The New England Journal of Medicine

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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
A ))*#ear*old woman pre"en$" wi$h redne"" of $he hand" and repor$" $he in$ermi$$en$ occurrence
of $in# (e"icle", "caling, and f i""uring, accompanied +# i$ching on $he palm", f inger", and dor"al
"ide" of $he hand". 'he ha" $wo #oung children and wor," a" a nur"e in a near+# ho"pi$al. 'he
ha" a hi"$or# of childhood ec-ema and a con$ac$ allerg# $o nic,el. .ow "hould $hi" ca"e +e
managed/
.and ec-ema, al"o called hand derma$i$i", i" an inf lamma$ion of $he ",in of $he hand"0 "ome
per"on" wi$h hand ec-ema ma# al"o ha(e foo$ ec-ema. T#pical clinical "ign" are redne"", inf
il$ra$ion of $he ",in, "caling, edema, (e"icle", area" of h#per* ,era$o"i", crac," 1fi""ure"2, and
ero"ion" 1!ig. 1A and 132.1 4$ i" common, wi$h a poin$ pre(alence of 5 among adul$" in $he
general popula$ion, and a 1*#ear pre(alence of up $o 105, depending on whe$her $he di"ea"e def
ini$ion include" mild ca"e".2 The incidence of wor,*rela$ed ca"e" 1which are u"uall# more "e(ere
$han ca"e" in $he gen* eral popula$ion2 $ha$ are repor$ed $o occupa$ional heal$h au$hori$ie" i"
+e$ween 0.6 and 1.7 ca"e" per 1000 wor,er" per #ear, wi$h much higher incidence" among
cer$ain oc* cupa$ion", "uch a" hairdre""ing.)
Manife"$a$ion" of hand ec-ema $end $o (ar# in "e(eri$# and appearance o(er $ime. %rac," and
+li"$er" ma# par$iall# or comple$el# pre(en$ $he performance of manual wor,, re"ul$ing in
di"a+ili$# and economic lo"".,7
The mo"$ common e8$ernal cau"e of hand ec-ema i" con$ac$ wi$h mild $o8ic agen$" or irri$an$"
1e.g., wa$er and "oap"2, cau"ing irri$an$ con$ac$ derma$i$i". Allergic con* $ac$ derma$i$i" i" le""
common $han irri$an$ con$ac$ derma$i$i" and ref lec$" a con$ac$ allerg# $o a "pecific "u+"$ance,
"uch a" ru++er, nic,el, or perfume". A$opic derma$i$i" i" an endogenou" cau"e of hand ec-ema0
one $hird $o one half of pa$ien$" wi$h hand ec-ema ma# ha(e a$op#, and a$op# ma# +e manife"$ed
e8clu"i(el# a" derma$i$i" of $he hand".2 4n man# pa$ien$", hand ec-ema ha" more $han one cau"e.
4n addi$ion, $here are "e(eral $#pe" of hand ec-ema wi$h no ,nown cau"e 1Ta+le 12. The"e are
h#per* ,era$o$ic ec-ema 1!ig. 1%2, recurren$ (e"icular hand ec-ema 1pomphol#8, d#"hidro$ic
ec-ema2 1!ig. 1D2, nummular ec-ema 1!ig. 1E2, and pulpi$i" 1chronic finger$ip derma* $i$i"2 1!ig.
1!2. 1Addi$ional image" are "hown in $he 'upplemen$ar# Appendi8, a(ail* a+le wi$h $he full $e8$
of $hi" ar$icle a$ NEJM.org.2 The $erm" d#"hidro$ic ec-ema and pomphol#8 are "ome$ime"
re"er(ed for acu$e (e"icular hand ec-ema a" oppo"ed $o chronic (e"icular hand ec-ema.
