COD

Contact Dermatitis Original Article

Contact Dermatitis

Classification of hand eczema: clinical and aetiological types. Based

on the guideline of the Danish Contact Dermatitis Group
Jeanne Duus Johansen1 , Marianne Hald1 , Bo Lasthein Andersen2 , Grete Laurberg3 ,
Anne Danielsen4 , Christian Avnstorp5 , Berit Kristensen6 , Ove Kristensen6 , Knud Kaaber7 ,
Jens Thormann8 , Torkil Menne 9 and Niels Veien3
1 Department of Dermato-Allergology, National Allergy Research Centre, Copenhagen University Gentofte Hospital, 2900 Hellerup, Denmark, 2 Dermatology

Clinic, Havnepladsen 3A, 5700 Svendborg, Denmark, 3 Dermatology Clinic, Vesterbro 99, 9000 Aalborg, Denmark, 4 Dermatology Clinic, Banegardspladsen
1,
1570 Copenhagen V, Denmark, 5 Dermatology Clinic, Roskildevej 264, 2610 Rdovre, Denmark, 6 Dermatology Clinic, Bredgade 50, 4400 Kalundborg,
Denmark, 7 Dermatology Clinic, Bredgade 30, 7400 Herning, Denmark, 8 Dermatology Clinic, Skovgade 23 C, 7100 Vejle, Denmark, and 9 Department of
Dermato-Allergology, Copenhagen University Gentofte Hospital, 2900 Denmark
doi:10.1111/j.1600-0536.2011.01911.x

Summary

Background. No generally accepted classification scheme for hand eczema exists.

The Danish Contact Dermatitis Group recently developed a guideline defining common
clinical types and providing criteria for aetiological types.
Objectives. To test the concepts of this guideline in a group of hand eczema patients.
Methods. Seven hundred and ten hand eczema patients were included from seven
dermatology clinics in Denmark. The hand eczema was classified into one of five clinical
types, with standard photographs as reference. The severity was scored by the physician,
who also made a final aetiological diagnosis.
Results. Irritant contact dermatitis was most frequent in chronic, dry fissured hand
eczema (44.3%), pulpitis (41.7%), and nummular hand eczema (40.9%), whereas allergic
contact dermatitis dominated in vesicular types of hand eczema, with recurrent (35%)
and few (24.2%) eruptions. Hyperkeratotic palmar hand eczema was the only clinical
type that constituted a distinct subgroup; it was found most frequently in older men and
had the strongest relationship, although not significant, with non-specific dermatitis.
Conclusions. The relationship between clinical type of hand eczema and aetiological
diagnosis fitted with general experience, but no simple relationship was found. This
emphasizes that patch testing and exposure analysis are mandatory. Hyperkeratotic
palmar hand eczema was identified as a distinct clinical subtype.
Key words: disease classification; hand eczema severity index; non-specific dermatitis;
quality of life.

The Danish Contact Dermatitis Group (DCDG) recently

published its guideline for classification of hand
eczema (1). In parallel, the group has conducted a

Correspondence:
Jeanne Duus Johansen, Department of DermatoAllergology, National Allergy Research Centre, Copenhagen University
Gentofte Hospital, Niels Andersens vej 65, 2900 Hellerup, Denmark. Tel:
+45 39777301; Fax: +45 39777118. E-mail: jedu@geh.regionh.dk
Conflicts of interest: No conflicts of interests to be declared.
Accepted for publication 19 February 2011

2011 John Wiley & Sons A/S Contact Dermatitis, 65, 1321

prospective study of clinical and aetiological types of hand

eczema, risk factors, and other characteristics of hand
eczema patients, based on the concept of this guideline.
Attempts have previously been made to characterize
hand eczema in clinical types, for example by Cronin (2)
and Wilkinson (3). The development and course of hand
eczema is a dynamic process, and is closely linked to the
environment. This means that the clinical expression of a
disease may depend on changes in living conditions, the
time period and the nature of exposure, and interactions
with genes.

