Association between smoking and hand dermatitis - a systematic review and meta-analysis

Chronic Hand Eczema

Chronic hand eczema (CHE) is a complex, challenging, and frequently multifactorial skin disease of the hands. It is very common in the general population, especially in certain professions. When hand eczema (HE) persists for longer than 3 months or has a minimum of two relapses per year after initial manifestation with complete clearance, it is considered chronic. In this case, health-related quality of life and the patient's working life are often impaired. CHE can be considered as an umbrella term because it covers different clinical pictures and etiologies. To date, there is no definite and unique HE classification. Treatment starts with identifying the individual HE etiology paralleled by symptomatic therapy (local and/or systemic and/or ultraviolet phototherapy). Sustainable management of HE requires the identification and avoidance of its triggering factors, from the professional and private environment. This includes ruling out allergic contact dermatitis if any HE persists for more than 3 months despite adequate therapy. Randomized controlled trials investigating the efficacy in HE are lacking for several treatment modalities. Patient education measures of skin protection and prevention complete the multimodal treatment.

Associations between tobacco smoking status and patch test results-A cross-sectional pilot study from the Information Network of Departments of Dermatology (IVDK)

BACKGROUND

Earlier studies suggested a potential association between tobacco smoking and nickel sensitization, but little is known about other contact allergens.

OBJECTIVES

To investigate the association of smoking status and contact sensitizations as well as subtypes of dermatitis, and to analyse the sensitization profiles of tobacco smokers.

PATIENTS AND METHODS

Within the Information Network of Departments of Dermatology (IVDK), we performed a cross-sectional multicentre pilot study comprising 1091 patch-tested patients from 9 departments, comparing 541 patients with a history of cigarette smoking (281 current and 260 former smokers) with 550 never-smokers.

RESULTS

We could not confirm the previously reported association between nickel sensitization and tobacco smoking. Moreover, sensitizations to other allergens, including colophony, fragrance mix I, Myroxylon pereirae and formaldehyde, were not increased in cigarette smokers compared with never smokers. Hand dermatitis (50.6% vs. 33.6%) and occupational cause (36.2% vs. 22.5%) were significantly more frequent among cigarette smokers compared with never-smokers as shown by non-overlapping 95% confidence intervals.

CONCLUSIONS

Although our study does not allow a firm conclusion on whether smoking status contributes to certain contact sensitizations, it confirms an association of smoking with hand dermatitis and occupational cause.

S2k-Leitlinie Diagnostik, Prävention und Therapie des Handekzems: S2k guideline diagnosis, prevention and therapy of hand eczema

Die S2k‐Leitlinie „Diagnostik, Prävention und Therapie des Handekzems (HE)“ gibt auf der Grundlage eines evidenz‐ und konsensbasierten Ansatzes konkrete Handlungsanweisungen und Empfehlungen für die Diagnostik, Prävention und Therapie des HE. Die Leitlinie wurde auf der Grundlage der deutschen Leitlinie „Management von Handekzemen“ aus dem Jahr 2009 und der aktuellen Leitlinie der European Society of Contact Dermatitis (ESCD) „Guidelines for diagnosis, prevention and treatment of hand eczema“ aus dem Jahr 2022 erstellt. Allgemeines Ziel der Leitlinie ist es, Dermatologen und Allergologen in der Praxis und Klinik eine akzeptierte, evidenzbasierte Entscheidungshilfe für die Auswahl sowie Durchführung einer geeigneten und suffizienten Therapie für Patienten mit Handekzemen zur Verfügung zu stellen. Die Leitlinie basiert auf zwei Cochrane‐Reviews zu therapeutischen und präventiven Interventionen beim HE. Die übrigen Kapitel wurden überwiegend basierend auf nicht systematischen Literaturrecherchen durch die Expertengruppe erarbeitet und konsentiert. Die Expertenkommission bestand aus Mitgliedern von allergologischen und berufsdermatologischen Fachgesellschaften und Arbeitsgruppen, einer Patientenvertretung und Methodikern. Im Rahmen einer Konsensuskonferenz am 15.09.2022 wurden die Vorschläge für die Empfehlungen und Kernaussagen unter Verwendung eines nominalen Gruppenprozesses konsentiert. Der strukturierte Konsensfindungsprozess wurde professionell moderiert. Die vorliegende Leitlinie hat eine Gültigkeit bis zum 22.02.2028.

