Hand eczema

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Classification according to ICD-10
L20 Atopic (endogenous) eczema
L23 Allergic contact dermatitis
L24 Toxic contact dermatitis
L25 Unspecified contact dermatitis
L30 Other dermatitis
ICD-10 online (WHO version 2019)

In medicine, inflammation of the skin on the hands that is not contagious is called hand eczema . This skin disease is widespread (see epidemiology) and problematic for those affected, as it can be associated with visible skin disease symptoms , severe itching or pain and associated with high levels of suffering ( see symptoms and complaints ). Depending on the course, appearance of the skin disease symptoms , severity or trigger factors ( see causes and disease types), various clinical pictures can be distinguished. The individual course of the disease in the individual case of chronic hand eczema cannot be foreseen and usually varies from patient to patient. With an appropriate search for the cause and diagnostics ( see diagnostics and meaningful examinations, differential diagnoses ), sustainable skin protection measures and early, comprehensive treatment, including internal treatment where indicated ( see treatment ), a favorable course can be expected.

Epidemiology

Hand eczema is common and widespread: study data show a one-year prevalence of up to 10% in the general population. It is believed that only 50–70% of those affected see a doctor. The frequency of hard running, chronic and recurrent disease -prone hand forms of eczema is estimated at 5-7%. About 2–4% of hand eczema patients also do not respond sufficiently to external (topical) therapy. As the most common occupational skin disease, chronic hand eczema often leads to endangerment or loss of the job due to persistent inability to work. An early onset of the disease before the age of 20, the severity of the initial manifestation and eczema in childhood seem to be related to a somewhat less favorable long-term prognosis. Women, especially in the age group up to 30 years, are more often affected than men.

Symptoms and ailments

As a rule, the skin inflammation in hand eczema is accompanied by the formation of blisters and pronounced itching, but massive cornification and painful tears can also occur. The quality of life of those affected is severely impaired , especially in severe and chronic forms, and the personal level of suffering is often very high. This is reinforced not least by the fact that the symptoms of skin diseases on the hands, which are visible to all fellow human beings, can lead to feelings of shame and fear of exclusion.

Causes and Types of Diseases

In principle, there are various possible causes for the development of skin inflammation on the hands. An interplay of several factors seems to be significant: environmental influences such as excessive contact with water, allergies or irritants and a genetic predisposition, for example in the sense of atopy or a genetic barrier damage to the skin, are significantly involved. It is rare that only a single trigger factor is responsible for the development of hand eczema in a patient.

Differentiation according to trigger factors

Three main groups of causes play a fundamental role in the development of chronic hand eczema: excessive contact with water and irritants (cumulative toxic exposure), contact allergies and atopic diathesis , which reflects a genetic readiness to react. Depending on the primary triggering factors, individual types of hand eczema can be differentiated and named: cumulative-toxic, contact-allergic or atopic hand eczema. Activities that are harmful to the skin and involve repeated, excessive contact with water or skin-irritating substances at work, housework and leisure (wet work) can damage the skin's protective function and thus promote the development of inflammation . This also applies to wearing protective gloves made of rubber and similar materials for a long time, because you sweat a lot underneath and thus a moist environment is maintained. By disrupting the skin's own protective barrier, the penetration of allergy-causing substances is also facilitated and the development of contact allergies is promoted. Contact allergies play a very important role in the development of hand eczema. If there is repeated contact with an active substance to which there is an allergy, the skin reacts with signs of inflammation. In many of those affected, the skin inflammation also affects the feet. It is not uncommon for a contact allergy to a component of the shoe leather processing to be found as the trigger. Contact allergies are particularly relevant and problematic in certain occupational groups in which allergy-causing substances are often handled, such as bricklayers or hairdressers. Severe and chronic hand eczema is considered the most common occupational skin disease . In this case, professional dermatological advice must be given by the dermatologist at an early stage. Hand eczema is particularly common in patients with a history of neurodermatitis , hay fever or allergic asthma. These diseases reflect the individual willingness to react or the genetic predisposition of the individual to be overly sensitive to a wide range of environmental influences. This is described using the terms atopy or atopic diathesis . Atopic diathesis is not infrequently associated with a genetic disruption of the skin's protective barrier, which weakens the resistance to skin-irritating substances and moisture and, through the easier penetration of allergy substances, can also promote the development of contact allergies.

Differentiation according to the predominant skin disease symptoms (Morphe)

Hyperkeratotic-rhagadiform hand eczema
Dyshidrotic hand eczema
Fingertip eczema

In terms of clinical appearance, various hand eczema subtypes can be distinguished according to the appearance of the main skin disease symptoms. One speaks of dyshidrotic hand eczema when the focus is on the formation of mostly itchy blisters, while cornification and cracks make up hyperkeratotic-rhagadiform hand eczema.

