion-Symptoms-Severity (mTLSS) scores. Between November 2010 and July 2018, data of 248 male and 190 female patients (mean age 49.71 ± 13.20 years) treated with alitretinoin were collected. Of them, 43.2% had irritant contact dermatitis, 22.2% allergic contact dermatitis, 18.0% atopic dermatitis, 16.7% mixed (irritant/allergic) type of eczema. At 3 months, the 420 re-evaluated patients showed significantly reduced mTLSS and PGA (P < .0000001 vs baseline for both); PGA was clear/almost clear in 35.6% of cases. At 6 months, the 341 re-evaluated patients showed significant (P < .0000001) improvement of mTLSS and PGA vs baseline and 3 months (PGA clear/almost clear: 41.4%). Relapses occurred in 125 patients; 58 underwent an additional course of alitretinoin, with similarly good results. No relevant safety issues were reported; 86 patients experienced adverse effects, which forced 40 to prematurely stop treatment. The DECISA project results confirm the real-life efficacy, safety and tolerability of alitretinoin in the treatment of moderate to severe CHE refractory to standard topical therapies.

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.

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.

Management of chronic hand and foot eczema. An Australia/New Zealand Clinical narrative

Chronic hand/foot eczemas are common, but treatment is often challenging, with widespread dissatisfaction over current available options. Detailed history is important, particularly with regard to potential exposure to irritants and allergens. Patch testing should be regarded as a standard investigation. Individual treatment outcomes and targets, including systemic therapy, should be discussed early with patients, restoring function being the primary goal, with clearing the skin a secondary outcome. Each new treatment, where appropriate, should be considered additive or overlapping to any previous therapy. Management extends beyond mere pharmacological or physical treatment, and requires an encompassing approach including removal or avoidance of causative factors, behavioural changes and social support. To date, there is little evidence to guide sequences or combinations of therapies. Moderately symptomatic patients (e.g. DLQI ≥ 10) should be started on a potent/super-potent topical corticosteroid applied once or twice per day for 4 weeks, with tapering to twice weekly application. If response is inadequate, consider phototherapy, and then a 12-week trial of a retinoid (alitretinoin or acitretin). Second line systemic treatments include methotrexate, ciclosporin and azathioprine. For patients presenting with severe symptomatic disease (DLQI ≥ 15), consider predniso(lo)ne 0.5-1.0 mg/kg/day (or ciclosporin 3 - 5 mg/kg/day) for 4-6 weeks with tapering, and then treating as for moderate disease as above. In non-responders, botulinum toxin and/or iontophoresis, if associated with hyperhidrosis, may sometimes help. Some patients only respond to long-term systemic corticosteroids. The data on sequencing of newer agents, such as dupilumab or JAK inhibitors, are immature.

Hyperkeratotic hand eczema: Eczema or not?

Background

Hyperkeratotic hand eczema (HHE) is a typical clinical hand eczema subtype with a largely unknown pathophysiology.

Objective

To investigate histopathology, expression of keratins (K), epidermal barrier proteins, and adhesion molecules in HHE.

Methods

Palmar skin biopsies (lesional and perilesional) were obtained from seven HHE patients and two healthy controls. Moreover, 135 candidate genes associated with palmoplantar keratoderma were screened for mutations.

Results

Immunofluorescence staining showed a significant reduction of K9 and K14 in lesional skin. Upregulation was found for K5, K6, K16, and K17 in lesional skin compared with perilesional and healthy palmar skin. Further, upregulation of involucrin and alternating loricrin staining, both in an extracellular staining pattern, was found. Filaggrin expression was similar in lesional, perilesional, and control skin. No monogenetic mutations were found.

Conclusion

Currently, the phenotype of HHE is included in the hand eczema classification system; however, it can be argued whether this is justified. The evident expression of filaggrin and involucrin in lesional skin does not support a pathogenesis of atopic eczema. The upregulation of K6, K16, and K17 and reduction of K9 and K14 might contribute to the underlying pathogenesis. Unfortunately, comparison with hand eczema studies is not possible yet, because similar protein expression studies are lacking.

Comparative Analysis of Epidemiological Data as Well as Quality of Life in Patients having Hand Eczema vis-à-vis Foot Eczema

Context:

Eczema of hand or foot though not life-threatening, not only impacts daily activities and work productivity adversely, but also impairs interpersonal relationships.

