“CLINICOEPIDEMIOLOGICAL AND ETIOLOGICAL STUDY OF HAND...
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“CLINICOEPIDEMIOLOGICAL AND ETIOLOGICAL
STUDY OF HAND ECZEMA”
Dissertation Submitted in Partial fulfillment of the University regulations for
MD DEGREE IN
DERMATOLOGY, VENEREOLOGY AND LEPROSY
(BRANCH XX)
MADRAS MEDICAL COLLEGE
THE TAMILNADU DR. M.G.R. MEDICALUNIVERSITY,
CHENNAI
MAY 2018
CERTIFICATE
Certified that this dissertation titled “CLINICO-
EPIDEMIOLOGICAL AND ETIOLOGICAL STUDY OF HAND
ECZEMA” is a bonafide work done by Dr. SHARMILA RAO.V, Post
graduate student of the Department of Dermatology, Venereology and
Leprosy, Madras Medical College, Chennai – 3, during the academic year
2015 – 2018. This work has not previously formed the basis for the award
of any degree.
Prof.Dr. U.R. DHANALAKSHMI Prof.Dr. K. NARAYANABABU MD., D.D., D.N.B., M.D., D.C.H., Professor and Head Dean Department of Dermatology Madras Medical College & Madras Medical College& Rajiv Gandhi Govt. General Hospital Rajiv Gandhi Govt. General Hospital Chennai-600 003 Chennai-600 003.
DECLARATION
The dissertation entitled “CLINICOEPIDEMIOLOGICAL AND
ETIOLOGICAL STUDY OF HAND ECZEMA” is a bonafide work
done by Dr. SHARMILA RAO.V at Department of Dermatology,
Venereology and Leprosy, Madras Medical College, Chennai – 3, during
the academic year 2015 – 2018 under the guidance of Prof.
Dr. S. NIRMALA M.D., Professor, Head of Department, Department of
occupational and contact dermatitis, Madras Medical College, Chennai.
This dissertation is submitted to The Tamil Nadu Dr. M.G.R.
Medical University, Chennai towards partial fulfillment of the rules and
regulations for the award of M.D Degree in Dermatology, Venereology
and Leprosy (BRANCH – XX)
Prof. Dr. S. NIRMALA, M.D,
Professor and Head of Department
Department of Occupational and Contact Dermatitis
Madras Medical College
Chennai-3
DECLARATION
I, Dr. SHARMILA RAO.V solemnly declare that this dissertation
titled “CLINICOEPIDEMIOLOGICAL AND ETIOLOGICAL
STUDY OF HAND ECZEMA”is a bonafide work done by me at
Madras Medical College during 2015-2018 under the guidance and
supervision of Prof. Dr.U. R. DHANALAKSHMI, M.D., D.D., D.N.B.,
Professor and Head of Department, Department of Dermatology, Madras
Medical College, Chennai-600003.
This dissertation is submitted to The Tamil Nadu Dr. M.G.R.
Medical University, Chennai towards partial fulfillment of the rules and
regulations for the award of M.D Degree in Dermatology, Venereology
and Leprology (BRANCH – XX).
PLACE: …………………………
DATE : DR.SHARMILA RAO.V
SPECIAL ACKNOWLEDGEMENT
My sincere thanks to Dr. R. NARAYANA BABU M.D., D.C.H., Dean,
Madras Medical College, Chennai-3 for allowing me to do this
dissertation and utilize the Institutional facilities.
ACKNOWLEDGEMENT
I am grateful to the Professor and Head of the Department of
Dermatology, Prof. Dr. U.R. DHANALAKSHMI, M.D., D.D., D.N.B.,
for her advice, guidance and encouragement for my study.
I would like to express my sincere and heartfelt gratitude to
Prof. Dr. S. KALAIVANI, M.D., D.V., Director and Professor, Institute
of Venereology, for her kindness and support throughout the study.
I sincerely thank my guide Prof. Dr. S. NIRMALA M.D., Professor
and Head of Department, Department of Occupational and Contact
Dermatitis for her valuable support. She has been a source of constant
motivation and encouragement throughout the study. I am extremely
grateful to her for guiding me throughout the study.
I sincerely thank Prof. Dr. R. PRIYAVATHANI ANNIE MALATHY,
M.D., D.D., D.N.B., M.N.A.M.S., Professor of dermatology for her help
and support.
I thank Prof. Dr. S. KUMARAVEL, M.D., D.D., Professor of
Dermatology for his advice and encouragement.
I thank Prof. Dr. V. SAMPATH M.D., D.D., Professor of Dermatology
for his advice and encouragement.
I thank Prof. Dr.A.RAMESH M.D., D.D., D.N.B., Professor of
Dermatology for his advice and encouragement.
I am grateful to Prof. Dr. J. MANJULA, M.D., D.N.B., Professor,
Department of Dermatology for her invaluable guidance, help and
encouragement.
I humbly thank my Co-Guide Dr.V.N.S. AHAMED SHARIFF,
M.D.D.V.L., Senior Assistant professor, Department of Dermatology for
his valuable guidance throughout my work. I would like to express my
sincere and heartfelt gratitude for the time which they devoted for my
research project.
I extend my gratitude to Dr.R. MADHU, M.D.,
(Derm) D.C.H., Dr. SAMUEL JEYARAJ DANIEL M.D.D.V.L.,
Dr.B.VIJAYALAKHSMI M.D.D.V.L., Dr.K.UMAMAHESWARI,
M.D.D.V.L., Dr.R.MANIPRIYA, M.D.D.V.L.,D.C.H and
Dr.C.L.CHITRA, M.D.DV.L, Dr. K. DEEPA M.D.D.V.L Assistant
professors, Department of Dermatology for their kind support and
encouragement.
I also thank my Assistant Professors Dr. P. PRABHAKAR,
M.D.D.V.L., Dr. C. VIDHYA, M.D.DVL., Dr.R.HEMAMALINI,
M.D.D.V.L., Dr.H.DHANASELVI, M.D.D.V.L., Dr.K.GAYATHRI,
M.D.D.V.L., Dr.E.BALASUBRAMANIAN M.D.D.V.L and
Dr.R.SNEKAVALLI M.D.D.V.L, DR.TAMIL SELVI M.D.D.V.L.,
DR.T.VANATHI M.D.D.V.L Institute of Venereology for their able
guidance.
I am thankful to my colleagues for their support throughout the
study. I am also grateful to all paramedical staffs for rendering timely
help to complete my study. Last but not the least I am profoundly grateful
to all patients for their co-operation and participation in this study. They
have been the principal source of knowledge which I have gained during
the course of my clinical research.
CERTIFICATE - II
This is to certify that this dissertation work titled
“CLINICOEPIDEMIOLOGICAL AND ETIOLOGICAL STUDY
OF HAND ECZEMA” of the candidate DR.SHARMILA RAO.V with
registration number 20153008 for the award of MD in the branch of
DERMATOLOGY, VENEREOLOGY AND LEPROLOGY.
I personally verified the urkund.com website for the purpose of
plagiarism Check. I found that the uploaded thesis file contains from
introduction to conclusion pages and result shows 11% percentage of
plagiarism in the dissertation.
……………………………………
Guide & Supervisor sign with Seal
CONTENTS
S.No. Title Page
1. Introduction 1
2. Review of literature 3
3. Aims & objectives 46
4. Methodology 48
5. Results 55
7. Discussion 71
8. Conclusion 78
9. Bibliography 80
10. Annexure 89-99
10.1 Proforma 89
10.2 Consent Form 94
10.3 Information Sheet 99
11 Master chart 103
ABBREVIATIONS
HE Hand eczema
ICD Irritant contact dermatitis
ACD Allergic contact dermatitis
MCBT Mercaptobenzothiazole
PPD Paraphenylenediamine
Introduction
1
Hand eczema, a condition referring to dermatitis which is confined
to hands occurs due to multiple endogenous and exogenous causes1. The
term hand eczema was first used by a physician Aetius Amidenus in the
sixth century2 The definition of eczema goes as` "an inflammatory skin
reaction characterized histologically by spongiosis with varying degrees
of acanthosis, and a superficial perivascular lymphohistiocytic infiltrate."
Clinically presents as itching, erythema, scaling, papulovesicles,
hyperkeratosis, or fissuring. The most common causes being due to
household activities or occupational. It usually runs a chronic course. The
disease commonly presents in an acute, sub acute or chronic pattern.
Acute phase is characterised by oozing lesions, sub acute phase by
scaling and crusting and chronic phase by lichenification.
