Symmetrical acral keratoderma revisited: proposal for a new term, 'pigmented carpotarsal hyperkeratosis'.

First reported from Taiwan mistakenly as acral acanthosis nigricans in 1991, pigmented carpotarsal hyperkeratosis or hyperkeratosis nigricans carpi et tarsi displays a peculiar distribution of velvety brown-grey hyperpigmented plaques symmetrically on the flexural side of the wrists and ankles and on the dorsal sides of the hands and feet. A marked epidermal hyperkeratosis with typically mild acanthosis and papillomatosis is observed in histology. Whitish maceration upon perspiration or water exposure, with exacerbation in summer but remission in winter, is common. The association with obesity, endocrine disorders, atopic dermatitis, ichthyosis or malignancy is unknown. Familial occurrence and hereditary patterns are ill-defined. There is preliminary evidence indicating a pathogenic role of missense mutation in the transcription factor 4 gene. Treatment is empirical, with good outcome with topical retinoids and keratolytic agents. Recurrence is common, and long-term prognosis is unclear. To be distinguished are acral acanthosis nigricans, palmoplantar keratoderma of the Nagashima type, palmoplantar keratoderma of the Bothnian type and aquagenic palmoplantar keratoderma. Most reported cases are from Southern China and are predominantly observed in men between the ages of 20 and 40 years. The currently used term 'symmetrical acral keratoderma' is non-specific and misleading and may lead to global unawareness, underreporting or misdiagnosis of this phenomenon. Further genetic and molecular studies are required to clarify its pathogenesis and relation to palmoplantar keratoderma.

Photographic Documentation and Hand Eczema Severity Index for Severity Assessment of Hand Eczema.

BACKGROUND: Hand eczema (HE) is a fluctuating disease, and an objective assessment of HE severity is coveted. OBJECTIVES: This study was undertaken to test the association between Hand Eczema Severity Index (HECSI) score and panel scores of photographs taken by dermatologists. METHODS: A total of 33 patients with mild HE were included. The patients were part of an intervention study, and HECSI scores and standardized photographs were taken at baseline and at follow-up after 5 months. Actual change in HECSI score was compared with rating of change from photographs. A total of 15 dermatologists were engaged in blinded evaluation of photographs. RESULTS: The highest correlation coefficients between delta HECSI scores and delta panel scores of photographs in the first and second evaluation rounds were found for moderate improvement and moderate worsening, rs = -0.46 (P = 0.009) and 0.52 (P = 0.003), respectively, and major worsening, r = 0.41 (P = 0.021). With respect to minor changes, no statistically significant correlations were found (P > 0.05). CONCLUSIONS: In patients with mild HE, photographic assessment was found useful for major and moderate changes only. Further studies would need to be performed in patients with moderate or severe HE, to evaluate whether clinical photographs are able to capture similar changes as HECSI scores.

Management of Atopic Hand Dermatitis.

This article provides an overview of clinical aspects of hand eczema in patients with atopic dermatitis. Hand eczema can be a part of atopic dermatitis itself or a comorbidity, for example, as irritant or allergic contact dermatitis. When managing hand eczema, it is important to first categorize the subtype and identify potential culprit allergens or irritants. First-line therapy should be a combination of emollients and topical corticosteroids; possible alternatives include topical calcineurin inhibitors or coal tar. Second-line therapy includes UV therapy and systemic therapy, including azathioprine, cyclosporine, methotrexate, and mycophenolate. Prednisolone should only be very infrequently used.

"Pseudo-Circumscribed Palmar or Plantar Hypokeratosis (Pseudo-CPH)": a Histologic Pattern Secondary to Trauma; Further Characterization of a Known Entity.

