Treatment of severe, chronic hand eczema: results from a UK-wide survey

Abstract

Article:Smith, IL, Brown, S orcid.org/0000-0002-1840-3786, Nixon, J orcid.org/0000-0003-1705-7698 et al. (11 more authors) (2017) Treatment of severe, chronic hand eczema. Results from a UK-wide survey. Clinical and Experimental Dermatology, 42 (2). pp. [185][186][187][188] https://doi.org/10.1111/ced.13015 © 2016 British Association of Dermatologists. This is the peer reviewed version of the following article: "Smith, I. L., Brown, S., Nixon, J., Cowdell, F. C., Ersser, S., Fernandez, C., Goodfield, M., Green, C. M., Hampton, P., Lear, J. T., Smith, C. H., Sunderland, L., Tubeuf, S. and Wittmann, M. (2017) ReuseUnless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version -refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher's website. TakedownIf you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. AbstractTreatment of severe hand eczema (HE) which is resistant to topical potent corticosteroid treatment is challenging. In 2013 we surveyed 194 UK dermatologists to obtain information about usual treatment pathways to inform the choice of the comparator in a trial of alitretinoin in severe HE (ALPHA trial); the results indicate that treatment approaches differ among UK dermatologists. Psoralen combined with ultraviolet A (PUVA) and alitretinoin were identified as the most frequent first line treatment options for hyperkeratotic HE, whereas oral corticosteroids were identified as frequent first line treatment for vesicular HE, followed by PUVA and alitretinoin. In terms of potential side effects of long-term or repeated use, oral steroids and ciclosporin A were reported to cause most concerns. There is uncertainty about which treatment gives the best short and long-term outcome due to a lack of definitive randomised controlled trials evaluating the effectiveness of different treatment pathways in severe HE.

An observer-blinded randomized controlled pilot trial comparing localized immersion psoralen-ultraviolet A with localized narrowband ultraviolet B for the treatment of palmar hand eczema

“…The introduction of an effective licensed oral agent for HE, alitretinoin, may also lead to a reduced demand for phototherapy. The U.K. National Institute for Health Research is currently conducting the ALPHA study comparing PUVA vs. alitretinoin, and these results may also have a big impact on treatment choice and the current widespread use of phototherapy for HE . For these reasons, the need for a definitive noninferiority trial of NB‐UVB vs. immersion PUVA will be reviewed following the results of ALPHA.…”

Management of chronic hand and foot eczema. An Australia/New Zealand Clinical narrative

“…(see Key points – Specific treatments). Systemic corticosteroids: Despite almost no clinical trial data, oral corticosteroids remain very popular in the treatment of chronic hand/foot eczema, in particular for the vesicular subtype 8,16 . A 2012 review advised that oral corticosteroids should only be used for one week 3 .…”

“…In a 24 week, open‐label trial of 118 patients with chronic hand eczema comparing alitretinoin and ciclosporin, 68.2% and 40.9% respectively, was categorised as responders 86 Methotrexate: Despite no reliable data on the use of methotrexate in hand and foot eczema, it is often used as the first additional immunomodulator after topical therapy, phototherapy, retinoids and systemic corticosteroids 8 . A retrospective review of 42 Dutch patients with chronic hand eczema treated for a median of 139 days found 37% had a good effect on the Physician Global Assessment (PGA) after 8–12 weeks 87 …”

Chronic hand eczema and hepatogenic pruritus with good response to apremilast

“…There are publications that defend the use of classic oral retinoids such as acitretin (Song et al, 2017), and more recently, as the only drug with recommendation grade IA, alitretinoin (Al-Dhubaibi & Settin, 2018;Blair & Scott, 2016). Other publications have reported those therapeutic preferences (Smith et al, 2017) by different dermatologists, which also include phototherapy or methotrexate. The comorbidities of the patients and the side effects of the treatments sometimes require prescribing other treatments off label on the technical data.…”