DEMATOLOGY: CLINICAL & BASIC SCIENCE SERIES HAND ECZEMA SECOND EDITION docx

HAND ECZEMA
SECOND EDITION
DERMATOLOGY: CLINICAL AND BASIC
SCIENCE SERIES
Series Editor Howard I.Maibach, M.D.
Published Titles:
Bioengineering of the Skin: Cutaneous Blood Flow and ErythemaEnzo
Berardesca, Peter Elsner, and Howard I.Maibach
Bioengineering of the Skin: Water and the Stratum CorneumPeter Elsner,
Enzo Berardesca, and Howard I.Maibach
Bioengineering of the Skin: Methods and InstrumentationEnzo Berardesca,
Peter Elsner, Klaus P.Wilhelm, and Howard I.Maibach
Bioengineering of the Skin: Skin Surface, Imaging, and AnalysisKlaus
P.Wilhelm, Peter Elsner, Enzo Berardesca, and Howard I.Maibach
Dermatologic Research TechniquesHoward I.Maibach
Health Risk Assessment: Dermal and Inhalation Exposure and Absorption
of ToxicantsRhoda G.M.Wang, James B.Knaak, and Howard I.Maibach
Pigmentation and Pigmentary DisordersNorman Levine
Protective Gloves for Occupational UseGunh Mellström, J.E.Walhberg, and
Howard I.Maibach
Skin Cancer: Mechanisms and Human RelevanceHasan Mukhtar
Human Papillomavirus Infections in DermatovenereologyGerd Gross and
Geo von Krogh
Contact Urticaria SyndromeSmita Amin, Arto Lahti, and Howard I.Maibach
Skin Reactions to DrugsKirsti Kauppinen, Kristiina Alanko, Matti Hannuksela,
and Howard I.Maibach
Dermatologic BotanyJavier Avalos and Howard I.Maibach
Hand Eczema, Second EditionTorkil Menné and Howard I.Maibach
Dry Skin and Moisturizers: Chemistry and FunctionMarie Loden and
Howard I.Maibach

DEMATOLOGY: CLINICAL & BASIC SCIENCE SERIES
HAND ECZEMA
SECOND EDITION
Edited by
Torkil Menné, M.D.
Howard I.Maibach, M.D.
CRC Press
Boca Raton London New York Washington, D.C.
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Library of Congress Cataloging-in-Publication Data
Hand eczema/edited by Torkil Menné and Howard I. Maibach.—2nd ed.
p. cm. — (Dermatology)
Includes bibliographical references and index.
ISBN 0-8493-7362 (Print Edition)-X (alk. paper)
1. Eczema. 2. Hand—Diseases. I. Menné, Torkil. II. Maibach, Howard I. III. CRC
series in dermatology
[DNLM: 1. Eczema. 2. Hand Dermatoses. 3. Occupational Diseases. WR 190 H236 2000]
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v

Preface
Hand eczema is one of the most common clinical conditions treated and
evaluated both among general dermatologists and in dermatological departments.
Hand eczema is the most common occupational skin disease and one of the most
frequent occupational disorders overall. Hand eczema can be long lasting and
incapacitating. Research within the last decades has expanded our knowledge
significantly. This knowledge has yet to find its way into general dermatological
textbooks.
D.S.Wilkinson provides a thorough introductory chapter on the definitions and
problems of classification. The book discusses the common varieties of hand
eczema and the indication for patch testing. Several chapters are devoted to
specific occupational exposures. New knowledge on risk factors and
toxicological aspects are dealt with in new chapters. The book contains a color
atlas of the various types of hand eczema including occupational hand eczema. In
addition to the comprehensive coverage of preventive measures, four chapters
are devoted to specific treatments such as UV-light, X-ray, and corticosteroids
and guidelines for management of hand eczema.
Editors
Torkil Menné, M.D., is Professor and Chairman, Department of Dermatology,
Gentofte Hospital, University of Copenhagen, Denmark. Dr. Menné obtained his
M.D. from the University of Copenhagen in 1971 and received a Ph.D. in 1983
at the same university for investigations on genetic and epidemiologic aspects of
nickel dermatitis.
Dr. Menné is the former Chairman of the European Environmental Contact
Dermatitis Research Group and a member of the Danish Contact Dermatitis
Research Group. He is author of 270 articles and co-author and editor of 5
books.
Howard I.Maibach, M.D., is Professor of Dermatology, School of Medicine,
University of California, San Francisco. Dr. Maibach graduated from Tulane
University, New Orleans, Louisiana (A.B. and M.D.) and received his research

