Tag: hand eczema

This is a 3-part series focused on hand eczema, with the privilege of having Dr Lynn Chiam, of Children & Adult Skin Hair Laser Clinic, to help explain further the type of hand eczema, its cause, treatment options and daily hand care. Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Singapore. Apart from paediatric dermatology, her other subspecialty interests include adult pigmentary conditions and laser dermatology. 

The first 2 part of the series are:

1. Basics of hand rash and different types of hand eczema, its symptoms and triggers
2. Treatment of Hand Eczema

Hand Eczema that Does Not Go Away

If the skin at the hand is too thick and hard, it will be more difficult for medication to penetrate deeply enough to improve the skin inflammation. This increases the likelihood of untreated and persistent hand eczema. Another reason why hand eczema does not go away could be the continued exposure to an irritant which has yet to be identified. Patch testing is then recommended.

MarcieMom: Dr Lynn, what are the ways to treat hand eczema when the skin has thickened?

Dr Lynn: For thickened skin, topical steroids of higher potency should be used. Ointment based steroids can be used instead of cream based steroids. Liberal and regular use of moisturizers should be emphasized. The use of wet wraps (occluding the creams with a wet glove) can also help to increase the penetration of the creams across the thickened skin.

Phototherpy (controlled use of UVA or UVB light) is sometimes used in this type of hand eczema.

MarcieMom: How often do you see in your practice that patients cannot recover due to continued exposure to allergens in their moisturizers or topical medication? When should one suspect that is the case and request for a patch test?

Dr Lynn: Allergy to topical medication and moisturizers are extremely rare. If patient had avoided all other possible irritants or allergens and have been compliant with medication and not getting better but worse, then the unlikely possibility of allergy to medication/ moisturizer can be considered and a patch test performed.

Daily Hand Care for Those with Sensitive Skin

Some skincare tips for those with hand eczema or sensitive skin are:

• Avoid frequent hand-washing or washing hands in hot water
• Moisturize after exposure to water
• Avoid irritants and triggers

MarcieMom: Dr Lynn, for those with hand eczema, should they be using an ointment instead of a lotion so that more of the moisturizer can be retained even with hand washing? Also, an ointment will be more protective against irritants.

Dr Lynn: Generally, ointment tend to be better absorbed and lock in the moisturizer for a longer period as compared to lotions. By repairing the skin barrier function faster than lotion, they tend to protect the skin and allow the skin to heal faster. They generally contain fewer preservatives and additives than creams.

MarcieMom: For occupations such as caterers, hair dressers, nurses and mechanics, will wearing gloves during their jobs help to reduce contact dermatitis? If yes, what type of gloves should they wear?

(I read some recommendations for vinyl gloves while others recommend cotton-lined gloves. Avoid latex gloves.) Are there any guidance on how long one should wear glove (since that trap sweat which is a possible irritant)?

Dr Lynn: Yes, wearing gloves is recommended for those in certain occupations where contact with certain irritants is repeated and prolonged. I will generally recommend cotton gloves as they generally do not cause irritation. However, if contact with water is necessary, use a water- proof gloves. If wearing latex gloves makes the rash worse, a patch test can be done to determine latex allergy.

Glove choice should be appropriate to the situation. Alternative to latex gloves include vinyl, nitrile and chloroprene. However, some of the chemicals used in the manufacture of non-latex gloves can also cause hypersensitivity.

I will advise patients to remove the gloves after about 20 minutes to allow sweat to evaporate. Dry the gloves inside out when not in use.

Thank you Dr Lynn for sharing with us skincare for hand eczema and understanding possible reasons why hand eczema is persistent. Hand eczema affects many adults and learning more about it help to manage the rash better.

This is a 3-part series focused on hand eczema, with the privilege of having Dr Lynn Chiam, of Children & Adult Skin Hair Laser Clinic, to help explain further the type of hand eczema, its cause, treatment options and daily hand care. Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Singapore. Apart from paediatric dermatology, her other subspecialty interests include adult pigmentary conditions and laser dermatology. 

Last week, we covered the basics of hand rash and different types of hand eczema, its symptoms and triggers. This week, we will focus on treatment.

Common treatment for Hand Eczema

1. Topical corticosteroids
2. Topical calcineurin inhibitors e.g. tacrolimus and pimecrolimus
3. Antihistamines
4. Phototherapy

MarcieMom: Dr Lynn, a few questions on common treatment options for hand eczema:

• For topical corticosteroids, are there typical potencies or type of corticosteroids (such as anti-fungal/ anti-bacterial) that are commonly prescribed for hand eczema?