' $ r a $ e g i e " a n d E ( i d e n c e
The New England Journal of Medicine
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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
Diagno"i"
A $horough pa$ien$ hi"$or# i" e""en$ial $o diagno"i", e"peciall# wi$h re"pec$ $o e8po"ure $o
irri$an$" and allergen" a$ home or a$ $he wor,place. The pre"ence of children in $he hou"ehold
1wi$h a""ocia$ed e8po""ure" $o "oap" and de$ergen$", occupa$ion" re9uiring fre9uen$ hand
wa"hing, and $he u"e of occlu"i(e glo(e" are recogni-ed ri", fac$or.12 %on$ac$ allergen" ma#
+e pre"en$ in dome"$ic and occupa$ional produc$". A hi"$or# of a$opic derma* $i$i" al"o
predi"po"e" pa$ien$" $o hand ec-ema.
.and ec-ema ma# +e confu"ed wi$h o$her ",in condi$ion" 1Ta+le 22, mo"$ fre9uen$l# p"oria"i"
and m#co"i". :"oria"i" i" generall# charac$eri-ed +# "harpl# demarca$ed le"ion", $he a+"ence of
i$ch* ing, and $he a+"ence of (e"icle" 1!ig. 2A2. .and ec-ema wi$h infec$ion ma# +e confu"ed
wi$h palmoplan$ar pu"$ulo"i", which i" regarded +# "ome e8per$" a" a (arian$ of p"oria"i" 1!ig.
232. A ",in +iop"# of $he palm i" unli,el# $o help in di"$ingui"hing p"oria"i" from ec-ema.
!ungal infec$ion 1m#co"i"2 "hould alwa#" +e ruled ou$ +# "craping "ome f la,e" for "$aining or
cul$ure, e"pecilall# if onl# one hand i" affec$ed 1!ig. 2%2. !igure" 2D and 2E "how o$her
condi$ion" $ha$ mimic hand ec-ema
%urren$ cla""if ica$ion "#"$em" for hand ec-e* ma are +a"ed on clinical and e$iologic fac$or"
1Ta+le 126*; and ha(e +een u"eful for ou$pa$ien$ popula$ion".1),1 'coring "#"$em" +a"ed on $he
"e(eri$# of "#mp$om" ha(e +een de(eloped +u$ are no$ rou$inel# u"ed in prac$ice.17 %a"e" are
cla""ified according $o cau"e when po""i+le, wi$h $he ac,nowledgmen$ $ha$ differen$ cau"e" of
hand ec-ema ma# +e indi"$ingui"ha+le on e8amina$ion. 4n man# ca"e", $he clinician i" re"$ric$ed
$o a mor* phologic de"crip$ion.
Addi$ional e(alua$ion 1+e#ond $a,ing a de$ailed hi"$or#2 "hould +e con"idered for pa$ien$" in
whom $he cau"e" of hand ec-ema remain unde$ermined. :a$ch $e"$ing ma# +e u"eful in
iden$if#ing a con* $ac$ allerg# $o e8$ernal agen$".10 3o$h $he American %on$ac$ Derma$i$i"
'ocie$# and $he European 'ocie$# of %on$ac$ Derma$i$i" recommend $he u"e of "$andard
"creening $ra#" 1a +a"eline "erie"2 $ha$ con$ain $he con$ac$ allergen" $ha$ are mo"$ com* monl#
found in $he home and wor,place 1e.g., me$al", ru++er addi$i(e", glue", and $he an$i+ac* $erial
and an$imold agen$" in co"me$ic"2.16 :a$ch $e"$ing i" recommended in all pa$ien$" wi$h chron* ic
hand ec-ema. The "en"i$i(i$# and "pecif ici$# of pa$ch $e"$ing depend on $he pa$ien$<" hi"$or# and
clinical appearance0 according $o a re$ro"pec$i(e anal#"i" conduc$ed in $he =ni$ed '$a$e", e8pand*
ing $he "$andard num+er of $e"$ allergen" would impro(e $he ra$e of de$ec$ion of con$ac$ allergic
reac$ion" from a+ou$ 275 $o a+ou$ 705.16*
The New England Journal of Medicine
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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
The New England Journal of Medicine
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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
:ric, $e"$ing, or de$ermining allergen*"pecific 4gE le(el" in $he "erum, i" generall# of limi$ed
(alue,1; al$hough i$ i" informa$i(e in ca"e" of pro* $ein con$ac$ derma$i$i" 1Ta+le 12 or con$ac$
ur$i* caria cau"ed +# la$e8 pro$ein" or fi"h pro$ein" 1!ig. 2!2. >ecurren$ con$ac$ ur$icaria can
+ecome ec-ema$ou" 1e.g., in per"on" handling food2, ma,ing clinical diagno"i" difficul$0 in "uch
ca"e", pric, $e"$ing can +e (alua+le. Te"$ing for "en"i$i(* i$# $o inhala$ion allergen" 1e.g., $he
hou"e*du"$ mi$e, ca$ dander, or pollen2 i" no$ recommended, "ince $here i" in"uff icien$ e(idence
"howing $ha$ e8po"ure $o "uch allergen" pro(o,e" or "u"$ain" hand ec-ema.
