Transcript
Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by LEO Pharma Inc. Here’s your host, Dr. Charles Turck.
Dr. Turck:
Welcome to DermConsult on ReachMD. I'm Dr. Charles Turck, and joining me to discuss the complexity of chronic hand eczema—from overlapping subtypes to evolving treatment considerations—are Dr. Christopher Bunick and Ms. Andrea Nguyen. Dr. Bunick is an Associate Professor of Dermatology at Yale School of Medicine in Connecticut. Dr. Bunick, thanks for being here today.
Dr. Bunick:
Thank you. Pleasure to be here.
Dr. Turck:
And Ms. Nguyen is a physician assistant at First OC Dermatology in Irvine, California. Ms. Nguyen, it's great to have you with us as well.
Ms. Nguyen:
Thank you so much. It's my pleasure to be here as well.
Dr. Turck:
Well, let's hear from you first, Ms. Nguyen. What makes chronic hand eczema such a unique and burdensome disease for patients?
Ms. Nguyen:
Chronic hand eczema, or CHE, can be a very profoundly impactful condition for patients who suffer from this condition. We do almost everything with our hands, and so for many patients, this affects so many different aspects of their life, whether it's their day-to-day activities or their social interactions.
For patients who have employment activities that require a lot of hand usage, it can also impact their livelihood and their financial health if their condition prohibits them from completing their tasks at work—for example, healthcare workers, hospitality workers, people who work in the food industry, and hairdressers. Many of these patients who have chronic hand eczema have difficulty completing tasks at work that are needed in their everyday tasks when they have flares or if they have persistent disease.
So there's quite a bit of emotional quality-of-life impact as well. There's a lot of sense of despair in patients who have very severe disease. I find that when they have fissures, many of the times the driver for the consultation for them to seek care is due to the pain associated with the fissures. And it can be incredibly painful even just to have running water over these openings in the skin. So it's profoundly impactful.
Dr. Turck:
Now, one of the clinical challenges with chronic hand eczema is that it's not a single uniform disease. So if we turn to you, Dr. Bunick, what are the most common subtypes and presentations you see in practice?
Dr. Bunick:
Well, it's exactly right. It's not one single entity, and that's what makes chronic hand eczema so difficult to diagnose and treat, but also difficult for patients themselves to experience. In my clinic, approximately five to 10 percent of all the patients I see have some form of hand eczema. And this fits with some of the clinical data that say the prevalence of chronic hand eczema may be upwards of around 10 percent of the population.
In my clinic, the most common subtypes that I see include irritant contact dermatitis, allergic contact dermatitis, atopic dermatitis of the hands, and vesicular hand eczema, which is also referred to as dyshidrotic hand eczema. Those are probably the most common types I see.
Irritant contact dermatitis is so common because it can come from simple things, like excessive washing of the hands just with water, contact with soaps—which people do every day when they wash their hands—detergents, as well as chemicals. Everyday chemicals could be household cleaners or actually occupational exposures. I've had a patient before that worked in a florist shop and touching different plants was driving her chronic hand eczema.
You always have to be thinking about the concept that more than one type of chronic hand eczema subtype could be present in the same patient. Research shows that upwards of 50 percent or more of chronic hand eczema patients have more than one subtype. This is really important because when you go to diagnose a patient, you don't necessarily have the ability to just look at the hands and say, "I know it is this subtype." When more than 50 percent have more than one subtype, it actually becomes a little trickier than that.
Dr. Turck:
Well, as a follow-up to that, Dr. Bunick, would you tell us how these different subtypes impact diagnosis and management?
Dr. Bunick:
Well, as I alluded to, the fact that there are multiple subtypes makes the diagnosis more challenging than what you would inherently think. Years ago, we might just think, "Ah, it's hand eczema. It's easy. Moisturize it, and put a steroid cream on it," but that's really not what's happening as we understand more about these different subtypes.
And when I think about treatment, I'm thinking about multiple different avenues. The inflammatory pathways that drive these different subtypes of chronic hand eczema are different. For example, an allergen to a metal may have a certain inflammatory driver, whereas an irritant contact dermatitis or an allergen to poison ivy is going to have a different inflammatory pathway driver. And these actually make the treatment more complex.
A lot of the treatment that we have done for chronic hand eczema historically has been moisturization approaches as well as topical corticosteroids. But chronic hand eczema, by definition, is chronic, and actually how we define chronic hand eczema is either three months of continuous hand eczema or two or more flares in a given 12-month period. When you have a chronic disease, the problem is you need to treat for prolonged periods. And topical corticosteroids actually have the ability to damage the skin barrier over longer periods of use. And when someone already has a compromised skin barrier and underlying inflammation, that chronic use of topical corticosteroids can actually drive further barrier impairment and further inflammation. And then with any other environmental exposures, this really becomes a cycle that a lot of chronic hand eczema patients experience that drives that disease. And we as clinicians now are trying to think about how to use non-steroidal approaches that tackle all these inflammatory pathways in order to treat all of the subtypes, even when two or more are present in the given patient.
Dr. Turck:
For those just tuning in, this is DermConsult on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Christopher Bunick and Ms. Andrea Nguyen about diverse presentations of chronic hand eczema and the clinical factors that inform related therapeutic decision-making.
Digging a little bit deeper into treatment, Ms. Nguyen, why can a chronic hand eczema-focused approach still be appropriate for a patient with atopic dermatitis involving both the hands and the body?
