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Hand Eczema 19 Tove Agner 19_335_344 05.11.2005 10:31 Uhr Seite 335 Chapter 19 Hand Eczema 19 Tove Agner Contents 19.1 Epidemiology 19.1 Epidemiology . 335 19.1.1 Frequency . 335 19.1.1 Frequency 19.1.2 Risk Factors . 335 19.1.3 Validity of Self-reported Hand Eczema . 336 The occurrence of hand eczema depends on basal 19.2 Etiology and Morphology . 336 characteristics such as age, sex, atopy, and occupa- 19.2.1 Allergic Contact Dermatitis . 337 tion in the population that are investigated. In a 19.2.2 Irritant Contact Dermatitis . 337 Swedish study the self-reported 1-year prevalence of 19.2.3 Contact Urticaria . 338 hand eczema in the general population was 11.8% in 19.2.4 Atopic Dermatitis . 338 1983 and had decreased to 9.7% in 1996 [36, 39]. The 19.2.5 Endogenous Forms . 338 crude incidence rate of self-reported hand eczema in 19.2.5.1 Acute and Recurrent Vesicular Hand Eczema individuals aged 20–65 years was recently reported to (Pompholyx) . 338 be 5.5 cases per 1,000 person-years [40]. The inci- 19.2.5.2 Hyperkeratotic Eczema . 338 dence of hand eczema is high among young people. 19.3 Occupational Hand Eczema . 339 In school children the 1-year prevalence of hand ec- 19.4 Prognosis . 340 zema was reported to be 7.3% for children aged 19.5 Treatment . 340 12–16 years and 10.0% for children aged 16–19 years 19.6 Prevention . 341 [50, 82]. Early onset of hand eczema is frequent, and 19.6.1 Regulation of Threshold Values for Allergens 341 in around one-third of cases onset of hand eczema 19.6.2 Identification of Risk Groups . 341 occurs before the age of 20 [40]. 19.6.3 Skin Protection . 341 19.7 Quality of Life . 342 19.1.2 Risk Factors 19.8 Differential Diagnosis . 342 References . 342 Hand eczema may often take a chronic course with a tendency to frequent relapses. A history of earlier hand eczema is a major indication of vulnerable skin, predisposing the individual to the development Hand eczema is a common disease in the general of hand eczema. Even short episodes of eczema may population, and one the most frequent diagnoses in predict a tendency to future disease, and the most dermatology. It affects occupational as well as private important risk factor for development of hand ecze- aspects of life, and the severity varies from mild and ma seems to be previous episodes of hand eczema transient to severe and chronic disease. Being a dis- earlier in life [56].Atopic dermatitis is another major ease that affects mainly young people, and often predictive factor, and considerably increased risk for interfering with their professional career, the disease development of hand eczema in persons with previ- is a burden not only to the patient but also to society. ous or current atopic dermatitis is well established. Development of hand eczema is in most cases in- In a population study a history of childhood eczema fluenced by multiple factors, involving exogenous as was found to be more important for development of well as endogenous aspects. An exact diagnosis is hand eczema compared to other risk factors such as necessary to correctly advise the patient about treat- female sex and occupational exposure [41]. The prev- ment and prevention of the eczema. Unfortunately alence of hand eczema in adults reporting moderate many cases of hand eczema take a chronic course. and severe atopic dermatitis in childhood was 25% The best way to avoid this seems to be early diagnos- and 41%, respectively [62], and a long-term follow-up es and effective treatment in the initial phase. study confirmed that more than 40% of patients at- 19_335_344 05.11.2005 10:31 Uhr Seite 336 336 Tove Agner tending the Karolinska Hospital in Stockholm for risk of developing hand eczema, and those who had atopic dermatitis in childhood had developed hand developed hand eczema first ran an increased risk of eczema when re-examined 25 years later [63, 64]. In a later developing nickel allergy [49]. This association recent population-based survey including 15,000 has been confirmed in more recent studies [8, 44, 50]. people, 42% of those who reported childhood ecze- In two cross-sectional studies examining the preva- ma stated positively that they had had hand eczema lence of hand eczema and contact allergy of the gen- at some time [44]. The importance of mucosal atopy eral population in Copenhagen, performed before for development of hand eczema is not fully agreed, and after nickel exposure regulation in Denmark, the but it is a significantly less essential risk factor than first study in 1990 found a significant association atopic dermatitis [23, 40, 57, 62]. Although the fre- between nickel allergy and a history of hand eczema quency of atopic dermatitis had been on the increase, in women, while the second study in 1998 could not the prevalence of hand eczema slightly decreased