Guidelines for the Diagnosis, Treatment, and Prevention of Hand Eczema

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Los cambios en la educación y el estilo de vida, tales como el uso de emolientes y guantes de protección, evitación de irritantes y alérgenos, son obligatorios durante todas las etapas del tratamiento. Se pueden valorar los corticoesteroides orales en caso de exacerbaciones. Adaptado de De León et al.<a class="elsevierStyleCrossRef" href="#bib0770">49</a>." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.F. Silvestre Salvador, F. Heras Mendaza, M. Hervella Garcés, D. Palacios-Martínez, R. Sánchez Camacho, R. Senan Sanz, A. Apellaniz González, A.M. Giménez-Arnau" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J.F." "apellidos" => "Silvestre Salvador" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Heras Mendaza" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Hervella Garcés" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Palacios-Martínez" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Sánchez Camacho" ] 5 => array:2 [ "nombre" => "R." 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The European guidelines for the diagnosis, prevention, and treatment of chronic hand eczema were published in 2015,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> but they do not cover the complexity of care that characterizes the different levels of the Spanish public healthcare system. In Spain, general practitioners (GPs) provide the first point of contact for patients with hand eczema, but the lack of national guidelines means that there are no standardized criteria for clinical management and referrals. This complexity is further aggravated by the diversity of regional healthcare models.Prompt diagnosis and treatment is necessary to prevent hand eczema from becoming chronic, but this requires coordination between the different levels of care. Systematized criteria thus are needed to determine how hand eczema patients should be treated in primary care, when they should be referred to a specialist, how they should be followed, and when they should be seen by an occupational health or health insurance physician. The Spanish Academy of Dermatology and Venereology (AEDV), through the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC), decided to draw up an updated review article to guide the diagnosis, treatment, and follow-up of hand eczema and offer unified, consensus-based criteria for referrals to secondary care.This document was drawn up by members of the AEDV, which led the initiative, and representatives of the Spanish Society of Primary Care Physicians (SEMERGEN), the Spanish Society of Family and Community Physicians (semFYC), the Spanish Society of General and Family Practitioners (SEMG), and the Spanish Society of Occupational Medicine and Safety (SEMST).MethodsThe document was prepared in several phases involving the review of existing evidence in various cycles of analysis and discussion. The process is described below:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Four members of the AEDV prepared a draft document containing the latest information on the definition, classification, diagnosis, and treatment of hand eczema. The literature search was performed in the US National Library of Medicine MEDLINE database and spanned articles published between 2008 and 2018. The results were filtered by relevance to the objectives of this guideline, although the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was not used The search was conducted using combinations of keywords (hand dermatitis, hand eczema, palmar dermatitis) that systematically covered all possible related uses. The qualifier terms were epidemiology, prevention, etiology, classification, pathophysiology, and treatment. Full searches were also made using specific drug terms, such as calcineurin inhibitors and alitretinoin. The draft document was also informed by existing guidelines, such as the European Society of Contact Dermatitis hand eczema guideline,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> the position paper of the European Cooperation in Science and Technology COST Action StandDerm (TD1206),<a class="elsevierStyleCrossRef" href="#bib0010">2</a> the Canadian dermatitis management guidelines,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and the Danish Contact Dermatitis guidelines for the diagnosis and treatment of hand eczema.<a class="elsevierStyleCrossRef" href="#bib0025">5</a></li><li class="elsevierStyleListItem" id="lsti0010">2The draft was discussed in depth in May 2018 by members of the AEDV panel and the representatives of the participating societies (D.P.M. for SEMERGEN, R.S.S. for semFYC, R.S.C for SEMG, and A.A.G for SEMST) to ensure that all possible clinical perspectives were taken into account.</li><li class="elsevierStyleListItem" id="lsti0015">3The discussions resulted in a definitive draft that was subsequently used to create an abbreviated set of recommendations for use by GPs and occupational health physicians in routine clinical practice. One of the main goals of this document was to standardize the criteria for referring patients with hand eczema to a specialist. It should be noted, however, that the document is not formally endorsed by the societies represented by the physicians involved in its development (SEMERGEN, semFYC, SEMG, and SEMST).</li></ul>DefinitionHand eczema, or hand dermatitis, is a multifactorial disease with several etiologic and morphologic variants. It is essentially an inflammatory skin disease that affects the hands; it causes significant discomfort and can have a major impact on patient quality of life.The clinical manifestations of hand eczema include erythema, edema, vesicles, crusting, scaling, lichenification, hyperkeratosis, and fissures. Hand eczema is considered acute when it predominantly consists of vesicles and crusting, and chronic when the main manifestation is hyperkeratosis. Early intervention is necessary as hand eczema can become chronic.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The condition is classified as chronic when it lasts for at least 3 months or relapses at least twice a year despite adequate treatment and treatment adherence.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>EpidemiologyNumerous studies have described the prevalence of hand eczema in the general population and varying professions.<a class="elsevierStyleCrossRefs" href="#bib0005">1,7</a> A large literature review of studies published between 1964 and 2007 reported a point prevalence of around 4%, a 1-year prevalence of nearly 10%, and a lifetime prevalence of 15%.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Similar rates have been described in a number of large, recent studies, many of which were conducted in Scandinavian countries. A large Norwegian epidemiological study involving over 50000 people, for example, reported prevalence rates of 11.3% for hand eczema in the general population and 4.8% for work-related hand eczema.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> A study of hand eczema in Swedish adolescents reported a 1-year prevalence of 5.2% and a lifetime prevalence of 9.7%; this incidence was similar to that observed in adults.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Another Swedish study described a 1-year prevalence of 15.8% in adults and reported that women were twice as likely as men to be affected.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> In Denmark, the 1-year prevalence rate observed for hand eczema in adults aged 28 to 30 years was 14.3%.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>The severity of hand eczema has also been studied. An Italian study found that 83.5% of patients with hand eczema had chronic eczema, 21.3% had severe eczema, and 62.0% had eczema refractory to standard therapy.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> In the CARPE registry of German patients with chronic hand eczema, 23.4% of patients had very severe eczema, 47.0% had severe eczema, 20.1% had moderate eczema, and 9.6% had mild or very mild eczema.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> In the Swedish study of adolescents with hand eczema, 27.0% of patients had moderate to severe disease.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Hand eczema tends to follow a relapsing, remitting course, and severity can change rapidly in individual patients.Risk factorsThe risk factors for hand eczema are highly variable, particularly when allergens are involved. A number of general factors, however, have been consistently identified as increasing risk:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">•Atopic dermatitis.<a class="elsevierStyleCrossRefs" href="#bib0005">1,10,11,14–20</a> A history of atopic dermatitis is the strongest predictor of chronic hand eczema in both children and adults. Atopic dermatitis is the most common cause of hand eczema in children.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> A study of chronic hand eczema in the general Danish population found an association between filaggrin mutations and chronic hand eczema in patients with atopic dermatitis.<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li><li class="elsevierStyleListItem" id="lsti0025">•Other atopic diseases, such as asthma and allergic rhinitis.<a class="elsevierStyleCrossRef" href="#bib0070">14</a></li><li class="elsevierStyleListItem" id="lsti0030">•Tobacco smoking.<a class="elsevierStyleCrossRefs" href="#bib0105">21–25</a> While a recent meta-analysis did not demonstrate that smoking was a risk factor for hand eczema, the authors concluded that based on the data available, they could not confirm that smoking did not influence disease course.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> A recent study of patients with work-related hand eczema in Denmark found a strong association between smoking and disease severity.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Although more studies are clearly needed, it is important to consider the inclusion of smoking cessation in treatment strategies for patients with hand eczema.<a class="elsevierStyleCrossRef" href="#bib0115">23</a></li><li class="elsevierStyleListItem" id="lsti0035">•Dry skin.<a class="elsevierStyleCrossRef" href="#bib0070">14</a></li><li class="elsevierStyleListItem" id="lsti0040">•Wet work and excessive hand washing.<a class="elsevierStyleCrossRefs" href="#bib0005">1,11,14,18</a>,<a class="elsevierStyleCrossRefs" href="#bib0135">27–29</a> As hand eczema can affect a patient’s ability to work and may also be classified as an occupational disease, it has a significant social and economic impact. Workers most at risk are workers in the food processing industry and those frequently exposed to water, such as healthcare professionals and hairdressers.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Healthcare workers have been identified as high-risk groups in Canada,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Korea,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> the Netherlands,<a class="elsevierStyleCrossRef" href="#bib0155">31</a> Denmark,<a class="elsevierStyleCrossRefs" href="#bib0095">19,28,32</a> Norway,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and Germany,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> with prevalence rates ranging from 21.0% to 47.0%. In a Danish study, 53% of healthcare workers with hand eczema had positive patch test reactions, mostly to nickel, thiomersal, fragrances, rubber chemicals, and colophonium.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> A German epidemiological study found that 90.3% of German nurses with occupational skin diseases had hand eczema and 13.5% had concomitant methicillin-resistant Staphylococcus aureus (MRSA) colonization, mainly in the nose (81.4%). Of these, 55.8% also had hand involvement.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Chronic hand eczema is very common in odontologists in Japan (46.4%).<a class="elsevierStyleCrossRef" href="#bib0070">14</a> In a recent study, hairdressers reported high rates of hand eczema compared with the general population, and many of them stated that they had left their job because of their condition.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> High prevalence rates have also been reported among hairdressers in Denmark,<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a> Turkey,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> and Croatia.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> The situation may vary significantly in other regions of the world. An Indian study, for example, found that most cases of occupational contact dermatitis occurred in farmers, construction workers, and housewives, and that 81.2% of patients with this diagnosis had hand eczema.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> The most common allergens identified were Parthenium hysterophorus in farmers, potassium dichromate in construction workers, and vegetables in housewives.</li><li class="elsevierStyleListItem" id="lsti0045">•Several studies have found hand eczema to be more common in women than men, but the exact reasons for this predominance are unknown.<a class="elsevierStyleCrossRefs" href="#bib0005">1,8,10,11</a>,<a class="elsevierStyleCrossRefs" href="#bib0195">39,40</a></li><li class="elsevierStyleListItem" id="lsti0050">•Certain mutations in the filaggrin gene (see next section).</li></ul>PathophysiologyAs hand eczema constitutes a group of highly heterogeneous conditions, no general pathological mechanisms have been established. It is, however, accepted that genetic factors (e.g., filaggrin mutations) and external factors (e.g., skin irritants) alter the structure and composition of the stratum corneum, disrupting the skin barrier and favoring the development of hand eczema. Filaggrin mutations have also been linked to the development of hand eczema, particularly in endogenous forms of the disease.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>Skin barrier disruption has a pathogenic role in chronic hand eczema and can lead to both irritant and allergic disease.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> One recent study showed that a number of important skin barrier proteins (filaggrin, hornerin, peptidases KLK5 and KLK7, and cystatin E/M) were downregulated in hand eczema.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> The skin barrier can be disrupted by both genetic and exogenous factors. Wet work is one of the main causes of skin irritation and can favor sensitization to antigens in hand eczema.<a class="elsevierStyleCrossRef" href="#bib0215">43</a>The pathogenic role of skin microbiome in chronic hand eczema is attracting increasing attention. Patients with hand eczema have higher rates of S aureus colonization than healthy individuals, and patients with severe disease have a significantly higher density of S aureus than those with milder disease.<a class="elsevierStyleCrossRef" href="#bib0220">44</a>Interleukins (ILs), such as IL-1 (IL-36α), may be involved in chronic hand eczema skin inflammation,<a class="elsevierStyleCrossRef" href="#bib0225">45</a> and IL-36α may therefore become a useful biomarker for helping in the complex diagnosis of chronic hand ezcema.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>ClassificationProper classification of hand eczema is the first step towards effective and efficient treatment, 12 and it is also essential for stratifying patients in epidemiological and clinical studies. Several classification systems based on clinico-morphologic features and etiologic factors have been proposed. The relationship between these systems, however, is complex, as disease presentation and progression can vary from one type of hand eczema to the next. At this time, there is no universally accepted classification system.The Danish Contact Dermatitis Group established 6 clinical (morphologic) types of hand eczema: recurrent vesicular hand eczema, chronic fissured hand eczema, hyperkeratotic palmar eczema, pulpitis, interdigital eczema, and nummular hand eczema.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6,46,47</a>The most common types of hand eczema are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0015">3,6,48,49</a> The authors of a recent study were able to classify 89% of patients using the above diagnostic subgroups and in 7% of cases, two main diagnoses were required for classification.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> Nonetheless, several authors have estimated that at least 20% to 26% of all chronic hand eczema cases are idiopathic as they do not fit into any of these etiologic groups.<a class="elsevierStyleCrossRefs" href="#bib0025">5,49</a> Mixed forms of chronic hand eczema are common.<a class="elsevierStyleCrossRefs" href="#bib0030">6,50</a> A retrospective study of patients with occupational contact dermatitis in Denmark, for example, found that 6.4% of patients had a combined diagnosis of allergic and irritant contact dermatitis.