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

Atopic Dermatitis

Epidemiology/prevalence/risk factors. Atopic dermatitis (AD) is a common, inherited, chronic inflammatory dermatosis that generally begins in infancy. The lifetime prevalence is estimated to be 30% of the population. Sixty percent of children who have one affected parent and 80% of children with two affected parents have atopic dermatitis (Stevens, 2005). Of those with AD in childhood, 60% to 70% will develop hand eczema (Hanifin, 2003). Many of these individuals will have hand in volvement if their work involves regular contact with hand irritants such as soap and water (SchFCrer et al., 2005).

Exacerbating factors. Irritant contact dermatitis is more common in atopics. Although the predisposition for AD is genetically determined, several exacerbating factors may influence the outbreak of skin changes, which include stress, sweating, itching and subsequent scratching, dry skin, and microbial agents. The expression of AD is a complex integration of environmental and genetic factors. AD can be exacerbated quickly by environmental trigger factors. Wool, lanolin, and harsh detergents are particularly irritating. Emotional stress can also lead to flares, which are characterized by increased itch, erythema, vesiculation, and excoriation, as well as expanded areas of involvement (Stevens, 2005). The fall season can flare eczematous activity due to low environmental humidity because of central heating at home or the workplace, a low outdoor temperature, and contact irritants (MF6ller, 2000).

Clinical features. Acute lesions of AD are eczematous — erythematous, scaling, and papulovesicular. Weep ing and crusted lesions may develop. Chronic lesions may present as lichenified plaques, papules, or nodules (Hanifin, 2003; Stevens, 2005). Lichenification denotes areas of thickened skin divided by deep linear furrows. Lichenified lesions are very difficult to treat; once established, they may persist for months, even with adequate therapy and avoidance of rubbing or scratching (Stevens, 2005). Atopic HD may involve the volar wrist and hypopigmentation of the flexural volar wrist (Warshaw et al., 2003). With long-standing disease, patients' fingernails may show signs of dystrophic changes such as thickening, transverse ridging, and furrowing; paro nychias may be a recurring problem (MF6ller, 2000). Recurrent bacterial, fungal, and viral skin infections are a frequent complication of AD. The lesions of AD provide an environment that can harbor several types of harmful bacteria, the most common being S. aureus (Hanifin, 2003). S. aureus is far more common on the skin of patients with AD than on the skin of persons who do not have this condition (Yagi et al., 2004). Cutane ous fungal and viral infections also occur frequently and with increased severity in patients with AD (Stevens, 2005).

Diagnosis. Atopic dermatitis re mains a clinical diagnosis and is not based on one single distinctive clinical feature or laboratory test, but rather results from a combination of patient and family history and clinical findings (MF6ller, 2000). These features include personal or family history of atopy, allergic rhinitis or asthma, and pruritus. Pruritus is a consistent feature of AD. The lack of itching should prompt consideration of alternative diagnoses (Hanifin, 2003). Atopic dermatitis characteristically presents with extensor in volve ment in infancy. In adolescence and adulthood, the pattern changes to involve the flexural areas (Hanifin, 2003; Hoffjan & Epplen, 2005).

Management. Treatments include topical or systemic corticosteroids, antihistamines, phototherapy, and/or antimicrobials. The use of mild, non-alkali soaps and frequent use of emollients are important elements in the long-term management of AD. Lotions and creams containing high amounts of water are usually inadequate, however, and can actually worsen AD. Products containing hydroxy acids, phenol, or urea can reduce dryness and scaling, but these can cause stinging and should therefore be used with caution (MF6ller, 2000; Stevens, 2005).

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