S2k guideline diagnosis, prevention, and therapy of hand eczema

The consensus-based guideline "Diagnosis, prevention, and treatment of hand eczema (HE)" provides concrete instructions and recommendations for diagnosis, prevention, and therapy of HE based on an evidence- and consensus-based approach. The guideline was created based on the German guideline "Management von Handekzemen" from 2009 and the current guideline of the European Society of Contact Dermatitis (ESCD) "Guidelines for diagnosis, prevention, and treatment of hand eczema" from 2022. The general goal of the guideline is to provide dermatologists and allergologists in practice and clinics with an accepted, evidence-based decision-making tool for selecting and conducting suitable and sufficient therapy for patients with hand eczema. The guideline is based on two Cochrane reviews of therapeutic and preventive interventions for HE. The remaining chapters were mainly developed and consented based on non-systematic literature research by the expert group. The expert group consisted of members of allergological and occupational dermatological professional associations and working groups, a patient representative, and methodologists. The proposals for recommendations and key statements were consented by using a nominal group process during a consensus conference on September 15, 2022. The structured consensus-building process was professionally moderated. This guideline is valid until February 22, 2028.

The Association of Smoking with Contact Dermatitis: A Cross-Sectional Study

Contact dermatitis is a chronic inflammatory skin disorder with a highly variable prevalence worldwide. Smoking plays a crucial role in mediating inflammatory skin conditions such as contact dermatitis. The present study aimed to investigate the association between smoking status and contact dermatitis in the Saudi population. The patients in the present study were individuals older than 18 years who were diagnosed with contact dermatitis and received a patch test at the Department of Dermatology of King Saud University Medical City from March 2003 through February 2019. All patients were interviewed by phone to complete a specific pre-designed questionnaire to assess tobacco use or exposure history. The total number of enrolled patients in the study was 308 (91 males and 217 females), all with contact dermatitis. Data from the present study suggest that the prevalence of allergic contact dermatitis in smokers may be less than that in non-smokers. Moreover, the prevalence of irritant contact dermatitis in smokers is more significant than in non-smokers. Finally, left-hand contact dermatitis is significantly associated with smoking. Therefore, there is a strong association between smoking and irritant contact dermatitis, especially in the Saudi population, regarding the left hand. Further epidemiologic studies are needed to further explore the role of smoking in the occurrence of contact dermatitis and to explore the possible mechanisms.

Risk factors of hand eczema: A population-based study among 900 subjects

BACKGROUND

Many risk factors such as atopic dermatitis (AD) have shown to associate with hand eczema (HE). However, studies concerning other atopic diseases, parental or longitudinal risk factors of HE are scarce.

OBJECTIVES

To examine the association between HE and atopic diseases, parental factors, environmental factors (keeping animals, exposure to moulds) and lifestyle factors (obesity, tobacco smoking, alcohol consumption and physical activity) at population level.

METHODS

Subjects belonging to the Northern Finland Birth Cohort 1966 Study (NFBC1966) (n = 6830) answered a comprehensive health questionnaire. The data was completed with parental information.

RESULTS

HE was reported in 900 (13.3%) individuals. All atopic diseases, parental allergy, female gender and obesity increased the risk of HE whereas physical activity decreased the risk of HE. A statistically significant association was not found between HE and tobacco smoking or alcohol consumption.

CONCLUSIONS

All atopic diseases, not only AD, seem to have influence on the presence of HE. In addition, parental and environmental factors associated with HE.

Incidence Rate of Hand Eczema in Different Occupations: A Systematic Review and Meta-analysis

Hand eczema is a chronic disease that results in economic and psychosocial burdens. The aim of this study was to systematically review and assess the magnitude of the association between exposure related to occupations and the incidence rate of hand eczema. A systematic search in PubMed, EMBASE, CINAHL and Cochrane databases, from inception to September 2017, of full-text observational studies reporting incident cases of hand eczema during employment, and a supplementary search in PubMed to September 2020, were conducted. Among 2,417 screened abstracts, 15 studies fulfilled the inclusion criteria. Incidence rates were reported per 100 person-years. Based on the Newcastle-Ottawa Scale, 9 studies were good quality, 2 fair quality, and 4 poor quality. Hairdressers had a high incidence of hand eczema of 21.4 (95% confidence interval [CI] 15.3–27.4), as did nurses, 16.9 (95% CI 11.2–22.7), and metal workers, 12.4 (95% CI 3.5–21.3). Hairdressers were predominantly women, and metal worker were predominantly men. Office occupations had an incidence rate of hand eczema of 4.9 (95% CI 1.2–9.6). The high risk of hand eczema for hairdressers, nurses, and metal workers, should be considered by healthcare policymakers. Even occupations with low irritant profile, such as office workers, were at risk of developing hand eczema, and more occupations should be investigated regarding the related risk of developing hand eczema.

