itching hand

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Review Article

Submitted: 10.5.2012

Accepted: 3.7.2012

Conflict of interest

None.

DOI: 10.1111/j.1610-0387.2012.08002.x

“The itching hand“ – importantdifferential diagnoses and

treatment

SummarySkin diseases affecting the hands receive particular individual attention and constitute

a considerable emotional burden. Many dermatoses also present with itching of thehands. Itch is often underestimated when it occurs in a comparably limited body area

such as the hands. The high occupational significance of the hands in many profes-

sions must, nevertheless, be stressed. One of the most frequent diagnoses in itching

of the hands is eczema. In the differential diagnosis, less common diseases such as

neurological and systemic diseases and adverse drug reactions must also be taken

into consideration. Itching of the hands can also be accompanied by other sensations,

such as burning, stinging and pain. A thorough history regarding sensations and dy-

sesthesias already allows for a diagnostic classification of the disease in some cases.

Itching of the hands requires a careful and thorough diagnostic approach. This forms

the basis of a specific and successful therapy which may be adapted stepwise, depen-

ding on the underlying cause, and also may require, in addition to causal therapy,

symptomatic antipruritic therapy. Therapy should follow the current guidelines for chronic pruritus and hand eczema. This article reviews over the differential diagnosis

and therapy of “itching hands”.

Elke Weisshaar,

Ursula Kallen, Melanie Weiß

Department of Clinical Social Medicine,

Occupational and Environmental

Dermatology, University Hospital

Heidelberg, Germany

Background

Itching of the hands can occur in a multitude of dermato-

logical diseases. The most important differential diagnoses

include eczema, particularly atopic dermatitis (AD), psori-asis palmaris and other skin diseases such as lichen planus,

porphyria cutanea tarda and infectious skin diseases such as

tinea manus (Table 1) [1, 2]. Systemic diseases, neurologi-

cal disorders, and adverse drug reactions and even psychi-

atric disorders must also be considered. Rarely, congenital

diseases such as progressive familial intrahepatic cholestasis,

a disease with autosomal recessive inheritance, can explain

pruritus of the hands already in early childhood [3]. Segmen-

tal or unilateral pruritus affecting only one hand has been

reported in neurofibromatosis [4]. All of these diseases can

present in the daily dermatological routine under the comp-

laint of “itching hands” [1–4].

Chronic pruritus is defined as pruritus persisting over 6

weeks [2]. It is the most common symptom of dermatological

diseases such as eczema, urticaria and scabies with its origin

directly in the skin. Pruritus can also occur in various sys-

temic diseases such as uremia, cholestasis, neuropathic and

psychiatric disorders and can thus be triggered by hematoge-nous and neuronal mediators in the central nervous system

[1–4]. According to the current IFSI (International Forum for

the Study of Itch) classification of pruritus, 6 categories with

respect to etiology (dermatologic, systemic, neurologic, so-

matoform/psychosomatic, mixed and unclear) are differenti-

ated [2]. Pruritus may be associated with specific dermatolo-

gical lesions, with lesion-free, clinically normal skin or with

secondary scratch artifacts [2]. Pruritus of the hands can fall

into all of these categories and clinical variants and thus be

the result of a multitude of etiologic factors.

It has been shown that the impact on quality of life due

to chronic pruritus is comparable to the impact of the chronic



Review Article Pruritus of the hands

32 © The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1101

pain syndrome [5]. Pruritus and pain are complex sensations

with both common and differing signaling pathways and

characteristics [6]. The well-known observation that scrat-

ching-induced pain improves or temporarily abolishes pruri-

tus demonstrates this. Pruritus is a separate and independent

sensation with its own peripheral and central processing. No-

netheless, pruritus cannot be separated from pain from the

neurophysiologic perspective, because common processing

and signaling pathways exist. Recent studies, for example,

demonstrate that mechanosensitive pain neurons can trans-mit pruritus. In central imaging corresponding brain regions

can be activated by pain and pruritus, and pruritus-specific

brain regions do not appear to exist [6]. Possible differences

exist with respect to the activation of central motor areas.

The simultaneous motor activation in pruritus might corre-

late with planning the scratch response, while in pain, the

stimulated hand is retracted [6]. In a very recent publication

it could be shown that heat and pain sensations are stronger

in proximal body sites than in distal body sites, while the

sensation of itch behaves inversely and is thus more intense in

distal body sites such as the hands [7].