Circumscribed palmar or plantar hypokeratosis (CPH) is defined clinically as well-circumscribed areas of erythematous eroded skin mostly over thenar or hypothenar eminences of the palms and less commonly soles. Histologically, lesions demonstrate a characteristic abrupt drop-off in the cornified layer leading to broad areas of hypokeratosis. In the original description in 2002, Perez et al favored these lesions to be a distinctive epidermal malformation. Since then, some reports implicate trauma; however, the exact etiology remains uncertain. The authors present 11 cases in which the histologic changes of CPH are present as an incidental finding that they favor to represent a reaction pattern to trauma. The changes of CPH overly traumatized neoplasms [ie, a poroma, squamous cell carcinoma (2), dermatofibroma], verruca vulgaris (3), inflammatory processes (lichen amyloid and granulomatous inflammation secondary to a ruptured infundibular cyst), and scar and fibrosing granulation tissue from previous procedures. Classic clinical findings of CPH are not present. The changes most commonly but not exclusively occur on acral skin (8/11), both volar (4) and dorsal skin (4). Six patients are female and 5 are male. Ages range from 21 to 87 years (median 64 years). The authors propose that, in some instances, the histologic changes of CPH are present as a secondary phenomenon and represent a reaction pattern to trauma. They name this finding of secondary histologic change of CPH as "pseudo-CPH" to distinguish it from primary lesions of CPH ("primary CPH") with classic clinical and histologic features.

Classification of hand eczema.

BACKGROUND: Classification of hand eczema (HE) is mandatory in epidemiological and clinical studies, and also important in clinical work. OBJECTIVES: The aim was to test a recently proposed classification system of HE in clinical practice in a prospective multicentre study. METHODS: Patients were recruited from nine different tertiary referral centres. All patients underwent examination by specialists in dermatology and were checked using relevant allergy testing. Patients were classified into one of the six diagnostic subgroups of HE: allergic contact dermatitis, irritant contact dermatitis, atopic HE, protein contact dermatitis/contact urticaria, hyperkeratotic endogenous eczema and vesicular endogenous eczema, respectively. An additional diagnosis was given if symptoms indicated that factors additional to the main diagnosis were of importance for the disease. RESULTS: Four hundred and twenty-seven patients were included, 379 (89%) of the patients could be classified directly into one of the six diagnostic subgroups, with irritant and allergic contact dermatitis comprising 249 patients (58%). For 32 (7%) more than one of the six diagnostic subgroups had been formulated as a main diagnosis, and 16 (4%) could not be classified. 38% had one additional diagnosis and 26% had two or more additional diagnoses. Eczema on feet was found in 30% of the patients, statistically significantly more frequently associated with hyperkeratotic and vesicular endogenous eczema. CONCLUSION: We find that the classification system investigated in the present study was useful, being able to give an appropriate main diagnosis for 89% of HE patients, and for another 7% when using two main diagnoses. The fact that more than half of the patients had one or more additional diagnoses illustrates that HE is a multifactorial disease.

Patch test results of hand eczema patients: relation to clinical types.

BACKGROUND: Allergic contact dermatitis is a well-known cause of hand eczema, although the influence of contact allergens on different clinical types of hand eczema remains still unclear. OBJECTIVE: To identify most common positive tested allergens among hand eczema patients and to define the relation between specific contact allergies and clinical types of hand eczema according to the guidelines of the Danish Contact Dermatitis Group (DCDG). METHODS: We included 1571 hand eczema subjects who were patch tested from 1 January 2002 to 31 December 2013. They were retrospectively classified according to the guidelines of the DCDG into six clinical types: recurrent vesicular hand eczema, chronic fissured hand eczema, hyperkeratotic palmar eczema, pulpitis, interdigital eczema and nummular hand eczema according to a newly developed flow chart. The prevalence of sensitizations and association with clinical type, atopic dermatitis, age and gender were studied. RESULTS: A total of 1395 subjects were classified into one of the six clinical types. The most frequently found clinical types were recurrent vesicular hand eczema (39.7%) and chronic fissured hand eczema (35.5%). Subjects with recurrent vesicular hand eczema were significantly more likely to have a contact allergy (OR 1.55), whereas subjects with hyperkeratotic palmar eczema and pulpitis were less likely to be sensitized (OR 0.51; OR 0.44). Overall, metals (nickel sulphate, cobalt chloride), fragrances and preservatives (methylchloroisothiazoline/methylisothiazoline, methyldibromoglutaronitrile) were the most frequent sensitizers in patients with hand eczema. This did not deviate in the different clinical types, although subjects with recurrent vesicular hand eczema were significantly more frequently sensitized to nickel sulphate and other allergens compared to other clinical types of hand eczema. CONCLUSION: In the diagnostic work up of hand eczema subjects with recurrent vesicular hand eczema should be patch tested, especially women of older age, although the need for patch testing in males with hyperkeratotic palmar eczema might be less imperative.