Trea$men$
Al$hough i$ would "eem logical $o a""ume $ha$ iden$if#ing and elimina$ing $he cau"a$i(e fac$or
could cure hand ec-ema, $hi" fea$ i" rarel# accom* pli"hed in prac$ice +ecau"e $he cau"e of
di"ea"e, e"peciall# in pa$ien$" wi$h chronic hand ec-ema, i" of$en mul$ifac$orial. Ne(er$hele"",
$rea$men$ will +e un"ucce""ful if cau"a$i(e or con$ri+u$ing fac$or" are no$ elimina$ed.
:romp$ $rea$men$ i" recommended +ecau"e hand ec-ema ha" a $endenc# $o +ecome chronic, in
which ca"e re"i"$ance $o $opical $rea$men$ i" common.1? %urren$ $rea$men$ "$ra$egie" are largel#
+a"ed on clinical e8perience and ma# differ from coun$r# $o coun$r#.6,;,20 !ew $herapie" ha(e
+een e(alua$ed in randomi-ed, con$rolled $rial",21 and $he $rial" $ha$ ha(e +een conduc$ed
$#picall# ha(e no$ di"$ingui"hed $#pe" of ec-ema. !igure ) "how" an algori$hm for $he
managemen$ of hand ec-ema.
Moi"$uri-er", Emollien$", and ',in :ro$ec$ion
The fre9uen$ applica$ion of emollien$" and moi"* $uri-er" i" rou$inel# recommended0 in man#
ran* domi-ed $rial" of o$her $rea$men$" for hand ec* -ema, $he u"e of emollien$" wa" allowed or
encouraged in +o$h $rea$men$ group". @in$men$" are preferred o(er cream", +ecau"e cream" ma#
con$ain po$en$iall# "en"i$i-ing pre"er(a$i(e" and mildl# irri$a$ing emul"if ier". 4n one "mall ran*
domi-ed $rial $ha$ compared $he eff icac# of $wo emollien$" A a pe$rola$um*+a"ed emollien$ and
an emollien$ con$aining ceramide 1a ",in lipid2
A $here wa" "imilar impro(emen$ in $he $wo $rea$men$ group" a$ 2 mon$h".2) Ano$her $rial of
2 wee,"< dura$ion repor$ed a non"ignif ican$ +en* ef i$ from $he addi$ion of a urea*con$aining
moi"* $uri-er $o a $opical glucocor$icoid 1+e$ame$ha"one2 a" compared wi$h $he u"e of $opical
+e$ame$ha* "one alone.2 3arrier cream" are of$en recom* mended for $he pre(en$ion of
The New England Journal of Medicine
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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
occupa$ional con* $ac$ derma$i$i", +u$ a %ochrane "#"$ema$ic re(iew concluded $ha$ $here i" in"uff
icien$ e(idence $ha$ "uch cream" ha(e a long*$erm pro$ec$i(e effec$.27
A more recen$ $rial in(ol(ing 277 ho"pi$al wor,er" wi$h hand ec-ema "howed a +enef i$ from
",in*care educa$ion and indi(idual coun"eling.26 The in$er(en$ion" included oral and wri$$en
in"$ruc* $ion" regarding $he u"e of glo(e" and recommen* da$ion" on $he a(oidance of irri$an$" a$
wor, and a$ home.