and clinical training at the University of Pennsylvania, Philadelphia. He received
an honorary doctorate from the University of Paris Sud in 1988.
Dr. Maibach is a member of the International Contact Dermatitis Research
Group, the North American Contact Dermatitis Group, and the European
Environmental Contact Dermatitis Group. He has published more than 1500
papers and 40 volumes.
Contributors
Tove Agner, M.D., Ph.D.
Department of Dermatology
Gentofte Hospital
University of Copenhagen
Hellerup, Denmark
S.Iris Ale
Department of Dermatology
University Hospital
Republic University
Montevideo, Uruguay
Kristiina Alanko
Section of Dermatology
Finnish Institute of Occupational Health
Helsinki, Finland
C.F.Allenby, M.D.
Lister Hospital
Herts, United Kingdom
Klaus E.Andersen, M.D., Ph.D.
Department of Dermatology
Odense University Hospital
Odense, Denmark
Saqib J.Bashir
Department of Dermatology

School of Medicine
University of California
San Francisco, California
David A.Basketter, B.Sc.
Environmental Safety Lab
Unilever Research
Sharnbrook, United Kingdom
Derk P.Bruynzeel, M.D.
Department of Dermatology
Free University Academic Hospital
Amsterdam, The Netherlands
Magnus Bruze, M.D., Ph.D.
Department of Dermatology
Lund University
Malmö General Hospital
Malmö, Sweden
Ai-Lean Chew
Department of Dermatology
School of Medicine
University of California
San Francisco, California
Ole B.Christensen, M.D., Ph.D.
Department of Dermatology
Ullevål Sygehus
Oslo, Norway
Edith M.De Boer, M.D.
Department of Dermatology
Free University Academic Hospital
Amsterdam, The Netherlands
Thomas L.Diepgen, M.D.

Department of Occupational and Social Medicine
Ruprecht-Karls-University Heidelberg
Heidelberg, Germany
Björn Edman, M.Sc., D.M.Sc.
Department of Dermatology
Lund University
Malmö General Hospital
Malmö, Sweden
Peter Elsner
Department of Dermatology
Friedrich-Schiller University
Jena, Germany
ix
Ernst Epstein, M.D.
San Mateo, California
Tuula Estlander, M.D., Ph.D.
Section of Dermatology
Institute of Occupational Health
Helsinki, Finland
Manigé Fartasch, M.D.
Department of Dermatology
Friedrich-Alexander-University ErlangenNuremberg
Erlangen, Germany
Sigfrid Fregert, M.D., Ph.D.
Department of Occupational Dermatology
Lund University
Malmö General Hospital
Malmö, Sweden
Peter J.Frosch, M.D.
Department of Dermatology

Städt Kliniken
University of Witten/Herdecke
Dortmund, Germany
G.Gallacher
Department of Dermatology
School of Medicine
University of California
San Francisco, California
Chee-Leok Goh, M.B.B.S., M.Med.,
M.R.C.P.
National Skin Centre
Singapore
C.Grief
Department of Dermatology
Friedrich-Schiller University
Jena, Germany
Birgitta Gruvberger
Department of Dermatology
Lund University
Malmö General Hospital
x
Malmö, Sweden
Lars Halkier-Sørensen, M.D.
Department of Dermatology
Marselisborg Hospital
Aarhus, Denmark
Daniel J.Hogan, M.D.
Dermatology and Cutaneous Surgery
School of Medicine
Louisiana State University

Shreveport, Louisiana
Riitta Jolanki, D.Tech.
Section of Dermatology
Institute of Occupational Health
Helsinki, Finland
Lasse Kanerva, M.D., Ph.D.
Section of Dermatology
Institute of Occupational Health
Helsinki, Finland
Bodil B.Knudsen
Department of Dematology
Gentofte Hospital
University of Copenhagen
Hellerup, Denmark
Kaija Lammintausta, M.D., Ph.D.
Department of Dermatology
Turku University Central Hospital
Turku, Finland
Antti I.Lauerma, M.D., Ph.D.
Department of Dermatology
University of Helsinki
Helsinki, Finland
Bernt Lindelöf, M.D., Ph.D.
Department of Dermatology
Danderyd Hospital
Stockholm, Sweden
Howard I.Maibach, M.D.
Department of Dermatology
xi
School of Medicine

