Treating Hand Eczema

It is estimated that 10% of the US population has hand eczema.¹ It can be caused by genetics or contact allergens, like fragranced soap or cleaning products. Although the best treatment option is to avoid triggers, ointments in the treatment pipeline are promising.²

To further discuss treatment of hand eczema, The Dermatologist reached out to Matt Zirwas, MD, who is a practicing dermatologist at Dermatologists of Central States in Bexley, Ohio.

The Dermatologist: What are the pearls to treating hand eczema? 

Dr Zirwas: If it involves the dorsal and interdigital aspects only, it is usually irritant contact dermatitis. If it involves the palmar aspects only, it is usually atopic dermatitis of the hands (formerly called dyshidrosis or dyshidrotic hand eczema).³ And if it involves both the palmar and dorsal aspects, then it is most likely allergic contact dermatitis.

In terms of treatment, penetration of topical agents on the palm is a huge reason for lack of response. The most effective way to overcome this is with depilatory cream. Have the patient apply the cream and leave it on the palm for about a minute, wipe and wash it off, then apply the topical prescription agent. This concept was published in the Journal of Investigative Dermatology in 2008.⁴ I usually instruct my patients to use this concept daily until the skin feels like normal thickness. Then I tell them to keep using the topical prescription regularly as directed but only use the depilatory once or twice a week (otherwise they will remove too much skin if they keep using it daily). Depilatory cream used similarly as monotherapy also works great for thickened skin on the soles of the feet or dry cracked heels. The only issue is that if there are deep fissures or erosions or significant active dermatitis the depilatory cream will sting and burn while it is on the skin.

 The Dermatologist: How do patient characteristics, such as age or race, play a role in treating hand eczema? 

Dr Zirwas: They play a role in the likely culprits of allergic and irritant dermatitis. Age tends to be a bigger factor than race.⁵ In school-aged children, I find that the soap in the bathrooms at school is often a big issue (eg, preservatives, antibacterials, fragrances) and slime (eg, methylisothiazolinone in the glue used to make it).⁶

 The Dermatologist: In your opinion, what knowledge gaps still exist regarding the treatment of hand eczema? 

Dr Zirwas: Mainly, we should now think of there as being 3, and only 3, pathophysiologic types of hand eczema: irritant contact dermatitis of the hands, allergic contact dermatitis of the hands, and atopic dermatitis of the hands. Most dermatologists still think of “dyshidrotic hand eczema” as a unique entity and as there being a general class of “endogenous hand eczema” that is distinct from “atopic dermatitis of the hands.”

 The Dermatologist: What research still needs to be done to bridge the knowledge gaps? 

Dr Zirwas: The only way to “prove” that endogenous hand eczema is pathophysiologically similar to atopic dermatitis will be with clinical trials demonstrating that targeted therapies (ie, biologics) are effective for endogenous hand eczema.

References

1. What is hand eczema? National Eczema Association. Accessed February 17, 2022. https://nationaleczema.org/eczema/types-of-eczema/hand-eczema/

2. JAK inhibitors are coming and they are the biggest eczema development in years. News release. National Eczema Association. Published January 4, 2021. Updated June 3, 2021. Accessed February 17, 2022. https://nationaleczema.org/jak-inhibitors-research/

3. What is dyshidrotic eczema? National Eczema Association. Accessed February 17, 2022. https://nationaleczema.org/eczema/types-of-eczema/dyshidrotic-eczema/

4. Lee JN, Jee SH, Chan CC, Lo W, Dong CY, Lin SJ. The effects of depilatory agents as penetration enhancers on human stratum corneum structures. J Invest Dermatol. 2008;128(9):2240-2247. doi:10.1038/jid.2008.82

5. Quaade AS, Simonsen AB, Halling AS, Thyssen JP, Johansen JD. Prevalence, incidence, and severity of hand eczema in the general population - A systematic review and meta-analysis. Contact Dermatitis. 2021;84(6):361-374. doi:10.1111/cod.13804

6. Simonsen AB, Ruge IF, Quaade AS, Johansen JD, Thyssen JP, Zachariae C. High incidence of hand eczema in Danish schoolchildren following intensive hand hygiene during the COVID-19 pandemic: a nationwide questionnaire study. Br J Dermatol. 2020;183(5):975-976. doi:10.1111/bjd.19413