Understanding the Various Types of Hand Eczema

Flaking, peeling, itching, crusting — hand eczema can wreak havoc on your ability to do daily life activities. “Hand eczema can have an incredible impact on your quality of life — it can cause pain, itch, dryness, cracked skin, burning sensations and chronic rashes, which can reduce your ability to sleep, work, do routine life activities or participate in sports and recreation,” said Dr. Lawrence Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego and vice-chair of the department of dermatology at University of California, San Diego School of Medicine.

Hand eczema is also prone to lots of secondary infections because skin is cracked and open. With the amount of use our hands get, it can be very problematic for people with hand eczema. Aside from the physical pain, there can also be mental anguish. “There is a deep psychological toll with people not wanting to shake hands or touch someone with eczema on their hands,” said Dr. Eichenfield.

Hand eczema affects about 14.5% of the general population worldwide at some point in their life, according to a 2021 paper.¹ Women and teens seem to be affected most by hand eczema. Women are more likely than men to have hand eczema, and as a result, a lower quality of life due to the symptoms.² The average age people develop hand eczema is 12 years old.³ According to a 2023 study, about 10% of teens age 16 to 19 reported hand eczema, while 1%–4% of preschool and school-age children reported chronic hand eczema.³

Although hand eczema is not exclusive to people with atopic dermatitis (AD), researchers have found that having AD does put you at higher risk for developing hand eczema.³ Many people with AD can experience eczema on their hands, but it might present differently on hands than the rest of the body. In addition, there may be overlap between hand eczema and other types of eczema.

Types of hand eczema

Hand eczema can be very difficult to diagnose due to the many different underlying causes. It can also be difficult to treat. “Hand eczema is often overlooked by healthcare providers and often not seen by dermatologists until it is severe and chronic, which can exacerbate its impact,” said Dr. Eichenfield.

There are several types of hand eczema. Here is a breakdown of the five main types of hand eczema:

• Irritant contact dermatitis – This is the most common type of hand dermatitis. It is typically caused by an irritant, like a chemical, that comes into contact with hands. Hot, cold, dry or wet conditions can also cause irritant contact dermatitis on hands. This type of hand eczema is often common for people in certain types of jobs, like mechanics, hairstylists, nail technicians and healthcare workers.⁴

• Allergic contact dermatitis – This type of hand eczema can often occur after a person has irritant contact dermatitis. With irritant contact dermatitis the skin can become cracked, which then allows allergens to penetrate the skin, which activates the immune system. With repeated, long-term exposure to these allergens, the patient can develop allergic contact dermatitis. This type of hand eczema can be more severe if the patient continues to expose themselves to the allergen.⁴

• Atopic hand eczema – This type of eczema is caused by a person’s immune system, and genetic factors like a filaggrin mutation, which does not allow the outer layers of the skin to fully develop. Atopic hand eczema is also caused by environmental factors, which disrupt the skin barrier. This skin barrier disruption can lead to allergic reactions. As a result, if a patient has atopic hand eczema, they may also develop allergic contact dermatitis and irritant contact dermatitis.⁴

• Dyshidrotic or “acute recurrent vesicular” hand eczema – This type of eczema often displays as bumps filled with clear liquid that burst open. They often bruise and form scales. It may only last for a few weeks, which is why it is called acute, but it may happen repeatedly.⁴

• Hyperkeratotic hand eczema – This type of eczema is typically associated with thick patches of cracked skin on the palms. This is a less common type of hand eczema that may also involve the soles of the feet. Hyperkeratotic hand eczema is difficult to treat. Patients often need to take oral or injected medications to see symptoms improve.⁴

How to diagnose hand eczema

So how do doctors diagnose hand eczema with so many different types and causes? “Hand eczema is really several different disorders, so the first thing a doctor needs to do is try to figure out what is causing it,” said Dr. Amy Paller, a pediatric dermatologist and chair of the dermatology department at Northwestern University. “Doctors look for clues like location of the rash or skin issues.”

The location of the rash can really help your doctor narrow down a diagnosis. “For example, contact dermatitis is usually on the tops of hands, but it can sometimes occur on palms,” explained Dr. Paller. “Allergic contact dermatitis of the hands can appear on either side of your hands. While dyshidrotic eczema can look like tapioca-like bumps on the sides of fingers or larger blisters or pus bumps.”

