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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, , and occupa- 19.2.1 Allergic Contact ...... 337 tion in the population that are investigated. In a 19.2.2 Irritant ...... 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 ...... 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 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

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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

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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. 19.2.2 Irritant Contact Dermatitis

Irritant contact dermatitis is the most common cause Core Message of hand eczema. In an epidemiological population- based study irritant factors were found to play either í Morphology may not be related a primary or an additional role in 73% of all cases of to etiology. hand eczema [31]. The most common exposure caus- ing irritant contact dermatitis on the hands is wet work, at the working place or at home.Young women are at special risk of this type of hand eczema, since this group has an increased frequency of occupation- 19.2.1 Allergic Contact Dermatitis al exposure to wet work, and at the same time has a significant domestic exposure. Having children below 4 years of age in the family Core Message and lacking a dishwashing machine have both been demonstrated to be separate and significant risk fac- í Patients with hand eczema lasting for more tors for hand eczema [57]. The level of pre-existing than 1 month should be patch tested. skin and barrier disruption is important for the skin’s susceptibility to further irritation. De- tergents have a significant ability to harm the barrier A positive with relevance to the current function of the skin, which can be quantified as in- hand eczema may be expected to occur in less than creased transepidermal water loss. This explains why one-third of all cases of hand eczema. Contact sensi- wet work is, in the majority of cases, a complicating tization may be the primary cause of hand eczema,or factor, since the disturbed barrier function leads to may be a complication of irritant or atopic hand ec- increased penetration by irritants,allergens,and bac- zema. The number of positive patch tests has been teria. The combined effects of irritants and allergens reported to correlate with the duration of hand ecze- may change the threshold value for elicitation of al- ma, indicating that long-standing hand eczema may lergic contact dermatitis, either by immunological often be complicated by sensitization [30]. The most effects or by enhanced penetration by [58]. common contact allergies in patients with hand ecze- Elicitation thresholds for allergens may be consider- ma are nickel, cobalt, fragrance-mix, balsam of Peru, ably influenced by simultaneous exposure. and colophony [36]. Contact sensitivity, especially to In a population-based twin study, hereditary risk nickel but also to other allergens, is generally consid- factors were found to play a significant part in the de- ered to be a risk factor for development of hand ecze- velopment of hand eczema in the general population, ma [30, 49, 50], and the risk increases with increasing when no extreme environmental exposure exists [6]. strength of contact allergy [7, 8]. The importance of This hereditary risk factor could only partly be ex- metal allergy for flare-up of hand eczema was under- plained by atopic dermatitis or contact allergy, and a lined in experimental studies of hand eczema in pa- separate genetic risk factor, independent of atopic tients with metal allergy. Exposure to even very low dermatitis and contact allergy, is suggested to be of doses of the metal caused a flare-up in the sensitized importance for development of irritant contact der- patients, but not in controls [52, 53]. matitis of the hands [7]. Recent papers also indicate that fragrance allergy can be a common and relevant problem in patients with hand eczema, since perfumes are often present 19_335_344 05.11.2005 10:31 Uhr Seite 338

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19.2.3 Contact Urticaria 19.2.5.2 Hyperkeratotic Eczema

Contact urticaria on the hands may, in a chronic Hyperkeratotic dermatitis of the palms is a clinically phase, imitate eczema, meaning that this entity can- characteristic entity which occurs mainly in men not be recognized from just the clinical examination. above the age of 40. is present sym- Skin prick tests or RAST tests are necessary to iden- metrically in the palms, and fissures are common, tify contact urticaria, which on the hands is most of- while vesicles are not found. It may, however, be pre- ten found after occupational exposure to latex gloves ceded by an initial vesicular stage. Although hard or food. Contact urticaria on the hands has an in- manual labor may be a risk factor for hyperkeratotic creased frequency in atopics. hand eczema, no such thing can be identified in the majority of cases [21, 46]. The differential diagnosis to may sometimes be difficult, but wide- 19.2.4 Atopic Dermatitis spread lesions are not found in hyperkeratotic ecze-