Mixed sensations can occur in diseases of the hands;

pruritus and pain can occur simultaneously or pruritus can

be perceived with burning, tingling and painful components.

Clinical examples are hand eczema with fissures, pustular

psoriasis (frequently pain or mixed sensations of pruritus and

pain) or neuropathies in brachioradial pruritus (BRP). In the-

se cases it is not sufficient to speak of pruritus of the hands.

Terminology that correctly describes these sensations has not

yet been developed. In such cases, both patients as well as

physicians speak of burning pain, itching pain or pruralgia.

Differential diagnoses and clinical features

Locations, morphology and symptoms (pure itch, mixed sen-

sations of burning and itch, dominance of burning and sharp

pain) can be of help in the differential diagnostic considera-

tions in pruritus of the hand. Unilateral hand involvement

may suggest tinea manus. The existence of erosions and fis-

sures clinically may explain pain or mixed sensations. The

latter can also indicate the neuropathic cause of BRP. It must

be remembered that other locations besides the hands must

be included in diagnostics. Therefore, the entire skin surface

including scalp and the oral mucosa must always be exami-

ned. Simultaneous involvement of the feet must be searched

for, which is frequently the case in dyshidrosiform hand and

foot dermatitis. Lesions on the entire body may reflect hema-

togenous allergic contact dermatitis or another specific skin

disease such as lichen planus or psoriasis.

Eczema

Hand eczema is the most frequent cause of pruritus of the

hands. Morphology, location and etiology are employed in

the classification of hand eczema [8–10]. Morphologically

erythema, vesicles, infiltration and scaling typify the initial

Table 1 Important differential diagnoses in pruritus of the

hands.

Eczemas

` Irritant (subtoxic-cumulative)

`Atopic

` Dyshidrosiform (particularly in atopic hand dermatitis,

but also in other dermatitis forms)

` Dyshidrosis lamellosa sicca

` Allergic

` Mixed forms of irritant, atopic, allergic

` Dyshidrotic hand dermatitis or hyperkeratotic-

rhagadiform hand dermatitis, constitutional

` Nummular dermatitis

` Protein contact dermatitis

Psoriasis

` Palmar/ palmoplantar

` Vulgaris (beware: inspection of further sites of predilection!)

` Pustulosis palmoplantaris (beware: inspection of the feet!)

Infectious diseases

` Fungal infection: tinea manus

` Bacterial infections

` Epizoonoses: insect bites, scabies, pediculosis, cimicosis

Lichen planus

Lymphomas

` Mycosis fungoides

` Other cutaneous lymphomas

Prurigo nodularis` Neuropathic cause, for example disorders of the

cervical spinal column

Rarer differential diagnoses:

` Neuropathic pruritus of the hands

` Adverse drug reaction

` Hand-foot syndrome

` Erythema multiforme

` Granuloma annulare

` Verrucae vulgares

` Syphilis stage II (rarely pruritus)

` Keratoma palmare et plantare

` Artifacts

` Precancerous lesions, malignant lesions: Bowen disease,

Bazex syndrome, radiodermatitis (rarely pruritus)




33© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1101

stage, while hyperkeratosis, fissures and lichenification of the

skin predominate in chronic disease. Further, a purely vesicu-

lar (dyshidrosiform) (Figure 1), a hyperkeratotic-rhagadiform

or nummular morphology may be present. Hand dermatitis

can be located on the dorsa of the hands, the palms, the sides

or the fingers, the fingertips, the interdigital folds and the

wrist [8–10]. In irritative (subtoxic-cumulative) hand derma-

titis, pruritus can particularly affect the interdigital spaces

and the dorsa of the hand and fingers. The palms are invol-

ved usually only after years of disease. The phenomenon of

spreading does not occur unless skin-irritating substances

also contact other body sites, such as the forearms. Allergic

contact dermatitis affects the contact sites such as the palms.

Specific locations such as the fingertips in acrylate allergy are

quite typical. Atopic skin diathesis is an important co-factor

in contact dermatitis of the hands [11].

