HAND DERMATITIS ------------------------------------------------ I have a 53yowf who seems to be allergic/pathergic to everything including cortisone. She began in February 1996 with fingertip peeling, tapioca eccrine dots and pustules that begin in the same sweat gland on her fingertips. Culture was negative. She initially responded to Temovate, now it makes her worse. She stopped her acrylic fingernails, still using polish, doesn't have/want to spend the money on patch testing and exacerbated this week after cutting up tomatoes. She improves with Keflex and I've started Sporanox for a trial this week as well. Her paronychiae are swollen, red, and cracked hence the antifungal. I've asked her to use Lotrimin to the cuticles overnight. Maida Burrow ------------ Could she have pustular psoriasis or pustular bacterid of Andrew? How about an aromatic retinoid trial? And she really needs patch tests. After you rule out contact, you could try Puva. Diane Thaler ------------ At a recent meeting I attended was a very useful talk given by Francis Storrs suggesting causes of hand dermatitis by patterns of involvement-fingertip involvement STRONGLY suggests contact dermatitis-a couple of examples: alstromeria in florists(and perhaps other?) who handle ornamental plants including chrysanthemums,tulips,feverfew; and good old corticosteroid contact allergy;I suggest that patch testing be considered. Pierre Jaffe ------------ I would concern myself about an "occult" contactant. I've seen several patients who were flower people, and sensitive to the plants they touched (both professional arrangers and in home types), as well as what appear to be "reactions" to plastics (including keyboards) and to stove and furniture polishes. Acrodermatitis repens may also be evolving now. A trial of topical Dovonex might prove useful, but I'll bet that the only thing that will make her much better will be Kenalog IM or bursts of prednisone. Robert I. Rudolph, M.D., FACP ----------------------------- Pierre, fingertip dermatitis is the greatest challenge in my practice. Did Francis mention other than flowers and corticosteroids? It seems a lot of them are formaldehyde sensitive, and most of them work with papers (desk jobs). But I don't know how to advise them. None have been steroid sensitive. Do you feel "hard plastics" are a problem? Could they be using furniture cleaners like Endust on the keyboard? Also, if there is a formaldehyde hand problem would they also have rectal/vag itch from recycled "cheap" single sheet toilet paper? Diane Thaler ------------ Broke out cutting up tomatoes? I would consider a dermal contact dermatitis masquerading as 'fingertip dyshidrosis' and patch test her to tomato, potato, raw meat, raw chicken, garlic, onion, carrots (sounds like a damn good stew) I am concerned that she doesn't want to be patch tested. If anyone needs patch testing, she does, and without it, you may be navigating in the dark (like we all do at times to make our patients happy) tough situation. Treatment wise: I would consider colchicine or low-dose Dapsone (more likely) but for a short 4-6 week course. Consider nickel-free diet (no nuts, chocolate, etc.)> never worked in my hands. Tough case: contact vs contact vs contact vs contact IMHO. Diane Thaler ------------ Diane, I couldn't agree with you more...fingertip dermatitis can be a challenge to the most astute clinician...Dr. Storrs cites her husband's hand dermatitis as a case in point! She points out that even if an offending agent is found with patch testing and eliminated,the dematitis may persist. Bottom line, topical steroids don't work well,plain vaseline is used a lot. Pierre Jaffe ------------ You might have to resort to acitretin or etretinate-which wouldn't be such a bad idea based on the reports from St. Louis of the aromatic retinoids helping with recalcitrant hand eczema as well. Since my case of itraconazole liver failure, I have been using Diflucan more and Sporonox less. Diane Thaler ------------ Here's Dr. Francis Storrs' "Tips for Managing Hand Dermatitis" 1. Once hand dermatitis of any type is in place, wet activities will worsen and prolong it. 2. Minimize washing and wetting and drying. a."wash" with Cetaphil or Aquanil instead of water whenever possible. b. Protect hands from water using cotton gloves inside a vinyl or neoprene glove.Good source for both: Allerderm Laboratories 28 Glenn Drive / P.O. Box 931 Hill Valley,CA 94942-0931 3.Use topical steroids in simple ointment base (petrolatum or plastibase)whenever possible. a. Hydrocortisone: 1) Hydrocortisone acetate (where dermatitis isn't too bad) made up in petrolatum 2) Locoid ointment (Hydrocortisone butyrate in plastibase). b. Fluorinated steroids (when dermatitis is "bad") 1) Triamcinolone acetonide 0.1%(TAC) pharmacist can make up in plain petrolatum. 