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IndianJDermatol.2014MayJun59(3):213224.

PMCID:PMC4037938

doi:10.4103/00195154.131372

HandEczema
UmaShankarAgarwal,RajKumarBesarwal,RahulGupta,PuneetAgarwal,1andSheetalNapalia1
FromtheDepartmentofDermatology,SMSMedicalCollege,Jaipur,India
1
DepartmentofDermatology,MahatmaGandhiInstituteofMedicalSciences,Jaipur,India
Addressforcorrespondence:Dr.UmaAgarwal,397,ShankarNiwas,SrigopalNagar,GujjarKiThadi,Jaipur,India.Email:dr.usag@gmail.com
Received2012AprAccepted2012Dec.
Copyright:IndianJournalofDermatology
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract

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Handeczemaisoftenachronic,multifactorialdisease.Itisusuallyrelatedtooccupationalorroutinehousehold
activities.Exactetiologyofthediseaseisdifficulttodetermine.Itmaybecomesevereenoughanddisablingto
manyofpatientsincourseoftime.Anestimated210%ofpopulationislikelytodevelophandeczemaatsome
pointoftimeduringlife.Itappearstobethemostcommonoccupationalskindisease,comprising935%ofall
occupationaldiseasesandupto80%ormoreofalloccupationalcontactdermatitis.So,itbecomesimportantto
findtheexactetiologyandclassificationofthediseaseandtousetheappropriatepreventiveandtreatment
measures.Despiteitsimportanceinthedermatologicalpractice,veryfewIndianstudieshavebeendonetilldate
toinvestigatetheepidemiologicaltrends,etiology,andtreatmentoptionsforhandeczema.Inthisreview,we
triedtofindtheetiology,epidemiology,andavailabletreatmentmodalitiesforchronichandeczemapatients.
Keywords:Etiology,handeczema,review

Introduction

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Whatwasknown?
1.Handeczemaisacommon,chronicoccupationaldisease.
2.Itsetiologyisdifficulttodetermineinmostofthecasesandtreatmentischallengingtodermatologist.
Handeczemaisaverycommonandwidespreadcondition,whichwaspresumablyfirstdescribedinthe19th
century.[1]Itisafrequentlyencounteredproblem,affectingindividualsofvariousoccupations.Varietyoffactors
maytakepartinthecausationofthisconditionincludingendogenousandexternal/environmentalfactorsacting
eithersinglyorincombination.Inthe19thcentury,dermatologistsdescribedseveralmorphologicalvariantsof
handeczemasuchaseczemasolare,rubrum,impetiginoides,squamosum,papulosum,andmarginatum.[2]
Theexactprevalenceofhandeczemaisdifficulttodeterminebecauseitisnotareportablediseaseandmany
whoareaffecteddonotseekmedicalattention.Anestimated210%ofpopulationislikelytodevelophand
eczemaatsomepointoftimeduringlife.Inaddition,2035%ofalldermatitisaffectsthehands.Itappearstobe
themostcommonoccupationalskindisease,comprising935%ofalloccupationaldiseaseandupto80%or
moreofalloccupationalcontactdermatitides.[3]Femalesaremorecommonlyinvolvedthanmales(2:1),
possiblybecauseofincreasedexposuretowetworkandhouseholdchemicals.[4]Irritantcontactdermatitis(ICD)
wasfoundtobeacauseofhandeczemainhalfofthecases,whereasallergiccontactdermatitiscomprised15%
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cases.[5]Duetothehighincidenceandprevalenceofthispathology,ithasenormoussocioeconomic
consequencesandamassiveimpactonpatientsqualityoflife.Theincreasinglycomplexandindustrialized
environmentofthe21stcentury,hasmadeitallthemoreimportanttofindtheexactetiologyofthediseaseandto
useappropriatepreventiveandtreatmentmeasures.
Variousmorphologicalformsofhandeczemaareseen,whichdifferonlyclinicallyratherthanhistologically.
Knowledgeofpatternofcontactsensitivityinpatientsofhandeczemamaygiveinsightofvariousetiological
agentsresponsibleforit,whichcanfurtherhelpinmanagementofthesepatients.Themanagementofhand
eczemadependsonitscause,whileallergicorirritantcontactdermatitisofthehandscanusuallybeelucidated
byproperhistorytakingandpatchtest,endogenoushandeczemaisoftendiagnosedafterexclusionoftheformer
conditions.

Definition

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Thewordeczemahasanobscureorigin.ItwasfirstusedbyAetiusAmidenus,physiciantotheByzantine
courtinthesixthcentury.Acurrentandacceptabledefinitionofeczemaisthatitisaninflammatoryskin
reactioncharacterizedhistologicallybyspongiosiswithvaryingdegreesofacanthosis,andasuperficial
perivascularlymphohistiocyticinfiltrate.Theclinicalfeaturesofeczemamayincludeitching,redness,scaling,
clusteredpapulovesicles,hyperkeratosis,orfissuring.Theconditionmaybeinducedbyawiderangeofexternal
andinternalfactorsactingsinglyorincombination.Dermatitismeansnothingmorethaninflammationofthe
skin.Thereisnouniversalagreementontheuseofthesetwotermsandtheyarethecauseforsomeconfusion.
Dermatitishasabroaderapplication,inthatitembracesallformsofinflammationoftheskin.
Aclearandworldwideaccepteddefinitionofwhatisincluded,asHandEczemadoesnotexist.Afterhaving
excludedthedisordersofknownetiology(e.g.,Tineamannum,scabies),welldefinednoneczematousdisorders
(e.g.,psoriasis,lichenplanus,granulomaannulare,porphyriacutaneatarda,keratosispalmoplantaris,fixeddrug
eruptions),andneoplasticdisordersfromthecategoryofhanddermatoses,andifhandsarenotinvolvedaspart
ofanextensiveskindisorder,diagnosisofcharacteristiccasesofhandeczemapresentlittledifficulty.Theterm
handeczema[6]impliesthedermatitiswhichislargelyconfinedtothehands,withnoneoronlyminor
involvementofotherareas.

Epidemiology

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Prevalenceofhandeczemavariesaccordingtothegeographicalregion.InaSwedishepidemiologicalstudy[7]of
20,000individualsbetweenages20and65,theprevalenceofhandeczemaoccasionallyduringthelastyearwas
foundtobe11%.Allformsofeczemaandcontactdermatitisaccountedfor1024%ofthepatients(19781981)
seenineighthospitalcentersinGreatBritain.[8]Itislikelythatatleast2025%ofthesehadeczemaconfinedto
thehands.Inananalysisof4825patientspatchtestedineightEuropeanCenters,theInternationalContacts
DermatitisResearchgroupfoundthatthehandsalonewereinvolvedin36%ofmalesand30%offemales.[9]
Agrup,withtheuseofquestionnairesurveyfollowedbyexamination,estimatedtheprevalenceofhandeczema
tobe1.2%insouthernSweden.[10]
Theincidenceofhandeczemawasfoundtobe10.915.8%invariousstudies[11]whileinIndiandermatologic
outpatientdepartmentof510%ofallergiccontactdermatitispatients,handinvolvementwasseenintwothirdof
cases.[12,13]
InalargestudyconductedbyMeding[14]inSweden,whichincludedacohortofabout20,000people,11.8%of
respondersreportedhavinghandeczemaonsomeoccasionintheprevious12months.Handeczemawasfound
tobealmosttwiceascommoninfemalesasinmales,witharatioof1.9,andwasmostcommoninyoung
females.Thelatterobservationhasalsobeennotedinotherprevalencestudies.
Themostcommoncauseofhandeczemaiscontactirritants.InMeding'sstudy,themostcommontypeofhand
eczemawereirritantdermatitis(35%),atopichandeczema(22%),andallergiccontactdermatitis(19%).The
correspondingfemales:malesratioswere2.6:1,1.9:1,5.4:1,respectively.Themostfrequentpositivepatchtest
wasforNickelandCobalt.Atotalof32%ofthepatientshadoneormorepositivereactionstothestandard
series.Similarresultshavebeenfoundinotherpublicationsonthepatchtestresults.Whenthedifferent
occupationalgroupsarecompared,theonlystatisticallysignificantincreaseinprevalenceofacontactallergy

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wasnotedamongwomeninadministrativeworkforcolophony.Whetherthisisattributabletoexposuretoresin
inpaperisnotknown.
Historyofchildhoodeczema,femalesex,occupationalexposure,atopicmucousmembranesymptoms(rhinitisor
asthma),andaserviceoccupationareestablishedimportantriskfactors.[15]Poorprognosticfactorsforhand
eczemaarewidespreadhandinvolvement,youngerageofonset,historyofchildhoodeczema,andcontact
allergy.