Ms. Nguyen:
Yes, you bring up a great clinical consideration for us, Dr. Turck, and it's really because many patients can have atopic dermatitis as well as an overlapping subtype of chronic hand eczema. And Dr. Bunick did an excellent job reviewing the different clinical features and different subtypes of chronic hand eczema, and it's very common that patients may have two or even three different drivers for their inflammatory dermatoses. And while treatment for atopic dermatitis will help for patients who have hand eczema really from the atopic dermatitis inflammation that’s driving the disease, that doesn't mean that you can't have an irritant contact dermatitis, an allergic contact dermatitis, or something else driving the inflammation that we see in the hands.
So it's quite often that I have atopic dermatitis patients that are well-controlled for their atopic dermatitis, but they still have persistent lesions on their hands. So many times when I see a patient, I do ask them, even if they have atopic dermatitis, whether they still have persistent hand lesions. The good thing is that most of the time when patients come in, their hands are very visible during a consultation. It's easy to have this discussion to do your consultation, whether it's an initial visit or a follow-up, and assess during the consultation whether you see hand lesions or not.
And I always like to ask patients as well how they are doing in between their visits or outside of the day that they just happen to be there for their appointment. Because for conditions like chronic hand eczema, we don't necessarily have the same level of disease 365 days a year. You will have days that are better and days that are worse, and patients' appointments don't always fall necessarily on the day that they are flaring. So another thing I have adopted over time is to really ask patients, "How many days a month are you suffering from your symptoms? Do you feel like it is impacting your quality of life? Do you feel like it's potentially a barrier for any activities that you otherwise would consider normal activities for anybody that you know in your general community, or do you find that you're unable to participate in certain sports or activities or complete tasks at work because you have so much discomfort associated with your chronic hand eczema?"
So have a dynamic approach to treatment and really consider even adjusting therapies with a clinical focus on chronic hand eczema. It is a great consideration for our patients and really something that we have the opportunity to do in today's landscape with treatment options for this condition.
Dr. Turck:
And as you think about treatment planning, Dr. Bunick, how do disease complexity and underlying inflammatory drivers influence your decision-making?
Dr. Bunick:
When I'm talking to patients about chronic hand eczema, I explain to them that I am not just trying to clear their skin. I'm also trying to incorporate into my treatment planning a treat-to-target approach. And what I mean by that is we've seen in atopic dermatitis and psoriasis the adoption of treat-to-target approaches where we try to hit minimal disease activity. So for me, that's clear skin, no itch or little or no itch, plus little or no pain. I think with chronic hand eczema, it's the triple combination—or the triple crown if you like horse racing—and that is clear skin, no itch, and no pain. And that's my goal with every patient. But it takes time. It's a chronic disease, and the idea that you're going to get better in one or two weeks, while some patients may, the majority of patients are going to need a consistent treatment plan where they're compliant with the treatment, and it could take a month to four months in order for patients to get better. So compliance is something that I emphasize.
And when I think about treatment, I'm thinking about it multi-pronged. We've talked about the different subtypes. We've talked about different ways the environment, the damaged skin barrier, certain chemical triggers, which could be certainly part of that environment, as well as the inflammation that's underlying all these subtypes. All of that has to be taken into consideration, and that means reviewing what patients are doing. What over-the-counter products are they doing? What are their hand-washing practices? What soaps or detergents are they using? How are they cleaning around the house? I'm asking all of that. What moisturizers are they using, and what therapies have they tried previously? And this is really the ultimate challenge of treating chronic hand eczema patients: you need to have all of this background in order to make some proper decisions.
And ultimately, when I think about the treatment of chronic hand eczema, what we now know is a lot more science behind the signaling pathways in the cell that underlie these different subtypes of chronic hand eczema. And what makes chronic hand eczema very interesting scientifically is that the JAK-STAT signaling pathway underlies the inflammation of most of these subtypes or all of these subtypes of chronic hand eczema, which is why we've seen a shift towards being able to modulate or inhibit this JAK-STAT signaling pathway as a treatment plan for chronic hand eczema patients.
Dr. Turck:
Well, it's clear from our discussion today that chronic hand eczema can be complex and difficult to manage. So if we turn to you now for the final word, Ms. Nguyen, what are some key considerations for using advanced treatment approaches in these patients?
Ms. Nguyen:
Absolutely. It's really a wonderful advancement in our specialty that we actually have advanced therapeutic options to consider for our patients. And it's really with the advancements in some of our non-steroidal options, looking specifically at our JAK-STAT pathways where we have now the advancement of JAK inhibitors. This is really a wonderful opportunity for our CHE patients to potentially get very good control of their chronic hand eczema because we know multiple inflammatory cytokine signal through the JAK-STAT pathway. And a consideration for us is that a topical JAK inhibitor may yield very nice results for some patients, considering that you don't necessarily have the same limitations of usage for a time duration like a topical corticosteroid.
So it’s really about considering treatment options that can potentially cover the multiple subtypes of chronic hand eczema irrespective of the underlying cause, whether it's a true allergy, irritant, or atopic, and having, hopefully, a more simplified treatment regimen for these patients.
Dr. Turck:
Well, with those considerations in mind, I want to thank my guests, Dr. Christopher Bunick and Ms. Andrea Nguyen, for sharing their insights on chronic hand eczema subtypes and treatment strategies. Dr. Bunick, Ms. Nguyen, it was great speaking with you both today.
Dr. Bunick:
Thank you so much. CHE's such an important topic. It was a pleasure to be a part of this.
Ms. Nguyen:
Thank you so much for having us.
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!