[New clinical classification for onychomycoses]. / Nouvelle classification clinique des onychomycoses.

We have updated our clinical classification on onychomycosis (2011) to render it of more practical value for the clinician. It should provide a better understanding of onychomycosis and facilitate an improved approach to treatment, taking into account, for example, the link between the proximal subungual variety and some superficial forms emerging from beneath the cuticle.

Is dermatitis palmaris sicca an irritant contact dermatitis?

BACKGROUND: Dermatitis palmaris sicca (DPS) is a common dry-fissured palmar dermatitis in Asian women. It may be an irritant contact dermatitis, but the immunophenotype of the cells in its infiltrate is unknown. OBJECTIVE: The aim of this study was to evaluate the role of inflammatory cells in the pathogenesis of DPS. METHODS: Patch testing was done in 68 patients with DPS, 87 subjects with hand eczema, and 31 healthy subjects. Immunophenotyping of cutaneous inflammatory cells was performed in 8 patients with DPS, 10 subjects with hand eczema, and 8 healthy individuals. RESULTS: Positive patch rates were higher in patients with DPS and those with hand eczema compared with healthy controls, but strong positive (++ or +++) reactions in DPS were fewer compared with hand eczema. Density of CD3, CD4, CD8, and CD68 cells in skin lesions of DPS and hand eczema was significantly higher than that in normal skin. Sparse CD20 cells were present only in hand eczema. Compared with hand eczema, the number of CD3, CD8, CD68, and dermal CD1a cells decreased, but epidermal CD1a cells and CD4/CD8 ratio increased in DPS. CONCLUSIONS: The absolute lack of CD20 cells and relative scarcity of dermal CD8 and CD1a cells in skin lesions might be insufficient to induce contact hypersensitivity, so DPS may be an irritant but not allergic contact dermatitis.

Hand eczema: an update.

Eczema, the commonest disorders afflicting the hands, is also the commonest occupational skin disease (OSD). In the dermatology outpatient departments, only the severe cases are diagnosed since patients rarely report with early hand dermatitis. Mild forms are picked up only during occupational screening. Hand eczema (HE) can evolve into a chronic condition with persistent disease even after avoiding contact with the incriminated allergen / irritant. The important risk factors for hand eczema are atopy (especially the presence of dermatitis), wet work, and contact allergy. The higher prevalence in women as compared to men in most studies is related to environmental factors and is mainly applicable to younger women in their twenties. Preventive measures play a very important role in therapy as they enable the affected individuals to retain their employment and livelihood. This article reviews established preventive and therapeutic options and newer drugs like alitretinoin in hand eczema with a mention on the etiology and morphology. Identifying the etiological factors is of paramount importance as avoiding or minimizing these factors play an important role in treatment.

Diagnosing chronic hand eczema by an algorithm: a tool for classification in clinical practice.

BACKGROUND: Diagnostic classification of chronic hand eczema (CHE) represents a major clinical and taxonomic challenge because of its wide aetiological and clinical heterogeneity. AIM: To develop an algorithm for the diagnosis and classification of CHE. METHODS: Well-defined aetiological, clinical and morphological criteria of CHE were arranged graphically in a diagnostic hierarchy, and validated in 137 German patients with hand eczema. RESULTS: The algorithm distinguished chronic hand eczema due to contact allergy, irritant damage or a combination of the two, each either with or without atopy, and also atopic hand eczema and idiopathic hand eczema lacking obvious causative factors. Foot involvement helped to distinguish idiopathic from irritant hand eczema. Each subtype could occur either with a hyperkeratotic-rhagadiform, dyshidrotic or mixed morphology, but certain hand eczema subtypes had clear morphological preferences. CONCLUSIONS: By providing a more precise clinical definition this diagnostic algorithm could improve the classification and taxonomy of hand eczema subtypes, facilitating more rational treatment decisions and allowing better treatment outcome analysis.

Classification of hand eczema: clinical and aetiological types. Based on the guideline of the Danish Contact Dermatitis Group.

