Saturday, January 03, 2009

Magic Cure?

Abstract: 45 yo man with two year history of painful fingers
Posted by DJ Elpern
HPI: The patient is a 45 yo electrician and professional pianist who developed hyperkeratotic patches on his hands two years ago. Nothing new in exposures. After much questioning, he remembered that his mother-in-law moved in with them around that time. (not kidding). The fissures are very painful, especially when playing keyboard. He can use gloves doing electrical work. Patch testing has not been done but is planned.
O/E: Hyperkeratotic areas around thumb and middle finger tips bilaterally. Fissures are deep but clean. He has had similar areas on thenar and hypothenar eminences in past. Remainder of cutaneous exam is unremarkable.
Photos:






Diagnosis: Hyperkeratotic Hand Eczema, Psoriasis variant? Fristional Contact Dermatitis
Treatment: He has tried potent topical steroids with occlusion and with the Soak and Smear technique. Crazy glue for fissures. Intralesional triamcinalone 10 mg/cc helped the palmar keratoses. He has had one month of methotrexate 10 mg per week. Only the intralesional TAC has helped but he does not want finger tips injected at this time.
Questions:
1. What do you think the diagnosis is? The role of trauma may be key as he works with his hands as an electrician and his fingers are "traumatized" on the keyboard.
2. Do you have any magical therapeutic suggestions?
3. I have heard that X-ray treatment was used in the past. Any rational for Grenz?
4. Further work-up
Reason Presented: This man is at his wit's end with pain. He can't play the piano since every time he hits a key he has exquisite pain. I have had one or two similar patients -- they just got better over a few years seemingly not related to treatment.
Reference:
E. McMullen, D.J. Gawkrodger, Physical friction is under-recognized as an irritant that can cause or contribute to contact dermatitis. Br J Dermatol. 2006:154;154-156
Department of Dermatology, Royal Hallamshire Hospital, Sheffield U.K.
Full Text of Article
Background The role of physical friction as an irritant in the causation of contact dermatitis is under-recognized. Frictional dermatitis is defined as an eczematous process in which physical frictional trauma contributes to the induction of a dermatitis process.
Objectives To examine the clinical background of patients in whom friction was contributing to dermatitis.
Methods Over a 30-month period during which 2700 new patients were seen, frictional irritancy was identified as playing a role in the dermatosis in 31 cases: in 27 of these, case notes were evaluated for a range of parameters.
Results Physical friction was identified as causing or contributing to the dermatitis in 18 men and nine women, mean age at onset 42 years. The hands, usually the fingers of the dominant hand, were affected in all but two cases. Occupational frictional activities were found in 25 cases: commonly handling small metal components, paper, cardboard or fabric, and driving. Potential frictional activities in hobbies were noted in 12 cases. Wet work irritancy contributed in four cases (15%). Patch testing showed relevant contact allergies as cofactors in seven of 25 subjects tested (26%). Psoriasis was a cofactor in four (15%), and atopic dermatitis in 11. The study was selective, being based in a teaching hospital clinic with a special interest in contact dermatitis. Frictional irritancy is often one of several factors contributing to dermatitis.
Conclusions The contribution of friction to contact dermatitis is under-recognized probably because dermatologists do not think about the potential for physical forces to induce eczematous changes in the skin.




14 comments:

  1. Henry FoongJanuary 03, 2009

    This looks like hyperkeratotic eczema but frictional contact dermatitis a good thought. I have similar cases – and you can imagine the frustrations treating these disorder. I don’t have any magic bullet for this. I used a lot of moisturizers during daytime, topical diprocel ointment at night occasionally dermovate ointment ( but beware of atrophy). I have given up MTX for this condition – it does not help much and the side effect not worthwhile. I don’t think it is psoriasis.   I also had a patient with ‘hyperkeratotic eczema affecting the palms mainly and patch test was positive to ceto steryl alcohol. So I think a patch test is worth doing to uncover unsuspecting allergens.

    A colleague of mine used acetretin 20mg 2 x weekly and the patient found it useful and helpful.  For your patient – I would do a patch test and if negative, I would do like the above and perhaps add acetretin 20mg 2x weekly to reduce the hyperkeratosis esp in non reproductive females. A daily dose would produce too much side effects like cheilitis. Topical Prophylene glycol is also very helpful I find.

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  2. Lisa ScatenaJanuary 03, 2009

    I favor a diagnosis of HK dermatitis, that said, perhaps I have just underdiagnosed frictional dermatitis. Similar patient who was a plumber. Patch testing unremarkable. Failed adequate trials of clobetasol under occlusion, methotrexate and soritane. Presently on Enbrel-doing well.

    Lisa Scatena, MD FAAD
    Assistant Prof Univ of Colorado
    Rocky Mountain Dermatology
    Boulder, CO

    ReplyDelete
  3. First of all Happy new year to all.
    I also think it's a HE.
    I am never treat HE with acetretin but i will try it in future.Thanks Henry for the information.

    2 years ago I was try to treat 2 patient with HE with Dapsone and i had seen good effect.Also as a topical treatment i gave them Hydrocortisone with urea(Calmurid HC) for a month and after that Synalar ointment for another one.I don't know if was the Dapsone which was work or the topical treatment but the point that i had seen good results.

