CASE HISTORY n

Prescriber 5 September 2013 z 57prescriber.co.uk

A30-year-old lady who had always suf-fered with dry skin had started a new

job as an intensive care nurse twomonths ago. During this time she wouldwash her hands over 20 times per day.For six weeks she had experiencedswelling of her hands with itchy erythema-tous patches and painful cracks in herpalms and across the dorsum of herhands.

She attended her GP who prescribedemollients and beclometasone 0.1 percent ointment, after which the symptomsimproved a little. However, in the followingmonth she became generally unwell andher right hand became swollen andpainful with pustules that began to weepand form yellow crusts.

She returned to her GP who started acourse of flucloxacillin and referred herfor review in the dermatology clinic afterthe infection had cleared. Patch testingrevealed no contact allergy. She wastherefore prescribed further emollients,soap substitutes and beclometasone 0.1per cent ointment and given advice onhow to avoid irritants. Specifically she wasadvised to avoid soap, latex gloves, directcontact with solvent-containing antisep-tics such as iodine and white spirit and to

wear latex-free gloves for any jobs involv-ing immersion of her hands in water, suchas bathing patients. She was also recom-mended to use alcohol gel instead ofwashing her hands if they were not visiblydirty. After strictly adhering to the advicefor six months her symptoms significantlyimproved.

Hand eczema is associated with bothconstitutional and environmental factors.In some cases a contact allergy leadingto an immunological hypersensitivity reac-tion may feature: this can be detected bypatch testing. In this case the main con-tributing factor was environmentalcaused by frequent hand washing withsoap in the intensive care unit. It couldtherefore be termed an occupational der-matitis.

The most common environmental fac-tor that leads to hand eczema is frequentimmersion of the hands in water, whichresults in the loss of the skin’s usual pro-tective barrier. This is particularly thecase if there is concomitant use of sol-vents and detergents and is an irritantreaction rather than an immunologicalresponse.1 Loss of barrier function canlead to increased risk of bacterial infec-tion resulting in cellulitis, particularly with

Painful, swollen, itchy hands

The hand eczema had developed as a result of frequent hand washing

Staphylococcus aureus and streptococcalstrains.1

This is a condition that is seen fre-quently within the healthcare workforcedue to the need for repeated thoroughhand washing. It has also been reportedthat up to 50 per cent of hairdressers willdevelop hand eczema within just threeyears of work.2

The inflammatory reaction can beameliorated through the application oftopical steroids. It is important to substi-tute soaps with moisturising lotions andto prevent further water loss from thedamaged skin by frequent emollientapplication. Irritants should be avoided,especially immersion in water and con-tact with potentially irritant substancessuch as solvents and certain food types

that are acidic or highly enzymatic, suchas citrus fruits and potato peel; patientsshould be advised to use nonlatex gloveswhen handling these.3 Superficial infec-tions should be treated promptly withantibiotics.

A randomised controlled trial carriedout in Denmark showed that counsellingand individualised patient educationabout minimising exposure to irritantssignificantly reduced the severity of handeczema and also improved the meanscore in the dermatology life qualityindex at five months compared to phar-maceutical treatment alone.4 This high-lights the importance of healthpromotion and tailored advice in optimis-ing the outcome when treating handeczema.

References1. www.dermnetnz.org/dermatitis/hand-der-matitis.html.2. Sheikh A, et al. BMJ 2007;335:399.3. Hand eczema patient information leaflet.British Association of Dermatologists.4. Ibler KS, et al. BMJ 2012;345:e7822.

By Dr Sophie Paget, an ST2 in medicineat Bristol Royal Infirmary

Readers are invited to send in similarinteresting case histories to Pre s criber, Wiley Interface Ltd, TheAtrium, Southern Gate, Chichester,West Sussex PO19 8SQ, or e-mail prescriber@wiley.com. We pay £85for those we publish.

n CASE HISTORY l Hand eczema

58 z Prescriber 5 September 2013 prescriber.co.uk