Hand Dermatitis: Review of

Clinical Features and Treatment Options

Spring Golden, MD, and Tatyana Shaw, MD
Nana

Hand dermatitis affects a significant portion of the population and can be caused by a
variety of endogenous factors (ie, atopy) as well as occupational and environmental
exposures. It is often a chronic problem with high costs to individuals, employers, and
society. This review discusses subtypes of hand dermatitis based on their clinical features
and pathogenesis. It also offers an approach to treatment.
Semin Cutan Med Surg 32:147-157 2013 Frontline Medical Communications
KEYWORDS hand dermatitis, chronic hand dermatitis, irritant contact dermatitis, allergic
contact dermatitis, frictional hand dermatitis, hyperkeratotic dermatitis, psoriasiform hand
dermatitis, nummular dermatitis, atopic dermatitis, vesicular dermatitis, dyshidrotic dermatitis, pompholyx

Nana

This article will review the many clinical variants of

and dermatitis is one of the most common entities enchronic hand dermatitis in hopes of helping clinicians accucountered in dermatology, affecting 2%-9% of the general population.1 The quality of life impact is significant, conrately diagnose those conditions as well as provide a treatsidering that hands play such an important role in social and
ment algorithm for their management.
occupational settings. Increased severity of hand dermatitis
correlates to decreased quality of life for many patients.2 FurApproach to Patient
thermore, hand dermatitis is often a chronic debilitating
and Diagnostic Studies
problem, which lasts on average 10 to15 years from onset.3
Treatment and management of the disease can be frustrating na2 There are many clinical variants of hand dermatitis, subtypes
and costly.
of which are listed in Table 1. Furthermore, many individuals
Nana Hand dermatitis is also the most common presentation of
will have a hybrid of those clinical entities, making an accuwork-related skin diseases. Epidemiological studies have inrate diagnosis challenging.8
dicated that about 80% of occupational related dermatoses
fiqih Hand dermatitis is a clinical diagnosis, relying on physical
affect the hands.4 Considering that many of the individuals
examination and a patients history more so than laboratory
do not seek medical care, true prevalence numbers are diffitesting. It presents with varying degrees of pruritic and occacult to obtain and might be even higher. One study found
sionally tender erythematous. The papules and plaques are at
that of the 63% of kitchen workers affected by hand eczema,
times scaly and crusty, which make them appear to be ill
5
only 35% actually contacted a physician. Wet-work envidefined and more sharply demarcated. Vesicles and bullae
ronments contribute to higher prevalence of hand dermatitis
are sometimes intermixed with plaques, but can also be the
in certain occupations, including health care workers, haironly morphologic feature present. Acute dermatitis will have
dressers, food industry employees, homemakers, and barmore erythema and a vesicular appearance versus chronic
6,7
tenders. Occupational allergen exposure can lead to the
dermatitis, which is more likely to have hyperkeratotic, lidevelopment of allergic contact hand dermatitis, a subtype of
chenified, and fissured plaques. Physical examination of the
hand dermatitis. Severe hand dermatitis has been a factor in
hands should include a careful look at the distribution of the
workers needing sick leave or switching occupations.
dermatitis (palmar, dorsal, fingers, web spaces, fingernail,
and periungual skin) as well as the extension of dermatitis to
Department of Dermatology, Oregon Health & Science University, Portland.
the wrists or forearms. Examination of the feet should be part
Disclosures: The authors have completed and submitted the ICMJE Form for
of the clinical investigation as some of the variants of hand
Disclosure of Potential Conflicts of Interest and none were reported.
dermatitis can have both hand and foot involvement. A comCorrespondence: Tatyana Shaw, MD, Department of Dermatology, Oregon
plete skin exam is necessary if there are other conditions such
Health & Science University, 3303 SW Bond Avenue, CH16D, Portland,
as psoriasis, mycosis fungoides, atopic dermatitis that are
OR 97239-4501. E-mail: shawta@ohsu.edu
1085-5629/13/$-see front matter 2013 Frontline Medical Communications
DOI: 10.12788/j.sder.0027

147

S. Golden and T. Shaw

148
Table 1 Clinical Variants of Hand Dermatitis
Type
Atopic Dermatitis
Allergic Contact Dermatitis
Irritant Contact Dermatitis

Hyperkeratotic/Psoriasiform/
Frictional Dermatitis
Nummular Dermatitis
Pompholyx/Dyshidrotic Eczema