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  4. Would be interested in seeing results of patch testing. Consider cyanoacrylate glue (Krazy Glue) to seal the painful fissures.

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  5. For me this is a variant of psoriasis but I would always do patch testing to avoid missing a relevant contact allergen. I think stress can precipitate this condition. Try tars under occlusion or hand PUVA using a topical psoralen solution and UVA light. Good protection from irritants required all the time though and some silver nitrate for the cracks ( color goes well with the tar!)
    Encourage the mother in law to go into a home- bit drastic though but try a session of respite care first!)
    Joking aside this is a difficult condition to treat in the abscence of a relevant contact allergen.

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  6. The ddx for hyperkeratotic fissured finger tips would be psoriasis, irritant(frictional in this case)contact dermatitis, and chronic finger tip eczema. I agree with Ian that its a difficult condition to treat. Avoidance of trauma, topical emollients, and potent topical steroids usually lead to clearance of the lesions but the condition recurs with discontinuation of treatment.

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  7. I agree with Rick Sontheimer... definitely would go with Super Glue (Crazy Glue) after patch testing.

    In my prior life (private practice, when I had the machines) I would have used Grenz therapy!

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  8. I would have him continue to use super glue for the fissures and also have him use codran tape at night.
    Could his mother n law be cleaning the piano with something or is there some other new chemical that is leading to a contact dermatitis.

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  9. Helge RiemannJanuary 05, 2009

    I would do patch testing, as planned, because I think ACD is possible (metals in wires or breaker boxes, or resins from insulation/housings, and I believe some wires contain
    colophony between the wire and the plastic insulation). Did you consider acitretin?

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  10. Fran StorrsJanuary 05, 2009

    Totally agree with your analysis. This is a fully under- appreciated condition. In absence of vesicles or itching, I don’t even patch test these people.

    Grenz ray is very helpful, as is tar, and sal acid in aquaphor. PO retinoids when all else fails but protection is at the base of therapeutic efficacy as you say.

    One of our residents just looked at these people’s mediator expression and tho it is like psoriasis ( increased IL 23 and 12) we all agree that clinically it is a different entity.

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  11. Well,being a professional pianist and electrician, contributes to the aetiology of friction to contact dermatitis. However, Psoriasis cannot be totally ruled out.
    Absolute resting and avoidance of friction of the finger tips should help to heal the condition.However, once everything returns to normalcy, may be he needs to modify his lifestyle as these frictions can again precipitate this condition.

    Shardul Poudyal

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  12. I have this exact same problem. I have never been given an offical "name" per se, however my hands look just like the one in this picture.

    I am an Administrative Assistant by trade. I've had this problem on and off for the last 4-5 years. My dermatologist has given me some type of cortisone shot which almost immediately alieviates my problem.
    I have used some topical solutions (names escape me right now) which help reduce but not alieviate the problem.

    It is worse on my dominant hand, however I do have some on my left hand as well. I've noticed it gets worse the more stress I'm under.

    Food for thought from a patient perspective.

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  13. My husband works with crop fertilizers (pot ash, which is KCl, is the biggest dermatologic culprit) and this is how both his hands look every winter when the weather gets dry. He gets large fissures in his finger tips and knuckles which bleed when neglected. He wears rubber gloves under his leather gloves, but the chemicals are ubiquitous at certain times of the year. It is very painful and can be debilitating for people that work with their hands. The problem is lots of people who work with their hands are very reluctant to stop working to let their hands heal.

    We have used everything OTC and finally found a regimine using OTC products that works magic:

    Every morning he applies a thin layer of Eucerin cream to the areas most likely to crack (knuckles and certain fingers) and allows it to soak in for 20-30 minutes while he gets things round for the morning or drives to work. The key is to do it between showering and exposure to the winter wind outside.

    As needed, after a warm shower but before bed, he will completely slather both hands in Eucerin cream and cover them with plastic sandwich (ziplock) bags, zipped shut to the wrists. The bags always fall off throughout the night and he wakes up with nice smooth hands. We do this 2-4 times per week.

    If he neglects his hands and gets bleeding fissures again, he uses tissue glue from the clinic and does the overnight bag treatment a few nights in a row. He also loves Eight Hour Cream because it does not burn open sores, but it is expensive so he uses it sparingly for smaller cracks overnight.


    Hope this helps! I love your online derm rounds!

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  14. 1) What do you think the diagnosis is?
    Psoriasis, palmar psoriasis presents with hyperkeratotic plaques and though the pictures show u havent mentioned fissuring. Fissuring is more a feature of palmar psoriasis than hand eczema.
    2) Side-effects on the fingers from super-potent topical corticosteroids are rarely reported. One suspects that they are not that unusual. When does the treatment get worse than the disease? (I should have been more diligent in follow-up)
    Palmar skin is thicker if you compare it to skin at other places on the body, side effects are rare
    3) Who thinks that these preparations can cause bone changes?
    Your comments will be appreciated.
    Bone changes are more due to ingested steroids compared to topical ones.
    I'd say a preparation of salicylic acid along with clobevate oint and emulsifying was will help. For the cuts they could be filled with gentamycin+ hydrocortisone cream.

    ReplyDelete

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