Chronic Hand Eczema Research Articles

Association of Erectile Dysfunction with Atopic Dermatitis: A Population‐Based Case‐Control Study

Some studies have highlighted the high prevalence of erectile dysfunction (ED) in patients with dermatological diseases such as psoriasis, chronic hand eczema, and systemic sclerosis. However, to date, there is still no study that has explored the relationship between ED and atopic dermatitis (AD). Using a population-based data set, this case-control study aimed to examine the association of ED with prior AD by comparing the risk of prior AD between patients with ED and matched controls in Taiwan. This study used administrative claims data from the Taiwan National Health Insurance program. We identified 3,997 patients with newly diagnosed ED as cases and randomly selected 19,985 subjects without a history of ED as controls. Conditional logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence interval (CI) for previously diagnosed AD between cases and controls. The prevalence and risk of having been previously diagnosed with AD between cases and controls were calculated. Of the 23,982 sampled subjects, 1,758 (7.3%) had been previously diagnosed with AD; it was found among 425 (10.6%) cases and among 1,333 (6.7%) controls (P<0.001). Conditional logistic regression analysis demonstrated that cases were more likely to have prior AD than controls (OR=1.60, 95% CI=1.42-1.80, P<0.001) after adjusting for monthly income, geographic location, urbanization level, hypertension, diabetes, coronary heart disease, hyperlipidemia, obesity, and alcohol abuse/alcohol dependence syndrome. There was an association between ED and prior AD. We suggest that clinicians should be more attentive to sexual complaints from patients with AD.

Efficacy and Tolerability of Alitretinoin for Chronic Hand Eczema Under Daily Practice Conditions: Results of the TOCCATA Open Study Comprising 680 Patients

This non-interventional observational open study (TOCCATA, sponsored by Basilea Pharmaceutica Germany) investigated the use of alitretinoin to treat chronic hand eczema under daily "real life" medical practice conditions in Germany. A total of 349 dermatologists through-out Germany enrolled 680 adult patients with chronic hand eczema. Patients were prescribed and treated with alitretinoin in accordance with the summary of product characteristics. The maximum observation duration was 24 weeks, with efficacy and safety parameters evaluated every 4 weeks. Efficacy was primarily evaluated by assessing disease severity according to the Physician Global Assessment. In total, 56.7% of patients achieved a Physician Global Assessment rating of "clear" or "almost clear" hands, with only small differences in patients with different morphological forms: hyperkeratotic-rhagadiform (59.2%), fingertip (52.2%) and vesicular (47.9%). This observational study demonstrates the effectiveness and tolerability of alitretinoin in everyday clinical practice in addition to the known efficacy and safety obtain-ed by randomized controlled clinical trials.

Oral Alitretinoin in Congenital Ichthyosis: A Pilot Study Shows Variable Effects and a Risk of Central Hypothyroidism

Congenital ichthyosis is a large group of hereditary skin disorders with different aetiologies, all of which are pre-sent at birth (1). The patients have dry, widespread scaling and thickened skin (2). At present there is no cure for ichthyosis and therapy is mostly symptomatic. Life-long treatment with emollients is essential, and some patients also use systemic therapy with retinoids, especially aci-tretin (3). The most serious adverse effect of retinoids is teratogenicity, which is a special concern for acitretin as it is excreted from the body slowly (3).Alitretinoin (9-cis retinoic acid) is a fairly new oral retinoid with more rapid clearance than acitretin. In contrast to acitretin and isotretinoin, alitretinoin binds to both types of nuclear retinoid receptors, retinoic acid receptors (RARs) and retinoid X receptors (RXRs). It is indicated for chronic hand eczema in most European countries and has been found to be well-tolerated (4). We report here our preliminary experiences from an uncontrolled study of alitretinoin in 4 patients with congenital ichthyosis. PATIENTS AND METHODS

A Review of the Use of the Dermatology Life Quality Index as a Criterion in Clinical Guidelines and Health Technology Assessments in Psoriasis and Chronic Hand Eczema

The Dermatology Life Quality Index (DLQI) is an easy and practical way of quantifying the impact of skin disease. The role of DLQI in treatment guidelines and its emergence as an eligibility and response criterion in health technology appraisal are discussed. This review analyzes the current available literature on the clinical use of the DLQI, with particular reference to its relationship with disease severity and as a criterion in the assessment of health technology. The need for future studies of chronic hand eczema to incorporate DLQI to document quality-of-life outcomes with new treatments is also discussed.

