Given that our hands are indispensable tools in daily life, avoiding potential triggers can be challenging, making hand eczema often more complicated to manage.
Hand Eczema & Pompholyx
July 5, 2023
How to treat hand eczema and other itchy rashes on the hands.
What is Hand Eczema?
To understand hand eczema, it's essential to grasp its technical definition. Eczema is a term describing inflammation in the skin, manifesting in typical symptoms such as itchiness, dryness, flaking, soreness, weeping, and changes in appearance. These changes may include redness in lightly pigmented skin and uneven pigmentation in heavily pigmented (darker) skin tones. Importantly, these symptoms aren't usually specific to a single cause of inflammation; hence, various disease processes can produce similar presenting symptoms.
Causes of Hand Eczema:
1. Atopic dermatitis
2. Contact dermatitis (allergic or irritant)
3. Pompholyx / dyshidrotic eczema
Identifying which underlying condition or conditions are present is important for effective management. The location of hand eczema presents unique challenges because our hands are indispensable for daily activities like washing, cooking, and eating. This constant use exposes our hands to numerous substances that can directly or indirectly worsen flare-ups. Additionally, hand eczema tends to impose a heavier psychological burden on individuals due to the visibility of their hands and their involvement in intimate actions like handshakes and touching
Article Outline:
1. Understanding Hand Eczema
2. Managing Hand Eczema
3. Treatment Options for Eczema
4. Work/Occupation and Hand Eczema
5. Frequently Asked Questions (FAQ)
1. Understanding Hand Eczema
The Different Subsets of Hand Eczema
Atopic Dermatitis (AD) - Atopic dermatitis, often synonymous with eczema, is a chronic skin condition characterised by compromised skin barrier function and an overactive immune system. Typically emerging in early childhood, AD follows a cycle of recurring flare-ups and periods of remission. Its hallmark symptom is persistent itchiness, often accompanied by soreness, weeping, and alterations in skin colour. Typically the condition becomes less severe in adolescence/adulthood. The condition usually affects the skin creases - fronts of elbows, backs of knees, neck and eyelids.
Contact Dermatitis - Contact dermatitis stems from skin inflammation due to direct contact with allergens or irritants, differing from AD, which is primarily influenced by genetic predisposition.
Irritant Contact Dermatitis (ICD) - ICD occurs upon direct exposure of the skin to irritant substances, usually manifesting within a few hours of contact. It commonly affects individuals with previously damaged, dry, or thin skin, where the skin's protective barrier is compromised.
Allergic Contact Dermatitis (ACD) - ACD arises from substances triggering an allergic response in the skin, typically developing 1-2 days after exposure. The delayed reaction time often complicates the identification of the trigger substance.
Pompholyx or Dyshidrotic Eczema - Pompholyx, also known as dyshidrotic eczema, presents as itchy blisters (vesicles and bullae) specifically on the palms of the hands and the soles of the feet. This condition often coexists with AD and contact dermatitis. About 30% of individuals with pompholyx have a contact allergy, common allergens include cosmetic products and nickel. It is also associated with palmoplantar hyperhidrosis (the technical name for excessive sweating of the hands and feet). Even with strict trigger avoidance, pompholyx tends to follow a chronic or recurring pattern.
Signs and Symptoms of Hand Eczema
Understanding the signs and symptoms of hand eczema plays a crucial role in identifying its underlying cause, though distinguishing between the various types can be challenging due to their potential coexistence:
Atopic Dermatitis (AD): Individuals with AD typically exhibit a longstanding history of eczema, often starting in early childhood and affecting classical areas of the skin. While the areas affected by AD may evolve, it's uncommon for adults with AD to suddenly develop the condition in new areas.
Contact Dermatitis: Contact dermatitis tends to present suddenly and affects body parts in direct contact with new substances. Hands are the most commonly affected body parts. Any new eczema emerging on the hands warrants assessment for contact dermatitis.
Irritant Contact Dermatitis (ICD): Identifying the causative agent for ICD often involves exploring the individual's history and recent irritant exposure. Pre-existing AD is common, as it weakens the skin barrier, making it more vulnerable to irritants, which can be physical (direct trauma) or chemical.
Allergic Contact Dermatitis (ACD): Individuals with ACD typically have an atopic history (a history of allergies). Identifying the causative allergy can be challenging due to the delayed nature of the reaction, furthermore, the causative substances are usually harmless to the general population, and individuals can become sensitised to previously non-reactive substances.
Pompholyx (Dyshidrotic Eczema): Pompholyx is a subset of eczema which presents with itchy blisters on the palms or soles of the feet and can be associated with both AD and contact eczema.
While these distinctions in signs and symptoms provide valuable insight into potential causes, the overlapping nature of these conditions can complicate diagnosis. Understanding an individual's medical history, and patterns of flare-ups, and conducting proper assessments are vital steps in unravelling the complexities of hand eczema and its underlying causes.
2. Managing Various Types of Hand Eczema
Atopic Dermatitis (AD):
Atopic dermatitis primarily involves a compromised skin barrier, leading to increased susceptibility to inflammatory flares. Effective management includes:
Moisturisers: Crucial for restoring the skin's natural barrier function by hydrating the skin and preventing moisture loss.
Steroids and Topical Calcineurin Inhibitors (TCIs): Utilised for flare control. Due to the thicker skin on the hands, stronger potency steroids (moderate to very potent) are often required to control flares.