13

CLASSIFICATION OF HAND ECZEMA DUUS JOHANSEN ET AL.

Even though the clinical descriptions are still in focus,

disease classification for hand eczema has moved from
morphology to aetiology, as for many other diseases (4).
An aetiological diagnosis offers the advantage of targeting
prevention and, in some cases, also providing more specific
treatment.
In the current study, consecutive hand eczema patients
were studied to give an update of clearly defined clinical
types and their relationships with aetiology. In particular,
an attempt was made to characterize patients who end
up with the diagnosis of non-specific dermatitis, a sort of
no mans land, where no targeted prevention is possible.

Materials and Methods

The study was designed as a cross-sectional multicentre
study performed from November 2008 to February 2010
by dermatologists from seven private practices that
are members of the DCDG. Consecutive patients with
hand eczema, referred to one of the seven participating
clinics with 17 dermatologists across Denmark, were
included prospectively. The medical history of the
patient was recorded by the treating physician with
regard to the MOAHLFA index, which includes sex,
occupational relationship, history of atopic dermatitis,
hand eczema, stasis eczema/ulcer, facial eczema, and age
above 40 years.
The clinical examination of the hands at the time
of patch testing included a severity score obtained by
the physician with the Hand Eczema Severity Index
(HECSI) (5) and an evaluation of the clinical type of
hand eczema. This was based on photographs and
descriptions as in the guideline of the DCDG for hand
eczema classification (1) in a slightly modified version, as
interdigital eczema was not included in the preliminary
versions of the guideline at the time when this study was
initiated. Those patients who could not be classified within
one of these categories were termed non-classifiable.
Thus, the clinical types consisted of five defined types
of hand eczema: vesicular hand eczema, chronic dry
fissured hand eczema, palmar hyperkeratotic hand
eczema, nummular hand eczema, and pulpitis. Palmar
hyperkeratotic hand eczema is shown in Fig. 1, as an
example; the other photographs can be seen in the
guideline (1). In addition, the dynamics of the hand
eczema were recorded as either rare eruptions, recurrent
eruptions, or constant activity. As vesicular hand
eczema, in particular, is known for its dynamic activity,
which also may indicate different subtypes (6, 7), the
results for vesicular hand eczema with rare eruptions
and with recurrent eruptions are given separately in the
following.

14

Fig. 1. Palmar hyperkeratotic hand eczema characterized by

hyperkeratotic changes in the palms, possibly extending to the
volar side of the fingers. There may be fissures, but there are no
vesicles at any time.

All patients were patch tested as a minimum with the

European baseline series of contact allergens and, when
required, with additional substances. Finally, the treating
physician recorded the aetiological diagnosis as allergic
contact dermatitis, irritant contact dermatitis atopic
dermatitis, non-specific dermatitis, or combinations of
these, according to the disease classification codes (World
Health Organization, ICD-10) DL23x, DL24x, DL209, and
DL309.
Patients filled in a questionnaire at inclusion regarding
duration of hand eczema, hand eczema in childhood,
triggers of eczema, current occupation, use of gloves at
work, type of gloves used, hand washing, occupational
relationship, and sick leave. On the basis of the
questionnaire, a variable was constructed for wet work for
those who had repeated hand washings (20 times/day),
or wet hands or use of occlusive gloves for at least 2 hr
during the working day.
In addition, the patients answered questions about
quality of life using the Dermatology Life Quality Index
(DLQI) (8). The DLQI score was calculated as the sum of
scores of each question, with a maximum score of 30 and
a minimum score of 0. The higher the score, the greater
the impairment of quality of life (QoL).
Patients also rated the severity of their hand eczema
currently and during the past year by use of a
visual analogue scale (VAS) from 0 (no eczema) to
10 (very severe eczema) and a photographic guide
showing photographs of different severity (9) Patients
were followed for a year with questionnaires and an
additional clinical examination. This article concerns the
results at the time of inclusion of the patients. The HESCI
was performed and the questionnaires filled in at the first
consultation and/or at the time of patch testing.

