Hand Dermatitis: A Review of Clinical Features, Diagnosis, and Management

Deborah A. Kedrowski, RN; Erin M. Warshaw, MD, MS

Disclosures

Dermatology Nursing. 2008;20(1):17-25. 

In This Article

Irritant Contact Dermatitis

Definition. Approximately 80% of all HD cases involve irritant contact dermatitis (ICD). Contact dermatitis of the hands can be either irritant or allergic in etiology (Goh, 1989). Irritants are harmful chemical or physical agents with a direct cytotoxic effect which, after single or repeated application, cause a non-allergic inflammatory reaction (Van der Walle, 2000). ICD is a nonspecific response of the skin to direct chemical damage involving release of inflammatory mediators, predominately from epidermal cells (see Figure 1). A corrosive agent (for example, bleach or solvent) may cause the immediate death of epidermal cells as is evident by chemical burns and cutaneous ulcers (Hogan, 2006).

Figure 1.

Irritant contact dermatitis

Mechanism. Susceptibility to ICD appears to result from a thin, permeable stratum corneum. The stratum corneum is an important barrier against penetration of the skin. It is a 1.6 mm (approximately 8-14 cells thick) semi-permeable membrane which retains body water and provides protection from the environment. The cells of the stratum corneum are mostly composed of keratin and a variety of lipids in the intercellular space. If this barrier is disrupted by chemical or physical irritants that damage the keratin, the result can be a disabling irritant dermatitis. Irritants remove surface lipids, denature epidermal keratins, or damage cell membranes. Because of these lipids, and the fact that the stratum corneum has a very low water content (only 10% by weight), the skin is most resistant to polar, water-soluble compounds, and least resistant to non-polar substances such as organic solvents. Solvents are a major cause of irritation as they remove essential fats and oils from the skin, which increases transepidermal water loss and leaves the skin susceptible to the increased direct toxic effects of other previously well-tolerated cutaneous exposures (Boyce & Pittet, 2002). Two major types of ICD are recognized, acute and cumulative. Exposure to potent irritants (for example, chemical acids or alkali solutions) triggers an acute eczematous dermatitis. Acute ICD can occur in any person, if duration and concentration of the contact with irritants is sufficient. Cumu la tive ICD results from repeated mild skin irritation such as that from soap and water. Cumulative ICD is more common that acute ICD (Van der Walle, 2000).

Occupational. ICD is the most commonly reported occupational skin disease and affects exposed areas of the skin, especially the hands (SchFCrer, Klippel, & Schwanitz, 2005). Contact dermatitis constitutes 90% to 95% of occupational dermatoses (Ingber & Merims, 2004) and occupation-related dermatitis accounts for 42% of all HD cases. Chronic HD is often a job-related disease and is usually associated with exposure to liquids and/or mechanical/chemical irritants. Occupations commonly associated with HD are listed in Table 2 . Almost 1 of every 3 nurses has some form of HD (Belsito, Fowler, & Marks, 2004). Patch testing in health care workers shows frequent sensitization to medications and disinfectants, as well as vaccine preservatives and rubber chemicals (see Figure 2) (Strauss & Gawkrodger, 2001). Occupational ICD is caused by repeated exposure to irritants such as soaps, detergents, solvents, or rubber. It usually begins with small, erythematous, pruritic, scaly patches. Painful fissures can also develop (Belsito et al., 2004).

Figure 2.

Patch test

Mechanical factors such as trauma, friction, pressure, and vibration may also induce skin changes. In dividuals who handle large amounts of paper may be affected by frictional hand dermatitis, sometimes term ed "wear-and-tear" dermatitis. Work-related frictional hand dermatitis may take years to develop. The clinical manifestations depend on the intensity and chronicity of the mechanical stimulus. Hyperkeratotic plaques may result from low-intensity stimuli such as from contact with carpet, artificial fur, or carbonless copy paper, whereas bullous lesions may develop after higher-intensity stimuli (Pigatto, 1992).

