Peter Saitta, DO Associate Clinical Professor · Corticosteroid Therapy for Alopecia Areata57 Triamcinolone acetonide 40mg monthly x 6 Then 40mg every 6 weeks x 18 months ... Botulinum

Peter Saitta, DO

Associate Clinical Professor

2

The Classification and Treatment of Hand

Eczema

3Objectives

Period prevalence

Risk factors

Classification systems

Differential diagnosis

First-line therapy options

4Period Prevalence

Prevalence

Number of new cases per time period

Period prevalence

Number of patients with outbreaks during a time

period

Varies 2-10%1-3

5Hand Eczema Risks

STUDY NO AD / NO

IRRITANT WATER

EXPOSURE

AD / NO

IRRITANT WATER

EXPOSURE

AD / IRRITANT

WATER

EXPOSURE

Meding et al. 1990 5-9% 14-23% 34-48%

Nilsson et al. 1986 16% 38% 62-72%

Rystedt et al. 1985 5% 37-50% 60-81%

6

Hand Eczema Risks: Atopic Dermatitis

Atopic dermatitis

Lammintausta et al. 1991

Coenraads et al. 1998

Meding et al. 2000

Meding et al. 2004

Toledo et al. 2008

7

Hand Eczema Risks: Allergic Rhinitis

and Asthma

Allergic rhinitis/asthma increases

risk of hand eczema

But not more than atopic dermatitis4

8

Hand Eczema Risks: Female Gender

Female gender increased risk Coenraads et al. 1983

Kavli et al. 1984

Lantinga et al. 1984

Bryld et al. 2000

Yngveson et al. 2000

Meding et al. 2001

Mortz et al. 2001

Dickel et al. 2002

9

Why Female Gender ?

Meding et al.5

Wet work in 19-29 year-olds

37.5% of women occupationally exposed

18.2% of men

Learbek et al.6

Private exposures

10

Hand Eczema Risks: Occupation

STUDY TYPE OF

STUDY

STUDY

POPULATION

INCIDENCE

(PER 100)

Lantinga et al.

1984

Retrospective General

Population

7.9

Uter et al. 1994 Prospective Hairdressers 152

Smit et al. 1994 Prospective Hairdressers

Nurses

328

145

Brisman et al.

1998

Retrospective Bakers M: 16.7 F:34.4

Uter et al. 1998 Prospective Office workers 41

Funke et al. 2001 Prospective Industrial Factory

Workers

47

11

Hand Eczema Risks: Smoking

Support Risk

Edman et al.

Montnemery et al.

Linneberg et al.

Negative Risk

Lerbeack et al.

Berndt et al.