Quality of life in psoriasis and chronic hand eczema: the discrepancy in the definition of severity in NICE guidelines and its implications

Quality of life in psoriasis and chronic hand eczema: the discrepancy in the definition of severity in NICE guidelines and its implications

Alitretinoin – molecular and cellular mechanisms of action

Background Chronic hand eczema (CHE) represents an inflammatory skin disease with a high prevalence ranging from 7-12% in Western industrialized countries. It was only starting from 2008 that the first, and until now the only, systemic treatment option, i.e. oral alitretinoin was approved in several countries for severe CHE unresponsive to potent topical corticosteroids. However, as the precise mechanism of actions (MOA) of alitretinoin in CHE are so far unknown, we undertook following investigations in order to shed some light on potential underlying immunomodulatory mechanisms.

PSS14 Burden of Disease in Patients With Severe Chronic Hand Eczema in Germany

PSS14 Burden of Disease in Patients With Severe Chronic Hand Eczema in Germany

PRS17 Prevalence and Cost of Severe Chronic Hand Eczema Refractory to Topical Potent Corticosteroids

PRS17 Prevalence and Cost of Severe Chronic Hand Eczema Refractory to Topical Potent Corticosteroids

Response to Treatment With Oral Alitretinoin in Patients With Chronic Hand Eczema That Is Refractory to Treatment With Potent Topical Corticosteroids: Experience in 15 Patients

Background Alitretinoin (9- cis-retinoic acid) is an endogenous derivative of vitamin A and functions as an agonist of both families of nuclear receptors (retinoic acid receptor-α, -β, -γ; retinoid X receptor-α, -β, -γ). It has been investigated in the treatment of chronic hand eczema in many studies in recent years and the results have been promising. Objectives To evaluate the efficacy and safety of oral alitretinoin in the treatment of chronic hand eczema that is refractory to treatment with potent topical corticosteroids and to analyze the long-term response to treatment. Materials and methods A prospective, observational, descriptive study was undertaken in 15 patients with chronic hand eczema that was refractory to treatment with potent topical corticosteroids. Patients were administered oral alitretinoin 30 mg/d for 3 months followed by 6 months of follow-up. Results A complete response, with “clear” hands was obtained in 7 patients (47%), 5 patients (33%) achieved a partial response (almost clear hands), 1 patient (7%) showed substantial improvement, 1 (7%) showed moderate improvement, and 1 patient (7%) did not respond to treatment. Relapse occurred within 6 months of treatment suspension in 54% of cases. The treatment was well tolerated. Side effects, observed in 50% of cases, were mild (headache, elevated lipid levels, slightly elevated transaminase levels, and epigastric pain), except in 1 patient, who had a substantial reduction in thyroid stimulating hormone levels. Conclusions The results of our study support the proposal of alitretinoin as an effective and safe short-term and medium-term treatment for chronic hand eczema in patients whose disease is refractory to treatment with potent topical corticosteroids.

Cost‐of‐illness of patients with chronic hand eczema in routine care: results from a multicentre study in Germany

It is broadly assumed that costs caused by chronic hand eczema (CHE) are significant. However, there is a lack of cost-of-illness studies on CHE. To determine the direct and indirect costs of CHE under routine conditions in Germany from the societal perspective. A cross-sectional survey was conducted in 24 outpatient practices and clinics across Germany. Patients with CHE refractory to potent topical steroids and insured by statutory health insurance were eligible. Clinical and cost data were collected using standardized questionnaires. Severity classes were defined according to a photographic guide and physician global assessment (PGA). Four treatment stages were defined based on the German CHE guidelines: topical treatments only (stage I), additionally ultraviolet (UV) radiation therapy (II), systemic therapy (III) and inpatient treatment (IV). Bivariate associations between costs and severity as well as treatment stage were assessed. Two hundred and twenty-three patients with CHE (mean age 45·7years, 56% women) enrolled in the study, of whom 63·2% were treated only with topical treatments, 15·7% additionally with UV radiation and 11·7% with systemic treatments. Of all patients, 9·4% had been admitted to hospital. Total costs per year and patient were €2128, including €1742 direct costs and €386 indirect costs. The total costs increased with treatment stages I-IV (P<0·001): €1044, €2307, €2697 and €8407, respectively. Accordingly, costs also correlated with clinical severity. Patients with CHE refractory to topical steroids incur marked costs to society. The costs increase disproportionately with escalating treatment stages, especially in patients admitted to hospital. Hence, new treatments may help to reduce the societal costs of CHE.

