Differential Diagnosis

Etiologic Classification
Comment
Irritant contact dermatitis (ICD)
  • Chronic exposure to irritants (mild toxic agents) causing skin inflammation, impaired skin barrier function, and development of contact allergy
  • In most patients there is a history of “wet” work (contact with soaps or solvents) or prolonged use of occlusive gloves
  • Diagnosis is often based on the absence of contact allergy (negative patch testing)
Atopic dermatitis (AD)
  • Patients often have a history of asthma, hay fever, or childhood AD
Allergic contact dermatitis (ACD)
  • Delayed-type, T-lymphocyte–mediated contact allergy to a chemical substance
  • Typical hand contact allergens include nickel (e.g., cell phones, tools, or jewelry), potassium dichromate/chromates (e.g., in leather or cement), rubber additives (including thiuram mix, carba mix, paraphenylenediamine [PPD], and mercaptobenzothiazole, often in gloves), cobalt chloride, and preservatives (e.g., in creams or cosmetics)
    • Cigarettes - may contain contact allergens in filters, paper, tobacco, menthol (mint, peppermint), licorice, colophony, formaldehyde
    • Hand jewelry ACD vs. "Wedding ring rash" occlusion dermatitis due to irritation from the buildup of soap, moisture, and debris underneath the ring
  • Diagnosis is supported by a history of exposure plus positive reaction to patch testing with contact allergens
Protein contact dermatitis
  • Frequently occurs in patients in professions involving food
  • Subtype of allergic contact dermatitis.
    • Initially, the reaction to proteins is contact urticaria, but eczema may develop. IgE reactions to specific proteins are often detected with SPT or sIgE
    • Latex allergy is a related phenomenon
Hybrid hand eczema
  • Combination of above

  • Differentiating ACD vs. ICD vs. AD: Location on hand can provide clues:
    • Dorsal hand and finger combined with the volar wrist suggest AD
    • ICD commonly presents as a localized dermatitis without vesicles in the webs of fingers; it extends onto the dorsal and ventral surfaces (‘‘apron’’ pattern), dorsum of the hands, palms, and ball of the thumb
    • ACD often has vesicles and favors the fingertips, nail folds, and dorsum of the hands and less commonly involves the palms

Morphologic Classification
Comment
Recurrent vesicular hand eczema (aka pomphpolyx, dyshidrotic eczema)
  • Recurrent vesicular eruptions on the palms and the palmar and lateral sides of the fingers (often also have eruptions on the soles of the feet)
  • A contact allergic reaction or atopic hand eczema may also be manifested as an identical vesicular eruption
Hyperkeratotic hand eczema
  • More common in middle-aged and elderly persons and in men
  • Sharply demarcated areas of thick scaling or hyperkeratosis on the palms (and frequently on the soles) often with painful fissures (vesicles are absent)
  • Differential
    • May be confused with psoriasis, but there is little or none of the redness and none of the scaling or nail changes typical of psoriasis
    • Lichen planus - may mimic hyperkeratotic hand eczema
Chronic fingertip dermatitis or pulpitis
  • Dry, fissured, scaling dermatitis of the fingertips, with occasional episodes of vesicles
  • On occasion, the cause may be a contact allergy
Nummular hand eczema
  • Round, coin-sized eczematous patches that appear on the back of the hands
  • May be a manifestation of ICD, ACD, or AD
Conditions with appearance similar to hand eczema
Comment
Psoriasis
  • Lesions are dry, scaling, and sharply demarcated, and there is an absence of vesicles
  • Lesions elsewhere on the body are characteristic
  • Palmoplantar pustulosis, a variant of psoriasis, should be considered when sterile pustules are present
Fungal infection (mycosis)
  • A fungal infection is especially likely when one hand is more prominently involved
  • Dry scaling of the palmar creases is characteristic
Scabies
  • Papules and burrows are present, likely to appear in the web spaces of the hands and the volar aspect of the wrists
  • Itchy papules are often present on the trunk and limbs
Granuloma annulare
  • Round or oval patches, with a demarcated raised edge, are characteristic and appear primarily on the dorsal side of the hands
Herpes simplex
  • Localized recurrent attacks of clustered vesicles, which are very painful but not itchy
Erythema multiforme, pityriasis rubra pilaris dermatomyositis
  • Not necessarily confined to the hands
  • In rare cases, reactive scaling and hyperkeratosis of the palms are associated with cancer or diet

Management

Hand eczema algorithm.png

References