MKSAP: 34-year-old woman with very dry, painful hands

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 34-year-old woman is evaluated for very dry, painful hands. She works in a daycare center and washes her hands 15 to 20 times daily, often for 2 to 3 minutes at a time. She has been applying lotion multiple times daily with no relief of the pain. She has a history of obsessive-compulsive disorder and takes no medications.

On physical examination, vital signs are normal. She has xerosis on the dorsal aspect of her hands with lichenification, erythema, and fissuring.

The remainder of the physical examination is unremarkable.

In addition to decreasing the frequency of hand washing, which of the following is the most appropriate therapy?

A: Petrolatum moisturizer
B: Topical diphenhydramine
C: Topical lidocaine gel
D: Topical neomycin

MKSAP Answer and Critique

The correct answer is A: Petrolatum moisturizer.

Less frequent washing and application of a thick emollient such as petrolatum are the treatments of choice for this patient. Irritant hand dermatitis often occurs through friction, removal of the protective skin barrier, and irritation from the surfactant properties of the soap in persons who overwash their hands. Overwashing is common in patients with obsessive-compulsive disorder. Irritant dermatitis will be especially marked on the dorsal hands where the stratum corneum is thinner than that of the palms. Topical petrolatum moisturizer is an inexpensive and effective way of repairing the damaged skin barrier by softening the stratum corneum, reducing skin water loss, and helping maintain a barrier to decrease further irritation. The petrolatum moisturizer should be applied several times daily, particularly after hand washing when it is most necessary.

Topical diphenhydramine is an antihistamine but irritant dermatitis is not driven by histamine. Therefore, an antihistamine will not be effective.

Although topical lidocaine may relieve the pain, it will not heal the skin barrier and it should not be applied repeatedly to fissured skin because of possible absorption.

Neomycin is not indicated since this patient does not have an infection. There is no purulence or crusting, and there are no pustules or erosions to indicate bacterial infection.

Key Point

  • Less frequent handwashing and application of a thick emollient such as petrolatum are the treatments of choice for irritant hand dermatitis caused by overwashing.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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