Topical therapy of hand eczema - analysis of the prescription profile from dermatologists in private practice

Chronic hand eczema (CHE) is a common dermatological disease. Due to different etiologies, severity levels, and high therapy costs, it presents a challenge for dermatologists. Nowadays, it is recommended that treatment be adapted to the severity of the disease. According to the guidelines on the management of hand eczema, topical corticosteroids are the first-line therapy for hand eczema. The present study investigated the prescription profile of topical treatments. Data sets from 13 191 patients with hand eczema were analyzed. The results indicate that topical corticosteroids are frequently prescribed for the treatment of hand eczema. Corticosteroid treatment (72.6 %) was most commonly prescribed by private practice physicians. Betamethasone was the most frequently prescribed, but other substances such as mometasone furoate, prednicarbate, clobetasol, and methylprednisolone aceponate were often prescribed as well. The results show that the concept of the risk-to-benefit ratio is reflected by the prescription profile of topical corticosteroids (therapeutic index). However, even corticosteroids with a less favorable therapeutic index are sometimes prescribed, perhaps due to economic reasons.

Diagnosing chronic hand eczema by an algorithm: a tool for classification in clinical practice

Diagnostic classification of chronic hand eczema (CHE) represents a major clinical and taxonomic challenge because of its wide aetiological and clinical heterogeneity. To develop an algorithm for the diagnosis and classification of CHE. Well-defined aetiological, clinical and morphological criteria of CHE were arranged graphically in a diagnostic hierarchy, and validated in 137 German patients with hand eczema. The algorithm distinguished chronic hand eczema due to contact allergy, irritant damage or a combination of the two, each either with or without atopy, and also atopic hand eczema and idiopathic hand eczema lacking obvious causative factors. Foot involvement helped to distinguish idiopathic from irritant hand eczema. Each subtype could occur either with a hyperkeratotic-rhagadiform, dyshidrotic or mixed morphology, but certain hand eczema subtypes had clear morphological preferences. By providing a more precise clinical definition this diagnostic algorithm could improve the classification and taxonomy of hand eczema subtypes, facilitating more rational treatment decisions and allowing better treatment outcome analysis.

Usefulness of Skin-Prick Tests in Children With Hand Eczema: Comparison With Their Use in Childhood and Adult Eczema

Background Hand eczema is not uncommon in children but it is rarely studied using skin-prick tests. Few reports have addressed their usefulness in children and none has specifically analyzed their use in children with hand eczema. Material and methods We performed a retrospective study of all children up to 16 years of age with hand eczema who were assessed in the Department of Dermatology at Hospital General Universitario in Alicante, Spain with the standard GEIDAC panel over a 5-year period. We compared the epidemiologic data and results of skin-prick tests in this group with those obtained in children with eczema at any site and in adults with hand eczema. Results The study included a total of 1695 patients: 141 (8.3%) children and 1533 (91.7%) adults. Hand eczema was diagnosed in 496 (31.9%) adults and 32 (22.7%) children. Positive results were obtained in skin-prick tests in 50% of children with hand eczema compared with 37.6% of children with eczema at any site and 50.6% of adults with hand eczema. The current relevance of the positive allergens found in children with hand eczema (76.2%) was greater than that observed in children with eczema at any site (61%) or in adults with hand eczema (43%). The most common allergens in children with hand eczema were kathon CG and fragrance mix I, whereas in the other 2 groups metals were the most common. The most common final diagnosis in children with hand eczema was allergic contact dermatitis (34.3%), which proved to be more common than atopic dermatitis. Conclusions We recommend the use of skin-prick tests in all children with chronic hand eczema.

