Hand (arm) eczema (hand dermatitis) is a common inflammatory skin disease affecting the hands. The disease is considered chronic if it lasts more than 3 months or recurs more than 2 times a year. The main signs of hand eczema are redness, thickening, scaling, blistering, cracks and erosions.
Hand eczema is the most common occupational skin disease. It is most common in people working in healthcare, the food industry and hairdressers. The disease has negative consequences not only for health, but also for the economy, often requiring lengthy treatment or even a change of occupation. Very severe hand eczema has a negative impact on the patient’s psychological state and general well-being.
According to studies, it affects almost 4% of the general population and the probability of experiencing an episode of hand eczema at least once in a lifetime is as high as 15%.
Causes of hand eczema
The interaction between environmental and genetic factors has a major impact on the development of the disease. It has been found that individuals with a mutation in the filaggrin gene (a protein encoded by this gene that is important for maintaining epidermal integrity) are more prone to develop hand eczema. In addition, the mutation is a risk factor for increased dry skin, ichthyosis and atopic dermatitis.
Working in a humid environment is another risk factor for hand eczema. Exposure to water for more than 3 hours (per day) already promotes certain changes in skin physiology and increases the risk of skin irritation. Other irritants include detergents, fragrances and preservatives in cosmetic products. Contact with fresh fruit, spices, plants, wood, dust, glass wool, etc., also cause skin irritation.
In addition, hand eczema is sometimes a manifestation of allergic contact dermatitis. Allergic contact dermatitis is a skin disorder that results from delayed-type hypersensitivity reactions. As many as 40-60% of patients with hand eczema also develop allergic contact dermatitis.
Signs of hand eczema
In the acute phase, hand eczema is characterised by reddening and swelling of the skin, with small vesicles that break and become wet.
As the disease becomes subacute or chronic, scaling, thickening of the skin and painful fissures develop.
Both hands, palms and dorsal surfaces, are affected. When hand eczema persists for several years, the nails are also affected, with thickening of the nail rollers and striations on the nail plate. Patients often complain of itching, burning and stinging.
Clinical variants of hand eczema:
- Chronic hand eczema with skin fissures
- Recurrent hand eczema with vesicles
- Pulpitis (inflammation of the fingertips)
- Hand eczema with predominantly squamous skin
- Monitic hand eczema
- Eczema of the interdigital surfaces of the hand
The morphology of the skin lesion can sometimes suggest the main culprit of the disease:
- If hand eczema is caused by exposure to irritants, it usually affects the palms or dorsal surfaces of the hands.
- Allergic contact dermatitis affects the dorsal surfaces of the hands, fingers and wrists.
- Chronic atopic eczema affects the hands, fingers and sides of fingers. Characteristic signs include reddening, scaling, cracking, nail dystrophy.
- Dyshidrotic eczema is characterised by a sudden, very itchy rash with blisters on the palms and/or soles of the hands. Frequent exacerbations of the disease lead to a chronic course characterised by a rash of red, thickened plaques and developing fissures.
Diagnosis of eczema of the hands (arms)
Diagnosis is based on examination by a doctor and skin patch tests. It is important to find out the patient’s occupation, hobbies, possible allergies, contact with irritating or allergenic substances and the protective equipment used. In addition, the health of family members is also taken into account – whether they have bronchial asthma, hay fever, etc.
A skin patch test is carried out if an allergic origin of hand eczema is suspected. The most common allergens identified in hand eczema are preservatives, fragrances, metals (e.g. nickel, cobalt), rubber.
Classification of hand eczema
Before prescribing treatment, it is important not only to clarify the origin of the disease, but also to determine the severity of the disease, its impact on general quality of life and daily activities. According to the PGA scale, the following grades of severity of hand eczema are distinguished:
Mild hand eczema. It is characterised by at least 2 of the following signs of skin damage: redness, scaling, scabbing, thickening, blistering, swelling, cracking, itching, pain. However, rashes cover <10% of the surface area of the skin on the hands. – Moderate hand eczema. The same lesions as in mild hand eczema, but the lesions are more widespread and cover 10-30% of the skin surface of the hand. – Severe hand eczema is diagnosed when > 30% of the hand skin is affected.
