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TREATMENT
Avoidance of causative irritants in the home or the workplace is the primary treatment for ICD. Strategies in the prevention of ICD include the identification of irritants with appropriate substitution, the establishment of engineering controls to reduce exposure, the utilization of personal protective equipment such as gloves and special clothing, and barriers such as ointments, emollients, or creams. Other preventive strategies include emphasizing personal and occupational hygiene, establishing educational programs to increase awareness in the workplace, and providing health monitoring.
In the workplace, by far the most effective measure for reducing the incidence of contact dermatitis is technical avoidance. This can be accomplished via shielding and personal protection of the workers and limiting the use of potent irritants to closed or automated systems. Preventive skin care at the workplace may mitigate occupational hand dermatitis among vulnerable populations and involves regular use of protective creams to intact skin, removal of irritants by mild cleaning agents, and enhancement of barrier function generation by emollients or moisturizers. Non-irritating fatty substances such as petrolatum preclude hydrophilic chemical penetration and restore barrier function. The efficacy of barrier creams for skin protection (as compared to bland emollients) remains a topic of debate. In a randomized controlled trial, both barrier creams and moisturizing vehicles were found to positively influence skin status and hydration, without significant differences in efficacy. Newer moisturizers containing ceramides can also improve barrier function, but further trials are necessary to ascertain their efficacy compared to traditional moisturizers. Lastly, while new bioengineering techniques have been proposed for the assessment of individual irritant sensitivity, their value in predicting occupational ICD, especially of the cumulative type, remains unclear.
Protective gloves can reduce risk of irritant hand dermatitis when appropriately selected and worn; however, gloves worn incorrectly or produced with poor quality control can actually instigate or worsen ICD. Glove failure can result in penetration, permeation, or contamination of hazardous materials, with irritation further compounded by the glovesโ occlusive environment.
The establishment of appropriate educational prevention programs is essential. A project in Finland showed a significantly better outcome for employees with occupational hand dermatitis attending an โeczema schoolโ-like clinic run by a specialized nurse compared with an unschooled control group. Another study found that most occupational skin diseases responded to effective secondary preventive measures, combining employee medical treatment with exposure analysis-based individual and group training in preventive measures. Education was important in making the employees aware of initial skin changes, such as slight erythema and scaling in the interdigital folds, indicating the need to optimize skin protection and care measures in order to prevent exacerbation and chronicity.
The goal of treatment is to restore normal epidermal barrier function. Topical corticosteroids are frequently used, but their efficacy has been controversial, as experimental studies have provided conflicting results. In one double-blind, vehicle-controlled study, statistically lower values of erythema and TEWL were observed in sites irritated by sodium lauryl sulfate after 7 days of treatment with betamethasone valerate. Systemic corticosteroids, although potentially helpful in reducing acute inflammation, are not useful in the treatment of chronic ICD unless corrective measures are taken to avoid the offending contactants. Narrowband ultraviolet B or photochemotherapy (PUVA) irradiation may be considered for chronic dermatitis that does not respond to any other form of therapy. Hyperkeratotic palmoplantar dermatitis
from frictional or chronic ICD or a combination of dermatitis and psoriasis may benefit from the adjunctive use of systemic retinoids such as acitretin and alitretinoin or systemic immunomodulators such as methotrexate, cyclosporine, and possibly targeted immunomodulatory (biologic) therapy.
Additional figures and tables on Causes of cheilitis in patients who were referred for patch testing, The Hand Eczema Severity Index (HECSI), and The modified Total Lesion Symptom Score (mTLSS) for hand eczema, available in our eBook (see inside front cover for access code).
L, Elsner P, Wahlberg JE, Maibach HI, eds. Handbook of occupational dermatology. Heidelberg: Springer-Verlag; 2000:221โ224.33. McMullen E, Gawkrodger DJ. Physical friction is under- tors by Subject. Extracted December 20, 2014. <https:// www.bls.gov/data/>.
In: Chew AL, Maibach HI, eds. Irritant dermatitis. Berlin: Springer-Verlag; 2006:269โ277.39. Schliemann S, Schmidt C, Elsner P. Tandem repeated ap-
2009 establishing a third list of indicative occupational exposure limit values in implementation of Council Directive 98/24/EC and amending Commission Directive 2000/39/EC. Official Journal of the European Union 1998;L338:87โ9. http://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32009L0161&from=EN.