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> Contact and atopic dermatitis may also coexist.<a class="elsevierStyleCrossRefs" href="#bib0260">52–54</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DiagnosisDiagnosis of hand eczema is clinical and based on history taking and physical examination. Diagnostic tests (patch tests, prick tests, microbiological tests, and skin biopsy) are useful for ruling out other diseases and establishing an etiologic diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0015">3,49</a>History taking is the first step in the diagnostic process. Both personal and work-related factors are important. The main factors that should be addressed during the patient interview are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. A note of the most significant findings from the interview should always be made in the patient’s medical record.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>During the physical examination, the whole skin surface should be inspected, with attention paid to signs of dermatophytosis. Close inspection of the feet is important. Clinically, it may be difficult to differentiate between chronic hand eczema and other skin diseases that affect the hand, in particular psoriasis and mycosis.<a class="elsevierStyleCrossRefs" href="#bib0030">6,54</a> Some of the key aspects that should be considered in the differential diagnosis are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Psoriasis is characterized by well-demarcated hyperkeratosis in discoid plaques, an absence of tingling and vesicles, and the presence of lesions on the scalp, nails, flexural areas of the elbows and knees, and buttocks. Patients with psoriasis also typically have a personal or family history of psoriasis or persistent seborrheic dermatitis. Fungal skin infections can be diagnosed by visual inspection or by potassium hydroxide testing or direct culture. Other conditions that can be confused with chronic hand eczema are lichen planus, mange, granuloma annulare, herpes simplex, erythema multiforme, pityriasis rubra pilaris, and dermatomyositis.<a class="elsevierStyleCrossRefs" href="#bib0030">6,54</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The clinical tools available for diagnosing chronic hand eczema are summarized in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. Patch testing is the gold standard and must be performed in all types of chronic hand eczema, regardless of the morphology of the lesions or the tentative diagnosis. Patch tests should also be contemplated in patients with refractory or recurrent eczema, eczema with an atypical or varying distribution, and eczema with patterns suggestive of allergic contact disease.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> Patch and prick tests can rule out an allergic cause. Skin biopsy and fungal culture are normally only useful for ruling out other skin diseases. When making a diagnosis, it is important to recall that hand eczema can be triggered by a wide range of external and internal factors acting alone or in combination.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>An algorithm to help identify the cause of chronic hand eczema is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Patch tests are essential for diagnosing chronic allergic contact hand eczema.<a class="elsevierStyleCrossRef" href="#bib0280">56</a> There are no useful diagnostic tools for detecting reactions to irritants in everyday clinical practice. Irritant contact hand eczema thus is often diagnosed on the basis of clinical patterns, testing of products handled by the patient, and patch test results (negative results are indicative of contact allergy). It should be noted, however, that contact and irritant hand eczema often coexist.<a class="elsevierStyleCrossRefs" href="#bib0255">51,56</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Protein contact hand eczema should be clinically suspected in any patient who develops pruritus, wheals, or eczema immediately after handling material of biological origin (e.g., fruit, fish, animal intestines). In this case, the eczema is caused by prolonged contact with the proteins and is therefore diagnosed using prick tests rather than patch tests (which detect allergy to haptens). Prick-to-prick tests with suspect foods provided by the patient are often necessary. Although the agents responsible for classic allergic hand eczema are low-molecular–weight chemical agents, standard patch tests tend to be negative in contact hand eczema induced by proteins. Protein contact hand eczema is common in patients with dermal-epidermal barrier disruption due to atopy or previous exposure to irritants.PreventionMeasures to mitigate or reduce the incidence of hand eczema can be classified as primary, secondary, or tertiary, depending on the stage of disease. Primary prevention measures aim to reduce the incidence of hand eczema in the healthy population. Secondary prevention measures, by contrast, are designed to prevent existing disease from becoming chronic, while tertiary prevention measures are designed to guide the clinical management of patients who have already developed chronic disease. The different measures, categorized by level of prevention, are summarized in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Primary PreventionPrimary prevention is essential and should start at schools, with a particular focus on children with atopic disorders, who are more prone to developing hand eczema later in life. The goal of primary prevention is to prevent exposure to potential causative agents identified as risk factors in the general population.Assessment of occupational risk involves identifying and quantifying risks at the workplace and is an essential component of primary prevention. Risks should then be classified and suitable preventive measures implemented using a multidisciplinary approach.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The main types of primary prevention measures are 1) technical/organizational measures, 2) personal protection measures (hand hygiene and use of gloves and moisturizers), 3) education, and 4) access to specialist care.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>An example of an effective organizational measure is the introduction of regulatory measures to reduce or eliminate exposure to certain allergens, such as chromate in cement or glyceryl monothioglycolate in hairdressing products.<a class="elsevierStyleCrossRefs" href="#bib0285">57,58</a> Accelerator-free medical gloves may be an effective alternative for healthcare professionals allergic to rubber accelerators.<a class="elsevierStyleCrossRef" href="#bib0295">59</a>Protective gloves are the most important primary prevention measure (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). Patients with hand eczema should always wear gloves over clean, dry hands when doing wet work or working with hazardous substances. Gloves should be worn as often as necessary but for the shortest time possible.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Disposable gloves should never be used more than once and damaged gloves should be disposed of immediately. Cotton gloves should be worn for general housework that does not require contact with liquids (e.g., dusting) and under other gloves that need to be worn for longer than 15minutes.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Latex gloves offer good protection against microorganisms and water-based products, but are relatively ineffective against oils, solvents, and chemical products. Nitrile gloves protect against oils and solvents, while vinyl gloves offer protection against most chemical products.<a class="elsevierStyleCrossRef" href="#bib0245">49</a><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>The authors of a Dutch study showed that a multifaceted hand eczema prevention strategy consisting of training (targeting special working groups), workplace reminders, and leaflets produced good overall results after a period of 6 months.<a class="elsevierStyleCrossRefs" href="#bib0300">60,61</a> The strategy, however, did not appear to be cost-effective.<a class="elsevierStyleCrossRef" href="#bib0310">62</a>Secondary PreventionThe goal of secondary prevention is the early detection, diagnosis, and treatment of hand eczema by specialists. Patient education programs should aim to bring about behavioral changes at work or at home and encourage patients to use skin protection measures and eliminate exposure to allergens and irritants. It has been suggested that this information should be given in writing.<a class="elsevierStyleCrossRefs" href="#bib0245">49,63</a> Job counseling may also be an effective approach for encouraging secondary prevention in young adults at risk of hand eczema, as found by a German study of young adults with atopic dermatitis starting in high-risk occupations.<a class="elsevierStyleCrossRef" href="#bib0320">64</a> Another German study demonstrated the long-term effectiveness of an interdisciplinary secondary prevention programme and stressed the importance of early detection and reporting of occupational hand eczema in the initial stages of disease.<a class="elsevierStyleCrossRef" href="#bib0325">65</a>Protective creams and emollients are very important as they can prevent early disease from progressing (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>). Barrier creams provide a protective layer and should only be used on healthy skin, never on inflamed skin. They protect against common irritants such as water, detergents, metals, resins, oil-based materials, and UV light and they may also favor skin hygiene.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> It is important to note, however, that barrier creams may give a false sensation of security, leading to undue exposure to allergens or irritants. Under no circumstances should barrier creams replace physical measures such as gloves. A wide range of emollients can be recommended and used in clinical practice and it is widely accepted that these products can improve hydration, prevent itching, and help repair the skin barrier. Use of moisturizers can prolong disease-free periods in patients with successfully treated hand eczema.<a class="elsevierStyleCrossRef" href="#bib0330">66</a> There is, however, limited evidence on the clinical effectiveness of specific formulations and as such no definitive recommendations can be made.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Moisturizers should not be worn during working hours as they increase the risk of sensitization to allergens that can cause eczema. Instead, they should be used outside working hours to favor skin barrier restoration. More recent developments for the treatment of specific lesions include prescription emollient devices, which contain a complex mix of components designed to mimic the composition of the skin.<a class="elsevierStyleCrossRef" href="#bib0335">67</a><elsevierMultimedia ident="tbl0035"></elsevierMultimedia>Tertiary PreventionTertiary prevention measures should be applied to patients who have already developed chronic hand eczema. The main goals in this case are to improve disease severity, reduce the use of corticosteroids, facilitate return to work, and improve quality of life. It may be advisable for patients with irritant contact hand eczema to temporarily stop work to prevent sensitization and favor full restoration of the skin barrier. A multidisciplinary approach involving dermatologists and occupational health specialists is recommended.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The Osnabrück model has been proposed as an effective long-term strategy for patient rehabilitation.<a class="elsevierStyleCrossRefs" href="#bib0340">68,69</a> A recent study of the long-term effects of a tertiary individualized prevention program found that 96.9% of patients were able to return to work after participating in the program. In addition, 82.7% were still working after 3 years and 75.0% remained in the same profession.<a class="elsevierStyleCrossRef" href="#bib0340">68</a>TreatmentTreatment of hand eczema should be individualized based on numerous factors, including age, clinical history, and profession. Treatment recommendations should be tailored to the cause of the hand eczema and the morphology and location of the lesions. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows an algorithm for managing hand eczema in primary care. The first step is to conduct a structured patient interview and a full physical examination. This will guide the differential diagnosis and help decide on initial treatment. General measures include avoidance of irritants and wet work and use of gloves and emollients (<a class="elsevierStyleCrossRefs" href="#tbl0030">Tables 6 and 7</a>). If necessary, high-potency topical corticosteroids may be considered (<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>). Patients with chronic hand eczema must always be referred to a dermatologist for additional tests and a definitive etiologic diagnosis. GPs should also consider granting the patient sick leave to enable full recovery.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a> summarizes the treatments available for hand eczema and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows an algorithm for managing hand eczema in specialist care settings. Personalized follow-up is essential as long-term treatment effectiveness is often difficult to predict due to the lack of definitive randomized controlled trials evaluating and comparing the efficacy of different treatments. In many cases, it is also impossible to compare treatments across clinical studies because of variations in patient populations and a lack of standardized outcome measures.<elsevierMultimedia ident="tbl0045"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>It is highly recommendable that acute hand eczema be treated as early as possible to prevent it from becoming chronic, as chronic disease can be much more difficult to treat. As widely known, it is also essential to prevent re-exposure to irritants and allergens and to allow sufficient time for the skin barrier to regenerate. One of the main goals of any treatment strategy should therefore be to identify exogenous causes and recommend lifestyle changes and preventive measures.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Topical TreatmentsMost cases of acute hand eczema can be adequately managed with a combination of preventive measures and topical treatments. These include corticosteroids, calcineurin inhibitors (tacrolimus, pimecrolimus), iontophoresis, tar, and astringent and antiseptic solutions such as potassium permanganate and aluminium acetate.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Topical CorticosteroidsTopical corticosteroids are the first-line treatment for hand eczema and can be highly effective in the short term (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<a class="elsevierStyleCrossRefs" href="#bib0015">3,49,63</a> Long-term use, however, can inhibit repair of the stratum corneum and cause skin atrophy (<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>). Topical corticosteroids should only be used for longer than 6weeks in exceptional circumstances and always under medical supervision.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The risk of immediate and delayed hypersensitivity reactions should also be considered. Any reactions should be investigated by patch testing.<a class="elsevierStyleCrossRef" href="#bib0350">70</a> As a general rule, hand eczema should be treated with high-potency corticosteroids (betamethasone valerate cream 0.05% or 0.1% or mometasone furoate cream 0.1%) administered once a day. A clinical trial involving 44 patients with hand eczema showed that once-daily application of a potent corticosteroid cream (betamethasone valerate 0.1%) was superior to twice-daily application, especially in patients with moderate eczema.<a class="elsevierStyleCrossRef" href="#bib0355">71</a> According to a recent study, approximately 50% of patients with chronic hand eczema do not respond to corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Calcineurin InhibitorsTopical calcineurin inhibitors (tacrolimus ointment 0.1% in patients ≥16 years or 0.03% in patients <16 years; pimecrolimus cream 1%) can be used in patients who do not respond or are allergic to topical corticosteroids. One study comparing betamethasone and tacrolimus with an emollient showed that betamethasone and tacrolimus resulted in a higher ceramide/cholesterol ratio and a lower inflammatory response.<a class="elsevierStyleCrossRef" href="#bib0360">72</a> It has been suggested that a combination of calcineurin inhibitors and corticosteroids could be a useful option for longer-term treatments.<a class="elsevierStyleCrossRef" href="#bib0245">49</a>PhototherapyPhototherapy is a standard treatment option for chronic hand eczema refractory to corticosteroids, although the general opinion is that long-term treatment can increase the risk of skin cancer.