This disease is of concern because the hands are affected which in
turn affects the person’s day to day quality of life. Some patients
experience difficulty in performing their routine activities3. Sometimes
even forces the patient to change their occupation. Identifying the cause
and eliminating it remains the main mode of management. A careful
history and clinical examination helps in finding the cause and identifying
the allergen (sensitising substance) in case of allergic contact dermatitis.
2
In instances where the offending agent cannot be found out by history and
clinical examination, patch testing with a series of antigen helps to
find out the incriminating agent. When the allergen is identified, avoiding
it helps to cure, or at least reduce the severity of eczema.
Atopic patients have a defective skin barrier and prone to develop
hand eczema both by irritants and allergens. So, a family and a personal
history of atopy should be elicited and if present appropriate protective
measures and treatment can be given. In India, very few studies have
been conducted regarding the demographic profile and the prevalent
morphology of hand eczema which is essential for knowing the burden of
the disease. This indirectly also prompts the government for allocation of
resources for research and treatment of this disease.
Moreover, sensitising substances varies according to locality,
occupation, socio economic status and environmental factors. Thus, this
study was done to assess the demographic profile, risk factors, and
incidence of atopy in hand eczema, most prevalent morphological pattern
and common sensitising agent of hand eczema in a tertiary care set up of
our hospital in Chennai.
Review of literature
3
Eczema which literally means ‘to boil’ is the inflammation of the
skin which occurs in a wide range of dermatoses characterized by itching,
dryness, erythema, excoriation, exudation, fissuring, hyperkeratosis,
scaling, vesiculation and lichenification. It is classified as acute, sub acute
and chronic forms characterised by vesicles and oozing lesions, scaling
and crusting, lichenification respectively. Hand eczema implies that the
dermatitis is largely confined to the hands, with either none or limited
involvement of other areas of the body4. Hand eczema usually has a
multifactorial aetiology which makes the treatment difficult. Hand
eczema is quite a stressful condition and has a significant impact on the
quality of life. Various morphological forms of hand eczema can have
several different causes. Similarly, a single cause can produce various
morphological patterns.
The most commonly adopted classification of hand eczema is as
follows5
4
CLASSIFICATION OF HAND ECZEMA
Etiological classification
EXOGENOUS ENDOGENOUS
Irritant contact dermatitis
a) chemicals like soaps,
detergents, solvents
b) physical like friction, trauma,
cold dry air
Idiopathic
Allergic contact dermatitis Immunological (atopic)
Ingested allergens Psycho-somatic(stress)
Protein contact dermatitis Dyshidrotic
Secondary dissemination
5
Morphological classification
Apron eczema Hyperkeratotic palmar eczema
Chronic acral dermatitis Pompholyx
Nummular dermatitis (Discoid
eczema)
Recurrent focal palmar peeling
Fingertip eczema Ring eczema
Gut eczema ‘Wear and tear’ dermatitis (dry
palmar eczema)
Other patterns (e.g. patchy vesiculo-squamous)
Epidemiological Profile
The exact prevalence of hand eczema has been difficult to estimate
because it is under reported. Around 2-10% of general population
experience minor degree of hand eczema at least once in their lifetime.
Almost, 20-35% of other dermatitis affects the hands. It comprises 9-35%
of all occupational disease and up to 80% of occupational contact
dermatitis.6
Females are affected more commonly than males (2:1), possibly
due to frequent and prolonged exposure to wet work and household
chemicals7.
6
Median incidence was found to be 9.6 per 1000-person years in
women and 4 in men. Young women report more of hand eczema than
elder women. This has been found in a Swedish health survey in which
one-year prevalence of hand eczema decreased from 12% in women aged
19-20 years to 6% in women aged 70-80 years.8 In men some studies
have shown reduction in frequency as age increases and in some studies,
there is no change in frequency as age advances. But the Indian study
shows an increase in the incidence of hand eczema in men in recent years
with almost 54% of the patients in the age group between 21-40 years.
In both sexes hand eczema has rarely been reported in age group
less than 20 years and elder than 61 years9. Handa et el reported in his
study out of 100 patients, only 7 were of age less than 20 years and 6
were more than 60 years of age10. This may be due to the reason that
elderly people have certain defects in induction and elicitation of allergic
contact dermatitis. Children have a limited exposure to allergens which
might explain fewer incidences in children. Prevalence of hand eczema
varies according to the geographical region. In a Swedish study including
20,000 individuals in the age group of 20 and 65, the prevalence was
found to be 11%11.
In a multicentre study of 4825 patients in eight European Centres,
by the International Contacts Dermatitis Research group reported that the
hands alone were affected in 36% of men and 30% of women12.
7
In an Indian contact dermatitis outpatient department, two third of the
patients had hand involvement13.
The most common cause of hand eczema is contact irritants. In
Meding's study, 35% had irritant dermatitis,22% had atopic eczema,19%
had allergic contact dermatitis. Females were found to have higher
incidence than males. In one study conducted in Rajasthan, higher
incidence was found in male, nickel was identified as the most common
sensitizer in females and potassium dichromate in males14.Similarly, in
another study conducted in Chandigarh, men outnumbered women.
Potassium dichromate was common sensitizer followed by fragrance mix
and nickel15 A total of 32% of the patients had one or more positive
reactions to the standard series16.
PREDISPOSING FACTORS
1) Atopic dermatitis
Atopy is the most common endogenous cause of hand eczema.
Development of hand dermatitis may be the first manifestation of atopic
state in adolescent or young adult when they get exposed to occupational
irritants or allergens. The involvement may be patchy and discoid pattern
may occur. There may be associated involvement of foot also. If the
patient had history of atopic dermatitis in childhood there is high chance
to develop hand eczema in later life17.
8
2) Irritant contact dermatitis
Contact irritants have been found out to be the most common
exogenous cause of hand eczema. Irritants like detergents, wet work,
alkaline agents, and cutting oils, organic Solvents, mineral oil and
friction causes hand eczema. This may be due to chemical irritants like
soaps, detergents, solvents or physical irritants like friction, minor trauma
and cold air. The patient complaints more of burning sensation than
pruritus. A person is susceptible to develop hand eczema if he/she
remains with wet hands for more than 2 hours daily, washes hands > 20
times / day, wears tight fitting gloves for around 2 hours per day18.
3) Allergic contact dermatitis
Allergic contact dermatitis is a well-known exogenous cause of
hand eczema. It may be the individual factor or may be associated with
irritant and/or atopic dermatitis. The common allergens are nickel, cobalt,
PPD, potassium dichromate, fragrance-mix, balsam of Peru, and
colophony19. Increased nickel sensitivity in adolescents’ due to ear
piercing with nickel needle and dental braces coated with nickel. Oral
ingestion of allergens like nickel and chromium also aggravates hand
eczema.
9
Formaldehyde and methyl dibromo glutaronitrile have also been found
out to be sensitizers20, 21 Allergic contact dermatitis to Parthenium
hysterophorus has also been frequently reported22.
4) Protein contact dermatitis
Protein contact dermatitis usually presents as chronic or recurrent
fingertip eczema. Contact with the proteins in fruits, vegetables, spices,
plants, animal proteins, grains, and enzymes causes dermatitis and can
present as urticarial or vesicular lesions within minutes of contact.
Patients may complain of stinging, burning, or itching lasting for 30
minutes to 3 hours. Initial lesions may be urticarial but with repeated
exposures eczema develops23. Food handlers, cooks and housewives are
at risk. It is a type I hypersensitivity reaction mediated by allergen-
specific IgE in a sensitized person.
5) Hormonal Factors
Premenstrual exacerbation and worsening during pregnancy has
been-reported suggesting a role of hormonal factors24.
10
6) Genetic Factors
Loss‐of‐function mutations of the filaggrin gene have been found
to be associated with early onset and resistant hand eczema in atopic
subjects. These patients develop digital fissures more commonly25.
7) Environmental factors
Most common exogenous cause of hand eczema is due to contact
irritants. Contact allergens including chromate, epoxy glues and rubber
are also important26. All patterns of hand eczema are possible in contact
allergy.
Certain occupations are particularly likely to provoke hand eczema.
Occupational eczema has been observed in barbers, fisherman, farmers,
construction workers, medical personnel, metal workers and caterers.
This observation has led various studies to determine the prevalence and
to initiate programmes for the prevention of hand dermatitis. Type 1
hypersensitivity reactions to some proteins can also cause hand eczema.
May cause a vesicular eczema of the fingers, especially in patients who
prepare seafood.
11
In health care workers allergy to latex in the gloves is the main
problem. It can cause contact urticaria to rhinitis, asthma and even
anaphylaxis.
