Hand eczema classification: a cross-sectional, multicentre study of the aetiology and morphology of hand eczema

Cross-Cultural Validation of the Quality of Life in Hand Eczema Questionnaire (QOLHEQ)

The Quality of Life in Hand Eczema Questionnaire (QOLHEQ) is the only instrument assessing disease-specific health-related quality of life in patients with hand eczema. It is available in eight language versions. In this study we assessed if the items of different language versions of the QOLHEQ yield comparable values across countries. An international multicenter study was conducted with participating centers in Finland, Germany, Japan, The Netherlands, Sweden, and Turkey. Methods of item response theory were applied to each subscale to assess differential item functioning for items among countries. Overall, 662 hand eczema patients were recruited into the study. Single items were removed or split according to the item response theory model by country to resolve differential item functioning. After this adjustment, none of the four subscales of the QOLHEQ showed significant misfit to the item response theory model (P < 0.01), and a Person Separation Index of greater than 0.7 showed good internal consistency for each subscale. By adapting the scoring of the QOLHEQ using the methods of item response theory, it was possible to obtain QOLHEQ values that are comparable across countries. Cross-cultural variations in the interpretation of single items were resolved. The QOLHEQ is now ready to be used in international studies assessing the health-related quality of life impact of hand eczema.

Fragility of epidermis in newborns, children and adolescents

Within their first days of life, newborns' skin undergoes various adaptation processes needed to accommodate the transition from the wet uterine environment to the dry atmosphere. The skin of newborns and infants is considered as a physiological fragile skin, a skin with lower resistance to aggressions. Fragile skin is divided into four categories up to its origin: physiological fragile skin (age, location), pathological fragile skin (acute and chronic), circumstantial fragile skin (due to environmental extrinsic factors or intrinsic factors such as stress) and iatrogenic fragile skin. Extensive research of the past 10 years have proven evidence that at birth albeit showing a nearly perfect appearance, newborn skin is structurally and functionally immature compared to adult skin undergoing a physiological maturation process after birth at least throughout the first year of life. This article is an overview of all known data about fragility of epidermis in 'fragile populations': newborns, children and adolescents. It includes the recent pathological, pathophysiological and clinical data about fragility of epidermis in various dermatological diseases, such as atopic dermatitis, acne, rosacea, contact dermatitis, irritative dermatitis and focus on UV protection.

Guidelines for diagnosis, prevention and treatment of hand eczema

The guidelines aim to provide advice on the management of hand eczema (HE), using an evidence- and consensus-based approach. The guidelines consider a systematic Cochrane review on interventions for HE, which is based on a systematic search of the published literature (including hand-searching). In addition to the evidence- and consensus-based recommendation on the treatment of HE, the guidelines cover mainly consensus-based diagnostic aspects and preventive measures (primary and secondary prevention). Treatment recommendations include non-pharmacological interventions, topical, physical and systemic treatments. Topical corticosteroids are recommended as first line treatment in the management of HE, however continuous long-term treatment beyond six weeks only when necessary and under careful me-dical supervision. Alitretinoin is recommended as a second line treatment (relative to topical corticosteroids) for patients with severe chronic HE. Randomized control trials (RCT) are missing for other used systemic treatments and comparison of systemic drugs in “head-to-head” RCTs are needed.The guidelines development group is a working group of the European Society of Contact Dermatitis (ESCD) and has carefully tried to reconcile opposite views, define current optimal practice and provide specific recommendations, and meetings have been chaired by a professional moderator of the AWMF (Arbeitsgemeinschaft der Wis-senschaftlichen Medizinischen Fachgesellschaften; Association of the Scientific Medi-cal Societies in Germany).No financial support was given by any medical company. The guidelines are expected to be valid until December 2017 at the latest.