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The treatment of choice is PUVA (topical psoralen and UV-A light), although potential adverse effects include erythema and skin burns.A recent study showed the potential benefits of using a 308nm excimer laser to treat chronic hand eczema; the treatment produced a 69% reduction in physician global assessment scores and a 70% reduction in lesion and symptom scores.<a class="elsevierStyleCrossRef" href="#bib0365">73</a> One advantage of excimer laser therapy is that by targeting specific sites, it results in a lower cumulative dose of UV radiation than other UV treatments.<a class="elsevierStyleCrossRef" href="#bib0365">73</a>Systemic TreatmentsAlitretinoinAlitretinoin (9-cis retinoic acid) has immunomodulatory and anti-inflammatory effects and is authorized for use in the treatment of severe chronic hand eczema that does not respond to or responds inadequately to topical corticosteroids.<a class="elsevierStyleCrossRefs" href="#bib0015">3,49,74,75</a> It is therefore recommended as a second-line treatment in patients with chronic hand eczema refractory to topical corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Several clinical trials and studies have provided strong evidence for the safety and efficacy of alitretinoin in the treatment of severe, refractory chronic hand eczema.<a class="elsevierStyleCrossRefs" href="#bib0380">76–78</a> In a large phase III trial involving patients with severe, refractory chronic hand eczema, 48% of patients responded well to oral alitretinoin compared with 17% for placebo at 24 weeks (P<.001).<a class="elsevierStyleCrossRef" href="#bib0395">79</a> A second phase III study involving 596 patients with severe chronic hand eczema showed similar results, with a response rate of 40% for alitretinoin versus 15% for placebo.<a class="elsevierStyleCrossRef" href="#bib0400">80</a>Another study analyzing the effectiveness of alitretinoin in patients with recurrent chronic hand eczema showed a response rate of 80% compared with 8% for placebo, suggesting that intermittent treatment with alitretinoin is suitable for the long-term management of chronic hand eczema.<a class="elsevierStyleCrossRef" href="#bib0405">81</a> An observational study of 680 German adults with chronic hand eczema found that alitretinoin was effective in 56.7% of patients with different morphologic forms (hyperkeratotic-fissured, fingertip, and vesicular) and also showed that alitretinoin was both effective and well tolerated in routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0410">82</a>Although the standard treatment duration for alitretinoin is 24 weeks, good tolerance has been observed up to 48 weeks.<a class="elsevierStyleCrossRef" href="#bib0415">83</a> A small Korean study showed that alitretinoin administered for just 12weeks led to considerable improvement in 44.4% of patients with chronic hand eczema.<a class="elsevierStyleCrossRef" href="#bib0420">84</a> Recent evidence from clinical practice in Spain also showed that alitretinoin is effective in the treatment of chronic hand eczema, and often produces satisfactory results after just 1 cycle.<a class="elsevierStyleCrossRef" href="#bib0425">85</a>Although treatment with alitretinoin is well tolerated, dose-dependent adverse effects have been observed. These include headache (20% of patients on 30mg/d), mucocutaneous events, hyperlipidemia, and altered thyroid function.<a class="elsevierStyleCrossRefs" href="#bib0395">79,80</a> Based on data from postmarketing studies spanning 6 years, additional adverse effects include nausea, hypertriglyceridemia, increased creatinine phosphokinase, and depression.<a class="elsevierStyleCrossRef" href="#bib0430">86</a> Long-term effects must also be considered as alitretinoin is teratogenic. As such, it should not be used during pregnancy or in the month preceding conception.A recent study showed that treatment with alitretinoin normalized the expression of several skin barrier genes, such as thymic stromal lymphopoietin, claudin 1, loricrin, filaggrin and cytokeratin 10.<a class="elsevierStyleCrossRef" href="#bib0435">87</a> These changes were correlated with general clinical effectiveness, suggesting that alitretinoin has a disease-modifying effect.<a class="elsevierStyleCrossRef" href="#bib0435">87</a> It has been hypothesized that alitretinoin may benefit patients with dyshidrotic eczema by regulating aquaporin 3 and 10.<a class="elsevierStyleCrossRef" href="#bib0440">88</a>Observational studies of German patients with severe chronic hand eczema have shown that alitretinoin produces rapid and significant improvements in quality of life and work productivity measured by physician global assessment scores and various quality-of-life markers.<a class="elsevierStyleCrossRefs" href="#bib0445">89,90</a> An Italian study of patients with chronic hand eczema also found that alitretinoin considerably improved patient quality of life.<a class="elsevierStyleCrossRef" href="#bib0455">91</a>AcitretinA retrospective study of acitretin in the treatment of chronic hand eczema showed that while the drug was effective, it was associated with a higher incidence of adverse events than alitretinoin (43.1% vs. 29.5%).<a class="elsevierStyleCrossRef" href="#bib0460">92</a> Nevertheless, the results of a recent study showed that low-dose acitretin induced clinical improvement in patients with various types of hand eczema.<a class="elsevierStyleCrossRef" href="#bib0465">93</a> Patients with hyperkeratotic hand eczema have been found to be more responsive.<a class="elsevierStyleCrossRef" href="#bib0460">92</a> A pilot study conducted in Canada showed that acitretin was effective in 33.3% of patients with severe chronic hand eczema.<a class="elsevierStyleCrossRef" href="#bib0470">94</a> Acitretin, like alitretinoin, is a retinoid drug and as such has teratogenic potential. It should not be used in women who might want to become pregnant within 3 years of stopping treatment.Systemic CorticosteroidsCurrent clinical practice guidelines suggest that systemic corticosteroids should not be used to treat severe chronic hand eczema for longer than 3 weeks. Long-term use is not recommended due to the risk of potentially dangerous adverse effects.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>CiclosporinCiclosporin has been used in patients with psoriasis, atopic dermatitis, and chronic hand eczema who have failed to respond to other treatments.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The earliest studies of the use of ciclosporin in the treatment of hand eczema showed that oral ciclosporin was as effective as a topical corticosteroid (beta-methasone-17,21-dipropionate) and offered equivalent improvements in quality of life.<a class="elsevierStyleCrossRefs" href="#bib0475">95,96</a> The drug also exhibited good long-term effectiveness, even after short treatment periods.<a class="elsevierStyleCrossRef" href="#bib0485">97</a> A recent retrospective study showed that 62.9% of patients responded well to ciclosporin after 3 months of treatment and that response was particularly good in patients with recurrent vesicular hand eczema. The median drug survival rate in patients with chronic hand eczema was 10.3 months. The main reasons for treatment interruption were adverse events, particularly at the start of treatment, and ineffectiveness.<a class="elsevierStyleCrossRef" href="#bib0490">98</a> Patients on ciclosporin should be carefully monitored as there is a risk of serious adverse events such as nephrotoxicity and an increased risk of cancer, a rise in blood pressure, and infections.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>AzathioprineThere is limited evidence on the efficacy of azathioprine for the treatment of hand eczema, but it is an option for patients in whom other treatments have failed or been insufficient.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> In certain cases, measurement of circulating 6-thioguanine nucleotide TGN) and methylated 6-methylmercaptopurine levels at baseline and thereafter at regular intervals can help optimize dosage regimens, improve clinical effectiveness, and prevent adverse effects, as azathioprine metabolites can cause hepatotoxicity.<a class="elsevierStyleCrossRef" href="#bib0495">99</a> Azathioprine has been approved for the treatment of Parthenium dermatitis in India, where this condition is very common.<a class="elsevierStyleCrossRef" href="#bib0500">100</a>Other TreatmentsMethotrexate and mycophenolate can be used off-label as second- or third-line treatments for hand eczema, but their use in this setting is supported by a low level of evidence.<a class="elsevierStyleCrossRefs" href="#bib0245">49,101</a> In one study, methotrexate administered over 8 to 12 weeks proved effective, but subsequent loss of effectiveness and onset of adverse events led to its interruption.<a class="elsevierStyleCrossRef" href="#bib0510">102</a> The drug also appears to be less effective than other systemic treatments such as acitretin.<a class="elsevierStyleCrossRef" href="#bib0515">103</a> Methotrexate has been used successfully in children with nummular eczema.<a class="elsevierStyleCrossRef" href="#bib0520">104</a> Oxybutynin, an alternative treatment for hyperhidrosis, has been found to improve coexistent dyshidrotic eczema.<a class="elsevierStyleCrossRef" href="#bib0525">105</a><elsevierMultimedia ident="tb0005"></elsevierMultimedia>FundingThis document was funded by an unconditional grant from GlaxoSmithKline.Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:22 [ 0 => array:3 [ "identificador" => "xres1327525" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1223706" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1327524" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1223707" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Definition" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Epidemiology" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Risk factors" ] ] ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Pathophysiology" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Classification" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Diagnosis" ] 11 => array:2 [ "identificador" => "sec0045" "titulo" => "Prevention" ] 12 => array:2 [ "identificador" => "sec0050" "titulo" => "Primary Prevention" ] 13 => array:2 [ "identificador" => "sec0055" "titulo" => "Secondary Prevention" ] 14 => array:2 [ "identificador" => "sec0060" "titulo" => "Tertiary Prevention" ] 15 => array:2 [ "identificador" => "sec0065" "titulo" => "Treatment" ] 16 => array:3 [ "identificador" => "sec0070" "titulo" => "Topical Treatments" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Topical Corticosteroids" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Calcineurin Inhibitors" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Phototherapy" ] ] ] 17 => array:3 [ "identificador" => "sec0090" "titulo" => "Systemic Treatments" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Alitretinoin" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Acitretin" ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "Systemic Corticosteroids" ] 3 => array:2 [ "identificador" => "sec0110" "titulo" => "Ciclosporin" ] 4 => array:2 [ "identificador" => "sec0115" "titulo" => "Azathioprine" ] 5 => array:2 [ "identificador" => "sec0120" "titulo" => "Other Treatments" ] ] ] 18 => array:2 [ "identificador" => "sec0125" "titulo" => "Funding" ] 19 => array:2 [ "identificador" => "sec0130" "titulo" => "Conflicts of Interest" ] 20 => array:2 [ "identificador" => "xack458287" "titulo" => "Acknowledgments" ] 21 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-07" "fechaAceptado" => "2019-04-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1223706" "palabras" => array:8 [ 0 => "Chronic eczema" 1 => "Dermatitis" 2 => "Emollients" 3 => "Topical corticosteroids" 4 => "General practitioners" 5 => "Hands" 6 => "Diagnosis" 7 => "Referral criteria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1223707" "palabras" => array:8 [ 0 => "Eczema crónico" 1 => "Dermatitis" 2 => "Emolientes" 3 => "Corticoides tópicos" 4 => "Médico de atención primaria" 5 => "Manos" 6 => "Diagnóstico" 7 => "Criterios de derivación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Hand eczema is a common condition associated with significantly impaired quality of life and high social and occupational costs. Managing hand eczema is particularly challenging for primary care and occupational health physicians as the condition has varying causes and both disease progression and response to treatment are difficult to predict. Early diagnosis and appropriate protective measures are essential to prevent progression to chronic eczema, which is much more difficult to treat. Appropriate referral to a specialist and opportune evaluation of the need for sick leave are crucial to the good management of these patients.These guidelines cover the diagnosis, prevention, and treatment of chronic hand eczema and highlight the role that primary care and occupational health physicians can play in the early management of this disease." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El eczema de manos es una patología frecuente con fuerte impacto en la calidad de vida de los pacientes y alto coste social y laboral. Su manejo por los médicos de atención primaria y de medicina del trabajo es complejo debido a la variedad de etiologías, la evolución difícilmente predecible de la enfermedad y la respuesta al tratamiento. El diagnóstico precoz y las medidas protectoras adecuadas son esenciales para evitar la cronificación, que es mucho más difícil de tratar. Una correcta derivación a un especialista y la valoración de una baja laboral en el momento adecuado resultan cruciales para un buen manejo de estos pacientes.En esta guía sobre el eczema crónico de manos analizamos el proceso diagnóstico, las medidas preventivas y los tratamientos, con especial énfasis en el papel del médico de atención primaria y de medicina del trabajo en los estados iniciales de su manejo." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "nota" => "*Please cite this article as: Silvestre Salvador JF, et al. Guía para el diagnóstico, el tratamiento y la prevención del eccema de manos. Actas Dermosifiliogr. 2020;111:26–40." ] ] "multimedia" => array:13 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2941 "Ancho" => 2508 "Tamanyo" => 491533 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Etiologic diagnosis of hand eczema." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2398 "Ancho" => 1591 "Tamanyo" => 328847 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Hand eczema management in primary care." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1933 "Ancho" => 2925 "Tamanyo" => 325691 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Treatment algorithm for hand eczema. Education and lifestyle changes, such as the use of emollients and protective gloves and avoidance of irritants and allergens are obligatory throughout all treatment phases. Oral corticosteroids can be considered for flares. Adapted from De León et al.<a class="elsevierStyleCrossRef" href="#bib0245">49</a>." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irritant contact hand eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Varied, but often presents with fissures or pulpitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normally affects interdigital spaces \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caused by prolonged or repeated exposure to irritants, frequent handwashing, use of occlusive gloves, alkaline substances, or oils \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Allergic contact hand eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Affects the site of contact (palms or fingertips), although preferentially affects the dorsum of the hands or fingers, where the skin is more vulnerable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caused by allergen exposure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Erythema/vesicular phases and subsequent excoriation, scratching, and lichenification tend to be easy to identify \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Protein contact hand eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Initial phase characterized by wheals or eczematous lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caused by food allergens, latex, or biologic materials \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atopic dermatitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Often affects the wrists, causes itching \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous history of atopic dermatitis, asthma, or rhinitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vesicular hand eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrent lesions with vesicular palmar eruption \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Can affect the lateral aspects of fingers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caused by stress, systemic contact dermatitis, dust allergens, and fungal infections \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hyperkeratotic hand eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Well-demarcated hyperkeratotic areas on the palms of the hands, without vesicles or pustules \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Some authors only consider eczema to be hyperkeratotic when preceded by a vesicular phase \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275663.