Trigger Avoidance: Vital in managing AD. Avoiding direct contact with soaps, cleaning products, and known triggers is essential for symptom control. While complete control may be challenging due to numerous triggering factors, awareness and avoidance, along with consistent moisturiser use and early flare-control treatment, help minimise symptoms.
Contact Dermatitis (ICD & ACD):
Trigger Identification and Avoidance: Given contact dermatitis is driven by external exposure to a substance, identifying the causative substance and avoiding further exposure is crucial to the condition management.
Similar Treatment Approaches: Moisturisers, Topical Corticosteroids (TCS), and Topical Calcineurin Inhibitors (TCIs) are used similarly to manage symptoms. Complete control is achievable if the trigger can be identified and avoided.
Pompholyx (Dyshidrotic Eczema):
Association with Contact Dermatitis: Given 30% of individuals with pompholyx have associated contact allergy, identifying and avoiding triggers in these individuals is crucial for effective management.
Moisturisers, TCI’s, and TCS are utilised to manage flares as described for AD, ICD & ACD.
Patch Testing in Hand Eczema
Purpose and Relevance: Patch testing serves as a valuable tool to confirm the diagnosis of allergic contact dermatitis and in these instances can pinpoint the specific trigger causing the allergic reaction. Given the increased prevalence of allergic contact dermatitis in hand eczema, patch testing is carried out much more regularly for individuals with hand involvement compared with individuals with AD affecting other areas of the body.
Process: Identification of Allergens: The process involves exposing the skin to a series of known allergens (substances known to cause allergic reactions). These substances are applied to small patches, which are then placed on the skin, typically on the back.
Monitoring and Observation: Typically the patches are kept on for 48 hrs and then assessed on days 2 (day of patch removal), 3/4 and 7. The skin is then observed for any signs of an allergic response.
Response: The response to the allergens is scored on a 6-point scale from 1 (negative reaction) to 6 (irritant reaction).
Due to its cost and time-consuming nature, patch testing should only be offered to individuals with a high likelihood of contact allergy.
3. Treatment Options for Eczema
Moisturisers:
Moisturisers play a pivotal role in managing active eczema flares across all forms. Inflammation in the skin leads to increased water loss and weakened skin barrier function. Modern moisturisers typically contain three core components:
Occlusive Agents: Oils that block moisture loss.
Humectants: Substances that bind moisture.
Emollients: Substances that smoothen the skin.
They come in various formulations ranging from lotions (low oil content, easily absorbed but evaporate rapidly) to creams and ointments (higher oil content, slower absorption/evaporation, but harder to apply).
Topical Corticosteroids (TCS):
TCS are the primary medications prescribed for managing eczema. They work by suppressing skin inflammation and are particularly effective during disease flares. These medications are based on cortisol, a naturally occurring hormone in the body with multiple functions, including immune system suppression and inflammation control. While useful for flare management, prolonged daily use (>6 weeks) can lead to side effects such as skin thinning and alterations in skin pigmentation (hypo/hyperpigmentation).
Topical Calcineurin Inhibitors (TCIs):
TCIs are another group of drugs commonly used to suppress the skin's immune response. They function by inhibiting calcineurin, a chemical responsible for inducing skin inflammation. These products are typically employed when individuals have not adequately controlled their condition with topical steroids and moisturisers or as a means to reduce the amount of topical steroids used.
For a comprehensive guide on the management of itchiness see our guide on Stopping The Itch.
4. Occupational Health and Hand Eczema
Contact dermatitis affecting the hands is the most prevalent work-related skin disorder. Occupations where this is commonly observed include: healthcare, food handling, building/construction, and metalworking. Individuals with contact allergies in these fields often experience frequent absences due to the challenge of avoiding repeated exposure to allergens. The severity of this condition sometimes leads individuals to consider career changes, especially when trigger avoidance, crucial for managing the condition, proves impossible within certain job roles.
If you have work-related eczema without a clear irritant contact cause, you should be offered patch testing to identify potential allergic trigger.
5. FAQs
Is Hand Eczema Different from Other Types of Eczema?
Irritants such as soaps and detergents, environmental factors such as weather conditions and dampness, and genetics can all cause eczema to flare. In some cases, your lifestyle choices may also trigger an eczema flare. Some patients find that dust mites, pet fur, pollen, and mould can also trigger the condition.
Does everyone with hand eczema require patch testing?
Not everyone with hand eczema requires patch testing. While there are higher rates of allergic contact dermatitis in hand eczema cases, performing patch testing on all individuals would be inappropriate. Certain factors warrant consideration for conducting patch testing:
Individuals with chronic or persistent dermatitis.
Those with atopic dermatitis that was previously well managed but has become challenging or impossible to control.
Individuals experiencing eczema flares related to their occupation.
Anyone with eczema showing new involvement in common contact sites, such as the face, eyelids, hands, legs, anus, or vulva.
What natural products can I use to manage my hand eczema?
Navigating natural products for managing hand eczema requires caution. While some may offer benefits, they can potentially worsen inflammation. Colloidal oatmeal stands out for its demonstrated anti-inflammatory properties and can benefit certain individuals. Other natural moisturisers like shea butter, coconut oil, and aloe vera can also be considered, but it's essential to approach them cautiously. It's advisable to test any new product on an area of unbroken skin before applying it to actively flaring skin. This precaution helps gauge potential reactions before broader use.
