Applying Guidelines to Chronic Hand Eczema Care: A Case-Based Approach

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. My name is Dr. Raj Chovatiya. I'm an Associate Professor at the Rosalind Franklin University of Medicine and Science in North Chicago, Illinois, and Founder and Director of the Center for Medical Dermatology and Immunology Research.

Joining me today to share patient cases that highlight key guideline recommendations for managing chronic hand eczema is Dr. Benjamin Ehst. Not only is he a board-certified dermatologist with a doctorate in immunology, but he's also an investigator at the Oregon Medical Research Center and dermatologist at the Broadway Medical Clinic in Portland, Oregon. Dr. Ehst, thanks so much for being here today.

Dr. Ehst:
Thanks for inviting me and a pleasure to be here, Raj.

Dr. Chovatiya:
So let's dive right in. Can you walk us through a patient case that demonstrates how you typically approach diagnosing chronic hand eczema?

Dr. Ehst:
I sure can. I prepared one specifically for you. So I have a patient I've followed for a number of years now. He first came to me, I think it was around the age of 58, and he's an executive for an airline, and he had spent years working his way up the ladder. And so a good portion of his career, he was on the actual manufacturing floor and developed irritated, itchy, and then eventually painful cracking, fissuring of his hands, and that was where his eczema started. And it got to the point that he needed to see a dermatologist because it was affecting his ability to work. And that is one of the troublesome issues with chronic hand eczema.

So this was a gentleman that came to me. He'd seen other dermatologists before. He actually carried a diagnosis of psoriasis, which I assume was based on the appearance of kind of plaques and scale on the hands. So he was a classic example. His eczema had been going on for more than several years at that point, and he had tried topical steroid, which is one of the first-line therapies. And he would tell me it would get better at times and get worse, but nothing ever really cured it.  One of the first things you do with hand eczema is you look at it and try and by history, we could say it's chronic. But you try and look at it and classify the category of eczema. And we know that most hand eczemas, especially when they’re chronic, tend to be multifactorial. So I looked at him and first said, “Well, it's not classic for psoriasis.” It didn't have very well-demarcated plaques. He had areas that were more edematous and would ooze. And just from the exam, I was leaning more towards eczema. The international guidelines always sort of, they make you at least think about the idea of patch testing or biopsying these patients. I didn't feel a biopsy was going to be helpful. Most of the time, it's a fairly inconclusive result, so I tend not to do that.

Patch testing in him was actually important, I thought. Again, he was around chemicals in the airline industry. I couldn't tease out specific potential allergens. And he didn't quite know exactly what he could be exposed to, but he had the suspicion maybe this was a work-related thing too. So we said, well, we should have you patch tested. I have a local expert in allergic contact dermatitis who did a full patch test panel and didn't find anything that seemed to be a relevant positive. And again, that's helpful; it ruled out potentially an allergic cause for this. So I think that was more reassuring to him that maybe this wasn't an occupational exposure at least.

So I thought it was an eczematous process. It fell into the chronic category. We had ruled out as best we could a contributing allergen. He certainly washed his hands a lot, which is a common cause of chronic hand eczema, usually an irritant-type reaction. So he was instructed to use emollients and do less hand washing, try to avoid allergens—everything we sort of do in these chronic patients.

Dr. Chovatiya:
Interesting case. I mean, maybe you can kind of tell me a little bit about when you're sort of sorting through all the possibilities that contribute to chronic hand eczema; I know that a lot of our training is really focused on trying to find a singular etiology for disease. And especially for us in the US, this idea of chronic hand eczema being this almost heterogeneous category is a little bit of a foreign one. How do you kind of go about that thought process, imagining that you probably are trained very similar to me, where your attending probably said you better choose one category?

Dr. Ehst:
Yeah. You always sort of said, if you can pick one diagnosis, that's what you want to go with. Don't try and complicate things by saying they have three or four things going on. But the reality with hand eczema is most if not all—I had a mentor who also said—hand eczema is always multifactorial. So I think you're absolutely right. It could be a diagnostic conundrum. And I like to not be too rigid. I like to say this is potentially different etiologies. I think that's why chronic hand eczema as a diagnostic category, which we don't have currently, would actually be helpful because you can try your best to split these apart into different etiologies. And the reality is the immune profile of what's going on may overlap. Your ultimate treatment options, they may be targeted enough to certain pathways that they'll help in certain individuals, but you may need a broader acting medication in the long run anyway.

