Hand eczema in the TOACS cohort: Prevalence, incidence and risk factors from adolescence to adulthood

EPIDEMIOLOGY AND HEALTH SERVICES RESEARCHBJD

British Journal of Dermatology

Hand eczema in The Odense Adolescence Cohort Study onAtopic Diseases and Dermatitis (TOACS): prevalence,incidence and risk factors from adolescence to adulthood*C.G. Mortz, C. Bindslev-Jensen and K.E. Andersen

Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, DK-5000 Odense C, Denmark

CorrespondenceCharlotte G. Mortz.

E-mail: [email protected]

Accepted for publication

9 March 2014

Funding sourcesThis work was supported by Aage Bang’s Founda-

tion and Odense University Hospital Research

Council.

Conflicts of interest

K.E.A. is an advisor to and C.G.M. is an investi-

gator for SmartPractice, Hillerød, Denmark.

*Plain language summary available online.

DOI 10.1111/bjd.12963

Summary

Background Several studies have evaluated the incidence and prevalence of handeczema in unselected adults. However, no studies have followed unselected ado-lescents from primary school into adult life to evaluate the course and risk factorsfor hand eczema.Objectives To estimate the incidence of hand eczema from adolescence to adult-hood and the prevalence of hand eczema in young adults, together with riskfactors for hand eczema.Methods A cohort of 1501 unselected eighth-grade schoolchildren (mean age14 years) was established in 1995. In 2010, 1206 young adults from the cohortwere asked to complete a questionnaire and participate in a clinical examination,including patch testing.Results The incidence of hand eczema was 8�8 per 1000 person-years. The 1-year-period prevalence of hand eczema in the young adults was 14�3% (127 of 891)and the point prevalence 7�1% (63 of 891), with significantly higher prevalencein females. At the clinical examination 6�4% (30 of 469) had hand eczema. Fac-tors in childhood of importance for adult hand eczema were atopic dermatitisand hand eczema. Wet work in adulthood was a risk factor, as was taking care ofsmall children at home. Interestingly, hand eczema among unselected youngadults was associated with sick leave/pension/rehabilitation, indicating possiblesevere social consequences. Only 39�0% of patients participated in the clinicalexamination, while 75�0% answered the questionnaire.Conclusions A high incidence and prevalence of hand eczema were found in 28–30-year-old adults, and were highly associated with childhood hand eczema andatopic dermatitis, along with wet work and taking care of small children inadulthood. There was no association with smoking, education level or nickelallergy in childhood.

What’s already known about this topic?

• Studies including the adult population have investigated the incidence and preva-

lence of hand eczema.

What does this study add?

• This is the first follow-up study of hand eczema in unselected young adults fol-

lowed from primary school. The incidence rate of hand eczema was 8�8 per 1000

person-years.

• Factors significant for adult hand eczema were childhood atopic dermatitis and

hand eczema, and exposure to wet work in adulthood.

• Hand eczema was associated with sick leave/pension/rehabilitation, indicating pos-

sible severe social consequences.

© 2014 British Association of Dermatologists British Journal of Dermatology (2014) 171, pp313–323 313

Hand eczema is a frequent, long-lasting disease having both

personal and work-related consequences resulting in sick

leave, job change and, in the worst case, disability retirement.

Population-based studies have confirmed that hand eczema

occurs with a point prevalence of around 4%, a 1-year-period

prevalence of approximately 10% and a lifetime prevalence of

15–20%.1–3 The median incidence rate of hand eczema in the

adult general population has been calculated as 5�5 per 1000

person-years (women 9�6, men 4�0).1,4–6Early onset of hand eczema is frequent, and in about one-

third of cases it occurs before the age of 20 years.5 In a

Swedish study of 10 950 adults, the self-reported 1-year prev-

alence of hand eczema was 12% in 19–29-year-old women

compared with < 6% among women aged 70–80 years.7 The

occurrence and work-related consequences of hand eczema in

young adults have been poorly investigated, and it is impor-

tant to study the incidence of hand eczema from adolescence

to adulthood to determine the effect of occupational exposure;

