Live Blog: Hands, Feet, and Eyelids – Different Approaches to Regional Dermatitis. Faculty: Matthew Zirwas, MD
In this live blog from the Annual Fall SDPA Conference in Orlando, Matthew Zirwas, MD, presented a lecture on some helpful tips to diagnose and treat regional dermatitis called “Hands, Feet, and Eyelids—Different Approaches to Regional Dermatitis.” Here are some of the highlights.
Dr. Zirwas stressed that the most useful factor in diagnosing regional hand dermatitis is distribution. Is the dermatitis on the palm? Back of hand? Between the fingers? Morphology and if the area itches are also helpful clues.
HANDS – THE WHERE & WHAT
If the dermatitis is solely palmar (located just on the palm) the dermatitis is most likely endogenous, staph driven (which Zirwas calls nummular hand eczema), or a physical irritant (by a chemical contact or laborious/intense hand use).
If the dermatitis is primarily in the web spaces the dermatitis is likely a chemical irritant and/or caused by frequent hand washing.
If the dermatitis is primarily on the fingertips likely the source of irritation is frictional, from activities such as constant texting, video game playing or keyboard typing. Dr. Zirwas explained this is called “low perpendicular force friction” which happens when delicate skin is in frequent contact with a slightly textured surface such as paper and keyboards. In these cases, rather than developing callouses, the patient will experience a painful peeling of the skin.
If the dermatitis is primary located on the palm and the back of the hand the dermatitis is likely allergic contact dermatitis. This usually happens when the whole hand is being covered with a substance (gloves, washing or applying lotion to the hands). This is in contrast to irritant contact dermatitis which typically presents only on the back of the hand or in between the fingers.
If the dermatitis is primarily located on the dorsal/flexal wrist the dermatitis is likely chemical irritant contact dermatitis. The wrists are typically much more susceptible to chemical irritants than an area such as the palm.
HANDS – TREATMENT PEARLS
Steroids will prevent irritant hand dermatitis from healing even though it may make the hand feel better. The only true keratolytic is thiogylcolic acid which is found in such products like hair removal creams (such as Nair). With his patients, Dr. Zirwas recommended they thickly apply a thioglycolic acid product to their hands and then firmly wipe it off with a towel and then apply a steroid. This increases the penetration of the steroid by 40 times because the thioglycolic acid will remove some of the layers of the skin to allow the steroid to reach more deeply into the affected area.
Zirwas emphasized that the most important factor that determines efficacy of a moisturizer for hand dermatitis is frequency, which is much more important than what moisturizer is being used. Zirwas recommended that providers encourage patients to set a watch to beep every thirty minutes as a reminder to apply the moisturizer. Applying moisturizer four times a day won’t cut it. Zirwas also noted that waterless sanitizers are better than washing, but can be extremely painful on an irritated hand.
EYELIDS – THE WHERE & WHAT
Zirwas stressed that with eyelid dermatitis where it is located will be the most useful lead. If the dermatitis is asymmetric, likely infected hands rubbing the eyes are the source. Common causes are nail polish, acrylic nails, hand moisturizers and hand soaps. If the eyes have a symmetric dermatitis, it may be makeup.
If the dermatitis goes beyond the eyelids (neck, jawline), likely the cause of the irritant is coming from something that’s covering the whole face, such as soap and shampoo (the scalp is often immune to irritation) or hair dyes. Substances in make-up applicators can also cause allergic reactions (rubber and nickel).
Dr. Zirwas prefers to treat eyelid dermatitis with topical steroids, sans sensitives and avoiding irritants (consciously rinse the eyelids). He advocated washing the face with a gentle cleanser.
EYELIDS – TREATMENT PEARLS
Dr. Zirwas shared his treatment approach to eyelid dermatitis. If the dermatitis is chronic, continuous he will recommend TIC treatment. If the eyelid dermatitis is intermittent, he will recommend a steroid treatment. Dr. Zirwas noted there may be resistance to applying steroids to the eyelids for fear of causing cataracts, but he is comfortable with his patients using a Class 4 steroid for 15 days per month, taking half the time off from medication. Dr. Zirwas noted the importance of having the patient rinse the eyelids very well after washing their face.
FEET – WHERE & WHAT
Dermatitis on the dorsal region of the foot suggests there is a physical irritant – perhaps a contact dermatitis from rubbing the top of the foot.
Plantar foot dermatitis could be tinea, endogenous, psoriasis or ACD. Dr. Zirwas stated that he will treat for tinea to see if that is the diagnosis. It is also helpful to look at other regions of the body to see if the psoriasis is anywhere else. If the patient’s psoriasis is solely localized on the plantar foot, Dr. Zirwas suggested that the dermatitis is either allergic or endogenous.
FEET – TREATMENT PEARLS
Dr. Zirwas suggested that if you suspect the patient is suffering from an allergy related to the material of their shoe, have the patient bring all their shoes and do a thin shave biopsy of the all the shoe soles. Tape the sample to the patient’s back (like an allergy test patch) and see if any of the shoe samples give an allergic reaction.
During the treatment phase, Dr. Zirwas recommended that patients wear two pairs of socks: a smooth, synthetic sock with a cotton sock over it, while taking a non-allergic steroid. Finally, he advised providers to consider telling the patient to apply a glycopyrrolate to reduce sweating.
Image: Mark Spearman