Guidelines for diagnosis, prevention and treatment of hand eczema - short version

Demographics, characteristics and medical treatment among adults with hand eczema in Denmark. A cross-sectional validation and registry-based study

BACKGROUND

The international classification of diseases, 10th revision (ICD-10) includes several unvalidated diagnostic codes for hand eczema (HE). Knowledge is sparse on HE patient characteristics.

OBJECTIVES

To validate selected HE ICD-10 codes in the Danish National Patient Registry (DNPR) and describe disease characteristics, lifestyle factors and medication use in adult HE patients.

METHODS

Nineteen HE ICD-10 codes were selected and validated based on patient charts. Five cohorts were constructed based on the diagnostic code, DL30.8H (HE unspecified), in the DNPR: (i) patients with DL30.8H code (n = 8386), (ii) patients with DL30.8H code, but without atopic dermatitis (AD) (n = 7406), (iii) sex- and age-matched general population (n = 8386) without HE. Two additional cohorts nested in the DNPR included participants from the Danish Skin Cohort, (iv) patients with DL30.8H code but without AD (n = 1340) and (v) general population cohort (n = 9876).

RESULTS

ICD-10 codes revealed positive predictive values ≥90% except irritant contact dermatitis (unspecified) (79.7%) and hyperkeratotic hand and foot eczema (84.1%). HE patients were most often women, middle-aged or older, of Danish ethnicity, had an atopic medical history and were smokers. Topical corticosteroid prescriptions were almost doubled in HE cohorts compared to general populations.

CONCLUSION

We validated several HE ICD-10 codes and identified important HE patient characteristics.

Adolescents' Knowledge and Attitudes Related to Hand Eczema: A Cross-Sectional Study

Background

Hand eczema (HE) is a common inflammatory skin disease occurring in subjects of any age. Literature data on knowledge of HE in different age-groups are scarce.

Purpose

To evaluate knowledge and attitudes related to HE among adolescents.

Methods

A total of 258 high school students were invited to participate in this project. A specially designed questionnaire created on the base of previous studies was used to assess adolescents' knowledge of HE. HE was self-reported answering the validated single question "Have you ever had hand eczema?"

Results

Data from 243 students (94.2% response rate) were obtained for final analysis. There were 117 (48.1%) females and 126 (51.9%), males with a mean age of 16.0±1.7 years. Sixty-eight students (28%) reported a personal history of HE, and 32.8% declared having knowledge of HE. More females than males (P=0.023) declared that they knew what HE was (39.3% and 26.2%, respectively). Hand cream was used on a regular basis by 49% of adolescents. Females used hand cream more frequently (P<0.001) than males. No difference in declared knowledge of HE was found between subjects with and without a personal history of hand lesions. Students declaring having adequate knowledge of HE used hand cream more commonly (P=0.045).

Conclusion

Although HE is a common disease in the general population, including adolescents, less than a third of subjects were aware of this entity. Almost half were using hand cream, but interestingly, personal history of HE did not increase the regular application of hand cream.

Self-reported Versus Physician-reported Severity of Chronic Hand Eczema: Concordance Analysis Based on Data from the German Chronic Hand Eczema Patient Long-Term Management Registry

Self-assessment of general health status has a significant influence on patient-related outcomes. The aims of this study were to investigate and compare the level of agreement between patients' and dermatologists' assessments of the severity of chronic hand eczema. From the German registry "German Chronic Hand Eczema Patient Long-Term Management Registry" (CARPE), 1,281 pairs of patients with chronic hand eczema and their dermatologists were included. Of these, 788 pairs served as a comparison 2 years after baseline. Concordance analyses found that complete concordance between patients' and dermatologists' assessments were 16.62% at baseline and 11.47% at follow-up. Overall, patients assessed their chronic eczema at baseline as more severe than did the dermatologists; whereas, at follow-up, patients assessed their condition as less severe than the dermatologists' assessment. Bangdiwala's B showed lower values of concordance for womens' and older patients' self-assessment with the dermatologists' assessments. In conclusion, dermatologists should consider the patient's perspective and the individual's assessment of their chronic hand eczema in order to provide effective care in clinical practice.