2011 John Wiley & Sons A/S Contact Dermatitis, 65, 1321

CLASSIFICATION OF HAND ECZEMA DUUS JOHANSEN ET AL.

Statistics

Data are presented as proportions in percentages for categorical variables and as median values and interquartile
range for continuous variables. The 2 -test was used
for comparison between groups. The MannWhitney
U -test and KruskalWallis test were used for comparison
of continuous measurements.
A logistic regression analysis was performed, with the
diagnosis of non-specific hand eczema (DL309) as the
dependent variable versus the remaining types, and with
the clinical types as explanatory variables. In a separate
step, the risk factors wet work (yes/no), occupational
relationship (yes/no) and one or more positive patch test
reactions were examined, and in a third step different
measures of severity were analysed as the explanatory
variables: long duration (over 5 years, yes/no), severely
impaired QoL ( 15), severe HECSI (>17), severe VAS at
present (>4), severe VAS previously (>5), and constant
activity (yes/no). Associations were expressed as odds
ratios (ORs) with 95% confidence intervals. The cutpoint of the most severely affected patients was based
on the 25th percentile for each of the variables HECSI
and VAS, and the choice of QoL 15 was based on the
recommendations from the National Institute for Health
and Clinical Excellence in the UK and their guideline for
treatment of severe chronic hand eczema with alitretinoin
(http://www.nice.org.uk).
Data analyses were performed with SPSS (SPSS,
Chicago, IL, USA) for Windows (release 18.0).

Results
A total of 710 hand eczema patients were included, 463
women and 247 men (ratio 1.87). The seven clinics
each contributed 30174 patients. The median age
was 39 years (range 1883 years), with women being
statistically significantly younger than men (Table 1).
A personal history of atopic dermatitis was present in
21.7%, with no difference between sexes. A duration of
hand eczema of >5 years was seen in 28.1%. The QoL
(DLQI) was more affected in women than in men, as
was the self-evaluated severity (on a VAS) in the past
12 months, whereas the HECSI scored by the treating
dermatologist at inclusion showed no differences between
sexes (Table 2). In 44% of cases, the eczema was either
caused or aggravated by the work, with no difference
between sexes (Table 1).
In 508 cases, hand eczema was classified into one of the
five defined clinical types, whereas in 49 (8.8%), the hand
eczema could not be classified in one of the clinical types
(Table 2). This information was missing for the remaining
153 cases; in 35 of these, the hand eczema had cleared at

2011 John Wiley & Sons A/S Contact Dermatitis, 65, 1321

the time of inclusion. Chronic, dry fissured eczema was the

most frequent (36.1%), followed by vesicular eczema with
recurrent eruptions (31.8%), nummular eczema (7.9%),
hyperkeratotic palmar eczema (7.4%), vesicular eczema
(rare eruptions) (5.9%), and pulpitis (2.2%). Both pulpitis
and hyperkeratotic palmar hand eczema were statistically
significantly more frequent in men than in women; for
the remainder, there were no sex differences. A tendency
was found for patients with hyperkeratotic palmar hand
eczema or nummular or pulpitis to be older than patients
without these clinical types, with median ages of 45, 47
and 55 years, respectively, in comparison with 39 years
for the whole group (Table 3).
Regarding the dynamics, dry fissured hand eczema,
hyperkeratotic palmar eczema and pulpitis showed a
tendency to have constant activity. Vesicular hand
eczema with rare eruptions was of a shorter duration
than the rest p = 0.04), had significantly lower HESCI
(p < 0.001) and DLQI (p < 0.05) scores, and lower
current self-evaluated severity on the VAS (p < 0.001).
The distribution of HECSI and DLQI scores according
to clinical type is presented in Figs. 2 and 3.
The relationship between aetiological diagnosis and
the different clinical types was analysed (Table 4). No
relationship between a history of atopic dermatitis or
current atopic hand eczema and any clinical type was
seen. Irritant contact dermatitis was most frequent in
chronic, dry fissured hand eczema (44.3%), pulpitis
(41.7%), and nummular hand eczema (40.9%), whereas
allergic contact dermatitis dominated in vesicular types
of hand eczema, with recurrent (35%) and few (24.2%)
eruptions. A diagnosis of non-specific dermatitis (DL309)
was most frequent among patients with hyperkeratotic
palmar hand eczema (43.9%) and vesicular hand eczema
with few eruptions (33.3%) (Table 4).
The characteristics of patients with a diagnosis of
non-specific dermatitis (DL309) were analysed by use of
multivariate analysis. No significant relationship with sex
was found, and the group, in general, was younger than
other hand eczema patients (p = 0.02). No clinical type
was significantly related to non-specific dermatitis, but the
OR for hyperkeratotic palmar eczema was the highest, at
4.3 (0.822.4), p = 0.09. Severe hand eczema measured
with the HECSI, DLQI and VAS at two time points and with
long duration showed no significant overrepresentation in
non-specific dermatitis. The results from the photographic
guide of severity gave the same result (data not shown).