Atopic hand dermatitis typically manifests morphologi-

cally in the form of pruritic vesicles on the palms and sides of

fingers as well as with involvement of the volar aspect of the

wrist with eczematous lesions and typically with lichenifica-

tion on the dorsa of the hands (Figure 2). The fingertips may

be affected with pulpitis-sicca-like lesions. Affected patients

always report of intense pruritus of the hands, while as a re-

sult of fissures – usually more of a problem in the winter than

in the summer – a mixture of pruritus and pain or predomi-

nantly pain are reported. Nummular dermatitis may appear

on the dorsa of the hands. These lesions often occur in atopic

individuals or within the context of atopic dermatitis. Num-

mular dermatitis can also appear without atopy. Ruling out

allergic contact dermatitis is mandatory. In our experience,

chronic dental and otorhinolaryngeal infections, as well as

Helicobacter pylori gastritis/infections, also should be exclu-

ded. In nummular dermatitis, the entire skin surface should

carefully be examined to rule out other lesions of nummular

dermatitis.

Allergic contact dermatitis of the hands manifests after

contact with the relevant contact allergens in the form of

sometimes intense pruritus, erythema, vesicles followed by

hyperkeratoses. Painful fissures are reported usually only in

chronic courses. In occupational dermatology, allergic con-

tact dermatitis is often observed as a secondary phenomenon

superimposed on other forms of eczema. An irritant contact

dermatitis usually is present over many years; the disturbed

barrier function facilitates the entry of potential contact all-

ergens. Depending on the contact allergen, the sensitization

process can last months to years. An additional allergic con-

tact dermatitis is then superimposed. In the clinical routine,

mixed forms of irritant and allergic contact dermatitis predo-

minate in these cases. In allergic contact dermatitis the lesions

occur on skin sites with contact to the allergen (Figure 3).

Figure 1 Dyshidrotic hand dermatitis with closely placed,

severely itching vesicles, especially on the palms of the hands,

and typical dot-like or annular scaling (dyshidrosis lamellosa

sicca).

Figure 2 A 29-year-old ceramic craftsman suffering from

atopic hand dermatitis with occupational aggravation.





When the contact allergen is volatile, the corresponding le-

sions with pruritus can also develop at sites not covered by

clothing such as the face/head, neck, arms and chest. By ap-

propriate careful allergological testing it is usually possible to

identify the responsible contact allergen. Usually a temporal

relationship exists between exposure to the allergen and the

onset of pruritus or the onset of the skin disease.

Hand dermatitis preferentially develops in various occu-

pational groups with skin irritation [12, 13]. Of 1,742 em-

ployees in health care professions who participated in a skin

protection seminar of secondary individual prevention (SIP)

of the German Social Accident Insurance Institution for the

Health and Welfare Services (BGW) in Karlsruhe [12, 13],

25.7 % (n = 448) had irritant hand dermatitis, 4.3 % (n = 74)

allergic contact dermatitis and 12.7 % (n = 222) atopic hand

dermatitis (status December 2011). Of those employed in the

health care sector, 45.5 % (n = 792) suffered from a mixed

form of the above-mentioned diagnoses, with the simultane-

ous occurrence of i rritant and atopic hand dermatitis being

the most common of the mixed forms (27.9 %, n = 486).

Of the 638 SIP participants employed as cleaning workers in

contrast 32.2 % (n = 206) had irritant hand dermatitis, while

in 2.8 % (n = 18) allergic contact dermatitis and in 6.1 %

(n = 39) atopic hand dermatitis was diagnosed. A mixed form

of all mentioned diagnoses was found in 45.8 % (n = 293)

with the mixed form of irritant and atopic hand dermatitis

being the most common with 26.9 % (n = 172). An atopic

skin diathesis [11] was present in 63.9 % of all participants,

with 66.8 % of those employed in the health care field and

56.3 % engaged in cleaning work being atopic individuals.

Of the 913 participants in the SIP workshops complaining

of pruritus (38.4 %), 63.8 % reported pruritus on the hands,

13.1 % pruritus on the body and 23.1 % in both locations

(Figure 4). Of the participants with irritant hand dermatitis,

interestingly 78.0 % complained of pruritus of the hands,

making this diagnosis the most frequent among participants

with pruritus of the hands (Figure 5). Of participants with

atopic hand dermatitis, 24.5 % reported pruritus of the

hands, while 39.4 % of this group complained of pruritus

on the hands and body; thus, patients with atopic dermatitis

most frequently had pruritus on the entire body (Figure 5).