Materials and Methods:

Cross-sectional study of 100 outpatients of hand and foot eczema at a tertiary care teaching institute. Epidemiological data was collated and quality of life (QoL) evaluated by dermatology life quality index (DLQI) score.

Results:

Forty seven had hand eczema, 45; foot eczema and 8; both. Peak incidence of hand eczema (38.2%) was in fourth decade and foot eczema (33.3%), fifth decade. Hand eczema was more frequent in females (32; 68%) and foot eczema in males (32; 71.1%). Hand eczema was more common among housewives (14; 29.7%) and foot eczema among manual labourers (26; 57.7%). A persistent course was seen in foot (44; 83%) whereas recurrent course in hand eczema (21; 38.1%). Aggravation on contact with irritants/allergens was associated more with hand (32; 58.1%) than with foot eczema (18; 33.9%). Association with atopy was not significant. Substance abuse was associated more with foot eczema (25; 47.1%). Impairment in QoL was significantly higher in hand eczema (mean DLQI, 16.33) as compared to foot eczema (12.83).

Conclusion:

Hand eczema prevalent among females showed a high rate of recurrence whereas foot eczema in males, has a persistent course. Atopy is not significantly associated. The impairment in QoL is much greater in hand eczema as compared to foot eczema. The studies on comparative analysis of hand vis-à-vis foot eczema do not appear to exist in literature whereas studies of QoL impairment on hand eczema are abound.

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.

Impact of Allergic Contact Dermatitis on the Quality of Life and Work Productivity

BACKGROUND

Allergic contact dermatitis (ACD) is a common chronic skin disease that generates considerable public-health and socioeconomic costs. This disease affects the quality of life and the occupational activity of patients.

AIMS

To assess the quality of life (QOL) of patients with ACD and study the impact of this disease on their work productivity.

METHODS

This is a cross-sectional study carried out from January 2012 to December 2014. All patients diagnosed with ACD in the Dermato-Allergology Unit of the Occupational Medicine Department at Farhat Hached University Hospital, in Sousse, were included. The impact of skin disease on the QOL of affected persons was assessed using the Dermatology Life Quality Index (DLQI). The work productivity was measured using the Work Productivity and Activity Impairment Allergic Specific questionnaire (WPAI: AS).

RESULTS

The study population consisted of 150 patients. The average score of DLQI was 6.5. Over the previous 7 days, absenteeism rate was 25.9 ± 15.3%, presenteeism rate was 50.2 ± 32%, overall work productivity loss was 29.6 ± 19.4%, and daily activity impairment was 50.4 ± 32.3%. The DLQI score was significantly associated with atopy (p = 0.03), relapses strictly greater than 10 (p = 0.02), presenteeism (p <10-3), overall work productivity loss (p = 0.01), and daily activity impairment (p = 0.03).

CONCLUSION

The impact of ACD on QOL and occupational activity seems important and requires specific attention from the occupational physician.

Efficacy and Safety of Oral Alitretinoin in Hand Eczema and Palmoplantar Pustulosis in Korean Patients

Background

Previous studies have demonstrated efficacy and safety of oral alitretinoin in hand eczema (HE) whereas in palmoplantar pustulosis (PPP), which can be difficult to distinguish from HE, efficacy of alitretinoin is still controversial.

Objective

This study aimed to investigate the efficacy and safety of oral alitretinoin in HE and PPP and factors that affect the response of these disorders to alitretinoin.

Methods

We retrospectively analyzed Korean adult patients with moderate-to-severe HE and PPP treated with oral alitretinoin, 46 patients for efficacy assessment and 55 patients for safety assessment.

Results

Among 46 patients who were treated with alitretinoin for at least 1 month, 29 patients (61.1% in HE and 40.0% in PPP) showed response to alitretinoin in the median 14 weeks after treatment. Hyperkeratotic HE showed higher response rate than either vesicular HE or PPP (p=0.026 and p=0.026, respectively). However, PPP with hyperkeratotic features showed as much response as hyperkeratotic HE (p=0.554). When responders and non-responders in total patients were compared, morphology, not diagnosis or initial severity, was the only significantly different factor between the two groups. After alitretinoin discontinuation in responders, relapse rate was 63.6% (7/11) and median time to relapse was 150 days (range, 76~730 days). Adverse events occurred in 47.3% (26/55); however, there were no serious adverse events.

Conclusion

In HE or PPP, lesions with hyperkeratotic morphology can be predicted to respond well to alitretinoin regardless of diagnosis.

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.