Severe hand eczema: finding the answers

This article was first published in the December 2019 edition of National Eczema Society’s membership magazine, Exchange.

Aimee Christodoulou introduces the ALPHA trial – a large-scale trial seeking to improve the lives of thousands of people with severe hand eczema.

Our hands are in constant use and we often don’t realise how much we rely on them to function in our daily lives. Severe hand eczema has such a dramatic impact on daily life that everyday tasks like writing, dressing and cooking can become very dif cult to do. That’s why the ALPHA trial is trying to find the most effective therapy for this.

Led by the Clinical Trials Research Unit at the University of Leeds, 25 NHS hospitals across the UK are recruiting people with severe hand eczema to take part in the trial. At the time of publishing [December 2019] we had recruited 380 patients, with just 75 left to find by March 2020. We expect the results to influence guidelines for treating the condition.

When is hand eczema ‘severe’?

Hand eczema is one of the most common skin condition, affecting up to 6 million people at any one time. Around 5–7% go on to develop severe hand eczema. Characteristics of severe hand eczema include:

  • severe itch, which often disturbs sleep and makes it dif cult to concentrate on work tasks
  • dry, broken skin, in the form of painful cuts, broken blisters or scratch marks
  • symptoms that fail to clear with strong topical steroids or are up immediately after stopping using them.

Severe hand eczema has a considerable impact on people’s work and social lives, causing a physical and psychological burden likened to other conditions that have unpredictable, fluctuating bouts, such as multiple sclerosis or migraine. Suffering from long-term, severe hand eczema can cause anxiety and depression and is among the leading conditions for sick leave and loss of productivity.

One participant on the trial explained: ‘Before I started on the trial, my hands were really, really sore. Every finger, every tip, was split. I couldn’t do many of the things that a normal person would have to deal with, like dressing, undressing, domestic situations. Even holding a paper, even reading a book, I couldn’t do without having some sort of covering, and even then the pressure through the covering, say cotton gloves, caused problems.’

Despite the severity of the condition, many people with severe hand eczema feel they are not receiving enough support. At a recent ALPHA trial patient event in Leeds, participants described difficulties obtaining a referral to dermatology specialists. Some said their GPs had an attitude of ‘It’s only your hands.’

Trial focus

One of the main questions that the ALPHA trial seeks to understand is which patients respond best to which type of treatment. The trial captures information on all treatments used for severe hand eczema, but our main focus is on the two current rst-line treatments used in the NHS. The first is alitretinoin – a tablet within the vitamin A class of drugs (called retinoids). It is taken once a day and works specifically on hands and feet. The second is PUVA – a form of phototherapy that involves exposing the hands to UV light after soaking them in a medicated solution (we use meladinine).

The chief investigator is Dr Miriam Wittmann, Associate Professor in In ammatory Diseases. She explained how they chose this focus: ‘We had long discussions within the trial team and really struggled to decide which treatments for severe hand eczema to focus on in the trial. Dermatologists currently cannot rely on guidelines and use a range of treatments without being able to rely on good evidence. Hence why ALPHA is such an important trial: to close the gap of lacking evidence.

‘In the end, we based the decision to include PUVA as a treatment option based on a survey of 194 UK dermatologists, who highlighted that both alitretinoin and PUVA are first-choice treatments for severe hand eczema in secondary care’, continued Dr Wittmann. ‘As well as analysing the effectiveness of different treatments, we are considering how factors like allergic background, duration, appearance and severity of the hand eczema can affect the person’s response to treatment. We are also evaluating the costs associated with hand eczema and its treatment.’

Results so far

Dr Wittmann explains: ‘While some patients show amazing responses to the treatments, a number of people with long-term, chronic hand eczema achieve an improvement but not full clearance, and only respond to the second or third treatment we try. However, with every patient included in the trial, we learn more about how to improve the treatment strategy for this often very stubborn and frustrating condition.’ One patient said: ‘Since completing the trial… I still get eczema and I still get splits but not as often. It’s amazing really.’ Another added: ‘It’s appeared again but it’s not as virulent, it’s not as sore, and I can manage [my hands] better now.

For more information see the Alpha Trial website.