Interventions for hand eczema

Adverse events from topical corticosteroid use in chronic hand eczema - Findings from the Danish Skin Cohort

Background

Topical corticosteroids (TCS) are used to treat most patients with chronic hand eczema (CHE), but knowledge about TCS-related adverse events in CHE is limited.

Objectives

To investigate patient-reported adverse events to TCS in CHE patients.

Methods

Data on adverse events related to TCS use in patients with CHE were analyzed from the Danish Skin Cohort; a prospective survey of a hospital cohort. We assessed patients' knowledge about TCS use and adverse event risks, and preference of TCS versus a nonsteroidal topical alternative.

Results

Of 724 adults with CHE (64.0% women; mean age 57.5 [standard deviation 12.8] years), 64.1% reported skin atrophy, 41.4% cracks/fissures, 23.9% bleeding, 45.9% pain/stinging sensation, 40.0% reduced hand dexterity, and 40.2% worsening of CHE signs or symptoms from using TCS. We observed CHE-severity-dependent associations (all groups; P < .0001). Most patients (76.4%) would prefer a nonsteroidal option, 10.9% were neutral/indifferent, and 12.7% would prefer TCS for CHE. The median numerical rating scale-score (ranging from 0 to 10) was 10 (interquartile range 6-10) for preferring a nonsteroidal topical treatment.

Limitations

Differences across TCS formulations were unexplored.

Conclusion

TCS-related cutaneous adverse events were common. There is a desire from patients for novel steroid-free topical alternatives for CHE treatment.

Occupational Dermatitis Treated with Alitretinoin

Occupational allergic contact dermatitis is an occupational skin condition which is characterized by a delayed cell-mediated hypersensitivity reaction triggered by one or more work-related substances. In this article, we describe a hairdresser who presented with occupational allergic contact dermatitis and was treated with alitretinoin. It is important to emphasize the value of early diagnosis and treatment of occupational contact dermatitis as this allows us to tackle the physical, psychosocial and cost-related burdens that this disorder brings.

The pan-JAK inhibitor delgocitinib in a cream formulation demonstrates dose-response in chronic hand eczema in a 16-week randomised phase 2b trial

BACKGROUND

Chronic hand eczema (CHE) is a burdensome disease, and new well-documented, safe, and efficacious treatments are warranted. In a recent CHE phase 2a trial, the pan-Janus kinase (JAK) inhibitor delgocitinib in an ointment formulation was found to be efficacious and well-tolerated.

OBJECTIVES

This trial assessed the dose-response, efficacy, and safety of delgocitinib cream in CHE.

METHODS

In this double-blind, phase 2b dose-ranging trial, adults with CHE and a recent history of inadequate response or contraindication to topical corticosteroids were randomised to delgocitinib cream 1, 3, 8, 20 mg/g or vehicle treatment twice daily for 16 weeks. Primary endpoint was Investigator's Global Assessment for CHE (IGA-CHE) treatment success (0 [clear] or 1 [almost clear] with a ≥2-point improvement from baseline to Week 16). Secondary endpoints were time to IGA-CHE treatment success and changes in Hand Eczema Severity Index (HECSI); other endpoints were itch and pain NRS scores, and Patient's Global Assessment (PaGA) at Week 16.

RESULTS

258 patients were randomised 1:1:1:1:1 to delgocitinib cream 1, 3, 8, 20 mg/g or vehicle. A significant dose-response relationship was established for IGA-CHE (p<0.025). IGA-CHE treatment success at Week 16 was achieved in 21.2% (1 mg/g), 7.8% (3 mg/g), 36.5% (8 mg/g), 37.7% (20 mg/g), and 8.0% (vehicle) of patients. Delgocitinib 8 and 20 mg/g showed a treatment effect against vehicle (p<0.001). Similarly, there were improvements in HECSI, itch and pain NRS scores, and PaGA. Delgocitinib cream was well-tolerated with majority of adverse events being mild or moderate and considered unrelated to treatment. Most frequently reported adverse events were nasopharyngitis (17.3%-29.4% in delgocitinib groups vs 40% in vehicle group), eczema (5.8%-11.3% in delgocitinib groups vs 16.0% in vehicle group) and headache (3.8%-11.5% in delgocitinib groups vs 4.0% in vehicle group).

CONCLUSIONS

In this trial, delgocitinib cream showed a dose-response relationship in terms of efficacy and was well-tolerated.