Pathogenesis

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Irritantcontactdermatitis
Irritantcontactdermatitisisaconditioncausedbydirectinjuryoftheskin.Anirritantisanyagentcapableof
producingcelldamageinanyindividualifappliedforsufficienttimeandinsufficientconcentration.
Immunologicprocessesarenotinvolved,anddermatitisoccurswithoutpriorsensitization.Irritantscausedamage
bybreakingorremovingtheprotectivelayersoftheupperepidermis.Theydenaturekeratin,removelipids,and
alterthewaterholdingcapacityoftheskin.Thisleadstodamageoftheunderlyinglivingcellsoftheepidermis.
Theseverityofdermatitisproducedbyanirritantdependsonthetypeofexposure,vehicle,andindividual
propensity.Normal,dry,orthickskinismoreresistanttoirritanteffectsthanmoist,macerated,orthinskin.
Cumulativeirritantdermatitismostcommonlyaffectsthinexposedskin,suchasthebackofthehands,the
webspacesofthefingers.
Thereisdifferencebetweenthemechanismofacuteandchronicirritantcontactdermatitis.Chronicirritant
contactdermatitisisduetodisturbedbarrierfunctionandincreasedepidermalcellturnoverwhileacuteICDisa
typeofinflammatoryreaction.MediatorsinvolvedinthistypeofreactionsareTNF,IL1,IL6,IL8,IFN,
IL2,andgranulocytemonocytecolonystimulatoryfactor.[16]
Allergiccontactdermatitis
AllergiccontactdermatitisisatypeIVhypersensitivityreactiononlyaffectingpreviouslysensitizedindividuals.
Acommonexampleofallergiccontactdermatitisistheallergicreactiontoplants,suchaspoisonivy,poisonoak,
andpoisonsumac.Contactallergensareinvariablysmallerthan500D,thuspenetratedeeperskinandafterbeing
conjugatedwithautologousproteins,sensitizationtakesplace.TwodistinctphasesinatypeIVhypersensitivity
reactionaretheinduction(i.e.,sensitization)phaseandtheelicitationphase.
Duringtheinductionphase,anallergen,orhapten,penetratestheepidermis,whereitispickedupandprocessed
byanantigenpresentingcell.Mostallergensincontactdermatitisareoflowmolecularweightandrequire
minimalprocessing.However,manyhaveacomplicatedstructureandaresignificantlyalteredbytheantigen
presentingcells.AntigenpresentingcellsincludeLangerhanscells,dermaldendrocytes,andmacrophages.The
processedantigenispresentedtoTlymphocytes,whichundergoblastogenesisintheregionallymphnodes.One
subsetoftheseTcellsdifferentiatesintomemorycells,whereasothersbecomeeffectorTlymphocytesthatare
releasedintothebloodstream.
Theelicitationphaseoccurswhenthesensitizedindividualisagainexposedtotheantigen.Serialbiopsiesduring
thefirst24hoursafterdinitrochlorobenzene(DNCB)challengein15sensitizedpatients[17]haveshownthat
DNCBpenetratestheepidermisveryrapidlyandassociateswithepidermalcells,bothkeratinocytesand
Langerhanscells(LCs),within1hourofapplicationandlocalizesinthesweatglandsanddeeplevelsofthe
pilosebaceousfolliclesby3hours,andat6hourslargedendriticDNCBpositivecellsappearinthepapillaryand
reticulardermis,particularlyaroundtheseappendages.Within24hoursofantigenapplication,LCsmigrateto
regionallymphnodeswheretheypresenttheantigentothecompatibleTlymphocyteswithinthelymphnodes.
CertainTlymphocyteslikeCD4+andCD45RA+becomephysicallyapposedtotheLCs,thusfacilitatingthe
transferofantigen.TheprocessedantigenispresentedtothecirculatingeffectorTlymphocytesthat,inturn,
producelymphokines.Manymediatorsorcytokinesarereleasednamely,IL1byantigenpresentingcellsandIL
2byTlymphocytes.ThecytokinescauseclonalproliferationofantigenspecificThelper1,CD4+lymphocytes
whichmightbecapableofrespondingtoaparticularantigenwhenfutureexposureoccurs.Theelicitationphase
requiresseveralhourstodevelop,and,asaresult,symptomsofallergiccontactdermatitisusuallydevelophours
todaysfollowingexposure.Onceacquired,contactsensitivitytendstopersist.Thedegreeofsensitivitymay
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declineunlessboostedbyrepeatedexposure,butwithahighinitiallevelofsensitivity,itmayremain
demonstrablethroughoutlife.
Roleofskinbarrierandgenetics
Therearemultiplecomponentsinepidermiswhichareimportanttobarrierfunction.Thesecomponentsare
claudin,desmoglein,filaggrin,ceramide,propercontrolofproteases,andvariousscaffoldingproteins
(involucrin,envoplakin,andperiplakin).Whenfunctioningproperly,thislayerisanefficientbarriertoepidermal
invasionofallergensandbacteriaandalsopreventswaterloss.Thefirstlineofdefensewithintheepidermal
barrieristhestratumcorneum,whichservesseveralfundamentalrolesinmaintainingprotectionfromthe
environmentaswellaspreventingwaterloss.Thestratumcorneumconsistsofamulticellularverticallystacked
layerofcellsembeddedwithinahydrophobicextracellularmatrix.Thisextracellularmatrixisderivedfromthe
secretionoflipidprecursorsandlipidhydrolases.Thesehydrolasescleavetheprecursorstoformessentialand
nonessentialfattyacids,cholesterol,andatleast10differentceramides,whichselforganizeintomultilayered
lamellarbilayersbetweenthecorneocytesandformawatertightmortarmaintainingskinhydration.[18]
Corneocytesinthestratumcorneumareheldtogetherbytightjunctionsandvariousscaffoldingproteinswhich
helpinmaintainingskinbarrier.Claudinsareafamilyofproteinsthatareimportantcomponentsofthetight
junctionsbetweencorneocytes.Claudindeficientpatientshaveaberrantformationoftightjunctionscausing
disruptionoftheskinbarrier.Claudinshelpinpreventingmoisturelossthroughthislayeroftheskin.Thistight
junctionalsoblocksaccessthroughtheskintovariousexternalenvironmentalallergens.Thus,claudinmayhelp
inpreventionofimmuneexposuretoallergicstimuli.Scaffoldingproteinsarerequiredforeffectiveepidermal
barrier.Lossofepidermalscaffoldingproteinssuchasinvolucrin,envoplakin,andperiplakinisassociatedwith
alterationsinepidermalbarrierfunctionandalteredformationofcornifiedepidermalenvelope.[19]
Anotherfactorwhichisrequiredfornormalfunctioningoftheepidermisispropercontrolofskinproteases
activity.SPINKisaproteinthatinhibitsserineproteaseactionintheskin.TheSPINKgeneisabsentin
Netherton'ssyndrome.Inthissyndrome,thepatienthassevereatopicdermatitis,scaling,andraisedserumIgE
level.LackofSPINKresultsinuncontrolledserineproteaseelastase2activity.Increasedproteaseactivity
negativelyaltersfilaggrinandlipid(ceramide)processingtherebydecreasingskinbarrierfunction.
Filaggrinisanimportantproteinfoundinlamellarbodiesofstratumgranulosumcorneocytes.Whenthese
granulesarereleasedtheybecomeavitalcomponentoftheextracellularmatrixofthestratumcorneum.The
filaggringeneresidesonhumanchromosome1q21withintheepidermaldifferentiationcomplex,aregionthat
alsoharborsgenesforseveralotherproteinsthatareimportantforthenormalepidermalbarrierfunction.[20]
Filaggrinnormallyassistsincytoskeletalaggregationandformationofthecornifiedepidermalenvelope.Itis
requiredfornormallamellarbodyformationandcontentsecretion.Furthermore,ascorneocytesmatureandstart
losingwater,filaggrindissociatesfromthecornifiedenvelopeandisprocessedintoacidicmetabolitesandacting
asosmolyteshelptomaintainhydration.TheseacidicmetabolitesalsokeepthepHbelowthethresholdrequired
fortheactivationofTh2inducingendogenousserineproteaseswhichhasimportantroleinpathogenesisof
atopichandeczema.Therefore,afilaggrinmutationcontributestoadisruptedepidermalbarrier,increasedwater
loss,inflammationandexposuretoenvironmentalallergensresultinginatopichandeczema.[21]
Animpairedexpressionofantimicrobialpeptides(AMPs)suchascathelicidinanddefensinswasdetectedin
lesionalskininpatientswithatopicdermatitis.[22]
DetergentscausestratumcorneumdamagebyremovalofthesurfacelipidlayerandincreaseTEWLleadingto
irritantcontactdermatitis.[23]
Stratumcorneumchymotrypticenzyme(SCCE)isaserineprotease,whichhasaroleinthedesquamationofskin
viatheproteolysisofdesmosomesinthestratumcorneum.AnelevatedexpressionofhK7(humantissue
kallikrein7)orSCCEintheepidermisleadstoincreasedproteolyticactivity,pathologicaldesquamation,and
inflammationinmanyskindiseasessuchasNethertonsyndrome,psoriasis,andatopicdermatitis.[24,25,26]
Etiology
Mostcasesofhandeczemahaveamultifactorialetiologywhichcanbebroadlydividedintotwogroups:
Exogenousandendogenouscauses.Amongexogenouscausescontactirritantsaremostlycommonlyblamedfor
handeczema.Theseincludesoaps,detergents,rubber,vegetables,etc.,Physicalfrictionandminortraumacan
alsocauseirritantcontactdermatitis.
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Ingestedallergenslikenickel,chromium,anddrugsusedtopicallylikeneomycinandhydroxyquinolonesare
otherfactorsresponsibleforhandeczema.Dermatophytidereactiontotineapediscanalsoinvolvehands.Certain
occupationsareparticularlylikelytoprovokehandeczemalikehairdressers,farmers,constructionworkers,
dentalandmedicalpersonnel,metalworkers,foodhandlers,etc.
Amongendogenouscauses,atopyisthemostcommoncauseofhandeczema.Roleofstress,hormones,and
xerosisisalsodocumented.Somecasesareidiopathic.
Bajajetal.[27]reportedpatchtestdatafromasinglegeneraldermatologycenterinNorthIndia.Outofthe1000
patientsanalyzed,positivereactionswereseenin590(59%)patients.Positivitytonickel(11.1%)neomycin
(7%),mercaptobenzthiazole(6.6%),nitrofurazone(6%),colophony(5.7%),fragrancemix(5.5%),andcobalt
chloride(5.4%)antigenswasseen.However,partheniumwasthemostcommonallergenbasedontheproportion
ofpatientstestedwithit(14.5%).Inmen,potassiumdichromate(30%)wasthemostcommonsensitizerandin
women,andnickel(43%)wasthemostcommontoshowpatchtestpositivity.
InastudyofpatchtestinginhandeczemabyKishoreetal.[28]thepositivepatchtestwasseenin82%ofthe
patientswhichwashighcomparedwithotherstudies.Potassiumdichromatewasthemostcommonsensitizer
testingpositivein26%ofthepatientswhilenickelwasthenextcommontestingpositivein18%ofthepatients.
Thehighpositivityforpotassiumdichromatewasexplainedbyitspresenceindetergentsandcements.
AstudybyKaurandSharma[29]inChandigarhfoundthat53.1%ofthepatientswithhandeczemawere
sensitivetometals.Ofthese,nickel,cobaltandchromatesensitivitywasseenin40.6,31.2and21.8%patients
respectively.Inthesamestudy,medicaments,rubber,andvegetablesensitivitywasfoundin40.6,13,and13%
patientsrespectively.Themiscellaneoussensitizerswerepositivein23.4%patientswithhanddermatitisthey
includedplants,oil,filecover,currencynotes,DDT,paraphenylenediamine,formaldehyde,mercuricchloride,
film,andpaperdeveloper.
Soapsanddetergentswerefoundtobethesecondmostcommonsensitizersinfemalesinastudyof71patients
byBajaj.[30]ThesefindingswerealsoobservedinanotherstudyundertakenbySinghandSingh[31]whowere
oftheopinionthatdetergentsareresponsibleforcausingbothirritantandallergiccontactdermatitis.
Vegetablesareacommoncauseofcontactdermatitisofhandsinhousewivesandcooks.Itoccursasscalingand
fissuringofpalmarsurfaceofindex,middlefinger,andthumbs.Themostcommonsensitizersaregarlic(Allium
sativum),onion(Alliumcepa),tomato(Lycopersiconesculentum),carrot(Daucuscarota),ladyfinger(Hibiscus
esculentes),andginger(Zanzibarofficinale).
AstudybyPasrichaandKanwar[32]reportedvegetablesensitivitytobeashighas75.8%and82.7%in
housewiveseczemarespectively.Garlicandonionwerethemostfrequentsensitizers.Thisstudyalsoshowed
thatallergiccontactdermatitistogarlicandonionhaspredominantinvolvementofindex,thumb,andmiddle
fingerofdominanthandandthumboftheotherhand(fingertipdermatitis).
Dermatitisonfingercalledtulipfingerisseeningardenersandbulbgrowers.[33]Mostgrowershadcontact
withNarcissussapduringtheinvestigation.Contactswithotherirritantssuchashyacinthdustandpesticides
seemedtobealsoresponsible.Patchtestsshowedthatcontactsensitizationexiststopesticidesandtoflowerbulb
extracts.
Wetworkisamajorexternalriskfactorforhanddermatitis.Inastudyoffemalecleaners,[34]itwasfoundthat
theyhadwethandsmorethanaquarteroftheworkingday.Waterassuchdecreasestheprotectivecapacityofthe
skinandocclusionfurtherincreasesirritanteffect.Inmanywetworkoccupations,lipidsolublechemicalsare
addedtowatertoachievethecleaningeffect.Intheskinthiseffectisunfavorablebecauseintracellularlipidsare
washedaway.Theselipidsareimportantfactorsincutaneousprotectivecapacity.Theremovaloflipidinduces
structuralandphysiochemicalalterationsintheskin,whichapparentlyfacilitatestheprocessofcutaneous
irritation.
Therearevariousendogenousfactorsofhandeczemaidiopathic(asinhyperkeratoticpalmardermatitis)and
atopystressandexcessivesweatingmayaggravatethiscondition.Atopyhasbeenconsideredthemostcommon
causeofhandeczema[35]andthemostfrequentlyinvolvedpartsofbodyarethehands.Theworstprognosiswas
seeninpatientsofatopichanddermatitis,aswellasitwasassociatedwithalongerduration,highcontinuityof
symptoms,andextensiveinvolvement.[36]
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Inastudyof777patientsofatopicdermatitis,[37]handinvolvementwaspresentin58.9%ofpatients.Thehand
involvementpresenteduniquephysical,social,andtherapeuticchallengesfortheatopicpatients.Itwasfound
thatinvolvementofdorsalhandsurfacesandthevolarwristmaysuggestatopyasacauseofhandeczema.
Clinicalpatternsofhandeczema
Therearedifferentpatternsofhandeczemawhichdifferonlyclinically,nothistologically.Severalclinical
variantsofhanddermatitishavebeendescribed,includinghyperkeratotic(i.e.,psoriasiformortylotic),frictional,
nummular,atopic,pompholyx(i.e.,dyshidrosis),andchronicvesicularhanddermatitis.Hybridsofthesepatterns
existandsomeexpertsdonotagreeonclassifications.[38]
Manypublishedclassifications[39,40,41]involveacombinationofetiologicalfactors(irritant,allergic,and
atopicdisease)andmorphologicalfeatures(pompholyx,vesicular,andhyperkeratotoiceczema,Table1).
However,nosingleclassificationofhandeczemaissatisfactory.
Table1
Classificationofhandeczema(HE).Overlappingdiseaseentitiesand
multifactorialetiologiesarecommon
OtherclassificationsystembasedonananalysisofpatientsattendingEuropeanpatchtestingcenterswasrecently
proposed.[41]Intotal,416patientsfromthe10participatingclinicswereincludedinthestudy.Itincludesseven
subgroupsaccordingtodemographics,medicalhistory,andlesionsmorphology[Table2].
Table2
Proposedclassificationofhandeczema[41]