More current results on pruritus of the hands are pro-

vided by the carpe CHE Registry (registry of chronic hand

eczema and long-time patient management), which in Sep-

tember 2011 contained 1036 patients [14]. 40.7% (n = 422)

of the patients showed atopic skin diathesis (unpublished

data). In total, 80.9% (n = 838) of the CHE registry patients

declared to suffer from pruritus, mild pruritus being most

frequent with 33.7% (figure 6). Furthermore, the intensity

of pruritus appeared to correlate with the severity level of

hand eczema and the impairment of skin-related quality of

life (measured with DLQI, the dermatological index for qua-

lity of l ife) [14].

Figure 3 A 60-year-old construction worker with multiple

occupationally relevant type IV sensitizations causing severe

allergic contact dermatitis.

Figure 4 Chronic pruritus (n = 913) according to location in

2,380 participants of a skin protection workshop for secon-

dary individual prevention initiated by the German Social

Accident Insurance Institution for the Health and Welfare Ser-

vices (BGW), Kar lsruhe, for health care, cleaning and kitchen

workers.





Palmar psoriasis

Psoriasis can lead to localized or generalized pruritus, which

is a common but often ignored and underestimated symptom

in patients with psoriasis [15]. This may, on the one hand, be

due to a lower frequency and intensity of pruritus in compa-

rison to other pruritogenic disease such as atopic hand der-

matitis, as well as impairment of psychosocial health which

may particularly manifest as social withdrawal [15]. Most

studies report that pruritus in plaque psoriasis that does not

present on the hands. A recent comprehensive review of stu-

dies on the subject of pruritus and psoriasis demonstrated

that in most studies, the hands were not taken into conside-

ration as a location affected by pruritus, but possibly only

assigned to the location “arms or limbs”. The location arm

was reported with a frequency of about 70 % in most studies

[15]. In the daily occupational dermatology practice, palmar

psoriasis represents an important clinical differential diagno-

sis. According to the experience gained from SIP workshops

and occupational dermatology inpatient treatment (tertiary

individual prevention, TIP) [12, 13, 16], 5–10 % of the der-

matoses of the hands represent palmar psoriasis. Clinically,

most often one sees infiltrated plaques located symmetrically

over the metacarpophalangeal and interphalangeal joints

(Figure 7). The palms are particularly affected presenting

with relatively homogenous involvement with fissures. Pus-

tular palmoplantar psoriasis is rarely if ever associated with

pruritus (Figure 8). Those affected usually report pain [17].

Clinically, the differentiation between eczema and psori-

asis can be difficult, with mixed forms (secondary eczemati-

zation of existing palmar psoriasis) also having to be conside-

red [15] (Figure 7). Clinically helpful in such cases are exact

allergological diagnosis, comprehensive history and possibly

even a biopsy, keeping in mind that the diagnosis of psoriasis,

particularly in biopsies of palmar skin, is often difficult.

Lichen planus

Lichen planus is a skin disease characterized by pruritic po-

lygonal papules (Figure 9) that in its classic form does not

preferentially manifest on the hands. Sites of predilection of

eruptive exanthematous lichen planus are the wrists and fo-

rearms that must also be considered in pruritus of the hands.

Palmar and plantar skin is rarely affected usually. The diag-

nosis can usually be made on the basis of clinical inspection,

the oral mucosa with the Wickham phenomenon and nail

lesions (onychoschizia, irregular pits and ridges, thinning of

the nail plate) providing clues. According to a recent study

96.7 % of patients with lichen planus suffered from pruritus,

with this being more intense than in patients with psoriasis

[18]. This study also demonstrates that pruritus in lichen pla-

nus frequently ceases after initiation of appropriate therapy,

while it ceases in psoriasis only with complete healing of all

cutaneous lesions [18]. Patients with lichen planus more fre-

quently report pruritus of the upper limbs; a differentiated

description – for example of the hands – is not included in

this study [18].

Lymphoma

Particularly in recalcitrant, especially hyperkeratotic-rhaga-

diform hand dermatitis that does not heal despite intensive

therapy, a lymphoma must be considered in differential diag-

nosis. These are usually characterized by moderate to severe

pruritus; in the tumor stage (mycotic stage) pruritus can be

very severe and is usually difficult to control. The clinical

Figure 5 Frequency and location of chronic pruritus in 2,380

participants of skin protection workshops for secondary in-

dividual prevention, initiated by the German Social Accident

Insurance Institution for the Health and Welfare Services

(BGW), Karlsruhe, depending on diagnosis.