taking atopic dermatitis and nickel allergy into account, how

many people will develop hand eczema when working in

various occupations with different exposure to allergens and

irritants?Atopic dermatitis is one of the most important risk factors

for hand eczema,8–11 whereas a possible association between

hand eczema and nickel allergy has been debated.12–15 Fur-

thermore, occupational exposure to water and detergents is

associated with hand eczema. However, although wet work

has been associated with hand eczema,7,16 some studies have

also rejected an association.17 Recently, it has been shown that

high water exposure over the entire day was considerably

more frequent than exposure at work, suggesting that a

significant proportion of water exposure occurs outside

work.18 Lifestyle factors such as smoking and alcohol, and also

socioeconomic factors, are reported as risk factors for hand

eczema.4,19–21

Most follow-up studies in adults are based on question-

naires without concomitant clinical examination by a derma-

tologist, and the information is given in adulthood, causing a

considerable recall bias about information from childhood.

Furthermore, questionnaire data do not always exclude other

dermatoses such as psoriasis.

Most studies have used one question, ‘Have you ever had

hand eczema?’ to estimate the prevalence of hand eczema.1

Self-reported eczema has been validated in several studies.22–24

The Nordic Occupational Skin Questionnaire (NOSQ)-2002

was developed for studies on hand eczema and relevant

exposure in order to obtain more standardized data, which

can be compared between studies and countries.25 The hand

eczema questionnaire was published in 1996, and alongside

the question, ‘Have you ever had hand eczema?’ it included

questions on location and duration.26 This questionnaire was

used to describe the prevalence of hand eczema among unse-

lected eighth-grade schoolchildren in Odense, Denmark

15 years ago.10 Since then, several other cohort studies have

used the questionnaire in occupational studies on hand

eczema.4,27,28

This investigation is a follow-up study of the school-

children’s cohort evaluated in 1995–96 (mean age 14 years)

and now reinvestigated after 15 years using the same

questionnaire supplemented with questions about relevant

exposure and occupation. As in 1995, a complete clinical

examination was performed by the same dermatologist to

determine the prevalence and extent of atopic dermatitis

and hand eczema, as well as the subtype of hand eczema,

also taking into account other skin diseases such as

psoriasis.

Materials and methods

Population and study design

Phase 1 of The Odense Adolescence Cohort Study on Atopic

Diseases and Dermatitis (TOACS) was conducted in 1995–96

as a cross-sectional study among 1501 eighth-grade school-

children (mean age 14 years) in the municipality of Odense.

This cross-sectional study included questionnaires, interviews

and clinical examinations, blood samples for IgE measure-

ment and patch tests. Phase 2 was conducted in 1996–97 as

a case–control study in selected groups of schoolchildren.

The population and study design of phases 1 and 2 have

been published.10

Phase 3 is a 15-year follow-up study in the same popula-

tion (28–30 years of age). From the original cohort, 1271

had given consent to be contacted again and had given their

personal identification number to be traced. An invitation to

the follow-up study was sent in 2010 together with a code

to an online questionnaire with 147 questions. After two

reminders the questionnaire was also sent twice in paper ver-

sion. Furthermore, the participants were offered a clinical

examination, blood samples for IgE measurement, skin prick

test, pulmonary function test and patch tests. The examina-

tion and testing took place in Odense, Copenhagen and Aar-

hus by the same investigator (C.G.M.) who performed the

phase 1 and 2 studies, assisted by two experienced dermato-

logical nurses and a laboratory technician. Pregnant women

were not allowed to participate in patch tests and skin prick

tests. Details about the follow-up study have been

reported.29,30

The Regional Ethical Committee for Southern Denmark

approved the study (S-VF-19950022).

