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Hand dermatitis
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Hand dermatitis

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Contributors: Gil Weintraub MD, Noah Craft MD, PhD
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Synopsis

Hand dermatitis includes common dermatologic conditions of varying etiology, severity, and morphology. The individual disorders are often multifactorial in nature and thus can be difficult to diagnose properly. While not life-threatening, the conditions can cause significant discomfort and distress and can interfere with a patient's occupation.

Acutely, hand dermatitis may present with pruritus, erythema, and vesicles that can erupt, weep, and crust. If left untreated, affected areas may develop scales that can progress into chronic lichenification, fissuring, and skin thickening.

Nearly all forms of hand dermatitis involve the epithelial barrier. Disruption of the superficial stratum corneum layer and deficiencies in the protective lipid bilayer lead to transepidermal water loss and dry skin that cracks easily. This loss of barrier function lowers the threshold for inflammation and results in skin that is more sensitive to environmental triggers such as irritants and allergens.

Hand dermatitis affects 2%-9% of the general population and accounts for over 80% of occupation-related cutaneous disorders. More than 70% of all hand dermatitis cases are due to some combination of atopic dermatitis, allergic contact dermatitis, and irritant contact dermatitis. The condition is more prevalent among females and those in occupations that involve contact with mechanical and chemical irritants as well as a repetitive wet-dry cycle of the hands associated with frequent hand washing. These occupations include agricultural workers, mechanics / automotive workers, health care professionals, food industry workers, janitors / cleaners, construction workers, painters, electricians, and beauticians / hairdressers. See also Dermatitis of nail folds.

Contact Allergen Exposures:
Rubber allergens
  • Exposure – latex, thiuram, carba mix
  • Association – gloves, health care workers
Fragrances
  • Exposure – fragrance mix, balsam of Peru
  • Association – skin care products, hair products
Preservatives
  • Exposure – methylchloroisothiazolinone, methylisothiazolinone, quaternium-15, formaldehyde
  • Association – skin care products, lubricants, household cleaning products
Metals
  • Exposure – nickel, potassium dichromate, gold, cobalt chloride, chromium
  • Association – jewelry, keys, coins, buttons, tools
Drugs
  • Exposure – neomycin sulfate, bacitracin
  • Association – topical antibiotics
Plants
  • Exposure – poison oak / ivy
  • Association – hiking, outdoor exposure
Common Etiologies:
  • Atopic hand dermatitis – Scaly, poorly defined pink plaques that form thin or thick lichenified fissures that develop on the dorsum of the fingers, hands, and wrist. Symptoms include intense itching, pain, and nail changes (eg, thickening of the nail fold or loss of cuticle). Family or personal history of atopy increases risk of atopic, allergic contact, and irritant contact dermatitis. Lesion sites are prone to secondary impetiginization with Staphylococcus aureus.
  • Allergic contact hand dermatitis – A type IV delayed hypersensitivity reaction to an allergen developing several days after initial exposure. Characterized by itching, burning, and pain. Contact sites will develop erythematous papules and vesicles that weep and crust over. Geometric shapes, right angles, and well-demarcated borders are clues. Often follows irritant contact dermatitis and can be found anywhere on the body.
  • Irritant contact hand dermatitis – Repetitive exposure to mechanical and chemical materials that abrade, irritate, and disrupt the epithelial barrier. Irritant contact hand dermatitis tends to develop within the first few months of starting work with a frequent wet-dry cycle. Symptoms include dry skin that is itchy, tender, and burning. Over time, erythematous, scaly plaques and lichenification develop due to scratching along the dorsum and palms. Involvement of the finger webs is suggestive. Irritant contact hand dermatitis increases the risk of developing allergen sensitization and allergic contact dermatitis.
  • Hyperkeratotic / psoriasiform dermatitis – Etiology is idiopathic but thought to be from the repetitive mechanical forces of friction and pressure. It develops slowly over time and is more common among men in their 40-60s and persons with an extended history of manual labor. Hyperkeratosis is symmetrical and well demarcated along the palms. Skin cracking and fissuring is common and may cause pain but no itching. This form of dermatitis tends to be chronic and difficult to treat effectively.
  • Nummular dermatitis – Well-demarcated, erythematous, coin- or oval-shaped plaques and papules commonly on the dorsum of the hand and fingers. The plaques are mildly pruritic, asymmetric, and likely appear elsewhere on the body. Question for a history of eczema.
  • Pompholyx / dyshidrotic eczema / vesicular hand dermatitis – Idiopathic, episodic recurrences of vesicles and bullae on the palms, fingers, and toes. Between episodes the skin appears normal, but during flares it will often become intensely pruritic as collections of small vesicles form along the side of fingers. Less commonly, large, tender bullae may form on the palms. Following episodes, skin will peel and crack over the course of several weeks.
Related topic: Allergic contact dermatitis (pediatric)

