Allergic coNtAct DermAtitis: HAND DermAtitis - The Dermatologist
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Allergic coNtAct DermAtitis: HAND DermAtitis - The Dermatologist

AllergenFocusAllergic ContactDermatitis: Hand DermatitisSara A. Hylwa, MD, and Mark D.P. Davis, MDthe immune system (sensitization to achemical and then elicitation of dermatitiswith re-exposure) and its frequentrecurrence rate. Differential diagnosesmay also be discussed. It is importantto note that irritant contact dermatitis(ICD), the most prevalent form of contactdermatitis, can, at times, precede orbe a concomitant diagnosis with ACD. 4,5Unlike ACD, ICD is not immune mediated;it occurs secondary to contact withan irritating or abrasive substance. Contacturticaria (a type I, IgE meditated,wheal- and flare-type hypersensitivityreaction), on the other hand, representsthe least prevalent form of contact dermatitis;one should note that contact urticariahas the potential to evolve intoa fully systemic, anaphylactic reaction.We direct the reader to key sources forsupplementary reading on this topic. 6,7,8In this column, we highlight ACDand explore top relevant allergens andregional- and topic-based presentations,as well as clinical tips and pearls for diagnosisand treatment.Allergic ContactDermatitis(ACD) isan important diseasethat notably affects14.5 million Americanseach year. 1 TheSara A. Hylwa, MDeconomic impact ofthis disease is high interms of both patientmorbidity as well asloss of income, schooland work — not tomention significantMark D.P. Davis, MD expenditures for visitsto health care providersand for medicaments. 1 Patch testing— the gold standard for ACD diagnosis— identifies possible relevant allergens.Once patch testing is performed and aculprit has been identified, education iscritical to ensure adherence to an avoidanceregimen. With avoidance, remissionof the dermatitis is possible. If the patientis unable to comply with the avoidanceregimen, they are at risk for recurrent orsustained dermatitis or progression to asystematized presentation. 2,3 In fact, educationof the patient often begins beforethe diagnostic patch test is even conductedto ensure that the patient has anappropriate understanding of potentialoutcomes and his or her central role inboth disease and treatment.During the initial consultation, physiciansmust educate patients aboutthe pathophysiology of ACD: its delayedpresentation, its relationship withHand DermatitisHand dermatitis (also known as handeczema) is a common dermatologic disorderthat affects all age groups. 9 Thesocioeconomic impact of hand dermatitisis profound, as the location of thedermatitis — and the pain and irritationassociated with it — affects a patient’sability to perform tasks both at homeand in the workplace. Some studies haveshown a higher prevalence of hand dermatitisin women than men, 10 which isgenerally attributed to women’s disproportionatelygreater role in householdchores, although not all studies corroboratethis finding. 11,12 Hand dermatitisoften has a relapsing and remittingcourse, but if the diagnosis is postponed,the dermatitis may become chronic. 1320 November 2011 | Skin & Aging | www.skinandaging.com20-24_SA11_AllergenFocus.indd 2011/1/11 10:44 AM

Allergen FocusTable 1.Differential DiagnosisDiagnosis Clinical Presentation CommentsAllergic Contact Dermatitis 28Acutely: erythema, papules, vesicles or bullae, oozing skin lesions, urticaria, excoriationsPatch testing is the gold standard for diagnosis.and/or crusts. Chronically: dryness, scaling, lichenification and fissuring. Favorsthe fingertips, nailfolds and dorsal aspects of the hand and fingers, generally sparingthe palm.Irritant Contact Dermatitis 28Acutely: erythema, papules, vesicles or bullae, oozing skin lesions, urticaria, excoriationsand/or crusts. Chronically: dryness, scaling, lichenification and fissuring. Favorsthe palm, ball of the thumb and the finger web-spaces with ‘apron-like’ pattern.Associated with ‘wet-work’ and mechanical irritation(friction or thermal trauma). Diagnosis of exclusion afterACD and AD have been ruled out.Atopic Dermatitis 28Recurrent Vesicular Hand