Questionnaire

The responders completed the questionnaire with questions

on atopic dermatitis, asthma, allergic rhinoconjunctivitis, hand

eczema, urticaria/angio-oedema, and type I and IV allergy.

The questionnaire included the same questions as in phase 1,

supplemented with new questions including occupational

aspects.10,25,26,29,31

The lifetime prevalence, 1-year-period prevalence and point

prevalence of hand eczema were determined using the NOSQ-

2002 questionnaire.25,26 The criteria for a history of hand

© 2014 British Association of DermatologistsBritish Journal of Dermatology (2014) 171, pp313–323

314 Hand eczema in the TOACS cohort, C.G. Mortz et al.

eczema were eczema (rash) on the fingers, finger webs, palms

or back of hands, which had appeared once and continued for

at least 2 weeks or had appeared several times or had been

persistent.10

Furthermore, questions on hand eczema and skin exposure

from NOSQ-2002 were used (C1–3, D1–12, E1–8, F1–4,

G2–3, G6–8, H1–2, T1–3),25 together with questions on

symptoms, frequency of hand eczema eruption, changes of

occupation or work functions, skin care, hand disinfection,

smoking and other diseases. Questions about education, occu-

pation and managerial responsibilities were adopted from the

NFA (National Research Centre for the Working Environment;

www.arbejdsmiljoforskning.dk/da). Occupation was classified

according to DISCO-08 (www.dst.dk/disco), the danish ver-

sion of the ISCO-08 (International Standard Classification of

Occupations; www.ilo.org/public/english/bureau/stat/isco/

isco08). Risk occupations were defined according to Skoet

et al.32 Wet work was defined as exposure to wet work > 2 h

per day, use of occlusive gloves > 2 h per day or very fre-

quent hand washing (> 20 times per day) according to Diep-

gen and Coenraads.33

The severity of hand eczema was evaluated based on a self-

administered photographic guide,34 used with permission

from Basilea Pharmaceutica (Basel, Switzerland). Furthermore,

a visual analogue scale (VAS) was included. Data on quality of

life were obtained using the Dermatology Life Quality Index

(DLQI),35 with permission from Andrew Finlay. The lifetime

prevalence of atopic dermatitis was defined by published ques-

tionnaire criteria.31

Clinical examination

The point prevalence of hand eczema was evaluated clini-

cally by the dermatologist (C.G.M.). Objective hand eczema

was defined as inflammation with itching erythema, papules

and/or vesicles and scaling localized to the fingers or fin-

ger webs, backs of hands or palms, and with a duration

of at least 2 days.10 The severity of hand eczema was

scored using the Hand Eczema Severity Index (HESCI).36 A

clinical examination of the entire skin was performed in all

participants. The 1-year-period and point prevalences of

atopic dermatitis were calculated using the Hanifin and

Rajka criteria.37 Severity was assessed by Scoring Atopic

Dermatitis.38

Patch test

T.R.U.E. TEST panels (SmartPractice, Phoenix, AZ, U.S.A.)

were used for patch testing. The prevalence, incidence and

persistence of contact allergy and allergic contact dermatitis in

the TOACS cohort have been reported elsewhere.29,30

Nickel sensitization was based on a patch test with T.R.U.E.

TEST, supplemented with a nickel sulfate dilution series.14 The

test results were scored according to the International Contact

Dermatitis Research Group criteria and have been described in

detail previously.10,14,29,30,39

Data handling and statistics

The questionnaire was answered electronically by 743 respon-

dents, and 156 answered a paper version. The responses were

subsequently entered into a database by the first author

(C.G.M.). All clinical data were entered twice; when differ-

ences were found, a comparison with raw input forms was

made and corrections made accordingly. Statistical analysis

was performed with Stata SE 11.0 (StataCorp, College Station,

TX, U.S.A.).