Figure 6 Pruritus intensity at the first visit in patients (n =

1,036) of the carpe study (chronic hand eczema registry on

long-term management of patients) [14].





presentation of lymphomas is highly variable and depends

on stage. Eczema-like, psoriasiform and leaf-like lesions can

exist, with arthropod-assault-like cutaneous reactions also

having been described in mantle cell lymphoma [19]. Parti-

cularly in the case of unspecific clinical and histological fin-

dings, for example in the premycotic stage, the diagnosis of a

lymphoma can be overlooked.

Additional diagnostic considerations

Depending on clinical features, infectious diseases such as ti-

nea manus, bacterial infections and scabies must be excluded

by appropriate diagnostic measures. Tinea manus (Figure 10)

typically presents with round erythematous lesions with

accentuated borders that can be accompanied by pruritus.

Dry, powdery palmar scaling without signs of significant

inflammation is also typical. Often only one hand is affected.

Intense scratching can alter the clinical picture, so that it no

longer resembles a typical fungal infection.

In scabies, typically small papules are found in the in-

terdigital spaces; in childhood the clinical picture may also

include dyshidrosiform, pustular lesions. Palms are typically

spared because of their thick, mechanically stable stratum

corneum, but can be affected in small children, the elderly

and members of the nursing profession due to manual trans-

fer (Figure 11). Diagnostic clues are comma-like, linear, win-

ding mite burrows measuring a few millimeters that can be

followed papules and papulovesicles due to scratching.

Porphyria cutanea tarda must be considered, when

blisters repeatedly appear on the dorsa of the hands that

are more strongly associated with pain than pruritus on

the background of fragile and sensitive skin, sometimes

with poorly healing wounds. Here, appropriate diagnostic

studies (Table 2) should be performed. Hemorrhagic

Figure 7 Mixed form of palmar psoriasis and irritant contact

dermatitis in a 55-year-old geriatric nurse. Since childhood,

the patient had suffered from psoriasis vulgaris. In the last

15 years, she has had erythematous scaly plaques over the

metacarpophalangeal and interphalangeal joints, as well as

vesicles, erythema and hyperkeratoses on the sides of thumbs

and fingers.

Figure 8 Pustular psoriasis in a 59-year-old nurse with

densely placed vesicles on erythematous skin on the palms

of the hands and the soles of the feet, particularly intense on

the palms as well as on the flexural and per iungual regions of

both great toes.

Figure 9 Clinical variants of lichen planus of the hand with

moderate but persistent pruritus.





blisters, erosions, crusts and milia, as well as hyper- and

hypopigmented scars can also be found in all sun-exposed

areas of the skin. As the lesions preferentially develop at

sites with great mechanical stress (by repeated microtrau-

ma), the dorsa of the hands and forearms are most often af-

fected. Attention should be paid to the fact that the triggers

of porphyria cutanea tarda can be highly variable; among

others, medications such as ciprofloxacin have been repor-

ted as triggers [20].

Prurigo nodularis

Prurigo nodularis means the development of skin nodu-

les that are secondary reactive alterations as a result of

chronic scratching due to chronic pruritus. According to

the international classification they correspond to group

3, i.e. secondary lesions acquired through scratching [2].

Prurigo nodularis frequently develops within the context

of a chronic skin disease, especially AD or atopic skin dia-

thesis [21], but also in a systemic disorder such as terminal

renal insufficiency. Therefore, the identification of the un-

derlying cause is most important in therapy [22]. In BRP

(see below) one should look for prurigo nodularis on the

dorsa of the hands and extensor surfaces of forearms and

upper arms (Figure 12). Clinical features and location do

not automatically indicate the underlying cause.