Differentclinicalpatternsofhandeczemaincludedinthisreview
1.Pompholyx(vesiculareczemaofpalmsandsoles),dyshidroticeczema
2.Patchyvesiculosquamouseczema
3.Hyperkeratoticpalmareczema(tyloticeczema)
4.Recurrentfocalpalmarpeeling
5.Discoideczema(nummulareczema)
6.Wearandteardermatitis(housewivesdermatitis)
7.Ringeczema
8.Fingertipeczema
9.Aproneczema
10.Gut/slaughterhouseeczema
11.Chronicacraldermatitis.
Clinically,handeczemaischaracterizedbysignsoferythema,vesicles,papules,scaling,fissures,hyperkeratosis,
andsymptomsofitchandpain.Chronichandeczemaisconsideredwhenhandeczemaisofmorethan6months
duration.
Histopathologicallyallpatternsshowsimilarchanges.Epidermisshowsspongiosis,acanthosis,parakeratosis,
infiltrationbylymphocyteswhiledermisshowvasculardilatationandlymphocyticinfiltration.
Pompholyx Pompholyx(vesiculareczemaofpalmsandsoles,dyshidroticeczema)isafrequentdeepseated

vesiculareruptionofidiopathicunknownoriginaffectingthepalmsandsolesrecognizedaspalmoplantar
pompholyx.[36]Itaccountsforabout520%ofallcasesofhandeczema.[10,30]Whenpompholyxoccursonthe
palms,itisnamedascheiropompholyx,andwhenonthesoles,podopomphoylx.Theconditionismorecommon
inhotweather.Soitistermeddyshidroticeczema.Theroleofsweatglandsisdisputed,althoughdistributionof
lesionscorrespondstoemotionallyactivatedpalmoplantarsweatingandhotweather.However,hyperhidrosisis
notaconstantfeature.Roleofatopymaybesignificant.