Jo+ coun"elor" "hould di"courage emplo#ee" from +ecoming e8po"ed $o irri$an$" a$ wor, 1e"*
peciall# in Bwe$ wor,C A e.g., wor, $ha$ in(ol(e" e8po"ure of $he hand" $o li9uid", "oap",
de$er* gen$", cu$$ing oil", or (ege$a+le juice"20 coun"elor" "hould "imul$aneou"l# encourage
ade9ua$e ",in* pro$ec$ion mea"ure".26 The role of pro$ec$i(e glo(e" i" con$ro(er"ial. Al$hough
glo(e" offer pro$ec$ion from irri$an$" 1e"peciall# during Bwe$ wor,C2, prolonged occlu"ion
ma# i$"elf +e a ri", fac$or for hand ec-ema.2; 4n accordance wi$h prac$ical e8perience and
"uppor$ from an e8perimen$al "$ud# in(ol(ing (olun$eer" wi$hou$ hand ec-ema, a co$$on lining
or inner glo(e i" recommended.2?
Topical Dlucocor$icoid"
:o$en$ $opical glucocor$icoid" are f ir"$*line phar* macologic $rea$men$ for hand ec-ema,
al$hough $here are limi$ed da$a from randomi-ed, con$rolled $rial" $o conf irm $heir eff icac#. 4n
an open*la+el "$ud#, $opical mome$a"one furoa$e wa" applied freel# for up $o ? wee," +#
pa$ien$" wi$h hand ec-ema0 almo"$ half of pa$ien$" had clearing a$ ) wee,", and ano$her 9uar$er
a$ 6 wee,". Tho"e who had clearing of ec-ema $hen par$icipa$ed in a $rial of main$enance $herap#
for up $o )6 wee,". :ar$icipan$" underwen$ randomi-a$ion $o one of $hree group"E one in which
$opical mome$a"one furoa$e wa" applied $hree $ime" a wee,, a "econd in which i$ wa" applied
$wo $ime" a wee,, and a $hird in which emollien$" alone were applied freel#. >ecurrence*free
ra$e" were "ignif ican$l# higher in $he group" recei(ing a glucocor$icoid 1;)5 and 6;5,
re"pec$i(el#2 $han in $he group u"ing emollien$" onl# 12652.)0 .owe(er, ",in a$ro* ph# i" a ri",
of prolonged $rea$men$ wi$h gluco* cor$icoid". The American Academ# of Derma$olo* g#
recommend" dail# u"e for 1 mon$h followed +# main$enance $herap# $wo $o $hree $ime" per
wee,.)1
4$ al"o recommend" oin$men$" o(er cream".