Chronic Vesicular Dermatitis

Fiqih
Clinical Presentation

Comments

Plaques on the dorsal hands, fingers and volar wrists

with or without nail changes
Dorsal hand and fingertip involvement that may progress
up forearms
Symmetrical, often involves web spaces extending to
dorsal hands. Plaques under the rings on the fingers

Increased risk of ACD

and ICD

Well defined hyperkeratotic erythematous plaques on

palms with fissuring
Asymmetrical, coin-like lesions on dorsal hands
Intermittent and recurrent bullae on palms or
papulovesicles on sides of fingers. Bland vesicles and
bulla, no erythema
Chronic eruption of vesicles on an erythematous base

Increased risk of ACD

Most common type of
hand dermatitis

Check for tinea pedis

and treat

Abbreviations: ACD, allergic contact dermatitis; ICD, irritant contact dermatitis.

Fiqih

Fiqih

reaction is possible if the patient has tinea pedis, but a negaconsidered in the differential diagnosis. As with many dermatologic conditions, the patients history gives important
tive KOH scraping from the hand plaques. At that point,
clues (Table 2), which can include a history of atopic dermatreatment of coexisting tinea pedis becomes important in the
titis, asthma, rhinitis, psoriasis, prior patch-testing results,
management of hand dermatophytid.
occupation, hobbies, hand-washing routine, skin care prod- dewi A skin biopsy is done when diagnosis is unclear and other
ucts, other contactants, symptoms, and chronicity of the disdermatologic conditions are considered (Table 3). Histologease.
ically, all subtypes of hand dermatitis will show spongiosis
Taking a bacterial swab culture can help rule out a bactewith mixed inflammatory infiltrate. Vesicular types are more
rial skin infection. Disrupted skin barrier seen in all subtypes
likely to show bigger spongiotic vesicles within epidermis.
of hand dermatitis predisposes to staphylococcal and strepHyperkeratotic/frictional types of hand dermatitis will show
tococcal skin infections. Staphylococcus aureus is the most
psoriasiform epidermal hyperplasia. Periodic acid-Schiff
common culprit; however, cases of methicillin-resistant
(PAS) staining can identify dermatophyte infection if biopsy
Staphylococcus aureus (MRSA) have been seen as well. Pashows psoriasiform spongiotic dermatitis with subcorneal
tients with a history of atopic dermatitis are at highest risk.
neutrophils.
Rarely, the herpes simplex virus can infect eczematous skin
Patch testing is done when allergic contact dermatitis is
of the hands and cause eczema herpeticum. Getting a Tzank
suspected.
smear or a viral swab for a viral culture or polymerase chain
reaction (PCR) is helpful if clinically one sees the scatter of
sharply demarcated small crusty erosions or vesicles.
Atopic Hand Dermatitis
Skin scrapings for a potassium hydroxide (KOH) prepara- dewi
Atopic dermatitis is one of the most common chronic inflamtion or a fungal culture is recommended when feet lesions are
matory skin conditions affecting 8% to 11 % of the United
present. Tinea manus can mimic chronic hand dermatitis. Id
States population.9-11 The pathophysiology of atopic dermatitis is characterized by mutations in the filaggrin gene and a
loss of epidermal barrier function resulting in dry, scaly, inTable 2 Important Aspects of the Patients History When Investigating Hand Dermatitis
flamed, and pruritic skin. It is well known that children with
a history of atopic dermatitis are more likely to develop hand
Patient History
dermatitis as adults.12 The prevalence of hand dermatitis in
Date of onset and progression
atopics is estimated to be around 60% for all ages.13
Associated symptoms such as burning, itching, or pain
Dewi Although there are many clinical presentations of atopic
Occupation and relationship to work (do symptoms
hand dermatitis, the most common distribution is over dorsal
improve on vacation)
hands and dorsal fingers (Figure 1). In a study by Simpson et
Hobbies
al, dorsal hand and volar wrist involvement was seen in most
Skin care products
cases of atopic hand dermatitis (Figure 2). The plaques are
Chemicals, glues, paints, or other materials touching hands
usually scaly, ill-defined, pink, thin, or lichenified (Figure 3).
Hand washing regimen
Previous therapies
Papules or vesicles can be present as well. Chronic volar wrist
History of atopic diathesis (childhood or adulthood
involvement can result in permanent hypopigmentation or
eczema, hay fever, asthma)
depigmentation of the area. Nail changes such as loss of the
History of other skin diseases (ie, psoriasis)
cuticle, thickening/inflammation of the nail folds, or irregular
Family history of skin diseases and atopy
ridging can occur. In addition to pruritus, painful fissures

