Hand eczema is a very common condition that affects an estimated 10% of the general population.1 It accounts for 80% of all occupational skin diseases and is a common cause of sick leave.2 In Spain, however, there are no national guidelines on how to prevent, diagnose, or treat this condition. The European guidelines for the diagnosis, prevention, and treatment of chronic hand eczema were published in 2015,3 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).

The document was prepared in several phases involving the review of existing evidence in various cycles of analysis and discussion. The process is described below:

• 1

  Four 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,3 the position paper of the European Cooperation in Science and Technology COST Action StandDerm (TD1206),2 the Canadian dermatitis management guidelines,4 and the Danish Contact Dermatitis guidelines for the diagnosis and treatment of hand eczema.5

• 2

  The 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.

• 3

  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. 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).

Hand 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.6 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.3

Numerous studies have described the prevalence of hand eczema in the general population and varying professions.1,7 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%.1 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.8 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.9 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.10 In Denmark, the 1-year prevalence rate observed for hand eczema in adults aged 28 to 30 years was 14.3%.11

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.12 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.13 In the Swedish study of adolescents with hand eczema, 27.0% of patients had moderate to severe disease.9 Hand eczema tends to follow a relapsing, remitting course, and severity can change rapidly in individual patients.

As 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.41

Skin barrier disruption has a pathogenic role in chronic hand eczema and can lead to both irritant and allergic disease.42 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.42 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.43

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.44

Interleukins (ILs), such as IL-1 (IL-36α), may be involved in chronic hand eczema skin inflammation,45 and IL-36α may therefore become a useful biomarker for helping in the complex diagnosis of chronic hand ezcema.45

Proper 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.5,6,46,47

The most common types of hand eczema are shown in Table 1.3,6,48,49 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.50 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.5,49 Mixed forms of chronic hand eczema are common.6,50 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.51 Contact and atopic dermatitis may also coexist.52–54

Diagnosis 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.3,49

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 Table 2. A note of the most significant findings from the interview should always be made in the patient’s medical record.

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.6,54 Some of the key aspects that should be considered in the differential diagnosis are shown in Table 3. 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.6,54

The clinical tools available for diagnosing chronic hand eczema are summarized in Table 4. 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.55 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.

An algorithm to help identify the cause of chronic hand eczema is shown in Fig. 1. Patch tests are essential for diagnosing chronic allergic contact hand eczema.56 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.51,56

Fig. 1.

Etiologic diagnosis of hand eczema.

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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.

Measures 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 Table 5.

Primary 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.2 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.2

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.57,58 Accelerator-free medical gloves may be an effective alternative for healthcare professionals allergic to rubber accelerators.59

Protective gloves are the most important primary prevention measure (Table 6). 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.2 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.2 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.49

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.60,61 The strategy, however, did not appear to be cost-effective.62

The 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.49,63 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.64 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.65

Protective creams and emollients are very important as they can prevent early disease from progressing (Table 7). 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.49 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.66 There is, however, limited evidence on the clinical effectiveness of specific formulations and as such no definitive recommendations can be made.3 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.67

Tertiary 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.3 The Osnabrück model has been proposed as an effective long-term strategy for patient rehabilitation.68,69 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.68

Treatment 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. Fig. 2 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 (Tables 6 and 7). If necessary, high-potency topical corticosteroids may be considered (Table 8). 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.

Fig. 2.

Hand eczema management in primary care.

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Table 9 summarizes the treatments available for hand eczema and Fig. 3 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.

Fig. 3.

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.49.

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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.3

Most 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.3

This document was funded by an unconditional grant from GlaxoSmithKline.

The authors declare that they have no conflicts of interest.