Codes

ICD10CM:
L30.9 – Dermatitis, unspecified

SNOMEDCT:
238539001 – Hand eczema

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Psoriasis – Well-demarcated, erythematous, silvery, scaling plaques classically distributed on the scalp, elbows, knees, and hands. Other clues include pitting nails, distal and proximal interphalangeal arthritis (psoriatic arthritis appearing as "sausage digits"), and pinpoint bleeding with scale removal (Auspitz sign). Pustular psoriasis is an uncommon variant presenting with sterile pustules that localize to hands and feet.
  • Tinea manuum – Superficial dermatophyte infection with diffuse, dry scaling that tends to affect only one hand but often includes both feet and affected nail plates. The plaque will have raised edges and central clearing versus nummular dermatitis, which will be relatively uniform. Scrape edge for potassium hydroxide (KOH) preparation.
  • Pityriasis rubra pilaris – Idiopathic scaling of follicular papules and yellowish-pink hyperkeratotic plaques across the body. The palms and soles become erythematous, thickened, and shiny. Biopsy is useful when specific for diagnosis.
  • Mycosis fungoides – Irregularly shaped reddish-brown or violaceous hyperkeratotic plaques that can present anywhere on the body. Skin biopsy will reveal characteristic cerebriform lymphocyte nuclei. CD4 / CD8 ratio greater than 10.
  • Dermatomyositis – Erythematous to violaceous flat-topped papules over the knuckles (atrophic dermal papules of dermatomyositis [formerly called Gottron papules]) as well as erythema and telangiectasia around the nail folds. Other signs include a heliotropic rash over the upper eyelids and symmetrical proximal muscle weakness. Laboratory blood signs include elevated muscle enzymes and anti-Jo-1 antibodies.
  • Scabies – Pruritic, erythematous, and often excoriated papules and nodules along the web spaces of the fingers / toes, volar wrists, elbows, axillae, buttocks, belt area, and feet. Look for burrows and close contacts with similar symptoms.
  • Secondary syphilis – Obtain serologic sensitivity testing to rule out syphilis (rapid plasma regain [RPR] or venereal disease research laboratory [VDRL]). Follow up positive results with FTA-Abs test. Ask about a history of primary chancre and/or systemic symptoms and skin signs.
  • Palmoplantar pustulosis – Chronic spontaneous eruption and resolution of vesicles and pustules on the palms and soles. Diagnosis of exclusion.
  • Herpetic whitlow – Crop of vesicles along affected fingers. Volar surface frequently involved. Look for coexisting primary herpes simplex virus (HSV) infection. Increase suspicion in health care workers / dental assistants who do not wear gloves or people with diabetes reusing lancets. Diagnose with Tzanck smear or viral culture.
  • Rocky Mountain spotted fever (RMSF) – Rash beginning on hands and ankles that over days progresses up the extremities to cover the trunk. No hyperkeratosis. Accompanied by fever, nausea / vomiting, and severe headache. Laboratory findings include thrombocytopenia and elevated liver enzymes.
  • Hand-foot-and-mouth disease (HFMD) – Fever, malaise, sore throat, and painful oral vesicles. Erythematous macules develop on hands and feet.
  • Toxic shock syndrome (TSS) – Desquamation of palms / soles 1 week after symptoms of fever; diffuse, blanching erythematous rash; gastrointestinal (GI) symptoms; and sepsis.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 05/11/2018
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Hand dermatitis
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Hand dermatitis : Erythema, Exudative, weeping, Pruritus
Clinical image of Hand dermatitis
An ill-defined scaly and fissured plaque on the palm.
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