Differentiation according to severity and course

Regardless of the underlying cause or the predominant skin disease symptoms, it is important for the selection and planning of treatment options to differentiate between the various types of disease, also according to their severity and disease course. While mild hand eczema heals quickly with appropriate skin specialist therapy and the cooperation of the patient, moderate degrees of severity persist for several weeks under the same conditions. Severe hand eczema is accompanied by persistent or persistently recurring, widespread and, moreover, severely debilitating skin disease symptoms for those affected. Hand eczema is to be assessed as chronic if it lasts for at least 3 months in spite of dermatological treatment measures or if it recurs at least twice in a period of 12 months (relapses) . Severe and chronic hand eczema symptoms in particular are often particularly persistent in the face of numerous attempts at treatment and are therefore extremely stressful for those affected.

Diagnostics and meaningful examinations, differential diagnoses

Various diagnostic steps can be helpful in classifying hand eczema in the individual affected and planning targeted treatment. Further allergy diagnostics are particularly useful here in order to clarify contact allergies or atopic diathesis as the cause of hand eczema. Checking the frequency of contact with water, irritants and allergy substances in private and at work is necessary in order to assess the individual skin exposure of the individual affected. Various other skin conditions may show up on the hands. For example, a fungal infection or psoriasis should be ruled out in every patient . In most cases, your own history and the corresponding examinations can provide information here.

treatment

The treatment of hand eczema should always be carried out by a dermatologist, because the various causes, the specific disposition of the patient and the differential diagnosis require the special expertise of the specialist. Treating hand eczema can be very time-consuming for the patient and his dermatologist. It is based on certain basic principles, with chronic and severe hand eczema in particular requiring a complex treatment concept. In addition to skin care and skin protection, as well as external (topical) applications with preparations containing active substances or light therapy, internal (systemic) therapy can also be considered. An immediate ban on contact with the triggering substances is very important for the success of the treatment, if necessary a change of job or occupation is to be made possible.

Avoid the trigger factors, basic measures and skin protection

Essential trigger factors for the development of chronic hand eczema such as skin-irritating damage, wet work, excessive contact with water or contact with proven allergy substances must first be strictly eliminated and avoided. In the treatment of all hand eczema types and degrees of severity, sustainable re-oiling and moisturizing of the skin with creams and ointments that are free of fragrances and preservatives are essential basic building blocks. In addition, protective measures specially adapted to the individual skin stress, for example with cotton or low-allergen plastic gloves, must be used. These measures, adapted to individual needs, should be continued after hand eczema has healed and are also effective as a preventive measure.

External treatment

The external treatment depends primarily on the prevailing skin disease symptoms. In the case of blistering or weeping symptoms, drying measures such as hand baths with synthetic tannins or greasy compresses can relieve the itching. In the presence of a cornification disorder with cracking, the softening of the skin with preparations containing urea or salicylic acid is in the foreground. To relieve inflammation, cortisone-containing creams and ointments are used in external hand eczema therapy, which can often be very effective. Severe and chronic clinical pictures in particular , however, often do not respond satisfactorily, which results in long treatment periods that can increase the risk of side effects occurring. In individual cases, especially in the case of atopic hand eczema, the treating dermatologist can consider the use of cortisone-free, anti-inflammatory creams or ointments containing the so-called calcineurin inhibitors tacrolimus or pimecrolimus as active ingredients .

Light treatment

In the treatment of chronic hand eczema, light therapy is of particular importance. However, not all dermatological practices or dermatological clinics offer this form of therapy, especially since it is associated with an increased expenditure of time for the patient. Over a period of four to six weeks, 3–4 radiation sessions should be carried out weekly. The most commonly used form of light treatment is PUVA therapy. The hands are pretreated with a cream that contains a light-sensitive active ingredient and then irradiated with ultraviolet light A (UV-A). After two days of treatment, a day off must be observed. However, due to possible risks such as premature skin aging or chronic light damage to the skin, light treatment is out of the question for long-term use.

Treatment effects of a therapy with pulsed blue light (400–500 nm, 28.9 J / cm²) lasting for months have been described for atopic hand eczema and for work-related hand eczema. In contrast to UV therapy, there was not a decrease, but an increase in lymphocytes and Langerhans cells in the skin. The anti-inflammatory mechanism of action of this light treatment is new and differs from other UV therapies in that there is no direct immunosuppression of the skin.

Systemic (internal) treatment

In addition to skin care, skin protection and external treatment, severe and chronic hand eczema in particular often also requires internal treatment. In principle, various active ingredients can be used for this. In the acute, severe episode with blistering, internal cortisone preparations, also in combination with certain antibiotics , can be very helpful in the short term. The active ingredient ciclosporin , which is approved for the treatment of severe neurodermatitis , can be used for severe, atopic hand eczema. The effectiveness of other substances, which are usually mediated by downregulation of the immune system , is reported on a case-by-case basis. However, these substances are not approved for hand eczema. An internal drug specifically for the treatment of chronic hand eczema has been approved for the first time since November 2008. It is a derivative of vitamin A called alitretinoin , which is also found naturally in the human body. This substance can be used to treat severe hand eczema of all causes and manifestations that show a chronic course of the disease and have not responded to external cortisone preparations. The effectiveness and tolerability of this form of treatment were checked and proven in an extensive clinical study program prior to approval. It was also shown that two thirds of the patients had not suffered a relapse 6 months after stopping the drug, which was defined as 75% of the initial findings and that if the hand eczema recurs, a new treatment is effective again. The duration of treatment with alitretinoin is approximately 3 to 6 months. During treatment, as well as one month before the start of therapy and after the end of therapy, women of childbearing age must use safe contraception and also carry out monthly pregnancy tests because the substance, like all derivatives of vitamin A, is teratogenic . The main side effects are temporary headaches in the first few days of treatment and an occasional rise in blood lipid and cholesterol levels . Regular laboratory tests of blood lipid levels can be useful as a control.