Ingestion of allergens like as nickel, chromium or balsam of Peru
has been found to cause or aggravate hand eczema in sensitized
individuals27.
12
PATHOGENESIS
IRRITANT CONTACT DERMATITIS
Irritant is a substance which causes direct damage to skin and
causes loss of protective layer of the epidermis. In ICD, there is no prior
sensitization or immunological reactions28. The severity of dermatitis
produced by an irritant depends on the type of exposure, vehicle and the
person’s susceptibility. Macerated and thin skin is more susceptible than
dry and thick skin. Cumulative irritant dermatitis common in dorsum of
the hands and web spaces of the fingers.
In chronic irritant contact dermatitis, there is disturbed barrier
function and acute ICD there is inflammatory reaction which involves the
mediators like TNF-α, IL-1, IL-6, IL-8, IFN-γ, IL-2, and granulocyte
monocyte-colony stimulatory factor 29.
ALLERGIC CONTACT DERMATITIS
Allergic contact dermatitis is a type IV hypersensitivity reaction
only affecting previously sensitized individuals. A common example of
allergic contact dermatitis is the allergic reaction to plants, such as poison
ivy, poison oak, and poison sumac. Contact allergen is generally of size
smaller than 500 D, so capable of penetrating deeper through the skin and
gets conjugated with autologous proteins following which sensitization
takes place30. Two distinct phases in a type IV hypersensitivity reaction
are the induction (i.e., sensitization) phase and the elicitation phase.
13
During the induction phase, an allergen, or hapten, penetrates the
epidermis, where it is picked up and processed by an antigen-presenting
cell. Most allergens in contact dermatitis are of low molecular weight and
require minimal processing. Antigen-presenting cells are Langerhans
cells, dermal dendrocytes, and macrophages. The processed antigen is
presented to T-lymphocytes in the regional lymph nodes. Differentiates
into memory cells and effector T lymphocytes that are released into the
blood stream.
The elicitation phase occurs when the sensitized individual is again
exposed to the antigen. Clinically visible reaction develops in 24-48 hrs.
Activated keratinocytes secrete IL-1 and express HLA DR on their
surface and augments the function of Langerhans cell. They present
antigen to the specific memory T cells in epidermis and elicit a rapid
inflammatory response. Once acquired, contact sensitivity tends to
persist. The degree of sensitivity may decline unless there is by repeated
exposure, but with a high initial level of sensitivity, it may remain
demonstrable throughout life 31.
14
CLINICAL VARIANTS
HYPERKERATOTIC PALMAR ECZEMA (TYLOTIC ECZEMA)
This type of eczema is characterised by pruritic, thickened scaly
fissured hyperkeratotic lesions over the palms and inner aspects of
fingers. Vegetables like onion and garlic, metals like nickel, detergents,
rubber are common allergens. Vegetables like onion and garlic have also
been incriminated. This type of hand eczema is usually confused with
psoriasis. In one Indian study of 230 patients with hyperkeratotic hand
eczema, about 130 patients had a positive patch test32 . This type is very
resistant to treatment.
.
HYPERKERATOTIC ECZEMA
15
POMPHOLYX
This type of hand eczema is characterised by vesicles in the palms
and soles named cheiropompholyx and podopompholyx respectively. It is
otherwise called dyshidrotic eczema. Pompholyx comprises about 5-20%
of all the hand eczemas. Most commonly occurs in hot weather and
palmoplantar hyperhidrosis. Many patients have an associated atopy.
There will be deep seated vesicles with severe itching and sago grain feel
on palpation. They dry up with peeling of overlying skin. Each episode
subsides spontaneously in 2-3 weeks. In a study conducted by Lodi et al,
nickel was found to be the commonest allergen33 followed by chromium,
cobalt and fragrance mix. So, patch testing should be performed in
recurrent pompholyx.
POMPHOLYX
16
APRON ECZEMA
This condition is characterised by involvement of the proximal
palmar aspect of two adjacent fingers and the palmar skin over the
metacarpophalangeal joints resembling an apron. Cause may be irritant,
allergic or endogenous34.
A P R O N E C Z E M A
CHRONIC ACRAL DERMATITIS
A chronic, pruritic, hyperkeratotic, papulovesicular eczema of hands and
feet, associated with elevated IgE levels. But generally, there is no
personal or family history of atopic tendencies35.
17
FINGERTIP ECZEMA
This condition involves the palmar surface of tips of few or all of
the fingers. Initially starts as moist lesion and later skin is dry cracked and
sometimes break down into painful fissures. May be localized or
occasionally extend to the palmar surfaces of the fingers. Two patterns
are recognised. The first form involves most of the fingers of the
dominant hand, particularly forefinger and thumb. This condition usually
worsens in winter and improves during holiday. This is a cumulative
irritant dermatitis where degreasing agents in combination with trauma
acts as causative factors; patch tests are negative. The second one
preferentially involves the thumb, forefinger and third finger of one hand.
This is generally occupational and either irritant or allergic. The condition
commonly involves the dominant hand, but allergy to onions, garlic or
due to kitchen products held in non‐dominant hand can be the cause. Here
patch testing may be useful.
F I N G E R T I P E C Z E M A
18
‘GUT’/SLAUGHTERHOUSE ECZEMA
Workers who cut and clean pig carcasses develop vesicular eczema
which starts in finger webs and spreads to the sides of the fingers. This is
a self‐limiting condition, even if patient continues to work, but recurrence
occurs
PATCHY VESICULOSQUAMOUS ECZEMA
This type of eczema has combination of irregular, vesiculo-
squamous and patchy lesions occurring on both hands asymmetrically.
Nail changes can occur if the nail folds are involved.
V E S I C U L O S Q U A M O U S E C Z E M A
19
RECURRENT FOCAL PALMAR PEELING
A milder form of pompholyx, also referred as desquamation en
aires, ringed keratolysis, keratolysis exfoliativa. During the summer
months, small areas of superficial, white desquamation develop on the
sides of the fingers and on the palms or on the feet. They have abrupt
onset and later peels off. Irritation may or may not be there and vesicles
are not seen. The condition is relatively asymptomatic.
FOCAL PALMAR PEELING
20
RING ECZEMA
This pattern affects young women and men. Slightly irritable patch
begins beneath a ring, generally a wide wedding ring and spreads to
involve the adjacent side of the middle finger and palm. This may be
confined, but sometimes followed by formation of discoid shaped patches
elsewhere or a generalised vesicular eczema. These patients are generally
not sensitive to gold but nickel, cobalt, chromium sensitivity may be
found on patch testing. Ring dermatitis can be a manifestation of
fragrance sensitization. If the ring is changed to other hand, there will be
same manifestation in the other hand also and wearing the ring for a few
minutes can cause irritation.
Mainly soaps and detergents accumulated under the ring and
friction may be the cause. On rare occasion, radioactive gold present in
the ring can cause radiation dermatitis can mimic this type of hand
eczema
.
21
R I N G E C Z E M A
WEAR AND TEAR DERMATITIS /DERMATITIS PALMARIS
SICCA/FRICTIONAL DERMATITIS/HOUSEWIVES ECZEMA
It is a cumulative irritant contact dermatitis due to household
products like soap, detergents, and cleansers. Friction and trauma may
play a role. Atopics are more vulnerable. Affects palmar and dorsal
surface of fingers, interdigital spaces and knuckles. Also called as
dermatitis palmaris sicca due to erythematous glazed appearance.
WEAR & TEAR DERMATITIS
22
NUMMULAR DERMATITIS
This type of hand eczema is also called as discoid eczema as it
appears as rounded plaque resembling a coin. May be limited to hands or
may be generalised exudative or dry type. Increased incidence of
association with atopy has been found out.
NUMMULAR DERMATITIS
23
DIFFERENTIAL DIAGNOSIS
Hand eczema can be clinically diagnosed but can be difficult to
differentiate from psoriasis and may become apparent only over time with
development of psoriatic lesions at other sites. Skin biopsy may be
required in some cases. Silvery scales, lesions over the knuckles, sharply
marginated ‘scalloped’ erythema along the borders of the fingers, and the
absence of itching, presence of nail pits, family history of psoriasis points
towards psoriasis.
Tinea manuum can mimic hand eczema. Unilateral scaling of the
palm should raise the suspicion of Trichophyton infection, and a discoid
shaped plaque due to Trichophyton verrucosum, pityriasis rubra pilaris
and lichen planus sometimes resemble hand eczema but usually has
typical lesions at other sites. Palmoplantar pustulosis can look similar to
pompholyx. A pustular bacteride secondary to infection elsewhere in the
body may be considered. Repeated attacks of pompholyx mimic psoriasis
vulgaris. Pompholyx can also resemble pemphigoid, linear IgA disease or
pemphigoid gestationis. Whole skin should be examined in any case of
hand eczema when the diagnosis is in doubt. Evidence of nickel allergy,
tinea pedis, and psoriatic patches should be looked for.
