Hands are made marvellously and as Sir Isaac newton puts it “The thumb alone would convince me of God’s existence”.It has gripping grasping and twisting ability. The skin of the palms is hairless, has patterns which help in identification(dermatoglyphics), is tough and durable but exquisitely sensitive. These unique gifts have to be cared for to prevent damage.
Hands take a beating but not everyone develops hand eczema. As hands are used not only used as one’s tools for work but for social expression, hand eczema has a negative impact on the quality of life. Diagnosis and management of hand eczema are challenging as often multiple factors are involved in causation, and avoidance of irritant or allergen is often not possible. Relapses also create an ongoing cycle of the disease. Many individuals who develop eczema are not able to continue with their profession and hence there is an economic consequence. Breaching of the stratum corneum is the first step causing inflammatory cells being called to the scene. Inflammatory activity and water losses lead to dryness, cracking, and inflammation. Stratum corneum (surface layer of the skin)lipids are mostly water-soluble and water exposure from “wet work” can eliminate additional lipids. Water loss from the stratum corneum leads to cracks, fissures, and further impairment of its barrier function. Genetic traits are often important in the causation.
Hand dermatitis is an inflammation characterized by signs of erythema or redness, raised itchy lesions,fluid-filled lesions, weeping, dryness and fissures and thickening and pigmentation of the skin. It varies in severity and can affect the back of hands, palms or both. Often it starts as an intermittent complaint but becomes severe and persistent. In the acute phase, there is intense itching redness and oozing whereas in the chronic phase it is dryness pigmentation and scaling with itching. Three important clinical variants are
People with atopic dermatitis are prone to developing hand dermatitis especially if the occupation involves wet work. the Involvement is symmetric involving typically the fingers and back of hands. There is itching, dryness and, mild redness and thickening and exaggeration of the skin surface markings. Other body areas such as the neck, front of elbows and back of knees may be also involved. Emotional stress can exacerbate dermatitis. Psoriasis has to be ruled out which presents similar to chronic eczema.
It is characterized by recurrent vesicles on the lateral aspect of fingers, palms and periungual area. The eruption is often preceded by severe pruritis or burning sensation Flares are reported with exposure to irritants, emotional stress or wearing occlusive gloves.
This is immunologically mediated. Skin reacts abnormally to a substance that does not affect others. It becomes sensitized and when it comes in contact with the same substance memory is activated and inflammatory cells are pulled in. Occasionally it can present as hives forex some who use latex gloves can immediately develop redness itching and swelling of hands lasting for about 20 minutes. Nickel, fragrances, cement, colouring agents,p-phenylenediamine in permanent dyes are some agents that can cause it. It can affect not just the areas coming in contact with it, but distant sites too. It can occur within about 48 hours after contact following prior sensitization.
Once a specific allergy has been identified, contact with the causative material must be strictly avoided long term to clear up dermatitis and to prevent its recurrence.
Initially termed as house wife’s eczema or dishpan hands it is the most common occupational disease contributing to about 70-80% of all occupational disorders. It develops when the healthy epidermal barrier is disrupted and secondary inflammation develops. Most cases are caused by cumulative exposure to one or more irritants including organic and inorganic acids, alkalis and bases, common solvents, alcohols, detergents, cleaners and disinfectants. There may be stinging, burning, pain and itching or clinical signs of erythema, scaling fissures, vesicles and necrosis. Friction and repetitive injury also damage the skin. A few minutes indiscretion can cause a flare-up lasting for a month. Acute ICD develops in response to a single exposure to an irritant which is not individual specific. The clinical presentation is erythema, edema, blisters or necrosis accompanied by a stinging, burning, or painful sensation. Lesions are demarcated and usually limited to the area of the hand that came in contact with the irritant.
Chronic irritant contact dermatitis may develop by repetitive exposure to an irritant or by a cumulative effect of several irritants. Slight erythema with fine scaling, often the first visible sign of ICD, rapidly can change to redness, swelling, scaling, fissures, and chapping when an additional insult to the skin moves it from subclinical damage to visible dermatitis. In long-standing chronic ICD, the clinical presentation may include erythema, edema, eczematous vesicles, itch, and thickening of the skin.
Fingertip fissures and cracks occur in individuals with occupations involving prolonged exposure to organic solvents, while finger web dermatitis occurs in individuals with wet work occupations. Nails may be damaged in chronic ICD.
Diagnosis requires a detailed history, careful examination of the body for other primary dermatoses and Patch test. A patch test is essential to diagnose contact dermatitis though it is often inconclusive.
The most important part of treatment is protection and prevention. Wear Gloves (latex, vinyl, or plastic) to avoid contact with detergents, scouring powders, solvents, bleach, raw foods, fresh lemons, fresh fruits, onions, etc. It is important to have more than one set of gloves and to avoid the hands sweating inside the gloves. Use gloves that are lined or use thin, cotton liner gloves to wear underneath the heavier, protective gloves. Atopy is a risk factor for latex allergy so synthetic rubber may be substituted for natural rubber.
Treatment includes application of steroids several times a day. Apply a small amount of medicine to the rash, and massage it in well. If the skin is still dry, you may apply plain white petrolatum (Vaseline) or other non-medicated hand creams. When the rash is better, the steroid is tapered, the petroleum jelly or moisturizers should be continued. It takes 2-3 months for the skin to totally recover. Hand Eczema is chronic and stubborn, and not treating the symptoms creates frequent recurrences. In cases that do not respond, phototherapy, oral steroids or immune modifiers can be used.
Dr Maria Kuruvila
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