Hand dermatitis

149

Table 3 Chronic Hand Dermatitis Mimickers

Dewi

Condition
Psoriasis

Dermatophyte infections
Scabies
Lichen planus
Dermatomyositis
Pitaryasis rubra pilaris
Mycosis Fungoides

Differentiating Factors
Well demarcated, erythematous, scaly plaques in characteristic for psoriasis distribution
(scalp, concha, extensor surfaces, gluteal cleft, umbilicus).
Nails with pitting, oil spots, distal onycholysis.
Palmoplantar pustulosis.
One hand, two feet involvement.
Burrows and erythematous papules in web spaces and volar wrists, lateral fingers.
Sharply demarcated, violaceous, flat topped scaly, polygonal papules and plaques.
Other typical for lichen planus locations, such as oral mucosa, wrists, ankles, nails.
Erythematous to violaceous plaques over DIP, PIP, MCP joints. May have dilated
capillaries in nail folds and ragged cuticles.
Hyperkeratotic yellow diffuse keratoderma/plaques. Confluent erythematous scaly
plaques with follicular accentuation over the body. Islands of spared normal skin.
Confluent erythematous hyperkeratotic plaques over the palms and soles.

Abbreviations: DIP, distal interphalangeal joint; MCP, metacarpal phalanges joint; PIP, proximal interphalangeal joint.

within hyperkeratotic lichenified plaques cause a lot of distress in those patients. Water exposure was the most frequently cited exacerbating factor for flares of atopic hand
dermatitis.9
Dewi Individuals with atopic dermatitis are more likely to develop both allergic and irritant contact dermatitis given their
innate impaired barrier function. Therefore, it is important to
consider all 3 of these causes of hand eczema in a patient with
a history of atopy.

airin The clinical presentation of allergic contact hand dermati-

Allergic contact dermatitis is a Type IV delayed hypersensitivity response that is elicited when an allergen comes into
direct contact with the skin. Development of dermatitis is
usually delayed by a few days from the time of allergen exposure. This is in contrast to a Type I immediate hypersensitivity reaction, which is seen in urticaria where contact with
an allergen results in hives within minutes to hours of exposure.

tis can include itching, stinging, burning, and pain. Patients

may also develop vesicles, bullae, erythematous papules,
weeping, and crusting. Fingertips, nail folds, and dorsal
hands are most commonly involved. However, any part of
the hand can be affected. Clinicians should be suspicious of
an allergic contact dermatitis if there is a change in the patients chronic pattern of dermatitis and if there is spread
from the patients palms to either the dorsal hands or forearms.
Often, irritant contact dermatitis predates development of
allergic contact dermatitis. Frequent water exposure helps
sensitization to contact allergens. In occupations where wetwork is combined with exposure to such allergens, allergic
contact dermatitis is more common. For instance, one study
of hand dermatitis in hairdressers in Bangkok reported relevant positive patch-test reactions in 75% of those cases. Reactions to paraphenylenediamine, nickel, and fragrance mix
were the most frequent causative allergens among those hairdressers.14 Similarly, in health care workers, frequent handwashing and preceding irritant contact hand dermatitis are

Figure 1 Atopic hand dermatitis with dorsal hand and periungual

disease distribution. Courtesy of Eric Simpson, MD.

Figure 2 Atopic hand dermatitis with volar wrist involvement. Courtesy of Eric Simpson, MD.

airin Contact Hand Dermatitis

Airin

Allergic Contact Dermatitis

airin
Foto
dicopas
ya

S. Golden and T. Shaw

150

Table 4 Allergens that Frequently Cause Allergic Contact

Hand Dermatitis*
namira
Allergens
Rubber Allergens
Thiuram
Carba Mix
Fragrances
Fragrance Mix
Balsam of Peru

Figure 3 Atopic hand dermatitis in an infant with dorsal hand involvement and nummular plaques on the ankles. Courtesy of Eric
Simpson, MD.

risk factors for the development of allergic contact dermatitis

to gloves (Figure 4). Any type of hand dermatitis or history of
atopy can be a risk factor for acquiring allergen sensitization.15-18
Airin The most common allergens causing allergic contact hand
dermatitis (Table 4 and Figure 5) are nickel (hand tools,
jewelry), rubber accelerators (gloves), neomycin (topical antibiotics), chromate (leather), and preservatives (skin care
products).15,19,20
Diagnosis of an allergic contact dermatitis is aided by patch
testing. Detailed exposure history from work, home, and
hobby environments gives important clues and guides the
selection of appropriate patch tests. Patch tests are applied to
the patients back for 48 hours under occlusion. The patch
tests are then read at 48 hours and at 5-7 days. A positive
reaction is attained when there is a fixed area of erythema that
is either blistered or elevated. Patients can also do a Repeat
Open Application Test (ROAT) to their own products by
applying them twice daily on the inner forearm for up to a

Figure 4 Allergic contact hand dermatitis in a typical glove allergen

distribution. Courtesy of Patricia Norris, MD.

