Chronic Hand Dermatitis - American Academy of … B003... · Chronic Hand Dermatitis-Handout ......
Transcript of Chronic Hand Dermatitis - American Academy of … B003... · Chronic Hand Dermatitis-Handout ......
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Chronic Hand Dermatitis-Handout
Alison Ehrlich, M.D., M.H.S
Professor and Chair
Department of Dermatology
George Washington University
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OBJECTIVES-CHRONIC HAND DERMATITIS (CHD)
• Epidemiology
• Overview of etiology
• Presentation-clues to diagnosis
• Treatment/management
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Definition: Chronic Hand Dermatitis
• Duration: > 6 weeks, 3mos, 6 mos.
• Mean Duration: 7-11 years.
• Frequency : at least 2 flares/year.
• Multifactorial etiologies and overlapping disease entities.• Endogenous and exogenous factors
• Persistent and recurring nature.
• No universal classification and consistent nomenclature.
CARPE CRITERIA:
• Dx duration ≥ 3mos.
• > 3 flares within 12 months.
• Resistant to previous steroid tx.
• No other active severe disease or infection.
Diepgen et al., 2011. JDDG
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Definition: Treatment Resistant CHD
Patients have failed to improve with the use of ultra-potent topical corticosteroids.
Scalone 2015, Ruzicka 2008, Paulden 2010
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Severity of Hand Dermatitis
• Mild
• Moderate
• Severe
• Fowler: Americans: 17/31 (54.8% )- moderate to severe hand dermatitis. Cutis 2006, 77, 385-392.
• Thyssen et al: moderate to severe disease- 30% . Contact Derm 2010, 62; 75-87.
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Epidemiology of Chronic Hand Dermatitis
• Chronic hand eczema: 1 yr prevalence of 10%, lifetime prevalence of 15% in the general population.
• Accounts for >80% of occupational dermatitis cases.
• 30% of patients, onset occurs prior to age 20.
• Mean duration > 10 yrs.
• 20% of patients will have ≥ 7 days of sick leave.
• 10% of patients will change their occupation.
Diepgen et al., JDDG 2011
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Risk Factors: CHD
• Female> Male
• Risk increases with age
• Nickel allergy
• h/o smoking
• Lower vs higher education
• Lower humidity climates
• Occupation: • Nursing, Medical, Service
industries
• Respiratory atopy w/out AD
• Genetic predisposition
• AD risk factor in <30 yrs of age
Menne et al., Contact Dermatitis. 2010
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Risk Factors: Nickel Allergy
• Ni allergic females –increased risk of hand eczema (Menne)
• 30% of Ni allergy had hand eczema: sig assoc both sexes ( Meding)
• 12-16yo Danes: Ni allergy + hand eczema (OR=2.36; CI 95% = 1.39-4.01). (Mortz )
Contact Dermatitis, 2010, 62;75-87
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Challenging To Determine Etiology: Chronic Hand Dermatitis
Contact allergy
Irritant exposure
Atopy
Psoriasis
Dyshidrosiform eczema (pompholyx)
Combination of above…
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Diagnostic Information: CHD
• History• Medical/Risk factors (atopy)*• Frequency of flares• Exposure to irritants or allergens from occupation or activities
• Physical examination• Morphology and Location on hands.• Hands and other body sites• Nails
• Patch test• Helpful in diagnosing allergic contact dermatitis (ACD)
• Skin biopsy• Useful?
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Distribution of Diagnosis for Hand Eczema
0
5
10
15
20
25
30
35
40
45
50
40
14.5
18
7
36
16 16
3 2
21
6
45.2
25.9
30.6
36.1
22.4
7
Perc
enta
ge
Lantinga
Meding
Diepgen
Meding et al.,1989Lantinga et al., 1984.Diepgen et al., 2011
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Precursor Lesions for Hand Dermatitis?
91.8
98.8
70
35
15
0
20
40
60
80
100
120
Erythema Lichenification Crusting Scaling Other
Perc
enta
gePrecursor Lesions
Lesions
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Irritant Contact Hand Dermatitis
• Chronic exposure to soap and water causing subacute eczematous inflammation
• Patients vary in their ability to withstand exposure to irritants
• Healthcare,industrial, mothers
Slide 13
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Atopic Hand Dermatitis
• Younger age of onset
• Involves the dorsal hand and fingers
• Dryness, mild erythema and lichenification
• Frequently accompanied by pruritus and pain
• Usually on both hands with involvement of other body area
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Psoriasis
• With or without involvement of other body areas.