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Types of Hand Eczema." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Personal and family history of allergies and skin diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Work-related history \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Pattern (acute, chronic, recurrent), with description of flares and remissions in relation to work (holidays, weekends), seasons, and lifestyle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Exposure to irritants or allergens (type, duration, frequency) at work and home \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Handwashing habits, skin care, use of gloves \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Impact on quality of life (social relationships, work, family life) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275656.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Factors to Investigate in a Patient With Possible Hand Eczema." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Psoriasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Family history of psoriasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Well-demarcated hyperkeratosis, discoid plaques, palmar involvement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Involvement of scalp, elbows, knees, buttocks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Long-standing refractory disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tinea manuum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typically unilateral \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mainly affects the palmar creases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Associated onychomycosis or tinea pedis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275658.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differential Diagnosis." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patch tests (delayed hypersensitivity) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Always perform in patients with chronic hand eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use baseline series (GEIDAC series in Spain) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interpret results in light of clinical history \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prick tests (immediate hypersensitivity) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use specific allergens from workplace or home \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use fresh food to diagnose protein contact dermatitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biopsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Useful for differential diagnosis but results are difficult to interpret; does not offer good diagnostic yield for differentiating between hand eczema and palmar psoriasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lateral or dorsal aspects of the hand \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275657.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical Tests Used to Diagnosis Chronic Hand Eczema." ] ] 7 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level of prevention \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Possible preventive measures \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="5" align="left" valign="middle">Primary</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of gloves and hand moisturizers (<a class="elsevierStyleCrossRefs" href="#tbl0030">Tables 6 and 7</a>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prevention of exposure through changes to regulations on permitted materials (e.g., certain preservatives in cosmetics or chrome in cement products) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventilation systems to reduce exposure to allergens or irritants \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specific health surveillance measures at the workplace to identify sensitized individuals before onset of symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General education on the use of gloves, skin care products, and other protective measures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle">Secondary</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Regular examinations at the workplace to identify and treat early symptoms of hand eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of moisturizers and other preventive topical skin care measures, led by a dermatologist \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Education at the workplace by dermatologists as part of specific skin care programs (seminars, leaflets, workshops) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle">Tertiary</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consideration of temporary sick leave to prevent sensitization and allow sufficient time for full skin barrier restoration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multidisciplinary or multifaceted approach targeting patients with chronic hand eczema and involving dermatologists, occupational medicine specialists, and other healthcare professionals \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275655.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preventing Hand Eczema." ] ] 8 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Use gloves during wet work. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Do not use gloves for long periods of time; wear cotton gloves under any gloves that need to be worn for more than 15minutes. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Change gloves regularly for jobs that involve wearing gloves all day (have three pairs available). Remember that wet gloves lose their protective capacity. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Use intact gloves that are both clean and dry inside. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Use gloves suited to the type of material being handled: cotton gloves for cardboard or paper, leather gloves for solids, disposable plastic gloves for food, and vinyl, nitrile, or rubber gloves for liquids. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275662.png" ] ] ] ] "descripcion" => array:1 [ "en" => "General Measures: Gloves." ] ] 9 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Emollients can be used during all treatment stages and for all types of eczema, except very acute eczema and highly fissured lesions, as their absorption could favor sensitization to certain components. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Use oil-based emollients for scaling/hyperkeratotic hand eczema and water-based emollients for exudative hand eczema. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">— Preferably use lotions and creams during the day and ointments at night. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275661.png" ] ] ] ] "descripcion" => array:1 [ "en" => "General Measures: Emollients." ] ] 10 => array:8 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The most commonly used corticosteroids in the treatment of hand eczema are high-potency corticosteroids (mometasone furoate cream 0.1% and betamethasone valerate cream 0.05% and 0.1%. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use topical corticosteroids for short periods (<6wk). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider using oral corticosteroids to treat flares if the eczema is highly disabling and cannot be controlled using other measures. Tapered dosage from 0.5 to 1mg/kg/d for 1 to 2 wk. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275659.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Use of Corticosteroids." ] ] 11 => array:8 [ "identificador" => "tbl0045" "etiqueta" => "Table 9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Topical treatments</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle">Emollients</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Using emollients during working hours can increase sensitization. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment adherence is important for optimal results. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emollient use may require supervision by a doctor or nurse. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="5" align="left" valign="middle">Topical corticosteroids</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Careful consideration should be given to potency and treatment duration. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Choose formulation based on lesion morphology and severity. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rule out fungal infections before starting treatment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Topical corticosteroids can cause allergies. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatments that must exceptionally last for >6wk require close supervision as they can cause skin atrophy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Calcineurin inhibitors</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Can be combined with topical corticosteroids to achieve longer disease-free periods. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Can be used during acute disease phases. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systemic treatments</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Systemic corticosteroids</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use only in acute phases of disease; not recommended for chronic hand eczema. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do not use for >3wk due to potential adverse effects. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="4" align="left" valign="middle">Alitretinoin</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Approved for the treatment of chronic hand eczema that does not respond to topical corticosteroids. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alitretinoin can produce considerable improvements in chronic hand eczema after just 12wk. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adverse effects may occur (e.g., headache, nausea, hyperlipidemia). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Teratogenic; avoid use in women who want to become pregnant. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acitretin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Effective, but associated with a higher rate of adverse events than alitretinoin. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Ciclosporin</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Option when other treatments fail. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Effective in atopic dermatitis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle">Azathioprine</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Option when other treatments fail. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Monitor for signs of hepatotoxicity due to accumulation of azathioprine metabolites. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2275660.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Treatment Recommendations for Hand Eczema." ] ] 12 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "Hand Eczema: Key Concepts<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0055">•Hand eczema is a multifactorial disease that is very common in the general population.</li><li class="elsevierStyleListItem" id="lsti0060">•Early diagnosis and treatment is essential for preventing chronic disease.</li><li class="elsevierStyleListItem" id="lsti0065">•Chronic hand eczema is eczema that persists for at least 3 months or recurs at least twice a year despite adequate treatment and treatment adherence.</li><li class="elsevierStyleListItem" id="lsti0070">•There is no universally accepted classification of hand eczema, but diagnostic subgroups can be established based on morphologic and etiologic criteria.</li><li class="elsevierStyleListItem" id="lsti0075">•Hand eczema is diagnosed clinically based on history taking and physical examination. Patch tests, prick tests, microbiological tests, and skin biopsies are useful for ruling out other diseases or establishing an etiologic diagnosis.</li><li class="elsevierStyleListItem" id="lsti0080">•When faced with a case of hand eczema, GPs should recommend adequate protection against irritants and moisture and correct usage of gloves and emollients.</li><li class="elsevierStyleListItem" id="lsti0085">•GPs should assess the need for sick leave in patients with chronic hand eczema and refer the patient to a specialist for additional tests.</li><li class="elsevierStyleListItem" id="lsti0090">•As hand eczema is often work related, risk prevention is essential in certain occupations.</li></ul>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:105 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiology of hand eczema in the general population – prevalence and main findings" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0536.2009.01669.x" "Revista" => array:7 [ "tituloSerie" => "Contact Dermatitis" "fecha" => "2010" "volumen" => "62" "numero" => "2" "paginaInicial" => "75" "paginaFinal" => "87" "link" => array:1 [ …1] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Minimum standards on prevention, diagnosis and treatment of occupational and work-related skin diseases in Europe - position paper of the COST action standerm (td 1206)" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jdv.14319" "Revista" => array:7 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2017" "volumen" => "31" "numero" => 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"10.1056/NEJMcp1104084" "Revista" => array:7 [ "tituloSerie" => "N Engl J Med" "fecha" => "2012" "volumen" => "367" "numero" => "19" "paginaInicial" => "1829" "paginaFinal" => "1837" "link" => array:1 [ …1] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of chronic hand eczema" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0536.2007.01179.x" "Revista" => array:7 [ "tituloSerie" => "Contact Dermatitis" "fecha" => "2007" "volumen" => "57" "numero" => "4" "paginaInicial" => "203" "paginaFinal" => "210" "link" => array:1 [ …1] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of, and work-related risk factors for, hand eczema in a Norwegian general population (The 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"contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence, incidence and predictive factors for hand eczema in young adults – a follow-up study" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "BMC Dermatol" "fecha" => "2013" "volumen" => "13" "paginaInicial" => "14" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hand eczema in the Odense adolescence cohort study on atopic diseases and dermatitis (TOACS): Prevalence, incidence and risk factors from adolescence to adulthood" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.12963" "Revista" => array:7 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2014" "volumen" => "171" "numero" => "2" "paginaInicial" => "313" "paginaFinal" => "323" "link" => array:1 [ …1] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical epidemiology of hand eczema in patients accessing dermatological reference centres: Results from Italy" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.13220" "Revista" => array:7 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2015" "volumen" => "172" "numero" => "1" "paginaInicial" => "187" "paginaFinal" => "195" "link" => array:1 [ …1] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics and provision of care in patients with chronic hand eczema: Updated data from the CARPE registry" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2340/00015555-1632" "Revista" => array:7 [ "tituloSerie" => "Acta Derm Venereol" "fecha" => "2014" "volumen" => "94" "numero" => "2" "paginaInicial" => "163" "paginaFinal" => "167" "link" => array:1 [ …1] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Self-reported hand eczema among dental workers in Japan – a cross-sectional study" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/cod.12656" "Revista" => array:7 [ "tituloSerie" => "Contact Dermatitis" "fecha" => "2016" "volumen" => "75" "numero" => "4" "paginaInicial" => "230" "paginaFinal" => "239" "link" => array:1 [ …1] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Colonisation with methicillin-resistant Staphylococcus aureus and associated factors among nurses with occupational skin 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Estadísticas

