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Patient education, prevention, and primary care are the cornerstones, with stepwise therapy + active maintenance therapy based on severity
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Hand eczema, also known as "housewife's hand", is a type of inflammation of the skin of the hands that occurs frequently in women. Recently, at the 29th Annual Meeting of Dermatology and Venereology of the Chinese Medical Association (CSD 2024), Professor Liang Yunsheng from the Dermatology Hospital of Southern Medical University brought you "Clinical Classification and Treatment Progress of Hand Eczema", and sorted out the causes, disease types and treatment plans of hand eczema in detail, let's take a look at how to diagnose and treat hand eczema!
Hand eczema is highly prevalent, and a variety of risk factors need to be vigilant
Hand eczema (HE) is an inflammatory, heterogeneous skin disease that occurs on the hands and wrists with pain and itching, with signs including erythema, scales, lichenification, hyperkeratosis, blisters, edema, and chapping, with pruritus and skin pain at its core.
Professor Liang Yunsheng emphasized that HE is a heterogeneous and recurrent disease, characterized by skin barrier dysfunction and skin inflammation, and patients will have an increased risk of Staphylococcus aureus infection. Chronic Hand Eczema (CHE) refers to HE that lasts for > 3 months or recurs > 2 times per year.
Epidemiology of 1HE
Professor Liang Yunsheng said that hand eczema is a high-incidence disease, with a prevalence of up to 9% in one year, and is a common occupational disease, 35% of women and 27% of men develop HE before the age of 20, and 63% of HE patients have a history of childhood eczema.
2Risk factors associated with HE
There are many risk factors associated with hand eczema, including occupations involving wet hands or frequent exposure to irritants/allergens (see figure below), previous or current atopic dermatitis, a history of eczema, asthma, and hay fever in childhood, and being a woman with the need to do household chores to care for children.
Professor Liang Yunsheng pointed out that the work content of medical staff is also the cause of the high incidence of HE in medical staff, and he suggested that those who need to be exposed to irritants or allergens at work should pay attention to the prevention of the disease.
Figure 1. Risk factors associated with HE
There are 4 major etiological features, and the morphology of skin lesions is diverse
Professor Liang Yunsheng said that the etiology of HE generally has multiple etiologies at the same time, but the etiology is unknown in 20% of cases, and there is no clear correlation between the etiology of HE and the morphology of the patient's skin lesions.
He pointed out that the etiology of HE is mainly divided into four aspects: irritation, atopy, allergic and protein-contact dermatitis/urticaria, among which atopic is an important indicator of poor prognosis in patients with hand eczema.
Table 1. There are 4 major etiological features of HE
Professor Liang Yunsheng said that the signs of HE are diverse, including erythema, scales, lichenification, hyperkeratosis, blisters, edema, chapped and nail dystrophy, etc., and it is necessary to pay attention to distinguish it from other skin diseases in clinical practice.
Figure 2. A variety of signs of HE (Source: Speaker PPT)
Endogenous and exogenous typing of HE
Professor Liang Yunsheng introduced that the 2021 version of the expert consensus on the diagnosis and treatment of hand eczema in China divides HE into four major types: exogenous, endogenous, mixed and unclassified, of which endogenous can be divided into three types, as follows:
Exogenous HE:
■1.刺激性接触性皮炎（ICD）
- Hand eczema caused by impaired skin barrier function due to long-term repeated exposure to irritants;
- Diagnosis is based on a history of irritant exposure, and patch testing is done to rule out allergic contact dermatitis.
■2.Allergic contact dermatitis (ACD)
- Type IV hypersensitivity reaction that occurs after exposure to an allergen;
- Positive exposure to allergens on patch testing confirms the diagnosis or suspects ACD.
■3.蛋白接触性皮炎/接触性荨麻疹（CU/PCD）
- Rapid development of urticaria at the site of contact with the hand after contact with "protein", followed by eczema-like lesions due to scratching;
- The pathogenesis is specific lgE-mediated type I hypersensitivity reaction, and a considerable number of patients have atopic constitution;
- Prick testing and serum-specific lgE testing can help confirm the diagnosis.
endogenous HE:
■1.Atopic wet hands (AHE)
- The patient has a history of AD with atopic diseases such as asthma and pollen, and has no history of exposure to irritants or allergens.