Preservatives
Methylchloroisothiazolinone
Methylisothiazolinone
Quaternium-15
Formaldehyde and releasers
Antibiotics
Neomycin sulfate
Bacitracin
Metal
Nickel
Potassium dichromate

Source
Gloves
Occupation: healthcare,
hairdressers
Skin care products,
cosmetics, hair
products
Skin care products,
cosmetics, lubricants,
household products

Topical antibiotics

Costume jewelry, keys,

coins, buttons, tools
Tanned leather gloves

*These allergens are a sampling of common allergens found to

cause allergic contact hand dermatitis and by no means an exhaustive list of contact dermatitis allergens.

week to see if a response is elicited. A diagnosis of allergic

contact dermatitis is made when a patient has a positive
patch-test reaction and a relevant exposure to the allergen in
question.

Irritant Contact Dermatitis namira

Irritant contact dermatitis is one of the most common variants of hand dermatitis comprising approximately 80% of all
contact hand dermatitis.15 Irritant contact hand dermatitis is
caused by repetitive exposure to mechanical and chemical
irritants such as water, soap, solvents, oils, friction, and
trauma. Irritants can cause the release of inflammatory cytokines, decrease in surface lipids, and denature epidermal keratinocytes, all of which lead to decreased barrier function and
a decrease in epidermal water content.15,16,21
The most common cause of irritant hand dermatitis is
hand washing where the wet-to-dry cycle disrupts the epidermal barrier. Irritant contact dermatitis usually appears
within 3 months of the first exposure to wet work. Those
individuals with an already compromised epidermal barrier,
such as those with atopic dermatitis, are more susceptible to
irritant hand dermatitis.15,22 Furthermore, irritant contact
hand dermatitis may lead to the development of an allergic
contact dermatitis. The disruption of the epidermal barrier
leads to enhanced susceptibility for allergen sensitization, as
discussed in the previous section.
Clinically, irritant contact dermatitis presents with xerosis,
scaly erythematous plaques, fissuring, and lichenification. It
commonly involves web spaces and can extend to the dorsal
and ventral surface of the hand and fingers (Figure 6). Vesicles do not typically form. Pruritus can be mild; however,

Hand dermatitis

151

Figure 6 Irritant contact hand dermatitis in a hospital worker. Web

spaces are often involved when wet-work is an exacerbating factor.
Courtesy of Susan Tofte, NP.

reyhan : tolong smua foto dan keterangan

dicopas dan translate

Figure 5 Allergic contact dermatitis to surgical gloves. (A) Lichenified

plaques over the radial portion of the dorsal hand near the thumb is a
very typical distribution for allergic contact dermatitis to gloves. (B)
Patch-testing results. Relevant positive patch tests to rubber accelerators (thiuram and carba mix) and 2 types of surgical gloves used by the
patient at work. Both sets of gloves contained rubber products.

stinging, burning and pain are frequently reported symptoms.

namira Both irritant and allergic contact dermatitis have a predilection for certain occupations. They are found to be more
common in hospital workers, construction laborers, food industry workers, janitorial workers, machinists/mechanics,
and beauticians (Figure 7).

reyhan Hyperkeratotic Hand Dermatitis

Hyperkeratotic or psoriasiform hand dermatitis comprises
approximately 2% of hand dermatitis.17 The cause of this
dermatitis is unknown; however, patients will often have a

Figure 7 (A, B) Irritant contact hand dermatitis in a barista. Only the

patients right thumb was repetitively exposed to water as she made
coffee drinks at work. Courtesy of Susan Tofte, NP.

S. Golden and T. Shaw

152

Figure 9 Frictional hand dermatitis. Courtesy of Eric Simpson, MD.