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Lodietal.[42]foundpersonalandfamilyhistoryofatopyin50%oftheirpatientscomparedto12%controlsin
studyofagroupof104patients.Nickelsulfatewastheallergenwiththehighestpositivityonpatchtesting:
20.19%versus6.25%ofthecontrolgroup.Inthisstudyitwasalsoobservedthatdifferenthaptensorantigens
canproducethesameclinicalandhistologicalpictureofpompholyxinpredisposedsubjects.Aspiriningestion,
oralcontraceptives,andregularsmokingincreasetheriskofpompholyx.
Patchyvesiculosquamouseczema Thispatternischaracterizedbyamixtureofirregularpatchy,

vesiculosquamouslesionsoccuringonbothhands,usuallyasymmetrically.
Hyperkeratoticpalmareczema(tyloticeczema) Thisconditionischaracterizedbyhighlyirritable,scaly,

fissured,hyperkeratotic,patchesonthepalms,andpalmarsurfacesofthefingers.Itisusuallyseeninmenof
middleage.Apatchtestisnegativebutfoundpositivein130outof230patientsinanIndianstudy.[43]
Recurrentfocalpalmarpeeling(desquamationenaires) Thisconditionisamildformofpompholyx

characterizedbysmallareasofsuperficialwhitedesquamationwhichdeveloponthesidesofthefingersandon
thepalms.Theconditionisrelativelyasymptomatic.Thereareusuallynovesicles,butsomepatientsmay
subsequentlydeveloptruepompholyx.
Discoideczema(nummulareczema) Discoideczemaischaracterizedbyplaquesofnonspecificmorphological

features,namelycircularorovalplaquesofeczemawithaclearlydemarcatededge.Discoideczemais
etiologicallyrelatedtoatopy,infection,physicalorchemicaltrauma,allergy,dryskin,stress,andtodrugslike
methyldopaandgold.Thediagnosticlesionofdiscoideczemaisacoinshapedplaqueofcloselyset,thinwalled
vesiclesonanerythematousbase.Thisarisesfromtheconfluenceoftinypapulesandpapulovesicles.Discoid
eczemaofhandsaffectsthedorsaofthehandsorthebacksideoffingers.
Wearandteardermatitis/housewivesdermatitis/dermatitispalmarissicca/Frictionaldermatitis This

conditionaffectshousewivesandcleanerswhofrequentlyimmersetheirhandsinwateranddetergents.This
patternischaracterizedbydryskinwithsuperficialcracks,whichstandsoutwhiteagainstanerythmatous
background.Skinoverthedorsaoftheknucklejointsmaybedryandchapped.
Ringeczema Thischaracteristicpatternparticularlyaffectsyoungwomen,soonaftermarriagerarelymenare

affected.Thisconditionischaracterizedbyapatchofeczemawhichdevelopsunderaringandspreadstoinvolve
theadjacentsideofthemiddlefingerandtheadjacentareaofthepalm.Patchisirritable.Thereisusuallyno
contactsensitivitytogold,copper,orotheralloys.Lessfrequently,allergiccontactdermatitisunderringshas
beenobserved,fromnickel,gold,andpalladium.[44]Thistypeofhandeczemaisprobablyduetoaccumulation
ofsoapanddetergentbeneathrings,butfrictionmayalsoplayarole.Repeatedfragrancecontactonirritatedskin
inasemioccludedareaundertheringsmayfacilitatesensitizationtocosmeticuseasreportedina16yearold
girl.[45]
Fingertipeczema ThisisknownaspulpiteinFrance,atermthataccuratelylocalizesittothepulpsrather

thanthebacksofthefingers.Thesebecomedryandglazedparchmentpulps,thencrackandevenfissureand
areextremelypainful.Usuallyitremainslocalizedbutmayoccasionallyextend.Twopatternsarerecognized.
Thefirstandthemostcommonpatterninvolvesmostofallofthefingers,mainlythoseofthedominanthand
particularlythumbandforefinger.Thispatternisworseinthewinter.Inthispatternpatchtestsarenegativeor
notrelevant.Itisacumulativeirritantdermatitisinwhichdegreasingagentscombinewithtraumaascausative
factors.Thesecondpatterninvolvespreferablythethumb,forefinger,andthirdfingerofthedominanthand.This
isusuallyoccupational.Patchtestsmayberewardinginthesecases.Itmaybeeitherirritant(e.g.,innewspaper
deliveryemployees)orallergic(e.g.,colophonyinpolishortotulipbulbs).Theremaybeallergytoonions,
garlic,orotherkitchenproducts.
Aproneczema ThewordaproneczemawasgivenbyCalnan.[46]Aproneczemaisatypeofhandeczemathat

involvestheproximalpalmaraspectoftwoormoreadjacentfingersandthecontiguouspalmarskinoverthe
metacarpophalangealjoints,thusresemblinganapron.Rarely,itiscausedbycontactallergens,butmayreflect
theeffectofirritants.Itismorecommoninwomenandislargelyendogenousinorigin.[47]
Gut/slaughterhouseeczema Itisseenasatransientvesiculareczemawhichbeginsfromthewebsofthefingers

andspreadstothesides.Eachepisodemaybemildandmayclearspontaneouslybutrecursatregularintervals.
Thisspecificallyaffectsworkersengagedineviscerationofcarcassesofanimalsinslaughterhouses.[48]
Pathogenesisisuncertain.
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Chronicacraldermatitis Chronicacraldermatitisisadistinctivesyndromeaffectingmiddleagedpatientsandis

characterizedbypruritic,hyperkeratoticpapulovesiculareczemaofthehandsandthefeet.[49]Itisassociated
withgrosslyelevatedimmunoglobulin(Ig)Elevelswithoutanypersonalorfamilyhistoryofatopy.
Contacturticariasyndromeandhandeczema
Contacturticariasyndrome(CUS)orproteincontactdermatitis,firstdefinedasabiologicentityin1975,
comprisesaheterogeneousgroupoftransientinflammatoryreactionsappearingwithinminutestohoursafter
contactwiththeelicitingsubstance.[50]Thisreactionusuallyoccursonnormaloreczematousskinandusually
disappearswithinafewhours.Contacturticaria(CU)inassociationwithhandeczemaisarelativelynewentity,
thefirstfewcasesbeingreportedjustover20yearsago.Usually,itistheimmunologicvarietyofCUthatis
associatedwithhandeczema.Sinceitsrecognitioninthe1970,anincreasingnumberofreportsofcontact
urticariainassociationwithhandeczemahavebeenpublished,todiversesubstances,includingvariousfoods,
animalandplantproducts,medicaments,andindustrialchemicals.Attheweakestend,patientsmayexperience
itching,tingling,orburningaccompaniedbyerythema(whealandflare).Atthemoreextremeendofthe
spectrum,extracutaneoussymptomsmayaccompanythelocalurticarialresponse,rangingfrom
rhinoconjunctivitistoanaphylacticshock.Thetypicalprimarylesion(erythema,orwhealandflare)withor
withoutsecondaryorganinvolvementresolvesinhours,butatypicalrecurrentepisodesviaunknown
mechanisms,convertintodermatitis(eczema).
Diagnosisofhandeczema
Thoughthediagnosisofhandeczemaisselfevident,manytimesitisdifficulttodifferentiateitfromsomeother
dermatologicaldisorderslikepsoriasis,tineamannum,lichenplanus,pityriasisrubrapilaris,palmarpustulosis.
Diagnosisofhanddermatitisneedsdetailedhistoryincludinggeneralmedicalstatus,onset,progressionand
remissionofdermatitis,work/jobhistory,otherexposures,familyhistoryandclinicalexamination.Theimportant
investigationsforconfirmationofallergiccontactdermatitisincludestandardpatchtesting,totalanddifferential
leucocytecountevidencingeosinophilia,serumIgElevel,skinbiopsy,pricktest,potassiumhydroxide
preparation,fungalandbacterialcultures,Gramstaining,radioallergosorbenttest(RAST),andinvitro
lymphocytestimulationtest.
Standardpatchtest
ThepatchtestwasfirstusedbyJoslyJadassohnin1896.Heestablishedtheroleofthepatchtestbyhissuccess
inreproducingtheclinicallectureofcontactdermatitisfromiodoformmercurysalts.Thetestisbasedonthe
principlethatwholeskinofanallergicindividualiscapableofreactingwiththecausativeantigen.Therefore,a
standardconcentrationoftheantigenappliedonnormallookingskinwouldalsoproducethesame
pathophysiologicalchange,asfoundinallergiccontactdermatitis.Incasesofallergiccontactdermatitisallergens
isappliedonapatchofthefilterpaperplacedonanimpermeablesheet/aluminumcupfixedtotheskinoverthe
backbyadhesivetape.However,theFinnchambersarethemostcommonsystemtoapplyallergensandconsist
ofsmallaluminumdisks,mountedonacrylicbasedadhesive,nonocclusive,hypoallergenictape.Themajor
disadvantageofthissystemisreactionofmetalsaltslikemercury,cobalt,andnickelwithaluminum.
Theskinareaselectedforthepatchtestshouldbeshavedofcoarsehairbeforeapplication.Theallergenisleftin
contactwithskinforabout48hoursandthenremovedtoseethedegreeoflocalinflammatoryreaction.Afteran
hourofremovingthepatches,thetestreactionsaregradedasinTable3.Thepatchtestreadingshouldalsobe
takenat96hours.[51]
Table3
ScoringofthepatchtestaccordingtoICDRGrecommendations