University of California
San Francisco, California
Birgitta Meding, M.D., Ph.D.
Department of Occupational Dermatology
National Institute of Occupational Health
Solna, Sweden
Torkil Menné, M.D., Ph.D.
Department of Dermatology
Gentofte Hospital
University of Copenhagen
Hellerup, Denmark
Gerd Molander
Department of Dermatology
University of Helsinki
Helsinki, Finland
Halvor Möller, M.D., Ph.D.
Department of Dermatology
Lund University
Malmö General Hospital
Malmö, Sweden
Eskil Nilsson, M.D.
Department of Dermatology
Sundsvall Hospital
Sundsvall, Sweden
Beate Pilz, M.D.
Department of Dermatology
Städt Kliniken
University of Witten/Herdecke
Dortmund, Germany
Dorte W.Ramsing

Department of Dermatology
Gentofte Hospital
University of Copenhagen
Hellerup, Denmark
Thomas Rustemeyer
Department of Pathology
xii
Free University Hospital of Amsterdam
Amsterdam, The Netherlands
Ingela Rystedt, M.D., Ph.D.
Department of Dermatology
Karolinska Hospital
Stockholm, Sweden
Hans J.Schwanitz, M.D., Ph.D.
Department of Dermatology and Theory of Health
University of Osnabrück
Osnabrück, Germany
Kyllikki Tarvainen, M.D.
Section of Dermatology
Institute of Occupational Health
Helsinki, Finland
Kristian Thestrup-Pedersen, M.D.
Department of Dermatology
University of Aarhus
Marselisborg Hospital
Aarhus, Denmark
Kristiina Turjanmaa, M.D., Ph.D.
Department of Dermatology
Tampere University Hospital
Tampere, Finland

Henk B.van der Walle, M.D., Ph.D.
Center of Occupational Dermatology
Ziekenhuis Rijnstate GZ
Arnhem, The Netherlands
Niels K.Veien, M.D.
The Dermatology Clinic
Aalborg, Denmark
W.Wigger-Alberti
Department of Dermatology
Friedrich-Schiller University
Jena, Germany
D.S.Wilkinson, M.D., F.R.C.P.
Whitecroft
Amersham, Bucks, United Kingdom
xiii
Hongbo Zhai
Department of Dermatology School of Medicine
University of California
San Francisco, California
xiv
Acknowledgment
The editors are grateful for the sponsoring of the color slides in this book by
Brocades Pharma A/S, Yamanouchi Group.
In honor of
Etain Cronin
a special friend of dermatology, her patients,
and her many admiring colleagues
Contents
Chapter 1 Introduction, Definition, and Classification
D.S.Wilkinson

1
Chapter 2 Epidemiology of Hand Eczema
Birgitta Meding
20
RISK FACTORS FOR HAND ECZEMA
Chapter 3 General Aspects of Risk Factors in Hand Eczema
Thomas L.Diepgen and Manige Fartasch
32
Chapter 4 Risk Factors for Hand Dermatitis in Wet Work
Kaija Lammintausta
52
Chapter 5 Experimental Evaluation of Risk Factors in Wet Work
Dorte W.Ramsing and Tove Agner
60
Chapter 6 Individual and Environmental Risk Factors for Hand
Eczema in Hospital Workers
Eskil Nilsson
75
Chapter 7 Statistical Relations Between Hand Eczema and Contact
Allergens
Björn Edman
94
TOXICOLOGY
Chapter 8 Prediction of Skin Irritation by Noninvasive
Bioengineering Methods
Tove Agner
107
Chapter 9 Experimental Acute Irritation in the Atopic Dermatitis
Population
G.Gallacher and H.I.Maibach

