The European Society Contact Dermatitis Guideline provides diagnostic and treatment recommendations for hand eczema

An expert group convened by the European Society of Contact Dermatitis (ESCD) has published an updated clinical practice guideline for the diagnosis, prevention and treatment of hand eczema. The guidelines committee wrote that the guidelines, published in Contact dermatitisshould be valid until 2025, after which the recommendations will be updated “as new evidence becomes available”.

Recommendations for prevention

The Guideline Development Group (GDG) on behalf of the ESCD has provided the following recommendations for the prevention of hand eczema:

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• Provide health education and training to high-risk individuals (e.g., hairdressers, healthcare workers, metalworkers, etc.) designed to motivate appropriate skin-protective behaviors (consensus-based recommendation ).
• Implement secondary prevention strategies early in affected patients to prevent disease relapse or progression (consensus recommendation).
• Offer tertiary prevention to patients with severe hand eczema or chronic hand eczema to reduce disease severity and adverse sequelae for more optimal long-term disease control (consensus-based recommendation) .

According to the GDG, the prevention of hand eczema should aim to identify and reduce or eliminate occupational and non-occupational causative exposures and ensure the maintenance of an intact skin barrier. In addition, the ESCD guidelines committee noted that clinicians should consider endogenous risk factors and other individual risk factors when making decisions about preventive strategies.

The guidelines committee noted that proper risk assessment is essential to identify and minimize harmful dermal exposures, citing STOP (substitution/elimination, technological measures, organizational measures and personal protective equipment) as a useful hierarchy of measures prevention that can be tracked in these assessments. (Table 1)

TABLE 1. Hierarchy of preventive measures (STOP principle) for hand eczema

Health education on the pathogenesis of hand eczema and the use of preventive measures is also suggested by the GDG “to improve the individual’s motivation and ability to apply appropriate protective measures as well as to foster a sense of empowerment in terms of taking charge of his/her own health.

Recommendations for diagnosis

Several recommendations were made by the ESCD steering committee on the examination and diagnosis of hand eczema:

• Carry out a careful anamnesis including a search for personal and professional exposures, as well as a clinical examination of the hands and the entire cutaneous integument (consensus recommendation).
• Perform diagnostic patch tests in all patients with hand eczema for more than 3 months or in patients not responding to adequate treatment, or in case of clinical suspicion of contact allergy (consensus recommendation).
• Perform patch testing with a reference series, extended by selected additional series/allergens, based on exposure (consensus-based recommendation).

The GDG said an exposure assessment can support the identification of an etiological cause of hand eczema and therefore “plays an important role in the implementation of specific preventive measures”. The Guidelines Committee made the following recommendations on the assessment of exposure to hand eczema:

• Perform an exposure assessment, using all available sources (e.g. ingredient labels and safety data sheets), prior to skin and prick testing, to identify potential environmental allergens to include in testing (consensus-based recommendation).
• Perform a qualitative and, if possible, quantitative assessment of exposure to the identified allergen following any positive patch-test or prick-test (consensus recommendation).

In addition, the GDG has made the following consensus recommendations for the classification of hand eczema:

• Etiological subtypes: allergic contact dermatitis; protein contact dermatitis/contact urticaria; atopic eczema of the hands.
• Clinical subtypes: Hyperkeratotic palmar eczema of the hands; acute recurrent vesicular eczema of the hands; nummular eczema of the hands; pulpitis (eczema on the fingertips).
• Mixed forms: More than one etiological and clinical subtype may be present.

Recommendations for treatment

Several treatment recommendations for hand eczema were made by the guideline committee:

General processing principle

• Identify and avoid responsible exogenous factors (consensus recommendation).

Emollients/Moisturizers

• All patients should use emollients/moisturizers frequently (consensus recommendation).
• Consider the patient’s skin condition, preferences, and existing (contact) allergies to personalize emollient choice (consensus-based recommendation).

Topical corticosteroids

• Initiate topical corticosteroids as first-line, short-term treatment (consensus recommendation).
• Long-term intermittent use of topical corticosteroids as maintenance therapy may be considered, but evidence for the effectiveness of this approach is limited (consensus-based recommendation).

Topical calcineurin inhibitors

• Tacrolimus ointment is offered as a short-term treatment for hand eczema (grade of recommendation: B).
• Tacrolimus ointment is suggested for patients with hand eczema who are either refractory to topical corticosteroids, fearful of topical corticosteroid side effects, or in the chronic stage of the disease (consensus recommendation).

Phototherapy

• Phototherapy is proposed for the hands of adult patients with chronic hand eczema refractory to topical corticosteroids (consensus recommendation).

The guidelines committee noted in a consensus statement that long-term use of phototherapy may increase the risk of skin malignancy.

Systemic treatment

• Initiate alitretinoin as a second-line treatment (compared to topical treatment) in patients with severe chronic hand eczema (consensus recommendation).
• Short-course oral corticosteroids are only offered for acute and severe inflammation as part of a treatment plan (consensus recommendation).
• Cyclosporine is suggested in patients with chronic hand eczema refractory or contraindicated to first and second line treatments (consensus recommendation).
• Azathioprine may be considered in patients with chronic hand eczema refractory or contraindicated to first- and second-line treatments (consensus recommendation).
• Methotrexate may be considered in patients with chronic hand eczema who are refractory or contraindicated to first- and second-line treatment (consensus recommendation).
• Acitretin may be considered in patients with chronic hyperkeratotic hand eczema if other treatments are unavailable or contraindicated (consensus recommendation).

Reference

Thyssen JP, Schuttelaar MLA, Alfonso JH, et al. Guidelines for the diagnosis, prevention and treatment of hand eczema. Contact dermatitis. 2022;86(5):357-378. doi:10.1111/cod.14035