2) Aristacort ointment is TAC in plain petrolatum. 3)Kenalog ointment is TAC in plastibase. 4)Synalar ointment (fluocinolone acetonide in pet). 5)Diprosone ointment(betamethasone dipropionate). 4. Steroid creams should be: a.Used only when ointments are impractical. They may actually wosen hand dermatitis, e.g. 1) too drying (contains too much water) 2) contains allergens (preservatives and propylene glycol). b. Used one or two times a day unless washed off. Note: an additional "hand out" on "Good Hand Care" to follow Pierre Jaffe ------------ Another Hand-out: "Good Hand Care"(again courtesy of Dr. Francis Storrs) from a recent meeting....This more as a take home for pts. Causes: The number of causes of hand rashes is almost limitless.A few of the more common are overexposure to water,too much dry air,soaps, and detergents,solvents,cleaning agents,rubber gloves or even ingredients in skin and personal care products.Once skin becomes red and dry,even so called "harmless" things like water and baby products can irritate skin further. Washing hands: Take your rings off to wash because they trap soap and water next to the skin. Use lukewarm water and rinse thoroughly after washing with soap. Blot your skin dry carefully. Apply moisturizer while your skin is still damp(see below). Use soap sparingly.Because soap strips oil from your skin,use it only when it's really needed,such as in skin-fold areas.Avoid detergents,perfumed soaps,which can be extra drying.Instead,you might want to try soap substitutes or soaps that contain moisturizers. Short warm showers are better for your skin than hot baths.Be sure to gently pat your skin dry and apply moisturizer. Lotions and moisturizers: Apply a moisturizer after each hand washing,immediately after bathing and after removing gloves.The rule of thumb for moisturizers is: the messier, the better. Ointments like white petroleum jelly effectiveness) by mineral oils, hydrating gels, and creams.Lotions, which contain mostly water, are the least effective as moisturizers. A WORD OF CAUTION: petroleum products and some others can damage latex gloves-be sure to use an approved moisturizer at work if you wear latex gloves.A greasy ointment like white petroleum jelly(e.g.Vaseline) applied to hands and covered with cotton gloves at night can really help. Gloves: Plastic or vinyl is better than latex and powder free is much better than powdered when choosing gloves for people with sensitive hands.WEAR THEM AT HOME too-for tasks such as dishes,folding laundry(the fabric soaks the moisture out of your hands),peeling vegetables or for handling citrus fruits or tomatoes.Keep several pairs of gloves at home in thekitchen, bathroom,laundry area,etc.Use gloves for non-wet housework and gardening too.Always replace gloves that develop holes. Dry gloves out between uses and change them if they become wet on twear them with a thin pair of cotton gloves under them to absorb water. Moisturize after removing your gloves. Use of cotton gloves underneath plastic household gloves is highly recommended. Cotton gloves can be worn without plastic gloves all day to protect hands from irritation. These cotton gloves should be washed frequently. Miscellaneous: Protect your hands from the cold dry air. Wear gloves or at least keep your hands in your pockets to prevent exposure to the cold and wind. Don't wear your rings to do housework,etc.Clean your rings frequently soaking them ammonia water( 1 tablespoon full per pint) overnight. Do not peel or press oranges,lemons,grapefruits,tomatoes, or onions with the bare hands.Avoid contact with solvents and stain removers as well as cleaning products for metals,glass,floors,cars and furniture. Don't pick at any loose ends of skin . These loose ends are best clipped off with a small nail clipper or scissor If dry skin doesn't respond to self-care measures,discussing other treatments with your doctor is always an option If you feel your problems are work related, please call us Pierre Jaffe ------------ Thank you for the info Dr Jaffe----one thing I have found helpful is to have my hand eczema patients and dry skin patients use a moisturizing lotion in place of soap to clean their hands. Lets face it most hand cleaning is ritual rather than necessary anyway and by using excessive moisturizer rubbed around like soap and rinsed off we are binding most dirt and germs et al in the excess and rinsing that down the drain hopefully killing two birds with one moisturizer...now I'm sure that should have flamed some of you obsessed with cleanliness W H Burrow ---------- I am seeking therapeutic suggestions for a patient of mine with recalcitrant dyshidrotic dermatitis. Both palms and soles are covered with confluent clusters of