121
Chapter 10 Quantitative Aspects of Allergen Exposure in Relation
to Allergic Contact Dermatitis on the Hands
David A.Basketter
130
CLINICAL TYPES
Chapter 11 Chemical Skin Burns
Magnus Bruze, Sigfrid Fregert and Birgitta Gruvberger
144
Chapter 12 Mechanical Trauma and Hand Eczema
Klaus E.Andersen
159
Chapter 13 Irritant Contact Dermatitis
Henk B.van der Walle
164
Chapter 14 Atopic Hand Eczema
Halvor Möller
174
Chapter 15 Acute and Recurrent Vesicular Hand Dermatitis
(Pompholyx)
Niels K.Veien and Torkil Menné
203
Chapter 16 Hyperkeratotic Dermatitis of the Palms
Torkil Menné
228
Chapter 17 Contact Urticaria and Hand Eczema
Ai-Lean Chew and Howard I.Maibach
233
SPECIAL OCCUPATIONS
Chapter 18 Principles of Occupational Hand Eczema

Magnus Bruze
248
Chapter 19 Hairdressers’ Eczema
Peter J.Frosch and Thomas Rustemeyer
268
Chapter 20 Evaluation of Skin Irritation in the Fishing Industry
Lars Halkier-Sorensen and Kristian Thestrup-Pederson
286
Chapter 21 Occupational Dermatitis by Metalworking Fluids
Edith M.De Boer and Derk P.Bruynzeel
318
Chapter 22 Dermatitis from Acrylate Compounds in Dental
Personnel
Lasse Kanerva, Tuula Estlander, Riitta Jolanki and Kristiina
Alanko
340
Chapter 23 Hand Eczema from Rubber Gloves
Bodil B.Knudsen and Kristiina Turjanmaa
373
Chapter 24 Hand Eczema in the Construction Industry
Chee-Leok Goh
390
Chapter 25 Hand Eczema in Farmers
Niels K.Veien
401
xviii
PREVENTION
Chapter 26 Protective Gloves
Tuula Estlander, Riitta Jolanki and Lasse Kanerva
418

Chapter 27 Emollients and Barrier Creams in the Prevention of
Hand Eczema
C.Grief, W.Wigger-Alberti and Peter Elsner
438
Chapter 28 Model Assay for Evaluation of Barrier Formulations
Hongbo Zhai and Howard I.Maibach
450
TREATMENT
Chapter 29 UV-Light Treatment of Hand Eczema
Ole B.Christensen
458
Chapter 30 X-Ray Treatment of Hand Eczema
Bernt Lindelof
470
Chapter 31 Corticosteroid Allergy and Hand Eczema
Antti I.Lauerma and Gerd Molander
478
Chapter 32 Guidelines for the Management of Hand Eczema
Tove Agner
484
Chapter 33 Methods for Testing Irritation Potential
Saqib J.Bashir and Howard I.Maibach
491
Chapter 34 Hand Dermatitis and Psoriasis Syndrome
S.Iris Ale and Howard Maibach
505
Chapter 35 Contact Urticaria and Hand Eczema
S.Iris Ale and Howard Maibach
518
APPENDICES

Appendix 1: Hand Dermatitis Treatment 545
Appendix 2: Hand Protection for Hand Dermatitis 547
Appendix 3: Overnight Plastic Occlusion for Hand Dermatitis 549
Index 551
xix
1
Introduction, Definition, and Classification
D.S.Wilkinson
CONTENTS
I. Introduction 2
A. Historical Background 2
B. Allergic Contact Dermatitis and the Patch Test 3
II. Definition 4
A. Definition of Eczema 4
B. Definition of Eczema and Dermatitis 5
C. Definition of Eczema of the Hands 5
III. Prevalence and Significance 6
A. Prevalence 6
B. Significance 7
1. Occupational 8
2. Domestic 8
3. Social 9
4. Psychological 10
IV. Classification 11
A. Diffuse or Patchy, Dorsal, and Palmar 12
B. Particular Patterns 12
1. Ring Eczema 12
2. Discoid Hand Eczema 13
3. Hyperkeratotic Hand Eczema 13
4. Fingertip Eczema 14

