From the Guidelines
On physical examination, eczema on the hands typically presents as dry, red, and inflamed skin with distinct patches that may appear scaly or thickened, as noted in the most recent guidelines 1. The affected areas commonly include the dorsal surfaces of the hands, the spaces between fingers, and the palmar surfaces. Patients often have visible fissures or cracks in the skin, particularly over joint surfaces and fingertips, which can be painful and may bleed.
- Vesicles (small fluid-filled blisters) might be present in acute flares, while chronic cases show lichenification (skin thickening with accentuated skin lines) due to persistent inflammation and scratching.
- The distribution is usually bilateral but can be asymmetric depending on hand dominance and exposure factors.
- The patient may demonstrate excoriations from scratching due to the intense pruritus that characterizes eczema.
- In severe cases, secondary bacterial infection may be evident with crusting, weeping, or pustules.
- The nails might show changes including pitting, ridging, or discoloration if the condition affects the nail matrix.
- Hand eczema often spares the central palm while affecting the edges and web spaces, which helps distinguish it from other dermatological conditions, as discussed in the guidelines for the management of atopic dermatitis 1. It is essential to consider allergic contact dermatitis as a potential exacerbator or alternative diagnosis to atopic dermatitis, particularly in cases with an atypical distribution of lesions or lack of response to standard therapies, as highlighted in the guidelines for the management of contact dermatitis 1.
From the Research
Physical Examination Findings of Atopic Dermatitis (Eczema) Involving the Hands
The physical examination findings of atopic dermatitis (eczema) involving the hands can be assessed using various methods, including:
- A review of the patient's medical history and a physical examination of the hands and other body sites 2
- The Hand Eczema Severity Index (HECSI) and the Hand Eczema Area and Severity score, which can predict the Investigator's Global Assessment (IGA) of disease severity 3
- A photographic guide, which can be used by patients to self-assess the severity of their hand eczema and has been shown to have good inter-rater agreement with dermatologist assessments 4
- Visual analogue scales (VASs), which can be used to assess disease severity, but may be subject to recall bias or response shifts 5
Common Clinical Presentations
The most common clinical presentations of hand eczema are:
- Atopic hand dermatitis
- Pompholyx
- Contact dermatitis (irritant contact dermatitis [ICD], allergic contact dermatitis [ACD]) 2 These presentations can be diagnosed through a combination of medical history, physical examination, and patch testing.
Severity Assessment
The severity of hand eczema can be assessed using various methods, including:
- A photographic guide, which can be used to grade severity into four groups: almost clear, mild, moderate, and very severe 4
- The HECSI and the Hand Eczema Area and Severity score, which can predict the IGA of disease severity 3
- VASs, which can be used to assess disease severity, but may be subject to recall bias or response shifts 5