Refractory hand dermatitis

Abstract

Hand dermatitis is often dismissed by medical practitioners as being trivial because of the limited area of skin involvement. However, the morbidity of sufferers is often not comprehended. All too often patients are not given the benefit of full investigation with appropriate treatment. Psoriasis localized to the hands is frequently misdiagnosed as hyperkeratotic eczema and requires potent treatment to clear. Fungal infections are also commonly overlooked. The majority of hand dermatitis seen in the community is due to irritant contact factors. The importance of identifying all the factors relevant to irritation needs to be communicated to patients. Good hand care needs to be maintained for a minimum period of 3 months after recovery to prevent relapses from occurring. Common failures of response are due to inadequate usage of a potent enough steroid, lack of occlusion, and failure to apply emollients with enough frequency. Any patient with hand dermatitis that has not responded after 4 weeks to advice on improved hand care combined with first-line treatment should be investigated for potential Type I and 1 V hypersensitivity. The pattern of involvement of the hands is often no clue as to causation. No patient should be told to change occupation without such investigations. Primary occupations are often blamed for the cause of dermatitis but in reality secondary occupations and domestic exposure may be the real reason for lack of response to treatment. Patients with resistant hand dermatitis may have to be considered for second line therapies including PUVA, cyclosporin, methotrexate and retinoids. Suggested instruction sheet for patients with hand dermatitis 1 Hand washing: Use lukewarm water and a soap substitute (e.g. Wash E45, Aqueous cream, Emulsifying ointment). If your hands are dirty use a nonperfumed soap without tar or sulphur. The soap should be used sparingly and the hands thoroughly rinsed. Dry carefully with a clean towel, especially between the fingers. If soap is used this should be followed with the application of a nonperfumed moisturizer. 2 If your skin is dry use a nonperfumed moisturizer (e.g. E45 cream, Diprobase cream Neutrogena Norwegian Formula hand cream, Aqueous cream, Oily cream BP, Emulsifying ointment, Liquid Paraffin/White Soft Paraffin) as frequently as possible to restore a feeling of suppleness. As your skin improves the frequency can be reduced. You can use different ones at different times of the day with less greasy preparations used when undertaking paperwork. 3 Avoid contact with detergents and other strong cleansing agents. 4 Avoid contact with shampoo. Use plastic gloves or let someone else shampoo your hair or your children's hair. 5 Avoid contact with polish: metal, wax, shoe, floor, car, furniture and window polishes. 6 Avoid contact with solvents: white spirits, petrol, paraffin, turps, thinners and trichlorethylene (tric). 7 Do not peel or squeeze citrus fruits with bare hands: oranges, lemons, limes, satsumas. 8 Do not apply hair lotion, hair cream or hair dye with bare hands. 9 Wear warm gloves in cold weather. 10 Rings should not be worn for work or housework until the skin has been clear for 3 months. Never wash your hands with soap while wearing a ring. Keep the inside of rings clean (brush under running water). 11 For washing up use running water if possible keeping the temperature of the water low. Use long handled brushes rather than cloths. Always wear gloves when in contact with washing up liquid or detergents. 12 When gloves are worn, use PVC rather than rubber – preferably with cotton gloves inside to reduce sweating and friction. They should not be worn for more than 20 minutes at a time. If water happens to enter a glove, it should be immediately removed. Gloves should be turned inside out and rinsed under warm water several times a week. The outside gloves should be replaced every few weeks for home use and more frequently for industrial use. 13 Washing machines and dishwashers are an ideal way of preventing further attacks. Use a measure when handling detergent powder. Remember that the resistance of the skin is lowered for at least 4 or 5 months after the dermatitis has apparently healed. Therefore continue to follow these instructions.