Incorporation of a barrier protection cream in the management of chronic hand dermatitis: focus on data supporting an established hand protectant formulation and modifications designed to assist in barrier repair.

Hand dermatitis (HD), which is also synonymously referred to as hand eczema, is a commonly encountered skin disorder in ambulatory dermatology practice that may be induced by a variety of etiological factors.1,2 Population studies have reported that HD affects approximately 10 percent of women and five percent of men over a duration range of 1 to 3 years.1 However, certain occupations and exposures, especially those commonly involved with “wet-work,” predispose to a much higher likelihood of both acute and chronic HD.1-4 HD comprises more than 90 percent of cases of occupational skin disease (OSD), with the one-year prevalence of occupation-associated HD reported to be up to 32 percent.4,5 It is important to note that HD is a general term that lumps together many potential clinical presentations and etiologies.1,2,6 As a result, the clinician is encouraged to take into consideration details related to the patient history and clinical presentation of HD, especially in cases of chronic HD. In most cases, exogenous factors are the predominant cause of HD and include frequent exposure of the hands to a variety of irritants and/or to “wet work” at work or home, without adequate hand protection and/or skin barrier repair; endogenous factors may predispose affected individuals to the development of HD and/or promote its chronicity (i.e., atopic skin, cutaneous allergy).1-7 One report estimated that approximately two-thirds of atopic individuals who perform wet work as hospital employees develop HD.8 Chronicity of HD is a common problem with two-thirds of individuals with HD followed over a 15-year period reporting persistence of HD.9 Loss of productivity and financial burden are also major consequences of HD, with approximately two-thirds of affected individuals reported to seek medical assistance and 21 percent taking sick leave because of HD.1 Irritant contact dermatitis (ICD), which is a diagnosis made by clinical assessment, is a common cause of both acute HD and chronic HD.1,3,4 Exposure of the hands to potent alkalis and acids are more likely to cause an acute and severe case of ICD (“chemical burn”), which does not necessarily predispose to chronic HD.1 Examples of common irritant exposures associated with chronic HD include frequent hand washing; frequent exposure to detergents, solvents, and cleaning agents; and use of poorly formulated skin cleansing products (i.e., harsh, soaps, scrubs).1,3,5 Detergents, solvents, and cleaning agents (designed for defatting or degreasing) are the major causes of the gradual development of ICD, which is the clinical pattern frequently noted in patients with chronic HD.1 Trapping of detergents and cleansers (including soaps) under rings can induce ICD of the hands.1 Allergic contact dermatitis (ACD), both immediate and delayed, can cause both acute and chronic HD, and is confirmed by patch testing.1,2,4-6 In cases of chronic HD, it is difficult to distinguish clinically between ICD and ACD, and both can coexist.1,10 In one report of patients with HD (N=220), the diagnosis was confirmed with patch testing in 12 percent using the standard series and in five percent using additional allergens, with positive therapeutic outcomes resulting from identification of the allergens.10 The more common allergens associated with ACD in patients with HD are nickel, ethylene diamine, rubber, preservatives, paraphenylenediamine, and potassium dichromate, although there are several other potential contactants.1 Occupational food handling may be associated with ICD, ACD, contact urticaria, or protein contact dermatitis.11 Local skin reactions related to handling of foods may present with immediate or delayed hypersensitivity and also contact urticaria; however, eczematous dermatitis may also occur due to several potential sources of ICD (i.e., frequent hand washing) or ACD (i.e., oleoresins of fruits and vegetables, essential oils of vegetables, color additives, flavoring agents, gums, waxes, spices [capsicum][cinnamon][nutmeg][cloves][vanilla], preservatives, antioxidants [i.e.][butylated hydroxyanisole]).1 Hyperkeratotic eczema (HE) represents a subtype of chronic HD characterized clinically by confluent hyperkeratosis of the anterior surface of hands (palms, digits) and/or distal and lateral digits with little to no visible cutaneous inflammation. The lack of visible inflammation and acute or subacute eczematous dermatitis correlates with the absence of pruritus in many cases, although fissuring may produce discomfort if deep splits develop, especially within natural creases over the finger joints. Low-grade eczematous inflammation may be present in some cases, which is sometimes associated with pruritus, especially of the palms and fingers. HE can also affect the plantar and lateral surfaces of the feet, with hyperkeratotic heels being a common presentation that almost exclusively affects young women. Pustular lesions are not present in HE, which is an important distinguishing feature from palmoplantar pustulosis (pustular psoriasis of the palms and soles). It is important to exclude dermatophyte infection in cases where HE is suspected clinically, as this would warrant use of a topical and/or oral antifungal therapy. Figure 1 demonstrates a 58-year-old woman with hyperkeratotic heels who responded to treatment with CeraVe® Renewing SA Foot Cream. In addition to the restorative barrier repair provided by the moisturizer components of this multivesicular emulsion formulation, salicylic acid included in this branded foot cream and other SA formulations in this product line provides a desmolytic effect, which promotes single cell desquamation that reduces scaling and hyperkeratosis. Although this case did not involve the hands, the clinical changes noted on the feet in Figure 1 are very similar to those seen in hyperkeratotic hand eczema. Figure 1 Hyperkeratotic heels