Figure 8 Psoriasis mimicking hyperkeratotic hand dermatitis. Courtesy of Patricia Norris, MD.

history of manual labor. It is more common in men 40-60

years of age.
reyhan This hand dermatitis is defined as symmetric hyperkeratosis of the palms that is well demarcated without involvement
of the wrists. Cracking and fissuring of the palms often causes
pain. This form of dermatitis also lacks vesicles. Itching can
be minimal. In some cases, there may be foot involvement.
Sometimes it is difficult to differentiate it from psoriasis (Figure 8). Absence of other clinical features of psoriasis or psoriatic arthritis is a helpful distinguishing factor.
Histologically one will see hyperkeratosis, parakeratosis,
acanthosis, and some spongiosis, which is otherwise known
as psoriasiform dermatitis. The course of this hand dermatitis
tends to be chronic and often resistant to treatment.

Frictional Hand Dermatitis reyhan

Frictional hand dermatitis is caused by the wear and tear of
repetitive mechanical forces. These mechanical forces include friction, pressure, trauma, and vibration. This dermatitis may take years to develop depending on the extent and
duration of those mechanical insults on the hands. Repetitive
friction causes hyperkeratotic plaques and occasionally
bullous lesions if the related force is of high enough intensity.
This type of hand dermatitis is not pruritic or vesicular.
Work-related frictional hand dermatitis has been reported by
those who handle money, carbonate copy paper, bus tickets,
artificial fur, panty hoses, carpeting material, and computer
mice.23,24 There is overlap between frictional hand dermatitis
and hyperkeratotic/psoriasiform dermatitis. In fact, they may
be the same entity (Figure 9).

Plaques are often asymmetric and can reoccur in different

places on the hand. Patients may also have nummular
plaques elsewhere on the body.

Vesicular Hand
Dermatitis and Dyshidrotic nisa
Hand Dermatitis/Pompholyx
Pompholyx (acute dyshidrotic hand dermatitis) has intermittent and episodic recurrences of vesicles and bullae that typically last 2 to 3 weeks before resolving (Figure 11). Between
episodes, patients have normal appearing skin. Sometimes
pompholyx presents with large tender bulla without surrounding erythema on the palms. More frequently, collections of very itchy small papulovesicles on the sides of the
fingers are seen (Figure 12). Secondary bacterial infections
can occur. Dermatophyte infection and an id reaction to a
dermatophyte elsewhere on the skin can present similarly.
Therefore, it is important to check the patients feet and do
potassium chloride scrapings to rule out a fungal infection.
Some studies have suggested that a nickel allergy may be
associated with pompholyx. In these studies, patients who
were allergic to nickel ingested nickel orally and had reacti-

reyhanNummular Hand Dermatitis

Nummular hand dermatitis does not have any specific age or
gender demographics. It is characterized by papules, vesicles,
and coined shaped eczematous plaques, which appear more
frequently on the dorsal hands and distal fingers (Figure 10).

Figure 10 Nummular hand dermatitis.

Hand dermatitis

Figure 11 Acute dyshidrotic hand dermatitis. Courtesy of Patricia

Norris, MD. nisa

nisa

nisa

vation of their dermatitis. However, the quantities of nickel

ingested in these studies were much higher than their typical
dietary value. Other studies have not found a relationship
with the ingestion of nickel causing worsening hand findings.17
Chronic vesicular hand dermatitis is a distinct clinical entity from pompholyx as it often lacks the episodic timing and
presents with more erythematous appearing vesicles. We see
the chronic appearance of pruritic vesicles on the palms
and/or on the fingertips. In some patients feet are also involved.

Treatment
nisa Basic Principles: Good Hand Care
The treatment of all subtypes of hand dermatitis is similar. All
treatment starts with attempts to restore skin barrier function
and avoidance of exacerbating factors. A recent trial of hospital workers with hand eczema showed improvement in the
patients dermatitis when education and counseling about
proper skin care was provided.25 Skin care products in the
form of thick creams, ointments, or petrolatum products are
important in helping to restore the skins protective barrier.26
Frequent reapplication, especially after hand washing, is key.
Avoidance of common irritants and skin care products with
an alcohol or water base helps to avoid further water evaporation and drying of the hands. Creams should also be fragrance-free and contain as few preservatives as possible to
avoid allergens that may result in an allergic contact dermatitis. It is also very important to cut down on wet work,
especially in occupations involving repetitive wet-to-dry cycles. Some of the hand sanitizers on the market are less irritating than the typical hand washing routine. Protective
clothing and changing work flow/environment can help to
avoid contact with allergens and irritants. Thin cotton gloves
under occlusive gloves are recommended. However, some
allergens can pass through the gloves. For instance, acrylate
monomers, which are used in dentistry, penetrate rubber
(latex and neoprene) and vinyl gloves.

