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Eczematous Hand Eruptions: Etiology and Treatment
Eczematous Hand Eruptions: Etiology and Treatment HERBERT MESCON, M.D.*
ApPROXIMATELY 10 per cent of the dermatologist's clinical time is spent in the care of patients with hand eruptions. 12 The housewife with sore hands, the machine operator or industrial worker who has need to use his hands and the salesman meeting many new people may have considerable interference with their vocation due to their disease. Eczematous eruptions of the hands differ appreciably from eczematous eruptions elsewhere on the cutaneous surface because of environmental and anatomical factors. Of prime importance is the fact that the hands are more exposed than any other region of the skin to all types of environmental trauma, such as chemical agents, cleansers and the like. While the palmar surface has a thicker keratin layer which acts as a physical cushion against some insults, it also tends to influence the visible reaction patterns; the vesicles being deeper seated are less likely to rupture and are more persistent. The hands are peculiar in that they contain large numbers of sweat glands and ducts on the palmar surface so that sweating abnormalities or interference may play a more imoprtant role in this region than elsewhere. When I use the term eczema or eczematous dermatitis I mean simply an acute, subacute or a chronic eruption, which in the acute phase has redness, vesicles, fissures, crusting, oozing and goes on to a more scaly, thickened, lichenified and sometimes fissured eruption in the chronic stage. Actually the terms acute, subacute and chronic dermatitis are much preferred to eczema and eczematolis dermatitis. For the purposes of this paper I will exclude a discussion of changes in the nails.
SUPERIMPOSED FACTORS
The same primary and superimposed factors that cause and prolong skin difficulties elsewhere must also be considered in the intelligent From the Department of Dermatology, Boston Univers1~ty School of Medicine and the Evans Memorial, Massachusetts Memorial Hospitals, Boston, Massachusetts.
* Professor and Head, Department of Dermatology, Boston Un'iversity School of Medicine; Chief of Dermatology, Massachusetts Memorial Hospitals. 1361
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SWEATING Heat /' Psychogenic
PSYCHOGENIC Pruritus Sweating ~ UNDERLYING SKIN DISEASE
OVERTREATMENT Irritants Sensitizer s
INFECTION Bacterial Fungal
Fig. 166. Complicating factors in hand eruptions.
management of hand eruptions. Although the physician may see an uncomplicated primary hand eruption, usually the underlying skin disease is masked by complicating factors and it is not until the complications can be brought under control or considerably diminished that he is able to make an accurate diagnosis of the underlying disease. Therefore, it is necessary first to discuss the four commonest complicating factors, which are: (1) secondary bacterial or fungus infection; (2) miliaria, heat rash or other sweat disturbance; (3) psychogenic factors, and (4) overtreatment (superimposed allergic sensitivity or irritancy) (Fig. 166). This does not mean that there may not be additional factors. While overtreatment is the commonest and most important superimposed factor, I will discuss it last because treatment directed toward the other secondary factors is a chief cause of overtreatment. Infections
Primary bacterial or mycological disease of the hands is rare except in specific occupational groups, e.g., anthrax in wool handlers, and monilial infections in vegetable and food handlers. In most hand eruptions there are oozing, scaling and crusted debris composed predominantly of proteins which are good food upon which bacteria may feed and multiply; also breaks (fissures, ulcerations) in the skin allow penetration of these bacteria to regions that would normally be inaccessible. The mere recovery of organisms including coagulase-positive staphylococci or beta hemolytic streptococci from cultures does not necessarily signify an active pathogenic role in a given eruption. Fortunately, most of the time these bacteria act only as saprophytes. A stained smear showing many polymorphonuclear neutrophilic leukocytes that have phagocytosed bacteria is considered a better criterion of active bacterial pathogenicity. The routine use of systemic antibiotics in hand eczemas without evi-
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dence of infection is not indicated. In an occasional case, bacteria may produce a local purulent reaction or even severe cellulitis which must be treated with appropriate antibiotics as determined by sensitivity studies. There is an overwhelming inclination by the physician to use local antibiotics. These are in fact rarely indicated but may be employed if the local bacterial infection is mild. Because of the danger of sensitivity reactions, the antibiotics used in these instances should be those which are not ordinarily employed systemically, such as bacitracin, tyrothrycin, gramicidin and neomycin (Spectrocin or Neosporin ointments). In the usual case, local treatment should be instituted toward making the soil unfavorable for bacterial proliferation. This can be done by getting rid of the crusts and oozing material, using frequent intermittent water soaks or baths (ten minutes every two hours or less depending on severity), after each of which the skin is allowed to dry. l'he addition of potassium permanganate in 1: 10,000 dilution, aluminum subacetate in 1:30 dilution, sodium chloride, starch, etc., is now generally agreed to make no difference, but if a patient is not willing to accept water itself as a medication, these agents may be used. Fungus infections of the hands are rare. Nevertheless, many physicians make the diagnosis of fungus infection of the hands with a frequency out of all proportion to its true incidence as proved by mycologicallaboratory studies. In rare instances monilial organisms may secondarily infect these hand eruptions. With the possible exception of mycostatin ointment in monilial infections, our specific antifungal treatment leaves much to be desired. Here, too, diminishing the favorable environment for proliferation by reducing constant exposure to moisture and using protective cotton-lined rubber or plastic gloves or separate cotton gloves inside rubber gloves will tend to diminish this secondary factor. Sweat Disturbances
The palmar surfaces of the hands contain the openings of numerous ducts leading from the eccrine sweat glands which are supplied by sympathetic cholinergic innervation. 2 The chief stimulus to sweating on most of the body is thermal while on the palms and soles psychogenic stimuli are the chief cause. Thus in an excited, high-strung, tense patient with emotional disturbances, increased production of palmar sweat (hyperhidrosis) will result. This can easily be demonstrated even in normal students who can be made to sweat on the palmar areas by having them solve a difficult mathematical problem. I routinely shake the hand of every patient coming into the office as a means of assaying tension. It has been shown experimentally (Fig. 167) that the prolonged application of hypertonic salt solution, urine, chloroform and mild irritants, and inflammatory dermatoses may cause closure of the sweat ducts. 8 Many medications, solvent cleansers, and even ordinary soaps inadequately removed will act as such irritants. After blockage of the ducts,
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PLUGGED
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HEAT
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MILIARIA EXCESS
SWEAT
MEDICATION SKIN
DISEASE
INFLAMMATION
t
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Fig. 167. Factors causing blockage of sweat ducts.
