What are the clinical signs and management options for a patient with chronic dermatitis in the hands?

Chronic Hand Dermatitis: Clinical Signs and Management

Clinical Presentation

Chronic hand dermatitis presents with dryness, lichenification (thickened skin), and fissuring, in contrast to acute dermatitis which shows erythema and vesiculation. 1

Key clinical features to identify:

• Pattern distribution: Involvement of palms, dorsal hands, fingertips, or web spaces helps distinguish subtypes, though pattern alone cannot reliably differentiate between irritant, allergic, or endogenous causes 2
• Morphology: Chronic cases show scaling, hyperkeratosis, and painful fissures rather than acute vesicles 1
• Associated symptoms: Pruritus is common; inquire about burning or stinging sensations 2
• Occupational/exposure history: Document initial symptom location, spread pattern, relationship to specific products or activities, and work/hobby exposures 2

Management Algorithm

First-Line Treatment

Immediately replace all soaps and detergents with emollients, even if they are not the identified cause, as these are universal irritants that perpetuate inflammation. 1, 2

• Topical corticosteroids: Apply mid-to-high potency corticosteroids (e.g., betamethasone valerate 0.1% or mometasone furoate 0.1%) twice daily to affected areas 1, 2
• Aggressive emollient therapy: Apply two fingertip units of moisturizer to hands after each washing; use the "soak and smear" technique (soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks) 2
• Protective measures: Use rubber or polyvinyl chloride gloves with cotton liners for household tasks; remove gloves regularly to prevent sweat accumulation which aggravates dermatitis 1

Diagnostic Evaluation

Refer for patch testing with an extended standard series of allergens if dermatitis persists beyond 2-6 weeks despite appropriate treatment, as clinical features alone cannot distinguish between irritant, allergic, or endogenous dermatitis. 1, 2

• Patch testing identifies specific allergens in allergic contact dermatitis, enabling complete avoidance 1, 2
• Consider workplace visits to identify hidden allergens and assess procedures causing accidental exposure 1, 2

Second-Line Treatment for Persistent Cases

If symptoms persist after 2 weeks of mid-potency corticosteroids, escalate to very high potency topical corticosteroids such as clobetasol propionate 0.05% twice daily for up to 2 weeks, which achieves clear or almost clear skin in 67.2% of severe cases. 2, 3

Alternative second-line options:

• Topical tacrolimus 0.1%: Apply twice daily where topical steroids are unsuitable, ineffective, or when concerns exist about steroid-induced skin damage; tacrolimus improves induration and scaling while avoiding long-term corticosteroid risks 1, 2, 3, 4
• Phototherapy (PUVA): Established treatment for chronic hand dermatitis resistant to topical steroids, supported by prospective clinical trials 1, 2, 4

Third-Line Treatment for Refractory Cases

For severe chronic hand eczema unresponsive to topical treatments and phototherapy, offer alitretinoin 30 mg daily, which improves both investigator-rated (RR 2.75) and participant-rated (RR 2.75) symptom control compared to placebo. 4

• Alitretinoin 30 mg has a number needed to treat of 4 for symptom control 4
• Headache is a common adverse event (RR 3.43 compared to placebo) 4
• Alternative systemic options include cyclosporine 3 mg/kg/day, which probably slightly improves symptom control compared to topical betamethasone 4
• Azathioprine and mycophenolate mofetil may be considered for steroid-resistant cases 1, 5

Critical Protective Measures

Select gloves based on specific chemical exposures and check Material Safety Data Sheets for permeation times—no glove is completely impermeable. 2

• For latex allergy, use accelerator-free neoprene or nitrile gloves 2
• In occupational settings, match glove type to chemical exposure; "impervious" gloves have finite permeation times (e.g., natural rubber latex gloves protect against methacrylate bone cement for only minutes, not prolonged contact) 1
• Apply moisturizer before wearing gloves to prevent barrier dysfunction 2

Do not over-rely on barrier creams alone—they have questionable clinical value in workplace settings and may create false security, reducing implementation of appropriate preventive measures. 1, 2

Common Pitfalls to Avoid

• Avoid washing hands with dish detergent or other known irritants, very hot or very cold water, and disinfectant wipes 2
• Do not apply products containing topical antibiotics without indication, as neomycin and bacitracin are common sensitizers 2, 6
• Avoid excessive occlusion without underlying moisturizer application 2
• Do not apply potent topical steroids within 2 days of patch testing, as this causes false negatives 2
• Avoid oral corticosteroids or immunosuppressants during patch testing; if unavoidable, keep prednisolone ≤10 mg daily 1, 2

Prognosis and Follow-Up

The long-term prognosis for chronic hand dermatitis, particularly occupational cases, is often poor: only 25% achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms. 1, 2

• Changing occupation does not improve prognosis in 40% of cases 1, 2
• Early identification and complete avoidance of allergens offers the best chance for resolution 2, 6
• Implement comprehensive educational programs for occupational contact dermatitis, which demonstrate improvements in established hand dermatitis and prevention of new cases 1, 2
• Reassess after 2 weeks of very high potency topical corticosteroid treatment 2, 3