12Poor Prognosis

ACD7

Delay onset of effective treatment8

Atopic Dermatitis9

Greater area of involved skin10

> 1 year of duration8

13Classification System

Etiology

Morphology

No clear link between morphology and

etiology11

Question the need of morphological

classification system

14

Classification System: Etiology

Irritant contact dermatitis

Allergic contact dermatitis

Atopic dermatitis

80%

Idiopathic

20%

15


Irritant Contact Dermatitis11

Most common

Wet work

Water

Mechanic / Machinery oils

Detergents

Tight-fitting gloves

Friction

16Wet Work

Wet hands or glove wearing > 2

cumulative hours daily11,12

Greater than 20 hand washes

daily12

17


Allergic Contact Dermatitis

Way more common in occupational exposures vs. private exposures

(Hobby)11

“Hand eczema that spreads”13

Protein Contact Dermatitis

RARE

Latex

Food proteins

Burning, stinging and itching seconds to minutes after contact14

Systemic Contact Dermatitis

VERY RARE

Specific definition11

Positive patch test

Ingest an oral version

Vesicular hand/foot rash

18


Atopic dermatitis

Other genetic

Filaggrin null mutations15,16

Twin studies show that MZ twin individuals having a co-

twin with hand eczema had an increased risk of hand

eczema compared with DZ twins6

Atopic dermatitis adjusted

Idiopathic CHE

20%11

19

Classification System: Morphology

Guidelines of the Danish Contact Dermatitis Group

Chronic dry fissured hand eczema

Vesicular hand eczema

Hyperkeratotic (Tylotic) hand eczema

Interdigital hand eczema

Pulpitis

Nummular hand eczema

Mixed

50.5% demonstrate multiple morphologies17

20

Chronic Dry Fissured Hand Eczema

21

Chronic Dry Fissured Hand Eczema

22

Palmoplantar Psoriasis

Well-Marginated

23


Abrupt Wrist Cut-off18

24


Micaceous Scale

25


Look Elsewhere

Frequency based on location19

1. Generalized Plaque – 49.3%

2. Localized Plaque – 16.9%

3. Guttate – 12.8%

4. Arthropathic – 7.7%

5. Palmoplantar – 7.5%

6. Pustular – 3.1%

7. Other – 2.7%

26

Vesicular Hand Eczema

Intermittent20

Intensely pruritic

Palms/soles, nail, and sides of fingers

Attacks between 1 and 10 months

Two historical descriptions

Pompholyx

Dyshidrosis

27


Frequency of location20

1. Hands alone – 46.8%

2. Feet alone – 24.1%

3. Hands and feet – 15.6%

4. Nail apparatus – 13.5%

28


Anatomic Location20 Fungi Positive

Hands 1.2%

Feet 47.8%

Epidermophyton interdigitale 100% of

feet cases

29


Lane et al.21

25% of any location positive fungal infection

Pitche et al.22

10% of any location positive fungal infection

Guillet et al.23

15.8% of any location with T. rubrum or candida

infection

30


Always check the feet

Foot involvement is rare

47.8% dermatophyte infection

31


Dyshidrosiform Pattern

32

33

34

35

Keratolysis Exfoliativa

36


Dyshidrosiform Pattern

Presence of erythema

Controversial

Progression of lesions24

Early stage

Vesicular

Late stage

Chronic dry fissured presentation

Studded with pinpoint necrotic vesicles

Wet glazed look with pinpoint necrotic vesicles

37

Vesicular Hand Eczema:

Late Stage Dyshidrosiform Pattern

38

Vesicular Hand Eczema: Pompholyx

Very rare

Single episode of palms and

soles

Vesicular and BULLOUS

eruption

39

Vesicular Hand Eczema:

Pompholyx

40

Autoimmune Blistering Disease and

Lymphoma

Dyshidrosiform bullous

pemphigoid

Herpes gestationis

Linear IgA

Lymphoma

41

Palmoplantar Pustulosis

Localized to palms and soles25

1. Soles only 47.36%

2. Palms only 31.57%

3. Both soles and palms 21%

Mildly pruritic

42

43

44

Hyperkeratotic Hand Eczema (Tylotic)

Middle-aged men

NEVER VESICLES

45

Hyperkeratotic Hand Eczema (Tylotic)

46


47

Tinea Manuum

48

Interdigital Hand Eczema

Dominant hand

Site for the start of irritant hand

dermatitis26,27

49


50


51

Erosio Interdigitale Blastomycetica

52

Scabies

53

54

55

Pulpitis

56

Pulpitis

57

Nummular Hand Eczema

Very rare

Must rule out atopic dermatitis

No elevated IgE or eosinophilia

Nummular Atopic Dermatitis

(Bologna)

58

Nummular Hand Eczema

59Mixed Variety

Any combination of above

60

Problems with Current Classification

Systems good for academic pursuit

Pure clinical pictures are less likely

50.5% demonstrate multiple morphologies17

Morphology changes frequently clinically and

histologically17

No clear link between morphology and

etiology

Johansen et al.28

Cronin et al.29

Diepgen et al.30

61Simplification

Is it an eczematous process?