Discussion
One major advance in this study was the use of clear
definitions of the clinical types of hand eczema supported

15

CLASSIFICATION OF HAND ECZEMA DUUS JOHANSEN ET AL.

Table 1. Data collected in consecutive hand eczema patients in dermatology clinics in Denmark. Basic characteristics (MOAHLFA) and
patients own assessment
n/total (%) or median values (percentiles)

Occupational relationshipa
Atopic dermatitisb
Leg (ulcer/stasis eczema)
Face
Age (years) median (25th to 75th percentile)
1830 years
3160 years
>60 years
Duration of hand eczema

Men n = 247

Women n = 463

Whole population
n = 710

p-value

88/221 (39.8)
36/247 (14.6)
2/247 (0.8)
11/247 (4.5)

193/417 (46.3)
118/463 (25.5)
0
15/463 (3.2)

281/638 (44.0)
154/710 (21.7)
2/710 (0.3)
26/710 (3.7)

0.14c
0.001
0.2
0.5

44 (3158)

37 (2851)

39.0 (2953)

0.0001d

58 (23.5)
142 (57.5)
47 (19.0)

149 (32.2)
277 (59.8)
37 (8.0)

207 (29.2)
419 (59.0)
84 (11.8)

OR (CI)e
0.3 (0.180.52)
0.4 (0.250.64)
1

n = 240

n = 453

n = 693

<6 months
6 months to 2 years
25 years
>5 years to 10 years
>10 years

56 (23.3)
86 (35.8)
42 (17.5)
24 (10.0)
32 (13.3)

74 (16.3)
167 (36.9)
73 (16.1)
39 (8.6)
100 (22.1)

130 (18.8)
253 (36.5)
115 (16.6)
63 (9.1)
132 (19.0)

OR (CI)e
2.4 (1.44.0)f
1.6 (1.02.6)
1.8 (1.03.1)
1.8 (0.93.4)
1

Long duration, >5 years

56 (23.3)

139 (30.7)

195 (28.1)

0.05c

27/232 (11.6)
n = 226
112 (49.6)
70 (31.0)
44 (19.5)
n = 239
3.0 (1.05.7)
n = 240
3.0 (1.55.0)
n = 236
5.5 (4.07.5)

64/427 (15.0)
n = 433
206 (47.6)
147 (33.9%)
80 (18.5)
n = 450
4.0 (2.08.0)
n = 447
3.5 (1.55.5)
n = 443
6.5 (4.58.0)

91/659 (13.8)
n = 659
318 (48.3)
217 (32.9)
124 (18.8)
n = 689
3.0 (2.07.0)
n = 687
3.0 (1.55.0)
n = 669
6.0 (4.08.0)

0.3c
0.7c

Hand eczema in childhood

Hand eczema eruptions
Present all the time
More than half of the time
Less than half of the time
DLQI score
Median (25th to 75th percentiles)
VAS present eczema
Median (25th to 75th percentiles)
VAS past 12 months
Median (25th to 75th percentiles)