5. Palmar Eczema 14
a. Dry Palmar 14
b. “Apron” Pattern 15
c. Subacute Recurrent Vesicular Type 15
6. Pompholyx 15
7. Rare Forms 16
a. Gut (Slaughterhouse) Eczema 16
b. Chronic Acral Dermatitis 16
c. Other Patterns 17
References 17
0-8493-7362-X/00/$0.00+$.50
© 2000 by CRC Press LLC
I.
INTRODUCTION
The eczematous group of skin disorders embraces a number of entities in which
endogenous exogenous, environmental, and cultural factors are often
interwoven. This is particularly true of eczema affecting the hands, a condition
that is frequently multifactorial, usually disabling or distressing to the sufferer,
and often difficult to treat. This difficulty is partly due to the intrinsic nature of
eczema itself and the special anatomical features of the palmar skin but also
because of the role of the hands in everyday social life and work and the inability
of the patient to comply fully with avoidance techniques.
This chapter is designed to present a general overview of the subject. All the
aspects touched on here are dealt with more fully in subsequent chapters. The
views expressed are personal and in no way invalidate the more detailed analyses
and conclusions reached by those working in particular fields of the subject.
Indeed, some may be considered to be idiosyncratic.
A.
HISTORICAL BACKGROUND
It may be considered curious to single out eczema of the hands as being worthy

of special study. The dermatologists of the 19th century, although well aware of
2 HAND ECZEMA, SECOND EDITION
variations due to site, were more concerned with morphological forms of the
disease (eczema solare, rubrum, or impetiginodes and, later, squamosum,
papulosum, and marginatum). In his long treatise on eczema, Hebra
1
devoted
less than a page to eczema of the hands and feet, and this in morphological
terms. Fox
2
stated that eczema in these sites is “chiefly remarkable for the
peculiar tenacity and persistence of the vesicles” and mentioned grocers’ and
bakers’ itch but little else. Radcliffe-Crocker
3
emphasizes the role of external
irritants. It is noteworthy, however, that all these outstanding clinicians devoted
far more space to a detailed discussion of treatment than is usually the case today.
The recognition of the hands as a region of particular interest has come about
gradually during this century and increasingly so in the last 50 years. There are
several reasons for this. The most important was the rapid growth of
industrialization of Western Europe and the U.S., accelerated by two world wars,
and especially the enormous development in the dye and chemical industries.
This led to an increasing realization of the importance of both irritant and
allergic dermatitis and to legislation to prevent this or to indemnify workers
suffering from it. Industrial dermatology finally came into its own,
4
215 years
after Ramazzini’s seminal treatise.
5
In the increasingly complex environment of the 20th century the housewife,

too, encountered new causes of hand dermatitis. The “soda rash” of the past gave
rise to more subtle and sophisticated forms of irritant and allergic dermatitis in
the house
6
and the garden.
7
Finally, with increasing affluence and media role-making, personal adornment
flourished and the social, professional, and psychological effect of disfigurement
on a visible area, such as the hands, undoubtedly prompted the increased use of
potentially sensitizing hand creams and a greater desire for medical attention.
B.
ALLERGIC CONTACT DERMATITIS AND THE
PATCH TEST
The ability of certain specific substances to cause dermatitis by external contact
had, of course, long been recognized. The early writers spoke of sulfur, mercury,
croton oil, and other such agents. As early as 1609 Captain John Smith had
recognized the effect of poison ivy, and Lady Mary Wortley Montague, 1718,
wrote a dramatic description of the disastrous result of applying “balm of
Mecca” to her own face.
8
Although irritant dermatitis from physical and chemical
agents was well known, anomalous reactions were regarded as examples of
constitutional idiosyncrasy. It was not until the experimental work of Bloch and
Steiner-Woerlich in 1926
9
and 1930
10
that the concept of allergic sensitization
was established; Jadassohn
11

had devised the epicutaneous patch test 30 years
earlier. The importance of this diagnostic tool was quickly recognized and
established on a firm basis by Sulzberger and Wise.
12
In the subsequent 60 years
the technique of patch testing has continually been extended and improved;
INTRODUCTION, DEFINITION, AND CLASSIFICATION 3
innumerable publications have attested to its value. As an investigative
procedure that is applied to human beings, it has its limitations and requires
careful interpretation, but it remains at present the best means of determining the
presence of cutaneous delayed-type allergy, if not always its relevance.
The introduction of the concept of “atopy” by Cocä and Cooke
13
at about the
same time provided a further stimulus to the investigation of hand eczema and
gave a new dimension to the concept of the “constitutional diathesis” of the older
authors.
II.
DEFINITION
A.
DEFINITION OF ECZEMA
This has had a checkered career in dermatology. The older writers referred to
eczema as a non-contagious “catarrhal inflammation” of the skin and recognized
the importance of the vesicle and the accompanying pruritus or burning
sensations (although Hebra
1
considered that vesicles were not essential for the
diagnosis). However, not everyone would accept all cases of dermatitis under
this title, and Norman Walker,
14