Photopatchtest
Somesubstancesarephotosensitizersinthatthesewillresultindermatitisonlyiftheskinaftercontactwiththe
substancesisexposedtosunlightorsomeotherequivalentsourceoflightemittingUVAradiation(usualdosesof
515J/cm2).Suchsubstancesaretobetestedbythephotopatchtest.
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TRUEtest(thinlayerrapiduseepicutaneoustest)
Itisanewtypeoftestsysteminwhichanallergengelisincorporatedonapolyestersheetwhichisthendried
andcutinto9mm9mmsquares.ItwasintroducedbyFischerandMalbach.[52]Thesetestpatchesare
mountedonanacrylictapecoveredwithasiliconizedprotectionsheetandpackedinairtight,lightimpermeable
envelopes.Readytoapplypolyesterpatchescoatedwithallergensinthehydrophilicgelareusedandtheyhave
theadvantageofexactdosage,thinsurfacespread,equaldistribution,andhighbioavailabilityoftheallergen.
TheTRUEtestpatchesarearrangedintwopanelsof12allergensonateststrip.Thesearereadytoapplypatches
andafterapplicationtheycanberemovedafter48hoursbyphysician.Thepatientsshouldbeaskedtowaitfor
halfanhourforaccuratereading.Thepatchesshouldbestoredbetween2Cand8Ctemperature.
AdvantagesoftheTRUEtest
1.Itiseasy,convenient,andreadytouse
2.Exactandlowerdosage,thinsurfacespread,andequaldistribution
3.Bettertapeadhesiveness
4.Lesschancesofconfusionandmistakesasitisareadymadepreparation.
DisadvantageoftheTRUEtest
1.Morechancesofwashingawaywithsweatingbecauseofhydrophilicmaterial
2.Expensive
3.Importantsteroidantigensarenotincluded
4.Suboptimalsensitivityforfragrancemixantigen.
Thereareotherreadytousepatchtests,namelyAccupatch(SmartPractice)andEpiquick(SmartPractice).[53]
Treatment
Handeczemahaschronicrelapsingandremittingcourse,itischallengingtothepatientsaswellastoa
dermatologist.Itisestimatedthat57%ofpatientswithhandeczemaarecharacterizedbyhavingchronicor
severesymptomsand24%ofseverecasesarerefractorytotraditionaltopicaltherapy.[41]Avoidanceof
allergensandirritantsistheusefulstepoftreatmentbutitisnotpossiblemostofthetimesbecauseofthe
widespreadoccurrenceofcontactallergensinhouseholdsubstancesaswellasinoccupationalenvironment
mostlyafterrapidlyincreasingindustrializationinlast60years.Aninimitablefeatureinmostofthecasesis
alteredbarrierfunctionafterdisruptionofstratumcorneum,thuscausingtransepidermalwaterloss.Nearlyall
formsofhandeczemabeginwithdisruptionofstratumcorneumbarrier.[54]Thusinitialmanagementusually
aimsatmaintenanceandrestorationofthebarrierandcontrollingtheinflammation.Mostofthetimes,itwould
bebeneficialtotakesymptomatictreatmenttoalleviatethesignsandsymptomsofthediseaseandtofollow
someoftheimportantprecautionsindaytodayactivities.Butitisfoundimpracticaltoapplyemollientsmany
timesasoutlinedbelow,soitisrecommendedtoapplyemollientproperlyovernight.Inareviewoftherapeutic
optionsinhandeczema,Warshawoutlinedtheusefulguidelinesforpreventionandlifestylemodificationinday
todayactivities.[38]ThemodifiedguidelinesareenlistedinTable4.
Table4
Preventionandlifestylemanagementinhandeczemapatients

Themanagementofpatientswithchronichandeczemaisoftenunsatisfactory.Althoughalotoftreatment
optionsexist,thereisnoconsensusoverthechoiceoftreatmentaccordingtodurationortypeoftheeczema.
Conventionallypatientswithhandeczemaaretreatedwithtopicalcorticosteroids,oralantihistamines,
emollients,andshortcourseofsystemiccorticosteroidsaccordingtotheseverityofdisease.Topicalsteroidsare
usuallythefirstlineagentstocontroltheinflammation.Varioustypesoftopicalcorticosteroidslikedesonide,
mometasonefuroate,clobetasolpropionate,betamethasonedipropionate,etc.,havebeenusedfortreatmentof
handeczema.Topicalsteroidsarefastactingandcontrolthediseaseinmostofthepatientsbuttheiruseis
limitedbyadverseeffectslikeskinatrophyandtelangiectasia.Otherproblemswiththeirusearereboundflare
ups,tachyphylaxisonregularuse,weakeningofskinbarrier,andlackofefficacyinseverelyaffectedpatients.It
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hasbeennotedthatlongtermuseoftopicalsteroidcanenhancetheproductionofstratumcorneumchymotryptic
enzymewhichimpairstheepidermalbarrierfunction.[39]Shortcourseofsystemicsteroidsisrequiredinthe
caseofseveredisease.Butadverseeffectsprofileofsystemicsteroidslimitslongtermuse.So,itisnecessaryto
comeupwithasteroidsparingagentwhichprovidesgoodresponseintheacutestageofthedisease,andhasless
rateofrecurrence.Variousimmunosuppressantshavebeeninvestigatedforuseinchronichandeczema.Different
treatmentmodalitiesareenlistedinTable5.
Table5
Differenttreatmentmodalitiesforhandeczema