24
TINEA MANUUM
EVALUATION
Biochemistry
Blood glucose examination to rule out diabetes mellitus
Complete blood count
Renal function tests
Serum electrolytes
Serum Lipids – to check for hyperlipidemia
Serum IgE
Scraping for fungus to rule out dermatophytosis.
If the history and examination is suggestive of contact
dermatitis then a patch testing should be performed.
Prick test can also be done
25
PATCH TEST
The patch test was introduced by Josly Jadassohn in 1896.In
housemaids, housewives other domestic workers, nurses, detergents
would be a frequent cause for hand eczema. Patch testing with detergents
and soap solution, vegetable antigens can be tried to identify the
cause36,37.
Allergic contact dermatitis can be diagnosed by patch testing.
Basis of Patch testing is that the primed antigen‐specific T lymphocytes
will be present throughout the body, and hence allergen can be applied to
upper back which will be comfortable for applying multiple antigens and
least disturbed. Chronic hand eczema is an indication for patch testing38.
The aim of testing is to elicit an immune response in an already
sensitised person by applying defined amounts of allergen and evaluating
the response. Chambers are used to ensure close contact with the skin.
Hypoallergenic and non‐irritant fixing tapes should be used. Patch test
should not be done in patients with active eczema because it decreases the
threshold of activity and may cause non‐specific reactions. Patches
should not be exposed to sun or other sources of UV light.
Immunosuppressants and steroids should be stopped before patch testing
as they may interfere with the positive response. Steroid doses up to 15
mg of prednisolone are acceptable.
26
Patch testing is generally avoided in pregnancy. Patch testing can be done
on young children but with lesser number of allergens due to lack of
space.
PATCH TEST CHAMBERS
Finn chamber
The chambers are available as strips of five or ten and have small,
occlusive aluminium discs incorporated in it with an acrylic
hypoallergenic adhesive. The AL system (filter paper discs which are
mounted on an aluminized paper) is not used nowadays. Square plastic
chamber named Van der Bend chambers and oval plastic chambers
named Epicheck are also available. Curatest F is a test system which is
water resistant. TRUE is ready‐to‐use patch test kit based on a dispersion
of the allergens in a hydrophilic polymer.
ANTIGENS USED IN INDIAN BATTERY SERIES
1) Vaseline
2) Wood alcohol
3) Perubalsam
4) Formaldehyde
5) Mercaptobenzothaizole
6) Potassium Bichromate
7) Nickel Sulphate
27
8) Cobalt Sulphate
9) Colophony
10) Epoxy resin
11) Paraben mix
12) Paraphenylenediamine
13) Parthenium
14) Neomycin sulphate
15) Benzocaine
16) Chloro cresol
17) Fragrance mix
18) Thiuram mix
19) Nitrofurazone
20) Black rubber mix
ALLERGENS PLACED IN FINN CHAMBER
28
“TRUE “TEST
PATCH TEST KIT-ALLERGENS
29
PATCH TEST KIT
READINGS AND INTERPRETATION OF PATCH TEST39
The scoring system devised by the ICDRG (International Contact
Dermatitis Research Group scoring system)39
Score Description
_ Negative
?+ Doubtful reaction; faint erythema only
+ Weak positive reaction; palpable erythema, infiltration, possibly papules
++ Strong positive reaction; erythema, infiltration, papules, vesicles
+++ Extreme positive reaction; intense erythema and infiltration and coalescing vesicles
NT Not tested
IR Irritant reaction of different types
30
31
FALSE POSITIVE REACTIONS
Excessive concentration of allergen
Contaminants
Irritant vehicle
Recent dermatitis at patch test site
Presence of dermatitis at distant sites
Adhesive tape reactions
Artifacts
‘Angry back’ reaction -recent dermatitis at the test area or even
other areas lowers the threshold for irritant reactions and causes
nonspecific irritant reactions. Also called excited skin syndrome 40
FALSE NEGATIVE REACTIONS
Insufficient concentration of allergen
improper adhesion of patch
Readings done too early
Pretreatment at the patch test site with topical steroids
UV exposure of patch‐test site and if the patient is on
immunosuppressants.
32
COMPOUND ALLERGY
It’s a condition when positive patch test reaction occurs to a finished
product but when individually tested with ingredients it is negative. So,
the product and its constituents should be patch tested when there is a
strong suspicion.
QUENCHING
Like the potentiation of allergic and irritant responses combination of
chemicals can also lead to quenching effect. This phenomenon has been
observed mostly in fragrance material aldehyde
COMPLICATIONS OF PATCH TEST
Pruritus
Folliculitis
flare of dermatitis
Irritant reactions due to inappropriately diluted allergen
sensitization
hyper or hypo pigmentation
Scarring and anaphylaxis
33
2) PRICK TESTING
With standardized allergens
Prick test with fresh food stuffs
Procedure
Pricks are done by standard method. Histamine is positive
control. Saline will be negative control. The maximum diameter
of the wheal is measured in mm
34
PRICK TEST
3) Serum IgE estimation
4) RAST (Radio Allergo Sorbent Test)41
The RAST is a radioimmunoassay test to detect
specific IgE antibodies to suspected allergens. IgE is
the antibody associated with Type I allergic response:
35
RAST (Radio Allergo Sorbent Test)41.
RAST rating
IgE level (kU/L) Comment
0 < 0.35 ABSENT OR UNDETECTABLE ALLERGEN SPECIFIC IgE
1 0.35 – 0.69 LOW LEVEL OF ALLERGEN SPECIFIC IgE
2 0.70 – 3.49 MODERATE LEVEL OF ALLERGEN SPECIFIC IgE
3 3.50 – 17.49 HIGH LEVEL OF ALLERGEN SPECIFIC IgE
4 17.50 – 49.99 VERY HIGH LEVEL OF ALLERGEN SPECIFIC IgE
5 50.00 – 100.00 ULTRA HIGH LEVEL OF ALLERGEN SPECIFIC IgE
6 > 100.00 EXTREMELY HIGH LEVEL OF ALLERGEN SPECIFIC IgE
36
5) RPA TEST (RNASE PROTECTION ASSAY)
Small quantities of RNA are measured by sample obtained from
tape stripping of human skin. This test discriminates between irritant and
allergic patch test reactions. Interleukin-4 (IL-4) levels were elevated in
allergic but not in irritant reactions.
6) CHEMICAL SPOT TESTS
For nickel, chromate, and cobalt42.
Dimethylglyoxime test for nickel
Dimethylglyoxime 1% (alcoholic solution) and ammonium
hydroxide (aqueous solution) are stored in separate bottles. A cotton bud
is dipped in each of this solution, rubbed on the test object. A pink
discoloration on the cotton bud indicates presence of nickel.
Acetylacetone method for formaldehyde
The sample to be tested is put in a disposable glass test tube and
2.5 mL of the reagent is added. The mixture is closed and placed in a
water bath at 60°C for 10 min. A yellow colour is produced in the
presence of formaldehyde, due to the formation of
3,5‐diacetyl‐1,4‐dihydrolutidine.
37
Other analyses
Tests for chromate and epoxy resins are difficult to perform. Tests
like chromatography, spectrophotometry, mass spectrometry and nuclear
magnetic resonance spectroscopy needs special equipment and expertise
38
Classification of severity43
Photographically documented severity assessment of chronic hand
eczema has been used in various clinical trial settings
1. Osnaberck hand eczema severity index (OHSI) (Range 0-18).
2. Hand eczema severity index (HECSI) (Range 0-360).
3. Manu score (Range 0-6480).
4. Hand eczema score for occupational screenings at the workspace
(HEROS) (Range 0-2260).
NICE guidelines recommend the measurement of DLQI for
alitretinoin usage
COMPLICATIONS AND CO‐MORBIDITIES
Secondary bacterial infection characterized by sudden
deterioration, pain and/or purulent exudates from the involved
areas.
In pompholyx, lymphangitis and cellulitis can occur
Nail changes on repeated episodes
Sensitization can occur involving other areas of the body.