Recent Trends in Occupational Contact Dermatitis

Occupational contact dermatitis (OCD) remains prevalent among workers and impacts quality of life and workability. The purpose of this review is to summarize the recent advances in occupational contact dermatitis as well as potential hazardous agents in the workplaces causing OCD. The review covers new developments in the epidemiology, etiology, diagnosis, and management of occupational contact dermatitis. This article also provides updated information on the prevalence of work-related skin symptoms and on new contact allergens among working population. It is emphasized that in the context of prevention of OCD, special attention should be focused on the identified high-risk occupational groups, especially healthcare workers and hairdressers starting with the apprentices. Current approaches include working out the standards and guidelines to improve the education, knowledge, diagnosis, and management of OCD based on a multidisciplinary team of medical specialists and an employer.

Hand dermatitis: a review of clinical features, prevention and treatment

Hand dermatitis is a socially significant health problem. This review provides a discussion on the clinical features and patterns as well as the differential diagnosis of hand dermatitis, because these are essential for proper diagnosis in clinical practice. The morphology, however, is poorly related to the etiology in chronic cases. In all cases of chronic hand dermatitis, a full diagnostic examination should be undertaken and the etiology should be clarified and addressed in the treatment concept, instead of just moving directly from a morphological diagnosis to therapy. Preventive measures should be included in the treatment concept according to etiology. A stepwise approach for escalating therapy is advised, including basic topical therapy, topical corticosteroids, calcineurin inhibitors, as well as phototherapy and systemic therapy with corticosteroids, alitretinoin, cyclosporine, methotrexate, azathioprine, and others.

Management of Chronic Hand Eczema

Management of hand eczema is complex because of the broad range of different pathogeneses, courses, and prognoses. Furthermore, the efficacy of most available treatments is not well established and the more severe forms can have a major impact on the patient's quality of life. Patient education, preventive measures, and the use of emollients are the mainstays in the management of hand eczema. High-potency topical corticosteroids are the treatment of choice, with calcineurin inhibitors used for maintenance. Phototherapy or systemic treatments are indicated in patients who do not respond to topical treatments. Switching from topical treatments should not be delayed to avoid sensitizations, time off work, and a negative impact on quality of life. Alitretinoin is the only oral treatment approved for use in chronic hand eczema.

Systemic antihistamines--a common outside the guidelines therapeutic strategy in hand eczema management

BACKGROUND

Hand eczema (HE) is the most common skin disease affecting hands. Although the current treatment guidelines do not recommend use of systemic antihistamines as routine therapy, they seem to be widely used by physicians handling with this problem.

OBJECTIVE

The aim of the study was to investigate the attitude to prescribe systemic antihistamines in HE.

MATERIAL AND METHODS

A 10-item questionnaire was distributed among physicians participating in regional dermatological conferences. 127 valid questionnaires were analysed.

RESULTS

A total of 127 physicians participated in the survey. 124 (97.6%) responders prescribe antihistamines in HE and 16 (12.6%) subjects declared routine use of oral antihistamines in the HE management. Significantly more dermatologists than other specialists used antihistamines in the treatment of HE accompanying atopic dermatitis (77.8% vs. 54.5%, P < 0.01) and dermatologists significantly more commonly used antihistamines in HE due to their anti-inflammatory properties (40.3% vs. 20.0%, P = 0.02). Regarding the type of eczema, antihistamines were prescribed most frequently in acute allergic HE (n = 92, 72.4%) and in HE accompanying atopic dermatitis (n = 86, 67.7%).

CONCLUSIONS

Despite the lack of the large, randomized, controlled studies on the effectiveness of the systemic antihistamines in the treatment of HE, this type of therapy seems to be prevalently used among the physicians.

Itching in patients with chronic hand eczema: data from the CARPE registry

BACKGROUND

Itching is a leading symptom of chronic hand eczema (CHE) having a great impact on patients. The determinants of itching in CHE are unclear.

OBJECTIVE

We performed a cross-sectional analysis investigating factors associated with the presence and severity of itch in CHE patients from the CARPE registry.

METHODS

We present baseline data on itch in relationship with sociodemographic factors, severity of CHE, atopy, contact allergy, treatment and patient- reported outcomes including health-related quality of life (HRQoL).