Brachioradial pruritus

Brachioradial pruritus (BRP) is a form of pruritus of prima-

rily extracutaneous origin affecting the nape, the upper back

and the extensor surfaces of the upper arms and forearms

usually appearing symmetrically and also often involving the

dorsa of the hands [23–26] (Figure 13). When nerve com-

pression affects the dorsal skin branch of the ulnar nerve,

this is termed cheiralgia paraesthetica, which can present

with pruritus of the hands. BRP may extend beyond the re-

gion of the M. brachioradialis until the chest. Pure itch ra-

rely predominates clinically, more likely mixed sensations of

itch, burning and pain [23–26] in the dermatome C5 and C6

[24, 25]. Seasonal variation of symptoms, particularly in the

summer months, might suggest UV light as a possible trigger

factor [24]. In a recent study, all patients had alterations of

the spinal column identifiable in magnet resonance imaging

(MRI). In 80.5 % of those affected, stenosis of the interver-

tebral foramina or protrusion of the cervical intervertebral

discs with the corresponding nerve compression was obser-

ved [25]. Spinal tumors must also be considered as cause [22,

23, 26]. Therefore, an appropriate neurological and espe-

cially radiological evaluation including MRI particularly of

the cervical and thoracic spinal column is indicated.

Hand-foot syndrome

Hand-foot syndrome is also known as palmoplantar eryth-

rodysesthesia or chemotherapy-associated acral erythema.

Clinically, painful erythema is observed on palms and soles

with dysesthesias such as a prickling sensation and tickling,

while pain predominates. It is unclear if this represents a sin-

gle disease entity or a heterogeneous collection of various dis-

orders with differing underlying mechanisms [27]. In recent

times, the disorder has been reported as a side effect par-

ticularly of the multikinase inhibitors (MKI) sorafenib and

sunitinib [27, 28]. Other possible drug triggers also include

doxorubicin, taxanes, 5-fluorouracil and capecitabine (pro-

drug of 5-fluorouracil) [29, 30].

Figure 10 Tinea manus with erythema of the palms and sca-

ling. Diagnostic clue: unilateral involvement.

Figure 11 Scabies of the hands with red, itching papules and

papulovesicles on the palm of the left hand in a 42-year-old

male nurse working in a nursing home.





Somatoform pruritus

Mental factors can also significantly impact the course of skin

diseases, including dermatoses of the hands [31–33]. About

50 % of patients with dermatoses of the hand are convinced

that “stress” affects the course of their skin disease [31]. In

this study, it was also demonstrated that the subjective

reaction to stress correlates with the severity of the skin di-

sease, depression and the experience of significant life events

[31]. In hand dermatoses or pruritus of the hands, compulsive

disorders such as compulsive hand-washing must be consi-

dered as well [32]. These patients are controlled by compul-

sive thoughts. The repetitive and continuous impulses can

Table 2 Diagnostic procedures in pruritus of the hands.

History (mandatory)

` Duration, course, symptoms, temporal relationships (e.g. with the use of topical and systemic medications), occupatio-

nal and leisure activity history, disease course during work vs. weekend and vacation

`Preexisting conditions in general, skin diseases, atopy, allergies

` Medications, smoking and alcohol consumption

` Lifestyle (skin care, hobbies, household activities)

Clinical examination (mandatory)

` Inspection of the entire body and mucous membranes

` General physical examination including lymph node status

Laboratory studies (according to history, especially in the event of a systemic cause)

` ESR, CRP, blood count with differential blood count, urea, creatinine, GGT, TOT, GPT, glucose

` When indicated, HbA1c, antibody serology, antistreptolysin/ antistaphylolysin titer, TSH, iron, ferr itin. Further studies ac-

cording to history, e.g. ANA, H. pylori serology, hepatitis serology (also see [22])

` Depending on diagnosis (for example in lymphomas: immunophenotyping, molecular biological studies)

` Urin analysis

Mycology, bacteriology (according to clinical findings)

` Smears, cultures

Histology (according to clinical findings)

` Skin biopsy with dermatohistopathologic evaluation including special stains, immunohistology and/or electron micro-

scopy as indicated

Allergology (when contact dermatitis or contact urticaria is suspected)

` Laboratory: total IgE and specific IgE (IgE-RAST), tryptase, mast cell metabolites

` Allergy test (with evaluation of the clinical relevance):

− Patch test

− Mandatory: Standard series or standard series for children

− Depending on history: Hairdressing supplies, disinfectants, ingredients of topical products, topical antibiotics, an-

tifungal agents, further medications, preservatives, fragrances and essential oils, rubber chemicals, plants, dentalmetals, corticosteroids, synthetic resins/ glues