Consensus Document

Guidelines for the Diagnosis, Treatment, and Prevention of Hand Eczema

Guía para el diagnóstico, el tratamiento y la prevención del eccema de manos

J.F. Silvestre Salvadora,

Autor para correspondencia

silvestre_jfr@gva.es

Corresponding author.

, F. Heras Mendazab, M. Hervella Garcésc, D. Palacios-Martínezd, R. Sánchez Camachoe, R. Senan Sanzf, A. Apellaniz Gonzálezg, A.M. Giménez-Arnauh

a Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain

b Servicio de Dermatología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain

c Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona, Spain

d Medicina de Atención Primaria, Centro de Salud Isabel II, Parla, Madrid, Spain

e Medicina General, Centro de Salud Ávila Rural, Ávila, Spain

f Equipo de Atención Primaria el Clot, Instituto Catalán de la Salud, Barcelona, Spain

g Departamento de Estomatología, Facultad de Medicina y Enfermería, Euskal Herriko Unibertsitatea-Universidad del País Vasco, Leioa, Bizkaia, Spain

h Departamento de Dermatología, Hospital del Mar, Universitat Autónoma, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hand eczema is a very common condition that affects an estimated 10&#37; of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It accounts for 80&#37; of all occupational skin diseases and is a common cause of sick leave&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In Spain&#44; however&#44; there are no national guidelines on how to prevent&#44; diagnose&#44; or treat this condition&#46; The European guidelines for the diagnosis&#44; prevention&#44; and treatment of chronic hand eczema were published in 2015&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but they do not cover the complexity of care that characterizes the different levels of the Spanish public healthcare system&#46; In Spain&#44; general practitioners &#40;GPs&#41; provide the first point of contact for patients with hand eczema&#44; but the lack of national guidelines means that there are no standardized criteria for clinical management and referrals&#46; This complexity is further aggravated by the diversity of regional healthcare models&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Prompt diagnosis and treatment is necessary to prevent hand eczema from becoming chronic&#44; but this requires coordination between the different levels of care&#46; Systematized criteria thus are needed to determine how hand eczema patients should be treated in primary care&#44; when they should be referred to a specialist&#44; how they should be followed&#44; and when they should be seen by an occupational health or health insurance physician&#46; The Spanish Academy of Dermatology and Venereology &#40;AEDV&#41;&#44; through the Spanish Contact Dermatitis and Skin Allergy Research Group &#40;GEIDAC&#41;&#44; decided to draw up an updated review article to guide the diagnosis&#44; treatment&#44; and follow-up of hand eczema and offer unified&#44; consensus-based criteria for referrals to secondary care&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This document was drawn up by members of the AEDV&#44; which led the initiative&#44; and representatives of the Spanish Society of Primary Care Physicians &#40;SEMERGEN&#41;&#44; the Spanish Society of Family and Community Physicians &#40;semFYC&#41;&#44; the Spanish Society of General and Family Practitioners &#40;SEMG&#41;&#44; and the Spanish Society of Occupational Medicine and Safety &#40;SEMST&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The document was prepared in several phases involving the review of existing evidence in various cycles of analysis and discussion&#46; The process is described below&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0025" class="elsevierStylePara elsevierViewall">Four members of the AEDV prepared a draft document containing the latest information on the definition&#44; classification&#44; diagnosis&#44; and treatment of hand eczema&#46; The literature search was performed in the US National Library of Medicine MEDLINE database and spanned articles published between 2008 and 2018&#46; The results were filtered by relevance to the objectives of this guideline&#44; although the PRISMA &#40;Preferred Reporting Items for Systematic Reviews and Meta-Analyses&#41; checklist was not used The search was conducted using combinations of keywords &#40;<span class="elsevierStyleItalic">hand dermatitis</span>&#44; <span class="elsevierStyleItalic">hand eczema</span>&#44; <span class="elsevierStyleItalic">palmar dermatitis</span>&#41; that systematically covered all possible related uses&#46; The qualifier terms were <span class="elsevierStyleItalic">epidemiology</span>&#44; <span class="elsevierStyleItalic">prevention</span>&#44; <span class="elsevierStyleItalic">etiology</span>&#44; <span class="elsevierStyleItalic">classification</span>&#44; <span class="elsevierStyleItalic">pathophysiology</span>&#44; and <span class="elsevierStyleItalic">treatment</span>&#46; Full searches were also made using specific drug terms&#44; such as <span class="elsevierStyleItalic">calcineurin inhibitors</span> and <span class="elsevierStyleItalic">alitretinoin</span>&#46; The draft document was also informed by existing guidelines&#44; such as the European Society of Contact Dermatitis hand eczema guideline&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> the position paper of the European Cooperation in Science and Technology COST Action StandDerm &#40;TD1206&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> the Canadian dermatitis management guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the Danish Contact Dermatitis guidelines for the diagnosis and treatment of hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0030" class="elsevierStylePara elsevierViewall">The draft was discussed in depth in May 2018 by members of the AEDV panel and the representatives of the participating societies &#40;D&#46;P&#46;M&#46; for SEMERGEN&#44; R&#46;S&#46;S&#46; for semFYC&#44; R&#46;S&#46;C for SEMG&#44; and A&#46;A&#46;G for SEMST&#41; to ensure that all possible clinical perspectives were taken into account&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0035" class="elsevierStylePara elsevierViewall">The discussions resulted in a definitive draft that was subsequently used to create an abbreviated set of recommendations for use by GPs and occupational health physicians in routine clinical practice&#46; One of the main goals of this document was to standardize the criteria for referring patients with hand eczema to a specialist&#46; It should be noted&#44; however&#44; that the document is not formally endorsed by the societies represented by the physicians involved in its development &#40;SEMERGEN&#44; semFYC&#44; SEMG&#44; and SEMST&#41;&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definition</span><p id="par0040" class="elsevierStylePara elsevierViewall">Hand eczema&#44; or hand dermatitis&#44; is a multifactorial disease with several etiologic and morphologic variants&#46; It is essentially an inflammatory skin disease that affects the hands&#59; it causes significant discomfort and can have a major impact on patient quality of life&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The clinical manifestations of hand eczema include erythema&#44; edema&#44; vesicles&#44; crusting&#44; scaling&#44; lichenification&#44; hyperkeratosis&#44; and fissures&#46; Hand eczema is considered acute when it predominantly consists of vesicles and crusting&#44; and chronic when the main manifestation is hyperkeratosis&#46; Early intervention is necessary as hand eczema can become chronic&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The condition is classified as chronic when it lasts for at least 3 months or relapses at least twice a year despite adequate treatment and treatment adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Epidemiology</span><p id="par0050" class="elsevierStylePara elsevierViewall">Numerous studies have described the prevalence of hand eczema in the general population and varying professions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a> A large literature review of studies published between 1964 and 2007 reported a point prevalence of around 4&#37;&#44; a 1-year prevalence of nearly 10&#37;&#44; and a lifetime prevalence of 15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Similar rates have been described in a number of large&#44; recent studies&#44; many of which were conducted in Scandinavian countries&#46; A large Norwegian epidemiological study involving over 50<span class="elsevierStyleHsp" style=""></span>000 people&#44; for example&#44; reported prevalence rates of 11&#46;3&#37; for hand eczema in the general population and 4&#46;8&#37; for work-related hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A study of hand eczema in Swedish adolescents reported a 1-year prevalence of 5&#46;2&#37; and a lifetime prevalence of 9&#46;7&#37;&#59; this incidence was similar to that observed in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Another Swedish study described a 1-year prevalence of 15&#46;8&#37; in adults and reported that women were twice as likely as men to be affected&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In Denmark&#44; the 1-year prevalence rate observed for hand eczema in adults aged 28 to 30 years was 14&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The severity of hand eczema has also been studied&#46; An Italian study found that 83&#46;5&#37; of patients with hand eczema had chronic eczema&#44; 21&#46;3&#37; had severe eczema&#44; and 62&#46;0&#37; had eczema refractory to standard therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In the CARPE registry of German patients with chronic hand eczema&#44; 23&#46;4&#37; of patients had very severe eczema&#44; 47&#46;0&#37; had severe eczema&#44; 20&#46;1&#37; had moderate eczema&#44; and 9&#46;6&#37; had mild or very mild eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In the Swedish study of adolescents with hand eczema&#44; 27&#46;0&#37; of patients had moderate to severe disease&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Hand eczema tends to follow a relapsing&#44; remitting course&#44; and severity can change rapidly in individual patients&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Risk factors</span><p id="par0060" class="elsevierStylePara elsevierViewall">The risk factors for hand eczema are highly variable&#44; particularly when allergens are involved&#46; A number of general factors&#44; however&#44; have been consistently identified as increasing risk&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Atopic dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10&#44;11&#44;14&#8211;20</span></a> A history of atopic dermatitis is the strongest predictor of chronic hand eczema in both children and adults&#46; Atopic dermatitis is the most common cause of hand eczema in children&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> A study of chronic hand eczema in the general Danish population found an association between filaggrin mutations and chronic hand eczema in patients with atopic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Other atopic diseases&#44; such as asthma and allergic rhinitis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Tobacco smoking&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;25</span></a> While a recent meta-analysis did not demonstrate that smoking was a risk factor for hand eczema&#44; the authors concluded that based on the data available&#44; they could not confirm that smoking did not influence disease course&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> A recent study of patients with work-related hand eczema in Denmark found a strong association between smoking and disease severity&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Although more studies are clearly needed&#44; it is important to consider the inclusion of smoking cessation in treatment strategies for patients with hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Dry skin&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Wet work and excessive hand washing&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11&#44;14&#44;18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a> As hand eczema can affect a patient&#8217;s ability to work and may also be classified as an occupational disease&#44; it has a significant social and economic impact&#46; Workers most at risk are workers in the food processing industry and those frequently exposed to water&#44; such as healthcare professionals and hairdressers&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Healthcare workers have been identified as high-risk groups in Canada&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Korea&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> the Netherlands&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Denmark&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;28&#44;32</span></a> Norway&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and Germany&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> with prevalence rates ranging from 21&#46;0&#37; to 47&#46;0&#37;&#46; In a Danish study&#44; 53&#37; of healthcare workers with hand eczema had positive patch test reactions&#44; mostly to nickel&#44; thiomersal&#44; fragrances&#44; rubber chemicals&#44; and colophonium&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> A German epidemiological study found that 90&#46;3&#37; of German nurses with occupational skin diseases had hand eczema and 13&#46;5&#37; had concomitant methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; colonization&#44; mainly in the nose &#40;81&#46;4&#37;&#41;&#46; Of these&#44; 55&#46;8&#37; also had hand involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Chronic hand eczema is very common in odontologists in Japan &#40;46&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In a recent study&#44; hairdressers reported high rates of hand eczema compared with the general population&#44; and many of them stated that they had left their job because of their condition&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> High prevalence rates have also been reported among hairdressers in Denmark&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> Turkey&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> and Croatia&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The situation may vary significantly in other regions of the world&#46; An Indian study&#44; for example&#44; found that most cases of occupational contact dermatitis occurred in farmers&#44; construction workers&#44; and housewives&#44; and that 81&#46;2&#37; of patients with this diagnosis had hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The most common allergens identified were <span class="elsevierStyleItalic">Parthenium hysterophorus</span> in farmers&#44; potassium dichromate in construction workers&#44; and vegetables in housewives&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Several studies have found hand eczema to be more common in women than men&#44; but the exact reasons for this predominance are unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8&#44;10&#44;11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Certain mutations in the filaggrin gene &#40;see next section&#41;&#46;</p></li></ul></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pathophysiology</span><p id="par0100" class="elsevierStylePara elsevierViewall">As hand eczema constitutes a group of highly heterogeneous conditions&#44; no general pathological mechanisms have been established&#46; It is&#44; however&#44; accepted that genetic factors &#40;e&#46;g&#46;&#44; filaggrin mutations&#41; and external factors &#40;e&#46;g&#46;&#44; skin irritants&#41; alter the structure and composition of the stratum corneum&#44; disrupting the skin barrier and favoring the development of hand eczema&#46; Filaggrin mutations have also been linked to the development of hand eczema&#44; particularly in endogenous forms of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Skin barrier disruption has a pathogenic role in chronic hand eczema and can lead to both irritant and allergic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> One recent study showed that a number of important skin barrier proteins &#40;filaggrin&#44; hornerin&#44; peptidases KLK5 and KLK7&#44; and cystatin E&#47;M&#41; were downregulated in hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> The skin barrier can be disrupted by both genetic and exogenous factors&#46; Wet work is one of the main causes of skin irritation and can favor sensitization to antigens in hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The pathogenic role of skin microbiome in chronic hand eczema is attracting increasing attention&#46; Patients with hand eczema have higher rates of <span class="elsevierStyleItalic">S aureus</span> colonization than healthy individuals&#44; and patients with severe disease have a significantly higher density of <span class="elsevierStyleItalic">S aureus</span> than those with milder