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Published on 26 January 2010

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The management of severe hand eczema

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Chronic hand eczema is a frequent, distressing disease with a high socioeconomic burden for patient and society and therefore requires complex disease management


Dr Sonja Molin

Klinik und Poliklinik
fur Dermatology und
Allergology
Ludwig Maximilian
University
Munich
Germany

Chronic hand eczema (CHE) is a common skin disease characterised by a persistent noninfectious skin inflammation of the hands. CHE has a high socioeconomic impact because it frequently results in invalidity, long-term sick leave or unemployment. Daily life and health-related quality of life are strongly impaired by the skin disease. Patients with CHE suffer a lot because their visible skin disease symptoms are regularly accompanied by severe itch or painful fissures and often do not or only insufficiently respond to various therapeutic options, especially topical treatment.[1-2]

Treatment decision due to aetiology, morphology, time course and severity
For therapeutic decisions in CHE it is essential to clearly characterise the individual hand eczema in each patient due to aetiology, morphology, time course and severity. National guidelines or consensus statements can give recommendations on classification, diagnostics and therapeutic strategies. Severe and refractory cases do need special attention and a complex dermatological disease management.[3-7]

A detailed survey regarding history and clinical manifestation as well as course of the disease can reveal excessive private or occupational contact with water/irritants or atopy that are typical for the development of irritant contact dermatitis or atopic hand eczema. Initial allergologic testing, like patch or prick testing, as well as serological IgE or specific IgE tests,
can help to clarify the presence of contact allergies or atopic diathesis in a CHE patient.

Topical treatment modalities should be adjusted to the predominant individual morphology, which makes it necessary clearly to differentiate subtypes as far as possible- eg, hyperkeratotic-rhagadiform or dyshidrotic CHE.

Main clinical aspect for treatment planning in CHE is the evaluation of time course and severity of the disease. Duration more than several (3-6) months as well as two or more relapses in 12 months is generally considered as chronic hand eczema.[3] In contrast to mild or moderate forms, where the hand eczema clears due to adequate dermatological treatment in less than few weeks, a severe course of disease is characterised by extensive, strongly impairing, relapsing skin lesions. This can be found in 2-4% of all hand eczema patients. A severe CHE does require an early, complex, dermatological therapeutic management as it is frequently recalcitrant to topical measures and skin protection alone.

Treatment modalities for CHE
Bland emollients, skin protection measures, intensive skincare with bland, fragrance- or preserving agents-free emollients, soap-free handwashing products and barrier creams, as well as exposure-adapted skin protection measures-for example with cotton gloves-are basic modules of CHE treatment. Each patient should be instructed to use them frequently and regularly.

Allergen and irritant avoidance
Cumulative toxic skin damage and contact allergies are common triggers for CHE development. Strict avoidance of known allergens and water or irritant exposure, wet work and mechanical irritation is mandatory in CHE treatment, but unfortunately is not always practical for every patient.

Topical therapy
An adequate topical therapy for CHE needs to be adjusted to the individually predominant morphology. Keratolysis with salicylic acid or urea is recommended for hyperkeratotic hand eczema, while dyshidrotic hand eczema can require astringent or drying measures, for instance with synthetic tanning agents. If bacterial superinfection is assumed, topical antibiotics or antiseptics should be used.

Potent topical steroids (eg, mometasone furoate) are the gold standard of topical anti-inflammatory treatment for CHE. In order to avoid adverse side effects like skin atrophy or skin-barrier impairment, intermittent use is recommended and duration of treatment should be limited to a few weeks or months. Especially severe courses of CHE are often refractory to even the most potent topical steroids. The use of topical calcineurin inhibitors like pimecrolimus or tacrolimus can be considered in some cases, especially for atopic hand eczema, where topical steroids should be avoided or have failed.

Phototherapy, physical therapy or irradiation treatment
Phototherapy with cream- or bath-psoralen plus ultraviolet (PUVA) therapy can be an efficient treatment option for CHE, but evidence is limited. Topical PUVA is time-consuming and not always practicable for every patient. Treatment duration normally is 4-6 weeks, with 3-4 sessions every week. Restricting factors can be the development of sunburn-like conditions, as well as the potential risk for the development of skin cancer or premature skin ageing.

In patients with palmar hyperhidrosis, iontophoresis can be helpful. Some reports also recommend Grenz ray irradiation for CHE.

Systemic therapy
Severe and chronic courses of CHE require systemic treatment by a dermatologist. The prescription of systemic steroids should be restricted to acute flares of severe hand eczema and should usually not exceed a time course of several days. Reports suggest acitretin (alone or in combination with PUVA therapy), as well as immunosuppressive agents like methotrexate, azathioprine, cyclosporin or mycophenolate mofetil as potential off-label treatment options for systemic treatment of CHE. Ciclosporin is licensed for the treatment of severe atopic eczema and can be considered for the treatment of severe atopic hand eczema.

The use of those substances can be limited by lack of evidence and the potential occurrence of severe adverse events.

In several European countries and Canada, a unique substance is newly licensed for the treatment of severe and chronic hand eczema, as well as hand eczema refractory to potent topical steroids. Alitretinoin, an endogenous vitamin A derivative, was proven to be highly effective in clearing all morphologic and aetiologic forms of CHE. Its efficacy and safety profile were evaluated in large clinical trials including more than 1,000 patients.[8] Due to its teratogenic potential, safe contraception and monthly pregnancy testing are mandatory during-as well as one month before and after-treatment of women of childbearing age. Common side effects are transient headache and elevation of blood cholesterol or triglyceride values.[9]

Conclusion
Because CHE is a frequent, distressing disease with high socioeconomic burden for patient and society, it does require a complex disease management. Especially severe cases do require systemic treatment in addition to basic measures with allergen or irritant avoidance, skin care and skin protection. With alitretinoin, an endogenous Vitamin A derivative, now for the first time a substance is licensed for the systemic treatment of severe CHE, amending the spectrum of therapeutic options.

References
1. Coenraads PJ. Hand eczema is common and multifactorial. J Invest Dermatol 2007; 127:1568-70.
2. Agner T et al. Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. Contact Dermatitis 2008; 59:43-7.
3. Diepgen TL et al. Guideline on the management of hand eczema. J Dtsch Dermatol Ges 2009;7.Suppl 3:S1-16.
4. English J et al. Consensus statement on the management of chronic hand eczema. Clin Exp Dermatol 2009;34:761-9.
5. Veien NK et al. Treatment of hand eczema. Skin Therapy Lett 2003;8:4-7.
6. Warshaw EM. Therapeutic options for chronic hand dermatitis. Dermatol Ther 2004;17:240-50.
7. Van Coevorden AM, et al. Overview of studies of treatments for hand eczema – the EDEN hand eczema survey. Br J Dermatol Ther 2004;151:446-51.
8. Ruzicka T et al. Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicentre trial. Br J Dermatol 2008; 158:808-17.
9. Molin S et al. Alitretinoin – die erste spezifisch zugelassene Therapie fur das chronische Handekzem. Hautarzt 2008;59:703-9.



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