Case study 1 – A 54-year-old male gardener with chronic hand eczema

Abstract

A 54-year-old man presented to his dermatologist with severe chronic vesicular hand eczema, which had been present for over 3 years. The patient had previously lost an arm in an earlier injury, and the disease on his remaining hand was causing significant distress and complications in his daily life. He worked as an odd-job man and gardener, so his remaining hand was vital to his chosen occupation. He was patch tested, which showed multiple contact allergies including a positive result to Compositae mix, sesquiterpene lactone mix, thiuram mix and potassium dichromate. Since the patch test, he had been using non-rubber gloves at work and tried to avoid coming into sustained contact with compositae plants such as asters, sunflowers and daisies. It was clear however, that despite these measures his occupation was exacerbating the disease and in turn the disease was interfering with his occupation. He was initially treated with ciclosporin (2–3 mg/kg/day) and concomitant potent topical corticosteroids continuously for many months, but despite this aggressive treatment, his eczema remained poorly controlled with frequent flares requiring the patient to take oral corticosteroids and antibiotics on a regular basis. Additionally he suffered from hypertension during treatment, potentially as an adverse reaction to ciclosporin. Later, the patient enrolled in a clinical trial with azathioprine 100 mg daily, but had minimal benefit after 6 months and was unable to tolerate the associated side effects of sickness and diarrhoea. Subsequent treatment with acitretin 25 mg daily for 3 months also proved ineffective, and as the patient had albinism, phototherapy was not an appropriate option. His disease therefore remained significant (Fig. 1) and his dermatologist prescribed oral alitretinoin 30 mg in October 2009. Patient 1: A 54-year-old male gardener. Prior to alitretinoin treatment. After 3 months’ treatment, he showed significant improvement in all symptoms and the Physician’s Global Assessment score improved from ‘very severe’ to ‘almost clear’ (Fig. 2). Patient 1: A 54-year-old male gardener. After 3 months’ alitretinoin treatment. The treatment was well tolerated, with no significant side effects or laboratory anomalies. The improvement in his condition led to the discontinuation of treatment in January 2009, but unfortunately he relapsed 2 months later as he was allergic to Compositae plants, which are ubiquitous in the environment. Retreatment with alitretinoin 30 mg once daily improved his condition again, and he remains on treatment. The patient was very happy with the results he achieved with alitretinoin treatment; he described it as the best treatment he has received for his hand eczema, and one that he considers to have transformed his life. He has been able to continue his chosen occupation, and he feels his overall quality of life has improved substantially.