BACKGROUND: No generally accepted classification scheme for hand eczema exists. The Danish Contact Dermatitis Group recently developed a guideline defining common clinical types and providing criteria for aetiological types. OBJECTIVES: To test the concepts of this guideline in a group of hand eczema patients. METHODS: Seven hundred and ten hand eczema patients were included from seven dermatology clinics in Denmark. The hand eczema was classified into one of five clinical types, with standard photographs as reference. The severity was scored by the physician, who also made a final aetiological diagnosis. RESULTS: Irritant contact dermatitis was most frequent in chronic, dry fissured hand eczema (44.3%), pulpitis (41.7%), and nummular hand eczema (40.9%), whereas allergic contact dermatitis dominated in vesicular types of hand eczema, with recurrent (35%) and few (24.2%) eruptions. Hyperkeratotic palmar hand eczema was the only clinical type that constituted a distinct subgroup; it was found most frequently in older men and had the strongest relationship, although not significant, with non-specific dermatitis. CONCLUSIONS: The relationship between clinical type of hand eczema and aetiological diagnosis fitted with general experience, but no simple relationship was found. This emphasizes that patch testing and exposure analysis are mandatory. Hyperkeratotic palmar hand eczema was identified as a distinct clinical subtype.

The Hand Eczema Trial (HET): Design of a randomised clinical trial of the effect of classification and individual counselling versus no intervention among health-care workers with hand eczema.

BACKGROUND: Hand eczema is the most frequently recognized occupational disease in Denmark with an incidence of approximately 0.32 per 1000 person-years. Consequences of hand eczema include chronic severe eczema, prolonged sick leave, unemployment, and impaired quality of life. New preventive strategies are needed to reduce occupational hand eczema. METHODS/DESIGN: We describe the design of a randomised clinical trial to investigate the effects of classification of hand eczema plus individual counselling versus no intervention. The trial includes health-care workers with hand eczema identified from a self-administered questionnaire delivered to 3181 health-care workers in three Danish hospitals. The questionnaire identifies the prevalence of hand eczema, knowledge of skin-protection, and exposures that can lead to hand eczema. At entry, all participants are assessed regarding: disease severity (Hand Eczema Severity Index); self-evaluated disease severity; number of eruptions; quality of life; skin protective behaviour, and knowledge of skin protection. The patients are centrally randomised to intervention versus no intervention 1:1 stratified for hospital, profession, and severity score. The experimental group undergoes patch and prick testing; classification of the hand eczema; demonstration of hand washing and appliance of emollients; individual counselling, and a skin-care programme. The control group receives no intervention. All participants are reassessed after six months. The primary outcome is observer-blinded assessment of disease severity and the secondary outcomes are unblinded assessments of disease severity; number of eruptions; knowledge of skin protection; skin-protective behaviour, and quality of life. TRIAL REGISTRATION: The trial is registered in ClinicalTrials.Gov, NCT01012453.

Nonmutilating palmoplantar and periorificial kertoderma: a variant of Olmsted syndrome or a distinct entity?

BACKGROUND: Olmsted syndrome is a rare keratinization disorder characterized by mutilating palmoplantar and periorificial keratoderma as the two major diagnostic features. Some authors believe that atypical cases without this standard combination may not really belong to Olmsted syndrome. Herein, we describe two familial cases with congenital nonmutilating palmoplantar and periorificial keratoderma, and discuss their similarities and differences with Olmsted syndrome. PATIENTS: The study included two sisters who presented with focal and punctate nonmutilating palmoplantar keratoderma (PPK), periorificial hyperkeratotic plaques, and widely distributed keratotic lesions. Fragile denuded areas of the skin were found in sites exposed to trauma. Fingernails showed a characteristic form of leukonychia. RESULTS: Histopathology of plantar keratoderma showed psoriasiform hyperplasia with marked compact hyperkeratosis, while vicinity of denuded skin revealed thin parakeratotic zone and dissolution of the granular cell layer. Immunohistochemistry demonstrated suprabasal staining pattern for acidic keratin (AE1) and uniform positivity, starting four to six layers above the basal layer, for cytokeratin 10. Electron microscopy showed defective keratinization. Cytogenetic studies revealed normal karyotype and no chromosomal breakage. CONCLUSION: Our cases share Olmsted syndrome in the early onset, and the presence of symmetrical PPK, periorificial keratoderma and keratotic lesions. However, the striking nonmutilating nature of PPK and the presence of unique features in our patients suggest a newly described keratinization disorder.

Hand dermatitis/eczema: current management strategy.