Dermatitis/Pompholyx 28Chronic Vesicular Hand Dermatitis 28Hyperkeratotic Hand Dermatitis 28Eczematous and constantly pruritic lesions. Acutely papulovascular with weeping,scaling, excoriations and crusting. Chronically with xerosis and lichenification. Favorsdorsum of the hand; extension to the volar wrist is classic.Relapsing-and-remitting, deeply seated, intensely pruritic, non-erythematous vesicleslocated on the lateral aspects of the fingers or palms. If bullae are present, the termpompolyx is used.Continuous pruritic vesicles on an erythematous base. Favors the palms.Well-circumscribed areas of dry, scaly, hyperkeratotic skin, often with painful fissures.Favors proximal or middle palms.22 November 2011 | Skin & Aging | www.skinandaging.comAssociated with atopy (allergic rhinitis, eczema andasthma).Associated with manual labor or exposure to a chronicfrictional irritant.Nummular Hand Dermatitis 28 Well-circumscribed, oval, pruritic, eczematous and erythematous plaques with somescale. Often begins with papules or papulovesicles that coalesce into plaques. Favorsdorsal hand. Has asymmetric distribution.Contact Urticaria 22 Transient wheals that occur immediately after allergen contact. Common agents causing contact urticaria: Foods (raw vegetables,fruit, meat, dairy products), metals (aluminum,nickel, rhodium), natural rubber latex. Diagnosis made byradioallergosorbent testing or the prick test.Photosensitivity Reactions 29Symmetric skin eruptions that typically begin in spring or summer; appear or are exacerbatedPhototesting and/or photopatch testing help in UV-exposed areas. Intractable pruritus and/or pain may be present. May haveimprovement over the summer with increasing sun exposure (‘hardening’).Psoriasis 30Plaque psoriasis: well-defined erythematous plaques with silver-white scale. Palmoplantarpsoriasis: pustular lesions with a background of erythema, thick hyperkeratotic plaqueswith significant erythema or a mixture of both.Tinea Manuum 31Asymmetric patches or plaques with dryness, erythema and mild scale. Active edgecommonly on dorsum of hand. Occassional fissuring. May be pruritic. Nails and feet oftenalso involved.Skin scraping with potassium hydroxide preparation and/or fungal culture help in diagnosis.Soft Tissue Infections (Cellulitis,Erysipelas) 32Id Reactions 33Lichen Planus 34Pityriasis Rubra Pilaris 35Syphilis 36Herpetic whitlow 37Scabies 38Fixed Drug Eruption 39Cellulitis: localized area of painful erythema with associated warmth, edema and anill-defined advancing boarder. Occurs commonly near breaks in the skin. Erysipelas:intensely erythematous, indurated, shiny plaque with well-demarcated boarders andraised margins.The formation of vesicles on the fingers in response to a distal infection – most commonlytinea pedis.Flat-topped, violaceous, pruritic papules, generally in a polygonal pattern; surface has afine reticular pattern of white dots and/or lines. Papules can be arranged in streaks.Follicular hyperkeratosis with reddish-orange or salmon-colored, scaly, pruritic plaques;widespread distribution over body with ‘islands of clearing.’ Palms and soles arehyperkeratotic with an orange hue and painful fissures. Scaling may be fine over faceand scalp but coarser on the lower body.Secondary syphilis presents with widespread macules/papules that are non-pruritic,non-vesicular, discrete, round and bilaterally symmetric; appear pale red to pink inlight-skinned individuals and pigmented in dark-skinned individuals; frequently involvesthe palms and soles. Non-tender lymphadenopathy and condylomata lata are other signsof secondary syphilis.Painful infection with herpes simplex virus 1 or 2 that generally affects the distalfinger(s) and occasionally toe(s). Prodrome consists of burning, pruritus or tinglingfollowed by erythema, pain and vesicles.Generalized intense pruritus that is worse at night. Burrows (short, wavy, grey lines on theskin surface) are pathognomonic and most commonly found in fingerweb spaces, thenarand hypothenar eminences and wrists. Inflammatory pruritic papules/vesicles/pustules canbe present on hands, flexor surfaces of the wrists, elbows, axillae, buttocks and/or