find this association [54]. This is probably due to di- between 1983 and 1996 in Swedish adults (from 11.8 to minished exposure to nickel after nickel legislation 9.7 [39]). The decrease in prevalence of hand eczema was introduced [14], and is an interesting example of could be an effect of an increased focus on preventive how regulations and legislation as preventive meas- measures for occupational diseases recently. ures may diminish the risk of contact allergy and Hand eczema occurs more frequently in females subsequently hand eczema. than in males [6, 12, 36, 41], the female:male ratio be- ing 1.8:1 [40]. Females are traditionally more exposed to wet work than males, and many jobs involving ex- 19.1.3 Validity of Self-reported tensive wet work, e.g., hairdressing, health care work, Hand Eczema catering and cleaning,are usually female jobs.Gener- ally,females report more hand washings per day than Much information about occurrence and risk factors males [40, 44], and they may often have more expo- for hand eczema is based on questionnaires asking sure to domestic skin irritants, including cooking either risk groups or the general population about and child caring. No sex-related difference in skin clinical signs of previous and present hand eczema. susceptibility to irritants has been reported from ex- Naturally, this way of obtaining information is not as perimental studies [2]. In a recent population-based precise as an objective assessment by a dermatolo- twin study, female sex was confirmed to be a risk fac- gist. The validity of self-reported hand eczema de- tor for development of hand eczema, but when co- pends on the type of population investigated,and has variates such as nickel allergy and wet work were in- been evaluated in several studies. It is generally cluded in the analysis the effect of gender was no agreed that the self-reported prevalence of hand ec- longer statistically significant [7]. This clearly indi- zema underestimates the true prevalence [38].A sim- cates that the high frequency of hand eczema in fe- ple question as “do you have hand eczema?” had males compared to males is caused by different expo- higher sensitivity and specificity than more complex sures. symptom-based questions, since it is difficult for in- Recent findings indicate that the increased risk for dividuals to identify skin signs compatible with the adult women to develop hand eczema is present in clinical diagnosis of hand eczema [73]. Standardized the age group 20–29 years only, in which group the questions for occupational hand eczema have been incidence rate is doubled as compared to males, developed, providing more standardized data [72]. while no increased risk for women is present beyond the age of 30 [40]. An increased amount of wet work in young females most likely explains this pattern 19.2 Etiology and Morphology [40]. However, female preponderance among hand eczema patients in school pupils has been reported, Core Message 19 probably due to increased frequency of atopic der- matitis and nickel allergy among females in the study population [50]. í A precise diagnosis is necessary Contact allergy and especially nickel allergy is for optimal treatment and prevention. generally accepted to be a risk factor for development of hand eczema [7, 8, 51]. The interaction between nickel allergy and hand eczema was analyzed by The most common etiology for hand eczema is irri- Menné et al. [49], who found it to be “both ways”: tant contact dermatitis (35%), followed by atopic compared with non-nickel-sensitive females, those hand eczema (22%), and allergic contact dermatitis who had become nickel sensitized ran an increased (19%), while endogenous forms other than atopic 19_335_344 05.11.2005 10:31 Uhr Seite 337 Hand Eczema Chapter 19 337 hand eczema such as pompholyx and hyperkeratotic in consumer products to which the hand are exposed eczema only constitute a minor group [36]. [22]. Formaldehyde allergy was found to be of signif- It is important to realize that the etiology of hand icance for patients with hand eczema. Of 117 women eczema cannot be determined from the clinical man- sensitized to formaldehyde, 52% had hand eczema, ifestations, and that different etiological diagnoses and the dominating exposure source was domestical- cannot be distinguished by clinical pattern [28, 35]. ly used cleaning products [13]. More recently, allergy Although a clinical presentation with numerous ves- to methyldibromo glutaronitrile was frequently icles may indicate an allergic contact dermatitis, and found to be relevant in patients with hand eczema a chronic,scaly appearance may lead to a suspicion of [83]. irritant contact dermatitis, these clinical signs may in some cases be misleading, and omission of a full di- agnostic program cannot be justified.
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