■2.Endogenous blistering type hand eczema
- Formerly known as dyshidrosis, it is characterized by recurrent cluster blisters on the palms, especially on the flexor margins of the fingers, often accompanied by moderate to severe itching;
- No history of related contact allergies, no history of exposure to dermatitis-related irritants.
■3.Endogenous keratinizing hand eczema
- Hyperkeratosis and painful fissures with clear borders in the palms and fingers of the abdomen, often involving the plantar region;
- It is mostly chronic, and no pustules or blisters appear during the course of the disease; The cause is unknown, and there is no history of irritant exposure.
In addition, Professor Liang Yunsheng said that mixed hand eczema has the characteristics of ICD, ACD or AHE at the same time, and ACD complicated by ICD is the most common in clinical practice. Unclassified hand eczema does not meet any of the above types of hand eczema and should continue to look for possible causes for targeted treatment.
Pay attention to hand skin protection, ladder + active maintenance therapy
Professor Liang Yunsheng emphasized that in the process of diagnosis and treatment of HE, the search for etiology is very important, and patients should collect a detailed medical history when they come to the clinic, and it is very important to have a history of exposure, allergies, and whether they have AD in the past. In addition, patch testing is done on patients, and it is recommended that all patients with hand eczema have a patch test to identify potential allergenic factors.
Professor Liang Yunsheng introduced that in the treatment of hand eczema, prevention and basic treatment are particularly important. Because hand eczema tends to recur and is difficult to cure, health education and preventive measures are important. Prevention focuses on hand skin protection, avoiding contact with irritants/allergens, and strengthening emollient hydration. Patients can use gloves wisely, avoid contact with irritants/allergens, use emollients wisely, keep the skin moisturized, try to avoid washing hands with strong cleaning agents, and choose gentle care products.
1. Local and physical therapy
In terms of specific treatment, Professor Liang Yunsheng said that at present, local treatment and physical therapy HE are effective for most patients. Topical glucocorticoids (TCS) are still the first-line treatment for HE, and "active maintenance therapy" is required for severe patients.
For some patients with mild to moderate disease, especially AHE, topical calcineurin inhibitors (TCIs) may be used as an alternative/supplemental regimen to TCS. Professor Liang Yunsheng also pointed out that ultraviolet therapy is suitable for moderate to severe recalcitrant recurrent chronic hand eczema that does not respond to TCS treatment.
2. Systemic treatment
Professor Liang Yunsheng said that alitretinoin is the first oral drug approved in Europe for the treatment of hand eczema, and it is a clear second-line treatment. Professor Liang Yunsheng said that another drug, acitretin, can be selected for second-line treatment in domestic clinical practice.
Other oral systemic drugs such as glucocorticoids or immunosuppressants such as cyclosporine and methotrexate are not recommended for long-term use, but only for short-term symptom relief if other drug treatments are ineffective.
brief summary
Finally, Professor Liang Yunsheng concluded that hand eczema is a long-term chronic disease, and there is currently a lack of safe and effective products that can be used for long-term use.
In conclusion, he pointed out that patient education, prevention and basic treatment are the basis of chronic disease management of hand eczema, and that clinical treatment according to the severity of the disease + active maintenance therapy is the only way to manage hand eczema well, and he hopes that there will be newer therapies in the future to help patients improve the disease in a long-term stable manner.
Expert Profile
Prof. Liang Yunsheng
- Chief physician, doctoral supervisor, director of the Department of Dermatology, Dermatology Hospital, Southern Medical University
- Member of the Immunology Group of the Dermatology and Venereology Branch of the Chinese Medical Association
- Chairman of the Dermatology and Venereology Branch of the Guangdong Precision Medicine Application Society
- Leader of the Allergy and Allergy Group of the Dermatology and Venereology Branch of Guangdong Medical Association
- He is mainly engaged in epigenetic mechanism and translational research of atopic dermatitis. He has won the "Outstanding Young and Middle-aged Physician of Chinese Dermatology", "Outstanding Young Scientist Award of Chinese Allergology", "Outstanding Doctoral Dissertation Award of Hunan Province", and the first prize of the "Most Influential Research Award" of Chinese Dermatology and Venereology in 2020
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Review of this article: Professor Liang Yunsheng
Editor in charge: Liu Sisi
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