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Hands up!

Chronic hand eczema is fairly common in the UK, and is an extremely inhibiting condition. With the skin feeling itchy, chapped and painful, sufferers are at times unable to perform basic tasks, but treatment options are still limited.

In any year, about one in 10 adults and adolescents live with hand eczema (HE), which can limit work opportunities, hinder participation in sport and other social activities, and, in severe cases, cause embarrassment, isolation and depression. The Chronic Hand Eczema Patient Impact Report found that 70 per cent of participants surveyed said that chronic hand eczema (CHE) had at least some impact on their existing, or ability to build new, relationships. Half (52 per cent) said that CHE influenced their career choice and 72 per cent reported that the condition affected their current work or education.

Despite the impact, about a third of people with HE do not seek medical help and the condition is easily overlooked. The report found that people with CHE waited for an average of eight years before seeing a healthcare professional (HCP) for the first time about the condition in the UK.

The survey pool

The survey of CHE patients used within the report, sponsored by Leo Pharma, took place in two stages. Firstly, five adults with CHE participated in hour-long interviews to design the questions. Secondly, 152 adults with CHE from across the UK completed an online survey. Patients were aged between 20-75 years and 79 per cent were female. All had lived with CHE for more than a year.

“The survey shows that assessment of CHE needs to be multifactorial, evaluating not only physical signs and symptoms, but the impact on quality of life, work and relationships. Better education for healthcare professionals in recognising the signs and symptoms of CHE is also very important,” says Dr Alia Ahmed, consultant dermatologist with a special interest in psychodermatology, Barts Health NHS Trust, London and one of the authors of the report.

The survey included a relatively small number of patients and those who agreed to take part may not reflect the views of everyone with CHE. “Nevertheless, the findings are representative of the experiences of CHE patients that I see in my clinical practice and are similar to previous published reports,” says Dr Ahmed.

It is important that customers with CHE remember to use gentle, non-fragranced hand soap and moisturise after washing their hands with an emollient.

Eczema evidence

HE occurs on the hands and/or wrists. As a rule of thumb, dermatologists regard HE that lasts for less than three months and that does not occur more than once a year as ‘acute’. During the acute phase, patients show macules (small, flat areas of discoloured skin), papules (small bumps), vesicles (blisters) and oedema (swelling). People with HE may experience itching, burning, pain, sleep problems and mood disturbances.

CHE lasts for more than three months or relapses at least twice a year – or both. People with CHE show crusting, scaling, hyperkeratosis (thickened skin) and fissures (skin cracks). About nine out of 10 people with CHE in the UK survey experienced skin that is itchy (96 per cent), dry or chapped (91 per cent) and cracked (88 per cent). Often CHE symptoms are almost unrelenting, with 47 per cent of participants saying their skin was itchy, 51 per cent saying their skin was dry or chapped, and 23 per cent noting their skin feels cracked every day or most days. Sometimes the itching can be “unbearable, impossible to satisfy and all [the person] can think about,” says Dr Ahmed.

Typically, however, CHE waxes and wanes. UK CHE patients reported an average of eight exacerbations (flares) a year. Each flare lasted an average of nine days. Some 86 per cent of people with CHE reported sleep disturbances during their last flare, because of, for example, itching and pain. Dr Ahmed suggests watching for ‘red flags’ that should trigger referral to a GP.

Red flags that require referral to a GP

  • Symptoms for more than three months
  • Repeated flares
  • Splitting of the skin (small cuts that are sore and can bleed)
  • Yellowing crusts or weeping from the skin (signs of infection)
  • Ongoing swelling of the skin
  • Severe itching
  • Impact on quality of life (e.g. ability to work).

Causes of hand eczema

Environmental factors, including chemicals encountered at work or immersing hands in water for long periods, account for about 60 per cent of the likelihood of developing HE. In the Health Literacy and Associated Factors in Subjects with Hand Eczema: A Dutch Population-based Study, researchers analysed 57,046 people with HE. They allowed for other factors that could influence the results. Wet activities increased the likelihood of developing HE by a third (odds ratio 1.33). Almost everyone in the UK survey, (94 per cent) reported that avoiding CHE triggers, which include soap, sanitiser, washing-up liquid and cleaning products, is difficult. Three-quarters (73 per cent) reported that CHE affected their ability to do housework.

Genetic and other biological factors, such as the effectiveness of the skin barrier or previously experiencing atopic dermatitis (allergic eczema), makes up 40 per cent of the risk. In the Dutch study, atopic dermatitis increased the risk of HE more than seven-fold (odds ratio 7.28). “Studies need to define the key immunological differences between CHE related to atopy [a genetic tendency to develop allergies] versus CHE without history of atopy,” Dr Ahmed says.

Managing hand eczema

Dr Ahmed suggests that the pharmacy team should consider making skin-care suggestions that may help manage CHE symptoms (see boxout). The team should also emphasise the importance of a healthy lifestyle. The Dutch study found that smoking at least eight cigarettes a day increased HE risk in the past year by 15 per cent. A smoking history of at least 15 pack-years increased HE risk by 18 per cent. Other studies link smoking, which increases inflammation throughout the body, to several chronic skin diseases including atopic dermatitis, palmoplantar pustulosis and psoriasis.

Fat, especially around the waist, pumps out chemicals that drive inflammation. In the Dutch study, obesity (body mass index of more than 30 kg/m2) increased the risk of HE in the past year by 15 per cent. A waist larger than 90cm increased the risk by 15 per cent and between 17 per cent and 25 per cent depending on circumference.

The pharmacy team can also make people aware of the importance of stress management. Chronic stress can, for example, unbalance the number and type of T-helper lymphocytes (a type of white blood cell) that protects the skin. Chronic stress increased HE risk in the past year by between 10 per cent and 42 per cent depending on the severity and the way researchers assessed distress.

Unfortunately, but not surprisingly, stress, anxiety and depression are common among people with CHE. In the UK report, 60 per cent of people with CHE reported stress or anxiety. More than half experienced frustration (59 per cent), embarrassment and shame (58 per cent), and anger and resentment (55 per cent). Some 41 per cent reported low mood or depression, while six per cent and five per cent reported thoughts of self-harm and suicide respectively. But only 14 per cent said that a healthcare professional had asked them about CHE’s emotional impact.

“Further studies need to assess the condition’s impact on families and close associates of people with CHE. Psychological profiling of people with CHE, in comparison to other skin conditions, is also important,” Dr Ahmed says. “Skin conditions have devastating psychological impacts, and in some cases, more than other systemic conditions, such as diabetes, asthma, chronic back pain and arthritis. There is, however, a widespread lack of psychological services for people with skin diseases. However, people with skin conditions are coming forward and discussing their experiences more openly. This is encouraging and normalising skin conditions is being adopted more widely by the media.”

Advice for CHE

  • Wash with soap substitutes
  • Apply greasy emollient regularly to strengthen the skin barrier
  • Treat infection promptly
  • Wear gloves overnight to improve penetration of emollients
  • Use topical anti-inflammatories (e.g. topical steroids)
  • Use oral anti-inflammatories for pain if not contraindicated
  • Minimise occupational exposures, triggers, allergens and irritants
  • Cover hands when engaging in wet work or environmental exposures
  • Seek a medical opinion from GP and/or dermatologist if symptoms are ongoing.
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