• Palms and volar aspects of the fingers .
• Less erythema in Hand plaques vs body plaques.
• Hand/nail involvement ↑ joint disease.
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Occupational Contact Dermatitis
• Contact Irritants • Water• Soaps and detergents• Cleansers• Acids/ Alkalis• Metalworking fluids• Solvents• Oils/coolants• Oxidizing agents• Reducing agents• Food products• Physical factors• Degreasers• Lubricants
• Contact Allergens• Biocides
• Chromate
• Dyes
• Epoxy and other resins
• Essences and fragrances
• (Meth)acrylates
• Metal salts (chromates, nickel)
• Plants and woods
• Rubber-processing chemicals
• Germicides
• Plastic resins
.
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Non-occupational Contact Dermatitis
Contact Irritants
• Household cleaners
• Food products
• Plants
• Water
Contact Allergens
• Fragrance
• Preservatives
• Nickel
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Reported ACD-Hand dermatitis
• Lettuce, compositae.
• Spices: garlic, cinnamon, ginger, allspice, clove.
• Hairdressers: most likely: glyceryl monothioglycolate, ammonium persulfate.
• Nail cometicians: acrylates.
• Cement workers: cobalt & chromates
• Woodwork teachers: isothiazolinone, nickel, formaldehyde, colophony
• Painters: nickel, cobalt, isothiazolinones, P-tert-buty-phenol formaldehyde.
• Dental workers:epoxy and acrylates.
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Top Allergens in Patients with Hand ACD
•Nickel sulfate
•Neomycin sulfate
•Balsam of Peru
• Fragrance mix
• Thimerosal
•Quaternium-15
• Formaldehyde
•Bacitracin
•Cobalt chloride
•Carba mix
Warshaw EM, et al. J Am Acad Dermatol. 2007;57:301-314.
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Protein Contact Dermatitis
• Chronic recurrent dermatitis
• Affects hands, arms and/or fingertips
• May present as chronic paronychia-food handlers
• Rxn may occur within minutes-vesicles, urticarial papules
• 50% associated with atopy
• Fruits, plants, spices, animal proteins, grains, enzymes, cheese, latex
Dermatitis 19:5: 2008, 241-251.
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Hand Eczema Management
• Systemic therapies• Cyclosporine• Methotrexate• Azathioprine• Mycophenolate mofetil• Oral corticosteroids• Oral retinoids• Biologics
• Phototherapy• UVB and excimer laser• PUVA
Diepgen TL, et al. Contact Dermatitis. 2007;57:203-210. 2) Warshaw EM. Dermatologic Therapy. 2004;17:240-250.
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Treatment: CHD
Tertiary therapy
Systemic agents:Methotrexate, cyclosporine, azathioprine, retinoids, oral
corticosteroids-pulsed.
Secondary therapy
Topical agentsMoisturizers, steroids, (soak/smear),calcineurin inhibitors,
coal tar agents, phototherapy,neurotoxin, Grenz
Primary therapy
Skin protection measures: Education, Gloves, lifestyle changes
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Treatment: CHD-Soak and Smear Regime
• Soak 20 minutes in pan of water
• Then Smear topical steroid without drying skin
• Possible additions:• Tar based emulsion
• Bath oil
• Cotton gloves
James et al. Arch Derm., 2005
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Treatment CHD: Local Bath PUVA
• 15min soak with 1mg 8-methoxypsoralen.
• Start PUVA at 0.25-0.5J/cm2.
• Treat 3x a week.
• Increase dose by 0.25-0.5J/cm2 every week.
Simon et al., Jaad. 1997., Zemstov. Jaad1998.
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Cyclosporine vs Betamethasone Dipropionate for CHD
•RCT study w/ Cyclosporine @ 3mg/kg/day vsBDP.
•Enrolled 41 pts, tx resistant for 6 weeks.
•Total disease activity score decrease 57%/58%.•no significant difference.