if these patients are psychogenically stimulated, the sweat is unable to flow to the surface, the sweat duct ruptures, and miliaria is produced. Therefore, a tense person, having a primary dermatitis to start with, may have a superimposed inflammatory miliariaI reaction. This superimposed sweating factor can be treated by two methods: (1) the use of relatively large doses of anticholinergic drugs acting peripherally, or (2) the use of drugs aimed centrally to reduce tension. The latter will be discussed later. T,he anticholinergic drugs such as atropine, belladonna and Banthine are ordinarily not effective in reducing palmar sweating unless they are given in doses large enough to produce undesirable side effects, such as excessive mouth dryness and visual disturbances, making continued use of such drugs undesirable. Psychogenic Factors
Psychogenic factors have been reported to play a role in most hand eruptions. The two known mechanisms are through (1) itching and (2) palmar sweating. The latter was discussed in the preceding paragraphs. Itching. Approximately 50 per cent of all dermatologic patients have itching as the chief complaint. Dermatitis of the hands is no exception. When itching is severe enough the patient scratches and does mechanical damage to the skin. This can greatly aggravate the inflammation, oozing, crusting and itching of a pre-existing dermatitis of any etiology. The ensuing increased severity results in more pruritus leading to further seratching, thereby setting up a vicious itch-scratch cycle (Fig. 168). Furthermore, well controlled experimental studies have shown that it takes a smaller stimulus to produce itching when a person is under stress and fatigued; this is why itching and scratching of the hands are more noticeable toward evening when the patient is tired and usually more irritable. Basically, two attacks are employed against pruritus, as follows: (1) replacement of the itching sensation by a more tolerable sensation,
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ITCH
SCRATCH
INFLAMMATION
SCRATCH
INFLAM MATION
ITCH
Fig. 168. The itch-scratch cycle.
namely, a change in temperature; and (2) a central one to diminish the patient's perception of itching. The former method is easily accomplished by the use of cool compresses. However, a rare patient will react more favorably to warm compresses. An example of the effect of cooling agents is the temporary relief of the pruritus associated with a mosquito bite by applying witch hazel or alcohol. Ordinary tap water can be used for compresses as described previously under infections. An alternative or additional cooling preparation is olive oil and water (1 part olive oil to 2 parts of water, or 1 part olive oil to 2 parts of lime water). The water will cool as it evaporates and the oily portion will tend to keep the skin lubricated and feeling less dry. Another way to break the itch-scratch cycle is to use an occlusive dressing such as a Gelocast or Dome paste bandage dressing that prevents scratching. This, left on for a few days, will allow the tissue to repair and will usually result in marked improvement. The central attack on itching involves either the use of drugs or, in severely disturbed patients, the help of a psychiatrist. Often the role of tension and its specific precipitating or aggravating factor can be elicited and evaluated only by prolonged questioning and observation. Not infrequently, the stressful situation may be something that the physician himself can help resolve. Many drugs have been used to reduce the central perception of itching. As a sedative, chloral hydrate 0.5 gram (7~ grains) p.r.n. is the best allaround agent. Of the barbiturates we prefer to use a shorter acting one, such as Seconal, which is reported to have a lower incidence of sensitivity. The antihistamines such as Benadryl and Pyribenzamine 25 to 100 mg. every three hours also tend to reduce itching when given systemically, through their sedative action. The higher dosages often are necessary.
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Most of the newer tranquilizing agents have been used. Rather large doses, e.g., 400 mg. of meprobamate every four hours, are necessary. Overtreatment (Superimposed Allergic Sensitivity or Irritancy)
Not infrequently, by the time a patient with an eruption on his hands presents himself to the physician the underlying skin disease has been greatly aggravated by substances applied to the skin. Usually the increase in inflammation is due to a direct primary irritant; less commonly it is an allergic contact reaction. Examples of the former are seen following the excessive use of cleansing agents such as turpentine and paint remover, or the use of strong alkali found in many soaps. The primary irritant effect of the strong compounds such as turpentine is well appreciated. Not as much can be said of soaps. The exact mechanism for the irritancy caused by soaps is not clearly understood. Many, especially the heavy cleansers, are strong alkalies, and it has been shown experimentally that the normal slightly acid pH of the skin may be altered for several hours after frequent usage of these compounds. 3 With repeated insults of frequent washings, particularly once the skin is damaged, it may take as long as one day for the skin to return to normal pH. Degreasing agents are also in wide use. Vast clinical experience supports the finding that excessive use of these agents is irritating, especially when the skin is already damaged. ll Anyone who doubts the excessive exposure to cleansing compounds by the average housewife need only follow her around during her chores on an average day. Especially is this true of the housewife with a hand eruption. Not infrequently, she washes her hands 30 to 50 times a day without realizing it. It is usually necessary to spend considerable time with such a patient emphasizing that this degree of cleanliness is not necessary or desirable in her case. Such patients must if necessary be coerced into not washing their hands as often as they usually do. Often they may have to completely refrain from washing their "sick" hands with cleansers, even as a part of their routine hygiene. Another point to remember is that the various cleansers are inadequately removed and tend to accumulate in the interdigital region and under rings. Ofttimes it becomes impossible to separate the patient completely from irritants. In these cases, protection must be supplied by such agents as lanolin, Vaseline, or olive oil and water. In recent years great emphasis has been placed upon the value of the silicone barrier creams; e.g., Pro-Derna, Silicare and Covicone. In routine practice they are not much superior to lanolin or Vaseline. It must be thoroughly explained to the patient that having the tube of lanolin or Vaseline in the house or at work does no good unless it is applied to the skin. Thick applications of the ointment, while they are more protective, act to occlude the free passage of sweat and should not be used. A thin, almost imperceptible
Eczematous Hand Eruptions: Etiology and Treatment
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SECONDARY
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ltCh~ Scratch
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Fig. 169. Illustrating the vicious cycle produced by excess treatment with sensitizing drugs.