disease&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Interleukins &#40;ILs&#41;&#44; such as IL-1 &#40;IL-36&#945;&#41;&#44; may be involved in chronic hand eczema skin inflammation&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> and IL-36&#945; may therefore become a useful biomarker for helping in the complex diagnosis of chronic hand ezcema&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Classification</span><p id="par0120" class="elsevierStylePara elsevierViewall">Proper classification of hand eczema is the first step towards effective and efficient treatment&#44; 12 and it is also essential for stratifying patients in epidemiological and clinical studies&#46; Several classification systems based on clinico-morphologic features and etiologic factors have been proposed&#46; The relationship between these systems&#44; however&#44; is complex&#44; as disease presentation and progression can vary from one type of hand eczema to the next&#46; At this time&#44; there is no universally accepted classification system&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The Danish Contact Dermatitis Group established 6 clinical &#40;morphologic&#41; types of hand eczema&#58; recurrent vesicular hand eczema&#44; chronic fissured hand eczema&#44; hyperkeratotic palmar eczema&#44; pulpitis&#44; interdigital eczema&#44; and nummular hand eczema&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;46&#44;47</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The most common types of hand eczema are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6&#44;48&#44;49</span></a> The authors of a recent study were able to classify 89&#37; of patients using the above diagnostic subgroups and in 7&#37; of cases&#44; two main diagnoses were required for classification&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Nonetheless&#44; several authors have estimated that at least 20&#37; to 26&#37; of all chronic hand eczema cases are idiopathic as they do not fit into any of these etiologic groups&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;49</span></a> Mixed forms of chronic hand eczema are common&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;50</span></a> A retrospective study of patients with occupational contact dermatitis in Denmark&#44; for example&#44; found that 6&#46;4&#37; of patients had a combined diagnosis of allergic and irritant contact dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Contact and atopic dermatitis may also coexist&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#8211;54</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diagnosis</span><p id="par0135" class="elsevierStylePara elsevierViewall">Diagnosis of hand eczema is clinical and based on history taking and physical examination&#46; Diagnostic tests &#40;patch tests&#44; prick tests&#44; microbiological tests&#44; and skin biopsy&#41; are useful for ruling out other diseases and establishing an etiologic diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">History taking is the first step in the diagnostic process&#46; Both personal and work-related factors are important&#46; The main factors that should be addressed during the patient interview are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; A note of the most significant findings from the interview should always be made in the patient&#8217;s medical record&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">During the physical examination&#44; the whole skin surface should be inspected&#44; with attention paid to signs of dermatophytosis&#46; Close inspection of the feet is important&#46; Clinically&#44; it may be difficult to differentiate between chronic hand eczema and other skin diseases that affect the hand&#44; in particular psoriasis and mycosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;54</span></a> Some of the key aspects that should be considered in the differential diagnosis are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Psoriasis is characterized by well-demarcated hyperkeratosis in discoid plaques&#44; an absence of tingling and vesicles&#44; and the presence of lesions on the scalp&#44; nails&#44; flexural areas of the elbows and knees&#44; and buttocks&#46; Patients with psoriasis also typically have a personal or family history of psoriasis or persistent seborrheic dermatitis&#46; Fungal skin infections can be diagnosed by visual inspection or by potassium hydroxide testing or direct culture&#46; Other conditions that can be confused with chronic hand eczema are lichen planus&#44; mange&#44; granuloma annulare&#44; herpes simplex&#44; erythema multiforme&#44; pityriasis rubra pilaris&#44; and dermatomyositis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;54</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The clinical tools available for diagnosing chronic hand eczema are summarized in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Patch testing is the gold standard and must be performed in all types of chronic hand eczema&#44; regardless of the morphology of the lesions or the tentative diagnosis&#46; Patch tests should also be contemplated in patients with refractory or recurrent eczema&#44; eczema with an atypical or varying distribution&#44; and eczema with patterns suggestive of allergic contact disease&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Patch and prick tests can rule out an allergic cause&#46; Skin biopsy and fungal culture are normally only useful for ruling out other skin diseases&#46; When making a diagnosis&#44; it is important to recall that hand eczema can be triggered by a wide range of external and internal factors acting alone or in combination&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">An algorithm to help identify the cause of chronic hand eczema is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Patch tests are essential for diagnosing chronic allergic contact hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> There are no useful diagnostic tools for detecting reactions to irritants in everyday clinical practice&#46; Irritant contact hand eczema thus is often diagnosed on the basis of clinical patterns&#44; testing of products handled by the patient&#44; and patch test results &#40;negative results are indicative of contact allergy&#41;&#46; It should be noted&#44; however&#44; that contact and irritant hand eczema often coexist&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#44;56</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Protein contact hand eczema should be clinically suspected in any patient who develops pruritus&#44; wheals&#44; or eczema immediately after handling material of biological origin &#40;e&#46;g&#46;&#44; fruit&#44; fish&#44; animal intestines&#41;&#46; In this case&#44; the eczema is caused by prolonged contact with the proteins and is therefore diagnosed using prick tests rather than patch tests &#40;which detect allergy to haptens&#41;&#46; Prick-to-prick tests with suspect foods provided by the patient are often necessary&#46; Although the agents responsible for classic allergic hand eczema are low-molecular&#8211;weight chemical agents&#44; standard patch tests tend to be negative in contact hand eczema induced by proteins&#46; Protein contact hand eczema is common in patients with dermal-epidermal barrier disruption due to atopy or previous exposure to irritants&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Prevention</span><p id="par0165" class="elsevierStylePara elsevierViewall">Measures to mitigate or reduce the incidence of hand eczema can be classified as primary&#44; secondary&#44; or tertiary&#44; depending on the stage of disease&#46; Primary prevention measures aim to reduce the incidence of hand eczema in the healthy population&#46; Secondary prevention measures&#44; by contrast&#44; are designed to prevent existing disease from becoming chronic&#44; while tertiary prevention measures are designed to guide the clinical management of patients who have already developed chronic disease&#46; The different measures&#44; categorized by level of prevention&#44; are summarized in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Primary Prevention</span><p id="par0170" class="elsevierStylePara elsevierViewall">Primary prevention is essential and should start at schools&#44; with a particular focus on children with atopic disorders&#44; who are more prone to developing hand eczema later in life&#46; The goal of primary prevention is to prevent exposure to potential causative agents identified as risk factors in the general population&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Assessment of occupational risk involves identifying and quantifying risks at the workplace and is an essential component of primary prevention&#46; Risks should then be classified and suitable preventive measures implemented using a multidisciplinary approach&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The main types of primary prevention measures are <span class="elsevierStyleItalic">1</span>&#41; technical&#47;organizational measures&#44; <span class="elsevierStyleItalic">2</span>&#41; personal protection measures &#40;hand hygiene and use of gloves and moisturizers&#41;&#44; <span class="elsevierStyleItalic">3</span>&#41; education&#44; and <span class="elsevierStyleItalic">4</span>&#41; access to specialist care&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">An example of an effective organizational measure is the introduction of regulatory measures to reduce or eliminate exposure to certain allergens&#44; such as chromate in cement or glyceryl monothioglycolate in hairdressing products&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">57&#44;58</span></a> Accelerator-free medical gloves may be an effective alternative for healthcare professionals allergic to rubber accelerators&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Protective gloves are the most important primary prevention measure &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; Patients with hand eczema should always wear gloves over clean&#44; dry hands when doing wet work or working with hazardous substances&#46; Gloves should be worn as often as necessary but for the shortest time possible&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Disposable gloves should never be used more than once and damaged gloves should be disposed of immediately&#46; Cotton gloves should be worn for general housework that does not require contact with liquids &#40;e&#46;g&#46;&#44; dusting&#41; and under other gloves that need to be worn for longer than 15<span class="elsevierStyleHsp" style=""></span>minutes&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Latex gloves offer good protection against microorganisms and water-based products&#44; but are relatively ineffective against oils&#44; solvents&#44; and chemical products&#46; Nitrile gloves protect against oils and solvents&#44; while vinyl gloves offer protection against most chemical products&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The authors of a Dutch study showed that a multifaceted hand eczema prevention strategy consisting of training &#40;targeting special working groups&#41;&#44; workplace reminders&#44; and leaflets produced good overall results after a period of 6 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">60&#44;61</span></a> The strategy&#44; however&#44; did not appear to be cost-effective&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Secondary Prevention</span><p id="par0195" class="elsevierStylePara elsevierViewall">The goal of secondary prevention is the early detection&#44; diagnosis&#44; and treatment of hand eczema by specialists&#46; Patient education programs should aim to bring about behavioral changes at work or at home and encourage patients to use skin protection measures and eliminate exposure to allergens and irritants&#46; It has been suggested that this information should be given in writing&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;63</span></a> Job counseling may also be an effective approach for encouraging secondary prevention in young adults at risk of hand eczema&#44; as found by a German study of young adults with atopic dermatitis starting in high-risk occupations&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> Another German study demonstrated the long-term effectiveness of an interdisciplinary secondary prevention programme and stressed the importance of early detection and reporting of occupational hand eczema in the initial stages of disease&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Protective creams and emollients are very important as they can prevent early disease from progressing &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46; Barrier creams provide a protective layer and should only be used on healthy skin&#44; never on inflamed skin&#46; They protect against common irritants such as water&#44; detergents&#44; metals&#44; resins&#44; oil-based materials&#44; and UV light and they may also favor skin hygiene&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> It is important to note&#44; however&#44; that barrier creams may give a false sensation of security&#44; leading to undue exposure to allergens or irritants&#46; Under no circumstances should barrier creams replace physical measures such as gloves&#46; A wide range of emollients can be recommended and used in clinical practice and it is widely accepted that these products can improve hydration&#44; prevent itching&#44; and help repair the skin barrier&#46; Use of moisturizers can prolong disease-free periods in patients with successfully treated hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> There is&#44; however&#44; limited evidence on the clinical effectiveness of specific formulations and as such no definitive recommendations can be made&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Moisturizers should not be worn during working hours as they increase the risk of sensitization to allergens that can cause eczema&#46; Instead&#44; they should be used outside working hours to favor skin barrier restoration&#46; More recent developments for the treatment of specific lesions include prescription emollient devices&#44; which contain a complex mix of components designed to mimic the composition of the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a></p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Tertiary Prevention</span><p id="par0205" class="elsevierStylePara elsevierViewall">Tertiary prevention measures should be applied to patients who have already developed chronic hand eczema&#46; The main goals in this case are to improve disease severity&#44; reduce the use of corticosteroids&#44; facilitate return to work&#44; and improve quality of life&#46; It may be advisable for patients with irritant contact hand eczema to temporarily stop work to prevent sensitization and favor full restoration of the skin barrier&#46; A multidisciplinary approach involving dermatologists and occupational health specialists is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The Osnabr&#252;ck model has been proposed as an effective long-term strategy for patient rehabilitation&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;69</span></a> A recent study of the long-term effects of a tertiary individualized prevention program found that 96&#46;9&#37; of patients were able to return to work after participating in the program&#46; In addition&#44; 82&#46;7&#37; were still working after 3 years and 75&#46;0&#37; remained in the same profession&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Treatment</span><p id="par0210" class="elsevierStylePara elsevierViewall">Treatment of hand eczema should be individualized based on numerous factors&#44; including age&#44; clinical history&#44; and profession&#46; Treatment recommendations should be tailored to the cause of the hand eczema and the morphology and location of the lesions&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows an algorithm for managing hand eczema in primary care&#46; The first step is to conduct a structured patient interview and a full physical examination&#46; This will guide the differential diagnosis and help decide on initial treatment&#46; General measures include avoidance of irritants and wet work and use of gloves and emollients &#40;<a class="elsevierStyleCrossRefs" href="#tbl0030">Tables 6 and 7</a>&#41;&#46; If necessary&#44; high-potency topical corticosteroids may be considered &#40;<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>&#41;&#46; Patients with chronic hand eczema must always be referred to a dermatologist for additional tests and a definitive etiologic diagnosis&#46; GPs should also consider granting the patient sick leave to enable full recovery&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a> summarizes the treatments available for hand eczema and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows an algorithm for managing hand eczema in specialist care settings&#46; Personalized follow-up is essential as long-term treatment effectiveness is often difficult to predict due to the lack of