Hand eczema is a common problem and when it occurs near the nail matrix it can produce a wavy nail. Eczema is so common that you probably have several current clients who have it. The lesions that distinguish this disorder can vary from fine scales to deep blisters that may be filled with fluid. Lesions are itchy, and the deeper they are the more they itch.
Hand eczema (also referred to as dyshidrosis or pompholyx) is sometimes accompanied by similar changes on the feet, or just the feet may be affected. Most cases of eczema on the foot are mistaken for athlete’s foot. The nails are most often affected by more severe outbreaks. Fingernail changes are common, but toenail changes are rare.
It’s difficult to tell whether the patient’s condition is eczema or allergic contract dermatitis just by looking at the lesions because the disorders look similar. I often ask these patients if they have any skin allergies, especially to jewelry containing nickel or chrome, which are common sensitizers. A history of rubber allergy would also raise questions about its possible role in the rash.
When the eczema starts under a ring it may be caused by a metal allergy. However, soap can also accumulate under a ring each time the patient uses a soap solution, such as dishwashing detergent, which can irritate sensitive skin enough to cause a rash, eczema is only on the hands and feet and so a rash elsewhere requires a more thorough search for an allergen. If the skin around earrings or watch also breaks out, it is a clue that the person has a contact allergy to metal.
People with hand eczema are highly susceptible to irritation. Irritating chemicals can cause an eczema flare up. Patients with an active rash will react to even mildly irritating solutions. It’s amazing how few people read the instructions on dish soap - most people use it at a much greater strength than the recommended concentration. I always ask the patient about her work, hobbies, and amount of house-work to find a source of the problem.
If there is a chemical irritation in one area, the lesions will appear and gradually move outward, appearing to spread. This is not a sign of infection, only a change in the local nerves and blood vessels.
This is often diagnosed in correctly as ringworm (a fungus). One of my laboratory workers would break out any time she got acetone on her hands.
In general, solvents are bad for hand eczema. Cosmetologists who work with irritating chemicals often are plagued by this disorder.
When the eczema occurs near the cuticle it causes inflammation near the matrix. This inflammation can cause the nail to be wavy. This is often blamed on “nerves.” There is no doubt that stress aggravates the process, but I emphasize to the patient that her skin is just reacting abnormally to the chemical we all produced under stress.
I explain that there isn’t anything wrong with the central computer (the brain), but that the peripheral equipment (the skin of the hands) is malfunctioning. This is an important distinction to me because I think it is unfair to blame a process we do not understand on the patient, who may interpret the outbreak of the rash to mean she cannot handle stress. When the patient hears this all the time, she begins to believe it. I prefer to tell her, based on my scientific knowledge that the skin is just responding abnormally.
When an eczema attack occurs suddenly, the best treatment is to soak the hands in a mixture of one part bath oil to 10 parts cool water. Plain cool water is the second best treatment. The low temperature reduces swelling and inflammation while the oil increases the permeability of the skin to let the fluid out of the blisters without causing as much destruction. I the fine scale, peeling type of eczema or between flare-ups of the more inflammatory type, lubricants, such as hand creams, help protect the skin from minor irritation that cause the eczema to spread.
The skin will become more prone to irritation during an eczema flare-up, so even soaps or other chemicals that normally would not irritate the skin will then add to the problem. It is also common for the lesion around the group of blisters to become more prone to irritation and the lesion will appear to get bigger. This often causes patients to think the condition is fungal disorder.
Advise the patient to wear protective plastic gloves. Rubber glove can cause contact allergies that look very similar to eczema.
The skin of the hand is very thick, so over-the-counter cortisone preparations won’t work on hand eczema. In fact, after habitual use over-the-counter preparations, a patient may require strong topical cortisones during flare-ups. Clients will appreciate your advice on how to prevent flare-ups or how to treat acute flare-ups. Although you can’t cure this ailment, your sensitivity will be a comfort to clients.
For reprint and licensing requests for this article, Click here.