Patch testing in children with hand eczema. A 5-year multicentre study in Spain

Hand eczema is common in children, but affected children are seldom patch tested. Relatively few studies have assessed patch testing in the paediatric population, and none has specifically evaluated its use in hand eczema in children. The aim of this study was to determine the prevalence of contact allergy in children with hand eczema, and to identify the most frequent allergens and their relevance. We performed a 5-year retrospective study of children (aged 0-15 years) with hand eczema tested with the Spanish baseline series at the Dermatology Departments of 11 Spanish hospitals. During the study period, 11 729 patients were patch tested, of whom 480 were children. Hand eczema was present in 111 (23.1%) of the children and in 3437 (30.5%) of the adults. Of the children with hand eczema, 46.8% had at least one positive reaction in the patch tests. Current relevance was found for 78% of the allergens detected. The most common allergens were nickel sulfate, methylchloroisothiazolinone/methylisothiazolinone, and fragrance mix I. Allergic contact dermatitis was the most frequent diagnosis (36%), followed by atopic dermatitis. Allergic contact dermatitis was the most usual diagnosis in our series of children with hand eczema. We recommend patch testing of all children with chronic hand eczema, as is already performed in adults.

Hand eczema in hairdressers: a Danish register-based study of the prevalence of hand eczema and its career consequences

Occupational hand eczema is common in hairdressers, owing to wet work and hairdressing chemicals. To estimate the prevalence of hand eczema and its career consequences among hairdressers in Denmark. A register-based study was conducted, comprising all graduates from hairdressing vocational schools from 1985 to 2007 (n = 7840). The participants received a self-administered postal questionnaire including questions on hand eczema, atopic dermatitis, and career change. A response rate of 67.9% (n = 5324) was obtained. Of the respondents, 44.3% no longer worked as hairdressers and had worked for an average of 8.4 years in the profession before leaving it. Hand eczema was more common among ex-hairdressers (48.4%) than among current hairdressers (37.6%) (p < 0.0001), and significantly more ex-hairdressers (26.8%) than current hairdressers (15.7%) had chronic hand eczema (p < 0.0001). Of the respondents with hand eczema, 75% were aged 15-24 years at onset, and 45.5% gave hand eczema as a reason for career change. In this group, logistic regression analysis showed that chronic hand eczema contributed the most to the decision to change career (odds ratio 50.12; 95% confidence interval 18.3-137). Hairdressers work an average of 8.4 years in the profession before leaving it, and hand eczema contributes significantly to this career change.

CARPE: a registry project of the German Dermatological Society (DDG) for the characterization and care of chronic hand eczema

The aim of the CARPE (German acronym: Chronisches Handekzem-Register zum Patienten-Langzeitmanagement; meaning: chronic hand eczema registry on long-term patient management) registry is to investigate characteristics and treatment modalities in patients affected by chronic hand eczema in Germany. The registry was built up under the auspices of the German Dermatological Society (Deutsche Dermatologische Gesellschaft, DDG). Patients with chronic hand eczema are prospectively assessed by dermatological examination and patient questionnaire. Socio-economic data and data on diagnostics, skin status, severity and treatment of chronic hand eczema and atopy criteria are repeatedly assessed. Here, we present baseline characteristics of the first 515 patients. 53.8 % of the patients were female, mean age was 47.3 years. The average duration of CHE was 7.7 years. 30.4 % had already received inpatient care, 31.2 % had been on sick leave in the past 12 months. 94.5 % had received topical corticosteroids prior to inclusion in the registry, 31.9 % topical calcineurin inhibitors, 38.3 % UV therapy, 28.6 % systemic antihistamines, 36.5 % systemic treatments, 14.9 % systemic corticosteroids, 25.8 % systemic retinoids. The CARPE project demonstrates the high medical burden and therapeutic challenge of chronic hand eczema and presents first data for health care research. Furthermore, the designed follow-up study will present important data about the natural history and prognosis of this chronic skin disease.

Utilidad de las pruebas epicutáneas en el eczema de manos en niños: estudio comparativo con el eczema en la edad pediátrica y con el eczema de manos en adultos