The results are given as prevalence proportions and 95%

confidence intervals (CIs). Comparisons between sexes were

made by v2-based table analysis. The incidence rate was calcu-

lated from 1995 to 2010 based on those without hand eczema

in 1995. A logistic regression model was performed among

those with current hand eczema (1-year-period prevalence in

2010) as the dependent variable and atopic dermatitis in

childhood (0–14 years), nickel sensitization and wet work

in eighth grade, and hand eczema during the last year in

eighth grade as independent variables. Further independent

variables, in adulthood, were wet work (exposure to wet

work > 2 h per day, use of occlusive gloves > 2 h per day or

very frequent hand washing, > 20 times per day), care for

children aged < 4 years for > 2 h per day, being on sick

leave/disability pension/rehabilitation, and smoking, educa-

tion and sex. The strategy for statistitical analysis was decided

in advance. Statistical significance was defined as P < 0�05.

Results

In total, 1206 of the 1271 original participants (95%) were

retrieved in Denmark through the national Central Person Reg-

ister; four had died, one person was missing and 60 had emi-

grated to other countries. After four reminders the response

rate for answering the questionnaire was 74�5% (899 of

1206), and 38�9% (469 of 1206) of those invited (52�2% of

those who responded by questionnaire) participated in the

clinical examination (Fig. 1). The 899 answering the ques-

tionnaire in 2010 were a representative part of the 1995

population, except that more women than men participated in

the follow-up questionnaire and more people with atopic

dermatitis in childhood participated (Table 1).

Questionnaire

Prevalence and incidence of hand eczema

The lifetime prevalence of hand eczema was 23�0% (205/

891; 95% CI 20�3–25�9). The 1-year-period prevalence of

hand eczema in the young adults was 14�3% (127/891; 95%

CI 12�0–16�7) and the point prevalence 7�1% (63/891; 95%

CI 5�5–9�0), with significantly higher prevalence in women

than in men (Table 2).

In 1995, 9�8% (87) of the 891 participants in phase 3 had

ever had hand eczema (eight of the 899 did not answer the

hand eczema questions). From 1995 to 2010, 14�7% (118 of

© 2014 British Association of Dermatologists British Journal of Dermatology (2014) 171, pp313–323

Hand eczema in the TOACS cohort, C.G. Mortz et al. 315

804) developed hand eczema, giving a calculated incidence

rate of 8�8 per 1000 person-years. Among women the inci-

dence rate was 11�0 per 1000 person-years and for men 6�0per 1000 person-years.

Description of current hand eczema (1-year-period

prevalence)

Further analysis was performed among the 127 individuals

with current hand eczema (1-year-period prevalence); 93 had

eczema on the fingers or finger webs (17 on the fingertips),

76 on the back of the hands and 34 on the palms. Of those

with hand eczema during the last year, 40�2% (51 of 127)

also reported eczema on the wrist and/or forearm (31 wrist,

25 forearm). The most commonly reported symptoms were

itching (82�7%), erythema (81�9%) and dry skin with scaling

(76�4%). Vesicles were reported by 36�2%.

The frequency of hand eczema eruption was reported to be

less than once every third month among 36�2% (n = 46),

more than once every third month among 29�1% (n = 37)

and (nearly) all the time by 31�5% (n = 40).

The severity of hand eczema in the questionnaire was evalu-

ated both at present and when the eczema was worst, using a

VAS and a photographic guide. At the time of the study the

VAS score was 0 in 29�0%, 1–3 in 42�0% and 4–6 in 17�0%,while only 11�0% reported a VAS score ≥ 7. When the eczema

was worst the VAS score was ≥ 7 in 38�0%, and 36�0% had a

VAS score of 4–6, while only 26�0% had a score of ≤ 3.

The photographic guide showed that 47�0% of patients

were clear of disease at the time of the study, 32�0% were

almost clear, 19�0% had moderate eczema, and 2�0% had

severe and 0�8% very severe hand eczema. When the eczema

was worst, 3�0% reported very severe eczema, 27�0% severe

eczema, 46�0% moderate and 22�0% almost clear or clear.

