Eczema on Hands and Feet

Eczema is a very non-specific term. It is often used as being synonymous with dermatitis that simply means inflammation of skin.

• Acute pompholyx eczema Pompholyx is also called dyshidrotic eczema or vesicular hand eczema. On the hands it is called cheiropompholyx and on the feet it is called pedopompholyx.
  On the palms or soles it often starts as tiny vesicles deep under the skin, described as like 'sago'. If severe, the vesicles may coalesce to form tense bullae. Eventually these burst to release exudate to the surface with subsequent formation of erosions. Eventually crusting occurs followed by healing or new lesions breaking out.
  Severe pompholyx around the nail folds may cause nail dystrophy, resulting in irregular ridges and chronic paronychia.
• Subacute Eczema on Palms and Soles: This presents as erosions, crusting and some exudate, but often the vesicles are not seen.
• Chronic Eczema on Palms and Soles: This results in excessive scaling or keratinization. Thick keratin or scale forms, which prevent easy movement of the hands and fingers resulting in painful fissures.
• Dorsum of Hands or Feet: Acute or subacute eczema presents as weeping, erosions and crusting. Chronic eczema is dry, scaling and may show chapping with shallow erosions if contact with irritants has occurred.

Hand and foot eczema may be classified as endogenous or exogenous although the aetiology may be mixed.

Exogenous eczema

Contact irritant dermatitis may result from any weak acid or alkali, including detergents, shampoos and cleaning materials. It may result from foodstuffs, oils and greases. These may affect the dorsum of the hand first, but prolonged use over months or years leads to involvement of the palms.

Contact allergy is due to a type IV hypersensitivity reaction and may be precipitated by such substances as formaldehyde, rubber compounds, preservative in creams or cutting oils. The eczema should only occur at the site of contact. This will be the soles from rubber in shoes but all over the hands from creams.

Endogenous Eczema

Endogenous eczema occurs when internal factors that are usually unknown, precipitate the eczema. Pompholyx eczema is usually endogenous, but is more common in hot climates. Atopic individuals are susceptible to hand eczema especially if exposed to irritants.

• Irrespective of the cause, continued contact with irritant substances will make any hand or foot eczema worse. This may mean taking time off work for engineers, cooks, hairdressers and others and possibly a change of employment. Advising a change of job is not to be taken lightly. The patient may have trained for years for that job, enjoys it and earns a good living. Alternative employment may be much less satisfactory. Nevertheless, if eczema is becoming chronic it may be necessary.
• Treat blisters, exudate or erosions by soaking the affected part in potassium permanganate solution 4 hourly until it is dry. Potassium permanganate is available as crystals or in a 1:1,000 solution. The strong solution is purple in colour but a few drops should be put into a basin to produce a light pink colour. If the solution is too strong, brown staining will occur.
• Apply a potent steroid cream or ointment twice a day until the condition remits. A potent form is required for such tough skin, especially the palms and soles. No steroid cream will suppress the eczema if the causative agent is not removed. Steroid creams may be applied under occlusion. There is some doubt as to whether the usual twice daily application of steroid creams is superior to just once daily application.¹ The latter may be more convenient and cheaper.
• Tacrolimus may be considered for moderate or severe atopic eczema for adults, or children over 2 years old, if the maximum strength and potency of topical corticosteroid has been adequately tried and has failed or where there is serious risk of important side effects from further use of topical corticosteroids.² This would normally be undertaken by a dermatologist.
• Hyperkeratotic plaques may be treated with 2-5% salicylic acid ointment, which can be applied at night under polythene occlusion. Beware of irritating normal skin.
• Avoid soap and detergents and wash hands using a moisturiser such as aqueous cream or emulsifying ointment. Regularly apply a moisturiser for dry skin between steroid applications. Protect hands when doing wet work with rubber or PVC gloves or cotton gloves for dry work.

If the offending irritant can be avoided, then gradual improvement may occur over about 6 months but some will still have troublesome eczema.

If exposure continues, then the outlook is very poor. Cement dermatitis is due to the chromium content and it produces a very nasty dermatitis that often continues even after stopping exposure. This may make the patient think that he gave up a lucrative job such as brick laying in vain. This is not true and had he not stopped the skin would be very much worse.

Most patient with hand and foot eczema should be patch tested to establish a cause. Diagnosis of irritant and contact dermatitis on clinical grounds alone is unreliable.³

An expert opinion may also be requested when an important decision has to be taken such as change in occupation that has taken years of training and provides a good income.