Chronic hand dermatitis can be a debilitating problem for patients. Unlike eczema in other areas of the body, the hands have thick skin, and present differently. This is a summary of a 2017 article published in SkinTherapyLetter: Chronic Hand Dermatitis: Case-based Approaches to Management. It focuses on 4 real patient cases with chronic hand dermatitis, and their results from treatment with alitretinoin (Brand name: Toctino in Canada).
Chronic hand dermatitis affects up to 10% of the population and has a high impact on a patient’s quality of life. Both genetic and environmental factors are involved. Symptoms include redness, scaling, fissures (cracks in the skin), and itch and are often challenging to treat. These symptoms often recur despite standard topical treatment. These symptoms can cause severe distress to patients, and in many cases, affect their work productivity and sometimes the ability to work at all. This article reviews 4 patient cases studies using alitretinoin (Toctino) and sees what can be learned:
Case 1
Patient history:
- 39 years old – a dairy farmer
- A 15-year history of redness, scaling, and fissures on the hands
- Strong topical steroids used for years but only had temporary effects
- Skin scraping for fungal testing turned out negative
- The patient could not attend regular phototherapy sessions
Prescription: Alitretinoin 30 mg orally, once daily, for 6 months
Results: By week 12, hands were almost clear. By week 24, hands were completely clear. The medication was stopped after 6 months. At follow-ups 5 years and then 11 years later, the patient’s hand remained clear.
Case 2
Patient history:
- 52 years old – female teacher
- A 15-year history of chronic hand dermatitis
- Moisturizers and mild to super-potent steroids were attempted for years without success
- 6 months of narrowband UVB phototherapy with only partial resolution
- Notably, this patient has a history of obesity and hypothyroidism
Prescription: Alitretinoin 30 mg orally, once daily, for 6 months
Results: The patient response was excellent. Liver enzymes were 1.5 times the upper limit of normal and 2 months after initial therapy, increased to 3 times the upper limit, so the alitretinoin was discontinued.
Ultrasound demonstrated fatty liver, and further workup revealed diabetes. Metformin was started, and with 10kg of weight loss, the transaminases returned to within the normal range, but her chronic hand dermatitis flared. Phototherapy and superpotent topical steroids were tried again but were not effective. Alitretinoin was slowly re-introduced, first at 10 mg, then 20 mg, and then 30mg. A positive response was seen, and the patient’s transaminases have remained within the normal range throughout a continued 3-year course with alitretinoin.
Case 3
Patient history:
- 68 years old woman – retired and caring for her elderly husband
- Involved in lifestyle modification – applying emollients, avoiding excess hand washing
- Topical corticosteroid and calcineurin inhibitor has not been effective
- Affecting her ability to do chores, hobbies, gardening due to pain and fissures in the skin
Prescription: Alitretinoin 30 mg orally, once daily. The prescription was reduced to 10mg daily.
Results: Good response on the skin, but suffered from a frequent headache. The chronic hand dermatitis symptoms partially returned. A potent topical steroid and a course of narrowband UVB phototherapy were added to the 10mg alitretinoin.
Case 4
Patient history:
- 34-year-old mechanic
- 3.5 years with chronic hand dermatitis
- Medium to superpotent topical steroids and calcineurin inhibitors failed
- Contact dermatitis was suspected – testing revealed reaction to methylisothiazolinone (in wet wipes for diapers he used for a child and in soap at work)
- Modified lifestyle to minimize exposure to methylisothiazolinone helped somewhat, but the hand was not clear
- Concerned to jeopardize employment, and requested further treatment
Prescription: Alitretinoin 30 mg orally, once daily. Continued avoidance of methylisothiazolinone.
Results: Good response at 30mg. In this case, patch testing to identify the allergen also helped to minimize further irritation.
Important takeaways:
- Alitretinoin (9-cis retinoic acid) is an endogenous retinoid (physiological vitamin A derivative) and is the only systemic agent approved for chronic hand dermatitis.
- It has been proven to be effective and safe both in clinical trials and in real-life doctor/patient experience.
- The majority of patients do not require long-term treatment. Some patients enter a remission period after 24 weeks. The majority of patients – among those who relapse and require treatment still recover retreating. For patients who require ongoing therapy, there are no safety concerns.
- Retinoids are potent teratogens (cause birth defects). Strict pregnancy prevention is necessary.
- Real-world experience (outside of clinical trials) has shown that combination therapy with UVB phototherapy can be beneficial and safe.
- Chronic hand dermatitis can occur with contact dermatitis, and these may be related. Patients should be referred to patch testing to confirm this.
Conclusion:
Chronic hand dermatitis has a significant impact on the quality of life and can be debilitating and cause disability. Many patients do not respond well to standard treatments, and it remains a challenging condition to manage.
Alitretinoin being added to the treatment options has changed the outlook for many patients, improving their ability to work and significantly improving their overall quality of life. Additional critical factors include: Confirming the diagnosis, assessing adherence, counseling patients on avoidance and prevention strategies, encouraging regular moisturizing, and referring to patch testing if contact allergy may be involved.
Resources for help for concerned patients: https://eczemahelp.ca/
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1Thyssen JP, et al. Contact Dermatitis. 2010 Feb;62(2):75-87.