Weak UVB Irradiation Promotes Macrophage M2 Polarization and Stabilizes Atherosclerosis

Atherosclerosis (AS) is a chronic cardiovascular disease endangering human health and is one of the most common causes of myocardial infarction and stroke. Macrophage polarization plays a vital role in regulating plaque stability. As an important component of sunlight, ultraviolet B (UVB) has been proven to promote vitamin D and nitric oxide synthesis. This research used an AS model in ApoE^−/− mice to study the effects of UVB on macrophage polarization and atherosclerotic plaque stability. In vitro, UVB irradiation increased arginase-I (Arg-I, M2 macrophage) and macrophage mannose receptor (CD206) expression, while the expression of inducible nitric oxide synthase (iNOS) (M1 macrophage) and CD86 was decreased. UVB promoted Akt phosphorylation in vitro. In vivo, UVB irradiation promoted the stabilization of atherosclerotic lesion plaques, while the phenotype of M2 macrophages increased. Our research provides new evidence for UVB in preventing and treating atherosclerosis.

2020 Korean Consensus Guidelines for Diagnosis and Treatment of Chronic Hand Eczema

Background

Hand eczema refers to eczema located on the hands, regardless of its etiology or morphology. Despite its high prevalence and significant impact on patients' quality of life, treatment is frequently challenging because of its heterogeneity, chronic and recurrent course, and lack of well-organized randomized controlled trials of the various treatment options.

Objective

These consensus guidelines aim to provide evidence-based recommendations on the diagnosis and management of hand eczema to improve patient care by helping physicians make more efficient and transparent decisions.

Methods

A modified Delphi method, comprising two rounds of email questionnaires with face-to-face meetings in between, was adopted for the consensus process that took place between February and September 2020. Forty experts in the field of skin allergy and contact dermatitis were invited to participate in the expert panel.

Results

Consensus was reached for the domains of classification, diagnostic evaluation, and treatment; and a therapeutic ladder to manage chronic hand eczema was developed.

Conclusion

These are the first consensus guidelines for chronic hand eczema in the Asian population, which will help standardize care and assist clinical decision-making in the diagnosis and treatment of chronic hand eczema.

Drugs for the Treatment of Chronic Hand Eczema: Successes and Key Challenges

Chronic hand eczema (CHE) is a common and burdensome inflammatory skin condition seen in up to 10% of the population, more often in high-risk occupational workers. Topical therapeutics comprise the standard of care, but up to 65% of cases do not resolve after treatment, and moderate-to-severe cases are often resistant to topical therapeutics and require systemic options instead. To date, there are no systemic therapeutics approved to treat CHE in the United States, but several drugs are under investigation as potential treatments for CHE. The primary focus of this review is on the novel therapeutics, topical and systemic, that are under investigation in recently completed or currently ongoing trials. This review also briefly outlines the existing treatments utilized for CHE, often with limited success or extensive adverse effects. CHE represents a major challenge for physicians and patients alike, and efforts to improve the minimally invasive diagnostic tools and treatment paradigms are ongoing. In the near future, CHE patients may benefit from new topical and systemic therapeutics that specifically target abnormally expressed immune markers.

Management of chronic hand and foot eczema. An Australia/New Zealand Clinical narrative

Chronic hand/foot eczemas are common, but treatment is often challenging, with widespread dissatisfaction over current available options. Detailed history is important, particularly with regard to potential exposure to irritants and allergens. Patch testing should be regarded as a standard investigation. Individual treatment outcomes and targets, including systemic therapy, should be discussed early with patients, restoring function being the primary goal, with clearing the skin a secondary outcome. Each new treatment, where appropriate, should be considered additive or overlapping to any previous therapy. Management extends beyond mere pharmacological or physical treatment, and requires an encompassing approach including removal or avoidance of causative factors, behavioural changes and social support. To date, there is little evidence to guide sequences or combinations of therapies. Moderately symptomatic patients (e.g. DLQI ≥ 10) should be started on a potent/super-potent topical corticosteroid applied once or twice per day for 4 weeks, with tapering to twice weekly application. If response is inadequate, consider phototherapy, and then a 12-week trial of a retinoid (alitretinoin or acitretin). Second line systemic treatments include methotrexate, ciclosporin and azathioprine. For patients presenting with severe symptomatic disease (DLQI ≥ 15), consider predniso(lo)ne 0.5-1.0 mg/kg/day (or ciclosporin 3 - 5 mg/kg/day) for 4-6 weeks with tapering, and then treating as for moderate disease as above. In non-responders, botulinum toxin and/or iontophoresis, if associated with hyperhidrosis, may sometimes help. Some patients only respond to long-term systemic corticosteroids. The data on sequencing of newer agents, such as dupilumab or JAK inhibitors, are immature.