RESULTS

Of 1,051 patients with CHE, 78.1% reported itching. Significant positive associations with itching were observed for younger age groups (17-25 and 26-45 years), for moderate, severe and very severe CHE and for small/moderate impairment in HRQoL. Atopic skin diathesis, hardly being able to realize treatment recommendations and very or extremely large impairments in HRQoL were associated with itch severity.

CONCLUSION

Taking the identified variables into account may help identify vulnerable groups most affected by (severe) itch.

The combined diagnosis of allergic and irritant contact dermatitis in a retrospective cohort of 1000 consecutive patients with occupational contact dermatitis

BACKGROUND

The diagnosis of combined allergic and irritant contact dermatitis is an accepted subdiagnosis for hand dermatitis, and it is often considered in a patient with contact dermatitis, a positive and relevant patch test result, and wet work exposure. We therefore hypothesize that it is arbitrary for wet work exposure to be taken into consideration in a patient with newly diagnosed relevant contact allergy. Furthermore, an overestimation of the diagnosis will probably occur if the criteria for wet work exposure are applied correctly, as many occupations have an element of wet work.

OBJECTIVES

To find the statistically expected number of combined allergic and irritant contact dermatitis cases in 1000 patients, and to evaluate the diagnostic criteria for the diagnosis.

METHODS

One thousand consecutive patients with occupational contact dermatitis from a hospital unit in Denmark were assessed.

RESULTS

The expected number of cases with the diagnosis of combined allergic and irritant contact dermatitis was 0.33%, as compared with the observed number of 6.4%. Females occupied in wet occupations were often diagnosed with combined allergic and irritant contact dermatitis (p < 0.005).

CONCLUSION

The diagnosis of combined allergic and irritant contact dermatitis should be used critically to avoid misclassification, and possible criteria for the diagnosis are proposed.

[Skin tests in chronic hand dermatitis]

Chronic hand dermatitis is often multifactorial but allergic causes are frequent and can complicate atopic dermatitis or irritant dermatitis. The management of patients affected by hand dermatitis includes detailed interrogation and a complete examination of the skin. Allergologic tests must be systematically realized if examination is suggestive of contact dermatitis or protein contact dermatitis, if an occupational origin is suspected but also in all patients in which treatment is ineffective. Skin tests include patch tests with the European standard series, specialized or additional series if necessary. Skin tests may also include personal items used by patients on a daily basis. If protein contact dermatitis is suspected skin tests include prick tests. Only complete and definitive eviction of allergens can allow a complete and definitive cure of chronic hand dermatitis.

The Quality of Life in Hand Eczema Questionnaire (QOLHEQ): validation of the German version of a new disease-specific measure of quality of life for patients with hand eczema

BACKGROUND

Health-related quality of life (HRQOL) is widely used as a patient-reported outcome to evaluate clinical trials. In routine care it can also be used to improve treatment strategies or to enhance patients' self-awareness and empowerment. Therefore a disease-specific instrument is needed that assesses in detail all the impairments caused by the disease of interest. For patients with hand eczema (HE) such an instrument was developed by an international expert group, but its measurement properties are unknown.

OBJECTIVES

To validate the German version of the Quality of Life in Hand Eczema Questionnaire (QOLHEQ), which covers the domains of (i) symptoms, (ii) emotions, (iii) functioning and (iv) treatment and prevention.

METHODS

The QOLHEQ was assessed up to three times in 316 patients with HE to test reliability and sensitivity to change. To test construct validity we also assessed several reference measures. The scale structure was analysed using the Rasch model for each subscale and a structural equation model was used to test the multi domain structure of the QOLHEQ.

RESULTS

After minor adaptions of the scoring structure, all four subscales of the QOLHEQ did not significantly misfit the Rasch model (α > 0·05). The fit indices of the structural equation model showed a good fit of the multi domain construct with four subscales assessing HRQOL. Nearly all a priori-defined hypotheses relating to construct validity could be confirmed. The QOLHEQ showed a sensitivity to change that was superior compared with all reference measures.