Dr Lynn: Topical steroids are the mainstay of treatment for hand eczema. Topical steroids reduce the redness and itch effectively by decreasing skin inflammation. Due to the thickness of the skin on the hands, higher potency steroid creams are usually used. When used for the correct duration and in the correct amount, side effects are very minimal. Steroid creams should only be used on the affected areas and are prescribed for twice a day use. When the condition has improved, lower potency creams can be used. Sometimes, decreasing the frequency of the creams is also practiced. Topical steroids should always be used together with moisturizers in the treatment of hand eczema.

In cases with secondary bacterial infection (especially in those with oozing and cracked skin), topical antibiotic creams can be used in conjunction with steroid creams.

• For topical calcineurin inhibitor, should sunscreen be used on sun-exposed part of the hand?

Dr Lynn: Topical calcineurin inhibitors (TCIs) are an alternative to steroid creams. As they have a slow onset of action, topical steroids are still used in the initially period. Topical calcineurin inhibitors are better used as maintenance agents. Side effects include a mild and temporary burning sensation. They are safe to use and in many studies over many years, they have not been associated with any major side effects or cancers.

Eczema guidelines propose that appropriate sun protection measures, such as minimisation of the time in the sun, use of sunscreen after applying TCI and covering the skin with appropriate clothing.

• Are there any precautions to take after applying the topical medication? e.g. not touch food, water?

Dr Lynn: I will normally advise my patients to allow about 15-30 minutes for the creams to be absorbed and to avoid washing hands during this period. Wearing a cloth glove can aid in the absorption and penetration of the creams and allows the person to do work without the creams getting in the way.

• Does avoidance of triggers play a larger role in management of hand eczema than medication? Is it likely that without exposure to triggers, skin inflammation at the hands will heal itself?

Dr Lynn: Although avoiding triggers does help significantly to prevent the eczema from progressing or being more severe, the use of anti-inflammatory agents like topical steroids and calcineurin inhibitors together with moisturizers are still essential to heal the skin.

MarcieMom: I read online of a new drug, oral alitretinoin, that has been reported to help with severe hand eczema. However, it has side effects such as headache, dry and flushing skin. It is also not recommended for pregnant women due to possibility of birth defect.

What is Alitretinoin (taken orally) and is it accepted among the dermatology community to prescribe it for severe hand eczema cases? When should a patient stop using it (ie when can one tell the side effects are too strong to justify taking the medication?)

Dr Lynn: Alitretinoin has been approved in certain countries for the treatment of severe hand eczema that has not responded to strong topical steroids. It belongs to a group of medicine known as retinoids. Currently, it is still not available in Singapore.

Certain blood tests need to be monitored while taking this medicine. Dryness, cracked lips, headache and hair loss may occur. If there is an increase in the liver enzymes and cholesterol levels, the dose of alitretinoin should be reduced/ stopped.

In view of the side effects to a fetus, women of child-bearing age should be properly counseled before starting the medicine and contraception advised.

Thank you Dr Lynn for explaining the treatment options for hand eczema. Next week we look forward to learning more about skincare and help for those whose hand eczema just won’t go away.

3-part series on Hand Eczema with Dr Lynn Chiam

• Types, symptoms and triggers
• Treatment of Hand Eczema
• Skincare for Hand Eczema

Dr Lynn Chiam

Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Children & Adult Skin Hair Laser Clinic, Singapore. Apart from paediatric dermatology, her other sub-specialty interests include adult pigmentary conditions and laser dermatology. 

Is it really Hand Eczema?

Rashes on your hand may not be eczema although hand eczema/ hand dermatitis is the most common type of hand rash. Various other rashes can be:

Psoriasis

Psoriasis is a chronic skin condition characterized by clearly defined white, silvery or reddish thick patches. Apart from the palms, look for other typical signs of psoriasis such as scalp involvement and nail deformities.

Tinea Manuum

This refers to fungal infection of the hands which can look similar to hand eczema. Fungal infection needs to be excluded if only one hand is affected. A fungal scrape (skin test) will be positive in tinea manuum.

MarcieMom: Dr Lynn, how frequent are the above in causing hand rashes? Are there other common differential diagnosis from hand dermatitis?

Dr Lynn: Hand eczema has been identified as one of the most common frequent dermatological disorder encountered in clinical practice. It is caused by a combination of internal (genetics, individual predisposition) and external factors (exposure to irritants and allergens). It is estimated that about 10% of the general population suffer from hand eczema. It is reported to be more common in women and in certain occupations like hairdressers, healthcare workers and domestic workers.