Persons with atopic dermatitis have a significantly increased risk for development of hand eczema when Table 1. Diagnosis of hand eczema exposed to irritants at work or at home [10]. Preven- Medical history questions: tive measures are taken to inform young people with Previous episodes of hand eczema atopic dermatitis to avoid professions including wet Atopic dermatitis (previous or current) or dirty work or food handling. Hand eczema in Psoriasis atopics often takes a chronic course, and a change of job seems to improve the prognosis less for atopics Exposures than for others [63]. Cellular immunity in atopics is Domestic decreased, and allergic contact dermatitis seems to Occupational occur in a smaller number of patients with past or Leisure time present atopic disease than in nonatopics [65]. Posi- tive patch tests, often related to topical treatments, Clinical examination are however sometimes found in atopics, and patch Assessment of severity tests should be performed as in other patients with Assessment of morphology hand eczema. Localization Extension Hyperkeratotic 19.2.5 Endogenous Forms Pompholyx

Patch testing 19.2.5.1 Acute and Recurrent Vesicular Should be performed in all patients with hand eczema Hand Eczema (Pompholyx) lasting for more than 1 month In case of positive patch test reactions Pompholyx is a clinical manifestation of hand ecze- Present relevance? (exposure assessment) ma with an uncertain etiology [48]. Preceded by - Past relevance? ing, a vesicular eruption occurs on the palmar as- Unknown relevance? pects of fingers and hands, interdigitally and some- Based on the examination above one of the following times in the periungual area. Infections and allergic diagnoses should be reached contact dermatitis should be excluded.A relationship Irritant contact dermatitis with atopic dermatitis, to tinea pedis, and to nickel Occupational 19 allergy has been suspected. In a recent study an asso- Nonoccupational ciation with tinea pedis was statistically confirmed, Allergic contact dermatitis (or allergic contact urticaria) while no association with atopy or nickel allergy Occupational could be established [8]. Nonoccupational Atopic dermatitis Endogenous dermatitis (other than atopic)

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Table 2. Treatment and prevention of hand eczema region. Legal aspects regarding occupational hand eczema and worker’s compensation influence the fre- Allergen and irritant avoidance quency at which cases are reported to the authorities, Exposure assessment and the true number of cases may very well be much Substitution of products causing irritation higher than the reported and/or recognized number. (domestic and occupational) The cost to society is high, including worker’s com- Substitution of products causing elicitation of allergy pensation, sick leave, retraining, and costs to health (domestic and occupational) services.In addition to being a burden to the individ- Personal protection ual, the disease is expensive for society since it most Avoidance of wet work often affects young people and is a predictor of long- Avoidance of dirty work and mechanical irritation term sick leave and unemployment [32]. of the skin of the hands Occupational hand eczema is more often due to ir- Information ritant than to allergic contact dermatitis [17, 68]. Fre- Skin protection program quent, harmful occupational exposures were report- Expectations – what can be done and what ed to be unspecified chemicals, water and detergents, is the prognosis dust and dry dirt [42]. In a recent Danish study the Notification of possible occupational cases highest numbers of occupational hand eczema were found among health care workers [68]. A large num- Treatment ber of hand eczema cases was reported among clean- Basic treatment (skin care program and moisturizers) ers and in people with wet work in hospitals [30, 42]. Topical therapy (topical steroids being High numbers were also reported among factory the most frequently used treatment) workers, cleaners, kitchen workers/cooks, and hair- Systemic therapy (limited to severe cases) dressers. The highest relative risk of eczema per em- Physical therapy (UVB, PVVA) ployee was found for bakers [68]. Bakers were report- ed to have a threefold increased risk of hand eczema as compared to the background population, due to exposure to dough and wet work [45].A high relative ma. Also in the case of clinically typical hyperkera- risk was also reported for hairdressers, dental sur- totic hand eczema, patch testing should be per- gery assistants, and kitchen workers/cooks. Common formed, since the clinical pattern may sometimes be for occupations with high risk of occupational hand misleading, or a complicating contact allergy may be eczema is exposure to wet work, which has also been identified (Tables 1, 2). identified as a risk factor for development for hand eczema. Many female-dominated occupations in- volve extensive wet work (healthcare workers, hair- 19.3 Occupational Hand Eczema dressers, catering). Focus on prevention of hand ec- zema within this area would be a benefit for the Skin diseases constitute up to 30% of all occupation- workers as well as for society, due to a reduction in al diseases. The most common work-related dermat- economic costs. osis is contact dermatitis, for which the annual inci- Also metal workers have an increased risk for de- dence is reported to be 12.9 per 100,000 workers [9, velopment of hand eczema. In a prospective study 19]. the 3-year cumulative incidence of hand eczema in metal workers was 15.3% as compared to 6.9% in Core Message “white collar-workers” [16]. A study of metal worker trainees found that, apart from atopic dermatitis, other major risk factors for development of hand ec- í Hand eczema is one of the most zema were mechanical factors as well as chemical ir- commonly recognized occupational ritants, and insufficient amount of recovery time [5]. diseases, and also one of the most Frequent causes of occupational allergic contact der- expensive in worker’s compensation. matitis are allergy to metals, rubber, biocides, and fragrances. Cases of occupational hand eczema should be re- Occupational contact dermatitis is most often locat- ported to the authorities as work-related disease. For ed on the hands. The true incidence of occupational further information on legal aspects of occupational hand eczema varies from one region to another, de- contact dermatitis within different countries see pending on industrialization and workplaces in the Chap. 45. 19_335_344 05.11.2005 10:31 Uhr Seite 340