0.001d
0.2d
0.004d

CI, confidence interval; DLQI, dermatology life quality index; OR, odds ratio; VAS, visual analogue scale.
a Patients own assessment.
b
Physicians assessment.
Analysed by c 2 - test (two-sided).
d
MannWhitney U-test.
e
logistic regression. The OR quantifies the risk; for example, the OR of 2.4f shows the risk of being male in patients with a short duration as
compared with patients with a duration of hand eczema over 10 years. In other words, males are significantly overrepresented in patients
with short duration of hand eczema.

by a photoguide with typical photographs, as previously

published (1).
Chronic, dry fissured eczema was the most frequent
(36.1%), followed by vesicular eczema with recurrent
eruptions (31.8%). Each of the clinical types nummular
eczema, hyperkeratotic palmar eczema, vesicular eczema
with rare eruptions, and pulpitis was seen in fewer than
10% of the patients. Both pulpitis and hyperkeratotic
palmar hand eczema were statistically significantly more
frequent in men than in women, whereas for the
remainder there were no sex differences. A tendency
was found for patients with hyperkeratotic palmar hand
eczema, nummular eczema or pulpitis to be older than

16

patients without these clinical types. This is in agreement

with previous studies (3, 10).
Vesicular hand eczema with few eruptions had a lower
severity score, both as assessed by the physician and in
current self-assessment. This may be attributable to the
shorter duration and the low number of eruptions, with
normal skin in between. This is supported by the finding
that self-assessment of severity for the past 12 months
was as severe as for the other types of hand eczema.
It is the rule rather than the exception that diseases,
in spite of having similar aetiologies, may show great
variations clinically (4). This also applies to hand eczema.
This study shows that there is no simple relationship

2011 John Wiley & Sons A/S Contact Dermatitis, 65, 1321

CLASSIFICATION OF HAND ECZEMA DUUS JOHANSEN ET AL.

Table 2. Data collected in consecutive hand eczema patients in dermatology clinics in Denmark; evaluation of hand eczema (physicians
assessment) was performed on the basis of the guideline of the Danish Contact Dermatitis Group
n/total (%) or median values (percentiles)

Clinical classification
Vesicular, rare eruptions
Vesicular, repeated eruptions
Dry fissured
Hyperkeratotic palmar
Nummular
Pulpitis
Non-classifiable
Dynamics (past 6 months)
Permanent activity
Recurrent
Rare eruptions
Severity
HECSI median
(25th to 75th percentiles)

Men n = 247

Women n = 463

Whole population
n = 710

p-value

n = 193
8 (4.1)
58 (30.1)
67 (34.7)
22 (11.4)
16 (8.3)
8 (4.1)
14 (7.3)

n = 364
25 (6.9)
119 (32.7)
134 (36.8)
19 (5.2)
28 (7.7)
4 (1.1)
35 (9.6)

n = 557
33 (5.9)
177 (31.8)
201 (36.1)
41 (7.4)
44 (7.9)
12 (2.2)
49 (8.8)

0.3a
0.6a
0.7a
0.01a
0.8a
0.04a
0.4a

86 (38.9)
76 (34.4)
31 (14.0)

123 (29.5)
184 (44.1)
52 (12.5)

209 (32.8)
260 (40.8)
83 (13.0)

0.02a
0.02a
0.5a

n = 209
7.5 (2.020.0)

n = 409
6.0 (3.016.0)

n = 618
6.5 (2.7518.0)

0.4b

HECSI, Hand Eczema Severity Index.

a 2 -test (two-sided).
b MannWhitney U-test.

Fig. 2. Hand Eczema Severity Index (HESCI) score in consecutive

hand eczema patients from dermatology clinics in Denmark. Data
were collected at the time of patch testing and are presented
according to clinical type of hand eczema, based on photographs
given in the guideline of the Danish Contact Dermatitis Group (1).
The boxes shows the quartiles, the line in the middle the median,
and the whiskers the range. There is a significant difference
between groups (p = 0.006) by KruskalWallis test.

