A scaly rash on the handsBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2252 (Published 28 March 2012) Cite this as: BMJ 2012;344:e2252
- H Reddy, specialist registrar1,
- A De Vittoris, general practitioner with specialist interest in dermatology2,
- S Wahie, consultant dermatologist2
- 1Department of Dermatology, James Cook University Hospital, Middlesbrough, UK
- 2Department of Dermatology, University Hospital of North Durham, Durham, UK
- Correspondence to: H Reddy
- Accepted 20 January 2012
A 30 year old mechanic attends with a scaly rash on both his palms. He describes cuts on his skin which are painful and affect his grip strength. This has caused him to have time off work.
What issues you should cover
Common causes of diffuse scaly rashes on the hands are eczema (atopic, irritant or allergic contact dermatitis, and pompholyx), psoriasis, scabies, and tinea. A patient can have more than one diagnosis (such as atopic eczema plus an occupational allergic contact dermatitis).
To help identify the cause(s) and effects of the rash, inquire about
Duration and evolution of disease
Presence of itch or rash elsewhere
Personal or family history of atopy (eczema, asthma, or hay fever) or psoriasis
Occupation and hobbies, and the impact of the rash on these
Suspected triggers and a review of work practices—particularly relevant for allergic and irritant contact dermatitis. Ascertain
What does the patient come into contact with at work? What is the duration from exposure to a suspected trigger to the rash flaring? Does the rash improve if the suspected trigger is removed or when the patient is off work? What is the frequency of hand washing?
Contacts with symptoms—relevant for scabies, although asymptomatic contacts do not exclude scabies in the index patient.
Pointers to diagnosis
Eczema is associated with itch, symmetrical erythema (redness), vesicles (small fluid filled lesions), scaling, papules (small spots), and lichenification (that is, accentuation of skin creases). Fissuring can occur and be tender. Fingernails might exhibit small depressions on the nail surface (“pitting”). Patients with atopic eczema might have signs in other flexural sites (such as forearms, backs of knees, eyelids, behind ears).
Irritant contact dermatitis presents with signs of eczema on the sides of digits and dorsal hands, particularly within finger web spaces. High risk employment (with exposure to solvents, detergents, etc) and frequent hand washing with soap and water are often implicated.
Allergic contact dermatitis presents with signs of eczema, but a clue to the diagnosis may come from the history. High risk workers include cleaners and healthcare professionals (use of rubber gloves), construction workers (cement use), and mechanics (contact with nickel, cobalt, and use of cutting oils). A geometric distribution matching the area of contact with the allergen is suggestive of the diagnosis (for example, a rash with cut-off at both wrists might suggest an allergy to rubber gloves).
Pompholyx eczema is an endogenous form of eczema (not caused by an exogenous allergen or irritant) on the palms or soles and presents with itch, vesicles, and scale.
Psoriasis is not usually itchy, generally symmetrical, and—in addition to erythema, scaling, and well defined plaques on the palms—can present with small, white, fluid-filled lesions (pustules) that become brown in later stages. Psoriasis should be looked for elsewhere (such as the elbows, knees, ears, scalp, umbilicus, soles of feet). Nail pitting can be accompanied by subungual hyperkeratosis (scale beneath the distal nail plate) and onycholysis (lifting of the distal nail plate).
Tinea of the palms can be itchy (but not always), be asymmetrical, have slow progression, and present with fine powdery scale of the palmar creases. Nail changes (such as onycholysis) or tinea elsewhere (such as the toenails, finger web spaces) can coexist.
Scabies should be considered in the presence of itch and burrows (wavy lines) on the palms, finger web spaces, or volar wrists with black or brown dots at the ends (representing mites). Examine other body parts (feet, genitalia, buttocks) to look for corroborating evidence.
What you should do
Empathy, reassurance, and patient information leaflets on hand care can help (available from Primary Care Dermatology Society website www.pcds.org.uk). If confident with the diagnosis, treat accordingly:
Eczema and psoriasis—Liberal use of greasy emollients as soap substitutes is important. Patients may require emollient pots (500 g) for home and workplace. Suspected allergens or irritants should be avoided if possible. Potent topical corticosteroids may be required for palmar involvement. Patients may fear the risks of topical steroids (such as skin thinning), so explain their potential benefit (a chance of rapid response and long term control) and effective use (how much to use, how to wean off slowly when the condition improves, and how to resume if the condition returns). Topical steroids can be applied under cotton gloves at night to improve penetration and disease control. One fingertip unit is the amount recommended to treat an area twice the size of an adult’s palm,1 and a 30 g tube applied to both palms daily may last an adult for two months, but quantities should be guided by disease severity.
Tinea—Take skin scrapings to confirm the diagnosis. Abstain from using topical corticosteroids and treat with an antifungal preparation. Often topical therapies are not sufficient and oral antifungal drugs might be needed.
Scabies—Appropriate anti-scabetic measures are needed for the patient and close contacts.
A patient with significant signs or disability should be reviewed within two to four weeks. If the condition shows no sign of improvement, consider whether the patient is compliant with treatment or if the diagnosis is correct.
Reasons for referral to specialists
Suspected allergic contact dermatitis, for patch testing
Cases of eczema or psoriasis that fail to improve with seemingly appropriate topical treatment; these might require phototherapy or oral therapies
When the diagnosis remains unclear
Primary Care Dermatology Society website. www.pcds.org.uk/clinical-guidance-and-guidelines/a-z-of-diagnosis. Contains information on hand dermatitis, pictorial examples, and patient information leaflets
NHS Clinical Knowledge Summaries. Clinical topics: skin and nail. www.cks.nhs.uk/clinical_topics/by_clinical_specialty/skin_and_nail. Evidence based information and practical, work based scenarios discussing the management of eczema, psoriasis, and scabies in primary care
Perry AD, Trafeli JP. Hand dermatitis: review of etiology, diagnosis, and treatment. J Am Board Fam Med 2009;22:325-30. doi:10.3122/jabfm.2009.03.080118
Cite this as: BMJ 2012;344:e2252
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.