“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