2011 John Wiley & Sons A/S Contact Dermatitis, 65, 1321

between clinical type of hand eczema and aetiology, an

observation that was also made by Cronin, who studied
four clinical patterns of hand eczema palms and fingers,
dorsa and fingers, fingers only, and the entire hands in
women (2). She found that all patterns of eczema were
equally prone to sensitization, and although irritants were
of greater importance in eczema of the fingers and dorsa
of the hands, they were nevertheless to be considered
significant in half (42%) of the palmar group (2).
Diepgen et al. recently investigated six different morphological features, such as erythema, infiltration, and
vesicles, in 416 hand eczema patients, and found no clear
relationship with aetiological group (11). They suggested
a classification system of five aetiological groups and
two clinical types (vesicular and hyperkeratotic hand
eczema) (11); however, no definitions were provided,
which affects its applicability and reproducibility. Wilkinson, in his chapter on classification of hand eczema in
1994, gave a description of different clinical types of hand
eczema, which he suggested as a starting point and a
reference frame within which the relevant factors and
behaviour of similar patterns could be studied (3). The
current study is based on this concept (1), and provides
a classification of hand eczema both at the clinical level
and at the aetiological level in all cases. Some useful
observations were made. There was no statistically significant relationship between the diagnosis of current atopic
eczema and any of the clinical types. This also applied
if a history of atopic eczema was used in the analysis

17

18
58 (32.8)
119 (67.2)
38 (2949)

57 (33.3)
7.0 (2.020.0)
3.0 (1.08.0)
3.0 (1.55.0)
5.5 (4.07.5)

8 (24.2)
25 (75.8)
38 (2655.5)

4 (12.5)
0 (07)
2 (1.05.0)
1.5 (0.53.0)
7.0 (4.08.0)

Vesicular, recurrent
eruptions
n = 177
22 (53.7)
19 (46.3)
45 (3258.5)
31 (75.6)
5 (12.2)
5 (12.2)
8 (19.5)
5.5 (2.2516.75)
3.0 (2.08.0)
4.0 (2.06.0)
5.5 (3.58.0)

108 (53.7)
70 (34.8)
17 (8.5)
55 (27.9)
6.0 (2.016.0)
3.0 (2.07.0)
4.0 (2.05.5)
6.5 (5.08.0)

Hyperkeratotic
palmar
n = 41

67 (33.3)
134 (66.7)
37.0 (2952)

Dry fissured
n = 201

10 (22.7)
18 (40.9)
9 (20.5)
11 (25%)
7.0 (3.018.0)
2.0 (1.05.0)
3.0 (2.05.0)
5.0 (3.46.6)

16 (36.4)
28 (63.6)
47 (30.059.75)

Nummular
n = 44

8 (66.7)
3 (25)
1 (8.3)
3 (25%)
10.5 (1.519)
4.0 (2.010)
3.2 (1.66.6)
5.5 (2.27.8)

8 (66.7)
4 (33.3)
55 (4061.3)

Pulpitis
n = 12

157 (55.1)
96 (42.1)
32 (14.0)

6.0 (2.016.8)
3.0 (1.07.0)
3.0(1.55.0)
6.0 (4.08.0)

179 (35.2)
329 (64.8)
39 (2953)

All n = 508

<0.0001
<0.0001
<0.0001
0.2
0.006
0.07
<0.001
0.058

0.007

p-valuea

b Information on dynamics was missing in 6 cases for dry fissured hand eczema and in 7 cases for nummular hand eczema. The total does not give 508, but 285, as vesicular forms are not
included.
p < 0.05 or p < 0.01: statistically significantly different from the whole group (all) by 2 -test or Fishers test if few cases (categorical variables) and MannWhitney U-test (continuous
variables).

a KruskalWallis test (continuous variables) or 2 -test for trend (categorical variables) was used to test for differences across all groups.