definitive randomized controlled trials evaluating and comparing the efficacy of different treatments&#46; In many cases&#44; it is also impossible to compare treatments across clinical studies because of variations in patient populations and a lack of standardized outcome measures&#46;</p><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">It is highly recommendable that acute hand eczema be treated as early as possible to prevent it from becoming chronic&#44; as chronic disease can be much more difficult to treat&#46; As widely known&#44; it is also essential to prevent re-exposure to irritants and allergens and to allow sufficient time for the skin barrier to regenerate&#46; One of the main goals of any treatment strategy should therefore be to identify exogenous causes and recommend lifestyle changes and preventive measures&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Topical Treatments</span><p id="par0225" class="elsevierStylePara elsevierViewall">Most cases of acute hand eczema can be adequately managed with a combination of preventive measures and topical treatments&#46; These include corticosteroids&#44; calcineurin inhibitors &#40;tacrolimus&#44; pimecrolimus&#41;&#44; iontophoresis&#44; tar&#44; and astringent and antiseptic solutions such as potassium permanganate and aluminium acetate&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Topical Corticosteroids</span><p id="par0230" class="elsevierStylePara elsevierViewall">Topical corticosteroids are the first-line treatment for hand eczema and can be highly effective in the short term &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49&#44;63</span></a> Long-term use&#44; however&#44; can inhibit repair of the stratum corneum and cause skin atrophy &#40;<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>&#41;&#46; Topical corticosteroids should only be used for longer than 6<span class="elsevierStyleHsp" style=""></span>weeks in exceptional circumstances and always under medical supervision&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The risk of immediate and delayed hypersensitivity reactions should also be considered&#46; Any reactions should be investigated by patch testing&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> As a general rule&#44; hand eczema should be treated with high-potency corticosteroids &#40;betamethasone valerate cream 0&#46;05&#37; or 0&#46;1&#37; or mometasone furoate cream 0&#46;1&#37;&#41; administered once a day&#46; A clinical trial involving 44 patients with hand eczema showed that once-daily application of a potent corticosteroid cream &#40;betamethasone valerate 0&#46;1&#37;&#41; was superior to twice-daily application&#44; especially in patients with moderate eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> According to a recent study&#44; approximately 50&#37; of patients with chronic hand eczema do not respond to corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Calcineurin Inhibitors</span><p id="par0235" class="elsevierStylePara elsevierViewall">Topical calcineurin inhibitors &#40;tacrolimus ointment 0&#46;1&#37; in patients &#8805;<span class="elsevierStyleHsp" style=""></span>16 years or 0&#46;03&#37; in patients &#60;<span class="elsevierStyleHsp" style=""></span>16 years&#59; pimecrolimus cream 1&#37;&#41; can be used in patients who do not respond or are allergic to topical corticosteroids&#46; One study comparing betamethasone and tacrolimus with an emollient showed that betamethasone and tacrolimus resulted in a higher ceramide&#47;cholesterol ratio and a lower inflammatory response&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> It has been suggested that a combination of calcineurin inhibitors and corticosteroids could be a useful option for longer-term treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Phototherapy</span><p id="par0240" class="elsevierStylePara elsevierViewall">Phototherapy is a standard treatment option for chronic hand eczema refractory to corticosteroids&#44; although the general opinion is that long-term treatment can increase the risk of skin cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The treatment of choice is PUVA &#40;topical psoralen and UV-A light&#41;&#44; although potential adverse effects include erythema and skin burns&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">A recent study showed the potential benefits of using a 308<span class="elsevierStyleHsp" style=""></span>nm excimer laser to treat chronic hand eczema&#59; the treatment produced a 69&#37; reduction in physician global assessment scores and a 70&#37; reduction in lesion and symptom scores&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> One advantage of excimer laser therapy is that by targeting specific sites&#44; it results in a lower cumulative dose of UV radiation than other UV treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Systemic Treatments</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Alitretinoin</span><p id="par0250" class="elsevierStylePara elsevierViewall">Alitretinoin &#40;9-cis retinoic acid&#41; has immunomodulatory and anti-inflammatory effects and is authorized for use in the treatment of severe chronic hand eczema that does not respond to or responds inadequately to topical corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49&#44;74&#44;75</span></a> It is therefore recommended as a second-line treatment in patients with chronic hand eczema refractory to topical corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Several clinical trials and studies have provided strong evidence for the safety and efficacy of alitretinoin in the treatment of severe&#44; refractory chronic hand eczema&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">76&#8211;78</span></a> In a large phase III trial involving patients with severe&#44; refractory chronic hand eczema&#44; 48&#37; of patients responded well to oral alitretinoin compared with 17&#37; for placebo at 24 weeks &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> A second phase III study involving 596 patients with severe chronic hand eczema showed similar results&#44; with a response rate of 40&#37; for alitretinoin versus 15&#37; for placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Another study analyzing the effectiveness of alitretinoin in patients with recurrent chronic hand eczema showed a response rate of 80&#37; compared with 8&#37; for placebo&#44; suggesting that intermittent treatment with alitretinoin is suitable for the long-term management of chronic hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> An observational study of 680 German adults with chronic hand eczema found that alitretinoin was effective in 56&#46;7&#37; of patients with different morphologic forms &#40;hyperkeratotic-fissured&#44; fingertip&#44; and vesicular&#41; and also showed that alitretinoin was both effective and well tolerated in routine clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Although the standard treatment duration for alitretinoin is 24 weeks&#44; good tolerance has been observed up to 48 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> A small Korean study showed that alitretinoin administered for just 12<span class="elsevierStyleHsp" style=""></span>weeks led to considerable improvement in 44&#46;4&#37; of patients with chronic hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> Recent evidence from clinical practice in Spain also showed that alitretinoin is effective in the treatment of chronic hand eczema&#44; and often produces satisfactory results after just 1 cycle&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">Although treatment with alitretinoin is well tolerated&#44; dose-dependent adverse effects have been observed&#46; These include headache &#40;20&#37; of patients on 30<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#44; mucocutaneous events&#44; hyperlipidemia&#44; and altered thyroid function&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79&#44;80</span></a> Based on data from postmarketing studies spanning 6 years&#44; additional adverse effects include nausea&#44; hypertriglyceridemia&#44; increased creatinine phosphokinase&#44; and depression&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> Long-term effects must also be considered as alitretinoin is teratogenic&#46; As such&#44; it should not be used during pregnancy or in the month preceding conception&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">A recent study showed that treatment with alitretinoin normalized the expression of several skin barrier genes&#44; such as thymic stromal lymphopoietin&#44; claudin 1&#44; loricrin&#44; filaggrin and cytokeratin 10&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> These changes were correlated with general clinical effectiveness&#44; suggesting that alitretinoin has a disease-modifying effect&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> It has been hypothesized that alitretinoin may benefit patients with dyshidrotic eczema by regulating aquaporin 3 and 10&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Observational studies of German patients with severe chronic hand eczema have shown that alitretinoin produces rapid and significant improvements in quality of life and work productivity measured by physician global assessment scores and various quality-of-life markers&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">89&#44;90</span></a> An Italian study of patients with chronic hand eczema also found that alitretinoin considerably improved patient quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Acitretin</span><p id="par0285" class="elsevierStylePara elsevierViewall">A retrospective study of acitretin in the treatment of chronic hand eczema showed that while the drug was effective&#44; it was associated with a higher incidence of adverse events than alitretinoin &#40;43&#46;1&#37; vs&#46; 29&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> Nevertheless&#44; the results of a recent study showed that low-dose acitretin induced clinical improvement in patients with various types of hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> Patients with hyperkeratotic hand eczema have been found to be more responsive&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> A pilot study conducted in Canada showed that acitretin was effective in 33&#46;3&#37; of patients with severe chronic hand eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> Acitretin&#44; like alitretinoin&#44; is a retinoid drug and as such has teratogenic potential&#46; It should not be used in women who might want to become pregnant within 3 years of stopping treatment&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Systemic Corticosteroids</span><p id="par0290" class="elsevierStylePara elsevierViewall">Current clinical practice guidelines suggest that systemic corticosteroids should not be used to treat severe chronic hand eczema for longer than 3 weeks&#46; Long-term use is not recommended due to the risk of potentially dangerous adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ciclosporin</span><p id="par0295" class="elsevierStylePara elsevierViewall">Ciclosporin has been used in patients with psoriasis&#44; atopic dermatitis&#44; and chronic hand eczema who have failed to respond to other treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The earliest studies of the use of ciclosporin in the treatment of hand eczema showed that oral ciclosporin was as effective as a topical corticosteroid &#40;beta-methasone-17&#44;21-dipropionate&#41; and offered equivalent improvements in quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#44;96</span></a> The drug also exhibited good long-term effectiveness&#44; even after short treatment periods&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a> A recent retrospective study showed that 62&#46;9&#37; of patients responded well to ciclosporin after 3 months of treatment and that response was particularly good in patients with recurrent vesicular hand eczema&#46; The median drug survival rate in patients with chronic hand eczema was 10&#46;3 months&#46; The main reasons for treatment interruption were adverse events&#44; particularly at the start of treatment&#44; and ineffectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> Patients on ciclosporin should be carefully monitored as there is a risk of serious adverse events such as nephrotoxicity and an increased risk of cancer&#44; a rise in blood pressure&#44; and infections&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Azathioprine</span><p id="par0300" class="elsevierStylePara elsevierViewall">There is limited evidence on the efficacy of azathioprine for the treatment of hand eczema&#44; but it is an option for patients in whom other treatments have failed or been insufficient&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In certain cases&#44; measurement of circulating 6-thioguanine nucleotide TGN&#41; and methylated 6-methylmercaptopurine levels at baseline and thereafter at regular intervals can help optimize dosage regimens&#44; improve clinical effectiveness&#44; and prevent adverse effects&#44; as azathioprine metabolites can cause hepatotoxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> Azathioprine has been approved for the treatment of <span class="elsevierStyleItalic">Parthenium</span> dermatitis in India&#44; where this condition is very common&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Other Treatments</span><p id="par0305" class="elsevierStylePara elsevierViewall">Methotrexate and mycophenolate can be used off-label as second- or third-line treatments for hand eczema&#44; but their use in this setting is supported by a low level of evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;101</span></a> In one study&#44; methotrexate administered over 8 to 12 weeks proved effective&#44; but subsequent loss of effectiveness and onset of adverse events led to its interruption&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">102</span></a> The drug also appears to be less effective than other systemic treatments such as acitretin&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a> Methotrexate has been used successfully in children with nummular eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> Oxybutynin&#44; an alternative treatment for hyperhidrosis&#44; has been found to improve coexistent dyshidrotic eczema&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">105</span></a><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0355" class="elsevierStylePara elsevierViewall">This document was funded by an unconditional grant from <span class="elsevierStyleGrantSponsor" id="gs0005">GlaxoSmithKline</span>&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of Interest</span><p id="par0360" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2019-03-07"
    "fechaAceptado" => "2019-04-21"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:8 [
            0 => "Chronic eczema"
            1 => "Dermatitis"
            2 => "Emollients"
            3 => "Topical corticosteroids"
            4 => "General practitioners"
            5 => "Hands"
            6 => "Diagnosis"
            7 => "Referral criteria"
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          "palabras" => array:8 [
            0 => "Eczema cr&#243;nico"
            1 => "Dermatitis"
            2 => "Emolientes"
            3 => "Corticoides t&#243;picos"
            4 => "M&#233;dico de atenci&#243;n primaria"
            5 => "Manos"
            6 => "Diagn&#243;stico"
            7 => "Criterios de derivaci&#243;n"
          ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Hand eczema is a common condition associated with significantly impaired quality of life and high social and occupational costs&#46; Managing hand eczema is particularly challenging for primary care and occupational health physicians as the condition has varying causes and both disease progression and response to treatment are difficult to predict&#46; Early diagnosis and appropriate protective measures are essential to prevent progression to chronic eczema&#44; which is much more difficult to treat&#46; Appropriate referral to a specialist and opportune evaluation of the need for sick leave are crucial to the good management of these patients&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">These guidelines cover the diagnosis&#44; prevention&#44; and treatment of chronic hand eczema and highlight the role that primary care and occupational health physicians can play in the early management of this disease&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">El eczema de manos es una patolog&#237;a frecuente con fuerte impacto en la calidad de vida de los pacientes y alto coste social y laboral&#46; Su manejo por los m&#233;dicos de atenci&#243;n primaria y de medicina del trabajo es complejo debido a la variedad de etiolog&#237;as&#44; la evoluci&#243;n dif&#237;cilmente predecible de la enfermedad y la respuesta al tratamiento&#46; El diagn&#243;stico precoz y las medidas protectoras adecuadas son esenciales para evitar la cronificaci&#243;n&#44; que es mucho m&#225;s dif&#237;cil de tratar&#46; Una correcta derivaci&#243;n a un especialista y la valoraci&#243;n de una baja laboral en el momento adecuado resultan cruciales para un buen manejo de estos pacientes&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">En esta gu&#237;a sobre el eczema cr&#243;nico de manos analizamos el proceso diagn&#243;stico&#44; las medidas preventivas y los tratamientos&#44; con especial &#233;nfasis en el papel del m&#233;dico de atenci&#243;n primaria y de medicina del trabajo en los estados iniciales de su manejo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">&#42;Please cite this article as&#58; Silvestre Salvador JF&#44; et al&#46; Gu&#237;a para el diagn&#243;stico&#44; el tratamiento y la prevenci&#243;n del eccema de manos&#46; Actas Dermosifiliogr&#46; 2020&#59;111&#58;26&#8211;40&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Etiologic diagnosis of hand eczema&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hand eczema management in primary care&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Treatment algorithm for hand eczema&#46; Education and lifestyle changes&#44; such as the use of emollients and protective gloves and avoidance of irritants and allergens are obligatory throughout all treatment phases&#46; Oral corticosteroids can be considered for flares&#46; Adapted from De Le&#243;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a>&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Irritant contact hand eczema</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normally affects interdigital spaces&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Caused by prolonged or repeated exposure to irritants&#44; frequent handwashing&#44; use of occlusive gloves&#44; alkaline substances&#44; or oils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Allergic contact hand eczema</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Affects the site of contact &#40;palms or fingertips&#41;&#44; although preferentially affects the dorsum of the hands or fingers&#44; where the skin is more vulnerable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Caused by allergen exposure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Erythema&#47;vesicular phases and subsequent excoriation&#44; scratching&#44; and lichenification tend to be easy to identify&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Protein contact hand eczema</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Initial phase characterized by wheals or eczematous lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Caused by food allergens&#44; latex&#44; or biologic materials&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Atopic dermatitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Often affects the wrists&#44; causes itching&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Previous history of atopic dermatitis&#44; asthma&#44; or rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vesicular hand eczema</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recurrent lesions with vesicular palmar eruption&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Can affect the lateral aspects of fingers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Caused by stress&#44; systemic contact dermatitis&#44; dust allergens&#44; and fungal infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hyperkeratotic hand eczema</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Well-demarcated hyperkeratotic areas on the palms of the hands&#44; without vesicles or pustules&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Some authors only consider eczema to be hyperkeratotic when preceded by a vesicular phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Types of Hand Eczema&#46;</p>"
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      4 => array:8 [
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          0 => array:3 [
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Personal and family history of allergies and skin diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Work-related history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Pattern &#40;acute&#44; chronic&#44; recurrent&#41;&#44; with description of flares and remissions in relation to work &#40;holidays&#44; weekends&#41;&#44; seasons&#44; and lifestyle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Exposure to irritants or allergens &#40;type&#44; duration&#44; frequency&#41; at work and home&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Handwashing habits&#44; skin care&#44; use of gloves&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Impact on quality of life &#40;social relationships&#44; work&#44; family life&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Factors to Investigate in a Patient With Possible Hand Eczema&#46;</p>"
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            "identificador" => "at0030"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Psoriasis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Family history of psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Well-demarcated hyperkeratosis&#44; discoid plaques&#44; palmar involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Involvement of scalp&#44; elbows&#44; knees&#44; buttocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Long-standing refractory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tinea manuum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Typically unilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mainly affects the palmar creases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Associated onychomycosis or tinea pedis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Differential Diagnosis&#46;</p>"
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            "identificador" => "at0035"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patch tests &#40;delayed hypersensitivity&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Always perform in patients with chronic hand eczema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Use baseline series &#40;GEIDAC series in Spain&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Interpret results in light of clinical history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Prick tests &#40;immediate hypersensitivity&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Use specific allergens from workplace or home&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Use fresh food to diagnose protein contact dermatitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Biopsy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Useful for differential diagnosis but results are difficult to interpret&#59; does not offer good diagnostic yield for differentiating between hand eczema and palmar psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lateral or dorsal aspects of the hand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical Tests Used to Diagnosis Chronic Hand Eczema&#46;</p>"
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            "identificador" => "at0040"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level of prevention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Possible preventive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="5" align="left" valign="middle">Primary</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use of gloves and hand moisturizers &#40;<a class="elsevierStyleCrossRefs" href="#tbl0030">Tables 6 and 7</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prevention of exposure through changes to regulations on permitted materials &#40;e&#46;g&#46;&#44; certain preservatives in cosmetics or chrome in cement products&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ventilation systems to reduce exposure to allergens or irritants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Specific health surveillance measures at the workplace to identify sensitized individuals before onset of symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General education on the use of gloves&#44; skin care products&#44; and other protective measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle">Secondary</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regular examinations at the workplace to identify and treat early symptoms of hand eczema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use of moisturizers and other preventive topical skin care measures&#44; led by a dermatologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Education at the workplace by dermatologists as part of specific skin care programs &#40;seminars&#44; leaflets&#44; workshops&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle">Tertiary</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consideration of temporary sick leave to prevent sensitization and allow sufficient time for full skin barrier restoration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multidisciplinary or multifaceted approach targeting patients with chronic hand eczema and involving dermatologists&#44; occupational medicine specialists&#44; and other healthcare professionals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275655.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Preventing Hand Eczema&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0045"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Use gloves during wet work&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Do not use gloves for long periods of time&#59; wear cotton gloves under any gloves that need to be worn for more than 15<span class="elsevierStyleHsp" style=""></span>minutes&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Change gloves regularly for jobs that involve wearing gloves all day &#40;have three pairs available&#41;&#46; Remember that wet gloves lose their protective capacity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Use intact gloves that are both clean and dry inside&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Use gloves suited to the type of material being handled&#58; cotton gloves for cardboard or paper&#44; leather gloves for solids&#44; disposable plastic gloves for food&#44; and vinyl&#44; nitrile&#44; or rubber gloves for liquids&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275662.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">General Measures&#58; Gloves&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Emollients can be used during all treatment stages and for all types of eczema&#44; except very acute eczema and highly fissured lesions&#44; as their absorption could favor sensitization to certain components&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Use oil-based emollients for scaling&#47;hyperkeratotic hand eczema and water-based emollients for exudative hand eczema&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212; Preferably use lotions and creams during the day and ointments at night&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275661.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">General Measures&#58; Emollients&#46;</p>"
        ]
      ]
      10 => array:8 [
        "identificador" => "tbl0040"
        "etiqueta" => "Table 8"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0055"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The most commonly used corticosteroids in the treatment of hand eczema are high-potency corticosteroids &#40;mometasone furoate cream 0&#46;1&#37; and betamethasone valerate cream 0&#46;05&#37; and 0&#46;1&#37;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use topical corticosteroids for short periods &#40;&#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>wk&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consider using oral corticosteroids to treat flares if the eczema is highly disabling and cannot be controlled using other measures&#46; Tapered dosage from 0&#46;5 to 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for 1 to 2 wk&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2275659.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Use of Corticosteroids&#46;</p>"
        ]
      ]
      11 => array:8 [
        "identificador" => "tbl0045"
        "etiqueta" => "Table 9"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0060"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Topical treatments</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Emollients</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Using emollients during working hours can increase sensitization&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatment adherence is important for optimal results&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emollient use may require supervision by a doctor or nurse&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="5" align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Topical corticosteroids</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Careful consideration should be given to potency and treatment duration&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Choose formulation based on lesion morphology and severity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rule out fungal infections before starting treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Topical corticosteroids can cause allergies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatments that must exceptionally last for &#62;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>wk require close supervision as they can cause skin atrophy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Calcineurin inhibitors</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Can be combined with topical corticosteroids to achieve longer disease-free periods&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Can be used during acute disease phases&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Systemic treatments</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Systemic corticosteroids</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use only in acute phases of disease&#59; not recommended for chronic hand eczema&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do not use for &#62;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>wk due to potential adverse effects&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="4" align="left" valign="middle"><span class="elsevierStyleHsp" style=""></span>Alitretinoin</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Approved for the treatment of chronic hand eczema that does not respond to topical corticosteroids&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alitretinoin can produce considerable improvements in chronic hand eczema after just 12<span class="elsevierStyleHsp" style=""></span>wk&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adverse effects may occur &#40;e&#46;g&#46;&#44; headache&#44; nausea&#44; hyperlipidemia&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Teratogenic&#59; avoid use in women who want to become pregnant&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttable-entry\n
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          "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0310" class="elsevierStylePara elsevierViewall">Hand Eczema&#58; Key Concepts<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Hand eczema is a multifactorial disease that is very common in the general population&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Early diagnosis and treatment is essential for preventing chronic disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Chronic hand eczema is eczema that persists for at least 3 months or recurs at least twice a year despite adequate treatment and treatment adherence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0330" class="elsevierStylePara elsevierViewall">There is no universally accepted classification of hand eczema&#44; but diagnostic subgroups can be established based on morphologic and etiologic criteria&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Hand eczema is diagnosed clinically based on history taking and physical examination&#46; Patch tests&#44; prick tests&#44; microbiological tests&#44; and skin biopsies are useful for ruling out other diseases or establishing an etiologic diagnosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0340" class="elsevierStylePara elsevierViewall">When faced with a case of hand eczema&#44; GPs should recommend adequate protection against irritants and moisture and correct usage of gloves and emollients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall">GPs should assess the need for sick leave in patients with chronic hand eczema and refer the patient to a specialist for additional tests&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall">As hand eczema is often work related&#44; risk prevention is essential in certain occupations&#46;</p></li></ul></p></span>"
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Información del artículo

ISSN: 15782190
Idioma original: Inglés

DOI:10.1016/j.adengl.2019.12.007

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