Topical Tacrolimu" and :imecrolimu"
Al$hough $opical calcineurin inhi+i$or" ha(e +een e8$en"i(el# in(e"$iga$ed and are widel# u"ed $o
$rea$ a$opic derma$i$i", e(idence of $heir eff icac# in hand ec-ema i" limi$ed. 'ide effec$" include
The New England Journal of Medicine
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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
a $ran"ien$ +urning "en"a$ion and "en"i$i(i$# $o ul* $ra(iole$ ligh$. :imecrolimu" 1applied $wice
dail#2 appeared $o +e "ligh$l# +u$ no$ "ignif ican$l# more eff icaciou" $han (ehicle cream alone in
$wo large randomi-ed clinical $rial" of ) and 6 wee,"< dura* $ion.)2,)) 4n a "mall $rial conduc$ed
wi$h pa$ien$" who had chronic d#"hidro$ic palmar ec-ema, $he admini"$ra$ion of $acrolimu" 0.15
$wice dail# re* "ul$ed in impro(emen$ ra$e" of 705 or more, +u$ $he ra$e" were no$ "ignif
ican$l# differen$ from $ho"e a""ocia$ed wi$h $he u"e of $opical mome$a* "one furoa$e.) 4n
ano$her "mall randomi-ed $rial, of 12 wee,"< dura$ion, $he u"e of $acrolimu" oin$men$ $wice
dail# wa" compared wi$h $he u"e of (ehicle cream alone among pa$ien$" pre(iou"l# $rea$ed wi$h
a "hor$ cour"e of oral glucocor$icoid". The u"e of $acrolimu" wa" a""ocia$ed wi$h grea$er
"u+jec$i(e impro(emen$ 1a" a""e""ed +# $he pa$ien$2 +u$ wa" a""ocia$ed wi$h no clear +en* ef i$
wi$h regard $o o$her ou$come", including $he $ime $o recurrence.)7 4n prac$ice, one op$ion i" $o
al$erna$e $he u"e of $he"e agen$" wi$h $opical glu* cocor$icoid".;,)
:ho$o$herap#
:ho$o$herap# i" widel# u"ed for hand ec-ema, and in man# clinic" i$ i" u"ed a" "econd*line
$rea$men$ for pa$ien$" in whom $opical $herap# ha" failed. 4n a 12*wee, $rial in(ol(ing )7 pa*
$ien$", pho$ochemo$herap# wi$h p"oralen and ul$ra(iole$ A 1:=FA2 wa" compared wi$h $rea$*
men$ wi$h ul$ra(iole$ 3 1=F32 alone, +o$h in $wo "$ud# group" and wi$hin $he "ame pa$ien$
1com* paring a $rea$ed hand wi$h an un$rea$ed hand2. =F3 wa" effec$i(e, +u$ :=FA appeared $o
+e more effec$i(e.)6 4n ano$her "mall $rial in(ol(ing pa* $ien$" wi$h chronic hand ec-ema, no
"ignif ican$ difference wa" repor$ed +e$ween $he u"e of :=FA and =F3.)6 Nau"ea 1from $he
$a+le$" of me$ho8* "alen, a deri(a$i(e of p"oralen2, edema, and pain are "ide effec$" of
pho$o$herap#. A long*$erm concern i" $he a""ocia$ed increa"ed ri", of non* melanoma ",in
cancer. 4n"$ead of admini"$ering an oral form of p"oralen, man# clinic" u"e a $op ical formula$ion
1a cream, gel, or +a$h prepara* $ion2.);,)? The re"ul$" of $wo randomi-ed $rial" "howed no
"ignif ican$ difference in eff icac# +e* $ween $opical and oral formula$ion" of p"o* ralen.)?,0
@n $he +a"i" of clinical e8perience, $opical glucocor$icoid" are of$en u"ed in com+i* na$ion wi$h
pho$o$herap#, e"peciall# earl# in $he cour"e of $herap#.
@ral >e$inoid"
@ral re$inoid" ma# +e u"ed for "e(ere chronic hand ec-ema, in par$icular $he h#per,era$o$ic
"u+$#pe. The oral re$inoid ali$re$inoin i" appro(ed for "e(ere chronic hand ec-ema in "e(eral
European coun* $rie" and %anada 1+u$ no$ in $he =ni$ed '$a$e"2. 4n a randomi-ed $rial in(ol(ing
10)2 pa$ien$" wi$h chronic hand ec-ema 1all $#pe"2 $ha$ compared $he u"e of )0 mg of
ali$re$inoin dail#, 10 mg of ali$re$inoin dail#, and place+o for up $o 2 wee,", $he percen$age" of
The New England Journal of Medicine
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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
pa$ien$" ra$ing $heir hand ec* -ema a" BclearC or Balmo"$ clearC a$ $he end of $herap# were 05,
25, and 175, re"pec$i(el#.1
:a$ien$" wi$h h#per,era$o$ic ec-ema had $he highe"$ re"pon"e ra$e" $o ali$re$inoin, +u$ $ho"e wi$h
(e"icular ec-ema al"o appeared $o +enef i$, al$hough formal "u+group compari"on" were no$
performed. The +enef icial effec$" of ali$re$inoin a" compared wi$h place+o were conf irmed in a
re$rea$men$ $rial among a "u+group of pa$ien$" who had had a relap"e.2 Ano$her oral re$inoid,
aci$re$in, admini"$ered a$ a do"e of )0 mg per da#, wa" al"o repor$ed $o +e effec$i(e in a "mall
place+o*con$rolled $rial in(ol(ing pa$ien$" wi$h $he h#per,era$o$ic (arian$ of hand ec-ema.)
