Dr. JiaDe Yu presented information about the burden, pathogenesis, diagnosis, and treatment of chronic hand eczema (CHE). CHE is hand eczema that lasts >3 months or relapses >2 times per year. It is considered a subtype of atopic dermatitis (AD) or contact dermatitis (CD) in the United States and a stand-alone diagnosis in Europe. Yu believes that CHE is distinct from AD and CD and should be considered its own diagnosis.
JiaDe Yu, MD, MS, chair and associate professor of dermatology, Virginia Commonwealth University School of Medicine
First, Yu discussed CHE burden and pathogenesis. CHE is the most common form of occupational dermatosis and leads to significant morbidity and lost income. Ninety percent of occupational skin diseases are attributed to CHE, including in 40% of workers in high-risk occupations such as hairdressers, healthcare workers, chefs, cleaners, and construction workers. Approximately 20% of workers with CHE switch jobs due to the condition.
Second, Yu described the clinical presentation of CHE and CHE subtypes. Clinical morphology can include scaling, redness, lichenification, eczema, hyperkeratosis, vesicles, fissures, and nail dystrophy. CHE mimickers include psoriasis, tinea, keratolysis exfoliativa, and palmoplantar keratoderma. Identifying CHE subtypes can guide diagnostic testing and treatment options. CHE subtypes include:
- Vesicular hand dermatitis: presents as deep vesicles or pustules that look like tapioca pearls. It is intensely itchy and may be associated with a systemic allergy triggered by consuming foods high in nickel or cobalt. The condition may improve in the patient consumes a low-nickel or low-cobalt diet for >1 month.
- Chronic fissured hand dermatitis: presents with painful splitting.
- Nummular hand dermatitis: presents as well-demarcated, coin-shaped lesions. It is less common and can be confused with psoriasis. Some evidence suggests it is associated with Staphylococcus aureus infection.
- Pulpitis: rare form of hand dermatitis most often seen in healthcare workers. It is associated with nail dystrophy and may mimic mechanical irritant CD.
- Interweb dermatitis: least common subtype usually caused by hand soap or sanitizer.
Third, Yu discussed CHE diagnosis and treatment. It is important to ask all patients with CHE about a history of AD, their occupation and hobbies, hand care routine, and possible exposures. Dermatologists should always consider allergic CD and make sure the cause is not avoidable before treating. The most common causes of allergic CD include methylisothiazolinone, a preservative found in soap and shampoo products, and nickel. Biopsy is a poor diagnostic test for CHE.
Treatment with topical steroids and calcineurin inhibitors is insufficient for most patients with CHE. Oral alitretinoin is FDA approved for CHE but unavailable in the United States. The first available FDA-approved treatment for CHE is delgocitinib, a topical pan-Janus kinase (JAK) inhibitor. Delgocitinib can be used daily to maintain efficacy. It has superior efficacy compared to oral alitretinoin with a similar safety profile and does not carry a Black Box Warning. Additional off-label treatment options for severe CHE include ruxolitinib (JAK inhibitor) and dupilumab (interleukin-4 receptor inhibitor).
Finally, Yu presented cases demonstrating CHE diagnosis and treatment.
Case 1
A 30-year-old female presented with hand dermatitis, eyelid dermatitis, and lip rash for 3 months. She was a hairdresser for >10 years; the rash was worsening and impacting her ability to work. Patch testing was positive for nickel, glyceryl thioglycolate (GMTG), ammonium persulfate, and majanthole, all possibly related to her workplace. Nickel is found in tools including scissors and clippers; GMTG is a reducing agent used in perms; ammonium persulfate is an oxidizing agent used for hair bleaching and highlights; and majanthole is a fragrance found in hair products.
Yu discussed options for the patient to avoid these allergens and continue working. Switching to stainless steel scissors with rubber padding improved the CHE but flares persisted. Adding vinyl gloves when shampooing, conditioning, and perming hair completely resolved the CHE.
Case 2
A 49-year-old female presented with hand dermatitis for 2 months. She worked as a surgical scrub nurse; the dermatitis flared after her shifts began but was fine when she was off or on vacation. Patch testing was positive for N,N-diphenylguanidine (N,N-DPG) and 2-mercaptobenzothiazole (2-MBT), often found in rubber gloves. Yu prescribed topical steroids and special gloves manufactured without these rubber accelerators.
Case 3
A 20-year-old male presented with hand dermatitis for 4 years. He was training as a concert violist. Hand moisturizers stopped working >1 year prior. Betamethasone helped, but the dermatitis worsened when it was discontinued. Patch testing, potassium hydroxide testing for tinea, and biopsy were negative. Delgocitinib was not yet available; dupilumab led to significant improvement.
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