Doc Talk

Red, itchy and inflamed skin on the hands

If not treated early, the scratching can lead to loss of fingerprints and damaged nails

The suffering was palpable.

There was a poignant pause before tears swelled up in her eyes as she recounted the pain and itch that kept her up all night.

Mrs B is a 48-year-old, fiercely independent housewife who prides herself on keeping her home neat and tidy, and her ability to whip up a scrumptious meal for her family in record time.

Recently, a new problem emerged that was threatening her quality of life.

Red itchy rashes that had started out as innocent-looking patches on her fingertips had insidiously progressed over time to affect her palms, the back of her hands, her finger pulps and finger webs.

Marked dryness, leading to deep cracks and fissures, caused excruciating cutting-like pain, especially when her hands came in contact with water.

After trying a myriad of over-the-counter creams that brought only short-lived relief, Mrs B was desperate, depressed and confused.


Mark Tang.

" Why now? Why me? And why just my hands?" she asked.

Cumulative exposure to harsh chemicals, washing, cooking and even plain tap water can - over time - lead to irritation and dryness.

HAND ECZEMA

She has hand eczema, which is one of the most common problems I see in my clinic.

There is no recent data on its prevalence in Singapore.

However, based on overseas data which normally reflects the situation here, the one-year prevalence of hand eczema in the general population is estimated to be nearly 10 per cent, with lifetime prevalence approaching 15 per cent.

The main issue is occupational hand eczema, which is under-reported.

Eczema comes from the Greek word "ekzein", meaning "to boil out", which aptly reflects the red, itchy and inflamed skin on Mrs B's hands.

The dryness is both a cause and a consequence of eczema, and reflects a disruption of the skin's protective barrier function.

Severe dryness and scratching result in painful cracks and bacterial infection, crusting and blisters.

Often, there is also a loss of nail cuticles and swelling of the nail folds, leading to abnormal nails too.

If not treated early, the vicious circle of inflammation, itching and scratching can lead to permanent consequences such as the loss of fingerprints, damaged nails and compromised hand function.

WHY JUST THE HANDS?

Our hands are exposed to high levels of products, chemicals, food, grease, microbes and water on a daily basis.

And, although the skin of our palms is thicker compared to skin on other parts of the body, cumulative exposure to these harsh chemicals, washing, cooking and even plain tap water can - over time - lead to irritation and dryness.

These are the key predisposing causes of hand eczema.

Hand eczema affects those who work a lot with their hands. It accounts for up to 30 per cent of work-related skin diseases.

Those who are in occupations such as hairdressing, surgery, nursing and cooking, as well as service crew and housewives, have the greatest risk.

Some of my patients have an obsessive fear of dirt, which causes them to habitually wash their hands many times a day.

Finally, there are "eczema" genes which predispose some people to developing hand eczema.

MANAGEMENT STRATEGIES

Hand eczema is particularly challenging to treat, given that a lot of the management actually depends on lifestyle or workplace modification.

In Mrs B's case, she was initially not accustomed to wearing gloves during wet work or cooking. It took a lot of encouragement, effort and determination to show her the benefits of complete hand protection and the avoidance of irritants such as soaps and detergents.

She was also treated with anti-inflammatory creams and emollients. Family support is critical and reassignment of household chores may be all that is needed in some cases.

In other cases, patch testing of the skin with various chemicals is a very useful way to identify "hidden" allergies.

A cornerstone of treatment is the frequent use of moisturisers to protect and repair the damaged skin barrier.

These hand emollients need to be cosmetically elegant, hypo-allergenic and fragrance-free, but they should also be long-lasting and acceptable for each patient, since each of us has different considerations, depending on lifestyles and occupational needs.

A hand moisturiser that is too oily or occlusive may be inconvenient for daytime use, especially when we have to work, shake hands with others and type on our smart devices.

In addition, hand moisturisers with anti-perspirants, such as aluminium salts, may help decrease maceration (soggy wetness of the skin) of the hands, due to sweat or prolonged wearing of occlusive gloves.

Another important aspect of therapy is to target the inflammation or redness of the skin using prescription-only topical creams.

While many patients are understandably very concerned about using medicated creams containing steroids, the short-term use of such creams is not only effective but also necessary to bring the eczema under control and reduce the risk of infection.

Once controlled, the steroid creams can be tapered off and replaced with other non-steroid options. There are always good options available, even for recalcitrant cases.

Unfortunately, hand eczema tends to have a chronic relapsing course.

It is frustrating and troublesome.

But, as in Mrs B's case, working together with your doctor, employer and family can make a big difference in keeping your hands healthy and functional for life.

• Dr Tang is a consultant dermatologist at The Skin Specialists and Laser Clinic at Mount Alvernia Medical Centre (www.theskinspecialists.com.sg). He was formerly head of the Eczema Clinic and Director of Research at the National Skin Centre.

A version of this article appeared in the print edition of The Straits Times on September 20, 2016, with the headline 'Red, itchy and inflamed skin on the hands'. Print Edition | Subscribe