153
studies are lacking, open-label studies have shown a benefit
with topical steroids. In an open-label study done by Veien et
al, mometasone fumarate was used freely by participants for
up to 9 weeks and 75% of the patients were found to be clear
by 6 weeks. In a follow-up study, individuals were randomized to use either mometasone 2 days per week, 3 days per
week, or use emollients alone freely. Individuals in both steroid treatment arms showed a longer recurrence-free rate,
83% in the 3 times per week group, and 67% in the twice
weekly group using steroids. Only 26% of the individuals
using only an emollient benefited.27 The American Academy
of Dermatology recommends that potent topical steroids be
used on the hands twice daily for up to a month and then
tapered down to 2 to 3 times per week for maintenance.28
Occlusion of the topical steroid with cotton gloves aides in
intensifying the therapeutic effect. Ointment vehicles of topical therapy are preferred over cream-based formulations as
they contain less water and preservatives.
If long-term topical treatment is needed, then calcineurin
inhibitors such as tacrolimus or pimecrolimus can be used
daily for maintenance therapy. Unlike topical steroids, these
therapies do not cause skin atrophy or telangietasias. Pimecrolimus was studied in 2 large randomized controlled clinical trials and found to be more efficacious in treating hand
dermatitis when used twice daily with overnight occlusion
compared to using just a vehicle cream alone.29 Similarly,
smaller studies have shown twice daily application of tacrolimus to be more beneficial than vehicle cream alone in both
clinical improvement and patient subjective views of improvement.30,31

Light and Radiation Therapy khrisma

Phototherapy is a second-line treatment for chronic hand
dermatitis. Both psoralen in conjunction with ultraviolet A
(PUVA) and ultraviolet B (UVB) light therapy have been studied. In a study done by Rosen et al, treatment with PUVA was
compared to UVB in 2 separate study groups and within the
same patient by applying each therapy to different hands.

khrisma Topical Therapy

A potent topical steroid is the initial prescribed treatment of
choice for hand dermatitis. Although randomized clinical

Figure 12 Small vesicles on the lateral aspects of fingers is typically

seen in dyshidrotic hand dermatitis. Courtesy of Eric Simpson, MD.