CONCLUSIONS

The QOLHEQ is ready to be used in its German version as a sensitive outcome measure in clinical trials and for routine monitoring. The treatment-relevant subscales enable its use to enhance patients' self-awareness and to monitor treatment decisions.

Hand eczema

Hand eczema is often a chronic, multifactorial disease. It is usually related to occupational or routine household activities. Exact etiology of the disease is difficult to determine. It may become severe enough and disabling to many of patients in course of time. An estimated 2-10% of population is likely to develop hand eczema at some point of time during life. It appears to be the most common occupational skin disease, comprising 9-35% of all occupational diseases and up to 80% or more of all occupational contact dermatitis. So, it becomes important to find the exact etiology and classification of the disease and to use the appropriate preventive and treatment measures. Despite its importance in the dermatological practice, very few Indian studies have been done till date to investigate the epidemiological trends, etiology, and treatment options for hand eczema. In this review, we tried to find the etiology, epidemiology, and available treatment modalities for chronic hand eczema patients.

Comparison of four methods for assessment of severity of hand eczema

BACKGROUND

Several instruments for the assessment of the severity of hand eczema and health-related quality of life (HR-QoL) related to hand eczema have been developed.

OBJECTIVES

The aim of the present study was to evaluate the correlation between frequently used methods.

METHODS

Consecutive patients with current hand eczema from three different centres participated in the study. Severity of hand eczema was assessed with the Hand Eczema Severity Index (HECSI), the Physician Global Assessment (PGA), the Clinical Photo Guide, and the Dermatology Life Quality Index (DLQI).

RESULTS

One hundred and nineteen patients with hand eczema were included in the study. All six pairwise correlation coefficients between the tested methods were highly statistically significant. Correlation was highest between the HECSI and the PGA (r = 0.82), and weakest, although still statistically significant, between the DLQI and the other three severity scores (r between 0.30 and 0.45). Age and frequency of eruptions did not influence the correlations. With respect to sex, there was a tendency for correlation between methods to be higher for men than for women.

CONCLUSION

We found an overall positive correlation between the four severity assessments applied. As the weakest correlation was found between the DLQI and the other methods, it is suggested that measurement of HR-QoL should be included for assessment of the severity and consequences of hand eczema, but the finding also indicates that a disease-specific tool for evaluation of HR-QoL in hand eczema patients is needed.

Alitretinoin for the treatment of severe chronic hand eczema

Chronic hand eczema is a common and often debilitating condition. Alitretinoin, a 9-cis-retinoic acid and pan-retinoic acid agonist, is a new and effective systemic treatment for chronic hand eczema, which provides another treatment option. A "clear" or "almost clear" response can be achieved in up to half of patients within a 24-week course of treatment. Even higher rates of remission can be obtained with a longer duration of treatment. Alitretinoin has a favorable overall profile of adverse effects; however, female patients who are at risk of becoming pregnant should follow a strict pregnancy-prevention program due to the teratogenic effects of this drug.

Skin care education and individual counselling versus treatment as usual in healthcare workers with hand eczema: randomised clinical trial

OBJECTIVE

To evaluate the effect of a secondary prevention programme with education on skin care and individual counselling versus treatment as usual in healthcare workers with hand eczema.

DESIGN

Randomised, observer blinded parallel group superiority clinical trial.

SETTING

Three hospitals in Denmark.

PARTICIPANTS

255 healthcare workers with self reported hand eczema within the past year randomised centrally and stratified by profession, severity of eczema, and hospital. 123 were allocated to the intervention group and 132 to the control group.

INTERVENTIONS

Education in skin care and individual counselling based on patch and prick testing and assessment of work and domestic related exposures. The control was treatment as usual.

MAIN OUTCOME MEASURES

The primary outcome was clinical severity of disease at five month follow-up measured by scores on the hand eczema severity index. The secondary outcomes were scores on the dermatology life quality index, self evaluated severity of hand eczema, skin protective behaviours, and knowledge of hand eczema from onset to follow-up.

