Pharmacist Counseling About Treatment for Chronic Hand Dermatitis Improves Patient Odds of Healing
What begins as a simple case of dry hands can turn into a significant health concern when the patient actually has chronic hand dermatitis. As the condition thickens skin and causes deep, painful cracks, it interferes with the ability to perform on the job and to do everyday tasks.
Only about half of these patients seek professional dermatological care, which means many self-treat. As a result, they depend on pharmacists to recommend OTC products when their symptoms don’t clear up. Pharmacists can use this opportunity to counsel about treatment options and to identify patients who should consult a physician.
Clinical Features of Hand Dermatitis
Hand dermatitis, or hand eczema, is called a “socially significant disease” due to its high morbidity and the fact that it affects quality of life and impairs work productivity, often causing employees to take sick leave. Its prevalence is 10 to 15 percent in the general population, but the rate may be as high as 30 percent in occupations where hands are exposed to irritants such as solvents, detergents, water, lubricants, foods products, resins and fragrances, to name just a few.1 These statistics highlight the impact of hand dermatitis:
- Hand dermatitis accounts for more than 80 percent of occupational dermatitis.
- Onset occurs before 20 years in 30 percent of patients.
- Duration averages 7 to 11 years.
- 10 percent of patients will have to change their occupation.
While there’s no universal classification system, hand dermatitis is considered to be chronic when the outbreak lasts more than three months or recurs two or more times yearly. Etiology is quite diverse and often difficult to determine. In fact, in 20 percent of cases, the cause may never be found. Possible etiologic factors include:
- External factors
- Irritant contact dermatitis
- Allergic contact dermatitis
- Protein contact dermatitis
- Atopic dermatitis
Experts believe that chronic hand dermatitis develops over time as the skin barrier is exposed to irritants that produce subclinical insults. At each exposure, the damage isn’t enough to cause an acute reaction, but cumulative damage gradually builds, leading to desquamation and lesions that progress to become fissured plaques. Symptoms include:
- Dry, chapped skin (earliest sign)
- Scaly patches
- Burning sensation
- Itching – may be associated with severity
- Thickened skin due to lichenification
- Deep, painful cracks
- Bleeding or weeping skin
Treatment for Chronic Hand Dermatitis
When patients are still in the early stage and only have dry skin, self-treatment is logical and the least expensive option. As the condition progresses, proper treatment is essential, not only for the patient’s comfort and to restore hand function, but also because the longer it goes untreated—the longer the condition persists—the more likely it is to become chronic.
Treatment for hand dermatitis always includes prevention and skin protection; it may also include topical or systemic medications. When self-care doesn’t provide relief, encourage patients to see a dermatologist; let them know about prescription options and that they may need more aggressive treatment to prevent the condition from becoming chronic.
Since some patients won’t follow up with a physician, you can help by teaching them about the importance of prevention and protection, based on these recommendations:
Prevention and skin protection advice:2
- Avoid exposure to irritants – The irritant may be obvious or it may require deep digging by a doctor. Be sure patients know that frequent hand washing, alcohol-based hand sanitizers and other common items like dish detergent are common irritants.
- Wear gloves – Use gloves for as short a time as possible, wearing cotton gloves at home, protective gloves at work or when hands are in water, and cotton gloves under occlusive gloves.
- Moisturize regularly – A rich, bland emollient applied frequently is essential to restore the skin barrier. In the workplace, apply protective cream before exposure, use mild cleanser to remove any irritants after exposure, then apply emollients or moisturizers.
- Continued use of emollients – Advise patients to keep using emollients daily and apply frequently even after symptoms subside. Educate them about the skin barrier, how it takes longer to heal and the importance of keeping it healthy to prevent future outbreaks.
Pharmaceutical treatment proceeds in a step-wise fashion, depending on symptom severity and patient response:3
- Topical corticosteroids – This is the primary treatment. Sufficient potency to quickly suppress inflammation should be used for a short time, then tapered to lower potency. Consider intermittent dosing to lower the risk of adverse effects, such as corticosteroids applied only on weekends or every other day for up to 36 weeks.
- Topical calcineurin inhibitors – While effective for chronic hand eczema, topical calcineurin inhibitors may not penetrate through hyperkeratosis and may need to be applied under occlusion. May worsen dermatitis symptoms or cause burning, stinging and erythema in some patients.
- High-potency topical corticosteroids
- Systemic retinoids – Alitretinoin is effective for hand dermatitis that doesn’t respond to standard therapy. In one study, 48 percent of patients achieved nearly complete clearance, 62 percent had partial response and median time to relapse was 5.5 months.4
- UV therapy – Insufficiently studied but broad- and narrow-band UVB, PUVA and UVA1 therapies have shown good results.
- Systemic therapy – corticosteroids, azathioprine (alone or as a corticoid-sparing agent), methotrexate and cyclosporine (up to 6 months at minimum effective dose but not combined with UV therapy or in patients with significant cumulative life-long UV exposure)
Pharmacists Can Encourage Patients to Stick with Treatment
It doesn’t take long to offer a word of encouragement or to ask a patient how they’re doing with the treatment regimen, yet that could be the key to patient adherence because it opens the door to managing any patient concerns. Patients using emollients are lured into thinking that such simple treatment isn’t as effective or important. Not to mention that emollient regimens are hard to maintain with heavy, greasy products. Additionally, many tend to think of hand dermatitis as curable rather than a long-term chronic condition.5 Their quality of life improves as pharmacists offer the information and support they need.
Pharmaceutica North America provides prescription drug products such as lidocaine ointment and diclofenac sodium and a diverse line of active pharmaceutical ingredients and OTC products. Contact us today—we’re here to answer questions and to talk about how we can support your pharmaceutical needs.
- “Chronic Hand Dermatitis,” 2016, https://www.aad.org/faculty/handout/SAM2016/accepted/BRF%20B003%20-%20Ehrlich%20-%2010928%209139.pdf ↩
- “Management of Chronic Hand Dermatitis: A Practical Guideline for the General Practitioner,” December 2016, http://www.skintherapyletter.com/fp/2016/11.1/1.html ↩
- “Hand Dermatitis: A Review of Clinical Features, Prevention and Treatment,” August 2015, http://www.medscape.com/viewarticle/849562 ↩
- “Efficacy and Safety of Oral Alitretinoin (9-cis Retinoic Acid) in Patients with Severe Chronic Hand Eczema Refractory to Topical Corticosteroids: Results of a Randomized, Double-Blind, Placebo-Controlled, Multicentre Trial,” April 2008, https://www.ncbi.nlm.nih.gov/pubmed/18294310 ↩
- “Knowledge, Attitudes and Behaviour in Everyday Life with Chronic Hand Eczema,” November 2013, http://www.medscape.com/viewarticle/814102_1 ↩