154

S. Golden and T. Shaw

matitis patients may show great benefit from starting this

Both forms of phototherapy were effective in improving the
medication. One double-blinded randomized trial of 41 pahand dermatitis; however PUVA treatment was found to be
tients showed that 50% of individuals given oral cyclosporine
more effective.32 Other studies have shown equal efficacy.33 If
at a dose of 3 mg/kg/day improved compared to 32% of
there is inadequate response when considering irritant effects
individuals given topical corticosteroids after 6 weeks.40 Anwith PUVA-soak therapy or side effects of oral psoralen inother trial of 41 patients after 1 year on oral cyclosporine (3
take, our recommendation is to start with narrow band UVB
mg/kg/day) showed between a 50%-79% improvement deand progress to PUVA.
pending on the type of hand dermatitis.41 In severe cases,
khrisma Grenz ray is a type of superficial ionizing radiation that has
cyclosporine doses of 5 mg/kg/day for 3 months can be helpbeen used to treat hand dermatitis. A double-blind study by
ful in halting a significant flare while allowing the patient to
Fairris et al showed that using superficial x-ray radiotherapy
bridge to a different long-term therapy. However, cyclosporin conjunction with topical steroids was more effective in
ine is not a good long-term medication due to its side effects
treating hand dermatitis compared to topical therapy alone.34
of nephrotoxicity, hepatotoxicity, and hypertension. CycloGrenz ray has also been reported to be beneficial in recalcisporine can be used to induce clearance or improvement of a
trant frictional hand dermatitis.35 Treatment using Grenz ray
patients hand dermatitis as the patient transitions to a more
typically involves 6 treatments of 200 to 400 rads spaced
long-term therapy.
every 1 to 3 weeks. This is followed by a 6-month break in
treatment. Grenz ray is a safe therapeutic option as the rays shankar Mycophenolate mofetil, azatihoprine, and methotrexate
are immunomodulating medications that have been used for
are almost entirely absorbed in the upper 3 mm of the derchronic hand dermatitis. Mycophenolate mofetil inhibits the
mis.36 However, it is recommended that individuals not exsynthesis of guanosine nucleotides needed for lymphocyte
ceed more than 5,000 rads in a lifetime.
proliferation. There are a few case reports of individuals with
dyshidrotic eczema having clearing with mycophenolate
Systemic Therapy shankar
mofetil therapy. One patient with a 4-year history of recalciFor acute or recurrent vesicular hand dermatitis, systemic
trant disease that was previously treated with corticosteroids,
glucocorticoids can be helpful if started at the onset of sympiontophoresis, and phototherapy was placed on 3 g/day of
toms and only used for up to 3 to 5 days.17 For some patients,
mycophenolate mofetil and had complete clearance of his
it is the only way they are able to halt a pompholyx flare
disease within 4 weeks. The dose was then reduced gradually
quickly. Allergic contact dermatitis and atopic hand dermaover a 1-year period without recurrence of dermatitis. Typititis may also benefit from systemic steroids if the dermatitis
cal doses of mycophenolate mofetil are between 2 to 3 grams
is severe. However, systemic glucocorticoids should not be
per day.42,43 Methotrexate is another medication that can be
used for long-term treatment of any form of hand dermatitis
used for hand dermatitis and works by inhibiting dihydrofodue to the many long-term side effects. Among the effects are
late reductase, which is an enzyme important in cell prolifercataracts, glaucoma, hyperglycemia, osteoporosis, and supation. In one study, low-dose methotrexate (12.5 to 22.5 mg
pression of the hypothalamic-pituitary-adrenal access.
per week) was given to 5 patients with recalcitrant pompholyx and all patients showed partial or complete remission of
shankarOral retinoids have been studied and proven to be efficacious in controlling hand dermatitis, especially the hyperkertheir disease while on methotrexate.44 Azathioprine, which
atotic/psoriasiform or frictional variants. Both alitretinoin
works by inhibiting ribonucleic and deoxyribonucleic acid
and acitretin improved chronic hand eczema. However, alitsynthesis, has been reported to help atopic dermatitis, allerretinoin is only approved for hand eczema in Europe and
gic contact dermatitis, and pompholyx. Participants in these
Canada. In one study, 40% of patients taking 30 mg of alitstudies were given daily doses between 100 mg and 150 mg
retinoin daily were clear and 24% of patients taking 10 mg
daily. The effects were seen typically between the 4th and 6th
37,38
Retinoids are a great third-line treatment for
were clear.
week of treatment.45 With all of these immunomodulating
chronic hand dermatitis given their good safety profile and
medications, frequent lab draws are necessary to evaluate for
less frequent lab monitoring compared to immunomodulathepatotoxicity, nephrotoxicity, and bone marrow suppresing medications. The main side effects of retinoids include
sion.
xerosis, increase in lipid levels, and teratogenicity. Therefore shankar Literature on the use of antitumor necrosis factor-
individuals of child-bearing age need to be carefully monitreatments is lacking. Given their anti-inflammatory potored with pregnancy tests and counseled about the side eftential and beneficial use in conditions such as psoriasis,
fects. Acitretin is not recommended for women of child-bearBechets disease, and pyoderma gangrenosum, the existing
ing age as currently there is a recommendation to avoid
literature may have some efficacy in treating hand dermapregnancy for 3 years after discontinuation of acitretin thertitis. There is one case study of a patient with a 6-year
apy.
history of recalcitrant pompholyx who was treated with
shankar Oral immunomodulating medications have also been tried
etanercept. She was placed on twice weekly 25 mg etanin the treatment of hand dermatitis. They are considered
ercept subcutaneous injections and, after 4 months, had
when topical therapy or phototherapy fails. Support for the
reached remission. However, she suffered a flare and her
use of immunomodulating drugs comes primarily from studdose was doubled to 50 mg twice weekly. Unfortunately,
ies in atopic dermatitis.39 Cyclosporine is one medication
this increase in dosage did not benefit her and treatment
known to suppress T-lymphocytes. In particular, atopic derwith etanercept was discontinued.46 More studies are

Hand dermatitis

jiwo

155

Table 5 Treatment Options

Medication
Topical steroids

Dosing

Lab Monitoring

Twice daily for 1 month

then decrease to 2-3
times per week
Twice daily

None

Two to three times

weekly slowly
increasing treatment
each visit
Six treatments of 200-400
rad every 1-3 weeks,
max lifetime dose 500010,000 rads
20-60 mg per day for 3-4
days

None

Oral retinoids (Acitretin

and Alitretinoin)