RESULTS

Follow-up data were available for 247 of 255 participants (97%). At follow-up, the mean score on the hand eczema severity index was significantly lower (improved) in the intervention group than control group: difference of means, unadjusted -3.56 (95% confidence interval -4.92 to -2.14); adjusted -3.47 (-4.80 to -2.14), both P<0.001 for difference. The mean score on the dermatology life quality index was also significantly lower (improved) in the intervention group at follow-up: difference of means: unadjusted -0.78, non-parametric test P=0.003; adjusted -0.92, -1.48 to -0.37). Self evaluated severity and skin protective behaviour by hand washings and wearing of protective gloves were also statistically significantly better in the intervention group, whereas this was not the case for knowledge of hand eczema.

CONCLUSION

A secondary prevention programme for hand eczema improved severity and quality of life and had a positive effect on self evaluated severity and skin protective behaviour by hand washings and wearing of protective gloves.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01012453.

"The itching hand"- important differential diagnoses and treatment

Skin diseases affecting the hands receive particular individual attention and constitute a considerable emotional burden. Many dermatoses also present with itching of the hands. Itch is often underestimated when it occurs in a comparably limited body area such as the hands. The high occupational significance of the hands in many professions must, nevertheless, be stressed. One of the most frequent diagnoses in itching of the hands is eczema. In the differential diagnosis, less common diseases such as neurological and systemic diseases and adverse drug reactions must also be taken into consideration. Itching of the hands can also be accompanied by other sensations, such as burning, stinging and pain. A thorough history regarding sensations and dysesthesias already allows for a diagnostic classification of the disease in some cases. Itching of the hands requires a careful and thorough diagnostic approach. This forms the basis of a specific and successful therapy which may be adapted stepwise, depending on the underlying cause, and also may require, in addition to causal therapy, symptomatic antipruritic therapy. Therapy should follow the current guidelines for chronic pruritus and hand eczema. This article reviews over the differential diagnosis and therapy of "itching hands".

The Quality of Life and Depressive Mood among Korean Patients with Hand Eczema

Background

Hand eczema is a disease frequently observed in dermatological practice. This condition has negative emotional, social, and psychological effects due to its impact on daily life and morphological appearance. Due to its considerable effect on the quality of life, this disease can lead to depression. However, not many studies have been performed on the quality of life and depression in hand eczema patients.

Objective

The purpose of this study is to investigate the association between the quality of life, depression, and disease severity in hand eczema patients in South Korea.

Methods

A total of 138 patients with hand eczema participated in this study. The patients' quality of life was assessed by a self-administered questionnaire using the Dermatology Life Quality Index (DLQI). Data on patients suffering from depression was obtained using the Beck's Depression Inventory (BDI-II). The disease severity was determined during the clinical examination, according to the Hand Eczema Severity Index (HECSI).

Results

We found positive associations between DLQI and HECSI scores (p<0.05). BDI-II scores had also statistically positive correlations with HECSI scores (p<0.05). DLQI and BDI-II scores both increased with disease severity.

Conclusion

Hand eczema negatively affected the quality of life and mood of patients relative to the disease severity. Therefore, we suggest that quality of life modification and emotional support should be included as a part of treatment for hand eczema.

Hand eczema

Hand eczema is an inflammation of the skin; the cause is often multifactorial. Initial management includes avoiding causative irritants or allergens (e.g., by wearing impermeable gloves) and applying emollients and potent topical glucocorticoids.

Canadian hand dermatitis management guidelines

BACKGROUND

Hand dermatitis (HD) is one of the most common skin conditions; however, it is not a homogeneous disease entity. The severity of HD may range from very mild cases to severe chronic forms, which may result in prolonged disability and, occasionally, refractory HD. Chronic hand dermatitis (CHD) is associated with a high health- economic burden and significant loss of quality of life.

OBJECTIVE

Although numerous treatment options are available, the management of CHD is often difficult and unsatisfactory. There is a paucity of well-designed, randomized, controlled clinical trials in support of the efficacy of established treatment modalities.