Dr. Chovatiya:
You know, we tend to think about topical corticosteroids as our first choice for pretty much every chronic inflammatory disease. And this is no different, and I imagine that probably was at least some of the first stuff that was tried for this patient. So what is kind of your general approach to thinking about therapy, both with TCS and then beyond TCS, and kind of what's missing and what's needed?

Dr. Ehst:
Yeah, great question. So yeah, you're right. I mean, topical corticosteroid can work for lots of inflammatory conditions. So that's usually my first-line approach. They're usually cheap and affordable. And I revisited that. He had been on topical steroid in the past, and I said, “Well, let's go back with an ultra-potent topical steroid.” I usually like to go strong, see if we can get some quick relief.

And then I see them back in, say, a month later, and I've said, “Well, use your ultra-potent for a couple weeks, and then you try and taper off,” and lo and behold, the problem with many of these patients is when they're using it consistently, it can work pretty well. And he would say the same thing: ‘It seems like the ultra-potent topical steroid can help me get better, but as soon as I try and get off of it, it comes right back.’ And the problem of course is these—so if you use ultra potent steroids, you worry about long-term use because you’re going to thin the skin in particular, and that leads to all its other complications. So finding something besides the topical corticosteroid is important.

So what's exciting is just recently, the FDA approved delgocitinib cream, which is a topical JAK inhibitor, as the first and only FDA approved medication for chronic hand eczema. That will be my go-to topical as a nonsteroidal for chronic hand eczema. 

So my approach is going to be a topical corticosteroid first, and then quickly moving to delgocitinib for patients with chronic hand eczema who need something that's safer over the long-term and can continuously use something chronically. And that's going to be my approach with this patient as well.

Dr. Chovatiya:
For those of you just tuning in, you're listening to DermConsult on ReachMD. I'm Dr. Raj Chovatiya, and I'm speaking with Dr. Benjamin Ehst about how we can put current chronic hand eczema guidelines into action using a case-based approach.

So, Dr. Ehst, let's turn our attention to long-term management. In your experience, how can we help patients maintain long-term control and minimize relapse? And what role does patient education play in this long-term management plan?

Dr. Ehst:
Yeah, great question. So I mean, that really is the crux of the problem with chronic hand eczema is it tends to be chronic, and you’ve got to find something that the patient's willing to do over the long term and that can maintain good control.

So sticking with my case, we actually decided that the topicals, at least the TCS/TCI category, wasn't working well. He actually wanted to try an oral JAK inhibitor. So we used one of the approved oral JAKs that are out there for atopic dermatitis, and it worked well. And his hands were cleared. The problem was he was unconvinced he wanted to stay on one of those for a longer term. So there you go; there's the long-term management question. We found something that worked well, but there was concern potentially about safety. So in his case, we then said, “How about we use an off-label topical JAK inhibitor?” You know, we have ruxolitinib approved in the US for atopic dermatitis. And in this case, he was able to start that and did well enough; I saw him back yesterday actually, and he finds if he uses the ruxolitinib topically a few times per week, his hands stay pretty well managed. He's happy; it's a manageable amount of use and attention he has to pay to his hands for his lifestyle.

Education is huge because like many folks, he wants to now slack on using emollients and moisturizer, and he wants to go back to washing his hands more often. And there's a huge role for education because you have to follow those routine barrier management scenarios. And I think constant reminder is always helpful. Every time if someone's doing really well, you still tell them you’re stuck with this genetic predisposition to usually problems with the barrier of the skin. And if you begin to slack off, you're asking for the inflammation to set up shop again; you're asking for the medication you're using to have to do more work than we really want it to. So moisturize, moisturize, moisturize, avoid these potential allergens, try to decrease irritation, and go from there.

Dr. Chovatiya:
I know that we've covered a lot today, and our time unfortunately is coming to an end. So, Dr. Ehst, do you have any key takeaways on maybe how we can better diagnose and treat patients with chronic hand eczema when thinking about the case that you presented?

Dr. Ehst:
Yeah, again, I think our emphasis on multifactorial nature and getting around this idea that we have to have a single diagnosis for this entity we're treating is important. I always try and keep in mind the patient in front of me, and I don't let my comfort level with a diagnosis prevent me from actually treating. So I think we have some good options, and I think we have a lot on the horizon that will allow us to treat these patients more successfully, and especially in this longer-term phase that they need treatment in.

Dr. Chovatiya:
With those final thoughts in mind, I want to thank my guest, Dr. Benjamin Ehst, for sharing these patient cases in chronic hand eczema care. Dr. Ehst, it was great having you on the program.

Dr. Ehst:
Thanks. My pleasure.   

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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!