The impact of hand eczema

Hand eczema (HE) is a widespread chronic inflammatory skin disease often with multiple provoking factors (e.g. professional), subjective complaints and with lesions located on visible areas. All of these lead to a severe negative impact of HE on patients' lives. Siewertsen et al.¹ have presented the results of a systematic review and meta-analysis on anxiety, depression and quality of life impairment in patients with HE.

The authors¹ were concerned that different measures of HE severity, quality of life and depression were used across their selected studies, complicating comparability. However the same dermatology-specific quality of life instrument, the Dermatology Life Quality Index (DLQI), was used in 82% of their included studies. The DLQI is the most widely used QoL instrument in dermatology both for general use and in the majority of individual skin diseases. Many national and international guidelines recommend QoL assessment in dermatology and some of them contain detailed recommendations on treatment goals and changes of treatment approaches based on DLQI score banding and minimal clinically important difference (MCID).² The meta-analysis by Siewertsen et al.¹ revealed that the mean DLQI scores of patients with HE corresponds to the lower range of the ‘very large effect on patient's life’ DLQI score band meaning descriptors. Interpretation of the scores and the ‘minimally important change’ for a disease-specific quality of life instrument for hand eczema (QOLHEQ) have been proposed.³ However, as pointed out by Siewertsen et al.,¹ to date only a few studies have used this instrument.

In patients with HE, scores of various disease severity measures correlated significantly with quality of life impairment scores, using the DLQI. This is also seen in other chronic inflammatory skin diseases. Generic health-related quality of life instruments may be used in any disease and in healthy individuals. The EuroQol-5D visual analogue scale scores demonstrated more impaired QoL in HE patients than in healthy controls, as did the separate domain scores of the Short Form-36.¹

Siewertsen et al.¹ mentioned among the limitations of their systematic review that they were not able to assess differences between male and female patients. However, a large international multicentre study previously demonstrated that only female patients with HE had higher scores for depression and anxiety than controls.⁴ In this context it is especially interesting that the meta-analysis by Siewertsen et al.¹ revealed significantly higher levels of anxiety in HE patients than in controls, but similar levels of depression.

Data on the association between HE and suicidal ideation when comparing patients with HE with healthy controls were collected from only a single study and so no meta-analysis was possible. The topic of suicidal ideation in HE is therefore poorly studied and may be a topic for future research. Comparison of the impact of different clinical subtypes of HE as well as different occupational factors should also be studied.

Although many dermatologists think they have good insight into the impact of disease on their patients, the concordance between clinician-reported measurements of disease burden and scores of patient-reported outcome measures appears to be poor. It is therefore important for clinicians to assess quality of life of their patients using validated instruments, preferably with validated score interpretation and known MCID (e.g. the DLQI). The European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient-Oriented Outcomes presented numerous reasons for quality of life assessment in routine dermatological practice.⁵ HE patients with anxiety and depression should be identified and referred to a psychodermatologist, psychologist or psychiatrist for psychological help.

The systematic review and meta-analysis by Siewertsen et al.¹ helps to attract further attention of professional community to the serious and far-reaching consequences of HE.

The author reported no conflict of interest.