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Eight Variants Of Hand Eczema
Hand eczema begins with dryness and itching.
Hand Eczema And Its Causative Factors
Hand eczema is defined as dermatitis (itching, redness and scaling of skin) largely confined to hands, with only minor involvement of other areas. It can be caused by various factors, which include the following:
1. Exogenous causes
- Contact irritants - Soaps, detergents, solvents, friction, minor trauma, and cold dry air.
- Contact allergens - Chromium, epoxy glues, rubber, seafood.
- Ingested allergens - Drugs, nickel, chromium.
- Infection - Following infected wounds.
- Secondary dissemination - Allergy on hands due to ringworm on foot (dermatophytid).
2. Endogenous causes
- Unknown cause
- Immunologic or metabolic - Atopic dermatitis.
- Psychosomatic - Aggravated by stress.
- Dyshidrosis - Exacerbated by excessive sweating.
The different types or variants of hand eczema include the following:
Pompholyx with fluid filled blisters
Chronic vesiculobullous hand dermatitis
1. Pompholyx or Vesicular Eczema Of Palms And Soles
This condition presents as small, fluid-filled blisters on palms (cheiropompholyx) or soles (podopompholyx). Usually, the onset is before age 40, commonly in adolescents and young adults. It gets worse in hot weather and is associated with a personal or family history of atopy or skin allergy. Attacks are common in spring and fall. Contact with certain allergens like isopropyl paraphenylenediamine (found in hair dyes a few years ago), dichromates, perfumes, fragrances and balsam ingredients, can cause this skin reaction. Ingestion of metals like nickel, chromium and cobalt along with food or dietary supplements can lead to pompholyx in susceptible individuals. Contact allergy of the feet from rubber shoe chemicals can cause eruption on palms, as well. Fungal infection elsewhere on the body, usually the feet, can provoke eczema of palms (pompholyx dermatophytid). A bacterial focus in the body, ingestion of aspirin or piroxicam, intravenous immunoglobulin therapy, oral contraceptives, cigarette smoking and mental stress increase the risk of pompholyx.
It begins with a sensation of heat and pricking or itching on the palms, followed by the appearance on sides of fingers, of crops of deep-seated clear vesicles, which appear like sago grains, in a symmetrical pattern. In mild initial attack, spontaneous self-resolution with peeling of the skin occurs in 2-3 weeks. Secondary infection with formation of pus-filled blisters and swelling of lymphatics (lymphangitis) can occur. Rubbing and inappropriate treatment can lead to the formation of eczemas that may extend beyond the volar surfaces. After recurrent attacks, the condition spreads to involve dorsum of fingers and cause nail dystrophy, with irregular transverse ridges, pits, thickening and discoloration. In most cases, recurrences occur for months or years.
Any obvious cause of eruption should be eliminated. In the acute phase, rest and bland applications are needed. The hands or feet are soaked 3-4 times a day, in either Burrow's solution (aluminium acetate 1%) or potassium permanganate solution (diluted 1:8000). Oral antibiotic tablets are prescribed in case of pus formation and fluid is aspirated from large blisters. As the eruption subsides, the soaks are replaced by zinc cream or oily calamine solution. Steroid creams and oral steroids are useful in subacute and chronic phases. For persistent pompholyx with scaling and thickening of the skin, steroids combined with coal tar solution, tacrolimus, pimecrolimus, retinoids and keratolytic agents (as salicylic acid) may be required. Tap water iontophoresis with pulsed direct current does not offer any direct benefits, but may lead to longer remissions in those treated. For severe pompholyx, UVB therapy, systemic, topical and bathwater PUVA and UVA1 and systemic immunosuppressants including low dose methotrexate, Mycophenolate Mofetil, cyclosporine, Grenz rays, and disulphiram therapy offer relief. Two severity indices, the Dyshidrosis Area and Severity Index (DASI) and the Total Signs and Symptoms Score (TSS) have been validated. For maintenance frequent ointment application and avoidance of irritants, along with vinyl gloves, is helpful.
Chronic vesiculobullous hand dermatitis is more common than true pompholyx. It consists of small 1-2 mm vesicles or blisters filled with clear fluid, on lateral aspects of fingers and soles. These chronic forms are persistent and frustrating to manage.
Focal palmar peeling - a mild form of pompholyx
2. Recurrent Focal Palmar Peeling
Also known as desquamation en aires, this is a mild form of pompholyx that begins in summer months as small areas of superficial peeling on sides of fingers, palms or soles. It is usually self-limited and heals with regular use of emollients. It may, later on, progress into true pompholyx.
3. Hyperkeratotic Palmar Eczema or Tylotic Eczema
This is a distinct form of hand eczema that presents as highly irritable patches with fissures, scaling and thickening of the skin on palms and palmar surface of fingers. Mostly present in middle-aged men, its cause has still not been found. It is extremely resistant to treatment. Steroid ointments, PUVA therapy, coal tar, salicylic acid and Grenz rays are the common treatment options that offer some relief.
4. Ring Eczema
Common in young women, a patch of eczema with skin irritation develops under a ring, that spreads to involve the adjacent side of the middle finger and adjacent area of palm. This may be followed by the appearance of discoid patches elsewhere. Transference of ring to the other hand leads to eczematous changes at the new site. Wearing the ring for only a few minutes even without washing, would cause irritation. The reason for this eczema is an accumulation of soap and detergent beneath the ring, which may tighten on fingers immersed in hot water. Repeated trauma and friction to the finger may also be the causative factors. In rare instances, radioactive gold in the ring may cause radiation dermatitis that mimics the common ring eczema. Patch tests show results for nickel, chromium and cobalt (that are the common contaminants in ornaments) or for "white gold" alloys that are present.
5. Wear and Tear Dermatitis
Also known as Housewives' eczema or Dry Palmar Eczema, this condition commonly occurs in individuals who frequently immerse their hands in water and detergents, and is presumably due to a combination of dryness, exposure to mild irritants such as soap and mild trauma, for example from wringing (squeeze or twist to make it dry) of dishcloth. The skin feels dry, it becomes crisscrossed with superficial cracks, and normal movements of the hand and fingers get difficult and painful. There may be associated dryness and chapping of fingers over the knuckles.
6. Apron Eczema
This variant occurs in the shape of an apron, involving the proximal palmar aspect of two or more adjacent fingers and the nearby palmar skin.
7. Chronic Acral Dermatitis
This is a chronic eczema of middle age that consists of the thickening of skin and presence of intensely itchy boils, bumps and blisters on the hand. It is associated with elevated levels of immunoglobulin IgE levels, with no personal or family history of atopy or allergies. It usually responds to oral steroids.
8. Patchy Vesiculosquamous Eczema
This consists of irregular patchy lesions with scaling and overlying small blisters that occur asymmetrically on both hands. The lesions keep changing places, appearing once at one site and again at another. Nail changes occur if nail folds are involved.
Disclaimer: The information in this hub is for educational purposes. It does not intend to replace your doctor or healthcare professional's advice.