Therapeutic options for chronic hand dermatitis

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.

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.

Diagnosis and treatment of hand dermatitis

PURPOSE

To enhance the learner's competence with knowledge of hand dermatitis.

TARGET AUDIENCE

: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to: 1. Demonstrate knowledge of the pathophysiology and assessment of, and diagnostic testing for, hand dermatitis. 2. Apply knowledge of hand dermatitis to patient care scenarios for treatment recommendations and patient education. Hand dermatitis is a common disorder with different clinical presentations. Contact (irritant and allergic) dermatitis is the most common subtype with atopic dermatitis and dyshidrotic eczema as common differential diagnoses. The exact diagnosis and differential diagnoses (psoriasis, fungal infections) are important for specific investigations and treatment plans.

Development and validation of a questionnaire on 'Satisfaction with dermatological treatment of hand eczema' (DermaSat)

Objective

To develop a self-administered short questionnaire to assess patient satisfaction with medical treatment for hand eczema (dermatitis) with good psychometric properties.

Method

The content of the questionnaire was determined on the basis of clinical consultation with groups of patients, from studying the existing instruments, and from discussions with a panel of seven experts. A first draft version containing 38 items organised in six dimensions was tested on a pilot sample of patients to assess its legibility. The extended version was then tested on a sample of 217 patients of both genders enrolled at 18 hospitals representative of the national distribution. The questionnaire was supplied together with the Morisky-Green compliance questionnaire, the health-related quality of life (HRQL) SF-12 questionnaire, and a visual analogue scale (VAS) of perceived health status to assess concurrent validity. The dimensionality was reduced by means of exploratory factor analysis, and reliability was evaluated on the basis of internal consistency and two halves reliability estimates. Item discriminant capability and questionnaire discriminant validity with respect to known groups of patients (by gender, principal diagnosis, age, disease severity and treatment) were also assessed.

Results

The reduction and validation sample was composed of 54% women and 46% men, of various educational levels with an average age of 43 years (SD = 13.7). Of those who responded, 26% were diagnosed with hyperkeratotic dermatitis of the palms and 27% of the fingertips, and 47% with recurring palmar dyshidrotic eczema. The questionnaire was shortened to a version containing 17 items grouped in six dimensions: effectiveness, convenience, impact on HRQL, medical follow-up, side effects, and general opinion. Cronbach's alpha coefficient reached a value of 0.9. The dimensions showed different degrees of correlation, and the scores had a normal distribution with an average of 58.4 points (SD = 18.01). Treatment satisfaction scores attained correlations between 0.003 and 0.222 with the HRQL measures, and showed higher correlations with the effectiveness (r = 0.41) and tolerability (0.22) measures, but very low correlation with compliance (r = 0.015). Significant differences were observed between some diagnoses and treatments.

Conclusions

The shortened questionnaire proved to have good psychometric properties, providing excellent reliability, satisfactorily reproducing the proposed structure and supplying evidence of validity.

Hyperkeratosis and Frictional Dermatitis from Practicing Kendo

Repetitive mechanical activity induces a cutaneous reaction. A 22-year-old male presented with painful hyperkeratosis on the right heel. The hyperkeratosis had gradually developed after taking up the practice of Kendo. He also had slightly atrophic macules with scales on the left sole. We believe these lesions were caused by repeated stamping and friction during Kendo practice. Physical stresses can induce some types of skin disorders. We postulate that skin reactions caused by repetitive mechanical activity are more common than generally realized and that the interaction between physical activity and cutaneous reactivity must be examined more closely.

Update on the use of alitretinoin in treating chronic hand eczema

Chronic hand eczema is a debilitating dermatological condition with significant economic, social, and functional impacts. To date, conventional treatments such as topical corticosteroids, phototherapy, and systemic immunosuppressants have yielded disappointing results, owing to either a lack of efficacy or significant adverse events. Oral alitretinoin (9-cis-retinoic acid) is a unique panagonist retinoid with immunomodulatory and anti-inflammatory activity that has emerged as a novel treatment for chronic hand eczema. Several large-scale clinical studies have demonstrated oral alitretinoin’s high efficacy rate of 28% to 89%, its safe tolerability profile, and its positive impact on quality of life, validating it as a therapeutic option for patients with severe chronic hand eczema refractory to standard treatment.