CONCLUSION

These guidelines cover the epidemiology, burden, quality of life, etiology, diagnosis, classification, and prevention of HD and provide guidance on management using an approach that is as evidence based as possible.

Diagnosing chronic hand eczema by an algorithm: a tool for classification in clinical practice

BACKGROUND

Diagnostic classification of chronic hand eczema (CHE) represents a major clinical and taxonomic challenge because of its wide aetiological and clinical heterogeneity.

AIM

To develop an algorithm for the diagnosis and classification of CHE.

METHODS

Well-defined aetiological, clinical and morphological criteria of CHE were arranged graphically in a diagnostic hierarchy, and validated in 137 German patients with hand eczema.

RESULTS

The algorithm distinguished chronic hand eczema due to contact allergy, irritant damage or a combination of the two, each either with or without atopy, and also atopic hand eczema and idiopathic hand eczema lacking obvious causative factors. Foot involvement helped to distinguish idiopathic from irritant hand eczema. Each subtype could occur either with a hyperkeratotic-rhagadiform, dyshidrotic or mixed morphology, but certain hand eczema subtypes had clear morphological preferences.

CONCLUSIONS

By providing a more precise clinical definition this diagnostic algorithm could improve the classification and taxonomy of hand eczema subtypes, facilitating more rational treatment decisions and allowing better treatment outcome analysis.

Hand eczema guidelines based on the Danish guidelines for the diagnosis and treatment of hand eczema

BACKGROUND

Classification of hand eczema has traditionally been based both on aetiology and clinical appearance. For 20% of cases, the aetiology is unknown.

OBJECTIVES

To suggest a classification based on well-defined aetiology as well as on predefined clinical patterns and on the dynamics of hand eczema.

METHODS

Literature studies and discussions among members of the Danish Contact Dermatitis Group.

RESULTS

Criteria are given for the aetiological diagnoses of allergic contact dermatitis of the hands, irritant contact dermatitis of the hands, protein contact dermatitis of the hands, atopic hand eczema and aetiologically unclassifiable hand eczema. Six different clinical patterns are described and illustrated. Suggestions for general treatment principles are given.

CONCLUSION

Operational guidelines for the diagnosis and treatment of hand eczema are described.

Recent advances in the management of hand dermatitis: does alitretinoin work?

Hand dermatitis can cause significant morbidity. It is not only pruritic, painful, and adversely affects manual dexterity, but it is also very visible, resulting in a substantial psychosocial and physical impact. The prevalence of hand dermatitis in the general population is 5% to 10%, and it appears to be twice as common in women than in men. Certain occupations predispose workers to hand dermatitis, especially those that require frequent hand washing or exposure to particular substances such as solvents. Hand dermatitis has a significant economic effect on society, and the socioeconomic and psychologic effect for the individual can be catastrophic. The need for effective management of this condition is, therefore, quite clear; however, historically hand dermatitis is difficult to treat. This contribution reviews the various types of hand dermatitis and how best to manage them and examines the role which the recently introduced drug alitretinoin now plays in managing this clinically challenging condition.

Gender aspects in skin diseases

Gender differences in medicine have been recognized in anatomy, physiology, as well as in epidemiology and manifestations of various diseases. With respect to skin disorders, males are generally more commonly afflicted with infectious diseases while women are more susceptible to psychosomatic problems, pigmentary disorders, certain hair diseases, and particularly autoimmune as well as allergic diseases. Significantly, more female sex-associated dermatoses can be identified than the male sex-associated dermatoses. Dermatoses in the genital area differ between men and women. Gender differences also exist in the occurrence and prognosis of certain skin malignancies. The mechanisms underlying gender differences in skin diseases remain largely unknown. Differences in the skin structure and physiology, effect of sex hormones, ethnic background, sociocultural behaviour and environmental factors may interact to exert the influences. A better understanding of gender differences in human health and diseases will allow the development of novel concepts for prevention, diagnosis and therapy of skin diseases.