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BackgroundHand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema.ObjectivesTo assess the effects of topical and systemic interventions for hand eczema in adults and children.Search methodsWe searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials.Selection criteriaWe included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments.Data collection and analysisWe used standard methodological procedures expected by Cochrane. Primary outcomes were participant? and investigator?rated good/excellent control of symptoms, and adverse events.Main resultsWe included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow?up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head?to?head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty?two studies were industry?funded.Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons.Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant?rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator?rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty.When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator?rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant?rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty.Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator?rated symptom control when compared to local narrow?band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant?rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow?band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty.Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator?rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant?rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well?tolerated application site burning/itching.A within?participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator? or participant?rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment.Evidence from these studies was rated as moderate certainty.Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator?rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant?rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty.Alitretinoin 10 mg improves investigator?rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant?rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate?certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high?certainty evidence). Outcomes were assessed between 48 and 72 weeks.Authors' conclusionsMost findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating.Well?designed and well?reported, long?term (more than three months), head?to?head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established.The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments.

Background: The efficacy and safety of methotrexate has been reported in a few clinical studies. The aim of this study was to identify the course of treatment with methotrexate in daily practice in patients with severe atopic dermatitis, with respect to reasons for discontinuation of treatment and side-effects. In addition we evaluated the effectiveness. Methods: Patient data (UMCG/UMCU, January 1997 - October 2013) were recorded in an Access database: patient characteristics; start/stop dates; subjective side-effects; objective side-effects (laboratory assessment); reasons to stop; retrospective Physician's Global Assessment (patients treated for at least 8 weeks). Results: A total of 46 patients (UMCG n=34; UMCU n=12) were treated with methotrexate (mean age 48.2 years). Eighteen patients still use methotrexate. The median treatment duration was 188.5 (11.0-1382.0) days, with a mean maintenance dose of 12.9 mg/week. The main reason for discontinuation of treatment was side-effects in 14/28 (50.0%) patients: 3 patients with objective side-effects (increased liver enzymes); 11 patients with subjective sideeffects. Other reasons for discontinuation were nonresponsiveness 6/28 (21.4%) and remission 2/28 (7.1%). Overall, gastrointestinal symptoms were the most common side-effects in 13/46 patients. A good clinical response to treatment was found in 20/38 (52.6%) patients; moderate response in 11/38 (29.0%) patients; no response in 7/38 (18.4%) patients. Conclusion: Results of methotrexate therapy in daily practice are not as good as the results from clinical trials. A substantial percentage of patients discontinued treatment, mainly due to side-effects. More results from daily practice are needed to appoint risk factors for discontinuation and treatment failure.

Background: Tea tree oil is used as natural remedy, but is also a popular ingredient in household and cosmetic products. Oxidation of tea tree oil results in degradation products, such as ascaridole, which may cause allergic contact dermatitis. This study investigates the prevalence of sensitizations to ascaridole, the optimal patch test concentration and cosensitization of ascaridole and oxidized tea tree oil. Materials & Methods: 319 dermatitis patients were patch tested with ascaridole 1%, 2% and 5% and 250 of them were in addition patch tested with oxidized tea tree oil 5%. Results were read on day 3 and day 7 according to a patch test calibration protocol. Results: With an increasing ascaridole test concentration, the frequency of positive reactions increased: ascaridole 1%: 1.4%; ascaridole 2%: 5.5%; ascaridole 5%: 7.2%. However, also the frequencies of irritant and doubtful reactions increased, especially for ascaridole 5%. A positive reaction to ascaridole was related to a positive reaction to tea tree oil (p

Tea tree oil is used as a natural remedy, but is also a popular ingredient in household and cosmetic products. Oxidation of tea tree oil may result in degradation products, such as ascaridole, which may cause allergic contact dermatitis. We investigated the prevalence of sensitization to ascaridole, the optimal patch test concentration and we studied co-sensitization of ascaridole and oxidized tea tree oil. A total of 290 patiënts with eczema were patch tested with ascaridole 1%, 2% and 5% in petrolatum. Ascaridole 2% seems to be the most favorable patch test concentration based on the ratio of positive (5.5%), irritant (1.7%) and doubtful (4.1%) reactions. Six patients showed a positive reaction to oxidized tea tree oil. All patients with a positive reaction to tea tree oil showed a positive reaction to ascaridole. This finding suggests that ascaridole is contact allergen in tea tree oil. A total of 24 patients showed a positive reaction to ascaridole without a positive reaction to tea tree oil. Six out of these 24 patients were exposed to tea tree oil en developed eczema after using products containing tea tree oil. Patch testing with ascaridole elicits clinically relevant positive reactions, which are missed by patch testing with tea tree oil alone.

Background: Allergic contact dermatitis to isobornyl acrylate has been reported in only two cases in literature. Therefore, isobornyl acrylate is not part of a (meth) acrylates patch test series. At our department an industrial worker presented with therapy-resistant hand eczema and sensitizations for various non-relevant acrylates. After scrupulous examination of his work area and an expanded patch test series, isobornyl acrylate 0.1% turned out to be the unexpected allergen. Objectives: (i) To investigate whether it is relevant to add isobornyl acrylate to the (meth) acrylate test series at our department. (ii) To determine the correct patch test concentration. (iii) To study whether there could be cross-reactivity with other acrylates. Methods: Patients with a proven acrylate sensitization, diagnosed between 1-1-2000 and 1-1-2012, were selected from the database of our department. Included subjects were patch tested with a dilution series of isobornyl acrylate (0.3%, 0.1%, 0.033% and 0.01% in petrolatum). Readings were performed on D2, D3 and D7 and graded according the ICDRG guidelines. Results: Twelve subjects were patch tested with the isobornyl acrylate dilution series. None of them showed signs of sensitization. Three subjects (25%) showed an irritant reaction on D3 to the isobornyl acrylate 0.3% dilution. Conclusion: We showed an additional rare case of allergic contact dermatitis to isobornyl acrylate. Cross-reactivity with other acrylates could not be demonstrated in this small group of patients. This study provides insufficient support for isobornyl acrylate to be added to a (meth) acrylates patch test series. The ideal patch test concentration seems to be 0.1%.