Other conditions that can mimic hand eczema include psoriasis (which affects about 1% of the local population) and tinea manuum, a fungal infection of the hands which is uncommon.

Different types of Hand Eczema/ Dermatitis

Hand eczema results in inflammation of the skin which can present with dryness, scaling, redness, vesicles( bubbles), fissures, thickening, pain and itch. Even within hand eczema, there are various forms of dermatitis:

Irritant Contact Dermatitis

This is the most common form of dermatitis, caused by repeated exposure to irritants like water (from repeated hand washing), soaps, detergents, food products or chemicals frequently exposed to in a job, such as solvents, lubricants, oils and coolants. Friction and repetitive rubbing of the skin also increases the likelihood of irritant contact dermatitis. The rash is typically found on the knuckle surface of the hands. Avoidance of the irritant material can bring about a significant improvement.

Allergic Contact Dermatitis

Allergic contact dermatitis only happens to a small number of people who are sensitized to a certain material. This means that in the past, they may have been in contact with the offending material and even though on the first contact, there may have been only a little or mild reaction, the skin “remembers” the material as an allergen. On the repeated contact with the same material, a worse rash will result. Common allergens include nickel, fragrances, preservatives and rubber. A patch test can confirm the allergy.

Atopic Dermatitis

Patients who have atopic eczema when young are more likely to develop atopic dermatitis on the hands as an adult. Look for involvement of the other areas on the body.

Pompholyx

Pompholyx has a distinctive appearance of itchy small blisters on the palms of the hands. It is also more closely associated with excessive sweating and can be found on the soles and toes.

Nummular Hand Dermatitis

This shows up as circular areas of redness, scaling on the backs of the hands and can appear oozy.

Symptoms of Hand Eczema

Symptoms include redness (erythema), itch (pruritus), pain, dry, peeling/ flaking skin, blisters (vesicles) and cracks (fissures), weeping (exudation) and swelling (oedema).

MarcieMom: Dr Lynn, there are quite a few types of dermatitis – do they have similar symptoms or can it be difficult to diagnose which type of dermatitis one suffers from? Does age, gender or occupation affect which type of dermatitis one suffers from?

Dr Lynn:Yes, the different types of hand eczema can have similar symptoms. However, there are certain clues to look out for. From the history of the onset of the rash, contact with certain materials, improvement with avoidance, one may be able to distinguish between irritant and allergic contact dermatitis. A positive or family history of atopy (allergic tendencies) and involvement of the feet points to atopic hand eczema.

More women are affected by hand eczema than men. The prevalence of hand eczema is also higher in certain occupations like healthcare workers, hairdressers and domestic workers. This is due to prolonged and repeated contact with certain harsh materials resulting in irritant contact dermatitis. In irritant contact dermatitis, the knuckles, finger tips and web-spaces are commonly affected. Improvement is noted with avoidance of the material.

In allergic contact dermatitis, the rash may persist even with further avoidance of the allergen. Patch testing can help determine the allergen.

In adults with atopic eczema affecting the hands, other areas of the body can also be affected. In the acute stage, red spots, oozing and excoriations can be seen. In the later stages, the skin becomes dry, cracked and thick. Secondary infections can also set in.

Triggers of Hand Eczema

Triggers of hand eczema are typically water, sweat, soaps, detergents, food products, solvents, lubricants, oils and coolants.

MarcieMom: Dr Lynn, regardless of whether it is irritant contact dermatitis, allergic contact dermatitis or atopic dermatitis, are the triggers similar? If yes, will avoiding these triggers be actions a hand eczema sufferer should take?

What are the factors that affect what form of dermatitis one get?

Dr Lynn: Yes, there are certain common triggers that will adversely affect the hands. Over-washing (even with just plain water), harsh soap, detergents and lubricants should generally be avoided by people with hand eczema. Wearing of gloves to reduce the contact of water and soaps with the skin is recommended if prolonged wet work is necessary.

Regular use of moisturizer can help prevent flares in people with hand eczema. Gentle soap in small amounts is recommended.

Keeping fingernails short prevent further damage of the skin while scratching. It is advisable to remove rings and bangles before hand-washing and wet work as they can trap moisturizer, dirt and bacteria.

MarcieMom: Thank you Dr Lynn for helping us to understand the different types of hand rash, hand eczema and its common triggers. Next week, we will look forward to learning about treatment of hand eczema.