.ow* e(er, cro""*"$ud# compari"on" of $he +enef i$" of aci$re$in and ali$re$inoin are no$ po""i+le
+ecau"e of difference" in $he "$ud# de"ign".
>e$inoid" $end $o +e preferred o(er oral im* muno"uppre""i(e agen$" gi(en $heir +e$$er "afe$#
prof ile. %ommon "ide effec$" a""ocia$ed wi$h re$inoid" are dr# ",in 1e"peciall# $he lip"2 and
an increa"e in le(el" of +lood lipid". >e$inoid" are $era$ogenic, "o i$ i" manda$or# for women of
re* produc$i(e age $o $a,e mea"ure" $o pre(en$ preg* nanc#. Ade9ua$e con$racep$i(e agen$" mu"$
+e pre"cri+ed and a mon$hl# pregnanc# $e"$ admin* i"$ered0 in "ome coun$rie", "igned informed
con* "en$ i" re9uired.
@ral 4mmuno"uppre""i(e Agen$" 4mmuno"uppre""i(e $herap# i" admini"$ered in pa$ien$" who
ha(e chronic hand ec-ema $ha$ i" unre"pon"i(e $o $opical $rea$men$ or pho$o$hera* p# 1or
re$inoid", when $heir u"e i" appropria$e2. The u"e of immuno"uppre""i(e agen$" i" +a"ed largel#
on e(idence "uppor$ing $heir eff icac# in $he $rea$men$ of a$opic derma$i$i".*6 %#clo"po* rine
i" $he mo"$ fre9uen$l# u"ed agen$. :o$en$ial ri"," include h#per$en"ion, decrea"ed ,idne# func*
$ion, and "e9uelae of immuno"uppre""ion. The +urden of ec-ema mu"$ +e weighed again"$ $he"e
ri",".
@$her agen$" occa"ionall# u"ed in prac$ice in* clude a-a$hioprine, m#cophenola$e mofe$il, and
low*do"e me$ho$re8a$e,6*; al$hough da$a from randomi-ed $rial" are lac,ing $o a""e"" $he
effi* cac# of an# of $he"e agen$" in $he $rea$men$ of hand ec-ema. 'e(eral wee," of a-a$hioprine
$hera* p# are generall# needed +efore $here i" an ap* precia+le clinical re"pon"e. 'hor$ cour"e" of
oral glucocor$icoid" are u"ed in "ome ca"e" $o achie(e rapid con$rol. All immuno"uppre""i(e
agen$" con* fer a ri", of "eriou" ad(er"e e(en$" 1hema$ologic and hepa$ic $o8ici$#, infec$ion", and
o$her effec$" of long*$erm immuno"uppre""i(e $herap#2.
The New England Journal of Medicine
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%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
A r e a " o f = n c e r $ a i n $ #
@nce hand ec-ema +ecome" chronic, cla""if ica* $ion ma# +e impo""i+le. A +e$$er under"$anding
of clinicopa$hological fea$ure" of $he differen$ $#pe" of hand ec-ema ma# impro(e cla""if ica$ion
and $he choice of $herap#. 'ome progre"" ha" +een made in $he under"$anding of $he role of
gene$ic and epigene$ic change" in ",in*+arrier func* $ion?0 fur$her re"earch in $hi" area migh$
help $o iden$if# pa$ien$" who ma# +enef i$ from +arrier* "$reng$hening "$ra$egie" a" oppo"ed $o
an$iin* f lamma$or# or immuno"uppre""i(e $rea$men$.