39
DISEASE COURSE AND PROGNOSIS
Hand eczema being a multifactorial disease has a relapsing and
remitting course. The prognosis can be improved by identification and
avoidance of responsible allergen and irritants. Hand eczema due to
atopic dermatitis may have a worse prognosis. Hand eczema over the
dorsal surface has less recurrence than over the palms. Also, eczema over
the dorsal hands clears faster. Patients with dyshydrosiform eczema either
have recurrence or go into chronic stage. Recognition and treatment at an
early stage will prevent the progression to more severe dermatitis
40
MANAGEMENT
GENERAL MEASURES
The main general measure would be avoidance of irritant or an
allergen. so contact of the suspected allergen or irritant should be spotted
out in work place, home, or leisure time activities44.
Frequent application of emollients should be done.
In acute phases application of saline soaks, would help by
removing the crust and has an anti pruritic action.
Potassium permanganate soaks can also be used.
Systemic antibiotics will be required if secondary bacterial
infection develops and flucloxacillin can be used empirically
to provide cover for staphylococci.
Use of cloth glove with a rubber glove over it can be done.
Polyvinyl chloride gloves can be used in patients with rubber
allergy. Soap substitutes should be prescribed. Patients
should be educated about the importance of avoidance of
allergens and irritants. Some allergens like acrylates and
epoxy resins can penetrate both rubber and vinyl gloves.
Over the counter topical preparation may contain alcohol
and propylene glycol which can have an irritant effect should
be avoided.
41
Topical corticosteroids will be required for almost all cases
of hand eczema. Potent and very potent topical
corticosteroids may be needed in severe hand eczema45.
Steroid impregnated adhesive tapes used in painful fissures
and in fingertips which helps in both physical protection and
local delivery of the drug. Topical steroid under occlusion
can be considered for resistant cases. Risks being secondary
bacterial infection and skin atrophy. After response is
obtained with daily steroid usage, a potent corticosteroid
cream can be intermittently used safely to prevent relapse. If
no response to topical steroid diagnosis should be reviewed.
Possibility of contact sensitization to topical medicament
bases, preservatives should be considered, with a patch test if
necessary.
Topical calcineurin inhibitors are the next option for treating
hand dermatitis. Tacrolimus acts better on the palms than
soles45.
Coal tar and salicylic acid have been used for chronic
hyperkeratotic lesions.
Intralesional injection of triamcinolone (10 mg/mL) into
recalcitrant patches of hand eczema may also be done46.
42
Aluminum chloride hexahydrate and tap water iontophoresis
and botulinum toxin has been tried for pompholyx46.
Bexarotene gel is also used in all forms of hand eczema47.
X rays and grenz rays have been used with some success48.
Phototherapy with PUVA, UVA1 and UVB therapy can be
tried for resistant cases. Found to be useful in hyperkeratotic
hand eczema, allergic contact dermatitis and dyshidrotic
hand eczema. Monochromatic excimer light can also be used
in chronic hand eczema49.
Oral corticosteroids can be used for acute hand eczema and
acute on chronic hand eczema in a dose of 0.5 - 1
mg/kg/day. Should be rapidly tapered.
Cyclosporine at 3 mg/kg/day was tried with slow tapering of
6 months. Should be discontinued if no response is noted
within 8 weeks. Blood pressure, serum potassium, and
creatinine should be monitored50.
Azathioprine can be used in a dose of 2 mg/kg/day. Hand
eczema due to Parthenium and atopic hand eczema responds
to Azathioprine 51. Dosage should be advised after checking
the TPMT levels.
43
Low dose Methotrexate 5-20 mg weekly has been used in
chronic hand eczema due to atopic dermatitis and
Parthenium dermatitis52.
The only licensed systemic therapy for chronic hand eczema
is alitretinoin (9‐cis‐retinoic acid). Alitretinoin which is an
isomer of Isotretinoin does not suppress sebum significantly
and so not useful in acne and has fewer incidences of side-
effects like xerosis and cheilitis.
Alitretinoin binds to both RARs and RXRs. Alitretinoin is
used currently in severe chronic hand eczema which fails to
respond to potent topical corticosteroids.
A largest randomized multicentre trial assessing the efficacy and
safety of oral alitretinoin (10 or 30 mg once daily for up to 24 weeks) in
comparison with placebo control was conducted for treatment of severe
hand eczema (Benefit of Alitretinoin in Chronic Hand Eczema (BACH)
study). Other modalities of treatment were stopped excluding emollients.
Patients were found to have clear/almost clear hands (28% in 10 mg
group, 48% in 30 mg group) compared with placebo (17%).
Hyperkeratotic and fingertip eczema showed highest response rate and
largest difference (28% in 10-mg group, 49% in 30-mg group) from
placebo (12%).
44
Fingertip subtype had the second highest response rate
(29% in 10-mg group, 44% in 30-mg group vs 18% in placebo), followed
by pompholyx subtype (23% in 10-mg group, 33% in 30-mg group vs
16% in placebo) .Time to response was significantly shorter in the 30-mg
group than in the 10 mg (p < 0.001). Both dosages achieved durable
remission with a median of 5.5 months in the 30-mg group and 6.2
months in the 10-mg group. Majority of the responders did not relapse by
the end of the 24-week observation period following treatment53. Side
effects noted were headache, muco-cutaneous side-effects,
hypothyroidism and hyper-triglyceridemia
The treatment of chronic hand eczema is difficult. Newer super
potent steroids like Halobetasol monohydrate can be used once-daily for a
short period during the initial phase of chronic-fissured HE. Cyclosporine
and Azathioprine are beneficial in HE with an atopic background.
When chronic hand eczema is characterized by combined allergic and
irritant contact dermatitis, filaggrin gene mutations may play a
role. Identifying the cause and avoiding it could result in complete
clearance in a case of ACD; however, in irritant and atopic dermatitis,
avoiding the irritant factor is not always feasible.
45
Most important intervention in management of hand eczema would
be lifestyle change of the patient with avoidance of all possible irritants
and allergens. They should be educated about day to day skin care.
Personal protection measures should be tailored according to each patient
based on his occupation and routine activities. Skin care and personal
protection measures should be individualised for each person and his/her
environment.
Aims & Objectives
46
S T U D Y
OBJECTIVES
To determine the following in the cases of hand eczema
1. To study the epidemiology of hand eczema.
2. To study the clinical pattern and etiological factors of the disease.
STUDY DESIGN
Descriptive study
STUDY PLACE
Department of occupational and contact dermatitis
Madras Medical College
Chennai
STUDY PERIOD
November 2016 to September 2017
47
ELIGIBILITY
INCLUSION CRITERIA
Patients with age more than 18 years presenting with hand eczema to
dermatology Outpatient department
EXCLUSION CRITERIA
1. Patients less than 18 years of age
2. Pregnant women
3. Patients with acute eczema
4. Patients with hand eczema on treatment with systemic steroids
Methodology
48
METHODOLOGY
This study was carried out as a clinical, epidemiologic and etiological
survey of hand eczema from November 2016 to September 2017.
The sampling procedure is summarized as follows.
I. All patients attending occupational and contact dermatitis
outpatient department having signs and symptoms of hand eczema
between the study period are selected for the study as per the
criteria mentioned above and enrolled in the study.
II. The sample size for the study is 50
III. All the subjects were interviewed in person.
IV. Detailed case history of each patient with reference to
a. Age
b. Sex
c. Duration and course of the disease
d. Occupation (domestic worker, food handler, farmer or
construction worker)
e. Type of work
f. Hobbies
g. History of wet work and frequent hand washing,
h. Aggravating and relieving factors
49
i. Personal and family history of atopy are obtained and
recorded
V. One of the senior and experienced professors helped to exclude
conditions like psoriasis, lichen planus and dermatophytosis
clinically.
VI. Symptomatology assessment
Symptoms like itching, watery discharge, burning sensation and
signs like unilateral or bilateral involvement of hands, sites of
involvement, morphology of lesions like oozing, scaling, crusting,
vesicles, hyperkeratotic, discoid lesions, history of other skin
lesions and presence of any nail changes are noted.
VII. The presence of associated skin findings of atopy was noted.
VIII. Risk factor assessment
IX. History of endogenous factors like atopy, stress is noted
X. History of exogenous factors like contact with detergents and
soaps, vegetables, flowers, frequent hand washing, wet work,
occupational exposure of oils and chemicals was also noted.
50
XI. PATCH TEST
Patch test was done for all patients with kit containing Indian
standard series which is approved by contact and occupational dermatosis
forum of India and has twenty allergens.
Patient ‘s upper back was chosen for application of patch test
Before patch testing once again it was confirmed whether the
patient is on systemic steroids or other immunosuppressants.
The patch made of non-allergenic, non-irritant, non-occlusive tape
and aluminum chambers named as Finn chamber.