Lifestyle factors and hand eczema: a systematic review and meta‐analysis of observational studies

Evidence regarding the association between lifestyle factors and hand eczema is limited.To extensively investigate the association between lifestyle factors (smoking, alcohol consumption, stress, physical activity, body mass index, diet, and sleep) and the prevalence, incidence, subtype, severity, and prognosis of hand eczema, a systematic review and meta‐analysis were conducted in accordance with the Meta‐analysis Of Observational Studies in Epidemiology consensus statement. MEDLINE, Embase, and Web of Science were searched up to October 2021. The (modified) Newcastle‐Ottawa Scale was used to judge risk of bias. Quality of the evidence was rated using the Grades of Recommendation, Assessment, Development and Evaluation approach. Eligibility and quality were blindly assessed by two independent investigators; disagreements were resolved by a third investigator. Data were pooled using a random‐effects model, and when insufficient for a meta‐analysis, evidence was narratively summarized. Fifty‐five studies were included. The meta‐analysis (17 studies) found very low quality evidence that smoking is associated with a higher prevalence of hand eczema (odds ratio 1.18, 95% confidence interval 1.09‐1.26). No convincing evidence of associations for the other lifestyle factors with hand eczema were found, mostly due to heterogeneity, conflicting results, and/or the limited number of studies per outcome.

Hand eczema and lifestyle factors in the Dutch general population: Evidence for smoking, chronic stress, and obesity

Background

Several risk factors, among other lifestyle factors, have been suggested for hand eczema (HE).

Objectives

To investigate a possible association between HE and lifestyle factors, including smoking, alcohol consumption, stress, body mass index (BMI), waist circumference, physical activity, diet, and amount of sleep in the Dutch general population.

Methods

Data from the large population‐based LifeLines Cohort Study was used. Individuals with HE in the past year were identified by a cross‐sectional questionnaire in 2020. At baseline, information on lifestyle factors was collected.

Results

In total 57 046 individuals were included in the present analysis. Smoking ≥8 cigarettes/day, and smoking ≥15 pack years showed a positive association with HE in the past year. In addition, chronic stress, a BMI >30 kg/m², and a waist circumference of >90 cm were positively associated with HE in the past year.

Conclusions

The current study indicates that lifestyle factors are associated with HE. Advice regarding lifestyle factors might contribute to enhance overall health, of which HE might possibly benefit in conjunction. Further studies should also focus on the association between lifestyle factors and the severity and prognosis of HE rather than on occurrence alone.

Smoking Habit and Correlation with Hand Eczema in Healthcare Workers in the Time of COVID-19

Background: Hand eczema, in time of COVID-19, is one of the most frequently diagnosed skin disorders in nurses. In this study, we sought to investigate whether smoking could be an additional risk factor for hand eczema in nurses during the COVID-19 pandemic. Method: Using a questionnaire about smoking details and hand eczema, we conducted a study among nurses involved in the frontline management of COVID-19 patients. A total of 1,000 questionnaires were sent out. The questionnaires were anonymous and based on self-reported answers, with no clinical examination or medical data evaluation. All nurses enrolled in the study were women, working in shifts for the last three months since the start of the COVID-19 pandemic. Results: Two-hundred forty-seven questionnaires were accepted for the study, after eliminating non-responders and nurses without hand eczema. The majority of nurses denied smoking (87.85%) in the past and at the moment of the study. Statistics related to years of smoking and occurrence of hand eczema showed no increase in the number of cases in correlation with the number of years of smoking. Similarly, a random distribution of cases of hand eczema was observed when compared to the number of cigarettes per day. Conclusion: Our data does not support the hypothesis that smoking is an independent risk factor for the development of occupational hand eczema during the COVID-19 pandemic.

Guidelines for the Diagnosis, Treatment, and Prevention of Hand Eczema

Hand eczema is a common condition associated with significantly impaired quality of life and high social and occupational costs. Managing hand eczema is particularly challenging for primary care and occupational health physicians as the condition has varying causes and both disease progression and response to treatment are difficult to predict. Early diagnosis and appropriate protective measures are essential to prevent progression to chronic eczema, which is much more difficult to treat. Appropriate referral to a specialist and opportune evaluation of the need for sick leave are crucial to the good management of these patients. These guidelines cover the diagnosis, prevention, and treatment of chronic hand eczema and highlight the role that primary care and occupational health physicians can play in the early management of this disease.

Factors influencing prognosis for occupational hand eczema: new trends

BACKGROUND

Variables traditionally reported to influence the prognosis of occupational hand eczema (OHE) are atopic dermatitis (AD) and contact sensitization. However, recent studies indicate that lifestyle factors may be of major importance.

OBJECTIVES

To identify factors influencing the prognosis in a cohort of patients with recognized OHE.

METHODS

In this register-based cohort study, individuals with hand eczema recognized as occupational disease in the period January 2010-December 2011 were identified using files from Labor Market Insurance Denmark and included in the study. At baseline, information on sex, age, occupation, wet work, AD and contact sensitization was collected. In 2015 participants received a questionnaire with questions about lifestyle factors, current occupation and healing of OHE.