Granlund[80]investigatedtheeffectoforalcyclosporineondiseaseactivity.Fortyonepatientswereenrolledto
takepartinthisrandomizedparallelgroupdesignstudywithpartialcrossoverinthesecondphase.Seventeen
patientsreceivedoralcyclosporine(3mg/kg/day)andplacebocreamfor6weeks.Theothergroupunderwent
topicaltreatmentwithbetamethasonedipropionate0.05%creamandplacebocapsules.After6weekstherewasa
crossoverofthosepatientswhodidnotrespondtotreatmentinthefirst6weeks.Thirdphaseconsistedofthe
followupperiodof24weekswithoutintervention.Therewasimprovementinbothofthegroups,butno
statisticallysignificantdifferencebetweenthegroupsintermsofparticipantanddoctorratedgood/excellent
controlandseverityscoring.
Egan[81]reporteduseoflowdoseoralmethotrexateinfivepatientswithrecalcitrantpalmoplantarpompholyx.
Thepatientsdidnotrespondtoconventionaltherapyandshowedsignificantimprovementorclearingafter
additionofmethotrexatetotheirtreatment.
Inanopenlabelstudy,Mittaletal.[98]usedmethotrexate1015mgweeklyinsingleordivideddosesfor12
weeksin15patientsofrecalcitranteczema(patientswithpompholyx,n=6),andfoundthattwopatientsof
pompholyxhadexcellentresponse(almostcompleteremission)andonepatientofpompholyxhadgoodresponse
(partialremission).Themaineffectofmethotrexateisonepidermalproliferationbyitsmetabolitepolyglutamate
causingadenosinerelease.[99]Onbindingwithadenosinereceptors,adenosineinhibitslymphocyteproliferation
aswellasproinflammatorycytokinesTNF,IL6,IL8,andincreasesproductionofIL1receptorantagonistin
monocyte.
Asinglecasereportdescribedapatientwitha4yearhistoryofrecurrentdyshidroticeczemaresistantto
corticosteroids,iontophoresis,andphototherapywhorespondedto1.5gofmycophenolatemofetiladministered
twicedailywithcompleteclearingin4weeks.Thedosewastaperedgraduallyover12monthswithout
recurrence.[82]Inanothercasereport,mycophenolatemofetilinduced,biopsyprovendyshidroticeczemawas
seen,whichresolvedondiscontinuationofmycophenolatemofetilandagainappearedonstartingthesame.
[100,101]
Beneficialroleofazathioprineindoses50100mg/dayisfoundinchronicrecalcitranthandeczemarecently.
[83,102]
Indifferentstudies,oralretinoidswerefoundtobeusefulinchronichandeczemarefractorytocorticosteroids.
Capella[86]investigatedtheuseofacitretin2550mg/dayfor1month,versusaconventionaltopicaltreatment
(betamethasoneandsalicylicacidointment).Fortytwopatientswithchronichyperkeratoticpalmoplantar
eczemawereenrolledinthissingleblindandmatchedsampledesigntrial.Theoralretinoidwassignificantly
betterthanthetopicaltreatmentafter30dayswithsignificantpersistence5monthsaftersuspensionofacitretin.
Ruzicka[84]usedthreedifferentdosesof9cisretinoicacid,anotherretinoid(alitretinoin)incomparisonwith
placebocapsules.Thistrialwasarandomizeddoubleblindmulticenterstudywith319participants.Thepatients
wereallowedtousestandardemollients.Inaddition,theyunderwenttreatmentwith10mg,20mg,40mg,or
placebocapsulesdailyfor12weeks.Significantdifferenceswerefoundintermsofclearanceoralmostclearance
inallalitretinoingroupscomparedtotheplacebogroup.Statisticallysignificantdifferenceswerealsoreported
forreductioninseverity(improvementindermatologicallifequalityindex)inallinterventiongroups.Thiswas
trueforparticipantandinvestigatorscoring.
Inaphase3trial,Ruzicka[85]assessedtheefficacyandsafetyofalitretinoininthetreatmentofseverechronic
handeczemarefractorytotopicalcorticosteroids.Atotalof1032patientsfromatotalof111outpatientclinicsin
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EuropeandCanadawererandomizedinthisdoubleblind,placebocontrolledprospectivemulticentertrial.The
patientsreceivedplacebo,10mgor30mgoforalalitretinoinoncedailyforupto24weeks.ThePhysician's
GlobalAssessmentwasusedtodetermineoverallchronichandeczemaseverity,witharesponsedefinedasclear
oralmostclearhands.Patientsinthe30mggrouprespondedbetterthaninthe10mggroup.Atotalof48%of
patientstreatedwith30mgofalitretinoinshowedaresponsewith75%meanreductionindiseasesignsand
symptoms.
Itwasobservedthatadequateironintakereducesnickelabsorptionfromintestine.Ironisabsorbedinpreference
tonickelbydivalentmetaltransporter(DMT)becauseofhighaffinity.Sobecauseofdownregulationuptakeof
nickelisdecreased.[101]Inacomparativestudyof23nickelsensitivechronicvesicularhandeczema(CVHE)
patients,lownickeldietalongwith30mgoforaliron(n=12,duration=12weeks)wasfoundsuperiortolow
nickeldietalone(n=11)inbringingfasterreductionintheseverityofCVHEinnickelsensitivepatients.[90]
Tenpatientsoutof12(83.3%)showedcompleteclearanceinstudygroupattheendof12weekswithno
recurrence,whileinthecontrolgroupfivepatients(5/11,45.5%)showedcompleteclearanceattheendofstudy.
Therewassignificantdecreaseinlevelsofnickelinthestudygroup.
Whatisnew?
1.Thisisacomprehensivereviewonetiology,classification,treatmentandvariousotheraspectsofhand
eczema.
2.Thisreviewgivesanupdateonhandeczemamanagement.

Footnotes

Goto:

SourceofSupport:Nil
ConflictofInterest:Nil.

References

Goto:

1.WillanR.London,England:Johnson1808.OnCutaneousDiseases.
2.MenneT,MaibachHI.Philadelphia:BocaRatonCRCPress1994.HandEczema.
3.ElstonDM,AhmedDD,WatskyKL,SchwarzenbergerK.Handdermatitis.JAmAcadDermatol.
200247:2919.[PubMed]
4.MedingB,SwanbeckG.Consequencesofhavinghandeczema.ContactDermatis.199023:6.[PubMed]
5.LantingaH,NaterJP,CoenraadsPJ.Prevalenceincidenceandcourseofeczemaonthehandsandforearmsin
asampleofgeneralpopulation.ContactDermatitis.198410:1359.[PubMed]
6.BerthJonesJ.Eczema,lichenification,prurigoanderythrodema.In:BurnsT,BreathnachS,CoxN,Griffiths
C,editors.TextbookofDermatology.8thed.WestSussex:WileyBlackwell2010.pp.2313.
7.MedingB,SwanbeckG.Prevalenceofhandeczemainanindustrialcity.BrJDermatol.1987116:62734.
[PubMed]
8.ReaJN,NewhouseML,HalilT.SkindiseaseinLambeth:Acommunitystudyofprevalenceanduseof
medicalcare.BrJPrevSocMed.197630:107114.[PMCfreearticle][PubMed]
9.FregertS,HjorthN,MagnussonB,BandmannHJ,CalnanCD,CroninE,etal.Epidemiologyofcontact
dermatitis.TransStJohnsHospDermatolSoc.196955:1735.[PubMed]
10.AgrupG.HandeczemaandotherdermatosesinSouthSweden.ActaDermVenereol.196949:191.
11.SharmaVK,KaurS.ContactdermatitisofhandsinChandigarh.IndianJDermatolVenereolLeprol.
198753:1037.
12.GohCL.Prevalenceofcontactallergybysex,raceandage.ContactDermatitis.198614:23740.[PubMed]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037938/