Your doctor will also ask a lot of questions to try to learn what might be causing hand eczema. They will do a thorough history of your hand issues. They may also need to do a biopsy to make sure the cause is not actually another disease like psoriasis or cancer.

Patch testing is another way for doctors to diagnose hand eczema. This is mainly used for irritant contact dermatitis and allergic contact dermatitis. Your doctor will apply various allergens and triggers to your skin and watch for redness, swelling, heat and other indications of an allergic reaction.

Patch testing is typically done for chronic hand eczema, not acute hand eczema. Acute hand eczema lasts less than three months and only occurs once a year. Chronic hand eczema lasts more than three months and reoccurs multiple times throughout the year.⁴

Current treatments for hand eczema 

For acute hand eczema, you can frequently improve your symptoms by identifying the external irritant or allergen and removing it from your daily life. Another way to improve symptoms is to wash your hands using lukewarm water and a mild soap and make sure to remove all the soap from your hands, including under rings, where moisture and allergens can get trapped.⁵ Moisturizing hands frequently is also key. The top layers of the skin require 10% hydration in order to be an effective barrier, and moisturizers can greatly improve hydration and prevent further water loss when the skin barrier has been disrupted.⁵

Medications are also available for treating hand eczema, especially when it has become chronic. “The typical treatment for most hand eczemas is topical steroids,” Dr. Paller said. “Chronic hand eczema usually requires a fairly strong treatment and so systemic medications (taken orally or by injection) sometimes need to be used.”

However, Dr. Eichenfield added, “due to the chronic nature of a lot of hand eczema, it is important that your care team finds a longer-term strategy for treatment beyond the occasional use of topical steroids.”

Although topical steroids are considered the first line of treatment for hand eczema, it has been difficult to assess which topical steroids are most effective specifically for hands. A 2022 University of Colorado study compared different types of topical steroids for hands and did not find statistically significant differences between them.⁶ Oftentimes, this means several topical steroids need to be tried before symptoms in a specific patient improve.

An oral medication called alitretinoin, which is specifically for treating hand eczema, has been approved in Canada, Europe, Israel and South Korea.^6,7 It has shown high efficacy for hand eczema. However, the U.S. has not yet approved it.^6,7 In fact, there is currently no approved treatment specifically for hand eczema in the U.S.⁷

Systemic (taken orally) steroids, retinoids and other immune modifiers like cyclosporin and methotrexate can be used in cases where topical medications are not effective.⁵ Recently, injectable JAK inhibitors and dupilumab have become the treatments of choice for chronic hand eczema that does not respond to other treatments.⁷

Dr. Eichenfield suggested that patients find an eczema expert and request patch testing, especially in cases where medications have not been successful and the hand eczema has lasted several months or comes back multiple times a year. He strongly encouraged patients to think about irritant and allergic contacts as being the driving force behind hand eczema.

Treatments in development for hand eczema 

There is still a lot of need for more treatments for hand eczema. “Researchers are trying to find better ways to diagnose hand eczema and get to the root cause faster to see if that can improve treatment recommendations and outcomes,” said Dr. Paller. “There is also definitely room for improvement in therapeutics for hand eczema specifically — and clinical trials are currently being done.”

Dr. Eichenfield is optimistic that new treatments for hand eczema will be available in the future. “Help is on the way!” he said. “There are new therapies in development, particularly looking at more effective long-term disease control. These newer approaches may include new nonsteroid topical agents or systemic medications, such as biologics and oral or even topical JAK inhibitors.”

In fact, a topical JAK inhibitor called delgocitinib has recently been studied in clinical trials for hand eczema in Europe.⁸ A total of 258 patients with hand eczema were given different doses of the topical drug and the highest dose (20mg/g) significantly reduced itch, pain and other hand eczema symptoms compared to patients who only received the topical cream not containing the drug.⁸

A similar trial with delgocitinib was performed at four different sites in the U.S. with AD patients rather than specifically hand eczema patients, according to ClinicalTrials.gov.⁹ Significant improvements were observed in these AD patients on the highest dose of delgocitinib compared to those who only received the topical cream without medicine. Further studies would be needed in the U.S. specifically for hand eczema to show its effect.