literature

Individual evidence

  1. ↑ a b c T. L. Diepgen et al: Management of chronic hand eczema. In: Contact Dermatitis . 2007; 57 (4), pp. 203-210. PMID 17868211
  2. ↑ a b J. P. Thyssen et al .: The epidemiology of hand eczema in the general population-prevalence and main finding. In: Contact Dermatitis. 2010; 62 (2), pp. 75-87. PMID 20136890
  3. ↑ B. Meding et al .: Fifteen-year follow-up of hand eczema: predictive factors. In: Journal of Investigative Dermatology . 2005; 124 (5), pp. 893-897. PMID 15854027
  4. ↑ a b P. J. Coenraads et al.: Hand eczemea is common and multifactorial. In: Journal of Investigative Dermatology. 2007; 127 (7), pp. 1568-1570. PMID 17568797
  5. ^ S. Molin et al.: Filaggrin mutations may confer susceptibility to chronic hand eczema characterized by combined allergic and irritant contact dermatitis. In: British Journal of Dermatology , 2009; 161 (4), pp. 801-807. PMID 19538184
  6. ↑ TL Diepgen et al: Guideline on the management of hand eczema. In: Journal of the German Dermatological Society . 2009; 7. Suppl (3), pp. S1-16. PMID 19522920 .
  7. ↑ J. English et al .: Consensus statement on the management of chronic hand eczema. In: Clinical and Experimental Dermatology . 2009; 34 (7), pp. 761-769. PMID 19747339
  8. ^ NK Veien et al.: Treatment of hand eczema. In: Skin Therapy Lett. 2003; 8 (5), pp. 4-7.
  9. ↑ EM Warshaw et al: Therapeutic options for chronic hand dermatitis. In: Dermatologic Therapy . 2004; 17 (3), pp. 240-250. PMID 15186370
  10. ↑ AM Van Coevorden et al .: Overview of studies of treatments for hand eczema - the EDEN hand eczema survey. In: British Journal of Dermatology. 2004; 151 (2), pp. 446-451. PMID 15327553
  11. ^ S. Molin et al.: Treatment for chronic hand eczema. In: MMW Fortschr Med. 2009; 151 (19), pp. 35-37. PMID 19827442
  12. ↑ J. Krutmann, K. Medve- Koenigs, T. Ruzicka, U. Ranft, JH Wilkens: Ultraviolet-free phototherapy. In: Photodermatology, Photoimmunology & Photomedicine . Vol. 21, No. 2, 2005, p. 59.
  13. ↑ K.-C. Appl: UV-free light therapy using DermoDyne® for occupational dermatoses, results of a prospective study. In: Prevention of work-related health hazards and diseases, 12th Erfurt days. Published by: Berufsgenossenschaft Nahrungsmittel und Gaststätten (BGN) ISBN 3-932906-73-X .
  14. ↑ D. Becker, E. Langer, M. Seemann, G. Seemann, I. Fell et al .: Clinical Efficacy of Blue Light Full Body Irradiation as Treatment Option for Severe Atopic Dermatitis. In: PLoS ONE . 6 (6), (2011), p. E20566. doi: 10.1371 / journal.pone.0020566
  15. ↑ MM Kleinpenning, T. Smits, MH Frun, PE van Erp, PC van de Kerkhof, RM Gerritsen: Clinical and histological effects of blue light on normal skin. In: Photodermatology, Photoimmunology & Photomedicine. Vol. 26, No. 1, 2010, p. 16.
  16. ^ A. Schwarz, M. Noordegraaf, A. Maeda, K. Torii, BE Clausen, T. Schwarz: Langerhans cells are required for UVR-induced immunosuppression. In: Journal of Investigative Dermatology. 2010 May; 130 (5), pp. 1419-1427.
  17. ↑ a b T. Ruzicka et al .: Oral alitretinoin (9-cis-retinoic acid) therapy for chronic hand dermatitis in patients refractory to standard therapy: results of a randomized double-blind, placebo-controlled, multicentre tria. In: Archives of Dermatology . 2004; 140 (12), pp. 1453-1459. PMID 15611422 .
  18. ↑ a b T. Ruzicka et al .: Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with servere chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicenter trial. In: British Journal of Dermatology. 2008; 158 (4), pp. 808-817. PMID 18294310
  19. ↑ S. Molin and others: Alitretinoin - the first specifically approved therapy for chronic hand eczema. In: The dermatologist . 2008; 59 (9), pp. 703-709. PMID 18704345
  20. ↑ R. Bissonette et al .: Successful retreatment with alitretinoin in patients with relapsed chronic hand eczema. In: British Journal of Dermatology. 2010; 162, pp. 420-426. PMID 19906075

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