vesicles. Responds to oral steroids (40 mg prednisone for 3 weeks) but recurs on the second day off prednisone. Topical steroids alone (Ultravate, Temovate etc) without effect. Balnetar soaks - not very helpful. Chris Dabski, M.D. ------------------ I have historically preferred steroid creams vice ointments for hand eczema, not because they are better, but because the pt will use them, thus the eczema gets better. Ointments are too greasy for many active people, compliance is bad, and improvement underwhelming. Dan Mitchell, MD ---------------- FOR THE ACUTE EARLY VESICULAR STAGE OF DYSHIDROTIC HAND ECZEMA: 1. Dissolve two Domeboro tablets in 2 ounces of Alpha Keri bath oil (Bristol-Myers, Evansville, IN) and 1 quart of cold water. 2. Wear thin cotton gloves. 3. Immerse the gloved hands in the solution. Squeeze out the excess solution. 4. Allow to almost air dry. Do not cover to prevent evaporation. 5. Keep the solution in the refrigerator. When the gloves are almost dry, repeat steps 3 and 4. 6. Repeat the above routine throughout the waking hours. 7. Decrease the frequency of treatment as the condition improves. After the acute condition subsides in a week or so, Bactroban (Beecham, Bristol, TN) ointment and a mild topical corticosteroid is applied. The above regimen proved to be quite helpful. After 6 months, it was reported that the condition was quickly controlled but mild recurrences still appeared, which in turn were readily controlled without sequelae. American Journal of Contact Dermatitis, Vol 5, No. 1 (March), 1994: p 55 "A.P. Truett III, MD -------------------- My approach to dyshidrosis/pompholyx: 1. R/O Nickel allergy (also ingested cobalt chromate). Patch-test and consider low nickel diet, even if patch test is negative. Patient has to stay on diet for at least 6 weeks. If patient responds to low nickel diet then consider antabuse as a nickel chelator. Do not place on antabuse intially as it may cause severe flare. 2. Doxycycyline/Minocycline. I have had excellent responses in approximately 50% of idiopathic pompholyx to 100mg bid. I am unsure why this works but I have a number of patients who can't miss more that several doses without flaring. 3. Hand/foot systemic PUVA always works but rule out contact dermatitis first. Secondary contact dermatitis always possible. 4. I have also added another posting that includes Dr. Fishers treatment with domeboro and alpha keri. Trey Truett, MD --------------- Cyclosporine would probably work fine. I've occasionally had good success with chloroquine and Plaquenil for atopic dermatitis and hand eczema. I have a couple of people who've improved on bid Elocom ointment with 5% diltiazem w/w added. Topical FK-506 will be worth trying when it becomes available after Christmas (Fujisawa is building a $25 million plant on Grand Island to make the stuff). Got a friendly radiotherapist? Grenz ray could give a long-term, drug-free remission. Is she allergic to nickel? Many dyshidrotics are. In Scandinavia nickel-free diets are touted a useful, and Antabuse has been used as a nickel chlating agent to deplete the patient of nickel. Kevin C. Smith MD FRCPC ----------------------- I agree that creams are more acceptable to more people,but I also feel that ointments get the job done better....for the active and fastidious person I'll have them use cream in the day and use ointments with gloves(cotton, ex.Dermal gloves) over night. Remains a challenge for us all. Pierre Jaffe ------------ Garlic bit under a band aid in one. Others were instructed to wear gloves when handling it and the rash resolved. The distribution is typically on the thumb and fingertips and comes (I think) from peeling the cloves. Peeling can be made easier by crushing cloves with the flat side of a knife, making fingertip exposure less. Guy Webster ----------- Guess nickel free would be exaggerated, let's be modest to get at least a nickel poor diet. Forbidden food: everything from cans everything that has been cooked in stainless steel oysters herring asparagus beans mushrooms onions corn spinach tomatoes peas pears tea cacao / chocolate, CHOCOLATE!!!Oh my God! and the pulver you put into the cakes to make it grow, carbonate or how it's called (I never bake on my own) Source: Kaaber K et al., British Journal of Dermatology 98:198, 1978 Another common recommendation is to let the first tap water in the morning go into the sink and not into the coffee machine. Personally, I think it is worth a try if there really IS a type IV allergy and symptoms that fit (eczema or food related diarrhea...). If the patient is really interested, there are lists with the amount of nickel per gram food. Maybe our British colleagues have it in English, otherwise I would try to translate on request. Hans J. Kammler ---------------