European Society of Contact Dermatitis Guideline Provides Diagnosis and Treatment Recommendations for Hand Eczema

A group of experts convened by the European Society of Contact Dermatitis (ESCD) has published updated clinical practice guidance for the diagnosis, prevention, and treatment of hand eczema. The guideline committee wrote that the guidelines, published in Contact Dermatitis, are expected to be valid until 2025, after which the recommendations will be updated “depending on the availability of new evidence.”

Recommendations for Prevention

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

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

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

The guideline committee noted that a proper risk assessment is critical for identifying and minimizing harmful skin exposures, citing the STOP (substitution/elimination, technological measures, organizational measures, and personal protective equipment) as a useful hierarchy of prevention measures that can be followed in these assessments. (Table 1)

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

	Measure	Example
S	Substitution/elimination	Eliminate hazardous exposure (prohibition, omission, or substitution) with a safer alternative
T	Technological measures	Automation Dust absorbing or ventilation systemEncapsulated machinesSplash guard
O	Organizational measures	Equal distribution of hazardous workRegular change between hazardous and non-hazardous tasks Exempt individuals with disease from hazardous tasks
P	Personal protective equipment	Use of personal protective equipment, such as protective gloves

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

Recommendations for Diagnosis

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

• Take a careful medical history that includes a search for personal and occupational exposures, in addition to a clinical examination of the hands and the entire skin integument (consensus-based recommendation).
• Conduct diagnostic patch tests in all patients with hand eczema of more than 3 months’ duration or in patients who do not experience a response to adequate treatment, or in cases of clinical suspicion of contact allergy (consensus-based recommendation).
• Conduct patch testing with a baseline series, extended by selected additional series/allergens, depending on exposure (consensus-based recommendation).

The GDG stated that an exposure assessment can support the identification of an etiological cause of hand eczema and therefore “plays a substantial role in implementation of specific preventive measures.” The guideline committee provided the following recommendations on exposure assessment for hand eczema:

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

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

• Etiological subtypes: allergic contact dermatitis; protein contact dermatitis/ contact urticaria; atopic hand eczema.
• Clinical subtypes: Hyperkeratotic palmar hand eczema; acute recurrent vesicular hand eczema; nummular hand eczema; pulpitis (fingertip eczema).
• 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 treatment principle

• Identify and avoid causative exogenous factors (consensus-based recommendation).

Emollients/moisturizers

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

Topical corticosteroids

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

Topical calcineurin inhibitors

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

Phototherapy

• Phototherapy is suggested for the hands of adult patients with chronic hand eczema who are refractory to topical corticosteroids (consensus-based recommendation).

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

Systemic Treatment

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

Reference

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