11/16

9/15/2016

Hand Eczema

13.EdmanB.Sitesofcontactdermatitisinrelationshiptoparticularallergens.ContactDermatitis.198513:129
35.[PubMed]
14.MedingB,WrangsjK,JrvholmB,PersonJ,ThornD,RautM,etal.Surveybasedassessmentof
prevalenceandseverityofchronichanddermatitisinamanagedcareorganisation.Cutis.200677:38592.
[PubMed]
15.MedingB,SwanbeckG.Predictivefactorsforhandeczema.ContactDermatitis.199023:15461.[PubMed]
16.ThestrupPedersonK,LarsenCG,RonnerigJ.Theimmunologyofcontactdermatitis.Areviewwithspecial
referencetothepathophysiologyofeczema.ContactDermatitis.198920:8192.[PubMed]
17.CarrMM,BothamPA,GaahrodgenDJ.EarlycellularreactionsinducedbyDinitrochlorbenzeneinsensitized
humans.BrJDermatol.1984110:63741.[PubMed]
18.EliasPM,SchmuthM.Abnormalskinbarrierintheetiopathogenesisofatopicdermatitis.CurrAllergy
AsthmaRep.20099:26572.[PubMed]
19.SevillaLM,NachatR,GrootKR,KlementJF,UittoJ,DjianP,etal.Micedeficientininvolucrin,envoplakin,
andperiplakinhaveadefectiveepidermalbarrier.JCellBiol.2007179:1599612.[PMCfreearticle][PubMed]
20.MorarN,EdsterP,StreetT,WeidingerS,DiWL,DixonA,etal.Finemappingofsusceptibilitygenesfor
atopicdermatitisintheepidermaldifferentiationcomplexonchromosome1q21.BrJDermatol.2007157:3.
21.BieberT.Atopicdermatitis.NEnglJMed.2008358:148394.[PubMed]
22.OngPY,OhtakeT,BrandtC,StricklandI,BoguniewiczM,GanzT,etal.Endogenousantimicrobialpeptides
andskininfectionsinatopicdermatitis.NEnglJMed.2002347:115160.[PubMed]
23.MiddletonJD.Themechanismofactionofsurfactantsontheisolatedstratumcorneum.JSocCosmetChem.
196920:399412.
24.EgelrudT,BrattsandM,KreutzmannP,WaldenM,VitzithumK,MarxUC,etal.hK5andhK7,twoserine
proteinasesabundantinhumanskin,areinhibitedbyLEKTIdomain6.BrJDermatol.2005153:12003.
[PubMed]
25.JohnsonB,HornT,SanderC,KohlerS,SmollerB.Expressionofstratumcorneumchymotrypticenzymein
ichthyosesandsquamoproliferativeprocesses.JCutanPathol.200330:35862.[PubMed]
26.HanssonL,BckmanA,NyA,EdlundM,EkholmE,HammarstrmB,etal.Epidermaloverexpressionof
stratumcorneumchymotrypticenzymeinmice:Amodelforchronicitchydermatitis.JInvestDermatol.
2002118:4449.[PubMed]
27.BajajAK,SaraswatA,MukhijaG,RastogiS,YadavS.Patchtestingexperiencewith1000patients.IndianJ
DermatolVenereolLeprol.200773:3138.[PubMed]
28.KishoreNB,BelliappaAD,ShettyNJ,SukumarD,RaviS.Handeczemaclinicalpatternsandroleofpatch
testing.IndianJDermatolVenereolLeprol.200571:2078.[PubMed]
29.KaurS,SharmaVK.ContactdermatitisofhandsinChandigarh.IndianJDermatolVenereolLeprol.
198753:1037.
30.BajajAK.Contactdermatitisofhands.IndianJDermatolVenereolLeprol.198349:1959.
31.SinghG,SinghK.Contactdermatitisofhands.IndianJDermatolVenereolLeprol.198652:1524.
32.PasrichaJS,KanwarAJ.Substancescausingcontactdermatitis.IndianJDermatolVenerolLepr.
197844:2648.
33.BruynzeelDP,deBoerEM,BrouwerEJ,deWolffFA,deHaanP.Dermatitisinbulbgrowers.Contact
Dermatitis.199329:115.[PubMed]
34.NielsenJ.Theoccurrenceandcourseofskinsymptomsofthehandsamongfemalecleaners.Contact
Dermatitis.199634:28491.[PubMed]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037938/

12/16

9/15/2016

Hand Eczema

35.ForsbeckM,SkogE,AsbrinkE.Atopichanddermatitis:Acomparisonwithatopicdermatitiswithouthand
involvement,especiallywithrespecttoinfluenceofworkanddevelopmentofcontactsensitization.Acta
DermatolVenereol.198363:9143.[PubMed]
36.MedingB,SwanbeckG.Epidemiologyofdifferenttypesofhandeczemainanindustrialcity.ActaDermatol
Venereol.198969:22733.[PubMed]
37.SimpsonEL,ThompsonMM,HanifinJM.Prevalenceandmorphologyofhandeczemainpatientswith
atopicdermatitis.Dermatitis.200617:1237.[PubMed]
38.WarshawEM.Therapeuticoptionsforchronichanddermatitis.DermatolTher.200417:24050.[PubMed]
39.BissonnetteR,DiepgenTL,ElsnerP,EnglishJ,GrahamBrownR,HomeyB,etal.Redefiningtreatment
optionsinchronichandeczema(CHE)JEurAcadDermatolVenereol.201024:120.[PubMed]
40.DiepgenTL,AgnerT,AbererW,BerthJonesJ,CambazardF,ElsnerP,etal.Managementofchronichand
eczema.ContactDermatitis.200757:20310.[PubMed]
41.DiepgenTL,AndersenKE,BrandaoFM,BruzeM,BruynzeelDP,FroschP,etal.Handeczema
classification:Acrosssectional,multicentrestudyoftheaetiologyandmorphologyofhandeczema.BrJ
Dermatol.2009160:3538.[PubMed]
42.LodiA,BettiR,ChiarelliG,UrbaniCE,CrostiC.Epidemiological,clinicalandallergologicalobservations
onpompholyx.ContactDermatitis.199226:1721.[PubMed]
43.MinochaYC,DograA,SoodVK.Contactsensitivityinpalmerhyperkeratoticdermatitis.IndianJDermatol
VenerolLeprol.198359:603.
44.SabroeRA,SharpLA,PeacheyR.Contactallergytogoldthiosulfate.ContactDermatitis.199634:3458.
[PubMed]
45.CrdobaS,SnchezPrezJ,GarcaDezA.Ringdermatitisasaclinicalpresentationoffragrance
sensitization.ContactDermatitis.200042:242.[PubMed]
46.CalnanCD.Eczemaforme.TransStJohnsHospDermatolSoc.196854:5464.[PubMed]
47.CroninE.Clinicalpatternsofhandeczemainwomen.ContactDermatitis.198513:15361.[PubMed]
48.HjorthN.Guteczemainslaughterhouseworkers.ContactDermatitis.19784:4952.[PubMed]
49.WinkelmannRK,GleichGJ.Chronicacraldermatitis:AssociationwithextremeelevationsofIgE.JAMA.
1973225:37881.[PubMed]
50.MaibachHI,JohnsonHL.Contacturticariasyndrome:Contacturticariatodiethyltoluamide(immediatetype
hypersensitivity)ArchDermatol.1975111:72630.[PubMed]
51.FregertS.2ndedition.Copenhagen:MunksgaardPublishers1981.ManualofContactDermatitis.Onbehalf
oftheInternationalContactDermatitisResearchGroupandtheNorthAmericanContactDermatitisGroup.
52.FischerTI,MaibachHI.Thethinlayerrapiduseepicutaneoustest(TRUEtest),anewpatchtestmethodwith
highaccuracy.BrJDermatol.1985112:638.[PubMed]
53.LachapelleJM.AleftversusrightsidecomparativestudyofEpiquickpatchtestresultsin100consecutive
patients.ContactDermatitis.198920:516.[PubMed]
54.HardingCR.Thestratumcorneum:Structureandfunctioninhealthanddisease.DermatolTher.200417:6
15.[PubMed]
55.BockM,WulfhorstB,GabardB,SchwanitzHJ.Efficacyofskinprotectioncreamsforthetreatmentof
irritantdermatitisinhairdresserapprentices.OccupEnvironDermatol.200149:736.
56.MygindK,SellL,FlyvholmMA,JepsenKF.Highfatpetrolatumbasedmoisturizersandpreventionof
workrelatedskinproblemsinwetworkoccupations.ContactDermatitis.200654:3541.[PubMed]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037938/

