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Atopic hand dermatitis

Authors: Dr Danielle McGeachie, Principal House Officer, Dermatology Department, Townsville University Hospital, Townsville, Australia; A/Prof Rosemary Nixon AM, Dermatologist, Skin Health Institute, Melbourne, Australia. Copy edited by Gus Mitchell. March 2021


Atopic hand dermatitis — codes and concepts
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What is atopic hand dermatitis?

Atopic hand dermatitis (also known as atopic hand eczema) is a multifactorial inflammatory condition affecting the fingers, hands, and wrists of an atopic individual. Atopic dermatitis is the most important risk factor for chronic hand dermatitis.

Atopic hand dermatitis

Who gets atopic hand dermatitis?

Atopic hand dermatitis occurs in at least 50–60% of people with active atopic dermatitis, including children. The prevalence of hand involvement increases with age, with hand dermatitis detected in 30–40% of atopic babies and toddlers (age 0–2 years), 55% of atopic children aged 3–12 years, and 65% in those aged over 12 years. This is probably due to increased exposure to irritants. Two-thirds of patients report developing hand dermatitis within one year of the onset of the atopic dermatitis.

What causes atopic hand dermatitis?

Atopic hand dermatitis is multifactorial with inherited and environmental factors contributing to skin barrier dysfunction and immune system dysregulation.

Skin barrier function in atopic dermatitis is impaired due to a deficiency in or defective function of filaggrin, increasing transepidermal water loss (TEWL), and the risk of contact dermatitis and infection.

Atopic hand dermatitis has increased Th2 activation and production of IL-4, IL-13, IL-31, CCL17, CCL18 and CCL22.

Irritant contact dermatitis more commonly complicates atopic hand dermatitis than allergic contact dermatitis. Water exposure is a frequent trigger reported to aggravate atopic hand dermatitis.

Irritant contact dermatitis complicating atopic hand dermatitis

What are the clinical features of atopic hand dermatitis?

Atopic hand dermatitis preferentially affects the backs of the hands (90%) and fingers (70%), and both aspects of the wrists (50-60%). Involvement of the palmar aspect of the hands and fingers is less common (30%). Atopic hand dermatitis commonly presents with pruritus and dryness, but may include other symptoms such as stinging, burning, and pain. Vesicular hand dermatitis or nummular dermatitis are uncommon presentations. Weeping and crusting can affect the skin surface.

Atopic hand dermatitis distribution patterns

Clinical signs include:

  • Acute atopic hand dermatitis — erythema, oedema, intensely itchy or burning vesiculation, xerosis
  • Chronic atopic hand dermatitis — persistent erythema, hyperkeratosis, lichenification, pain or stinging, fissuring.

However, there are no specific morphological features to distinguish hand dermatitis due to atopic dermatitis from other aetiologies, although the distribution may give a clue. Skin signs that suggest atopic hand dermatitis include hyperlinear palms, keratosis pilaris, and changes of atopic dermatitis elsewhere.

Clues to the diagnosis of atopic dermatitis

Nail changes associated with dermatitis involving the distal fingers include coarse pitting, transverse ridges/grooves, and loss of cuticle.

Nail changes associated with atopic hand dermatitis

How do clinical features vary in differing types of skin?

Atopic hand dermatitis in skin of colour shows less obvious erythema and more postinflammatory hyperpigmentation than in white skin, and the overlying scale is often a grey colour.

What are the complications of atopic hand dermatitis?

[see also Complications of atopic dermatitis]

How is atopic hand dermatitis diagnosed?

Atopic hand dermatitis is usually a clinical diagnosis based on a history of atopy and exclusion of other diagnoses. Assessment should include looking for aggravating factors such as exposure to irritants and allergens at home and at work.

Investigations may include:

What is the differential diagnosis for atopic hand dermatitis?

What is the treatment for atopic hand dermatitis?

General measures

Obsessive hand care is essential and is required long-term to minimise recurrence or flares due to environmental factors. Advice should be sought before commencing work in an occupation involving wet work or exposure to chemicals such as hairdressing or healthcare.

  • Minimise exposure to irritants including water, soap, and detergents
  • Minimise ‘wet work’
  • Hand hygiene — alcohol-based hand sanitisers with glycerine are less irritating than soap and water
  • Frequent application of simple unperfumed hand emollients [see Emollients for eczema and Emollients and moisturisers]
  • Gloves should be worn for all wet or dirty work at home and in the workplace. [see Gloves for hand protection].

Topical treatments

Phototherapy

Systemic therapy

For severe or treatment-refractory atopic hand dermatitis:

What is the outcome for atopic hand dermatitis?

Prompt treatment is recommended as hand dermatitis tends to become chronic. Patients are particularly prone to developing irritant contact dermatitis, but have the same risk of developing allergic contact dermatitis as the general population. Moderate to severe dermatitis is a strong predictor of persistent disease.

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Related information

 

Bibliography

  1. Coenraads PJ. Hand eczema. N Engl J Med. 2012;367(19):1829–37. doi:10.1056/NEJMcp1104084. PubMed
  2. Dubin C, Del Duca E, Guttman-Yassky E. Drugs for the treatment of chronic hand eczema: successes and key challenges [published correction appears in Ther Clin Risk Manag. 2021 Mar 18;17:233]. Ther Clin Risk Manag. 2020;16:1319–32. doi:10.2147/TCRM.S292504. Journal
  3. Giwercman C, Lerbaek A, Bisgaard H, Menné T. Classification of atopic hand eczema and the filaggrin mutations. Contact Dermatitis. 2008;59(5):257–60. doi:10.1111/j.1600-0536.2008.01426.x. Journal
  4. Halling-Overgaard AS, Zachariae C, Thyssen JP. Management of atopic hand dermatitis. Dermatol Clin. 2017;35(3):365–72. doi:10.1016/j.det.2017.02.010. PubMed
  5. Menné T, Johansen JD, Sommerlund M, Veien NK; Danish Contact Dermatitis Group. Hand eczema guidelines based on the Danish guidelines for the diagnosis and treatment of hand eczema. Contact Dermatitis. 2011;65(1):3–12. doi:10.1111/j.1600-0536.2011.01915.x. PubMed
  6. Oosterhaven JAF, Voorberg AN, Romeijn GLE, de Bruin-Weller MS, Schuttelaar MLA. Effect of dupilumab on hand eczema in patients with atopic dermatitis: an observational study. J Dermatol. 2019;46(8):680–5. doi:10.1111/1346-8138.14982. PubMed Central
  7. Simpson EL, Thompson MM, Hanifin JM. Prevalence and morphology of hand eczema in patients with atopic dermatitis. Dermatitis. 2006;17(3):123–7. doi:10.2310/6620.2006.06005. PubMed

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