Venous eczema affects the lower legs (Fig. 4) and is associated with underlying venous disease (p. 72). Incompetence of the deep perforating veins increases hydrostatic pressure in dermal capillaries. Pericapillary fibrin deposition impedes oxygen diffusion and leads to clinical changes.

Fig. 4 Venous eczema.

Clinical presentation

Most patients are middle-aged or elderly women. Leashes of venules and haemosiderin pigmentation around the ankles are early signs. Eczema develops, sometimes with fibrosis of the dermis and subcutaneous tissue (lipodermatosclerosis) and ulceration. Contact allergy to an applied medicament can complicate the picture.

Management

An emollient, alone or with a mild or moderately potent steroid ointment, is needed. Tar-impregnated bandages applied once or twice a week are useful, especially when ulceration coexists. Venous disease or ulceration is treated on its own merit (p. 72).

Hand dermatitis

Hand dermatitis is a common, often recurrent condition that varies from being acute and vesicular to chronic, hyperkeratotic and fissured. The condition results from a variety of causes, and several factors are often involved. In children, hand dermatitis is mostly due to atopic eczema. An atopic predisposition often underlies adult hand dermatitis, especially if caused by repeated exposure to irritants.

Allergic causes need excluding, and most adults with hand dermatitis require patch testing. Fungal infection is ruled out by microscopy and culture, especially in unilateral hand dermatitis, and the feet are examined because tinea pedis can provoke a hand dermatitis as an ‘id’ phenomenon (p. 58). A core of patients are left who have an endogenous recurrent hand dermatitis often characterized by sago-like vesicles on the sides of the fingers, on the palms and sometimes on the soles.

Clinical presentation

Hand dermatitis often presents as a chronic eczema, but may appear as a vesicular eruption known as pompholyx. Vesicles may be seen with atopic eczema or contact dermatitis but, in pompholyx, there is usually no associated disorder. The onset is in young adults, particularly in warm weather, and it is often recurrent. Involvement can be confined to a few microvesicles on the fingers, or it can be extensive with bullae affecting the whole hand (Fig. 5). Some of these patients are nickel sensitive.

Fig. 5 Acute pompholyx involving the entire palmar surface of the hand in a nickel-sensitive woman.

Management

Acute pompholyx requires drainage of large blisters and the application (once or twice a day) of wet dressings (e.g. immersed in 0.01% aqueous potassium permanganate or Burow’s solution of 0.65% aqueous aluminium acetate). Oral antibiotics are given if bacterial infection is present. Some dermatologists prescribe systemic steroids, but these are usually not necessary. Once the acute stage settles, potent or highly potent steroid lotions or creams are used with cotton gloves. For chronic or subacute cases, a steroid ointment and emollients are helpful. Advice for patients with hand dermatitis is given in Table 2. Alitretinoin (p. 34) has recently been licensed for severe chronic hand eczema refractory to potent topical corticosteroids.

Table 2 Hints on hand care for patients with hand dermatitis

Hand washing

Use warm water and unscented soap; avoid paper towels and hot air dryers; instead use a dry cotton towel.

Protection

Avoid wet work if possible, or otherwise wear cotton gloves under vinyl or nitrile gloves; wear gloves in cold weather and for dusty work.

Medicaments

Use emollients regularly throughout the day; apply steroid ointments twice a day.

Avoid handling

Shampoos, hair preparations, detergents, solvents, polishes, certain vegetables (e.g. tomatoes, potatoes), peeling fruits (e.g. oranges) and cutting raw meat.