Hyperkeratotic Hand Eczema due to Use of Rubber Gloves While Driving

Dear Editor:

Hyperkeratotic hand eczema (HHE) is defined as a lesion of hand dermatitis that shows thick hyperkeratotic plaques with or without deep fissures. This diagnosis was established in 2%~5% of patients with hand dermatitis1, 2. HHE is considered to have multiple causes, such as exposure to repetitive irritation, atopy, contact allergy, and friction3. Previous studies have revealed that contact sensitization is less common in HHE2. Here, we report a case of chronic HHE associated with contact sensitization to black rubber mix and thiuram mix.

A 50-year-old nonatopic male patient presented with chronic HHE that had been refractory to previous treatments for the last 2 years. Physical examination revealed relatively well-demarcated erythematous scaly plaques on the palmar sides of both hands (Fig. 1A). He was a salesman who had always driven a car to his meetings. For 3 years, he had been wearing his work gloves, which had rubber on the palmar side, to prevent his hand from sliding off the steering wheel while driving because of his palmar hyperhidrosis (Fig. 2A). He had received eczema treatment with potent topical corticosteroid creams and moisturizer at local clinics; however, his symptoms did not improve. Then, he was referred to our hospital. We performed patch tests with a thin-layer rapid use epicutaneous (TRUE) test kit (Mekos Laboratories AS, Hillerod, Denmark). There were positive reactions to thiuram mix(++) and black rubber mix(++) at 48 h, and additional positive reactions to p-tertbutylphenol formaldehyde resin(+) and p-phenylenediamine(+) at 96 h (Fig. 2B). He was advised to apply a topical steroid with medium potency and to drive without wearing gloves, and his symptoms improved 2 weeks later (Fig. 1B). Thereafter, he underwent use tests with the work gloves, which worsened his symptoms.

Fig. 1
(A) Localized scaly yellowish plaques on the palmar sides of both hands. (B) Two weeks after avoiding exposure to the offending allergen.

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Fig. 2
(A) Blue rubber dotted work gloves. (B) Positive patch test reactions to thiuram mix(++), black rubber mix(++), p-tertbutylphenol formaldehyde resin(+), and p-phenylenediamine(+) at 96 h.

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A hyperkeratotic morphology is known to be less frequently associated with contact sensitization, irritant exposure, and atopic dermatitis1. Thus, strongly positive reactions to more than two materials during the patch test have clinical implications. We made a diagnosis of HHE due to repetitive use of the work gloves on the basis of the patient's history, patch tests, and use tests.

Thiurams are accelerants that are commonly used to manufacture natural rubber latex products. These mixes are present in natural or synthetic rubber products making up materials that are used either at work or at home4. Many tire workers are sensitized to black rubber mix. Concerning nonoccupational exposure, it has been shown that black rubber footgear and the rubber tips of walking sticks can also cause contact dermatitis5. Positive reaction to p-tertbutylphenol formaldehyde resin is related to contact with waterproof glue, bonded leather, and construction materials, whereas that to p-phenylenediamine is related to contact with permanent or semipermanent hair dyes, dyed textiles, and cosmetics; however, these are less relevant compared with our case. In conclusion, this report suggests that patients with HHE should be comprehensively evaluated through history taking and correctly treated by avoiding the suspicious material.