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19.4 Prognosis Understanding the diagnosis improves the prognosis for the patient [3,24],and is necessary to ensure com- Hand eczema is a long-lasting disease. A mean dura- pliance. Making the patient understand the impor- tion of 11.6 years was reported [36], 12.0 and 9.9 years tance of avoiding skin contact with allergens in the for allergic and irritant contact dermatitis, respec- case of allergic contact dermatitis may be a time- tively,while atopic hand eczema was reported to have consuming procedure, and several consultations may a duration of 16.3 years. Another study reported 41% often be necessary. The message that the patient of cases to be healed when re-examined after 3 years needs to understand is often quite complex, and it is [30]. Hand eczema may often lead to sick leave, and a challenge for the dermatologist to keep the infor- the mean total sick leave time for hand eczema pa- mation as simple and as practical as possible. Inde- tients was reported to be 4 weeks per year [43]. In a pendent of the diagnosis the patient should be in- cohort of patients with occupational hand eczema, structed in good skin care habits. Written informa- sick leave for more than 5 weeks per year owing to the tion and videos may be helpful. Reports on eczema eczema was reported by 19.9%. It is generally agreed schools for patients with hand eczema are few, and that frequent and long-lasting sick leave is often re- more experience is needed [27] (Table 3). lated to atopic hand eczema. Earlier studies have re- An extremely important aspect of the treatment of ported a higher degree of severity in patients with al- hand eczema is use of moisturizers. Topically applied lergic contact dermatitis as compared to irritant con- improve skin barrier function, and the effect of tact dermatitis on the hands, as measured by symp- the moisturizer corresponds to the amount of lipids tom duration, sick leave, and extent of involvement in the product [18]. Recently it was investigated [1, 15, 43, 47]. New data, however, indicate that this has whether moisturizers containing skin-related lipids changed.A recent study reports occupational irritant were more effective than petrolatum-based creams in contact dermatitis to be more strongly associated patients with chronic hand eczema, and advantage of with severe hand eczema than allergic contact der- the skin-related lipids for treatment of contact der- matitis [25], and in a recent Danish study on occupa- matitis could not be demonstrated [29]. Since use of tional hand eczema a substantially greater severity moisturizers may sometimes be neglected or looked among those with occupational irritant contact der- upon as being “not important” by the patients, it is matitis was found [69]. This alteration in risk factors necessary for the dermatologist to underline the sig- for severity is probably explained by recent regula- nificance of moisturizers, and help the patient to se- tion of exposure to allergens such as nickel and chro- lect an effective and acceptable one. Males seem to be mate, which has reduced the risk for allergic contact less familiar than females with the use of moisturiz- dermatitis. Having a food-related occupation ap- ers, and the importance of moisturizers should be pears to be associated with an increased risk of job emphasized to this group in particular. loss [69]. Table 3. Skin protection program based on evidence from clin- It is generally assumed that a long delay before di- ical and experimental studies agnosis and treatment of hand eczema leads to a poor prognosis, although there are no substantial Wash your hands in lukewarm water. data available to support this hypothesis. Rinse and dry your hands thoroughly after washing Considering the severe consequences of having Use gloves when starting wet-work tasks hand eczema, it is evident that prevention of the dis- Protective gloves should be used when necessary ease should be promoted. but for as short a time as possible Protective gloves should be intact and clean and dry inside When protective gloves are used for more than 10 min, 19.5 Treatment cotton gloves should be worn underneath Hand wash may be substituted by use of disinfectant when 19 Three important steps in the treatment of hand ecze- the hands are not wet a visibly contaminated ma are: Do not wear finger rings at work Apply moisturizers on your hands during the working day or after work í To ensure that the patient understands the Select a -rich and fragrance-free moisturizer precise diagnosis (e.g., allergic or toxic contact Moisturizers should be applied all over the hands dermatitis) and its consequences including the fingerwebs, fingertips, and back of the hand í To teach the patient good skin care habits Take care also when doing housework, use protective í To initiate an effective medical treatment (top- gloves for dishwashing, and warm gloves when going ical, systemic, or physical thereapy/therapies). outside in winter 19_335_344 08.11.2005 12:21 Uhr Seite 341