Acute – vesicles/bullae

Subacute/Chronic – scaling/erythema

62Simplification

IF ACUTE

CHECK THE FEET

CHECK THE FEET

CHECK THE FEET

63Simplification

Hand Eczema

Evaluation Irritant

Do you touch liquids many times a day including

water?

Evaluation Atopic

Did you have childhood eczema, allergies or asthma?

Allergic

What do you do for work?

64

Additional Work Up: Patches

Standard Series

Toledo et al.

Linberg et al.

Menne et al.

Worker’s

Compensation

Irritant contact

dermatitis31-33

21% with positive

patch test34

30% relevant

Nickel (100%)

ACD worse prognosis7

65Treatment

#1 Treatment is the same

#2 Blow them up

Faster clearance at disease onset lowers risk of chronicity43

#3 And then juice em up

Systemic and topical steroids35

One episode – 38.4%

Intermittent non-cyclic – 30.8%

Intermittent cyclic-28.5%

Chronic – 2.3%

Patients perceive systemic agents as powerful

#4 Don’t stop treatment if it gets better

66Treatment

#5 Shake their hands

#6 What worked before, may not work again

#7 It gets better with time

Period prevalence decreases with aging

78% of subjects claimed improvement of

symptoms over 15 years36

67

Study Years to Follow-Up Persistence

Agrup et al. 2 years 72%

Burrows et al. 10-13 years 79%

Reichenberger et al. 15 years 46%

Fregert et al. 3 years 68%

Gooskes et al. 15 years 55%

Lammintausta et al. 5 years 34%

Driessen et al. 5 years 50%

Keczkes et al. 15 years 69%

Latinga et al. 3 years 59%

Rystedt et al. 3 years 83%

Pryce et al. 2 years 75%

Chia et al. 1 year 28%

Wall et al. 10 years 55%

Halbert et al 10 years 76%

Rosen et al 5 years 66%

Nethercott et al. 2 years 37%

Susitaival et al. 12 years 44%

68

Treatment: Hand Care Instructions

Decrease number of washes daily

(Brancaccio)

“Your hands are broken, if your leg was

broken would you still walk on it”

Alcohol based disinfectants are less

irritating to the skin than soap and water26

Apply emollient within 2-3 minutes of wash24

Greasy as possible

Fragrance free

Apply as many times during day as you

like

69Treatment: Gloves

Use gloves when wet work or dirty work

Latex or vinyl

Tight-fitting

Cotton liner

Change when damp

70

First-Line: Topical Steroids

Which one should I use?17

Potent 65.5%

Moderate 30.53%

Superpotent 2.3%

Mild 1.67%

How often and for how long?11

Once daily dosing equal efficacy as twice daily

Two-week intervals

Even switching in the same class can prove to be

beneficial (Holland)

71

Alternatives to Topical Steroids

Tacrolimus 0.1% vs. mometasone furoate37

50% improvement in both groups

Pimecrolimus vs. mometasone furoate38

Did not reach statistical significance

Used in combination with steroids

Clear (Cohen)

1st week: ¾ Steroid Ointment ¼ Tacrolimus

2nd week: ½ Steroid ointment ½ Tacrolimus

3rd week: ¼ Steroid ointment ¾ Tacrolimus

4th week: ALL Tacrolimus

5th-on: ALL Tacrolimus Fri, Sat, Sun

72

First-Line: Systemic Steroids

First Blow

Prednisone 40-60mg daily initial dose and taper

between 3-4 weeks39

Intramuscular Kenalog 40-80mg40

Limit 4 shots per year (Wolverton)

Second Blow

Prednisolone 30mg daily for 3 days at onset of

eruptions41

Prednisone 40-60mg x 1 dose on day 1 of the

eruption23

73

Routine Intramuscular Steroid

A Comparison on the Efficacy, Relapse Rate and Side

Effects among Three Modalities of Systemic

Corticosteroid Therapy for Alopecia Areata57

Triamcinolone acetonide 40mg monthly x 6

Then 40mg every 6 weeks x 18 months

Total treatment duration = 24 months (2 years)