− In photoallergic contact dermatitis: Minimal erythema dose, photo patch test

− Sodium lauryl sulfate as an indictor of skin irritability (also following the guideline for chronic pruritus)

− Prick testing: atopic allergens, moulds, medications, latex food stuffs

Supplemental consultations (depending on findings)

` Internal medicine

` Neurology

` Orthopedics

` Psychosomatic medicine, psychiatry

Further studies (depending on findings and especially in the case of brachioradial pruritus and prurigo nodularis of the

hands, arms and/or upper trunk)

` Radiologic diagnostics (MRI when neuropathic pruritus is suspected)





result in the manifestation of irritant hand dermatitis. In

addition to adequate dermatologic therapy, psychotherapy

(behavioral therapy) and often drug therapy is necessary

here. Artifacts (intentional generation or pretending of phy-

sical or mental symptoms) must also be considered [33].

Artifacts may be found on the hands, confounding the

expert assessment of occupational diseases and disability

determinations [33]. Erythema, swelling, infiltration, erosions,

crusts and necrotic areas can be seen. Clinical examination

in some cases allows for interpreting the cause of the lesion

that can be produced in various manners such as rubbing,

biting, scratching, cutting and suctioning the skin. This dis-

order demands psychosomatic care and therapy, while those

affected in the case of intentional or conscious simulation are

hardly accessible to psychotherapeutic measures, as no mo-

tivation exists. While diseases of relevance to occupational

dermatology usually affect the hands, in the case of artifacts

lesions on the entire body must be evaluated, as the lower legs

are also easily accessed (Figure 12).

Diagnostic approach

Pruritus of the hand demands a painstaking work-up (Table 2).

This always includes a comprehensive history and dermatolo-

gic examination. This encompasses exact registration of the

sensations, the involved locations as well as dermatologic-

allergologic and general medical history. In pruritus of the

hand, the complete occupational history plays a particularly

important role, as hand dermatitis as cause of pruritus of

the hands is particularly frequent in manual labor and other

occupations with skin irritation [12, 13, 16]. A history of

leisure activities is also of significance with respect to manu-

al hobbies such as constructing models, working on motor

vehicles or even knitting, very popular again among women

of all age groups.

As therapy needs to be oriented on the cause of pruritus,

careful diagnosis is of utmost importance [9, 22]. The extent

of the evaluation depends on the symptoms, clinical features

and the severity of pruritus as well as the findings obtained

during evaluation (Table 2). Particularly in cases when the

cause of pruritus cannot be classified by clinical examinati-

on and morphological assessment, a comprehensive work-up

according to the current guideline on chronic pruritus [22]

should be performed. In accordance with our own extensi-

ve experience in the field of chronic pruritus, occupational

dermatology and in the diagnostics and therapy of hand der-

matoses, a diagnostic approach to pruritus of the hands as

presented in Table 2 is recommended.

Therapy

Comprehensive and thorough diagnosis is an important

foundation for therapy. The extent of the diagnostic evalua-

tion and the resulting therapy is oriented on the symptoms,

clinical findings and the severity of pruritus. If it is obvious

that the pruritus is exclusively caused by hand dermatitis

will we follow the stepwise therapy of hand dermatitis accor-

ding to the degree of severity [9]. The therapy of pruritus of

the hands depends on the underlying cause, clinical features,

the history (allergic contact dermatitis, occupation) as well

as the individual therapeutic response (Table 3). For this we

refer to the guidelines on chronic pruritus, on chronic hand

dermatitis and on therapy of psoriasis [9, 22, 34–36]. A case

collection from occupational dermatology with highly pruri-

togenic hand dermatitis demonstrated good efficacy of syste-

mic therapy with alitretinoin in hyperkeratotic-rhagadiform

and dyshidrosiform hand dermatitis and in pustular psori-

asis [37].

Figure 13 Chronic pruritus with excoriated nodules and

plaques in the sense of neuropathic pruritus in a 55-year-old

patient with chronic pruritus of the hands, the arms and the

genital region and a history of multiple herniated vertebral

discs in the lumbo-sacral region and degenerative processes

in the cervical spine region.