RESULTS

In total, 2703 patients received the questionnaire; 1491 responded to the question about healing of OHE and were included in the study. Altogether, 19·3% of patients reported complete healing at follow-up. Current tobacco smoking and a high level of stress were factors inversely associated with healing of hand eczema (P < 0·001 and P = 0·030, respectively), while a high level of exercise was significantly related to healing of eczema (P = 0·011). Change of profession was a favourable prognostic factor, while age, sex, AD, contact sensitization and education did not significantly influence prognosis.

CONCLUSIONS

Traditionally important risk factors such as AD and contact sensitization had no marked influence on prognosis, while lifestyle factors were of major importance. Our findings indicate that risk factors may vary over time, allowing for new perspectives on prevention. What's already known about this topic? Occupational hand eczema has a relapsing course and a poor overall prognosis. Atopic dermatitis and contact sensitization have previously been reported as risk factors for a poor prognosis. What does this study add? The results indicate that lifestyle factors are of importance for the prognosis of occupational hand eczema. Traditionally reported risk factors such as atopic dermatitis and contact sensitization do not currently influence prognosis.

Hyperkeratotic hand eczema compared to other subgroups of hand eczema - a retrospective study with a follow-up questionnaire

BACKGROUND

Only a few clinical trials on hand eczema have included further classification into subtypes, and there is a need for studies evaluating the present classifications.

OBJECTIVES

To examine differences in demographic factors, lifestyle factors and severity between subgroups of hand eczema patients, with a focus on hyperkeratotic hand eczema.

METHODS

This was a retrospective study including hand eczema patients referred to the outpatient dermatological clinic, Bispebjerg Hospital, between January 2013 and July 2014. The study comprises information on subdiagnoses, treatment and foot eczema from patient files, as well as a follow-up questionnaire.

RESULTS

A total of 120 patients were included, 10 of whom were diagnosed with hyperkeratotic hand eczema. A significantly higher proportion of the patients with hyperkeratotic hand eczema were male (p = 0.002) and received systemic or ultraviolet (UV) treatment (p = 0.026). The frequency of tobacco smoking was significantly higher in patients with hyperkeratotic hand eczema (p = 0.016), as well as in the other subgroups combined (p = 0.049), than in the background population.

CONCLUSIONS

Studies evaluating the subdiagnoses of hand eczema are needed, to further validate the classification system, and to provide more detailed information about demographic factors, severity and possible risk factors for different subgroups of hand eczema.

The association of smoking with contact dermatitis and hand eczema - a review

Given the high prevalence of allergic contact dermatitis (ACD), irritant contact dermatitis (ICD), hand eczema (HE), and smoking, and the impact that smoking has on skin disease, the authors reviewed the existing literature to assess the association between smoking and contact dermatitis or hand eczema. Using the PubMed and SCOPUS databases, a literature search identified articles related to allergic contact dermatitis, irritant contact dermatitis, and hand eczema and a possible association with smoking. The search period included articles prior to and including April 2016. Seven of eight articles described a positive relationship between smoking and allergic or irritant contact dermatitis, while nine of nineteen articles found a positive association between smoking and hand eczema. Published studies document that smoking may be an important risk factor for both allergic and irritant contact dermatitis as well as hand eczema.

Smoking and Hand Dermatitis in the United States Adult Population

Background

Hand dermatitis is a common chronic relapsing skin disease resulting from a variety of causes, including endogenous predisposition and environmental exposures to irritants and allergens. Lifestyle factors such as smoking have been implicated in hand dermatitis.

Objective

To evaluate the association between tobacco exposure and hand dermatitis using the 2003~2004 National Health and Nutrition Examination Survey (NHANES) database.

Methods

Data were retrieved and analyzed from 1,301 participants, aged 20~59 years, from the 2003~2004 NHANES questionnaire study who completed health examination and blood tests. Diagnosis of hand dermatitis was based on standardized photographs of the dorsal and palmar views of the hands read by two dermatologists.

Results

There were 38 diagnosed cases of active hand dermatitis out of the 1,301 study participants (2.9%). Heavy smokers (>15 g tobacco daily) were 5.11 times more likely to have active hand dermatitis (odds ratio [OR], 5.11; 95% confidence interval [CI], 1.39~18.88; p=0.014). Those with serum cotinine >3 ng/ml were also more likely to have active hand dermatitis, compared with those with serum cotinine ≤3 ng/ml (OR, 2.50; 95% CI, 1.26~4.95; p=0.007). After adjusting for confounding factors such as age, atopic diathesis, occupational groups, and physical activity, the association between tobacco exposure and active hand dermatitis remained significant.

Conclusion

Smoking has a significant association with the presence of active hand dermatitis. It is important to consider smoking cessation as part of management of hand dermatitis.