What causes itchy hands and how are they treated?

Itchy Hands: Causes and Treatment

Itchy hands are most commonly caused by hand dermatitis (irritant, allergic, or atopic), and treatment should begin immediately with eliminating all irritants, intensive moisturization, and topical corticosteroids when conservative measures fail. 1, 2

Common Causes of Itchy Hands

Hand Dermatitis (Most Common)

• Irritant Contact Dermatitis (ICD) accounts for approximately 80% of occupational hand dermatitis cases and results from exposure to soaps, detergents, hot water, alcohol-based sanitizers, and frequent hand washing 1
• Allergic Contact Dermatitis (ACD) develops from sensitization to specific allergens including preservatives (methylisothiazolinone, quaternium-15, formaldehyde), fragrances, rubber accelerators in gloves, nickel, and topical antibiotics (neomycin, bacitracin) 1, 3
• Atopic Hand Dermatitis occurs in individuals with personal or family history of atopic dermatitis, asthma, or allergic rhinitis 2, 4

Other Causes to Consider

• Systemic diseases: iron deficiency, uremia, hepatic disease (especially cholestasis), malignancy, hematological disorders, endocrine disease 1
• Neurological disorders and psychological factors 1
• Adverse drug reactions 1

Immediate Management Steps

Eliminate All Irritants and Allergens

• Stop using all traditional soaps, detergents, fragrances, and harsh products immediately 1, 2
• Avoid hot or very cold water; use only lukewarm or cool water for hand washing (water temperature above 40°C damages the stratum corneum through lipid fluidization) 1
• Avoid dish detergent, bleach, disinfectant wipes on skin, and alcohol-based products when possible 1
• Do not apply gloves to wet hands, as this traps irritants and increases dermatitis risk 1

Proper Hand Hygiene Technique

• Wash hands with lukewarm water and gentle cleanser for 20 seconds, paying attention to commonly missed areas (fingertips, hypothenar eminence, dorsum) 1
• Use dispersible creams as soap substitutes instead of conventional soaps 2
• Pat dry gently with non-frictional technique; never rub 1, 2

First-Line Treatment

Intensive Moisturization (Essential Foundation)

• Apply fragrance-free emollients containing petrolatum or mineral oil immediately after hand washing to damp skin 2, 5
• Use a minimum of 2 fingertip units of moisturizer per hand, spread evenly as a thin layer 1
• Apply moisturizers 3-4 times daily or more frequently as needed 2, 4
• Consider the "soak and smear" technique for severe cases: soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 2

Topical Corticosteroids

• Topical corticosteroids are the pharmacological mainstay when conservative measures fail 2, 5
• Start with the lowest potency necessary to control symptoms 1, 2
• Apply to affected areas 2-4 times daily 5
• Hydrocortisone (over-the-counter) can be used for mild cases in adults and children over 2 years 5
• Caution: Consider potential topical steroid-induced damage to the skin barrier with prolonged use; use intermittently when possible 1, 2

Diagnostic Considerations

Differentiate the Type of Dermatitis

• Important caveat: The morphology and pattern of hand dermatitis is NOT reliable for distinguishing between irritant, allergic, or atopic dermatitis 2
• Obtain detailed occupational and recreational exposure history 2
• Ask about personal history of childhood atopic dermatitis, asthma, rhinitis, and family history of atopy 2
• New-onset hand dermatitis or change in baseline pattern should prompt consideration for patch testing to identify specific allergens 1, 2

When to Investigate Systemic Causes

• If hand dermatitis is atypical or refractory, consider checking for iron deficiency, renal function, liver function, and other systemic causes 1

Second-Line and Advanced Treatments

For Recalcitrant Cases

• Stronger topical corticosteroids for limited periods 1, 2
• Phototherapy (PUVA or narrowband UVB) for adults with inadequate response to topical treatments 2
• Occupational modification may be necessary if work-related exposures cannot be adequately controlled 1

Systemic Therapy (Severe Refractory Cases)

• Cyclosporine 3 mg/kg/day improves symptom control compared to topical betamethasone after 6 weeks; monitor creatinine, blood pressure, renal function, magnesium, and potassium 2
• Azatioprina 1-3 mg/kg/day; consider measuring TPMT activity to guide dosing 2
• Methotrexate 7.5-25 mg/week with folate supplementation; monitor liver enzymes 2

Critical Pitfalls to Avoid

• Never use surface-cleaning disinfectant wipes on skin (contain harsh agents like N-alkyl dimethyl benzyl ammonium chloride) 1
• Avoid applying topical antibiotics (neomycin, bacitracin) as they are common allergens 1
• Do not use superglue (ethyl cyanoacrylate) to seal fissures 1
• Avoid occlusion with gloves or wraps without first applying moisturizer 1
• Do not wash hands immediately before or after using alcohol-based sanitizer, as this increases dermatitis risk 1

When to Refer to Dermatology

Refer to a dermatologist if: 2

• No improvement after 6 weeks of appropriate treatment
• Suspected allergic contact dermatitis requiring patch testing
• Change in baseline dermatitis pattern
• Recalcitrant cases requiring phototherapy or systemic therapy