coat applied several times a day will serve the purpose and will be less objectionable to the patient. Allergic Sensitivity
It is a well known clinical and experimental dictum that the damaged skin is not only more susceptible to irritants but also to the effect of contact sensitizers. Thus topical penicillin, sulfonamides, antihistamines and anesthetics, all of which have a high incidence of sensitization even in normal persons, have a higher index of sensitization in the patient with damaged skin. Even those compounds with a low index of sensitization may become significant sensitizers. The physician who does not understand the principles of the treatment of hand eczemas continues using new and different anti-itch and anti-infection compounds, each of which is potentially the cause of additional sensitivity reactions. These in turn cause more itching, scratching, oozing, secondary infection, and more complaints by the patients which result in more complicated therapy by the uninitiated physician (Fig. 169). As a consequence, the patient and the physician enter into a vicious cycle which further aggravates the dermatitis. The treatment of these cases is, in essence, the "denial of treatment" in its commonly conceived fashion. By this I mean that all active medications must be stopped. If the reaction is acute enough, only water compresses should be used. In less acute cases, bland ointment bases such as lanolin, Vaseline, polysorb hydrate, or olive oil and water may be used. The local application of 0.5 to 1 per cent hydrocortisone or prednisolone ointment or lotion is also effective in reducing the allergic reaction. GENERAL PRINCIPLES OF TREATMENT
Before discussing the specific dermatologic diseases it is best to formulate a concept and outline briefly the general principles of treatment of hand eruptions, correlating these with the factors already discussed. Of course the primary factor in any treatment regimen is identification and elimination of the cause; all treatment is compromised without this. Soaks. In the acute dermatitides, tap water soaks should be used for ten minutes every two hours to remove crusts and debris, and for their soothing and antipruritic action. As already mentioned, potassium per-
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manganate1: 10,000, aluminum subacetate 1 :30, isotonic saline, starch or oatmeal solution may be used if the patient or the physician is unwilling to accept tap water. In chronic dermatitis, soaks and compresses are to be used less frequently. Corticosteroids. LOCAL. The advent of local steroid therapy has been one of the greatest single therapeutic advances in the treatment of hand eruptions. The exact mode of action of these compounds has not been elucidated; however, they seem to reduce itching and inflammation. There are over 200 preparations on the market, containing from 0.1 to 2.5 per cent active medication alone or in combinations with antibiotics, tars, Vioform, vitamins and other hormones. I personally prefer to use a straight steroid preparation, such as 1 per cent hydrocortisone ointment or lotion or 0.5 per cent prednisolone ointment, because often the other additional medications are unnecessary, add expense and may be potential sensitizers. Systemic effects are not a problem from the absorption of corticosteroid locally applied to the hands. SYSTEMIC. Systemic steroids (cortisone 200 mg./day, hydrocortisone 80 mg./day, prednisolone 40 mg./ day) may be employed for short-term therapy only if the disease is severe. Dosage can usually be reduced in two or three days and stopped in one or two weeks. If a flare-up occurs beyond this time, then one must suspect that the causative factors have not been removed and they must be re-examined. The same absolute and partial contraindications to systemic corticosteroid therapy apply in hand eruptions as in eruptions elsewhere, namely severe hypertension, severe diabetes, infection, fractures, renal disease, uncontrolled edema, etc. Long-term systemic steroid therapy is rarely indicated and must be utilized only with full realization of its dangers. Attempts should periodically be made to taper off and stop this therapy even though temporary flare-ups ensue. Antihistamines, Sedatives and Tranquilizers. These compounds may be used systemically, singly or in combinations, to reduce itching and tension as stated in detail in the section on psychogenic factors. Antihistamines locally applied have been advocated by some authors. In contrast to their systemic use, when topically applied they may be potent sensitizers and therefore I do not recommend them. Antibiotics. These are indicated only if infection is present as evidenced by purulent exudate, cellulitis or lymphangitis. Appropriate systemic antibiotic therapy is indicated in severe infection; in less severe cases topical antibiotics such as Neosporin (polymixin B sulfate, zinc bacitracin, neomycin sulfate in petrolatum base) and Spectrocin ointment or lotion (neomycin and Gramicidin) can be used. Antibiotics which might be used systemically at a future date should not be used locally because of the danger of sensitization. Penicillin, sulfonamides (except sulfaceta-
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mide) and streptomycin, all of which are potent sensitizers, especially are contraindicated for topical use. Soap Substitutes. In the acute eruption any form of soap or soap substitute is contraindicated. In long-term chronic eruptions a cleanser is usually demanded by the patient and a suitable soap substitute can be used (Phisoderm for dry skin, Lowilla cake, Dermolate, etc.). It should be employed as infrequently as possible and then thoroughly rinsed off the skin. Protection. I have already discussed the use of protective agents such as lanolin, Vaseline, olive oil, and the silicone creams in the section on overtreatment. Their value cannot be overemphasized. The patient must be re-educated in the avoidance of cleansers. Since it may be impossible to avoid the use of some irritants, gloves may be employed, preferably cotton gloves covered by rubber or plastic gloves. However, prolonged use of nonporous gloves is contraindicated because they enhance accumulation of sweat. X-radiation. I have rarely had to resort to this modality because improvement could be obtained with other less potentially harmful modalities. While there is no doubt that x-ray is effective as an anti-inflammatory agent, I feel it is contraindicated for the following reasons: (1) The improvement is temporary and not permanent. (2) Ofttimes patients get cumulatively excessive radiation through failure to tell of previous x-ray therapy. Treatment of Acute Versus Chronic Hand Eruptions. While most details have already been given, it is necessary to re-emphasize certain differences in therapy of acute and chronic hand eruptions. As in dermatologic therapy elsewhere, acute eruptions are best treated with soaks, compresses and lotions. However, chronic hand eruptions present a unique characteristic of a thickened skin in a region where the skin is subject to bending and stretching. When the less pliable inflamed skin is subjected to these movements, fissures (cracks) result and may be extremely tender and painful. Occasional soaks seem to be beneficial by soothing and relieving itching and removing debris. Frequent soaks tend to promote dryness, fissuring and discomfort. Plain Vaseline, zinc oxide ointment, Lassar's paste, lanolin, olive oil and water 1: 1 or 1: 2, or olive oil and lime water 1: 1 or 1:2, or polysorb hydrate may be used frequently for fissuring and dryness. SPECIFIC DISEASES
The vast majority of hand dermatitides are in ambulatory patients with no demonstrable systemic disease. The in-patient with severe systemic disease and hand eruption is a statistical rarity. Identification of specific disease is complicated by the limited number of ways that the skin can react to any stimulus, i.e., the clinical manifestations of several different diseases may be identical.
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Eruptions Due to Prilllary Irritants and Local Sensitizers
Primary irritancy and local sensitization are responsible for more than 50 to 70 per cent of all cases of eczematous eruptions of the hands. 4 In fact, practically all industrial eczematous hand eruptions are precipitated by these two factors. Approximately 66 per cent of all industrial compensation cases are dermatologic 6 and the vast majority of them are connected with hand eruptions. Every time a new chemical process and its finished product are introduced, they are potential sources of sensitization and/or irritancy. It is usually difficult to differentiate between the two, although the sensitizers may manifest themselves more acutely. A careful history is essential in determining the possible etiologic agents, and frequently irritancy and sensitization coexist. The two most useful tests in diagnosis are the patch test and the usage test. The patch test has definite limitations and the mere finding of a positive test does not necessarily indicate that the hand eruption is due to sensitivity. Contrariwise, a negative patch test doeR not preclude the existence of sensitivity. Among the factors which must be considered are the method of application, location of the patch, the concentration and physical nature of the substances applied, and the reactivity of the patient's skin. To properly evaluate these factors requires considerable experience and the reader is referred to the chapter in Schwartz, Tulipan and Birmingham.6 A final point to emphasize is that indiscriminate patch testing may lead to a widespread flare-up of the existing disease. The usage test employs the following criteria: (a) the eruption clears in a reasonable time (usually within two weeks) when the hands are completely sheltered; (b) the eruption flares upon re-exposure to the offending agent; (c) the eruption clears when the agent is removed again. An acute flare-up shortly (hours) following re-exposure to the offending agent is suggestive, but not conclusive, evidence that sensitivity is the chief factor. Certainly, if many exposures are necessary to produce a recrudescence then sensitivity was not the prime cause. In reference to this group of hand eruptions, there are three additional points which must be emphasized: (1) If rings are worn, when patients wash they will usually fail to adequately remove irritants or sensitizers from beneath the rings. Thus there is an accumulation of materials including sweat in this region, so that in reality the patient has a constant patch test in this area. It is understandable why many of these dermatitides will begin in this region. (2) Skin which is clinically dry tends to be more sensitive to irritants. Skin tends to be drier in the winter than in the summer. This is exemplified by the fact that the housewife's type of eczema is much more common in the winter than in the summer. Also, the hand skin of older people is drier than that of a younger person. As an example, the surgeon who could scrub his hands with impunity at the age of 30 finds that his hands become easily irritated at the age of 60.
