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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
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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)
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Review Article Pruritus of the hands
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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.
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Review Article Pruritus of the hands
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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.
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Review Article Pruritus of the hands
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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].
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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.
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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.
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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)
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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.
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Review Article Pruritus of the hands
40 © The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1101
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
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Review Article Pruritus of the hands
41© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1101
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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