Lakhasly

Hand eczema is the commonest work-related skin disease
and most often affects those engaged in 'wet work'.
Collaboration between general practitioners, dermatologists
and occupational physicians is often necessary to determine
whether occupational exposure is the cause of hand eczema,
and to identify the triggering allergen or irritant. Prevention,
early diagnosis and intervention are important to avoid
chronification, sickness absence, the need for retraining,
and incapacity for work.
Hand eczema (or hand dermatitis) is an inflammatory skin disease localised to
the hands, wrists or lower forearms (1). It is considered to be work-related when
occupational exposure, in whole or in part, is the cause of the disorder. Workrelated hand eczema should be suspected when the patient reports
onset/exacerbation at work and improvement during holidays and/or weekends
(2).
Work-related hand eczema | Tidsskrift for Den norske legeforening
BRITT GRETHE RANDEM
EVA STYLIANOU
A Norwegian population-based study showed a prevalence of hand eczema of
11.3 %, of which just over one-third was work-related (3). Various data sources
suggest that the disorder occurs frequently in service workers and offshore
workers (4, 5). Figure 1 shows the proportion of the workforce treated by the
specialist healthcare service for contact dermatitis in the period 2012–14.Clinical picture, risk factors and classification
Hand eczema can be classified on the basis of aetiology, morphology and/or
localisation (1). It is also useful clinically to distinguish between acute and
chronic eczema (1).
Work-related hand eczema | Tidsskrift for Den norske legeforening
Acute hand eczema usually presents as erythema, oedema, vesicles and papules.
The rash usually begins as pruritic millimetre-sized vesicles, often located on
the palms and on the sides of the fingers.
Chronic hand eczema is characterised by erythema, oedema, skin thickening,
scaling, fissures and erosions. Cases typically have a duration of more than
three months, with three or more flares in the previous year, in the absence of
any other underlying disease or infection and with no response to local steroid
therapy (6).
Endogenous risk factors include changes in the skin barrier such as atopic
eczema (7, 8). Mutation of the gene for filaggrin, a barrier protein in the skin, is
a risk factor for both atopic eczema and chronic hand eczema (9).
Exogenous risk factors can be divided into two main groups: irritant and allergic
hand eczema.
Irritant hand eczema is the result of an inflammatory reaction following
exposure to chemical, physical and/or mechanical irritants. The commonest
cause is wet work Box 1) ((10). Occupational groups that are particularly
exposed to wet work include hairdressers, healthcare personnel, cleaners,
kitchen/canteen workers, mechanics, construction workers and farmers (4, 11).
Women and young workers tend to be most exposed (3, 4). Irritant hand eczema
is a diagnosis of exclusion, and patients must be assessed for possible allergyrelated causes of the eczema (2).Box 1 Definition of wet work (10)
Wet work is work in which the hands:
are in contact with water for two hours or more per day,
are washed more than 20 times per day, or
are covered by tight gloves for two hours or more per dayAllergic hand eczema occurs as a result of skin contact with a substance that
triggers an immunological response, most often a cell-mediated immunological
response (type IV). Frequent occupational allergens are hair dyes, preservatives,
metals, rubber, formaldehyde, epoxy, acrylates and isocyanates (11). The most
vulnerable occupational groups include hairdressers, mechanics, welders and
dentists (11) (Figure 2).Diagnosis
When work-related hand eczema is suspected, the aim is to identify the
triggering allergen or irritant. The diagnosis is made through a thorough,
targeted medical history, clinical examination and supplementary testing (2).
This is a time-consuming process that requires collaboration between general
practitioners, dermatologists, the occupational health service and/or
occupational medicine departments. Patients should be referred promptly to the
specialist healthcare service whenever work-related hand eczema is suspected.
Medical history
Work-related hand eczema | Tidsskrift for Den norske legeforening
The occupational anamnesis maps the patient's occupational exposure to skin
irritants and allergens in order to identify any association between occupational
exposure and disease onset/ exacerbation and any improvement during time off
work. The occupational anamnesis and systematic review of safety data sheets
can often permit the diagnosis of work-related allergic hand eczema (12).