genitalia.Only reliable clinical finding is same-site recurrence (ie, lesions recur at the same siteeach time a medication is taken). Most common type composed of well-defined round/oval erythematous macules or papules that may have a violet hue and heal with residualhyperpigmentation. Other types include generalized, erythema-multiforme-like, toxicepidermal necrolysis-like, linear, wandering, non-pigmenting and bullous.Perform serologic testing (FTA-abs, VDRL, RPA) to makediagnosis. Darkfield microscopy of condylomata lata, genitalmucosal lesions or skin papules can also be performed.Consider as diagnosis in health care workers.Skin scrapings showing mites, eggs or mite pelletsconfirm the diagnosis.20-24_SA11_AllergenFocus.indd 2211/1/11 10:44 AM

Allergens in Occupational versusNon-occupational Hand DermatitisIn general, the allergens underlyingoccupational and non-occupationalACD-related hand dermatitis are similar:9,41 Templet et al 41 retrospectively reviewedthe results of 329 patients withhand dermatitis who presented for patchtesting and concluded that the mostcommon substances causing sensitizationin patients with either occupationalor non-occupational hand dermatitiswere quaternium-15, formaldehyde,thiuram mix and carba mix.Nevertheless, in their review of handdermatitis, Elston et al 42 differentiatebetween allergens in the two groups,writing that the most common occupationalallergens include first aid medications,germicides, metallic salts (eg,chromate, nickel), organic dyes, plants,plastic resins and rubber additives, andthe most common non-occupationalallergens include fragrance, preservativesand nickel. Furthermore, Goh etal 25 compared patch test results for 721patients with occupational and non-occupationalhand dermatitis and showedthat potassium dichromate and epoxyresin allergy occurred more frequentlyin the occupational group, whereasfragrance mix allergy was significantlymore frequent in the non-occupationalgroup. Sun et al 43 patch tested 68 patientswith occupational ACD of thehand and found the most significantallergens were dichromate, nickel, cobalt,fragrance mix, epoxy resin, thiurammix and p-phenylenediamine; however,comparisons with non-occupational allergenswere not made. Lastly, physiciansshould recognize that some allergens aremore predominate in certain occupationalsettings (as Table 2 summarizes).Rubber is a frequent cause of ACD.One study by Bendewald et al 76 showedthat 31.7% of 773 patients who underwentpatch testing to a rubber serieshad a positive allergic reaction to at leastone rubber allergen. Of note, both theNACDG cross sectional analysis 9 andDuarte study 10 concluded that rubbercompounds — a frequent componentin gloves — were the most commonoccupational hand dermatitis allergens.It should not come as a surprise, then,that workers with occupations requiringthe regular use of gloves, such as healthcare workers, machine operators, techniciansand cleaning service employees,had the highest rates of ACD-relatedhand dermatitis. 9,41 In addition to usinggloves in the workplace, many patientscommonly use gloves at home; thus,when educating patients, it is imperativeto inquire about the use of gloves andother possible sources of rubber exposure,such as contact with neoprene. 77Vinyl gloves should be recommended asa substitute, as they do not contain thesensitizing rubber substances. 10Practicals of Patch TestingAs mentioned above, patch testing is oftennecessary to distinguish ACD-related handdermatitis from other causes of hand dermatitisand to identify the allergen(s) responsible.Screening patch test trays are available,which isolate the most common allergensubstances and offer the physician clues topotential allergen sources. The North AmericanStandard Series includes allergens fromseveral different categories; 78 however, supplementaltrays are also available, includingones for dental materials, cosmetics and fragrance/flavors,as well as occupation-specifictrays at some institutions.The use of supplemental trays is helpfulbecause, by including constituents andcross-reactors of an allergen in question,the chance of provoking relevant positivereactions is greater. 