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Skin Care Today
Managing Hand Eczema
First do no harm
A
lmost everyone, except perhaps royalty, will have some form of hand dermatitis at some point in their lifetimes. Many studies show that 5 percent of the population with European ancestry have had an overt case of this disorder, and another 10 percent of that population have clinical symptoms, even though their condition may not be obvious in a physical examination. These patients may have only subjective findings.
   The most obvious cases of hand dermatitis could be diagnosed by medical students—red, scaly, eczematous hands and fingers with cracks and fissures that can eventually bleed. However, if the plaques are sharply marginated, located in the central palm, and associated with plaques on other parts of the body, the diagnosis is more likely psoriasis, which affects 3 percent of the Caucasian population. The more
exogenous. The endogenous form is found in that approximately third of the population that is atopic—those with allergies, asthma, and eczema. Foods or airborne allergens may cause their hand eczema, as well as substances topically applied to the skin. Exogenous factors in hand eczema include those to which one has a true allergy and those that are simply irritants.
   Allergic contact dermatitis (ACD) occurs in 10 to 15 percent of the population and is usually caused by a type-IV, delayed-type hypersensitivity. This typically takes 24 to 96 hours to develop. ACD can be caused by a number of substances, such as plants
feels stinging and burning and quickly develops dermatitis. This type of reaction is knows to afflict 5 to 8 percent of health care workers who have extensive use of latex gloves.
   Environmental safety has presented a new cause of hand dermatitis in offices. Many of the hand eczema sufferers now work in offices handling paper or corrugated boxes. The recycled paper contains residual chemicals that irritate the skin, such as formaldehyde and whiteners, and cause irritant or allergic contact dermatitis. In physician offices there seem to be as many or more hand
subtle cases require more clinical expertise. There may be little or no erythema, especially in darker skin types. Magnification may be required to reveal the scaling. Or there may be no clinical
Topical products
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contain no steroids
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signs whatsoever—simply the symptoms of burning, stinging, sensitive hands that are generally "uncomfortable."

Possible Etiologies
Hand dermatitis can be divided in two major categories—endogenous and
(chrysanthemums, poison oak and ivy), foods (parsley, onion, garlic), fragrances, clothing, dyes, rubber, solvents, metals, chemicals such as formaldehyde, and many more. Diagnosis of ACD in any part of the body, including the hands, involves patch testing. "Level one" patch testing is done by most dermatologists. It consists of the application of 20 common allergens to the upper back. These chemicals are left in place for 48 hours, then the area is observed for allergic reactions to any of the applied substances. More sophisticated ACD testing is done at tertiary-care dermatology centers to look for more esoteric and unusual allergic reactions. The obvious treatment for ACD is to avoid the offending antigen, which may be quite difficult at times, for example, nickel is ubiquitous and very hard to avoid completely.
   Sometimes, the allergic reaction is a type-I, IgE-mediated reaction that occurs immediately upon contact with the antigen. This is frequently seen in the medical setting—the nurse who dons a pair of latex gloves and immediately
dermatitis problems with the office staff as with doctors and nurses.
   Irritant contact dermatitis (ICD) is almost ubiquitous. It can be caused by any excessive exposure to water or an irritating substance, such as soaps, shampoos, perms, facial cosmetics, cosmetic nail glues, recycled office papers, nickel in jewelry, powder in gloves, or garden chemicals. Exposure to chemicals in the workplace, or at home doing hobbies, can also be the cause of ICD. As said before, a full–blown classic case of hand dermatitis may not develop in everybody, but irritation will be noticed by most. If an irritant were used long enough and in large enough quantities, an irritant contact dermatitis would develop in anyone.
   Less common causes of hand dermatitis include tinea (especially if only one hand is involved—remember to check both feet for fungus causing the "two foot, one hand" itchy scaliness), which requires a KOH prep for diagnosis. Psoriasis and other skin disorders are easily diagnosed by dermatologists by coexisting skin findings.
———
Laura E. Skellchock, M.D.

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