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(3) In humans, Strauss and Kligman 10 have recently demonstrated experimentally that existing areas of dermatitis of varied cause may exhibit a flare-up if the patients are exposed to a different protein allergen (i.e., short ragweed or crabmeat) to which they are specifically sensitive. This may be a secondary factor in causing hand eruptions to persist. The treatment of this group of hand eruptions has been discussed previously under the sections on therapy and on superimposed factors. The main principles of therapy of this group of agents are removal of the offending agent from the environment and protection of the skin. Printary Fungus Infections and Trichophyton (Id) Reactions
Contrary to the general impression of most physicians, primary fungus infections of the hand are rare. Unless there are areas of ringworm in adjacent areas in the body, usually the only lesion seen is a chronic scaling, mildly erythematous, hyperkeratotic lesion involving the entire palm, almost invariably due to Trichophyton rubrum. While the clinical picture is quite typical, it is necessary to confirm the diagnosis by laboratory methods. The treatment, which is often difficult and unsatisfactory, is discussed in detail in another article in this symposium. 9 Trichophyton "id" reactions are more common. They are usually characterized by symmetrically distributed tiny, relatively deep-seated vesicles occurring on the sides of the fingers and palmar regions, and associated with some scaling. The criteria for diagnosing an id reaction are the following: (1) There must be an active inflammatory fungus infection (laboratory confirmed) elsewhere on the body. Often it is the overtreatment of the active primary focus which precipitates the id reaction. (2) Fungus organisms must not be found in the hands by laboratory examination. (3) The Trichophyton skin test must be positive. (4) Following successful treatment of the primary lesion, the id will improve. If these criteria are adhered to, the tendency to diagnose many conditions as an id reaction will be eliminated. No specific treatment of the hands is necessary. Active antifungal therapy should be directed only to the primary site. Ingested Food Allergy
In earlier series as many as 50 per cent of hand eruptions were due to ingested food allergies; more recent series have indicated that less than 10 per cent of the cases are due to food allergy.! My own personal opinion is that practically no cases are primarily due to food allergy; however, it may act as a secondary factor according to the experimental work already cited. The clinical picture of these hand eruptions is not specific and patch testing does not usually reveal the offending agent. Careful histories must be taken and the only way to determine the offending agent is by a strict elimination diet. The best simple method is to place the
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patient on sugar and water for 24 hours and then add a single new item to the diet every 24 hours. Nummular Eczema
This is a descriptive term referring to coin-shaped patches of erythema, scaling and lichenification usually on the dorsum of the hands, with a tendency to central clearing and vesicles at the border. This morphologic description may include specific disease entities such as atopic dermatitis and contact dermatitis. Usually the exact etiology is unknown, although psychogenic stress, irritancy and local or systemic allergy have been considered. Treatment of this condition is nonspecific and is that of any other acute, subacute or chronic dermatitis. In general, the lesions are relatively resistant to therapy. Among the preferred medications are 3 per cent Vioform cream and local corticosteroids. Dyshidrosis
This clinical entity is characterized by deep-seated noninflammatory small vesicles over the entire palmar surface and sides of fingers or any portion thereof. Early workers considered it to be due to abnormalities of sweating since it is usually associated with hyperhidrosis. However, histologic serial sections have failed to reveal a direct connection between the vesicles and the sweat apparatus. 7 The etiology is unknown but the prevalent opinion is that the condition is of psychogenic origin. For treatment some success has been reported with the use of tranquilizers and sedation, otherwise treatment is nonspecific. Pustular Lesions of the Palms
There remains to be discussed a group of ill-defined pustular dermatoses of the palms. These have been described under the separate titles of pustular psoriasis, pustular bacterid and acrodermatitis continua or dermatitis repens. These so-called entities are differentiated on many fine points by many protagonists; however, more and more investigators consider them all to be variants of the same disease. I share this latter opinion. Much of the confusion has arisen from the fact that the pustular lesions of the palms have been seen in patients with psoriasis elsewhere-and in certain cases they may well be psoriasis. Acrodermatitis continua may have undermined borders to involve the distal portion of the hands and sometimes results in atrophy. In all of these lesions, cultures from the pustules are characteristically sterile. Treatment of this group is nonspecific and involves all the principles that have already been outlined. SUMMARY
In the treatment of eruptions of the hands the identification and removal of the etiologic agents is the ideal method of management. How-
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ever, in most cases multiple etiologic factors are present and frequently the superimposed factors may mask or persist even after the original underlying cause is removed. One must understand the interrelationship between psychogenic factors (sweating and itching), bacterial and fungus infection either primary or secondary, primary irritants, and local or systemic allergic factors. Reducing or eliminating one of the links in this multiple factor system may effect marked improvement or cure. REFERENCES 1. Flood, J. M. and Perry, D. J.: Recurrent Vesicular Eruptions of the Hands Due to Food Allergy. J. Invest. Dermat. 7: 309-327, 1946. 2. Hurley, H. H. Jr. and Mescon, H.: Localization of Specific Cholinesterase About the Eccrine Sweat Glands of Human Volar Skin. Proc. Soc. Exper. BioI. & Med. 92: 103-106,1956. 3. Jambor, J. J.: An Etiologic Appraisal of Hand Dermatitis. 11. The Role of Soaps and Detergents as Primary Irritants. J. Invest. Dermat. 24: 387-396, 1955. 4. Samitz, M. H., and Albom, J. J.: The Allergic and Non-Allergic Causes of Eczematous Hand Eruptions. Ann. Allergy 9: 336-345, 1951. 5. Schwartz, L., Tulipan, L. and Birmingham, D. J.: Occupational Diseases of the Skin. Philadelphia, Lea & Febiger, 1957, Chap. 5, pp. 55-94. 6. Schwartz, L., Tulipan, L. and Birmingham, D. J.: Occupational Diseases of the Skin. Philadelphia, Lea and Febiger, 1957, Chap. 3, pp. 26-30. 7. Shelley, W. B.: Dyshidrosis (Pompholyx). A.M.A. Arch. Dermat. & Syph. 68: 314-319, 1953. 8. Shelley, W. B. and Horvath, P. N.: Experimental Miliaria in Man. J. Invest. Dermat. 14: 9-20, 1950. 9. Strauss, J. S.: The Treatment of Superficial Ringworm Infections. MED. CLIN. NORTH AMERICA. This issue. 10. Strauss, J. S. and Kligman, A. M.: The Relationship of Atopic Allergy and Dermatitis. A.M.A. Arch. Dermat. 75: 806-811, 1957. 11. Sulzberger, M. B. and Baer, R. L.: Eczematous Eruptions of the Hands. In Yearbook of Dermat. & Syph. p. 7-44, Chicago, Year Book Publishers, 1948, pp. 7-44. 12. Sutton, R. L. Jr. and Ayers, S. Jr.: Dermatitis of the Hands. A.M.A. Arch. Dermat. & Syph. 68: 266-285, 1953. 80 E. Concord Street Boston 18, Massachusetts
ApPROXIMATELY 10 per cent of the dermatologist's clinical time is spent in the care of patients with hand eruptions. 12 The housewife with sore hands, the machine operator or industrial worker who has need to use his hands and the salesman meeting many new people may have considerable interference with their vocation due to their disease. Eczematous eruptions of the hands differ appreciably from eczematous eruptions elsewhere on the cutaneous surface because of environmental and anatomical factors. Of prime importance is the fact that the hands are more exposed than any other region of the skin to all types of environmental trauma, such as chemical agents, cleansers and the like. While the palmar surface has a thicker keratin layer which acts as a physical cushion against some insults, it also tends to influence the visible reaction patterns; the vesicles being deeper seated are less likely to rupture and are more persistent. The hands are peculiar in that they contain large numbers of sweat glands and ducts on the palmar surface so that sweating abnormalities or interference may play a more imoprtant role in this region than elsewhere. When I use the term eczema or eczematous dermatitis I mean simply an acute, subacute or a chronic eruption, which in the acute phase has redness, vesicles, fissures, crusting, oozing and goes on to a more scaly, thickened, lichenified and sometimes fissured eruption in the chronic stage. Actually the terms acute, subacute and chronic dermatitis are much preferred to eczema and eczematolis dermatitis. For the purposes of this paper I will exclude a discussion of changes in the nails.