Total of TEN 40mg injections annually

74


A Comparison on the Efficacy, Relapse Rate and Side

Effects among Three Modalities of Systemic

Corticosteroid Therapy for Alopecia Areata57

56 subjects IM Triamcinolone acetonide arm (29 in

prednisolone)

16 dysmenorrhea (vs 3)

3 abdominal pain (vs 1)

1 worsening acne (vs 0)

5 adrenocortical impairment (vs 2)

Both groups resolved in 2 months without

steroid taper

75


Twelve-year clinico-therapeutic experience in pemphigus: a

retrospective study of 54 cases58

Intramuscular triamcinolone acetonide was given in cases

of poor compliance

80mg IM on day 0, 4, 7, 28

40mg IM every for weeks x 6 doses

Total duration of treatment = 6 months

Total of TEN injections

1 subject with weight gain

1 subject with cushingnoid features

Resolved within 4 months without steroid taper

76


Triamcinolone acetonide: a new management of

noncompliance in nephrotic children59

8 monthly doses of IM Triamcinolone

acetonide 2mg/kg Each month dose decreased by 10-20%

Total duration of treatment = 8 months

Total of EIGHT injection

All subjects had decreased longitudinal

growth

Normalized

77

Treatment: If infected

S. aureus

Systemic antibiotics superior to topicals24

78

Treatment: If Hyperhidrosis

Botulinum toxin A42

– Left versus right study

– Vesicular hand dermatitis only

– 100 units plus topical steroids

Botulinum toxin43

– Left versus right study

– Vesicular hand dermatitis only

– 162 units of botox but no steroids

79

Ultraviolet Light

UVA >>> NBUVB >>> UVB52

– Apoptosis of lymphocytes through reactive oxygen species and FAS ligand

– Increase in IL-10 inhibition of interferon –gamma.

Efficacy PUVA53,54

– Systemic = Topical = Bath

– Bath with least side effect

• Decreased UVA doses due to uniform absorption

• Phototoxicity risk disappears after 2 hours

– Sunblock and gloves

– High dose UVA-1

• Max single dose of 130J/cm2

• Cumulative dose 1720J/cm2

• As effective as cream puva52

Reduction in pruritus in first week55

80

Other Systemics

Azathioprine 100-150mg daily44

Methotrexate 15-25mg weekly45

Mycophenolate mofetil 2g/day46

Cyclosporine 2.5mg/kg/day47

Etanercept 25mg twice weekly48

81

Alitretinoin (9-cis-retinoic acid)

Approved Europe

– Indicated for chronic hand eczema refractory to

topical and systemic steroids

– Not for vesicular hand dermatitis

Panagonist RXR, RAR

Retinoid Adverse Events

– Headache, mucocutaneous dryness, elevated liver

enzymes, elevated blood lipid levels,

teratogenicity

No combination studies

82

Alitretinoin (9-cis-retinoic acid)

Alitretinoin 30mg daily49

– Median time to clear hands is 12 weeks

Placebo, Alitretinoin 10mg, 20mg, 40mg daily

doses for 12 weeks50

– 70% reduction in 50%

Alitretinoin 10mg, 30mg daily for 24 weeks51

– 100% reduction in 48%

– More response with 30mg

83

Summary

Period prevalence

2-10%

Risk factors

Atopic dermatitis, allergic rhinitis/asthma, occupation, wet

irritant exposure

Classification systems

Etiology and morphology

Not practical day-to-day clinic

Differential Diagnosis

Check the feet

First-line therapy options

Blow em up and then juice em up

84

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Documents

Peter Saitta, DO Associate Clinical Professor · Corticosteroid Therapy for Alopecia Areata57 Triamcinolone acetonide 40mg monthly x 6 Then 40mg every 6 weeks x 18 months ... Botulinum