Artificial Intelligence in Dermatology Image Analysis: Current Developments and Future Trends

BACKGROUND

Thanks to the rapid development of computer-based systems and deep-learning-based algorithms, artificial intelligence (AI) has long been integrated into the healthcare field. AI is also particularly helpful in image recognition, surgical assistance and basic research. Due to the unique nature of dermatology, AI-aided dermatological diagnosis based on image recognition has become a modern focus and future trend. Key scientific concepts of review: The use of 3D imaging systems allows clinicians to screen and label skin pigmented lesions and distributed disorders, which can provide an objective assessment and image documentation of lesion sites. Dermatoscopes combined with intelligent software help the dermatologist to easily correlate each close-up image with the corresponding marked lesion in the 3D body map. In addition, AI in the field of prosthetics can assist in the rehabilitation of patients and help to restore limb function after amputation in patients with skin tumors.

THE AIM OF THE STUDY

For the benefit of patients, dermatologists have an obligation to explore the opportunities, risks and limitations of AI applications. This study focuses on the application of emerging AI in dermatology to aid clinical diagnosis and treatment, analyzes the current state of the field and summarizes its future trends and prospects so as to help dermatologists realize the impact of new technological innovations on traditional practices so that they can embrace and use AI-based medical approaches more quickly.

Patients' perspectives on quality of care for chronic hand eczema: a qualitative study

Background

Hand eczema (HE) has a significant impact on patients’ quality of life and work‐related activities. However, little is known about the patients' perspectives on quality of care for HE.

Objectives

To evaluate the patient perspective of the HE care process in a tertiary referral center.

Methods

Qualitative, semi‐structured focus groups were carried out, recorded, transcribed, and analysed using an inductive‐deductive thematic approach.

Results

Fifteen patients participated in four focus groups. Time and attention, together with being listened to and understood by the health care professional, were the most important aspects of care for HE mentioned by participants. Other aspects of care that were regarded as important were that diagnoses, causes and follow‐up of HE were not always clear to the participant; more psychosocial support was needed, and that participants experienced frequent changes in doctors. Information provided by nurses was valuable, but more individualized advice was needed.

Conclusions

To better meet the needs of patients, more explanation should be given about the causes of HE and the final diagnosis. Besides focusing on the treatment, it is also important to focus on its impact on the patient and options for psychosocial and peer support should be discussed. Furthermore, the beneficial role of the specialized nurse as part of integrated care was emphasized.

Lifetime prevalence and determinants of hand eczema in an adolescent population in Germany: 15-year follow-up of the LISA cohort study

BACKGROUND

Hand eczema is a common inflammatory skin disorder in both adolescence and adulthood.

OBJECTIVES

We sought to assess the lifetime prevalence of hand eczema and associated exogenous and endogenous risk factors among adolescents in Germany.

METHODS

This was a cross-sectional study embedded into a prospective population-based birth cohort in four regions of Germany, which recruited healthy neonates born between November 1997 and January 1999. We included 1736 participants who had completed the 15-year follow-up from birth cohort and 84.6% (1468/1736) had clearly reported whether they have ever had hand eczema. All the data were based on questionnaires and blood tests (immunoglobulin E). Multivariable logistic regression analysis was used to examine endogenous and exogenous factors in relation to the lifetime prevalence of hand eczema among adolescents.

RESULTS

One thousand four hundred and sixty-eight adolescents (715 girls, 48.7%) were included in the final analysis. The lifetime prevalence of hand eczema among adolescents at the age of 15 was 10.4% (95% confidence interval [CI]: 8.9%-12.1%), with a significantly higher lifetime prevalence among girls than boys (12.7% vs. 8.2%, P = 0.005). Multivariable logistic regression analysis indicated statistically significant associations between the lifetime prevalence of hand eczema and having ever been diagnosed with atopic dermatitis (aOR = 1.8, 95% CI: 1.1-2.8) or having ever had dry skin (aOR = 1.9, 95% CI: 1.1-3.1), respectively. No statistically significant independent associations were found between asthma, hay fever, allergy-related clinical symptoms, immunoglobulin E positivity and other exogenous factors in relation to hand eczema.

