Annual
Clinical
and Experimental Dermatology, 2002, 27:328-337.
Refractory hand dermatitis
Ian Foulds
Hand dermatitis is often dismissed by medical
practitioners as being trivial because of the limited area of skin involvement. However, the morbidity of sufferers is often
not comprehended. All too often patients
are not given the benefit of full investigation with appropriate treatment. Psoriasis localized to the hands is frequently
misdiagnosed as hyperkeratotic eczema and requires
potent treatment to clear. Fungal infections
are also commonly overlooked.
The majority of hand dermatitis seen in the
community is due to irritant contact factors. The importance of identifying all the factors
relevant to irritation needs to be communicated to patients. Good hand care needs to be maintained for a minimum
period of 3 months after recovery to prevent relapses from occurring. Common failures of response are due to
inadequate usage of a potent enough steroid, lack of occlusion,
and failure to apply emollients with enough frequency.
Any patient with hand dermatitis that has not
responded after 4 weeks to advice on improved hand care combined with first-line
treatment should be investigated for potential Type I and 1 V
hypersensitivity. The pattern of
involvement of the hands is often no clue as to causation. No patient should be told to change occupation
without such investigations.
Primary occupations are often blamed for the
cause of dermatitis but in reality secondary occupations and domestic exposure
may be the real reason for lack of response to treatment.
Patients with resistant hand dermatitis may
have to be considered for second line therapies including PUVA, cyclosporin, methotrexate and retinoids.