13/16

9/15/2016

Hand Eczema

57.BielfeldtS,WehmeyerA,RippkeF,TauschI.Efficacyofanewhandcaresystem(cleansingoilandcream)
inamodelofirritationandbyatopiceczema.Dermatosen.199846:15965.
58.LodnM,WirnK,SmerudK,MelandN,HnnsH,MrkG,etal.Treatmentwithabarrierstrengthening
moisturizerpreventsrelapseofhandeczema.Anopen,randomized,prospective,parallelgroupstudy.ActaDerm
Venereol.201090:6026.[PubMed]
59.MollerH,SvartholmH,DahlG.Intermittentmaintenancetherapyinchronichandeczemawithclobetasol
propionateandfluprednidenacetate.CurrMedResOpin.19838:6404.[PubMed]
60.UggeldahlPE,KeroM,UlshagenK,SolbergVM.Comparativeeffectsofdesonidecream0.1%and0.05%in
patientswithhandeczema.CurrTherRes.198640:96973.
61.GuptaAK,ShearNH,LesterRS,BaxterML,SauderDN.Betamethasonedipropionatepolyacrylicfilm
forminglotioninthetreatmentofhanddermatitis.IntJDermatol.199332:8289.[PubMed]
62.VeienNK,LarsenPO,ThestrupPedersenK,SchouG.Longterm,intermittenttreatmentofchronichand
eczemawithmometasonefuroate.BrJDermatol.1999140:8826.[PubMed]
63.GrattanCE,CarmichaelAJ,ShuttleworthGJ,FouldsIS.ComparisonoftopicalPUVAwithUVAforchronic
vesicularhandeczema.ActaDermatolVenereol.199171:11822.[PubMed]
64.SchemppCM,MullerH,CzechW,SchopfE,SimonJC.Treatmentofchronicpalmoplantareczemawith
localbathPUVAtherapy.JAmAcadDermatol.199736:7337.[PubMed]
65.StegeH,BerneburgM,RuzickaT,KrutmannJ.CreamPUVAphotochemotherapy.Hautarzt.199748:8993.
[PubMed]
66.HanifinJM,StevensV,ShethP,BrenemanD.Noveltreatmentofchronicseverehanddermatitiswith
bexarotenegel.BrJDermatol.2004150:54553.[PubMed]
67.SchnoppC,RemlingR,MohrenschlagerM,WeiglL,RingJ,AbeckD.Topicaltacrolimus(FK506)and
mometasonefuroateintreatmentofdyshidroticpalmareczema:Arandomized,observerblindedtrial.JAm
AcadDermatol.200246:736.[PubMed]
68.ThelmoMC,LangW.Anopenlabelpilotstudytoevaluatethesafetyandefficacyoftopicallyapplied
tacrolimusointmentforthetreatmentofhandand/orfooteczema.JDermatolTreat.200314:13640.[PubMed]
69.BelsitoDV,FowlerJF.Pimecrolimuscream1%:Apotentialnewtreatmentforchronichanddermatitis.
Cutis.200473:318.[PubMed]
70.CherillR,TofteS,MeyerK,HanifinJ.SDZASM981iseffectiveinthetreatmentofchronicirritanthand
dermatitis:A6weekrandomized,doubleblind,vehiclecontrolled,singlecentrestudy.ContactDermatitis.
200042:167.
71.ThaiD,SteinmeyerK,EbelinME,ScottG,KaufmannR.Occlusivetreatmentofchronichanddermatitis
withpimecrolimuscream1%resultsinlowsystemicexposure,iswelltolerated,safe,andeffective:Anopen
study.Dermatology.2003207:3742.[PubMed]
72.EgawaK.TopicalvitaminD3derivativesintreatinghyperkeratoticpalmoplantareczema:Areportoffive
patients.JDermatol.200532:3816.[PubMed]
73.HillVA,WongE,CorbettMF,MendayAP.Comparativeefficacyofbetamethasone/clioquinol(BetnovateC)
creamandbetamethasone/fusidicacid.JDermatologTreat.19989:159.
74.FowlerJF.Askinmoisturizingcreamcontainingquaternium18bentoniteeffectivelyimproveschronichand
dermatitis.JCutanMedSurg.20015:2015.[PubMed]
75.FowlerJF.Efficacyofskinprotectivefoaminthetreatmentofchronichanddermatitis.AmJContact
Dermat.200011:1659.[PubMed]
76.BollagW,OttF.Successfultreatmentofchronichandeczemawithoral9cisretinoicacid.Dermatology.
1999199:30812.[PubMed]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037938/

14/16

9/15/2016

Hand Eczema

77.OdiaS,VocksE,RakosiJ,RingJ.Successfultreatmentofdyshidrotichandeczemausingtapwater
iontophoresiswithpulseddirectcurrent.ActaDermatolVenereol.199676:4724.[PubMed]
78.vanCoevordenAM,KamphofWG,vanSonderenE,BruynzeelDP,CoenraadsPJ.Comparisonoforal
psoralenUVAwithaportabletanningunitathomevshospitaladministeredbathpsoralenUVAinpatients
withchronichandeczema.ArchDermatol.2004140:14636.[PubMed]
79.RosenK,MobackenH,SwanbeckG.Chroniceczematousdermatitisofthehands:AcomparisonofPUVA
andUVBtreatment.ActaDermatolVenereol.198767:4854.[PubMed]
80.GranlundH,ErkkoP,ErikssonE,ReitamoS.Comparisonoftheinfluenceofcyclosporineandtopical
betamethasone17,21dipropionatetreatmentofseverechronichandeczema.ActaDermatolVenereol.
199676:3716.[PubMed]
81.EganCA,RallisTM,MeadowsKP,KruegerGG.Lowdoseoralmethotrexatetreatmentforrecalcitrant
palmoplantarpompholyx.JAmAcadDermatol.199940:6124.[PubMed]
82.PickenackerA,LugerT,SchwarzT.Dyshidroticeczematreatedwithmycophenolatemofetil.ArchDermatol.
1998134:3789.[PubMed]
83.ScerriL.Azathioprineindermatologicalpractice.Anoverviewwithspecialemphasisonitsuseinnon
bullousinflammatorydermatoses.AdvExpMedBiol.1999455:3438.[PubMed]
84.RuzickaT,LarsenFG.Oralalitretinoin(9cisretinoicacid)therapyforchronichanddermatitisinpatients
refractorytostandardtherapy.Resultsofarandomized,doubleblindplacebocontrolled,multicentretrial.Arch
Dermatol.2004140:14539.[PubMed]
85.RuzickaT,LyndeCW,JemecGB,DiepgenT,BerthJonesJ,CoenraadsPJ,etal.Efficacyandsafetyororal
alitretinoin(9cisretinoicacid)inpatientswithseverechronichandeczemarefractorytotopicalcorticosteroids:
Resultsofarandomized,doubleblind,placebocontrolled,multicentretrial.BrJDermatol.2008158:80817.
[PubMed]
86.CapellaGL,FracchiollaC,FrigerioE,AltomareG.Acontrolledstudyofcomparativeefficacyoforal
retinoidsandtopicalbetamethasone/salicylicacidforchronichyperkeratoticpalmoplantardermatitis.J
DermatologTreat.200415:8893.[PubMed]
87.VeienNK,KaaberK,LarsenPO,NielsenAO,ThestrupPedersenK.Ranitidinetreatmentofhandeczemain
patientswithatopicdermatitis:Adoubleblind,placebocontrolledtrial.JAmAcadDermatol.199532:10567.
[PubMed]
88.WhitakerDK,CilliersJ,deBeerC.Eveningprimroseoil(Epogam)inthetreatmentofchronichand
dermatitis:Disappointingtherapeuticresults.Dermatology.1996193:11520.[PubMed]
89.SharmaAD.Disulfiramandlownickeldietinthemanagementofhandeczema:Aclinicalstudy.IndianJ
DermatolVenereolLeprol.200672:1138.[PubMed]
90.BurrowsD,RogersS,BeckM,KelletJ,McMasterD,MerrettD,etal.Treatmentofnickeldermatitiswith
trientine.ContactDermatitis.198615:557.[PubMed]
91.MennT,KaaberK.Treatmentofpompholyxduetonickelallergywithchelatingagents.ContactDermatitis.
19784:28990.[PubMed]
92.PigattoPD,GibelliE,FumagalliM,BigardiA,MorelliM,AltomareGF.Disodiumcromoglycateversusdiet
inthetreatmentandpreventionofnickelpositivepompholyx.ContactDermatitis.199022:2731.[PubMed]
93.SharmaAD.Irontherapyinhandeczema:Anewapproachformanagement.IndianJDermatol.
201156:2959.[PMCfreearticle][PubMed]
94.CartwrightPH,RowellNR.ComparisonofGrenzraysversusplacebointhetreatmentofchronichand
eczema.BrJDermatol.1987117:736.[PubMed]
95.FairrisGM,MackDP,RowellNR.SuperficialXraytherapyinthetreatmentofconstitutionaleczemaofthe
hands.BrJDermatol.1984111:4459.[PubMed]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037938/

15/16

9/15/2016

Hand Eczema

96.KingCM,ChalmersRJG.Adoubleblindstudyofsuperficialradiotherapyinchronicpalmareczema.BrJ
Dermatol.1984111:4514.[PubMed]
97.FairrisGM,JonesDH,MackDP,RowellNR.ConventionalsuperficialXrayversusGrenzraytherapyinthe
treatmentofconstitutionaleczemaofthehands.BrJDermatol.1985112:33941.[PubMed]
98.MittalA,KhareAK,GuptaL,MehtaS,GargA.Useofmethotrexateinrecalcitranteczema.IndianJ
Dermatol.201156:224.[PMCfreearticle][PubMed]
99.CronsteinBN.Themechanismofactionofmethotrexate.RheumDisClinNorthAm.199723:73955.
[PubMed]
100.SemhounDuclouxS,DuclouxD,MiguetJP.Mycophenolatemofetilinduceddyshidroticeczema.Ann
InternMed.2000132:417.[PubMed]
101.TallvistJ,BowlusCL,LonnerdalB.Effectofirontreatmentonnickelabsorptionandgeneexpressionofthe
divalentmetaltransporter(DMT1)byhumanintestinalCaco2cells.PharmacolToxicol.200392:1214.
[PubMed]
102.AgarwalUS,BesarwalRK.Topicalclobetasolpropionate0.05%creamaloneandincombinationwith
azathioprineinpatientswithchronichandeczema:Anobserverblindedrandomizedcomparativetrial.IndianJ
DermatolVenereolLeprol.201379:1013.[PubMed]
ArticlesfromIndianJournalofDermatologyareprovidedherecourtesyofMedknowPublications

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