CONCLUSION

Our study fills a research gap on the epidemiological burden of hand eczema among adolescents. One out of ten ever suffered from hand eczema until age 15 years indicating that hand eczema constitutes a significant burden in paediatric populations. The role of atopic dermatitis in hand eczema reinforces previous findings. Exogenous risk factors warrant further investigation.

Increased prevalence of irritant hand eczema in health care workers in a dermatological clinic due to increased hygiene measures during the SARS-CoV-2 pandemic

BACKGROUND

Hand hygiene measures in the general population and in health care workers have increased considerably since the outbreak of the COVID-19 pandemic.

OBJECTIVES

To investigate the prevalence and symptoms of hand eczema, as well as hygiene measures and concepts of care, in German health care workers.

MATERIALS & METHODS

This was an observational questionnaire study to investigate hygiene and skin care habits, as well as the prevalence and symptoms of hand eczema in 66 nurses and doctors of our dermatology department before and during the SARS-CoV-2 pandemic.

RESULTS

Hand washing and hand disinfection procedures increased significantly during the COVID-19 pandemic. Self-diagnosed hand eczema was reported by 33% of the participants, with a median duration of 14 days. The majority of staff currently affected by hand eczema were free of eczema a month previously (82%) and would treat their skin condition with emollients (77%). Erythema, scaling, burning and fissures were reported by 66.1% of the participants and were classified as predominant signs of toxic-irritant hand dermatitis rather than contact allergy.

CONCLUSION

Overall, the SARS-CoV-2 pandemic has led to a significant increase in the incidence of signs of irritant hand eczema despite intensified emollient use as a preventive measure. Awareness of the prevalence of hand eczema in health care workers in Germany during the COVID-19 pandemic should be raised, and preventive measures should be intensified.

Handekzem – Gleiche Therapie für alle Formen?

Es gibt nicht einen einzigen Typ des chronischen Handekzems (CHE) – weder morphologisch noch immunologisch. Schutz und Präventionsmaßnahmen können für alle Typen des CHE definiert werden. Die Therapie muss passen und zielgerichtet sein. Einige Therapien können jedoch für alle Typen des Handekzems angeboten werden wie topische Kortikosteroide, Calcineurinantagonisten, UV-Therapie und Alitretinoin, ggf. auch Dupilumab, was in größeren Studien untersucht werden sollte. Die Wahrnehmung des Handekzems sollte gerade in Zeiten der Irritation durch Desinfektion der Hände erhöht werden, damit Prävention und frühzeitige Therapie erfolgen können.

New evidence on the minimal important change (MIC) for the Hand Eczema Severity Index (HECSI)

BACKGROUND

How changes in hand eczema (HE) severity correlate with the single scores on the Hand Eczema Severity Index (HECSI) is sparsely investigated and particularly needed in clinical trials.

OBJECTIVES

To find the minimal important change (MIC) for HECSI based on patient's and physician's assessments using different methods.

METHODS

In this prospective follow-up study, three different anchors were used: two anchor questions for patients and physician, respectively, and the Physician Global Assessment (PGA) with a photographic guide. MIC was estimated by mean change in patients with a one-step increase to anchor-questions, receiver-operating characteristic (ROC) plot, and smallest detectable change (SDC).

RESULTS

One hundred fifty-two patients with HE (63.8% female) were included at baseline (89% completed follow-up). The mean change, ROC cutoff, and SDC values were 7.1, 4.5, 21.4 (patient-rating), 8.2, 4.5, 8.3 (physician-rating), and 16.6, 6.5, 27.1 points (PGA), respectively. SDC stratified by baseline severity was 2.9 and 11 points for mild and moderate-severe HE (physician-rating), respectively.