It is important to distinguish hand eczema from psoriasis and fungal infections. Although the symptoms of all these diseases appear similar at first sight, their diagnosis, and even more so their treatment methods, are different. It is therefore not recommended to self-treat, but rather to consult a dermatologist for immediate treatment.
Treatment of the hands (arms)
Patient education
One of the most important links in the treatment of hand eczema is to educate patients about the possible causes of the disease and how to avoid them. For example, if an allergic cause is identified, the patient is told what the substance is, where it is found and how to avoid it. Other disease provoking factors are also explained, as well as proper care of the skin on the hands.
Avoidance of allergens and irritants
The most common substances that acute hand eczema are water and working in damp environments, cleaning agents, solvents, oxidising agents, acids and alkalis. Among physical agents, metal tools, wood, glass wool, paper, dust and soil are important. Allergens are also often found in soaps, food, industrial solvents and oils, cement, gloves and cosmetics.
It is advisable to avoid aggressive detergents and to develop good hand-care habits. Hands should be washed in lukewarm water using a mild, fragrance-free soap. It is particularly important to dry between the forearms. After washing, hands should be immediately moisturised with a moisturising cream. It is recommended to avoid too frequent hand washing as this slows down the healing of hand eczema. If the hands are not visually soiled, an alternative is to use a hand sanitiser (to minimise contact with water and soap).
Skin protection
Gloves. Vinyl or latex-free gloves can be used for many household tasks: cooking, gardening, cleaning the house. This helps to avoid direct skin contact with food, soil and chemicals, which can exacerbate hand eczema or slow the healing of existing rashes. However, vinyl gloves are preferable because they contain fewer allergenic substances. If the gloves are worn for > 10 minutes, it is recommended to wear a thin cotton glove underneath to act as an absorbent layer, i.e. to soak up perspiration and thus prevent further irritation.
Some materials used at work can easily penetrate even gloves, e.g. acrylates used in dentistry can easily penetrate rubber and vinyl gloves. Therefore, if the patient is allergic to acrylates, special protective gloves must be fitted. It is also important that the gloves are of the correct size, dry inside and free from defects.
Moisturising creams also play a very important role in the treatment of hand eczema. In normal skin, the protective barrier is the stratum corneum of the epidermis, which is composed of cells with a high protein content and intercellular lipids. Moisturising creams maintain this protective layer thanks to humectants and emollients such as glycerol, urea, etc. The main task of humectants is to attract water and retain it in the stratum corneum. Emollients soften dry, flaky skin and prevent further water loss.
Barrier creams mimic intracellular lipids, which consist of ceramides, free fatty acids and cholesterol. Research has shown that the proper use of barrier creams prolongs the intervals between episodes of hand eczema exacerbations. These creams should be applied to the affected areas at least 2 times a day. They protect the epidermis from irritants.
For mild to moderate hand eczema, corticosteroid ointments are prescribed, usually 1 to 2 times a day. The duration of treatment is limited to 4 weeks. Parallel emollients are administered with unlimited application frequency.
In severe or frequently recurring hand eczema, when corticosteroid ointments are ineffective, oral corticosteroids, retinoids or phototherapy are prescribed.
Secondary bacterial infections (usually caused by golden staphylococcus aureus) are treated with oral antibiotics.
Phototherapy, PUVA therapy is recommended in cases where patients are not eligible for systemic treatment or do not wish to take oral medication. PUVA is administered 2 to 3 times a week, with a recommended course of treatment of about 12 weeks.
Hand eczema is a chronic inflammatory skin disease with a wavy appearance. Often several different treatments are needed to control the exacerbation. Good hand skin care skills are also essential for good results. If you are bothered by hand rashes, do not delay and consult a dermatologist.
