What is the appropriate management of hand eczema in children?

Management of Hand Eczema in Children

Children with hand eczema should receive patch testing to identify allergic contact dermatitis, particularly when eczema is persistent or fails to respond to standard atopic dermatitis treatment, as contact allergy is found in approximately one-third of pediatric hand eczema cases. 1, 2

Diagnostic Approach

Key Historical Features to Elicit

• Exposure history: Specifically ask about homemade slime (the most common trigger in recent pediatric cases), store-bought slime, sporting equipment/gloves, nail products, outdoor plants, and school craft activities 3
• Atopic history: Personal history of atopic dermatitis, asthma, or hay fever, plus family history of atopic disease in first-degree relatives 1, 4
• Chronicity: Duration of symptoms, with lesions present >1 year suggesting chronic hand eczema requiring more aggressive investigation 3
• Occupational/recreational factors: School activities, hobbies, and any repetitive hand exposures 1

Physical Examination Priorities

• Distribution pattern: Bilateral hand involvement suggests atopic or irritant dermatitis, while asymmetric involvement may indicate allergic contact dermatitis 2, 3
• Lesion morphology: Look for weeping/crusting (bacterial superinfection), grouped punched-out erosions (eczema herpeticum), or vesiculation 1, 5
• Examine other body sites: Flexural involvement, facial eczema, or generalized xerosis supports atopic dermatitis 1, 4

Patch Testing Indications

Patch testing is essential and should not be delayed in children with hand eczema. 1 The British Journal of Dermatology guidelines emphasize that clinical features alone cannot reliably distinguish allergic from irritant or atopic hand eczema. 1

When to Refer for Patch Testing

• Any child with persistent hand eczema where contact allergy cannot be ruled out 1
• Children with hand eczema who fail first-line atopic dermatitis treatment within 1-2 weeks 4
• All children with eyelid eczema accompanying hand eczema 1

Expected Findings

In pediatric hand eczema cohorts, patch testing identifies:

• Atopic dermatitis: 36% of cases 2
• Allergic contact dermatitis: 33% of cases 2
• Most common allergens: Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), thiomersal, nickel, mercury, and cobalt 2, 3

Treatment Algorithm by Etiology

First-Line Management (All Types)

• Emollients: Apply liberally at least twice daily to entire hands, not just affected areas 6, 4
• Soap substitutes: Use dispersible cream cleansers instead of soap 1, 4
• Irritant avoidance: Cotton gloves under protective gloves when wet work is unavoidable; avoid wool and extreme temperatures 1

Inflammatory Flares

• Topical corticosteroids: Use the least potent steroid that controls inflammation; mild steroids for maintenance, moderate potency for acute flares 1, 6
• Alternative anti-inflammatories: Topical calcineurin inhibitors or JAK inhibitors for steroid-sparing maintenance 7, 8

Allergic Contact Dermatitis (Once Identified)

• Allergen avoidance: In 53% of pediatric cases, trigger removal alone results in complete resolution 3
• Specific interventions: Discontinue homemade slime, switch to MCI/MI-free products, avoid nickel-containing jewelry/fasteners 3

Red-Flag Complications Requiring Urgent Action

Bacterial Superinfection

• Clinical signs: Crusting, weeping, or honey-colored exudate 1, 4
• Management: Obtain bacterial swabs and initiate flucloxacillin or cephalexin empirically 4, 5

Eczema Herpeticum (Medical Emergency)

• Clinical signs: Multiple uniform "punched-out" erosions or vesiculopustular eruptions of similar size and shape 5
• Management: Immediate systemic acyclovir; send viral swab or smear for electron microscopy 1, 5
• Rationale: The Taiwan Academy of Pediatric Allergy states this "may progress rapidly to systemic infection in the absence of antiviral therapy" 5

Common Pitfalls to Avoid

• Assuming all hand eczema is atopic: One-third of pediatric hand eczema is allergic contact dermatitis, which requires allergen identification and avoidance rather than escalating anti-inflammatory therapy 2
• Delaying patch testing: Children with hand eczema should be patch tested early, as the number of allergens identified increases with the number of patients referred 1
• Dietary restriction without supervision: This is of little or no benefit and risks nutritional deficiency 6, 4
• Dismissing modern triggers: Homemade slime has become the leading cause of pediatric allergic hand eczema due to high concentrations of MCI/MI preservatives in craft glues 3

Parent Education Essentials

• Demonstrate application technique: Show proper emollient application and quantity needed; provide written instructions 1, 4
• Address steroid fears: Explain that appropriate topical corticosteroid use is safe and that undertreatment causes more harm than appropriate treatment 1, 4
• Infection monitoring: Teach recognition of weeping, crusting, or punched-out lesions requiring prompt medical attention 4, 5
• Realistic expectations: Even mild hand eczema can severely impact school work and social life, justifying active management rather than waiting for spontaneous resolution 6