Hand eczema is a chronic condition that involves inflammation or dermatitis of the skin of the hands. The causes of hand eczema can be multi-factorial, involving both predisposing and external factors. In one-third to one-half of cases, hand eczema is considered atopic, meaning that affected individuals are predisposed to develop asthma, hay fever or eczema (Coenraads, 1998). The most common external causes of hand eczema are contact with mild toxic agents or irritants, for example, water and soaps, leading to irritant contact dermatitis.
Allergic contact dermatitis is caused by skin contact with allergens and occurs in people who have developed a contact allergy to a specific substance, for example, perfumes. It is less common than irritant contact dermatitis. Ingested allergens may occasionally provoke hand eczema, for example, nickel. In many people with chronic hand eczema, a combination of these factors play a role, while, for several types of hand eczema, the cause remains unknown (Jensen, 2006).
The symptoms associated with hand eczema include a persistent itch that can be intense and lead to sleep loss in those affected. Cracks, blisters and hyperkeratosis can develop, leading to pain and reduced mobility of the hands. This can have a negative impact on the ability of people to manage their activities of daily living, as well as perform manual work, resulting in significant disability and economic losses for both the individual and society as a whole (Christoffers et al, 2019). In addition, the symptoms of hand eczema can have a flow-on effect on the psychological wellbeing of those affected and lead to anxiety, low self-esteem and social phobia with an associated social stigma (Christoffers et al, 2019).
There are many different treatments used to control and manage the signs and symptoms associated with hand eczema, including:
- Skin protection measures, for example, gloves
- Topical treatments, for example, corticosteroid creams
- Systemic treatments, for example, oral corticosteroids.
Objective/s
The primary objective of the review summarised here (Christoffers et al, 2019) was to assess the efficacy of topical and systemic interventions for hand eczema in adults and children.
Intervention/methods
Christoffers et al's (2019) review included randomised controlled trials (RCTs) of interventions for hand eczema versus no treatment, placebo or other active ingredients. Studies that focused on primary prevention of hand eczema or non-pharmacological interventions were excluded.
The primary outcomes considered were:
- Percentage of participants with self-rated good/excellent control of symptoms
- Percentage of participants with investigator-rated good/excellent control of symptoms
- Adverse events–both short-term (during the treatment period) and long-term (after completion of the treatment phase).
The secondary outcomes included:
- Participant-rated reduction in severity
- Investigator-rated reduction in severity
- Time until relapse
- Dose reduction.
Results
The review included 60 RCTs on different interventions for hand eczema that involved a total of 5469 participants. This included published studies from the period 1967 to 2018 and unpublished data registered in trial registries up to April 2018. All studies were performed in a secondary setting and included participants who had chronic hand eczema of differing grades of severity.
The majority of studies were relatively small with between 12 to 158 participants, with over half (n=2893) of the participants included in five trials. Three of these trials considered the use of oral retinoid alitretinoin and two considered a topical calcineurin inhibitor. Overall, the studies were of short duration, with only 11 studies having a duration of greater than 4 months.
For the corticosteroid creams and ointments intervention, the authors reported that, when compared with vehicle foam, clobetasol propionate foam increases participant-rated control of hand eczema (516 versus 222 per 1000); however, the difference was less clear for investigator-rated control, and there were more adverse events reported with the intervention, for example, application site burning or pruritus. These findings were based on moderate-certainty evidence. The use of mometasone furoate foam three times per week seemed to be associated with a slight improvement in investigator-rated control of symptoms, compared with twice weekly application. Some mild atrophy was reported in both groups. These findings were based on low-certainty evidence.
Christoffers et al (2019) authors compared various types of irradiation with ultra-violet light. Local PUVA seemed to lead to improvement in investigator-rated symptom control when compared with local narrow-band UVB; however, the 95% confidence interval indicated that local PUVA might make little or no difference (moderate-certainty evidence).
Participants who received treatment with the topical calcineurin inhibitor, tacrolimus, over a two-week period were probably more likely to achieve improved investigator-rated symptom control compared with those who received the vehicle treatment. This finding was based on moderate-certainty evidence.
Investigator- or participant-rated control of symptoms was slightly improved with the oral immunosuppressant cyclosporine than with topical betamethasone cream (corticosteroid). The risk of adverse events, for example, dizziness, was similar between the groups. These results were based on moderate-certainty evidence.
Treatment with an oral vitamin A derivative (retinoid) alitretinoin (10 mg) achieved better investigator-rated symptom control compared with placebo (307 versus 194 participants per 1000). Similar results were found for participant-rated symptom control (high-certainty evidence). When the dosage was increased to 30 mg, the risk of headaches was higher compared with the placebo (74 versus 251 per 1000; high-certainty evidence).
The authors cautioned that most findings reported were from single studies with low precision (Christoffers et al, 2019). The heterogeneity among studies and small sample sizes limited the authors' ability to detect differences between treatments. In addition, many studies were at high or unclear risk of bias in one or more components of trial design. Some 22 studies were funded by pharmaceutical companies.
Conclusions
The findings of this review did not point to one standard treatment or treatment regime as best practice for managing the signs and symptoms of hand eczema.
The use of mometasone furoate foam thrice weekly, versus twice weekly, seemed to produce a slight improvement in investigator-rated control of symptoms. Local PUVA seemed to lead to greater improvement compared with local narrow-band UVB; however, this difference was not significant.
The use of tacrolimus ointment seemed to improve investigator-rated symptom control better compared with vehicle foam. Oral cyclosporine slightly improved investigator- and participant-rated control of symptoms compared with topical betamethasone dipropionate cream.
Treatment with an oral retinoid, alitretinoin, led to improved investigator-/participant-rated symptom control compared with placebo. The benefit was more apparent when the dose as increased (10 to 30 mg), but the higher dose was associated with an increased frequency of adverse events.
Implications for practice
The wide range of treatment options included in the review (Christoffers et al, 2019) underscores the fact that there is no one standard treatment option for hand eczema. Topical corticosteroids and UV phototherapy were two of the major treatment options; however, the authors found insufficient evidence to support one type of treatment over another. Overall, there were limited data to support the best way to treat hand eczema, and the results of the review, therefore, cannot be used to inform clinical practice. For these reasons, further research in this area using large RCTs is key to informing best evidence-based practice.