Men
Women
Age (years) median
Dynamicsb
Constant activity
Recurrent
Rare eruptions
Duration >5 years
HECSI
DLQI
VAS present
VAS past year

Vesicular, rare
eruptions
n = 33

n/total (%) or median values (percentiles)

Table 3. Characteristics of the different clinical types of hand eczema in consecutive hand eczema patients in terms of dynamics and severity measured by a severity score [Hand Eczema
Severity Index (HECSI)], quality of life [Dermatology Life Quality Index (DLQI)] and self-assessments on a visual analogue scale (VAS) for the present and past year

CLASSIFICATION OF HAND ECZEMA DUUS JOHANSEN ET AL.

2011 John Wiley & Sons A/S Contact Dermatitis, 65, 1321

 2011 John Wiley & Sons A/S Contact Dermatitis, 65, 1321

0.005
0.001
0.5
0.003
194 (38.2)
123 (24.2)
98 (19.3)
109 (21.5)
5 (41.7)
2 (16.7)
1 (8.3)
2 (16.7)

More than one diagnosis can be given for each patient.

p < 0.05 in comparison with All.

5 (12.2)
4 (9.8)
8 (19.5)
18 (43.9)
68 (38.4)
62 (35)
35 (19.8)
32 (18.1)
9 (27.3)
8 (24.2)
3 (9.1)
11 (33.3)

89 (44.3)
39 (19.4)
44 (21.9)
40 (19.9)

18 (40.9)
8 (18.2)
7 (15.9)
6 (13.6)

0.6
0.2
0.02
0.002
110 (21.7)
256 (50.4)
115 (22.6)
197 (38.8)
2 (16.7)
6 (50)
6 (50)
3 (25)
10 (22.7)
18 (40.9)
15 (34.1)
16 (36.4)
9 (22.0)
12 (29.3)
8 (19.5)
7 (17.5)
48 (23.9)
95 (47.3)
43 (21.4)
70 (34.8)
38 (21.5)
90 (58.8)
37 (20.9)
88 (49.7)
3 (9.1)
10 (30.3)
6 (18.2)
13 (39.4)

Atopic dermatitis, personal history

Occupational relationship
Wet work
A positive patch test reaction
Final diagnosisa
Irritant contact dermatitis
Allergic contact dermatitis
Atopic dermatitis
Non-specific dermatitis

All n = 508
Pulpitis
n = 12
Nummular
n = 44
Hyperkeratotic
palmar
n = 41
Dry fissured
n = 201
Vesicular recurrent
eruptions
n = 177
Vesicular, rare
eruptions
n = 33

instead of current atopic dermatitis. It is interesting that

no specific morphology was identified for atopic hand
eczema. Many clinicians would have expected that the
dorsal dry type with fissures would be a dominating type.
Others would probably expect it to be the volar pattern,
and others recurrent vesicular type. It might very well be
that there are different subtypes of atopic dermatitis,
depending, for example, on genetic factors and the
combination of barrier defects and the tendency for there
to be an inflammatory response. Preliminary research
has indicated that severe atopic dermatitis combined with
filaggrin mutation might represent the dorsal dry aspect
with fissures on the fingers (12). Previous researchers
have speculated that the recurrent vesicular type is
particularly common in relation to food allergies (7). Only
large numbers of patients studied in a uniform way, with
extensive gene analysis, will clear up this matter.
Irritant contact dermatitis was most frequent in
chronic, dry fissured hand eczema (44.3%), pulpitis
(41.7%), and nummular hand eczema (40.9%), whereas
allergic contact dermatitis dominated in vesicular types
of hand eczema, with recurrent (35%) and rare (24.2%)
eruptions, which fits with the general experience, but
also shows that patch testing and exposure analysis
are necessary to achieve an aetiological classification.

n (%)

Fig. 3. The Dermatology Life Quality Index (DLQI) score in

consecutive hand eczema patients from dermatology clinics in
Denmark. Data were recorded at inclusion according to clinical type
of hand eczema, based on photographs given in the guideline of the
Danish Contact Dermatitis Group (1). The higher the score, the
more affected is the quality of life. The boxes shows the quartiles,
the line in the middle the median, and the whiskers the range.
There is a significant difference between groups (p = 0.07) by
KruskalWallis test.