SUPERIMPOSED FACTORS
The same primary and superimposed factors that cause and prolong skin difficulties elsewhere must also be considered in the intelligent From the Department of Dermatology, Boston Univers1~ty School of Medicine and the Evans Memorial, Massachusetts Memorial Hospitals, Boston, Massachusetts.
* Professor and Head, Department of Dermatology, Boston Un'iversity School of Medicine; Chief of Dermatology, Massachusetts Memorial Hospitals. 1361
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SWEATING Heat /' Psychogenic
PSYCHOGENIC Pruritus Sweating ~ UNDERLYING SKIN DISEASE
OVERTREATMENT Irritants Sensitizer s
INFECTION Bacterial Fungal
Fig. 166. Complicating factors in hand eruptions.
management of hand eruptions. Although the physician may see an uncomplicated primary hand eruption, usually the underlying skin disease is masked by complicating factors and it is not until the complications can be brought under control or considerably diminished that he is able to make an accurate diagnosis of the underlying disease. Therefore, it is necessary first to discuss the four commonest complicating factors, which are: (1) secondary bacterial or fungus infection; (2) miliaria, heat rash or other sweat disturbance; (3) psychogenic factors, and (4) overtreatment (superimposed allergic sensitivity or irritancy) (Fig. 166). This does not mean that there may not be additional factors. While overtreatment is the commonest and most important superimposed factor, I will discuss it last because treatment directed toward the other secondary factors is a chief cause of overtreatment. Infections
Primary bacterial or mycological disease of the hands is rare except in specific occupational groups, e.g., anthrax in wool handlers, and monilial infections in vegetable and food handlers. In most hand eruptions there are oozing, scaling and crusted debris composed predominantly of proteins which are good food upon which bacteria may feed and multiply; also breaks (fissures, ulcerations) in the skin allow penetration of these bacteria to regions that would normally be inaccessible. The mere recovery of organisms including coagulase-positive staphylococci or beta hemolytic streptococci from cultures does not necessarily signify an active pathogenic role in a given eruption. Fortunately, most of the time these bacteria act only as saprophytes. A stained smear showing many polymorphonuclear neutrophilic leukocytes that have phagocytosed bacteria is considered a better criterion of active bacterial pathogenicity. The routine use of systemic antibiotics in hand eczemas without evi-
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dence of infection is not indicated. In an occasional case, bacteria may produce a local purulent reaction or even severe cellulitis which must be treated with appropriate antibiotics as determined by sensitivity studies. There is an overwhelming inclination by the physician to use local antibiotics. These are in fact rarely indicated but may be employed if the local bacterial infection is mild. Because of the danger of sensitivity reactions, the antibiotics used in these instances should be those which are not ordinarily employed systemically, such as bacitracin, tyrothrycin, gramicidin and neomycin (Spectrocin or Neosporin ointments). In the usual case, local treatment should be instituted toward making the soil unfavorable for bacterial proliferation. This can be done by getting rid of the crusts and oozing material, using frequent intermittent water soaks or baths (ten minutes every two hours or less depending on severity), after each of which the skin is allowed to dry. l'he addition of potassium permanganate in 1: 10,000 dilution, aluminum subacetate in 1:30 dilution, sodium chloride, starch, etc., is now generally agreed to make no difference, but if a patient is not willing to accept water itself as a medication, these agents may be used. Fungus infections of the hands are rare. Nevertheless, many physicians make the diagnosis of fungus infection of the hands with a frequency out of all proportion to its true incidence as proved by mycologicallaboratory studies. In rare instances monilial organisms may secondarily infect these hand eruptions. With the possible exception of mycostatin ointment in monilial infections, our specific antifungal treatment leaves much to be desired. Here, too, diminishing the favorable environment for proliferation by reducing constant exposure to moisture and using protective cotton-lined rubber or plastic gloves or separate cotton gloves inside rubber gloves will tend to diminish this secondary factor. Sweat Disturbances
The palmar surfaces of the hands contain the openings of numerous ducts leading from the eccrine sweat glands which are supplied by sympathetic cholinergic innervation. 2 The chief stimulus to sweating on most of the body is thermal while on the palms and soles psychogenic stimuli are the chief cause. Thus in an excited, high-strung, tense patient with emotional disturbances, increased production of palmar sweat (hyperhidrosis) will result. This can easily be demonstrated even in normal students who can be made to sweat on the palmar areas by having them solve a difficult mathematical problem. I routinely shake the hand of every patient coming into the office as a means of assaying tension. It has been shown experimentally (Fig. 167) that the prolonged application of hypertonic salt solution, urine, chloroform and mild irritants, and inflammatory dermatoses may cause closure of the sweat ducts. 8 Many medications, solvent cleansers, and even ordinary soaps inadequately removed will act as such irritants. After blockage of the ducts,
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URINE PROLONGED SALINE
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t
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MEDICATION SKIN
DISEASE
INFLAMMATION
t
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Fig. 167. Factors causing blockage of sweat ducts.