79 Preparing samplesfrom the patient’s own work or homeenvironment for patch testing should alsobe considered. These self-procured productscan be tested “as is” or may requirepreparation prior to testing. 79Pearls of TreatmentThe goal of treatment in hand dermatitisis to reduce the clinical symptoms, improvethe patient’s quality of life and prevent relapses.Lifestyle modifications are paramount.Avoidance of known irritants and allergensis the key to preventing relapsesand inducing remission for patientswith ICD or ACD. Although completeavoidance is ideal, it is not always practical.Programs such as the Contact AllergenManagement Program (CAMP),a service offered through the AmericanContact Dermatitis Society (ACDS), 80and the Contact Allergen ReplacementDatabase (CARD), developed by MayoClinic, 81 allow the provider to enter apatient’s known contact allergens andAllergen Focusproduce a ‘shopping list’ of products voidof those particular substances. These programscan also exclude cross-reactors.Protection of the hands is also important,especially when irritants or allergenscannot be avoided. Vinyl gloves with cottonliners should be worn when performingwet-work, dusty work or workin cold weather. 22 Gloves may need to beremoved frequently, as sweating may exacerbatethe dermatitis. 22 To determinethe most appropriate glove for a specificchemical encountered in the occupationalsetting, consult Workplace Management( 15Patients should be educated aboutproper hand washing techniques. Uselukewarm or cold water and mild barsoaps without fragrance, coloring orantibacterial agents while washing. Pathands dry, especially between the fingers,and then immediately apply a generousamount of bland cream or ointment(eg, petroleum jelly). 22 The ‘soakand smear’ technique, where patientssoak their hands for 20 minutes in waterbefore applying an ointment, has beenfound to enhance therapeutic efficacy. 82Moisturizing should be repeated manytimes throughout the day; 22 the aggressiveuse of emollients helps providehydration to the skin and improve theskin’s barrier function. 83Although lifestyle changes can significantlyhelp improve the clinicalsigns and symptoms of hand dermatitis,medical therapy is occasionally neededto gain further symptomatic control.Medical therapy is usually initiated ina step-wise fashion: First-line therapyconsists of topical steroids, topical immunemodulators or topical retinoids,while second line therapy consists ofphototherapy, ionizing radiation or systemictherapy with oral steroids, oralretinoids or other immune-modulators(ie, methotrexate, cyclosporine). 28 nDr. Hylwa is a preliminary medical residentat the University of Rochester. She willbegin residency in dermatology at the Universityof Minnesota in 2012.Dr. Davis is Professor of Dermatologyand Chair of the Division of Clinical Dermatologywithin the Department of Dermatologyat Mayo Clinic, Rochester. He has aspecial interest in patch testing and allergiccontact dermatitis.November 2011 | Skin & Aging | 2320-24_SA11_AllergenFocus.indd 2311/1/11 10:44 AM

Allergen FocusTable 2. Occupation Related Allergens and Sample ReferencesOccupation Categories Specific AllergensGarlic Diallyl disulfide 42,44 Allicin 42 Allyl propyldisulfide 42Lettuce Compositae mix 42,45,46Ginger 42,46Food HandlersCinnamon 42,46Allspice 42,46Clove 42,46Tomato 46Carrot 46Perm compoundsGlyceryl monothioglycolateHairdressersHair dyes Ammonium persulfate 42,47 Paraphenylenediamine (PPD) 48Shampoo/Shower gel Cocamidopropyl betaine 49Metals Nickel sulfate 48Cosmetologists Nail Products (Meth)acrylate compounds 50 Bisphenol A 51CementChromate/chromiumCobalt 42,52Reactive DilutantsO-cresyl glycidyl etherCyclohexanedimethanolPhenyl glycidyl ether(CGE) 42,54 54 glycidul ether 54Construction &Manufacturing24 November 2011 | Skin & Aging | www.skinandaging.com1,6-hexanediol diglycidylether 54 Allyl glycidyl ether 54Epoxy resin 54,55Wood* Colophony 56 Pine extract 56 Spruce extract 56 Juniper extract 56Preservatives Isothiazolinones 42,56,57 Formaldehyde 56,57Metals Nickel 56,57 Cobalt 42,57Soldiers Oil-related compounds Gun oil 58 Hydraulic oil 58 Automotive