CONCLUSION

Identification of the MIC for the HECSI is important in relation to evaluation of treatment, intervention, and sample-size calculations. An improvement of 8.3 points on the HECSI is recommended as the MIC. MIC values may differ according to baseline severity, and this variation should be clarified in future studies.

Prevalence, incidence, and severity of hand eczema in the general population - A systematic review and meta-analysis

Accurate assessments of the burden of hand eczema (HE) in the general population are important for public awareness and intervention. The aim of this systematic review and meta-analysis was to provide updated estimates of prevalence and incidence, alongside additional epidemiological endpoints on HE in the general population. PubMed, Embase and Web of Science were searched for studies reporting the prevalence and/or incidence of HE in the general population. Proportion meta-analyses were performed to calculate pooled estimates of prevalence, incidence, severity, and the proportion of individuals with HE and a history of atopic dermatitis. Sixty-six studies were included in the quantitative analysis encompassing 568 100 individuals. The pooled estimates for lifetime, 1-year, and point prevalence were 14.5% (95% confidence interval [CI]: 12.6-16.5), 9.1% (95% CI: 8.4-9.8) and 4.0% (95% CI: 2.6-5.7), respectively. The pooled incidence rate of HE was 7.3 cases/1000 person-years (95% CI: 5.4-9.5). The occurrence of HE was 1.5-2 times higher in females than males. More than one third suffered from moderate/severe disease and around one third had a history of atopic dermatitis. HE was a recurrent, long-lasting disease with an average age at onset of the early- to mid-twenties. In conclusion; HE is a highly prevalent disease in the general population and carries a significant risk of long-term or chronic disease.

Berufsdermatologie: Was ist neu im Jahr 2021?

Zum 01. 01. 2021 tritt eine weitreichende Reform des Berufskrankheitenrechts in Kraft, wonach der sog. „Unterlassungszwang“ als Voraussetzung für die Anerkennung einer Berufskrankheit abgeschafft wird. Die Berufskrankheit (BK) Haut Nr. 5101 wird daher neu definiert als „schwere oder wiederholt rückfällige Hauterkrankungen“; ob die Hauterkrankung zur Unterlassung der hautgefährdenden Tätigkeit zwingt und diese unterlassen wurde oder ob Versicherte ihre Tätigkeit fortführen, ist für die Anerkennung einer BK 5101 nicht mehr von Belang. Sind die Voraussetzungen der Schwere und/oder der wiederholten Rückfälligkeit gegeben, ist eine BK-Anzeige zu erstellen und, nach geplanter Ergänzung des Vertrags Ärzte-Unfallversicherungsträger, gleichzeitig ein Hautarztbericht zu erstatten. Mit einer größeren Zahl anerkannter Fälle einer BK 5101 ist zu rechnen; für diese Versicherten besteht dann ein lebenslanges Anrecht auf die dermatologische Versorgung der BK-Folgen durch die Gesetzliche Unfallversicherung und ggf. auch auf eine Rentenzahlung. Zumindest für die Fälle von leichten beruflichen Hauterkrankungen behält das seit 1972 bewährte Hautarztverfahren weiterhin seine Bedeutung.

Keine Änderungen ergeben sich 2021 für die Berufskrankheiten Nr. 5102 (Hautkrebs durch PAK) und 5103 (Plattenepithelkarzinome und multiple aktinische Keratosen durch solare UV-Strahlung). Neue Erkenntnisse ergaben sich jedoch für UV-bedingte Basalzellkarzinome (BZK). In einer jüngst publizierten großen multizentrischen Fall-Kontroll-Studie konnte gezeigt werden, dass bei Personen mit hoher beruflicher UV-Exposition ein mehr als 2-fach signifikant erhöhtes Risiko für BZK an beruflich UV-exponierten Körperlokalisationen besteht. Damit ist für diese Personengruppe das sog. „Verdoppelungsrisiko“ nachgewiesen, und auf der Basis dieser neuen Erkenntnisse ist die Meldung entsprechender Fälle mit einer BK-Anzeige nach § 9 Abs. 2 SGB VII möglich.