About 5 mm of solid antigen and in case of liquid antigen around
15 micro liters or 0.1 ml was placed in the discs.
The kit is available as two strips with each strip containing two
columns of antigen of five each.
These two strips with the allergens were stuck to the patient’s
upper back
The antigens are numbered over the adhesive plaster with an
indelible ink
The corners of the patch were also marked on all the four sites
which would give us an idea whether the patch was displaced or
not.
51
The patients were advised not to take shower for the duration of
test, and avoid activities like exercise which would induce
sweating and dislodge the patches
The patients were advised not to expose the patches to sun or other
sources of UV light.
The patients were asked to come after 48 hours for reading
The patches were removed and patient is made to wait for next one
hour for the erythema and edema developed due to pressure of the
strips to subside
After removal of the patches, allergens are numbered over the body
as their positions cannot be distinguished once the pressure effects
have subsided
The readings are done and interpreted according to International
contact dermatitis research group scoring system which is as
follows.
52
PATCH TEST INTERPRETATION
- Negative
?+ Doubtful. Faint erythema only
+ Weak positive reaction.
Palpable erythema, infiltration and papules
+ Strong positive reaction.
Erythema, infiltration, papules and vesicles
+++ Extreme positive reaction. Intense erythema, infiltration and coalescing vesicles.
IR Irritant reaction
NT Not tested.
True allergic reactions were distinguished from irritant reaction by
presence of itching and infiltration, extension beyond the margins
The patch test readings are noted and the person is advised to avoid
the particular allergen
Patients were advised skin care and importance of regular
application of emollient
Patients were advised protection measures like wearing gloves
according to the occupation.
53
Patients were given appropriate treatment according to disease
severity
Ethical committee approval was obtained from the institute ethics
committee.
STATISTICAL ANALYSIS
The collected data was entered for analysis in Microsoft Excel.
This data was exported to Statistical Package for Social Sciences software
(SPSS) version 22.0. Mean, standard deviations and range were employed
to describe continuous variables, while frequency distributions were
obtained for dichotomous variables.
ETHICAL ISSUES
All the participants were made aware about the nature and purpose
of the study.
It was also informed to all the participants that all data provided by
the patients were kept confidential and will be used only for the
study purpose.
Willingness and signature of the participants was taken on a
previously designed consent form.
Written consent was obtained from all the subjects who
participated in the study before data are collected.
54
Detailed description of the study and the aspects of patient
confidentiality were explained to the subject and voluntary
participation is sought.
Institutional ethics committee of Madras medical college reviewed
the study proposal for ethical consideration and approval of the
committee was obtained prior to the study.
Results
55
Tables &Figures
Table.1: Distribution of HE cases according to sex
Gender
Frequency (n=50)
Percentage (%)
Male
21
42
Female
29
58
The prevalence of the disease is common in the female
population as about 58% of the patients in our study are females. This is
a significant finding as although the earlier studies reported an increased
prevalence in females,recently reported studies in the Indian literature
shows an increasing trend in male gender.
56
Table.2. Distribution of HE cases according to age
Age N=50 Percentage (%)
< 20 Years 5 10
20 - 29 Years 6 12
30 - 39 Years 13 26
40 - 49 Years 19 38
More than 50 Years 7 14
About 38% of the affected patients were in the age group 40-49
years and 26% in the age group 30-39 years. Hand eczema has been
found to be common in the occupationally active age group which
matches with our study. The increased prevalence in age group 40-49
years may be due to the decreased awareness of protective measures or
decreased implementation. Our study has shown about lesser percentage
in elderly patients as these patients have a relative anergy response to
contact sensitizers
57
Table.3. Distribution of HE cases according to duration of disease
Duration N=50 Percentage (%)
< 6 months 7 14
6 - 12 months 10 20
1 - 2 years 13 26
2-5 years 18 36
>5 years 2 4
About 36% of the patients had the disease for around 2-5 years.
The duration of the disease ranged from 6 months to more than five years
58
Table.4. Distribution of HE cases according to duration of disease
N Minimum Maximum Mean S.D
Age(Years) 50 8 64 38.12 11.193
Duration(Months) 50 2 96 17.78 16.663
The mean age of occurrence of the disease was 38.12 years which
corresponds to the occupationally active group. The mean duration of the
disease was 17.78 months.
Table.5. Distribution of HE cases according to Patch test
Patch test N=50 Percentage (%)
Negative 4 8
Positive 46 92
Patch test was positive in 92% of the patients and was negative in
8% of the patients. Among the patients who had negative patch test 4%
were men and 4% were women.
59
Table.6 Distribution of HE cases according to Occupation
Occupation N=50 Percentage (%)
Domestic Worker 4 8
Housewife 14 28
Farmer 3 6
Security 3 6
Electrician 2 4
Mechanic 4 8
Laborer 3 6
Supervisor 2 4
Mason 4 8
Student 2 4
Hotel Worker 1 2
Army 1 2
Factory Worker 1 2
Tailor 1 2
Dentist 1 2
Driver 1 2
Water can delivery
man 1 2
Computer Operator 1 2
Handicraft 1 2
60
Table.7. Distribution of HE cases according to Skill Category
Occupation N=50 Percentage (%)
Housewife 18 36
Skilled 14 28
Non-skilled 10 20
Laborer 7 14
Professional 1 2
In our study 28% of the patients were housewives followed by 8%
mason and 8% mechanic. Occupational wise group comprised of
unskilled workers (17), skilled workers (14), house wives (18) and white-
collar jobs (1). This is because of the increased occupational exposure of
allergens and household exposure in housewives.
61
Table.8. Patch test results
S.No Allergens Total Male n=19 Female n=27 No Percent No Percent
1 PPD 8 2 10.5 6 22.2 2 Parthenium 6 3 15.8 3 11.1 3 Nickel 11 2 10.5 9 33.3 4 Fragrance mix 4 0 0 4 14.8 5 Colophony 3 3 15.8 0 0 6 Black rubber mix 2 2 10.5 0 0 7 Balsam of Peru 2 1 5.3 1 3.7
8 Potassium dichromate 5 3 15.8 2 7.4
9 Epoxy resin 2 2 10.5 0 0 10 MCBT 1 0 0 1 3.7 11 Neomycin 1 1 5.3 0 0 12 Lanolin 1 0 0 1 3.7
Overall nickel positivity was seen in 11 patients of which 9 were
females and 2 were males. PPD positivity was seen in 8 patients of which
6 were females and 2 were males. Parthenium sensitivity was seen in 3
female and three male patients. Potassium bichromate in total of 5
patients of which 3 male and 2 female. Few patients had sensitivity for
fragrance mix, colophony, black rubber mix, colophony, epoxy resin,
MCBT, neomycin and lanolin. Most common sensitiser in female was
nickel, fragrance mix, PPD and in male were potassium bichromate,
colophony and parthenium.
62
Table.9. Distribution of HE cases according to pattern of HE
Types Frequency Percentage (%) Housewife Eczema/Dry palmar eczema
13 26.0
Unspecified 17 34.0 Fingertip 4 8.0 Apron 1 2.0 Hyperkeratotic 6 12.0 Discoid 3 6.0 Ring Eczema 1 2.0 Chronic acral 3 6.0 Pompholyx 2 4.0
Most common type of hand eczema in our study was unspecified
(34%)followed by housewives/dry palmar eczema (26%).This result
shows that hand eczema cannot be always classified into any one
morphological pattern. The most common allergen in unspecified group
was PPD, potassium dichromate and parthenium.4% of the patients had
pompholyx and all the patients had an atopic history and nickel
sensitivity. Most common allergen among housewives was fragrance mix
and nickel. Patients with hyperkeratotic eczema had variable sensitivity
with commonest being parthenium and fragrance mix. Fingertip eczema
was most common among housewives and mechanics and had variable
contact sensitivity.
63
Table.10. Distribution of HE cases according to factors aggravating HE
Aggravating factors Frequency n=50
Percentage (%)
Nil 16 32
Soap 3 6
Onion/Vegetables 2 4
Stress 4 8
Sweating 10 20
Wet work 4 8
Food items 2 4
Cement 2 4
Grease, Oil 2 4
Artificial items 5 10
About 20% of the patients reported that their hand eczema
worsened by sweating followed by 10% of the patients reported
exacerbation on wearing artificial jewels/watch/clips.8% of the patients
found wet work and stress as aggravating factors. Majority of the patients
were not able to find any aggravating factors. A proportion of patients
found soaps, detergents, vegetables, certain food items, working in
cement and grease as aggravating factors.