Addi$ional da$a from randomi-ed $rial" are needed $o a""e"" and compare $he (ariou" $hera*
pie" u"ed for chronic hand ec-ema. More da$a are needed $o inform $he role of ali$re$inoin in $he
$rea$men$ of (e"icular hand ec-ema.
D u i d e l i n e "
Duideline" ha(e +een pu+li"hed +# profe""ional medical "ocie$ie" in a few coun$rie", including
Denmar, and Derman#.;,20 4n addi$ion, $here i" a con"en"u" "$a$emen$ from $he =ni$ed
Gingdom22 and a guideline from a %anadian group of e8* per$".6 The American Academ# of
Derma$olog# ha" pu+li"hed guideline" on $he u"e of $opical glucocor$icoid", $he main"$a# of
$rea$men$ for hand ec-ema.)1 A 3ri$i"h guideline on pho$o$her* ap# include" a commen$ on $he
u"e of pho$o$her* ap# in hand ec-ema.); The recommenda$ion" pre"en$ed here are largel#
con"i"$en$ wi$h $he"e guideline" and con"en"u" "$a$emen$".
% o n c l u " i o n " a n d > e c o m m e n d a $ i o n "
The pa$ien$ de"cri+ed in $he (igne$$e ha" (e"icular* $#pe a$opic hand ec-ema. .er hou"ehold,
which include" "mall children, and her jo+ a" a nur"e, which re9uire" fre9uen$ hand wa"hing and
$he u"e of occlu"i(e glo(e", are "ource" of con$inued e8po"ure $o irri$an$". :a$ch $e"$ing i"
recommended $o rule ou$ con$ac$ allerg# $o ru++er compo* nen$" in medical glo(e" and $o
pre"er(a$i(e" in li9uid clean"er". %on$ac$ allerg# $o nic,el, diag* no"ed +# mean" of pa$ch
$e"$ing, i" of$en o+"er(ed in women, +u$ i$" rele(ance $o $he cau"e of $hi" pa$ien$<" hand ec-ema
i" uncer$ain. :ric, $e"$ing i" no$ nece""ar#.
:a$ien$" "uch a" $he one de"cri+ed "hould +e coun"eled $o a(oid A or a$ lea"$ drama$icall#
reduce A e8po"ure $o irri$an$" 1and con$ac$ al* lergen", when de$ec$ed +# pa$ch $e"$ing2 and
"hould inform $heir emplo#er of $he recommen* da$ion". !or $hi" pa$ien$, 4 would recommend $he
The New England Journal of Medicine
Downloaded from nejm.org on April 26, 201. !or per"onal u"e onl#. No o$her u"e" wi$hou$ permi""ion.
%op#righ$ & 2012 Ma""achu"e$$" Medical 'ocie$#. All righ$" re"er(ed.
u"e of impermea+le glo(e" wi$h a co$$on lining when performing Bwe$C $a",". !re9uen$ applica*
$ion of emollien$" 1prefera+l# oin$men$"2 i" an e""en$ial par$ of managemen$, in com+ina$ion
wi$h applica$ion of po$en$ $opical glucocor$icoid" once or $wice dail# for a$ lea"$ wee,". 4f
$opical glucocor$icoid" are no$ effec$i(e and $he pa$ien$ ha" acce"" $o :=FA $rea$men$, 4 would
recom* mend a cour"e of :=FA com+ined wi$h $opical glucocor$icoid". A "hor$ cour"e 11 wee,2
of oral glucocor$icoid" ma# +e needed $o achie(e rapid con$rol0 long*$erm u"e i" no$
recommended, gi(en $he ad(er"e effec$". !or "e(ere ca"e" of hand ec* -ema $ha$ are unre"pon"i(e
$o $opical $herap# or :=FA, oral c#clo"porine ma# +e con"idered. @$her immuno"uppre""i(e
agen$" are al"o an op$ion, al$hough $he# are u"ed le"" fre9uen$l#