Navigating the CHE Patient Journey: From Diagnosis to Treatment

Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by LEO Pharma Inc. Here’s your host, Dr. Raj Chovatiya.

Dr. Chovatiya:  
Welcome to DermConsult on ReachMD. I'm Dr. Raj Chovatiya, Associate Professor at the Rosalind Franklin University Chicago Medical School and Founder and Director of the Center for Medical Dermatology and Immunology Research in Chicago. And joining me to share his perspectives on the patient journey in the evolving treatment landscape for chronic hand eczema, or CHE for short, is Dr. Jeff Yu. Dr. Yu is an Assistant Professor of Dermatology at Harvard Medical School and a dual-certified adult and pediatric dermatologist at the Massachusetts General Hospital in Boston. Dr. Yu, thanks so much for being here today.

Dr. Yu: 
Thank you so much for having me and for talking about this important topic.

Dr. Chovatiya: 
Well, let's start it off. If we're thinking about that patient journey, which is perhaps the most important part of this CHE story, could you share some of your best practices for assessing and diagnosing patients when it comes to chronic hand eczema? 

Dr. Yu: 
One of my most important clinical duties here at Mass General Hospital in Boston is doing occupational and contact dermatitis, so a lot of the work that I do is patch testing. A lot of these patients that come in with chronic hand eczema come in seeking answers to, why do I have this rash on my hands? Why am I being debilitated to the point where I cannot work? Do I need to switch my job? Do I need to do something different? I think it's such a big problem that we just do not pay enough attention to. It's probably one of the most common things that I see in my clinic. 

It's really hard to tell the difference between chronic hand eczema from some of these hand dermatoses, namely things like psoriasis, and sometimes infections, like a fungal infection like tinea, for example. And a biopsy, as you know, really doesn't help when it comes to chronic hand eczema. A lot of times, it tells you that it's psoriasiform dermatitis, right? Like, what does that mean? Is it eczema, is it psoriasis, or is it something else? So I think it ends up being a very difficult diagnosis to really tell objectively looking at it pathologically. So I think CHE overall is a pretty nonspecific but really important term, and it can encompass various diagnoses: atopic dermatitis, allergic contact dermatitis, and irritant contact dermatitis. And the treatment for them is not the same, but it's also important to think through. 

So when I see one of these patients, things that I really want to try to pay attention to, for example, is taking a really detailed history, making sure that I understand, do you have a history of eczema? Is your family history of eczema? Have you been dealing with this for a long time, or is it something that started just last week? I want to know what your daily exposure is. Are you a new mother? Are you a healthcare worker? Are you a hairdresser? What are your exposures at work as well as at home? And then finally, I want to make sure that there are no other products that you're putting on your hands that might be making it worse. Are you dabbing essential oils here and there? Are you a florist that you're dealing with a lot of floral products and essential oils? These are all important things that I want to assess from the get-go. 

The next step I want to make sure is that it's not an infection, right? Like, how many times have we been fooled by fungus? Fungus sees us; we might not see it. So you want to make sure it's not a fungal infection before going down that line. We patch test them to make sure that it's not some sort of an allergic reaction, and then we extensively educate on good hand practices because more often than not, that's probably what they need—over-handwashing, not moisturizing, not wearing gloves, things like that. 

Dr. Chovatiya: 
Dr. Yu, tell me. Once we diagnose a patient, what treatment options are currently available and what are some of the key efficacy and safety considerations? 

Dr. Yu: 
So everybody that comes in with some sort of a hand dermatitis that we say is most likely chronic hand eczema, we begin by making sure that they are practicing good hand hygiene. Good hand hygiene does not mean washing your hands to the tune of happy birthday or whatever it may be, but it really means that we are washing our hands when necessary; we are using soaps that are not going to perturb the pH of our skin or dry out our skin too much. We are making sure that we are moisturizing after we are washing our hands, and if we are coming in contact with any sort of caustic chemicals—whether you are working in a kitchen, whether you're working as a hairdresser, or whether you're working as a nurse or a physician—using gloves when necessary is absolutely quintessential to making sure that we are maintaining good hand hygiene. 

Beyond that, if you're doing all of those things and your hands are red, scaly, itchy, or swollen, then I think this is where we start talking about some of these treatments that are now currently available. I believe topical steroids are an oldie but a goodie, and I think will continue to be the first-line treatment for the foreseeable future for CHE for various reasons. They're cheap, they're effective, and you can get it the same day; if you're someone who's been suffering from this, you really don't want to wait a few weeks for prior authorization to come through. You want to get some immediate relief, and I think most dermatologists would probably agree that this is going to be the first thing the patients are going to get when they leave the office. 

However, topical steroids are not safe to use for chronic disorders. You want to make sure that you're using it less than two weeks to a month. So what are you going to do for the rest of the time? Just topical moisturizers are probably not going to hit it, so we really need some nonsteroidal that are available. Now better than last year, better than two years ago, better than five years ago, we have more options available at our disposal. Topical calcineurin inhibitors have been out for quite some time. Topical JAK inhibitors are currently available as well and topical PDE 4 inhibitors, whether this is crisaborole or roflumilast. All of these have had evidence that benefit those with chronic hand eczema, even though none of them are specifically labeled for chronic hand eczema. We know that these can be effective.

