Hand eczema and occupational hand dermatitis: causes, protection and treatment

Eczema is the name for a group of conditions that make the skin dry and irritated. On the hands it is also called hand dermatitis. NHS information on contact dermatitis describes a type of eczema triggered by contact with a particular substance, which clears or improves if the cause is identified and avoided. In other people the hands are affected by atopic eczema, which the NHS says is common on the elbows, knees and hands and often runs in families.

NICE Clinical Knowledge Summaries point out that atopic dermatitis, allergic contact dermatitis and irritant contact dermatitis are not easily told apart by appearance and that the cause may be mixed. A person with a tendency to eczema may find that wet work or frequent hand washing is enough to set it off.

Because hands are used all day, hand eczema is more than a cosmetic issue. NICE CKS lists reduced quality of life, functional impairment that may threaten employment, and secondary skin infection as the main complications.

The NHS lists itchy, blistered, dry and cracked skin, with lighter skin looking red and darker skin looking dark brown, purple or grey. Symptoms usually appear within a few hours or days of exposure to an irritant or allergen.

NICE CKS describes acute contact dermatitis as typically showing redness and tiny blisters, sometimes with dryness, scaling or larger blisters. Chronic dermatitis shows dryness, thickened skin (lichenification) and painful splits or fissures. The pattern on the hand can help: dermatitis in the webs of the fingers suggests irritant contact dermatitis.

• Dry, rough or cracked skin on the fingers, palms or backs of the hands.

• Itching, soreness or burning, sometimes with small blisters.

• Thickened, scaly skin after long-standing eczema.

• Worse after work, better on days away or on holiday, which can point to a work trigger.

Irritant contact dermatitis is a direct physical or toxic effect of a substance on the skin and needs no prior sensitisation. NICE CKS lists repeated water exposure, detergents, cleaning agents, acids and alkalis and certain plants. Allergic contact dermatitis is a delayed hypersensitivity reaction to a specific allergen after sensitisation and re-exposure, with common allergens including cosmetics, skin care products, nail varnish, fragrances, hair dye, nickel, topical antibiotics and corticosteroids, and plants such as sunflower and primula.

The NHS adds that handling raw uncooked fruit and vegetables may trigger allergic contact dermatitis in some people, and mentions that rubber gloves can themselves irritate the skin. HSE has dedicated advice for employers and workers on skin at work, including choosing the right gloves and frequently asked questions for hairdressing, catering, cleaning and dental practice.

A tendency to atopic eczema, asthma or hay fever may make the skin more vulnerable. The NHS says atopic eczema is more likely when a parent has it or a close family member has asthma or hay fever.

A GP will look at the skin and ask about work, hobbies, products used, and when symptoms improve. NICE CKS lists differential diagnoses including atopic and seborrhoeic dermatitis, skin infections such as cellulitis, impetigo and fungal infection, and other conditions such as urticaria, psoriasis and lupus.

If the cause is unclear or the dermatitis is not responding, the NHS says a GP may refer you to a dermatologist. NICE CKS says patch testing may be required to identify the cause, and it is arranged through dermatology when an allergic cause is suspected.

NICE CKS recommends dermatology referral for occupational contact dermatitis, severe, chronic or recurrent dermatitis especially of the hands and face, dermatitis that has become difficult to control in primary care, and presentations that look atypical or are not responding.

The first step is avoiding contact with the stimulus. NICE CKS lists liberal emollient use, consideration of topical corticosteroids according to the situation, and treatment of any secondary infection. The NHS says a pharmacist can recommend emollients, topical corticosteroids are used for severe symptoms, and oral corticosteroids for widespread severe episodes are rare.

The NHS advises rinsing skin with warm water and an emollient as soon as possible after contact, wearing gloves but taking them off now and again because sweating can worsen symptoms, wearing cotton gloves under rubber gloves if rubber irritates, checking ingredients of soaps and cosmetics, using emollient soap substitutes instead of regular soaps, and applying emollients frequently and in large amounts.

The NHS atopic eczema advice also warns that emollients can make dressings, clothing and bedding more flammable, so avoid smoking or naked flames, and advises against putting fingers into emollient pots or using aqueous cream, which can irritate.

NICE CKS notes that prognosis varies and depends on the agent and whether exposure can be avoided. Occupational cases may need adjustments such as different gloves, task changes or, occasionally, a change of role. The CKS says employers have a legal duty to assess risks at work and to prevent or adequately control exposure to hazards, and to report occupational skin disease to the HSE. Occupational health departments, where available, are a practical place to start the conversation.

The NHS says that for atopic eczema you should continue to moisturise even if your eczema improves, and its contact dermatitis advice stresses avoiding triggers and protecting the skin to prevent symptoms. If your eczema is blistered, crusty, leaking, painful, swollen or warm, or you feel unwell with a high temperature, the NHS says to ask for an urgent GP appointment or call NHS 111 because it may be infected.

Most hand eczema is managed by pharmacists and GPs, with a dermatology referral for patch testing or difficult cases and occupational health input through work. Patch testing is arranged through dermatology departments, and waiting times vary by area.

Some people see a private dermatologist to shorten the wait for patch testing or to get advice on adjusting their working life. The diagnostic approach and the medicines are the same. If you do this, take a list of the products you use at work and at home, since identifying exposures is where most of the value lies.