A 62-year-old man comes to the office due to worsening itchy, dry skin on the hands. For 2 years, he has experienced thickened, cracking skin at the dorsum of both hands that has extended to the fingers. The patient tried moisturizing lotions, with partial relief, but the symptoms relapsed if he did not apply the lotions regularly. Medical history is notable for seasonal allergies and an occasional herpes rash on his upper lip following upper respiratory infections. He works as a janitor and does not use tobacco, alcohol, or illicit drugs. Examination shows scaly skin and erythema on the fingers, finger webs, and dorsum of both hands, as shown in the exhibit. No other skin lesions are seen. Which of the following is the most likely diagnosis?

Question

A 62-year-old man comes to the office due to worsening itchy, dry skin on the hands.  For 2 years, he has experienced thickened, cracking skin at the dorsum of both hands that has extended to the fingers.  The patient tried moisturizing lotions, with partial relief, but the symptoms relapsed if he did not apply the lotions regularly.  Medical history is notable for seasonal allergies and an occasional herpes rash on his upper lip following upper respiratory infections.  He works as a janitor and does not use tobacco, alcohol, or illicit drugs.  Examination shows scaly skin and erythema on the fingers, finger webs, and dorsum of both hands, as shown in the exhibit.  No other skin lesions are seen.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d374_3ce9_bc81_df618d410a8b_MD0003_00 This patient has chronic irritant contact dermatitis (ICD), likely because of frequent handwashing and occupational exposure to cleaning solutions. ICD can be triggered by water, detergents, solvents, and other chemicals, as well as physical irritants such as metals, wood, and fiberglass. These irritants disrupt the epidermal barrier through chemical or physical (eg, microtrauma) damage to keratinocytes, increasing epidermal permeability and water loss. An inflammatory response follows at the site of exposure. A single exposure to strong irritants can induce erythematous papules, edema, vesicles, and bullae (ie, acute ICD). In contrast, repeated exposure to mild irritants (eg, water, dilute detergents) over time causes chronic ICD (as seen in this patient), which presents with dry scales, lichenification, and fissuring. erythematous papules fissuring Treatment of chronic ICD includes avoidance of irritants (eg, using barrier gloves), frequent application of emollients to restore the skin barrier and reduce water loss, and topical corticosteroids to decrease inflammation. (Choice B) Herpetic whitlow is an acute herpes simplex virus infection of the fingers caused by inoculation of the virus (eg, from concurrent herpes labialis) into broken skin. Lesions (ie, painful vesicles on an erythematous base) typically resolve spontaneously in 1-2 weeks, not years. Herpetic whitlow (Choice C) Psoriasis can affect the hands, presenting as red plaques with thick, silvery scales on the palms and dorsal fingers. However, patients with hand psoriasis usually also have psoriatic nail disease or additional psoriatic lesions elsewhere on the body. Psoriasis nail disease (Choice D) Scabies can affect the hands but presents acutely as small, intensely pruritic papules and irregular burrows. More diffuse skin involvement is seen in crusted scabies, but this typically occurs in immunocompromised patients (eg, advanced HIV disease). Chronic scaling and improvement with emollients are not characteristic. Scabies crusted scabies (Choice E) Tinea manuum is a dermatophyte infection of the hands that presents as pruritic, scaly patches on the palms or as annular plaques with a raised border on the dorsum. It may resemble chronic ICD but does not improve with emollients alone, is usually unilateral, and most commonly occurs in patients with concurrent tinea pedis (via autoinoculation from scratching). scaly patches annular plaques Educational objective: Chronic irritant contact dermatitis is characterized by scaling, lichenification, and fissuring and commonly affects the hands. It is caused by exposure to chemical (eg, detergents, solvents) or physical (eg, metals, fiberglass) irritants that disrupt the epidermal barrier, triggering an inflammatory response. Treatment includes emollients, topical corticosteroids, and irritant avoidance. References: Irritant contact dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/30293200)

A 62-Year-Old Man Comes to the Office Due to Worsening