Acitretin 10-50 mg per

day
Alitretinoin 10-30 mg
per day

Cyclosporine

3 mg/kg/day

Pregnancy test, CBC, LFTs,

renal function, fasting
lipid panel monthly for 3-6
months then every 3
months
Blood pressure, CBC, renal
function, LFTs, Mg, K,
Uric acid, fasting lipids at
baseline, every 2 weeks
for 1-2 months and then
monthly

Mycophenolate mofetil

2 to 3 grams per day

Methotrexate

12.5 to 22.5 mg per week

with daily folic acid
supplementation

Azathioprine

50-150 mg per day

Topical calcineurin
inhibitors
PUVA or narrow band
UVB

Grenz ray

Oral prednisone

None

Side Effects
Atrophy,
telangiectasias,
acne/rosacea, striae
Skin malignancies,
lymphoma
Skin malignancies,
headaches, nausea

None

Skin malignancies

Consider checking glucose

levels especially in
diabetic patients,
long-term use will need
bone density evaluations

Cataracts, glaucoma,
hyperglycemia,
osteoporosis, and
suppression of the
hypothalamicpituitary-adrenal
access
Xerosis, increase in
lipid levels,
hepatotoxicity, and
teratogenicity

Pregnancy test, CBC, CMP,

Hepatitis B and Hepatitis
C, PPD at baseline, then
CBC and CMP every 2-4
weeks during dose
escalation and then every
3 months when dose
stable*
CBC, CMP, urinalysis at
baseline, 1-2 weeks after
initiation, then monthly for
1-2 months then every 3
months
Thiopurine
methyltransferase at
baseline, CBC, CMP,
pregnancy test, urinalysis,
and PPD at baseline,
every 2 weeks for 2
months then every 3
months

Hyperlipidemia,
hypertension,
hepatotoxicity,
nephrotoxicity,
hyperkalemia,
hyperuricemia,
hypomagnesemia
GI symptoms,
opportunistic
infections, bone
marrow suppression

Hepatotoxicity, bone
marrow suppression,
pulmonary fibrosis/
pneumonitis,
carcinogenesis, oral
ulcers, GI upset
GI upset, bone marrow
suppression,
hepatotoxicity,
increased risk of
infections,
carcinogenicity

*Mycophenolate mofetil prescription now requires registration with the Mycophenolate REMS. Physicians are required to educate patients
about the teratogenicity of the medication. Reproductive age females must have a pregnancy test before initiating the drug, 8-10 days after the
initial pregnancy test and monthly while on the drug. Patients must also use contraception while taking mycophenolate and for 6 weeks after
discontinuation of the drug. All pregnancies during treatment must be reported to the Mycophenolate Pregnancy Registry.
Abbreviations: CBC, complete blood count; CMP, comprehensive metabolic panel; GI, gastrointestinal; K, potassium; LFT, liver function tests;
Mg, magnesium; PPD, purified protein derivative tuberculin test; PUVA, psoralen ultraviolet A; UVB, ultraviolet B.

S. Golden and T. Shaw

156

jiwo

therefore needed to assess whether treatment with antitumor necrosis factor- medications would be helpful.
Finally, patients with hand dermatitis should also be assessed for bacterial infections and, if present, should be
treated with either systemic or topical antibiotics.
Treatment options, dosing, monitoring and side effects are
listed in Table 5.47

Conclusion

jiwo

Chronic hand dermatitis is commonly encountered in the

practice of dermatology. Numerous types of chronic hand
dermatitis exist, including atopic dermatitis, allergic contact
dermatitis, irritant contact dermatitis, hyperkeratotic/psoriasiform dermatitis, frictional dermatitis, chronic vesicular
dermatitis, and dyshidrotic dermatitis/pompholyx. Hand
dermatitis is often a combination of these entities and therefore may prove to be a diagnostic challenge. This paper highlights the clinical distinctions between the various forms of
hand dermatitis to help clinicians establish accurate diagnoses and differentiate hand dermatitis from other primary dermatology conditions. Treatment of hand dermatitis starts
with helping to repair the skin barrier with proper hand-care
hygiene. Avoiding wet and dry cycles as well as moisturizing
is of utmost importance. First-line prescription therapy involves using potent topical steroids and often a topical calcineurin inhibitor as maintenance therapy. Light therapy,
either PUVA or narrow band UVB, and Grenz ray therapy are
considerations for hand dermatitis that failed topical treatment. Finally, oral retinoids or immunomodulating medications can be used as they are helpful in many inflammatory
skin disorders. Physicians must work together with patients
to find a treatment option that best suits the patient as studies
have shown that chronic hand dermatitis can negatively impact ones quality of life.

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