64
Table.11. Atopy distribution in HE cases
Atopy N=50 Percentage (%)
Positive 15 30
Negative 35 70
Table.12. Patch test positivity in atopic patients
Patch Test Result Group Atopy history Total Yes No
Negative Count 0 4 4
% within Patch test result
0 100 100
Positive Count 15 31 46
% within Patch test result
32 67 100
Pearson Chi-Square with Fisher Exact p value 0.302 which is not significant.
About 30% of the patients in our study gave history of atopy. Most
of the atopic patients had nickel sensitivity. About 32.6% of the patients
with positive patch test had a history of atopy and 67.4% of the patients
with positive patch test had no history of atopy. Pearson Chi-Square with
Fisher Exact p-value was 0.302 which is not significant stating that no
significant correlation between atopic status and contact sensitisation.
Figures
65
42%
58%
MaleFemale
Figure.1. Distribution of HE cases according to sex
DISTRIBUTION OF GENDER
66
Figure.2. Distribution of HE cases according to age
56
13
19
7
0
2
4
6
8
10
12
14
16
18
20
< 20 Years 20 - 29 Years 30 - 39 Years 40 - 49 Years >= 50 Years
DISTRIBUTION OF AGE GROUP
Frequency
67
Figure.3. Distribution of HE cases according
to duration of disease
7
10
13
18
2
0
2
4
6
8
10
12
14
16
18
20
1-6 months 6-12 months 1-2 years 2-5 years above 5 years
DISEASE DURATION
Frequency
68
Figure.4. Distribution of HE cases according to
Skill Category
0
2
4
6
8
10
12
14
16
18
2018
19
7
2
4
Frequency
69
Figure.5. Percentage of allergen positivity by gender
The most common sensitizer in female is nickel (31%) followed by
PPD (20.7 %). The most common sensitizer in male is potassium
dichromate (14.3%) and colophony (14. 3%).
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
9.5
13.5
9.5
0.014.3
9.5
4.8
14.3
9.5
0.0
4.8
0
20.7
10.3
31
13.8
0 0
3.4
6.9
0
3.4
0
3.4
PERCENTAGE OF ALLERGENS POSITIVITY PRESENCE BY GENDER
MALE FEMALE
70
Other common sensitizers in male and female were parthenium. In
males, PPD, nickel, black rubber mix, balsam of Peru, epoxy resins and
neomycin were other sensitizers females, fragrance mix, PPD, balsam of
Peru, MCBT, lanolin, potassium dichromate were common sensitizers.
Discussion
71
A total of 50 patients were included in the study of which 29 were
female (58%) and 21 were male (42%).Our study has shown an increased
incidence in females when compared to males. This observation is very
similar to the study conducted by Sharma et al in Chandigarh in 1998 54
and Hamershoy et al 55 in Danish patients in 1977. In contrast, studies
conducted by Akhtar et al in 2004 and Handa et al 56 in 2012 in
Chandigarh has shown an increased incidence in males. This variation in
sex prevalence may be due to confounding factors like occupation. A
particular sex is not a risk factor for hand eczema but increased
prevalence may reflect an increased exposure to allergens.
About 38% of the affected patients were in the age group 40-49
years and 26% in the age group 30-39 years. The mean age of HE on our
study was 38 years with a SD of 1.2 Hand eczema has been found to be
common in the occupationally active age group by study conducted by
Vishwender et al57 and Handa et al, which is an observation very similar
to our study. The increased prevalence in age group 40-49 years may be
due to the decreased awareness of protective measures or decreased
implementation. Our study has shown about lesser percentage in elderly
patients and this observation may be due to the reason that these patients
have a relative anergy response to contact sensitizers.
72
The duration of the disease was from 6 months to more than 5
years. Most of the patients had the disease (18%) for around 2 to 5 years.
This is due to the chronicity of the disease. The mean duration of illness
was found to be 17.8 months (SD 16.6) which is slightly less than that
when compared to other Indian studies. Similar reports were published by
vishwender et al in a study conducted in Rajasthan in the year 2016 and a
Danish study 58 in 2012.
In our study 28% of the patients were housewives followed by 8%
mason and 8% mechanic. Occupational wise group comprised of
unskilled workers (17), skilled workers (14), house wives (18) and white-
collar jobs (1). This is because of the increased occupational exposure of
allergens and in housewives increased exposure to household allergens.
The reason for this observation may be due to increased exposure to
household chemicals and allergens at workplace. Similar observations
have been found in study conducted by Handa et al56 and Vishwender et
al57.
Most common type of hand eczema in our study was unspecified
(34%)followed by housewives/dry palmar eczema (26%).This result
shows that hand eczema cannot be always classified into any one
morphological pattern. The most common allergen in unspecified group
was PPD, potassium dichromate and parthenium and had relevance with
their occupation.
73
Housewives eczema was present in 10% of the patients.
Housewives develop hand eczema due to repeated exposures to
household allergens. Also, the barrier function of the skin is deficient in
them owing to cumulative irritant contact dermatitis which further
enhances the allergen penetration. Fragrance mix and nickel were the
commonest sensitizers. Generally, vegetables are the frequent sensitizers
in women in India.
In our study,4% of the patients had pompholyx and all the patients
had an atopic history and nickel sensitivity. Atopy as a risk factor in
pathogenesis of pompholyx has been controversial. Some studies have
shown a strong association and some studies have shown no association
of pompholyx with atopy was mentioned in Odozze et al59 and Dedoer et
al60 in their studies. Nickel and fragrance mix were the sensitizers found
in our study. Handa et al in their study in Chandigarh have found nickel,
ppd, fragrance mix as commonest sensitizers in pompholyx.
Hyperkeratotic eczema was found in 12% of the patients. These
patients had variable patch test positivity. There was no significant
association with atopy in our patients. This observation has been
supported by study conducted by handa et al in Chandigarh. Fingertip
eczema was found in 8% of patients in our study. Mostly they were
housewives or industrial workers.
74
A small proportion of the patients had ring eczema, apron eczema,
discoid and chronic acral dermatitis. High prevalence of unspecified type
of hand eczema signifies that it is not always possible to classify hand
eczema morphologically.
Most common allergen among housewives was fragrance mix and
nickel. Patients with hyperkeratotic eczema had variable sensitivity with
commonest being parthenium and fragrance mix. Positive association
with atopy was not found in our study.
Fingertip eczema was present in 4 patients in our study. It was
most common among housewives and mechanics and had variable
contact sensitivity.
In our patients only palmar surface of the hands were involved in
16 patients, both palmar and dorsal surface of hands were involved in 16
cases. Only dorsum of the hands was involved in 8 cases and fingers only
in 8 cases and whole hand including nails were involved in 2 cases.
Dorsal surface of the hand has a thin skin compared to palmar surface so
the dorsal surface will be affected in the initial stages.
75
Patch test to one or more allergens was positive in 46 patients
(92%) which are similar to a study done by Samahy et al61. The most
common allergen which were positive in our study were nickel sulphate
(43.8%), PPD (32.7%) followed by Potassium dichromate(23.2%),
Colophony, Fragrance mix and parthenium. Among these female patients
had a high sensitivity to nickel sulphate and Fragrance mix. In male
patients, the commonest sensitizers were Potassium dichromate and
Colophony.
Nickel sulphate
Female sex and wet work are considered as a risk factor for developing
nickel allergy. In our study housewives and domestic workers have been
shown to have more nickel sensitivity which correlates with the
observation of Uter W et al62. Nickel sulphate has been found in door
knobs, watch, clips, stainless steel vessels which we commonly use and
this gets released by the action of detergents.
Potassium dichromate
It has been reported that Potassium dichromate is considered as a
most common sensitizer among male patient and this sensitivity is more
commonly associated with manual labours and masons and holds good
for our study too. The postulated reason could be due to quality of the
cement where ferrous sulphate salt has not been added. Potassium
dichromate is present in cement, leather, yellow paints, varnish and glue.
76
Fragrance mix
Fragrance mix has been a common sensitizer in our study among
female patients and may be the cause for this sensitivity.
PPD
Sensitivity to paraphenylenediamine has been observed in 32.7%
of patients in our study and all the patients have given history of use of
hair dye.
Parthenium
The parthenium plant has been found in forest, crop lands, road
side and along railway tracks, streams and river and also in hot and humid
areas. It caused due to the airborne dry particles including trichomes and
sesquiterpenelactones. Sensitivity to parthenium has been observed in
26.9% of patients in our study.