Disidrose: aspectos clínicos, etiopatogênicos e terapêuticos

A disidrose e as erupções disidrosiformes são dermatoses vesiculosas muito freqüentes e de localização palmar e/ou plantar, de difícil tratamento e de evolução recidivante. Sua cura definitiva depende da descoberta do agente etiológico e da possibilidade de sua retirada definitiva. Fatores emocionais, atopia, medicamentos, substâncias de contato, etc. têm sido relatados como seus causadores. Além do tratamento com corticosteróides, atualmente novas drogas têm sido indicadas nos casos mais graves e/ou refratários.

The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis

The topical calcineurin inhibitors (TCIs) pimecrolimus and tacrolimus are approved for atopic dermatitis but have additional potential in other inflammatory skin diseases. This article reviews their clinical use in non-atopic dermatitis diseases. In seborrheic dermatitis, asteatotic eczema, and contact dermatitis, TCIs are of great benefit and can compete with topical corticosteroids. In psoriasis, TCIs have shown clinical efficacy and safety in facial and intertriginous lesions. Further investigations into possible combinations of TCIs with other established treatments such as UVB irradiation in this disorder are necessary. Initial studies in cutaneous lupus erythematosus have been promising, whereas the response in rosacea and rosacea-like eruptions has been mixed. TCIs have been associated with good clinical responses in oral lichen planus and anogenital lichen sclerosus et atrophicus. In vitiligo, TCIs are associated with some degree of repigmentation, with better results being seen in children and in facial and neck areas. TCIs have a synergistic effect with UVB irradiation in vitiligo. There is a long list of small series and case reports documenting use of TCIs in various other skin conditions that warrant further validation. Although the established mode of action of TCIs is T-cell control, other effects also need to be considered. Specifically, TCIs reduce pruritus and erythema, which cannot be explained by T-cell interactions, and further investigations are needed in these fields.

Dyshidrosis: Epidemiology, Clinical Characteristics, and Therapy

Dyshidrosis is a common chronic dermatitis of the hands and feet that may cause significant physical discomfort, psychological distress, and occupational impairment. Topics reviewed in this article include epidemiology, clinical findings, quality of life, and therapeutic considerations. Dyshidrosis is often difficult to manage; therefore, extra attention is given in this review article to current treatment options.

Topical pimecrolimus for skin disease other than atopic dermatitis

Pimecrolimus is an ascomycin macrolactam. It is a specific calcineurin inhibitor that allows topical application. The highly lipophilic nature of this compound reduces the risk of systemic absorption through normal and inflammed skin. Pimecrolimus shows activity not only against T-cell activation, but also against mast cells and pruritus. Pimecrolimus 1% cream is approved for atopic dermatitis, and also has a great potential in other inflammatory skin diseases. Clinical trials have been performed in contact- and seborrhoeic dermatitis, genital lichen sclerosus, intertriginous psoriasis and cutaneous lupus erythematosus. In other diseases, the available data are limited to small case series, or individual cases of graft-versus-host disease or Netherton's disease. Although the use of calcineurin inhibitors in the treatment of vitiligo is promising, detailed studies with pimecrolimus and ultraviolet-irradiation are necessary and there is a need for prospective randomised, double-blind controlled trials.

Radiation Therapy for Chronic Vesicular Hand Dermatitis

BACKGROUND

Chronic vesicular hand dermatitis is a chronic disease that can be debilitating for patients, and many treatment options do not provide lasting remission.

OBJECTIVE

We attempted to determine the efficacy of megavoltage irradiation in the treatment of this disease.

METHODS

Between July 2001 and March 2005, 9 patients with severe chronic vesicular hand dermatitis had megavoltage radiation therapy to their sites of disease. Eight pairs of hands and seven pairs of feet were irradiated (15 total sites).

RESULTS

All patients had an improvement in their disease during the course of radiation therapy. Patients were followed after radiation therapy for a median follow-up time of 20.2 months (range, 1 to 45 months). The disease completely resolved in 7 of the 15 (47%) sites irradiated. There was a decrease in the severity or frequency of flare-ups at the other 8 sites (53%).

CONCLUSION

Megavoltage radiation therapy may be effective in the treatment of chronic vesicular hand dermatitis and may provide durable remissions in some patients.