What is the treatment for hypersensitivity of the hands?

Treatment of Hand Hypersensitivity

For hand hypersensitivity, immediately implement strict avoidance of irritants and allergens, apply moisturizers after every hand washing, and use topical corticosteroids for active inflammation, with progression to advanced therapies only if symptoms persist beyond 6 weeks. 1

Initial Assessment and Trigger Identification

The first critical step is determining whether you're dealing with irritant contact dermatitis (ICD), allergic contact dermatitis (ACD), or another form of hand dermatitis, as this guides management. 1 Most hand hypersensitivity stems from either irritant exposure (soaps, detergents, water itself) or allergic triggers that require patch testing to identify. 2, 1

Key Triggers to Eliminate

• Avoid all harsh soaps, detergents, frequent hand washing with hot water, and disinfectant wipes, as these damage the skin barrier. 1, 3
• Use only lukewarm or cool water for hand washing rather than hot water. 1, 3
• Switch to fragrance-free, dye-free cleansers without allergenic surfactants or preservatives. 1, 3
• For healthcare workers or those requiring hand sanitizers, use alcohol-based products with at least 60% alcohol and added moisturizers, but never wash hands with soap immediately before or after using alcohol-based products. 1

First-Line Treatment: Barrier Protection and Moisturization

Aggressive moisturization is the cornerstone of treatment and must be implemented immediately after every hand washing. 1

Proper Moisturization Technique

• Apply moisturizer immediately after hand washing using two fingertip units for adequate hand coverage. 1, 3
• Pat hands dry gently rather than rubbing to minimize trauma. 1, 3
• Choose fragrance-free moisturizers containing petrolatum or mineral oil, which are most effective and least allergenic. 3
• Use pocket-sized tubes rather than jars to prevent contamination and enable frequent reapplication throughout the day. 1

Advanced Moisturization for Severe Cases

• Implement the "soak and smear" technique nightly: soak hands in plain water for 20 minutes, then immediately apply thick moisturizer to damp skin for up to 2 weeks. 1, 3

Topical Corticosteroid Therapy

Topical corticosteroids are the primary anti-inflammatory treatment when conservative measures fail, but must be used judiciously to avoid steroid-induced barrier damage. 1

• Apply hydrocortisone 1% to affected areas not more than 3 to 4 times daily for adults and children 2 years and older. 4
• For more severe inflammation, stronger topical steroids may be necessary, though prolonged use can paradoxically damage the skin barrier. 1
• Be aware that topical corticosteroids themselves can cause contact hypersensitivity in 2-5% of patients attending contact dermatitis clinics, particularly in those with stasis dermatitis. 5, 6

Important Caveat About Corticosteroid Efficacy

One study found topical corticosteroids ineffective for surfactant-induced irritant dermatitis compared to vehicle alone, suggesting their benefit may be limited in pure irritant contact dermatitis. 7 However, clinical guidelines still support their use for inflammatory flares. 1

Protective Measures and Glove Use

Gloves are the mainstay of protection for hand dermatitis, but improper use can worsen the condition. 2

Proper Glove Selection and Use

• For general household tasks, use rubber or polyvinyl chloride household gloves, possibly with cotton liners or worn over cotton gloves. 2
• Remove gloves regularly as sweating and occlusion may aggravate existing dermatitis and impair stratum corneum barrier function. 2
• For suspected glove-related allergic contact dermatitis, switch to accelerator-free gloves (neoprene or nitrile). 1, 3
• Use cotton glove liners under protective gloves if occupational exposure is unavoidable. 3
• Apply water-based moisturizers under gloves (oil-based products can break down latex and rubber). 1, 3
• Never apply gloves when hands are still wet from washing or sanitizer. 1, 3

Occupational Considerations

• In occupational settings, glove selection depends on the specific chemicals involved, as "impervious" gloves have finite permeation times for any substance. 2
• A workplace visit may be necessary to identify all potential skin hazards and implement effective avoidance strategies. 2

When to Suspect Allergic Contact Dermatitis

If hand dermatitis does not improve with standard irritant avoidance and moisturization, consider allergic contact dermatitis requiring patch testing. 1

• Patients with persistent eczematous eruptions should be patch tested to at least an extended standard series of allergens. 2
• Patch testing should be prescribed and interpreted by someone trained in contact dermatitis investigation, with readings at day 2 and day 4. 2
• Common allergens include nickel, rubber additives, preservatives, and fragrances. 2
• For nickel-sensitive patients with positive patch tests, low nickel diets may provide some benefit. 2

Advanced Therapies for Recalcitrant Cases

Consider advanced treatment when hand dermatitis does not improve after 6 weeks of conservative treatment. 1, 3

Second-Line Treatment Options

• Stronger topical corticosteroids may be tried first. 1
• Phototherapy (psoralen plus UVA) has prospective clinical trial support for steroid-resistant chronic hand dermatitis. 2
• Systemic immunosuppressants including azathioprine and cyclosporine are supported by prospective clinical trials for recalcitrant cases. 2
• Long-term intermittent use of mometasone furoate has been demonstrated effective in chronic hand eczema. 2

Critical Pitfalls to Avoid

• Do not use superglue to seal fissures or vesicles. 1, 3
• Avoid washing hands with dish detergent or other known irritants. 1, 3
• Do not increase glove occlusion duration without underlying moisturizer application. 1, 3
• Avoid applying known allergens once identified through patch testing. 1
• Do not rely on barrier creams alone, as they are of questionable value in protecting against irritants and may create false security. 2

After-Work Creams

• After-work creams and soap substitutes have controlled clinical trial evidence showing benefit in reducing the incidence and prevalence of contact dermatitis and should be encouraged in occupational settings. 2

When to Refer to Dermatology

• Refer for suspected allergic contact dermatitis requiring patch testing. 1, 3
• Refer if no improvement after 6 weeks of conservative treatment. 1, 3
• Refer for consideration of phototherapy or systemic therapy in recalcitrant cases. 3
• Refer if there is any change in the baseline pattern of the dermatitis. 1, 3

Prognosis Considerations

The long-term prognosis for occupational contact dermatitis is often poor, with only 25% of patients completely healed after 10 years in one Swedish study. 2 Half still had periodic symptoms and one quarter had permanent symptoms. 2 Importantly, in 40% who changed occupations, the overall prognosis was not improved, emphasizing the importance of early aggressive intervention. 2