Careful examination of the skin and nails is an important part of the physical examination of the hand. Skin lesions can provide important clues to the diagnosis of systemic conditions, which can affect the joints. In addition, skin disease can affect wound healing and surgical outcomes. This chapter will cover basic clinical features and treatment of common cutaneous conditions, which the hand surgeon is likely to encounter and be called on to recognize.
I. Eczema (Fig. 34.1)
Hand eczema is a common cause of discomfort and disability. It is most common in atopic individuals, but many patients experience the onset of symptoms in adulthood and have no prior history of eczema.
Hand eczema is characterized by erythema and scaling of the palms. The involved areas may be hyperkeratotic and crack easily. Patients often complain of pruritus and/or pain from fissures.
Pompholyx, or dyshidrotic eczema, is a form of hand eczema that presents with deep-seated vesicles on the lateral fingers and hands.
The clinical features of hand eczema overlap with contact dermatitis. It is important to perform a careful history and consider patch testing to evaluate for environmental allergens or irritants that could be exacerbating the condition.
First-line treatment involves topical steroids depending on the severity of disease. Topical steroids may be used with occlusive dressings for limited time periods to increase their penetration and efficacy. Patients who are not responsive to topical treatment may require treatment with short courses of oral prednisone or steroid-sparing agents.
Skin care is essential to decrease the severity and frequency of flares. Patients should apply thick creams or ointments (i.e., petroleum jelly) as often as possible throughout the day and particularly after washing hands. Gloves should be worn for all wet work. Alcohol-based hand sanitizers should be avoided in favor of mild soaps. It is important to instruct patients that this is a chronic condition and emphasize that these measures are an important part of their treatment.
II. Contact Dermatitis (Fig. 34.2)
Allergic contact dermatitis is caused by a delayed-type (type IV) hypersensitivity reaction. It occurs 24 to 48 hours after re-exposure to an allergen.
Irritant contact dermatitis is a nonspecific inflammatory reaction and may occur on first exposure to a chemical.
Acute lesions are erythematous, edematous plaques, which may become vesicular. Scaling and lichenification characterize chronic lesions.
Pruritus is a prominent symptom.
Contact dermatitis often involves the dorsal hands. This may help to differentiate it from hand eczema, which is generally confined to the palmar surface and lateral edges of the hand.
In a recent study, the compounds most commonly implicated in allergic contact dermatitis of the hand were quaternium-15, formaldehyde, nickel sulfate, fragrance mix, thiuram mix, balsam of Peru, carba mix, neomycin sulfate, and bacitracin.
Patients with suspected contact dermatitis should be referred to a dermatologist for patch testing if an etiologic agent cannot be identified by history.
Topical steroids are the mainstay of treatment. Patients must also be educated to avoid all substances containing the causative chemical, if one can be identified. Short course oral steroids tapered over 2 to 3 weeks may be necessary to manage severe flares.
Psoriasis is a Th1-mediated immunologic disorder that results in an abnormal increase in the rate of keratinocyte proliferation.
It classically manifests as well-demarcated erythematous plaques with thick, silvery scale. On the hands, it may present with palmar scaling and hyperkeratosis that is difficult to distinguish from eczema. Psoriasis can also present pustules on the palms and soles.
Patients may have localized disease limited to the hands or hand involvement in the context of generalized disease. Other common sites for psoriasis are the extensor elbows and knees, scalp, and nails. Typical lesions in these areas can help distinguish psoriasis from eczema.
Nail changes in psoriasis include onycholysis, pigmentary changes that resemble oil spots, subungual debris, and pitting. These changes can resemble onychomycosis.
Approximately 10% to 30% of patients with psoriasis will have some degree of associated arthritis.
Figure 34.3 Psoriasis. This patient’s lesions are symmetric. She also has similar plaques on her feet. (From Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders. 2nd Ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)
Figure 34.4 Psoriasis. This is the pustular variant of psoriasis. (From Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders. 2nd Ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)
Figure 34.5 Psoriatic arthritis. “Sausage finger deformity” of the distal interphalangeal joint. Note onycholysis. (From Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders. 2nd Ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)
Treatment depends on the extent of cutaneous disease and the presence of arthritis.
Topical treatment options for limited disease include the following:
Superpotent topical steroids can be used on the thicker skin of the palms and soles for acute flares.
Once the disease is controlled, topical steroids can be used intermittently alternating with calcipotriene or tazarotene to decrease the risk of atrophy.
Oral steroids may cause severe flares of psoriasis when discontinued, and they should be avoided in most cases.
Vitamin D analogue
Helps to regulate keratinocyte differentiation
May work synergistically with topical steroids.
Helps to regulate keratinocyte differentiation
Both UVB and psoralen with UVA (PUVA) are effective
For disease limited to the hands and feet, topical psoralen followed by UVA treatments can be effective. This avoids the side effects of oral psoralen and decreases UV exposure to uninvolved areas.