Ever since its inception a couple of centuries ago, hand dermatitis/eczema has been in the reckoning. Idiosyncrasies continued to loom large thereafter, till it acquired its appropriate position. Dermatitis/eczema are synonymous, often used to indicate a polymorphic pattern of the inflammation of the skin, characterized by pruritus, erythema and vesiculation. A spectrum delineated into acute sub-acute and chronic dermatitis of the hands. Pompholyx, recurrent focal palmer peeling, ring, wear and tear and fingertip eczema, apron, discoid eczema, chronic acral dermatitis, gut and patchy papulosquamous eczema are its clinical variants. Occupational dermatitis/eczema may be contributory. Etiological definitions are clinched by detailed history of exogenous and endogenous factors. However, scientific confirmation of the entity is through patch testing by using available antigens.

The hand-foot-syndrome associated with medical tumor therapy - classification and management.

The hand-foot-syndrome (HFS, palmoplantar erythrodysesthesia, chemotherapy-associated acral erythema) is characterized by painful predominantly palmo-plantar lesions. The association with different chemotherapeutic agents has been known for over 20 years. More recently, HFS has been reported in association with regimens using targeted agents, in particular the multikinase inhibitors (MKI) sorafenib and sunitinib. The HFS associated with MKI has a different distribution and clinical appearance than the traditional disorder. In this review, similarities and differences between chemotherapy- and MKI-associated HFS are discussed and current recommendations for their prophylaxis and management are summarized.

Integrated, multidisciplinary care for hand eczema: design of a randomized controlled trial and cost-effectiveness study.

BACKGROUND: The individual and societal burden of hand eczema is high. Literature indicates that moderate to severe hand eczema is a disease with a poor prognosis. Many patients are hampered in their daily activities, including work. High costs are related to high medical consumption, productivity loss and sick leave. Usual care is suboptimal, due to a lack of optimal instruction and coordination of care, and communication with the general practitioner/occupational physician and people involved at the workplace. Therefore, an integrated, multidisciplinary intervention involving a dermatologist, a care manager, a specialized nurse and a clinical occupational physician was developed. This paper describes the design of a study to investigate the effectiveness and cost-effectiveness of integrated care for hand eczema by a multidisciplinary team, coordinated by a care manager, consisting of instruction on avoiding relevant contact factors, both in the occupational and in the private environment, optimal skin care and treatment, compared to usual, dermatologist-led care. METHODS: The study is a multicentre, randomized, controlled trial with an economic evaluation alongside. The study population consists of patients with chronic, moderate to severe hand eczema, who visit an outpatient clinic of one of the participating 5 (three university and two general) hospitals. Integrated, multidisciplinary care, coordinated by a care manager, including allergo-dermatological evaluation by a dermatologist, occupational intervention by a clinical occupational physician, and counselling by a specialized nurse on optimizing topical treatment and skin care will be compared with usual care by a dermatologist. The primary outcome measure is the cumulative difference in reduction of the clinical severity score HECSI between the groups. Secondary outcome measures are the patient's global assessment, specific quality of life with regard to the hands, generic quality of life, sick leave and patient satisfaction. An economic evaluation will be conducted alongside the RCT. Direct and indirect costs will be measured. Outcome measures will be assessed at baseline and after 4, 12, 26 and 52 weeks. All statistical analyses will be performed on the intention-to-treat principle. In addition, per protocol analyses will be carried out. DISCUSSION: To improve societal participation of patients with moderate to severe hand eczema, an integrated care intervention was developed involving both person-related and environmental factors. Such integrated care is expected to improve the patients' clinical signs, quality of life and to reduce sick leave and medical costs. Results will become available in 2011.

Hand dermatitis in primary care: A nurse practitioner's role in management.

PURPOSE: Discuss chronic hand contact dermatitis (CD) and its management by nurse practitioners (NPs) in primary care. DATA SOURCES: Clinical studies, practice guideline, and clinic case. CONCLUSION: Hand CD is a common form of dermatitis in primary care. Recognition and avoidance of irritants and allergens, proper hand protection, and topical treatments can alleviate this chronic problem, significantly relieve symptoms, and promote skin health. IMPLICATIONS FOR PRACTICE: A national shortage of dermatologists has caused more patients to seek treatment for skin disorders in primary care. NPs need to be prepared to diagnose and manage common skin problems in primary care.