Background Hand eczema is not uncommon in children but it is rarely studied using skin-prick tests. Few reports have addressed their usefulness in children and none has specifically analyzed their use in children with hand eczema. Material and methods We performed a retrospective study of all children up to 16 years of age with hand eczema who were assessed in the Department of Dermatology at Hospital General Universitario in Alicante, Spain with the standard GEIDAC panel over a 5-year period. We compared the epidemiologic data and results of skin-prick tests in this group with those obtained in children with eczema at any site and in adults with hand eczema. Results The study included a total of 1695 patients: 141 (8.3%) children and 1533 (91.7%) adults. Hand eczema was diagnosed in 496 (31.9%) adults and 32 (22.7%) children. Positive results were obtained in skin-prick tests in 50% of children with hand eczema compared with 37.6% of children with eczema at any site and 50.6% of adults with hand eczema. The current relevance of the positive allergens found in children with hand eczema (76.2%) was greater than that observed in children with eczema at any site (61%) or in adults with hand eczema (43%). The most common allergens in children with hand eczema were kathon CG and fragrance mix I, whereas in the other 2 groups metals were the most common. The most common final diagnosis in children with hand eczema was allergic contact dermatitis (34.3%), which proved to be more common than atopic dermatitis. Conclusions We recommend the use of skin-prick tests in all children with chronic hand eczema.

Pharmacokinetics, efficacy and safety of alitretinoin in moderate or severe chronic hand eczema

Recent studies have found that alitretinoin can induce clinically significant responses in subjects with severe chronic hand eczema (CHE) unresponsive to topical corticosteroids. To assess the pharmacokinetics (PK), efficacy and safety of alitretinoin 10 or 30 mg once daily. This was a randomized, double-blind study, which enrolled 32 subjects aged 18-75 years with CHE unresponsive to potent topical corticosteroids. Subjects received alitretinoin 10 mg (n = 16) or 30 mg (n = 16) once daily for 12 or 24 weeks. Standard PK variables [area under the curve (AUC) of plasma concentration vs. time, maximum plasma concentration (C(max)), time to maximum plasma concentration (t(max)), elimination half-life (t(1/2)), total systemic clearance (CL/F) and volume of distribution (Vd/F)] were determined for alitretinoin and metabolites. Efficacy was assessed using the Physician's Global Assessment (PGA) scale. Chronic administration of alitretinoin for up to 24 weeks did not result in accumulation or time-dependent changes in the disposition of alitretinoin. Exposure was found to be proportional to dose. Systemic exposure (AUC) to alitretinoin was proportional to dose for 10 and 30 mg alitretinoin; 62.8% of subjects achieved clear/almost clear hands in the 30 mg group and 12.5% in the 10 mg group. Alitretinoin was well tolerated. Chronic administration of alitretinoin for 12-24 weeks did not lead to accumulation or time-dependent changes in drug exposure. Alitretinoin was effective and well tolerated in the treatment of subjects with moderate or severe CHE unresponsive to potent topical corticosteroids.

Influence of alitretinoin on the pharmacokinetics of the oral contraceptive ethinyl estradiol/norgestimate

Alitretinoin (9-cis retinoic acid) is currently registered in many European countries and in Canada as the only licensed treatment for severe chronic hand eczema unresponsive to potent topical corticosteroids. Alitretinoin, like all retinoids, is teratogenic, and women of child-bearing potential must strictly adhere to pregnancy-prevention measures. To investigate the influence of alitretinoin on the pharmacokinetics (PK) of ethinyl estradiol/norgestimate (Ortho Tri-Cyclen 28(®)), a commonly prescribed combination oral contraceptive. In total, 16 healthy premenopausal women received three consecutive cycles of the triphasic contraceptive ethinyl estradiol/norgestimate together with concomitant oral alitretinoin 40 mg once daily during cycle 2. Steady-state PK (noncompartmental analysis) of ethinyl estradiol, 17-deacetyl norgestimate, alitretinoin and its main metabolite 4-oxo-alitretinoin were assessed alone and in combination. The PK profiles of ethinyl estradiol and 17-deacetyl norgestimate were similar when contraceptives were given alone or with alitretinoin, and the area under the plasma concentration vs. time curve and the maximum concentration met the conventional criteria for PK equivalence. Similarly, the influence of ethinyl estradiol/norgestimate on systemic exposure to alitretinoin and 4-oxo-alitretinoin was not clinically relevant. Alitretinoin was well tolerated when given either alone or with ethinyl estradiol/norgestimate. There was no clinically relevant influence of alitretinoin on the PK of ethinyl estradiol/norgestimate, and no influence of ethinyl estradiol/norgestimate on systemic exposure to alitretinoin and 4-oxo-alitretinoin. Consequently, oral contraception with ethinyl estradiol/norgestimate is an appropriate primary method of birth control during alitretinoin treatment for women of childbearing potential.

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

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.