Figure 12 Prurigo nodularis in a patient with underlying

psychiatric disease. The upper body and the upper limbs re-

vealed multiple partly excoriated nodules. The legs showed

multiple skin lesions appearing as if “pierced”, which were

classified as artifacts due to self-mutilation. The 67-year-old

patient reported intense chronic pruritus of the entire skin;

self-mutilation of the legs was denied.





ConclusionsDue to the exposed nature of hands, a skin disease affecting

them receives special individual attention and may have a si-

gnificant mental impact. Many skin diseases on the hands

are also associated with chronic pruritus. A tendency exists

to underestimate this when it occurs on a comparably small

area of the body. At the same time, the great significance

of the hands as working tools in many professions must be

stressed. The most important differential diagnosis of pruri-

tus of the hands is the group of eczemas. Other diseases such

as BRP can be associated with sensations such as burning,

piercing and pain in the skin, which in some cases facilitates

the differential diagnostic classification of the disease. Pruri-

tus of the hands demands a thorough diagnostic approach.

This is the foundation of targeted therapy that depending on

the underlying cause can be adapted in a stepwise fashion

and includes besides causal therapy symptomatic antipruritic

therapy. Therapy should be planned in accordance with the

current guidelines on therapy of chronic pruritus, of hand

dermatitis and further specific guidelines, for example on

therapy of psoriasis vulgaris [9, 22, 36].

Table 3 Therapeutic algorithm for pruritus of the hands.

General approach depending on skin condition and diagnosis:

` Hand baths (disinfectant, tanning agents)

` Emollients (ideally without fragrances or preservatives), stage-adapted topical therapy (also see below)

` Particularly in occupations with skin irritation: Instruction on skin care measures, skin protection (when indicated glove

counseling) and, when appropriate, maintaining factors and trigger substances

` Avoidance of exposure (contact allergens, wet work, skin-irritating substances)

` Symptomatic-antipruritic topical therapy (e.g. polidocanol, tanning agents, combinations of ointments and wet dres-

sings, menthol)

` Systemic antihistamines such as cetirizine, desloratadine (effective in case of an allergic cause, high-dose therapy when

needed: desloratadine 3 x 10 mg, also effective for other indications)

` In case of occupational relevance: submitting a dermatologist’s report, perhaps inspection of the working place

` Perhaps skin protection workshop, atopic dermatitis and/or pruritus educational program [12, 13, 38, 39]

In hand dermatitis: (also see [9])

` In step 1: antiseptics and symptomatic-antipruritic agents, topical corticosteroids, topical calcineurin inhibitors, tap wa-

ter iontophoresis (in case of dyshidrosis, hyperhidrosis)

` In step 2: in addition to step 1 highly potent topical corticosteroids, UV phototherapy, alitretinoin` In step 3: in addition to step 1 and 2 alitretinoin, systemic corticosteroids (only on a short-term basis) cyclosporine

When bacterial infections are suspected:

` Topical and/or systemic antibiotics according to smear with microbiological culture and sensitivity, broad-spectrum anti-

biotics only on a short-term basis (beware: contact sensitization, secondary fungal infections)

When a fungal infection is suspected:

` First identification of the pathogen and unspecific disinfection

` Topical antifungal agents, when needed also systemic antifungal agents according to culture and sensitivity

When allergic contact dermatitis, contact urticaria or protein contact dermatitis is suspected:

` Allergological diagnostics including patch and prick testing, perhaps scratch testing, specific IgE

Examples of further therapies according to the diagnosis made:

` UV phototherapy: cream PUVA therapy, bath PUVA therapy` Topical corticosteroids, topical calcineurin inhibitors

` Discontinuation of causative or triggering medications, for example beta blockers, multikinase inhibitors

` Topical and systemic antipsoriatic agents

` Acitretin in psoriasis, lichen planus

` Cyclosporine in psoriasis, atopic dermatitis, prurigo nodularis

` Gabapentin, pregabalin, naltrexone in neuropathic pruritus, prurigo nodularis

` Serotonin reuptake inhibitors, tetracyclic antidepressants in somatoform pruritus, prurigo nodularis

` Stage-adapted lymphoma therapy





Correspondence to

Prof. Dr. Elke Weisshaar

University Hospital Heidelberg

Department of Clinical Social Medicine

Occupational and Environmental Dermatology

Thibautstraße 3

69115 Heidelberg, Germany

E-mail: [email protected]

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itching hand

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