an influential writer and teacher, would not have
it at all—a “chaotic conglomeration” and a “name which is a cloak for
ignorance.” This dichotomy has bedevilled the literature ever since.
We own to the histopathologists a more precise approach to a definition.
Spongiosis and a dermal lymphohistiocytic infiltrate are always present at some
stage and the spongiotic vesicle is the hallmark of the disease, although
spongiosis is seen in other conditions. Yet these histopatho-logical features are
the result of a dynamic sequence of events, influenced by intensity, site, and time,
and modified by trauma, infection, or treatment.
A current and acceptable definition of eczema is that it is “an inflammatory
skin reaction characterized histologically by spongiosis with varying degrees of
acanthosis, and a superficial perivascular lymphohistiocytic infiltrate. The
clinical features of eczema may include itching, redness, scaling and clustered
papulovesicles. The condition may be induced by a wide range of external and
internal factors acting singly or in combination.”
15
Calnan
16
regarded eczema as having an analogy with conditions such as iritis
and colitis, in which a diverse etiology and a variable and unpredictable course
are also features. He also stressed the infinite variety of the quality and quantity
of the limited number of signs that make up the disease. It is the “lack of orderly
or homogeneous arrangement of [these] in the area which is most characteristic
of eczema.”
16
He further commented that “writing an account of eczema does
not necessarily denote a fixed position.”
16
Nowhere is this more true than in
discussing some of the aspects of eczema affecting the hands.

4 HAND ECZEMA, SECOND EDITION
B.
DEFINITION OF ECZEMA AND DERMATITIS
The word “eczema” has an obscure origin. It was first used by Aëtius Amidenus,
physician to the Byzantine Court in the sixth century, in referring to a
phlyctenular condition the Greeks commonly (vulgo) called “eczemata”, but it is
uncertain whether he was describing eczema, boils, or something else.
“Dermatitis” means nothing more than inflammation of the skin (derma).
There is no universal agreement on the use of these two terms and they are the
cause of some confusion. Most dermatologists now regard them as synonymous
for all practical purposes, although many will continue to use one or other term
preferentially. Dermatitis has a broader application in that it embraces all forms
of inflammation of the skin, including eczema, but not all forms of dermatitis are
eczematous.
15
In common usage, at least in Great Britain and parts of Europe, “eczema” is
too entrenched a term to be abandoned,
16
although many efforts have been made
to dislodge it. Both terms are in general use in the context of hand eczema. We
speak of “soluble oil dermatitis” and (usually) of “housewives’ dermatitis” rather
than eczema, but of palmar or discoid forms of the condition. Another nuance is
apparent in many published reports; those authors who are dealing with
exogenous or occupational causes of the disease tend to prefer the term
“dermatitis” and those concerned with endogenous or constitutional causes
prefer eczema.
17
There are, of course, good historical reasons for this.
A final twist is given by the legal and psychological implications, in Great
Britain at least, of the use of the term “dermatitis” in dealing with patients with

occupational disease. In an effort to avoid prejudging the issue, many
dermatologists will avoid using this word when manual workers present with
eczema of the hands, at least until the connection with their work is firmly
established.
In this book both terms are used, and in this chapter the terms are to be
regarded as synonymous unless otherwise stated. After nearly 1450 years, the
word “eczema” remains, then, one that is in common use, as it was in Byzantium
when “Graeci vulgo appellant”.
C.
DEFINITION OF ECZEMA OF THE HANDS
For the purpose of this chapter, and indeed of the book as a whole, the term
“hand eczema” is taken to refer to eczema wholly or largely confined to the hands,
although it is accepted that pompholyx and hyperkeratotic eczema may affect the
feet concurrently or subsequently. It does not exclude the presence of a mycotic
infection of the feet or of noneczematous lesions elsewhere, but the patients
present with a complaint of hand eczema and not of lesions elsewhere.
INTRODUCTION, DEFINITION, AND CLASSIFICATION 5