Chronic Hand Eczema Guidelines From an Expert Panel of the International Eczema Council

Background

Assessment of chronic hand eczema (CHE) is complex and warrants standardization.

Objective

We sought to guide clinicians on the assessment of CHE.

Methods

An electronic questionnaire regarding the diagnosis and assessment of CHE was completed by councilors (n=45) of the International Eczema Council, an international group of clinicians and researchers with expertise in CHE. The survey consisted of 52 statements for consensus.

Results

Overall, nine statements (17.3%) had strong, twenty-three (44.2%) moderate, 12 (23.1%) low, and 8 (15.4%) very low levels of agreement. Five statements had considerable disagreement, including the value of conducting a skin biopsy (62.2% disagreement), investigating for possible type 1 reactions (60.0%), conducting a fungal culture (44.4%), finding no history of relevant allergens and/or irritants (31.1%) in most or all cases, and performing patch testing irrespective of lesion location and morphology (28.9%). Agreement was generally highest among respondents from Europe (28.6–77.8% agreement), followed by Asia (7.1%–35.7% agreement), North America (0%–35.5% agreement), and other (0%–13.3% agreement).

Conclusions

There were substantial differences of agreement, suggesting there are many knowledge and/or practice gaps with respect to CHE. Future research is needed to inform evidence-based and/or consensus guidelines for CHE.

Safe and effective use of alitretinoin in children with recalcitrant hand eczema and other dermatoses - a retrospective analysis

BACKGROUND

Alitretinoin is a systemic retinoid licensed for use in adult patients suffering from chronic hand eczema recalcitrant to potent topical steroids. Experience with its use in childhood is lacking.

OBJECTIVES

To report on the efficacy and safety of alitretinoin treatment in a cohort of children and adolescents with chronic hand eczema (CHE) and other inflammatory skin diseases.

METHODS

We performed a retrospective chart review of all consecutive patients under the age of 18 years treated with alitretinoin at our paediatric skin centre. Physician's Global Assessment (PGA) was used as the primary outcome measure.

RESULTS

Thirteen children (9 girls and 4 boys) were enrolled in this study. The median age at start of treatment with alitretinoin was 11.5 years (range 5.8-15.8 years). Nine children were diagnosed with CHE, two with severe atopic dermatitis (AD), and two with inherited ichthyosis [netherton syndrome (NS), autosomal recessive congenital ichthyosis (ARCI)]. Moderate to excellent response (PGA decrease of ≥1 point) was observed in 7 (78%) of the nine patients with CHE, one of the two patients with extensive AD and in the one patient with ARCI. In the remaining four subjects, no convincing effect was documented. Tolerability was overall very good. The most common adverse event was headache in 10 patients (77%) during the initiation of treatment, leading to interruption of therapy in one subject.

CONCLUSIONS

Alitretinoin seems to be highly effective and safe for the treatment of paediatric CHE and should thus be considered in children with refractory disease under topical therapy. Larger studies are required to corroborate these findings.

Occupational Dermatosis

PURPOSE OF REVIEW

The purpose of this review is to provide an update on occupational contact dermatitis including gaps in knowledge and practice. Occupational contact dermatitis is the most common occupational skin disease.

RECENT FINDINGS

New sources of exposure for known allergens and new allergens are continually being reported. Through clinical databases and surveillance systems, effects of prevention efforts or introduction of new allergens or new uses of known allergens can be monitored. Though the diagnostic process is clear, there are delays in workers seeking care. As early detection and intervention improves outcomes, screening should be implemented. Gaps in primary prevention in the workplace are identified and should be addressed to reduce the burden of disease. Surveillance systems support the prevention mandate. Understanding limitations of our knowledge and identifying gaps in practice can lead to initiatives to address research and practice needs and improve prevention of occupational dermatoses.