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Topical corticosteroids are still the core treatment 19.6.1 Regulation of Threshold Values for hand eczema [78],and their use is reported in 51% for Allergens of patients with hand eczema [43]. However, few studies are available on the efficacy and side-effects when used as a long-term treatment. Nine weeks of Exposure of the skin to allergens in sufficiently high treatment with mometasone furoate was reported to concentrations to cause sensitization is decisive in clear 80% of cases, and maintenance therapy 3 times the development of allergic contact dermatitis on the weekly for 36 weeks did not cause any significant hands. Regulation of allergen exposure, by either leg- side-effects [79]. However, the chronicity of the dis- islation on threshold values or regulation of precau- ease increases the risk of side-effects due to long- tions in the handling of allergenic products, reduces term treatment with topical corticosteroids. Use of allergen exposure and subsequently reduces the fre- topical steroids under occlusion for short periods, quency of allergic contact dermatitis.One example of e..g., 1 h a day for a few weeks, may be helpful for hy- this is nickel exposure regulation, of which a positive perkeratotic eczema, but increases the risk of side-ef- effect has been documented [54]; other examples are fects considerably. When the eczema continues in regulation of chromate in cement, and recently pro- spite of treatment the possibility of contact allergy to hibition of the preservative methyldibromo gluta- topical corticosteroids should be considered. ronitrile in cosmetics. or may be suitable treat- ments for some types of hand eczema, but more ex- 19.6.2 Identification of Risk Groups perience with these preparations is needed [66, 75, 76]. In severe cases systemic treatment with immuno- Previous or current atopic dermatitis is, as already suppressants such as cyclosporine, azathioprine or mentioned, a significant endogenous risk factor for methotrexate may sometimes be necessary, but ran- development of hand eczema, and counseling about domized controlled trials on these treatments for avoiding wet and dirty occupations should be given hand eczema are not available. Acitretin is an effec- to atopics as early as in childhood.A separate genetic tive treatment for keratotic hand eczema [77]. Botuli- risk factor, independent of atopic dermatitis, has re- num toxin has been used in the treatment of pom- cently been suggested to be important in the devel- pholyx [74]. Physical treatment with PUVA therapy opment of irritant contact dermatitis of the hands or UVB may be considered, and UVA-1 treatment was [7], but further studies are needed to confirm this hy- recently advocated for pompholyx [59]. Grenz rays pothesis. have traditionally been used particularly for treat- Exposure to wet work is a special risk factor for ment of hyperkeratotic hand eczema [33], although development of hand eczema, and to achieve the op- nowadays it has been widely replaced by newer treat- timal effect of preventive efforts the focus for preven- ments because of its potential carcinogenic side-ef- tion should aim at reducing wet exposure. fects. To compare the efficacy of different medical treat- 19.6.3 Skin Protection ments for hand eczema randomized controlled trials are needed. In clinical trials the evaluation should comprise objective assessment of the eczema as well Protection of the hands is essential for the prevention as self-assessment by the patients. Instruments for of hand eczema and is a fundamental aspect in its self-assessment are available either as a VAS-score or treatment. The effects of protective measures, such as as health-related quality of life [80], and a scoring use of moisturizers and gloves, have mostly been systems for standardized objective evaluation has documented in laboratory studies with experimen- been proposed [20, 84]. tally damaged skin [11]. An intervention program for people working in wet occupations has been devel- oped, based on results from experimental studies, 19.6 Prevention and its effectiveness was documented in an interven- tion study [19]. Since hand eczema is a disease that may often be- Use of gloves in wet work has generally been rec- come chronic, is a burden for the patient, and is a ommended and accepted as an important preventive great cost to society, prevention is obviously an at- measure. Compliance with this recommendation is tractive alternative. Prevention should aim mainly at good in some but far from all jobs [81]. Although the exposure, but knowledge about endogenous risk fac- protective effect of gloves should not be doubted, tors should also be taken into account. gloves may sometimes be the cause of hand eczema. Protective gloves may cause irritant contact derma- 19_335_344 05.11.2005 10:31 Uhr Seite 342