Risk factors. The intensity of cumulative ICD depends on several endogenous and exogenous factors. It is primarily caused by friction or frequent contact with mild skin irritants like soap, water, detergents, etc. (Van der Walle, 2000). For example, handwashing frequency of more than 35 times per shift was clearly linked with occupational hand dermatitis in intensive care unit workers. Occupational ICD affects wo men almost twice as often as men in contrast to other occupational diseases that predominantly affect men (Meding, 1994). Generally women are exposed more to cutaneous irritants from their disproportionately greater role in housecleaning and the care of small children. In addition, many professions at high risk for ICD (for example, hairdressing, nursing) are predominately composed of women (Templet, Hall, & Belsito, 2004; Van der Walle, 2000; Warshaw et al., 2003). Predisposing factors include heat or cold, occlusion, and humidity (Van der Walle, 2000). Low temperature and humidity reduces the water content of the stratum corneum, which can lead to cracking. Occlusion promotes percutaneous absorption and may facilitate skin irritation and enhances the effect of irritants to which an individual has previously been exposed. Heat can cause sweating which in turn can dissolve some types of industrial chemical powders that may come in contact with the skin. This increases the toxic or irritant effects of the chemical as solutions penetrate the skin more readily than solids. Susceptibility to irritants is also more common in winter (Schmid, Christoph Broding, Uter, & Drexler, 2005).

Often several factors affect the skin simultaneously. One key en do genous factor is atopy. Those with atopic dermatitis are particularly prone to developing ICD of the hands (Hannuksela & Hannuksela, 1995; Nassif, Chan, Storrs, & Hanifin, 1994; SchFCrer et al., 2005). Individuals with a history of atopic eczema are more susceptible to mild irritants and should avoid professions with intensive exposure to irritants. Unfortunately, patients with atopic dermatitis remain highly susceptible to ICD (Van der Walle, 2000) and may find that the tasks of many common occupations (for example, nursing, hairdressing) produce too much direct skin irritation to continue with these careers.

Diagnosis. No diagnostic test exists for ICD, yet identifying and minimizing exposure to cutaneous irritants is essential. Although patch testing is the gold standard for allergic contact dermatitis, no patch test exists that proves that a cutaneous irritant is responsible for a particular case of ICD. Diagnosis rests on exclusion of allergic contact dermatitis and history of sufficient exposure to a cutaneous irritant (Ingber & Merims, 2004; Van der Walle, 2000).

Management. The principles of management involve avoidance, protection, and substitution (Bourke et al., 2001; Van der Walle, 2000) (see Table 3 ). Avoiding potential skin hazards is self-evident. Gloves are the mainstay of protection for ICD of the hands (Bourke et al., 2001). For general purposes and household tasks, rubber or PVC household gloves (Van der Walle, 2000), possibly with a cotton liner or worn-over cotton gloves (Ramsing & Agner, 1996), should be sufficient. It is important to remove gloves regularly as sweating may exacerbate existing dermatitis. There is also some evidence that occlusion by gloves may compromise the integrity of the stratum corneum barrier function (Wulfhorst, Schwanitz, & Bock, 2004). In an occupational setting, the type of glove used will depend upon the nature of the chemicals to which the individual is exposed. In forma tion pertaining to specific glove selection based on chemical exposure can be found at https://www.ansellpro.com/specware. Some allergens can penetrate rubber gloves, in which case vinyl gloves may offer more protection (Van der Walle, 2000). Patients should use bland emollients after washing hands with soap and at bedtime (Warshaw et al., 2003). It may be possible to substitute non-irritating agents. The most common example of this is the use of a soap substitute (Bourke et al., 2001) such as CetaphilAE, AveenoAE, or Pur poseAE. Mild soap-free skin cleansers in place of soap on affected areas and avoiding solvents or abrasives to cleanse the hands is often effective.

Topical corticosteroids can help with inflammation (Bourke et al., 2001), but will not address the root cause; avoiding the irritant is the most important. Often ICD precedes ACD and may begin as soon as 3 months after the first "wet work" exposure and often recurs quickly upon re-exposure to irritants (Warshaw et al., 2003). Patient education is key for preventing recurrences.

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