Self-Reported Skin Disorders Among Health Care Workers

This study aimed to estimate the point prevalence and 1-year period prevalence of skin disorder symptoms (SDS) among health care workers (HCWs) and to explore the possible risk factors. A random sample of 400 HCWs from 13 government health centers in Brunei Darussalam self-administered an adapted Nordic Occupational Skin Questionnaire (NOSQ-2002/SHORT). The point and 1-year prevalence of SDS were 12% and 19%, respectively. Having a history of SDS before the current job, exposure to SDS-exacerbating materials at the workplace, and having clinical roles were correlated for both prevalence estimates. Frequent handwashing and moderate use of latex gloves were associated with higher risk of SDS at 1-year. Female HCWs were more likely to report SDS. In multivariate analyses, only contact with SDS-exacerbating materials at the workplace, prejob SDS, and moderate glove usage were significant predictors of SDS.

Effectiveness of a skin care programme for the prevention of contact dermatitis in healthcare workers (the Healthy Hands Project): A single-centre, cluster randomized controlled trial

BACKGROUND

Healthcare workers (HCWs) are at risk of developing hand dermatitis (HD). Guidelines recommend moisturizers to prevent HD, but in practice their effectiveness has been poorly investigated.

OBJECTIVES

To assess whether an intervention aimed at improving skin care leads to a reduction in HD severity.

METHODS

In this 1-year randomized controlled trial, 9 wards (285 HCWs) were allocated to an intervention group (IG), and 10 wards (216 HCWs) were allocated to the control group (CG). The intervention included provision of cream dispensers with electronic monitoring of use, regularly communicated to the HCWs. The primary and secondary outcomes were change from baseline in Hand Eczema Severity Index (HECSI) score (ΔHECSI) and change in natural moisturizing factor (NMF) level (ΔNMF).

RESULTS

At 12 months, the rates of loss to follow-up were 41% and 39% in the IG and the CG, respectively. The HECSI score was reduced in the IG by -6.2 points (95%CI: -7.7 to -4.7) and in the CG by -4.2 points (95%CI: -6.0 to -2.4). There was no significant difference in ΔHECSI or ΔNMF between the groups. Relative improvement in the HECSI score was significantly higher in the IG than in the CG (56% vs 44%). In a subgroup of HCWs with mild HD, the IG showed a larger HECSI score decrease than the CG (P < 0.001).

CONCLUSION

Although there was no significant effect on the primary outcomes, the intervention showed overall positive effects on the HECSI score.

Evaluating the effect of electronic monitoring and feedback on hand cream use in healthcare workers: Healthy Hands Project

BACKGROUND

Healthcare workers (HCWs) are at high risk of developing hand dermatitis (HD). Current guidelines on HD prevention recommend the use of emollients; however, in practice, adherence is poor.

OBJECTIVE

To assess whether the provision of creams, electronic monitoring and feedback on cream consumption can improve skin care in HCWs.

METHODS

A cluster randomized controlled trial was conducted on 19 academic hospital wards, including 501 HCWs, for 12 months. The intervention wards (n = 9; 285 HCWs) were provided with hand cream dispensers equipped with an electronic system to monitor use, which was regularly communicated to the HCWs by the use of posters. The process outcomes were self-reported cream consumption in both groups, and electronically measured consumption per ward in the intervention group (IG) vs the control group (CG).

RESULTS

Self-reported cream use at follow-up was significantly higher in the IG than in the CG, before (odds ratio [OR] 2.27; 95%CI: 1.29-3.97; P = 0.004) and during (OR 3.30; 95%CI: 1.80-6.06, P < 0.001) the shift, whereas at baseline there was no difference between the groups. In the IG, electronically measured cream use was, on average, 0.4 events per shift per HCW.

CONCLUSION

The intervention improved hand cream use, and may therefore be considered as a practical strategy to promote skin care in HCWs. Notwithstanding this, the application frequency remained lower than recommended in the present study and current guidelines.