Safety data sheets contain information on hazards and recommended safety
precautions when using chemicals. The employer is obliged to ensure that safety
data sheets are available. Assistance from specialists in occupational medicine
can be useful in interpreting these. The company occupational health service
can provide information on exposure conditions, occupational hygiene
measurements, workplace visits, adaptation of occupational tasks and relocation
during the treatment phase.
The environmental anamnesis focuses on risk factors associated with the home
and leisure activities. Cosmetics and personal hygiene products may contain
allergenic substances. Caring for young children, gardening, and maintenance of
vehicles and machinery can entail wet work. Hobbies can involve the handling
of glue, paint, plants and tropical hardwoods. In various sporting activities such
as handball, weightlifting, golf and tennis, players may come into contact with
rubber-based allergens or resins (e.g. in the grips on golf clubs/tennis rackets).
Climatic conditions such as humidity, heat, cold and UV light can also be
contributing factors.
Clinical examination and supplementary testing
The hands must be examined for signs of acute or chronic eczema. The patient
may be tested using procedures such as epicutaneous testing, skin prick testing
and/or blood IgE assays (Figure 3). In rare cases, a skin biopsy may be
necessary to rule out other inflammatory skin diseases such as psoriasis. An
asymmetric pruritic rash may raise clinical suspicion of dermatophytosis. Other
common differential diagnoses include atopic eczema, scabies and palmoplantarEpicutaneous testing (patch testing) is used to diagnose allergic contact eczema
in cases of chronic or recurrent hand eczema. The testing is conducted by
applying patches to the patient's back bearing low concentrations of selected
Work-related hand eczema | Tidsskrift for Den norske legeforening
allergens. The patches must remain in place for 48 hours. The test material is
selected based on the occupational and environmental anamnesis such that
relevant contact allergens from both the home environment and the workplace
are included. There are also test series available for various occupational
exposures, such as a hairdressing series, an oil and cooling fluids series, a dental
series, etc. Testing with the patient's own materials is performed when indicated
(2).
Skin prick testing and specific IgE assays are used in cases of suspected protein
contact dermatitis. Skin prick testing can be performed using standardised
extracts or via the prick-by-prick test method with fresh materials, such as fish,
fruit or vegetables.
When the triggering agent cannot be determined, it may (exceptionally) be
necessary for the patient to go on sick leave as a test to clarify whether the
eczema is work-related.Treatment
The most important aspect of treatment is early intervention to identify and
remove relevant irritants/allergens. We recommend following the guidelines
available for the treatment of chronic hand eczema (13).Prevention
The main objective of primary prevention is to ensure that the skin remains
healthy in the work environment. Work-related hand eczema is best prevented
by reducing exposure to skin irritants and allergenic substances, for example by
replacing products that cause irritation. Information on risk factors and skin care
can help with prevention in at-risk groups (2).
Proper use of gloves helps protect the hands when it is not possible to remove or
replace harmful substances. The type of gloves that are appropriate will vary,
and the company occupational health service can assist in finding the correct
type. It is important to be aware that glove use may in itself cause hand eczema,
either as a result of sensitisation to the glove material (e.g. thiurams,
carbamates, latex) or because of the moist environment that the glove creates,
so-called occlusion dermatitis. Using cotton gloves or bamboo gloves under
tightfitting gloves can keep the hands dry (14).
The main goal of secondary prevention is early diagnosis and treatment to avoid
a chronic and recurrent course. Suspected cases of work-related illness should
be reported to the Norwegian Labour Inspection Authority (form 154b). The
Labour Inspection Authority can visit workplaces and recommend preventive
measures (5).The aim of tertiary prevention is medical, occupational and social rehabilitation.
Chronic hand eczema can lead to long-term sickness absence, the need for
retraining and/or loss of the capacity to work (10). Persons with work-related
hand eczema should apply to the Norwegian Labour and Welfare
Administration to have the condition approved as an occupational illness.
Making adjustments to the workplace may help the employee remain in work.
When this is not possible, retraining may be necessary