lubricant 58 White spirit 58 Gasoline 58FarmersHospital EmployeesGardenersLaboratory TechniciansIndustrial WorkersCow dander 42,59Plants Frullanceae species 60 Composate 60 Magnoliaceae species 60 Lichens 60Plant derivativesEugenol 60 Oak moss 60 Atranorin 60 Turpentine 60 Colophony 60Wood tars 60 Sorbic acid 60Lactones Alantolactone 60 Iso-alantolactone 60 Helenin 60Rubber Accelerators Yiuram mix 61 Carba mix 61 Mercaptobenzothiazole 61Preservatives Thimerosal 61Metals Nickel sulphate 61Epoxy hardening agents Diaminodipheylmethane 61Compositae 62Chrysanthemums 62Marguerite daisies 62Lettuce 62Rubber additives Carba mix 63Solvents Pyradine derivatives 64Plastic and GluesEthylenediamine 65 Triethylenetetramine 65 Diethylenetriamine 65 Diaminodiphenylmethane 65 Melamine formaldehyde resin 65Phenol formaldehyde resin 65 Cresylglycidylether 65 Phenylglycidylether 65 N,N-dimethyl-p-toluidine 65Acrylate compounds 66Paint (UV-light curable) Epoxy diacrylate 66 3-acryloxypropoxy)2,2-bis[4-(2-hydroxyphenyl]-propane66Cobblers Contact adhesive (glue) Ethyl cyanoacrylate 67Dental composite resin Bisphenol A 66Periodontal dressings,impression materials,ColophonyDental workers cavity varnishes, cements,temporary filling materialsTriethylene glycol dimethacrylate(TEGDMA) 69Dental prostheses Cadmium chloride 69 Benzoyl peroxide 69 Methylmethacrylate 69Metalworkers Metalworking fluid Alkanolamineborates 70Paper processing workersCationic starch2,3-epoxypropyl trimethylammonium chloride(EPTMAC) 71SlimicideCl+Me-isothiazolinone(Kanthon-LX) 71Massage therapists/AromatherapistsEssential oilsOil of cinnamon 72 Oil of cloves (eugenol) 72 Ylang-ylang 73 Myrrh 73 Frankincense 73Chamomile 73 Cypress 73 Rosewood 73 Geranium 73 Vetiver 73Basil 73 Lavender 73 Marjoram 73 Sage 73 Eucalyptus 73Tea-tree 73 Lemon 73 Orange 73 Benzoin 73Perfumes Lemongrass oil 73 Neroli oil 73 Peppermint oil 73Fragrance mix 73Olive oil 74* The most common sensitizing woods are tropical hardwoods. 7520-24_SA11_AllergenFocus.indd 2411/1/11 10:44 AM

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Sánchez-Pérez J, García-Díez A. Occupational allergic contactdermatitis from eugenol, oil of cinnamon and oil of clovesin a physiotherapist. Contact Dermatitis. 1999;41(6):346-347.73. Selvaag E, Holm JO, Thune P. Allergic contact dermatitisin an aroma therapist with multiple sensitizations to essentialoils. Contact Dermatitis. 1995;33(5):354-355.74. Isaksson M, Bruze M. Occupational allergic contactdermatitis from olive oil in a masseur. J Am Acad Dermatol.1999;41(2 Pt 2):312-315.75. Scheman AJ, Xu Y, Osborne A. Allergic contact dermatitis toFraxinus americanus and Macherium acutifolium. Am J Contact Dermat.1999;10(4):233-235.76. Bendewald MJ, Farmer SA, Davis MD. Patch testing withnatural rubber latex: the Mayo Clinic experience. Dermatitis.2010;21(6):311-316.77. Johnson RC, Elston DM. Wrist dermatitis: contact allergyto neoprene in a keyboard wrist rest. Am J Contact Dermat.1997;8(3):172-174.78. allergEAZE Allergens. allergEAZE. [1 screen] 2011. Availableat: Accessedon March 28, 2011.79. Nijhawan RI, Jacob SE. Patch testing: the whole in additionto the sum of its parts is greatest. Dermatitis. 2009;20(1):58-59.80. ACDS CAMP. American Contact Dermatitis Society.2011. Available at: Accessed March 24, 2011.81. CARD: Contact Allergen Replacement Database. 2011.Available at: Accessed onMarch 24, 2011.82. Gutman AB, Kligman AM, Sciacca J, James WD. Soakand smear: a standard technique revisited. Arch Dermatol.2005;141(12):1556-1559.83. Warshaw EM. Therapeutic options for chronic hand dermatitis.Dermatol Ther. 2004;17(3):240-250.Section Editor:Sharon E. Jacob, MDDr. Jacob, the SectionEditor of Allergen Focus,directs the contact dermatitisclinic at Rady Children’sHospital – Universityof California in SanDiego, CA. She is alsoAssociate Clinical Professorof Pediatrics and MedicineWOS (Dermatology) at the Universityof California, San Diego.Disclosure: Dr. Jacob is the principal investigatorfor Smartchoice USA PREA-2 trial.November 2011 | Skin & Aging | 2520-24_SA11_AllergenFocus.indd 2511/1/11 10:44 AM

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