Hand eczema patients currently have some options as many of the recently developed therapeutics for AD can also be used for hand eczema for people who have overlapping conditions. 

At Rady Children’s Hospital/UC San Diego, Dr. Eichenfield is currently part of an effort to organize collaborative research to study hand eczema in children and teens. Part of this research, which was recently published in May 2023, looked at how pediatric physicians in the U.S. and Canada take patient histories, which diagnostic methods are most broadly used in pediatric hand eczema and how physicians approach their selection of therapies.¹⁰ The hope is that with these results, healthcare providers can create a set of guidelines for the management of pediatric hand eczema to get ahead of what Dr. Eichenfield called a “neglected condition.”

 Key takeaways:

• Hand eczema can be caused by many different factors and can overlap with AD.
• Though AD and hand eczema may have different underlying causes, they are also very frequently linked.
• Hand eczema can be a challenging disease to diagnose.
• Trying to identify the underlying cause of hand eczema can help with treatment.
• Current treatment options include avoiding specific irritants and allergens, following handwashing and moisturizing recommendations and being open to trying different medications.
• New drugs that treat AD, like dupilumab and JAK inhibitors, can help improve hand eczema.
• Clinical trials to test drugs specifically for hand eczema are ongoing.

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NEA Funds New Hand Eczema Research

In 2022, the National Eczema Association (NEA) awarded a Spotlight Research Grant to Michael Haft, a dermatology research fellow at the University of California, San Diego, to study pediatric hand eczema. His work is studying 200 youths across 10 medical centers in the U.S. to better understand chronic hand eczema in children and teens. The goal is to evolve best practices in the treatment of chronic hand eczema for kids.

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References:

1. 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  

2. Silverberg JI, Simpson B, Abuabara K, et al. Prevalence and burden of atopic dermatitis involving the head, neck, face, and hand: a cross sectional study from the TARGET-DERM AD cohort. J Am Acad Dermatol. 2023;89(3):519-528. doi:10.1016/j.jaad.2023.04.052

3. Haft MA, Park HH, Lee SS, Sprague JM, Eichenfield LF. Pediatric chronic hand eczema: epidemiology, clinical presentation, and management. JAAD Int. 2023;11:165-173. Published 2023 Feb 27. doi:10.1016/j.jdin.2023.02.008

4. Agner T, Elsner P. Hand eczema: epidemiology, prognosis and prevention. J Eur Acad Dermatol Venereol. 2020;34 Suppl 1:4-12. doi:10.1111/jdv.16061

5. Alavi A, Skotnicki S, Sussman G, Sibbald RG. Diagnosis and treatment of hand dermatitis. Adv Skin Wound Care. 2012;25(8):371-382. doi:10.1097/01.ASW.0000418540.54237.e5

6. Strock D, Maghfour J, Dellavalle RP. From the Cochrane Library: Interventions for hand eczema. J Am Acad Dermatol. 2022;86(2):e31-e34. doi:10.1016/j.jaad.2021.09.048

7. Dubin C, Del Duca E, Guttman-Yassky E. Drugs for the treatment of chronic hand eczema: successes and key challenges [published correction appears in Ther Clin Risk Manag. 2021 Mar 18;17:233]. Ther Clin Risk Manag. 2020;16:1319-1332. Published 2020 Dec 31. doi:10.2147/TCRM.S292504

8. Bauer A, Thyssen JP, Buhl T, et al. Treatment with delgocitinib cream improves itch, pain and other signs and symptoms of chronic hand eczema: results from the hand eczema symptom diary in a phase IIb Randomized clinical trial. Contact Dermatitis. 2023;89(1):46-53. doi:10.1111/cod.14303

9. ClinicalTrials.gov. Dose-ranging trial to evaluate delgocitinib cream 1, 3, 8, and 20 mg/ g compared to delgocitinib cream vehicle over an 8-week treatment period in adult subjects with atopic dermatitis. https://clinicaltrials.gov/study/NCT03725722?intr=delgocitinib&rank=6&tab=results. Last updated July 8, 2021. Accessed August 23, 2023.

10. Haft, M.A., Park, H.H., Lee, S.S. et al. Diagnosis and management of pediatric chronic hand eczema: The PeDRA CACHES survey. Pediatr Drugs 25, 459–466 (2023). https://doi.org/10.1007/s40272-023-00574-x