Eriksson et al. Derm Venereol. 1996.
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Mycophenolate Mofetil (MMF) for AD
• Severe AD, N=10
•MMF,1g/d-week 1, then 2g/day for 12 weeks.
•Median Scorad score decreased from 68.3 to 22 (p=0.007).
Diek et al., BJD. 2000
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Acitretin for CHD, Hyperkeratotic Varient
• A single-blind placebo-controlled study.
• Treatment of hyperkeratoticHD(eczema keratoticum).
• 14 pts -30mg/day Acitretin, 15-placebo
• Inclusion: hyperkeratotic palms +/-fissures
• Overall score improvement:• Acitretin-51% • Placebo- 9%
0
10
20
30
40
50
60
70
80
Acitretin
Placebo
Veien et al., Acta Derm Venereol 2001.
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Bexarotene gel 1% for Severe CHD
• Phase I/II open label randomized trial, n=55.
• Stepwise increase in application q2wks: QOD to TID• Arm 1: Bexarotene 1%
• Arm 2: Bexarotene 1% + topical low potency steroid.
• Arm 3: Bexarotene 1% + topical mid potency steroid.
• Response rate:• PGA
• H-EASI
Breneman et al., Dermatol 2004; 150: 545–53.
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Botulinum Toxin for Dyshidrotic HD
• Controlled prospective pilot study with left-right comparison.
• Objective; Is chemical de-innervation of sudoriferic nerves superior to topical corticosteroids?
• Topical corticosteroids + neurotoxin (100units Botox®) to more severely affected hand.
• BTXa decreased itch and sweating. • (BTXA inhibits substance P release)
• Mean DASI in (N=6) at week 8:• BTXa group changed from 36 to 3• Steroid only changed from 28 to 17
Karamfilov J Eur Acad DermatolVenereol 2002; 16: 40–2.
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Methotrexate forRecalcitrant Palmoplantar Pompholyx
•Pompholyx accounts for 5-20% of HD cases.
•Case series: 5 patients controlled on 12.5-20mg/week of MTX.
•All patients had previously failed topical corticosteroids and were receiving oral steroids when MTX was added.
Kruger JAAD 1999;40;612-14.
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Complicated Contact Dermatitis
• 77 yo woman
• Patch tested outside facility. (+) colophony
• Using steroids, develops 12 fingernail onychomycosis.
• Refuses continued steroids, currently failing topical tacrolimus.
• Sent for 2nd opinion.
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Future therapies-CHD
•Duplimumab
•Apremilast
•Alitretinoin
•AN2728
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Duplimumab
•Fully human monoclonal antibody
•Directed against the shared alpha subunit of IL-4 receptors
•Blocks signaling from both interleukin-4 and interleukin-13
• In Phase III trials for atopic dermatitis
Radin et al., n engl j med.2014
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Alitretinoin for Chronic Hand Eczema
• RCT Phase III, double blinded, placebo controlled.
• Dosing 30mg po qd.
• Primary endpoint % clear or almost clear w/ PGA score at week 24;• Handel : 40% Alitretinoin vs 15% on
placebo • Bach: 48% Alitretinoin vs 16.6%
• AE’s: headaches, flushing, nausea, increased TG’s.
JEADV 2010, 24 (Suppl. 3), 1–20
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CHD: Novel Topicals in Development
•Crisaborole (AN2728) is boron-based PDE4 inhibitors.
•Mechanism;• An increase in intracellular cAMP activation of PKA.• Phosphorylation and negative regulation of transcription
factors of various cytokines.
JSID Abstracts / Journal of Dermatological Science 69 (2013) e1–e46, Anacor Press Release 7/13/15
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OPA-15406• PDE 4 inhibitor, selectivity for 4B
• Phase II RCT for AD dosed at 0.3% and 1.0%
• Clear or almost clear @ week 4:• Vehicle 2.7%
• OPA low dose 14.6%
• OPA high dose 20.8%
• VAS pruritus scores week1 mean change: 36.4% in 1% arm.
Hanifin et al. Jaad 2016
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In Summary
•Consider potential for dual diagnosis for CHD.
•Take complete history on exposures.
•Lifestyle modifications can be helpful.
•Given QOL issues, treatment beyond topical steroids should be considered.