Table 4. Characteristics of the clinical types in relation to risk factors and final diagnosis in consecutive hand eczema patients seen in dermatology clinics in Denmark

p-value
( 2 test
for trend)

CLASSIFICATION OF HAND ECZEMA DUUS JOHANSEN ET AL.

19

CLASSIFICATION OF HAND ECZEMA DUUS JOHANSEN ET AL.

The diagnosis of allergic contact eczema is based on

the result of a diagnostic test showing that immunological changes are triggered by a specific chemical,
in combination with typical clinical symptoms and an
exposure assessment (1). This is quite similar to classification of infectious diseases (4). In fact, the aetiological
factors are also the pathogenic factors in infectious diseases, as well as in allergic contact dermatitis, which
should make it especially favourable for targeted treatment and prevention.
One of the great challenges is to refine the definition
of irritant contact dermatitis. This diagnosis is based on
the presence of risk factors that are generally present in
the environment. In a recent Swedish investigation, 20%
of the population of working age acknowledged occupational skin exposure to water (13). The lack of a diagnostic
test increases the risk of misclassification. In twin studies,
it has been shown that wet work is only a risk factor if
a certain genetic disposition is present (14). Work should
be performed to identify this genotype and eventually
develop a diagnostic test, which could be a combination
of genotypes and immunological markers, for this disease
category as a new basis for an aetiological classification.
Hyperkeratotic palmar hand eczema seemed to constitute a special category, mostly being seen in older men
and with less relationship to aetiological groups. This is in
agreement with the study by Hersle and Mobacken, who
described 32 cases of typical hyperkeratotic palmar hand
eczema (10). In this original publication, a photograph
was included that shows the characteristics; this is similar
to the photograph used in the current investigation (1).
Hyperkeratotic palmar hand eczema is characterized by
hyperkeratotic changes in the palms, possibly extending
to the volar side of the fingers. There may be fissures,
but there are no vesicles at any time. It is distinguished
from psoriasis by being without psoriasis-type scaling and
with out psoriasis elsewhere. It is not related to psoriasis (10); it may even be questioned whether it should
be classified as eczema, as it is very monomorphic. It
could be of interest to study whether this type of hand
eczema is related to smoking and excessive alcohol consumption, and whether a relationship with metabolic

syndrome exists, as for psoriasis. Hyperkeratotic palmar

hand eczema offers a clinical type, which benefits from systemic treatment with retinoids (15). It is important to be
strict about the definition of this distinct subtype of hand
eczema, and not use the term hyperkeratotic eczema
for chronic eczema in general, where hyperkeratosis is
present.
The present study is of a reasonable size, but in some
resspects still has limited power in studying the effect of
exogenous factors, which interacts with different genotypes to produce a variety of clinical symptoms. If progress
is going to be made in our understanding and classification
of hand eczema, large-scale studies are needed, including
collection of biological material for genotyping.
Non-specified dermatitis as a diagnosis was equally
frequent in men and in women. It was most frequently
used in the youngest age group (1830 years), which
may indicate that it is a diagnosis used in the early
phase of eczema. No relationship with any of the measures of severity or with any clinical type was found,
except for hyperkeratotic palmar eczema, for which a
non-significant tendency was found (p = 0.09).
Disease classification is a human construction, and is
not something that exists in nature. It is only meaningful
if it serves a purpose, which could be as a prognostic indicator, or to help with selection for therapy or prevention.
However, a first step of any classification is to have clear
definitions. The DCDG has provided a proposal for this (1),
and follow-up of this cohort is being performed; this may
help in clarifying the benefits and drawbacks.

Acknowledgements
The help of research nurse Anne-Marie Topp and of
computer scientist Sren Gade is gratefully acknowledged. The authors are very grateful to the Foundation for Professional Development in Private Practice,
Danish Regions (Fonden for Faglig Udvikling af Speciallaegepraksis, Danske Regioner), who supported this study
financially.

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