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titis or allergic contact dermatitis due to contact sen- 6. Bryld LE, Agner T, Kyvik KO, Brøndsted L, Hindsberger C, sitization to rubber additives, or they may cause con- Menné T (2000) Hand eczema in twins: a questionnaire investigation. Br J Dermatol 142 : 298–305 tact urticaria due to immediate natural rubber latex 7. Bryld LE, Hindsberger C, Kyvik KO, Agner T, Menné T allergy [60, 61, 71]. The diagnostic work to be done (2003a) Risk factors influencing the development of hand when suspecting glove-related dermatitis includes eczema in a population-based twin sample. Br J Dermatol exposure assessment (how many hours a day), as well 149 : 1214–1220 as a patch test for rubber additives and a skin prick 8. Bryld LE, Agner T, Menné T (2003b) Relation between ve- sicular eruptions on the hands and tinea pedis, atopic der- test or RAST test for latex. matitis and nickel allergy. Acta Derm Venereol (Stockh) 83 : 186–188 9. Cherry N, Meyer JD, Adisesh A (2000) Surveillance of oc- 19.7 Quality of Life cupational skin disease: EPIDERM and OPRA. Br J Der- matol 142 : 1128–1134 10. Coenraads PJ, Diepgen TL (1998) Risk for hand eczema in Not surprisingly, hand eczema has been demonstrat- employees with past or present atopic dermatitis. Int Arch ed to have a negative impact on quality of life, and fe- Occup Environ Health 71 : 7–13 males seem to report a higher degree of discomfort 11. Coenraads P, Diepgen TL (2003) Problems with trials than males [37]. Also psychological factors may have and intervention studies on barrier creams and emollients a significant impact on the disease, although this ar- at the workplace. Int Arch Occup Environ Health 76 : 362–366 ea needs further studies [55]. Subjects diagnosed by 12. Coenraads PJ, Nater JP,van der Lende R (1983) Prevalence patch testing more than 36 months after disease on- of eczema and other dermatoses of the hands and arms in set seem to have worse quality of life scores than the Netherlands. Association with age and occupation. those diagnosed earlier, and hand eczema and gener- Clin Exp Dermatol 8 : 495–503 13. Cronin E (1991) Formaldehyde is a significant allergen in alized eczema seem to be equally detrimental to women with hand eczema. Contact Dermatitis 25 : 276–282 quality of life [26, 67]. 14. Danish Ministry of the Environment (1989) Statutory or- der no 472, 27 June 1989 15. Fregert S (1975) Occupational dermatitis in a 10-year ma- 19.8 Differential Diagnosis terial. Contact Dermatitis 1 : 96–107 16. Funke U, Fartasch M, Diepgen TL (2001) Incidence of work-related hand eczema during apprenticeship: first re- In most cases of hand eczema the diagnosis does not sults of a prospective cohort study in the car industry. provide any difficulties, but there are some pitfalls Contact Dermatitis 44 : 166–172 that should be avoided. A diagnosis often to be mis- 17. Halkier-Sorensen L (1996) Occupational skin diseases. taken for hand eczema is dermatomycosis, which Contact Dermatitis 35 : 1–120 18. Held E, Agner T (2001) Effect of moisturizers on skin sus- should always be suspected when hand eczema is ceptibility to irritants. Acta Derm Venereol (Stockh) 81 : limited to one hand. Psoriasis is more difficult to dif- 104–107 ferentiate from hand eczema, but sharply demarcat- 19. Held E, Mygind K, Wolff C, Gyntelberg F, Agner T (2002) ed extension of the lesions should raise the suspicion. 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