For patients who have very severe hand eczema, we start thinking about systemic agents. I've personally seen success with monoclonal antibodies, such as dupilumab and oral JAK inhibitors, and certainly phototherapy if the patients have the time to do it can be very helpful. And then finally, we have some of those older disease-modifying antirheumatic agents, like methotrexate and cyclosporine; those things that we often will use for patients with chronic hand eczema as well.
 
Dr. Chovatiya: 
How do you work with your patients, given all the treatments you just talked about, to select the right treatment and create a personalized care plan? 

Dr. Yu: 
Yeah, so important because what good is a plan if patients can't stick to it, right? So I think with any condition, for me as a personal way that I like to practice, I leave it up to the patient. I will always ask the patient, how much does this bother you? Sometimes patients will have horrible hand eczema and they'll say, “This doesn't bother me much at all.” And then sometimes patients will have relatively mild hand eczema, and they say, “This bothers me so much that I cannot work; it’s really getting in the way of my day-to-day.” So I think a large component of our treatment plan should be what does the patient want, how does the patient feel, and what will work best for these patients. So sometimes, one-size-fits-all really does not fit all, especially for this kind of unique patient group. So my job, at least the way I see it, is to layout the options. Staying abreast with what is available out there, letting them know what the options are, and trying to help them figure out what will work in their life the best. 

Number two is I want to make sure they understand the side effects, especially when we're coming to some of these systemic agents, I want to make sure that they know what the risks/benefits profile is. Is it going to be effective for their hand eczema, what the data looks like, and then of course, importantly, what their potential side effects are and making sure that the side effect is acceptable to them. And then finally, I make sure that it's affordable, right? I mean, that's always a huge, important part. With all these new therapies—awesome, great—the problem is that if they can't get it, if they can't afford the copay on them, or if they can't afford picking up the tube of medicine from the pharmacy, it's really not going to be very worthwhile for them. So I do work with the patient to make sure that whatever treatment we come up with is acceptable and workable for them.

Dr. Chovatiya: 
For those just tuning in, you're listening to DermConsult on ReachMD. I'm Dr. Raj Chovatiya, and I'm speaking with Dr. Jeff Yu today about the CHE patient journey. 

So, Dr. Yu, can you share us a case that highlights some of the strategies and contributions and considerations we've discussed so far when it comes to thinking about chronic hand eczema and how we manage it?

Dr. Yu: 
Sure. So recently I had a woman who was 26 years old, and she was a baker at a very well-known local bakery. And she was kind enough, of course, to bring in pastries for every visit, so we really enjoyed seeing her. But the problem for her was that she worked long hours in a food industry, and she had pretty significant scaling and redness on her hands that we ultimately diagnosed as being chronic hand eczema. So looking at her hands, we made sure that it wasn't an infection, and we made sure that it fits well with this diagnosis of chronic hand eczema clinically, and we kind of went down that treatment algorithm. 

Number one, we made sure we figured out what her exposure was. We made sure that we figured out how she takes care of her hands at work. And the short answer was she didn’t, right? She washed it with hot water and went right back to working with flour, yeast, and various flavoring, working with all of these food items that potentially can cause and worsen hand eczema. We patch tested her to make sure that she wasn't allergic to the gloves that she was wearing. We made sure that she wasn't allergic to the flavoring that she was using in food. We made sure that she wasn't allergic to the dyes that she was coming in contact with, and she was completely free of allergens from that perspective. 

So then the next step that we did was we just did really good hand care plus topical agents. We did topical steroids, plus some non-topical steroids, and then we were able to get her hands into a really good place where she was able to continue working. We enforced wearing vinyl gloves, not rubber, but vinyl gloves. We made sure that she was moisturizing throughout the day. We had her use a cotton glove liner as well underneath some of these gloves so her hands do not get too sweaty from the work. And then with all of these interventions, her hands were able to be cleared up 80, 90 percent to the point where she was no longer bothered when she was at work. 

Dr. Chovatiya: 
What an amazing case, Dr. Yu, and we just have about a minute left, so maybe I can pick your brain and look ahead in CHE. Is there anything in the pipeline that you've been reading about, you've been studying, or trials you’ve been participating in that you think are really going to change the way we manage patients, or are we sort of out of luck for the magical cure-all that we're hoping for? What do you see in the future? 

Dr. Yu: 
Yeah. One of the most exciting things that I am looking forward to is having another agent that is specifically for CHE. Now we've never had a drug that was specifically indicated for chronic hand eczema, so I'm really excited to have this nonsteroidal and seemingly highly effective cream option available for our patients who are suffering with hand eczema—something they can use every single day in lieu of topical steroids. 

Dr. Chovatiya: 
Lastly, Dr. Yu, can you share some key takeaways on how we can best manage and support our patients with CHE throughout their care journey?

Dr. Yu: 
Yes. I think there are three important things. Number one, make sure you have the correct diagnosis. Biopsies are not always helpful. Clinical judgment is important. Number two, prevention and avoidance can pay dividends, perhaps even steroid-sparing and therapy-sparing. And then finally, there are various treatment options that are now available from topicals to systemics, but the most important thing is making sure that it works with your patient.
 
Dr. Chovatiya: 
And with that, I want to thank my guest, Dr. Jeff Yu, for walking us through the patient journey and the role of current and emerging therapies in our approach to chronic hand eczema. Dr. Yu, it was wonderful having you on the program.
 
Dr. Yu: 
Thank you so much for having me. It was great talking about this.

Announcer:
This episode of DermConsult was sponsored by LEO Pharma Inc. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.