if these patients are psychogenically stimulated, the sweat is unable to flow to the surface, the sweat duct ruptures, and miliaria is produced. Therefore, a tense person, having a primary dermatitis to start with, may have a superimposed inflammatory miliariaI reaction. This superimposed sweating factor can be treated by two methods: (1) the use of relatively large doses of anticholinergic drugs acting peripherally, or (2) the use of drugs aimed centrally to reduce tension. The latter will be discussed later. T,he anticholinergic drugs such as atropine, belladonna and Banthine are ordinarily not effective in reducing palmar sweating unless they are given in doses large enough to produce undesirable side effects, such as excessive mouth dryness and visual disturbances, making continued use of such drugs undesirable. Psychogenic Factors
Psychogenic factors have been reported to play a role in most hand eruptions. The two known mechanisms are through (1) itching and (2) palmar sweating. The latter was discussed in the preceding paragraphs. Itching. Approximately 50 per cent of all dermatologic patients have itching as the chief complaint. Dermatitis of the hands is no exception. When itching is severe enough the patient scratches and does mechanical damage to the skin. This can greatly aggravate the inflammation, oozing, crusting and itching of a pre-existing dermatitis of any etiology. The ensuing increased severity results in more pruritus leading to further seratching, thereby setting up a vicious itch-scratch cycle (Fig. 168). Furthermore, well controlled experimental studies have shown that it takes a smaller stimulus to produce itching when a person is under stress and fatigued; this is why itching and scratching of the hands are more noticeable toward evening when the patient is tired and usually more irritable. Basically, two attacks are employed against pruritus, as follows: (1) replacement of the itching sensation by a more tolerable sensation,
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ITCH
SCRATCH
INFLAMMATION
SCRATCH
INFLAM MATION
ITCH
Fig. 168. The itch-scratch cycle.
namely, a change in temperature; and (2) a central one to diminish the patient's perception of itching. The former method is easily accomplished by the use of cool compresses. However, a rare patient will react more favorably to warm compresses. An example of the effect of cooling agents is the temporary relief of the pruritus associated with a mosquito bite by applying witch hazel or alcohol. Ordinary tap water can be used for compresses as described previously under infections. An alternative or additional cooling preparation is olive oil and water (1 part olive oil to 2 parts of water, or 1 part olive oil to 2 parts of lime water). The water will cool as it evaporates and the oily portion will tend to keep the skin lubricated and feeling less dry. Another way to break the itch-scratch cycle is to use an occlusive dressing such as a Gelocast or Dome paste bandage dressing that prevents scratching. This, left on for a few days, will allow the tissue to repair and will usually result in marked improvement. The central attack on itching involves either the use of drugs or, in severely disturbed patients, the help of a psychiatrist. Often the role of tension and its specific precipitating or aggravating factor can be elicited and evaluated only by prolonged questioning and observation. Not infrequently, the stressful situation may be something that the physician himself can help resolve. Many drugs have been used to reduce the central perception of itching. As a sedative, chloral hydrate 0.5 gram (7~ grains) p.r.n. is the best allaround agent. Of the barbiturates we prefer to use a shorter acting one, such as Seconal, which is reported to have a lower incidence of sensitivity. The antihistamines such as Benadryl and Pyribenzamine 25 to 100 mg. every three hours also tend to reduce itching when given systemically, through their sedative action. The higher dosages often are necessary.
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Most of the newer tranquilizing agents have been used. Rather large doses, e.g., 400 mg. of meprobamate every four hours, are necessary. Overtreatment (Superimposed Allergic Sensitivity or Irritancy)
Not infrequently, by the time a patient with an eruption on his hands presents himself to the physician the underlying skin disease has been greatly aggravated by substances applied to the skin. Usually the increase in inflammation is due to a direct primary irritant; less commonly it is an allergic contact reaction. Examples of the former are seen following the excessive use of cleansing agents such as turpentine and paint remover, or the use of strong alkali found in many soaps. The primary irritant effect of the strong compounds such as turpentine is well appreciated. Not as much can be said of soaps. The exact mechanism for the irritancy caused by soaps is not clearly understood. Many, especially the heavy cleansers, are strong alkalies, and it has been shown experimentally that the normal slightly acid pH of the skin may be altered for several hours after frequent usage of these compounds. 3 With repeated insults of frequent washings, particularly once the skin is damaged, it may take as long as one day for the skin to return to normal pH. Degreasing agents are also in wide use. Vast clinical experience supports the finding that excessive use of these agents is irritating, especially when the skin is already damaged. ll Anyone who doubts the excessive exposure to cleansing compounds by the average housewife need only follow her around during her chores on an average day. Especially is this true of the housewife with a hand eruption. Not infrequently, she washes her hands 30 to 50 times a day without realizing it. It is usually necessary to spend considerable time with such a patient emphasizing that this degree of cleanliness is not necessary or desirable in her case. Such patients must if necessary be coerced into not washing their hands as often as they usually do. Often they may have to completely refrain from washing their "sick" hands with cleansers, even as a part of their routine hygiene. Another point to remember is that the various cleansers are inadequately removed and tend to accumulate in the interdigital region and under rings. Ofttimes it becomes impossible to separate the patient completely from irritants. In these cases, protection must be supplied by such agents as lanolin, Vaseline, or olive oil and water. In recent years great emphasis has been placed upon the value of the silicone barrier creams; e.g., Pro-Derna, Silicare and Covicone. In routine practice they are not much superior to lanolin or Vaseline. It must be thoroughly explained to the patient that having the tube of lanolin or Vaseline in the house or at work does no good unless it is applied to the skin. Thick applications of the ointment, while they are more protective, act to occlude the free passage of sweat and should not be used. A thin, almost imperceptible
Eczematous Hand Eruptions: Etiology and Treatment
/
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_
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~
.
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SECONDARY
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~
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Fig. 169. Illustrating the vicious cycle produced by excess treatment with sensitizing drugs.
