Allergy Care - Occupational Hand Eczema

Irritant contact eczema

This is caused by repeated exposure to irritant chemicals, e.g. shampoos, oil, cement, and is the most common work-related skin condition. It usually affects the back of the hands and is most commonly seen in people whose job brings them into regular daily contact with the offending irritant. This persistent assault on the skin can gradually result in the development of hand eczema, especially when exposure to the irritants cannot be avoided. Some people even have to change jobs or give up work if the eczema gets severe and cannot be effectively treated.

Certain professions/industries are associated with a greater risk of developing irritant contact eczema, namely cleaning, hotel and catering, construction, dentistry, hairdressing, health services, machinery (metal workers, mechanics), printing, forestry, fishing, and farming.

Allergic contact eczema

This is an allergic reaction to sensitising chemicals, and usually occurs after being repeatedly exposed to a particular substance. Unlike irritant contact eczema, it will only occur in people with a genetic tendency towards such a reaction. Because it doesn’t occur immediately, it can be difficult to identify the cause, but avoiding the substance causing the allergy is usually the first step in treating this type of eczema. Typical examples are people who are allergic to nickel (in costume jewellery), latex in gloves, or hair dye.

Atopic eczema

This is the most common type of eczema where people have a genetic or hereditary tendency (i.e. they are born with the tendency) to have allergic reactions that affect their skin. People with atopic eczema often have hayfever and/or asthma as well, and this is particularly common in children.

Impact on patients’ lives

Since hand eczema is highly visible, there is a debilitating social stigma attached which may cause embarrassment and low self-esteem. An estimated 9% of patients with occupational hand eczema suffer from moderate to severe depression. Symptoms like night-time itching may significantly affect sleep, while physical symptoms such as cracks (fissuring) and thickening (hyperkeratosis) may cause significant distress and impairment of manual dexterity and function. This affects daily living and means that some patients may have to change jobs or are unable to work, resulting in sick leave, lost productivity, and early retirement.

The need for frequent visits to the doctor and to regularly apply greasy applications, all add to the burden of the disease. Regardless of the original combination of factors which triggered chronic hand eczema, the prognosis (predicted course of disease and likelihood of recovery) is generally poor and treatment is the same. Severe chronic hand eczema has a significant impact on quality of life, comparable to that of generalised eczema and severe psoriasis.

A number of surveys have been conducted over the past few years to try and quantify the impact of occupational hand eczema:

o In a survey conducted in the UK among GPs with special training in occupational medicine,    work-related skin conditions were responsible for about 10% of all diagnoses, with 15% of    those being issued with sick certificates.

o A survey conducted in Denmark found that occupational hand eczema led to prolonged sick    leave in 20% and job loss in 23% of participants over the course of a year.

o Another observational study in Denmark found that 12% of participants had taken sick leave    due to hand eczema, and 9% had changed jobs.

o National statistics from the US suggest that 15% of people with contact dermatitis have    limitation of activity due to involvement of the hands.

o A survey found that people with chronic hand eczema have a worse quality of life and impaired    activity and work performance compared to those without hand eczema.

Treatment

The key to successful treatment is to try and identify the cause of the problem, and doctors may even do patch testing to blood test to help identify the specific substances. In irritant and allergic contact eczema, avoiding contact with the offending chemicals and protection of the hands using silk or cotton gloves is often sufficient, but this is often difficult or not possible in occupational hand eczema.

Moisturisers (emollients) are essential to help maintain the hydration and integrity of the skin and avoiding soaps by using soap substitutes also helps. Steroid creams and ointments of varying strengths are often used to relieve the inflammation of the skin and antibiotics may be required if the eczema becomes infected. Other therapeutic options include topical (i.e. creams/ointments) immunosuppressants and ultra-violet light treatment (commonly PUVA).

Long term (chronic) severe cases of hand eczema can be very difficult to treat successfully and it may be necessary to use oral formulations of potent steroids or immunosuppressants. Azathioprine and ciclosporin are powerful immunosuppressants that were originally developed to prevent the rejection of organ transplants and they are sometimes used in eczema even though there is a relative lack of evidence of their effect.

In the September 2008, a new treatment was launched for severe chronic hand eczema. It is a member of the retinoid group of medicines which are derived from vitamin A and have been used effectively in the treatment of many skin diseases such as psoriasis and acne for the past 40 years. It is a capsule that is taken once a day and is called alitretinoin (Toctino). In clinical trials it has been shown to be effective in producing clear/almost clear hands in nearly 50% of patients within six months and has recently been recommended for use in the NHS by NICE.

Like all medicines it has a number of possible side effects including headache and increasing your cholesterol levels. As a retinoid it can cause severe birth defects so women of child bearing potential need to adhere to strict pregnancy prevention measures. Alitretinoin is only available from dermatologists (usually based in hospital) or GPs with expertise in the use of oral retinoids.

This availability of alitretinoin on the NHS brings much needed hope to sufferers of severe hand eczema as it is the first new treatment specifically developed for this debilitating condition that offers the potential for clear hands and return to normal functioning, including work.

References:

1. Toctino Summary of Product Characteristics September 2008
2. Diepgen T et al. Management of chronic hand eczema. Contact Dermatitis 2007; 57: 203-210
3. National Institute for Health and Clinical Excellence: Alitretinoin for the treatment of severe chronic hand eczema. Technology Appraisal TAG177 August 2009. Available at www.nice.org.uk
4. English J et al. Consensus statement on the management of chronic hand eczema. Clin Exp Dermatol, 2009; 34(7): 761–769
5. Blome C et al. Measurement of patient-relevant benefits in the treatment of chronic hand eczema – a novel approach. Contact Dermatitis 2009; 61:39-45
6. Hussey L et al. Work-related ill-health in general practice, as reported to a UK-wide surveillance scheme. British Journal of General Practice 2009: 637-640
7. Lerbaek A et al. Clinical characteristics and consequences of hand eczema – an 8-year follow-up study of a population-based twin cohort. Contact Dermatitis 2008; 58: 210–16
8. Fowler JF et al. Impact of chronic hand dermatitis on quality of life, work productivity, activity impairment, and medical costs. J Am Acad Dermatol 2006; 54: 448–57

 

For more information about hand eczema and ways to manage the condition visit www.myhandeczema.co.uk.