Few patients in our study with patch test positivity had a sensitivity
for lanolin colophony, neomycin, black rubber mix, epoxy resin, balsam
of Peru and MCBT. Among these patients with history of atopy were
significantly sensitive to nickel (p=0.035).
77
About 30% of the patients in our study gave history of atopy. Most
of the atopic patients had nickel sensitivity. About 32.6% of the patients
with positive patch test had a history of atopy and 67.4% of the patients
with positive patch test had no history of atopy.Pearson Chi-Square with
Fisher Exact p-value was 0.302 which is not significant stating that no
significant correlation between atopic status and contact sensitisation.
Thus, it is clear that hand eczema is a multifactorial disease
influenced by various endogenous and exogenous factors. A good
proportion of patients showing patch test positivity indicate the
importance of allergic contact dermatitis in the pathogenesis of hand
eczema.
Conclusion
78
CONCLUSION
This descriptive study conducted in the Indian population in our
hospital which is a tertiary care centre has shown the importance of
age, occupation, atopy, environmental factors and allergic sensitisation
in the development and recurrence of hand eczema.
In our study women, most commonly housewives were affected more
than men. This shows the requirement of awareness of protective
measures/education among housewives. Also, the importance of patch
test in identifying the allergen responsible for the disease
causation/exacerbation. The occupationally active age group has found
to be commonly affected in our community.
Patch testing with Indian standard battery of allergens has been very
useful investigation in cases of hand eczema revealing allergic contact
dermatitis as aetiology in 92% cases in our study. This can be further
improved by adding few self-prepared antigens like soaps, detergents
and vegetables like onion, garlic. The present study revealed that
Nickel (43.8%), PPD (32.7%) Parthenium (26.9%), Potassium
dichromate (23.2%) were the most common Sensitizers in cases of
hand eczema in our study. Patch testing in our study helped to
establish the allergic etiology in majority of the cases.
79
Identifying the allergen is very important in these patients as
identifying and avoiding the allergen helps the patient to be free of the
disease. This indirectly helps by improving the emotional status of the
patient and improving the quality of life. Also decreases the
absenteeism from work and reduces the number of sick leaves.
Identifying the most common allergen associated with a particular
group of people/occupation helps us to advice the patient to use
protective measures accordingly and change the occupation if
possible. Our study has found out nickel and fragrance mix as
commonest allergen among housewives, potassium dichromate among
masons.
Our study has found a positive association of nickel sensitivity in
atopic patients. So, avoidance of nickel can be tried in atopic patients
with hand eczema where patch test facilities are not available.
Identification and avoidance of allergens can help in clinical
improvement in patients with hand eczema
Identifying the particular allergen associated with specific occupation
in a group of patients can help to pre-organize the working conditions
and implement protective measures for employees who are prone for
hand eczema thereby reduce the incidence and prevalence of the
disease
80
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Annexures
89
CLINICOEPIDEMIOLOGICAL AND ETIOLOGICAL
STUDY OF HAND ECZEMA
CASE PROFORMA
NAME: AGE: SEX: M/ F
PH.NO: ADDRESS:
HT: Cms WT: Kg
HISTORY:
COMPLAINTS R L
Red and swollen fingers
Itching, oozing
Tiny blisters in palm
scaling, cracked skin
Hyper pigmentation, thickened skin
Duration
90
RISK FACTORS:
1. OCCUPATION DOMESTIC WORKER☐
HOME MAKER☐ BARBER☐ FOOD HANDLER☐ CONSTRUCTION WORKER☐ FARMER☐ OTHERS☐
2.HAND WASHING PER DAY 0-5 times 6-10 times 11-20 times >20 times 3.HISTORY OF ATOPY
YES
NO
4.FOOD ALLERGY
YES
NO
5.OTHER SKIN LESIONS
YES
NO
91
6.FRAGRANCE USE YES
NO
8. PREVIOUS EPISODES YES
NO
9.FAMILY HISTORY YES
NO
EXAMINATION:
GENERAL EXAMINATION:
SYSTEMIC EXAMINATION: CVS:
RS:
CNS:
92
DERMATOLOGICAL EXAMINATION:
SKIN CHANGES RIGHT HAND
LEFT HAND
1.Erythema 2.Edema 3.Oozing 4.Crusting 5.Scaling 6.Lichenification 7.E/O Secondary Infection 8.Nail Changes 9.Palmar Vesicles
EXAMINATION OF HANDS
INVESTIGATIONS
PATCH TEST (INDIAN STANDARD BATTERY SERIES)
DIAGNOSIS PATCH TEST READING Done on Faint erythema – (?)
Reading on Erythema & papules -+
Adverse reaction Erythema, edema vesicles – 2+
Result Erythema, edema, vesicles /
ulceration - 3+
Negative reaction - (-)
Irritant reaction - (IR)
Not tested - (NT)
93
PATCH TEST ANTIGENS
S.No Name Result S No Name Result
1 Vaseline 17 Wool alcohols
2 Potassium dichromate 18 Blackrubber mix
3 Cobalt sulphate 19 Thiuram mix
4 Neomycin sulphate 20 Formaldehyde
5 Benzocaine
6 Para-Phenylenediamine
7 Parabens mix
8 Nickel sulphate
9 Colophony
10 Plant antigens-
Parthenium
11 Perubalsam
12 Epoxy Resin
13 Fragrance mix
14 Mercaptobenzothiazole
15 Nitrofurazone
16 Chlorocresol
TREATMENT GIVEN:
94
95
96
97
98
99
INFORMATION SHEET
Title:
“CLINICOEPIDEMIOLOGICAL AND ETIOLOGICAL
STUDY OF HAND ECZEMA”
Name of Investigator : Dr.V.Sharmila Rao
Name of Participant :
Purpose of Research : The purpose of this study is to analyse the
various epidemiological factors influencing hand eczema, clinical
pattern and etiological factors of the disease.
Study Design : Cross sectional study
Study Procedures
In this study, history, examination and routine blood test will be
done for all subjects. Patch test will be done and aetiology determined.
Patient is advised to follow general measures like avoiding prolonged
contact with water, avoid allergens etc. patients will be treated with
emollients, topical and systemic steroids, antibiotics,
immunosuppressants according to the need of the patient.
Possible Risks : No risks to the patient
Possible benefits :
To patient : Specific aetiology of hand eczema for that patient is
detected and the patient is provided with any of the above mentioned
treatments.
100
To doctor & to other people : The results of the study will help in
confirming the role of environmental factors in the causation of the
disease ,most common etiological factor of hand eczema and emphasize
the importance of work modification and habitual changes in preventing
the disease in the future.
Confidentiality of the information obtained from you: The privacy of
the patients in the research will be maintained throughout the study. In
the event of any publication or presentation resulting from the research,
no personally identifiable information will be shared
Can you decide to stop participating in the study: Taking part in this
study is voluntary. You are free to decide whether to participate in this
study or to withdraw at any time
How will your decision to not participate in the study affect you:
Your decision will not result in any loss of benefits to which you are
otherwise entitled.
…………………………. …………………………
Signature of Investigator Signature of Participant
Date :
Place :
101
PATIENT CONSENT FORM “CLINICO EPIDEMIOLOGICAL AND ETIOLOGICAL STUDY OF HAND ECZEMA”
Name of the Principal investigator: Dr.V.SHARMILA RAO
Name of the Institution: Rajiv Gandhi Government General Hospital,
Chennai
Patient’s Name :
Patient’s Age :
Outpatient No :
Patient may check (�) these boxes
I confirm that I have understood the purpose of procedure for the
above study. I have the opportunity to ask question and all my
questions and doubts have been answered to my complete
satisfaction.
I understand that my participation in the study is voluntary and that I
am free to withdraw at any time without giving reason, without my
legal rights being affected.
I understand that sponsor of the clinical study, others working on the
sponsor’s behalf, the ethical committee and the regulatory
authorities will not need my permission to look at my health
records, both in respect of current study and any further research
that may be conducted in relation to it, even if I withdraw from the
study I agree to this access. However, I understand that my identity
will not be revealed in any information released to third parties or
published, unless as required under the law. I agree not to restrict
the use of any data or results that arise from this study.
102
I agree to take part in the above study and to comply with the
instructions given during the study and faithfully cooperate with
the study team and to immediately inform the study staff if I suffer
from any deterioration in my health or wellbeing or any
unexpected or unusual symptoms.
I hereby consent to participate in this study
I hereby give permission to undergo complete clinical examination
and diagnostic tests including haematological, biochemical,
radiological tests and to undergo treatment
………………………………. ……………………………
Signature/thumb impression Signature of Investigator
Patient’s Name and Address: (DR.V.SHARMILA RAO)
103
104