coat applied several times a day will serve the purpose and will be less objectionable to the patient. Allergic Sensitivity
It is a well known clinical and experimental dictum that the damaged skin is not only more susceptible to irritants but also to the effect of contact sensitizers. Thus topical penicillin, sulfonamides, antihistamines and anesthetics, all of which have a high incidence of sensitization even in normal persons, have a higher index of sensitization in the patient with damaged skin. Even those compounds with a low index of sensitization may become significant sensitizers. The physician who does not understand the principles of the treatment of hand eczemas continues using new and different anti-itch and anti-infection compounds, each of which is potentially the cause of additional sensitivity reactions. These in turn cause more itching, scratching, oozing, secondary infection, and more complaints by the patients which result in more complicated therapy by the uninitiated physician (Fig. 169). As a consequence, the patient and the physician enter into a vicious cycle which further aggravates the dermatitis. The treatment of these cases is, in essence, the "denial of treatment" in its commonly conceived fashion. By this I mean that all active medications must be stopped. If the reaction is acute enough, only water compresses should be used. In less acute cases, bland ointment bases such as lanolin, Vaseline, polysorb hydrate, or olive oil and water may be used. The local application of 0.5 to 1 per cent hydrocortisone or prednisolone ointment or lotion is also effective in reducing the allergic reaction. GENERAL PRINCIPLES OF TREATMENT
Before discussing the specific dermatologic diseases it is best to formulate a concept and outline briefly the general principles of treatment of hand eruptions, correlating these with the factors already discussed. Of course the primary factor in any treatment regimen is identification and elimination of the cause; all treatment is compromised without this. Soaks. In the acute dermatitides, tap water soaks should be used for ten minutes every two hours to remove crusts and debris, and for their soothing and antipruritic action. As already mentioned, potassium per-
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manganate1: 10,000, aluminum subacetate 1 :30, isotonic saline, starch or oatmeal solution may be used if the patient or the physician is unwilling to accept tap water. In chronic dermatitis, soaks and compresses are to be used less frequently. Corticosteroids. LOCAL. The advent of local steroid therapy has been one of the greatest single therapeutic advances in the treatment of hand eruptions. The exact mode of action of these compounds has not been elucidated; however, they seem to reduce itching and inflammation. There are over 200 preparations on the market, containing from 0.1 to 2.5 per cent active medication alone or in combinations with antibiotics, tars, Vioform, vitamins and other hormones. I personally prefer to use a straight steroid preparation, such as 1 per cent hydrocortisone ointment or lotion or 0.5 per cent prednisolone ointment, because often the other additional medications are unnecessary, add expense and may be potential sensitizers. Systemic effects are not a problem from the absorption of corticosteroid locally applied to the hands. SYSTEMIC. Systemic steroids (cortisone 200 mg./day, hydrocortisone 80 mg./day, prednisolone 40 mg./ day) may be employed for short-term therapy only if the disease is severe. Dosage can usually be reduced in two or three days and stopped in one or two weeks. If a flare-up occurs beyond this time, then one must suspect that the causative factors have not been removed and they must be re-examined. The same absolute and partial contraindications to systemic corticosteroid therapy apply in hand eruptions as in eruptions elsewhere, namely severe hypertension, severe diabetes, infection, fractures, renal disease, uncontrolled edema, etc. Long-term systemic steroid therapy is rarely indicated and must be utilized only with full realization of its dangers. Attempts should periodically be made to taper off and stop this therapy even though temporary flare-ups ensue. Antihistamines, Sedatives and Tranquilizers. These compounds may be used systemically, singly or in combinations, to reduce itching and tension as stated in detail in the section on psychogenic factors. Antihistamines locally applied have been advocated by some authors. In contrast to their systemic use, when topically applied they may be potent sensitizers and therefore I do not recommend them. Antibiotics. These are indicated only if infection is present as evidenced by purulent exudate, cellulitis or lymphangitis. Appropriate systemic antibiotic therapy is indicated in severe infection; in less severe cases topical antibiotics such as Neosporin (polymixin B sulfate, zinc bacitracin, neomycin sulfate in petrolatum base) and Spectrocin ointment or lotion (neomycin and Gramicidin) can be used. Antibiotics which might be used systemically at a future date should not be used locally because of the danger of sensitization. Penicillin, sulfonamides (except sulfaceta-
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mide) and streptomycin, all of which are potent sensitizers, especially are contraindicated for topical use. Soap Substitutes. In the acute eruption any form of soap or soap substitute is contraindicated. In long-term chronic eruptions a cleanser is usually demanded by the patient and a suitable soap substitute can be used (Phisoderm for dry skin, Lowilla cake, Dermolate, etc.). It should be employed as infrequently as possible and then thoroughly rinsed off the skin. Protection. I have already discussed the use of protective agents such as lanolin, Vaseline, olive oil, and the silicone creams in the section on overtreatment. Their value cannot be overemphasized. The patient must be re-educated in the avoidance of cleansers. Since it may be impossible to avoid the use of some irritants, gloves may be employed, preferably cotton gloves covered by rubber or plastic gloves. However, prolonged use of nonporous gloves is contraindicated because they enhance accumulation of sweat. X-radiation. I have rarely had to resort to this modality because improvement could be obtained with other less potentially harmful modalities. While there is no doubt that x-ray is effective as an anti-inflammatory agent, I feel it is contraindicated for the following reasons: (1) The improvement is temporary and not permanent. (2) Ofttimes patients get cumulatively excessive radiation through failure to tell of previous x-ray therapy. Treatment of Acute Versus Chronic Hand Eruptions. While most details have already been given, it is necessary to re-emphasize certain differences in therapy of acute and chronic hand eruptions. As in dermatologic therapy elsewhere, acute eruptions are best treated with soaks, compresses and lotions. However, chronic hand eruptions present a unique characteristic of a thickened skin in a region where the skin is subject to bending and stretching. When the less pliable inflamed skin is subjected to these movements, fissures (cracks) result and may be extremely tender and painful. Occasional soaks seem to be beneficial by soothing and relieving itching and removing debris. Frequent soaks tend to promote dryness, fissuring and discomfort. Plain Vaseline, zinc oxide ointment, Lassar's paste, lanolin, olive oil and water 1: 1 or 1: 2, or olive oil and lime water 1: 1 or 1:2, or polysorb hydrate may be used frequently for fissuring and dryness. SPECIFIC DISEASES
The vast majority of hand dermatitides are in ambulatory patients with no demonstrable systemic disease. The in-patient with severe systemic disease and hand eruption is a statistical rarity. Identification of specific disease is complicated by the limited number of ways that the skin can react to any stimulus, i.e., the clinical manifestations of several different diseases may be identical.
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Eruptions Due to Prilllary Irritants and Local Sensitizers
Primary irritancy and local sensitization are responsible for more than 50 to 70 per cent of all cases of eczematous eruptions of the hands. 4 In fact, practically all industrial eczematous hand eruptions are precipitated by these two factors. Approximately 66 per cent of all industrial compensation cases are dermatologic 6 and the vast majority of them are connected with hand eruptions. Every time a new chemical process and its finished product are introduced, they are potential sources of sensitization and/or irritancy. It is usually difficult to differentiate between the two, although the sensitizers may manifest themselves more acutely. A careful history is essential in determining the possible etiologic agents, and frequently irritancy and sensitization coexist. The two most useful tests in diagnosis are the patch test and the usage test. The patch test has definite limitations and the mere finding of a positive test does not necessarily indicate that the hand eruption is due to sensitivity. Contrariwise, a negative patch test doeR not preclude the existence of sensitivity. Among the factors which must be considered are the method of application, location of the patch, the concentration and physical nature of the substances applied, and the reactivity of the patient's skin. To properly evaluate these factors requires considerable experience and the reader is referred to the chapter in Schwartz, Tulipan and Birmingham.6 A final point to emphasize is that indiscriminate patch testing may lead to a widespread flare-up of the existing disease. The usage test employs the following criteria: (a) the eruption clears in a reasonable time (usually within two weeks) when the hands are completely sheltered; (b) the eruption flares upon re-exposure to the offending agent; (c) the eruption clears when the agent is removed again. An acute flare-up shortly (hours) following re-exposure to the offending agent is suggestive, but not conclusive, evidence that sensitivity is the chief factor. Certainly, if many exposures are necessary to produce a recrudescence then sensitivity was not the prime cause. In reference to this group of hand eruptions, there are three additional points which must be emphasized: (1) If rings are worn, when patients wash they will usually fail to adequately remove irritants or sensitizers from beneath the rings. Thus there is an accumulation of materials including sweat in this region, so that in reality the patient has a constant patch test in this area. It is understandable why many of these dermatitides will begin in this region. (2) Skin which is clinically dry tends to be more sensitive to irritants. Skin tends to be drier in the winter than in the summer. This is exemplified by the fact that the housewife's type of eczema is much more common in the winter than in the summer. Also, the hand skin of older people is drier than that of a younger person. As an example, the surgeon who could scrub his hands with impunity at the age of 30 finds that his hands become easily irritated at the age of 60.
Eczematous H and Eruptions: Etiology and Treatment
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(3) In humans, Strauss and Kligman 10 have recently demonstrated experimentally that existing areas of dermatitis of varied cause may exhibit a flare-up if the patients are exposed to a different protein allergen (i.e., short ragweed or crabmeat) to which they are specifically sensitive. This may be a secondary factor in causing hand eruptions to persist. The treatment of this group of hand eruptions has been discussed previously under the sections on therapy and on superimposed factors. The main principles of therapy of this group of agents are removal of the offending agent from the environment and protection of the skin. Printary Fungus Infections and Trichophyton (Id) Reactions
Contrary to the general impression of most physicians, primary fungus infections of the hand are rare. Unless there are areas of ringworm in adjacent areas in the body, usually the only lesion seen is a chronic scaling, mildly erythematous, hyperkeratotic lesion involving the entire palm, almost invariably due to Trichophyton rubrum. While the clinical picture is quite typical, it is necessary to confirm the diagnosis by laboratory methods. The treatment, which is often difficult and unsatisfactory, is discussed in detail in another article in this symposium. 9 Trichophyton "id" reactions are more common. They are usually characterized by symmetrically distributed tiny, relatively deep-seated vesicles occurring on the sides of the fingers and palmar regions, and associated with some scaling. The criteria for diagnosing an id reaction are the following: (1) There must be an active inflammatory fungus infection (laboratory confirmed) elsewhere on the body. Often it is the overtreatment of the active primary focus which precipitates the id reaction. (2) Fungus organisms must not be found in the hands by laboratory examination. (3) The Trichophyton skin test must be positive. (4) Following successful treatment of the primary lesion, the id will improve. If these criteria are adhered to, the tendency to diagnose many conditions as an id reaction will be eliminated. No specific treatment of the hands is necessary. Active antifungal therapy should be directed only to the primary site. Ingested Food Allergy
In earlier series as many as 50 per cent of hand eruptions were due to ingested food allergies; more recent series have indicated that less than 10 per cent of the cases are due to food allergy.! My own personal opinion is that practically no cases are primarily due to food allergy; however, it may act as a secondary factor according to the experimental work already cited. The clinical picture of these hand eruptions is not specific and patch testing does not usually reveal the offending agent. Careful histories must be taken and the only way to determine the offending agent is by a strict elimination diet. The best simple method is to place the
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patient on sugar and water for 24 hours and then add a single new item to the diet every 24 hours. Nummular Eczema
This is a descriptive term referring to coin-shaped patches of erythema, scaling and lichenification usually on the dorsum of the hands, with a tendency to central clearing and vesicles at the border. This morphologic description may include specific disease entities such as atopic dermatitis and contact dermatitis. Usually the exact etiology is unknown, although psychogenic stress, irritancy and local or systemic allergy have been considered. Treatment of this condition is nonspecific and is that of any other acute, subacute or chronic dermatitis. In general, the lesions are relatively resistant to therapy. Among the preferred medications are 3 per cent Vioform cream and local corticosteroids. Dyshidrosis
This clinical entity is characterized by deep-seated noninflammatory small vesicles over the entire palmar surface and sides of fingers or any portion thereof. Early workers considered it to be due to abnormalities of sweating since it is usually associated with hyperhidrosis. However, histologic serial sections have failed to reveal a direct connection between the vesicles and the sweat apparatus. 7 The etiology is unknown but the prevalent opinion is that the condition is of psychogenic origin. For treatment some success has been reported with the use of tranquilizers and sedation, otherwise treatment is nonspecific. Pustular Lesions of the Palms
There remains to be discussed a group of ill-defined pustular dermatoses of the palms. These have been described under the separate titles of pustular psoriasis, pustular bacterid and acrodermatitis continua or dermatitis repens. These so-called entities are differentiated on many fine points by many protagonists; however, more and more investigators consider them all to be variants of the same disease. I share this latter opinion. Much of the confusion has arisen from the fact that the pustular lesions of the palms have been seen in patients with psoriasis elsewhere-and in certain cases they may well be psoriasis. Acrodermatitis continua may have undermined borders to involve the distal portion of the hands and sometimes results in atrophy. In all of these lesions, cultures from the pustules are characteristically sterile. Treatment of this group is nonspecific and involves all the principles that have already been outlined. SUMMARY
In the treatment of eruptions of the hands the identification and removal of the etiologic agents is the ideal method of management. How-
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ever, in most cases multiple etiologic factors are present and frequently the superimposed factors may mask or persist even after the original underlying cause is removed. One must understand the interrelationship between psychogenic factors (sweating and itching), bacterial and fungus infection either primary or secondary, primary irritants, and local or systemic allergic factors. Reducing or eliminating one of the links in this multiple factor system may effect marked improvement or cure. REFERENCES 1. Flood, J. M. and Perry, D. J.: Recurrent Vesicular Eruptions of the Hands Due to Food Allergy. J. Invest. Dermat. 7: 309-327, 1946. 2. Hurley, H. H. Jr. and Mescon, H.: Localization of Specific Cholinesterase About the Eccrine Sweat Glands of Human Volar Skin. Proc. Soc. Exper. BioI. & Med. 92: 103-106,1956. 3. Jambor, J. J.: An Etiologic Appraisal of Hand Dermatitis. 11. The Role of Soaps and Detergents as Primary Irritants. J. Invest. Dermat. 24: 387-396, 1955. 4. Samitz, M. H., and Albom, J. J.: The Allergic and Non-Allergic Causes of Eczematous Hand Eruptions. Ann. Allergy 9: 336-345, 1951. 5. Schwartz, L., Tulipan, L. and Birmingham, D. J.: Occupational Diseases of the Skin. Philadelphia, Lea & Febiger, 1957, Chap. 5, pp. 55-94. 6. Schwartz, L., Tulipan, L. and Birmingham, D. J.: Occupational Diseases of the Skin. Philadelphia, Lea and Febiger, 1957, Chap. 3, pp. 26-30. 7. Shelley, W. B.: Dyshidrosis (Pompholyx). A.M.A. Arch. Dermat. & Syph. 68: 314-319, 1953. 8. Shelley, W. B. and Horvath, P. N.: Experimental Miliaria in Man. J. Invest. Dermat. 14: 9-20, 1950. 9. Strauss, J. S.: The Treatment of Superficial Ringworm Infections. MED. CLIN. NORTH AMERICA. This issue. 10. Strauss, J. S. and Kligman, A. M.: The Relationship of Atopic Allergy and Dermatitis. A.M.A. Arch. Dermat. 75: 806-811, 1957. 11. Sulzberger, M. B. and Baer, R. L.: Eczematous Eruptions of the Hands. In Yearbook of Dermat. & Syph. p. 7-44, Chicago, Year Book Publishers, 1948, pp. 7-44. 12. Sutton, R. L. Jr. and Ayers, S. Jr.: Dermatitis of the Hands. A.M.A. Arch. Dermat. & Syph. 68: 266-285, 1953. 80 E. Concord Street Boston 18, Massachusetts