Table 1 Comparison of baseline characteristics (1995) between participants and nonparticipants in the questionnaire in the follow-up study

(2010)

Baseline characteristic

Participants in follow-up

questionnaire

Nonparticipants in follow-up

questionnaire

P-valuePrevalence (%) n/N Prevalence (%) n/N

Sex

Female 56�3 506/899 38�4 207/539Male 43�7 393/899 61�6 332/539 < 0�05

Present or past atopic dermatitis 23�9 215/899 16�9 91/539 < 0�01Present or past hand eczema 9�8 88/899 8�3 45/539 0�36Present or past allergic rhinitis 19�7 177/899 16�9 91/539 0�19Present or past asthma 12�0 108/899 11�3 61/539 0�69Contact allergya 15�4 120/778 14�7 54/368 0�74Positive specific IgEb 28�1 171/609 33�1 86/260 0�14aIn phase 1, 1146 of 1438 participated in patch testing; bin phase 1, 869 of 1438 gave blood samples for IgE measurement.

Phase 1 (1995) Phase 2 (1996) Phase 3 (2010)

1501 eighth-grade school children invited 1206 adults invited

Questionnaire1438 (95·8%)

Clinical examination, interview Further testing in cases and Clinical examination, interview1340 (89·3%) controls (563) including 469 (38·9%)

skin prick, skin barrier andpulmonary function tests

Patch test Blood sample Patch test Skin prick test1146 (76·3%) 869 (57·9%) 442 (36·7%) 460 (38·1%) 466 (38·6%)

Questionnaaire899 (74·5%)

Blood sample

Fig 1. Flowchart and participation of the cohort in phases 1–3 (reproduced from Mortz et al.30).



In 51 of the 127 patients with hand eczema during the last

year, contact with certain materials, chemicals or anything else

at work was reported to aggravate the eczema. The most com-

mon self-reported exacerbation factors at work were frequent

hand washing or wet work (n = 16), protective gloves (n =

11), soap (n = 10), detergents (n = 6) and food or plants (n

= 5). In 48 of 127, the eczema improved when away from

normal work, as at weekends or during holidays. In total, 75

of 127 with current hand eczema reported onset of hand

eczema at 18 years of age or later; 41 of these 75 (55�0%)had the same type of work as when the hand eczema started,

and 36 of 75 (48�0%) had the same work function.

Hand eczema was reported to affect daily occupational

activities in 36�2% of this group (46 of 127). The most com-

mon statements were, ‘I have to use protective gloves’ (n =

27), ‘I have been sick listed or otherwise off work’ (n = 9)

and ‘I have changed jobs’ (n = 7). None was on pension

owing to hand eczema.

In 55 of 127 patients with hand eczema during the last year,

procedures outside the workplace were reported to worsen the

hand eczema. The most common factors reported were expo-

sure to detergents and other household cleaning and laundry

products (n = 40), frequent hand washing or work with wet

hands (n = 67), soap, shampoo and other personal hygiene

products (n = 16), and handling of food (n = 16).

Hand eczema was reported to have a negative influence on

patients’ financial situation [medical and other linked

expenses, lost workdays, work capacity and/or change of job]

in 35�0% (44 of 127), with 6�0% having some to substantial

financial loss, and 29�0% reporting that they had extra

expenses. The NOSQ questions on how hand eczema affected

life during the last 12 months showed that the most affected

areas were daily activities at home (74 of 127), mood (55 of

127), occupational work (41 of 127) and sleep (36 of 127).

The DLQI was between 0 and 18 (median 1) among those

with hand eczema during the last year. Factors with the high-

est scores were itchy, sore, painful or stinging skin (68 of

121), skin condition interfered with shopping or looking after

home or garden (32 of 121) and eczema prevented the per-

son from working or studying (26 of 121) (six did not

answer the question on quality of life).

Factors from childhood, educational level and smoking

habits

Atopic dermatitis in childhood occurred in 23�9% of those

answering the questionnaire in phase 3, and hand eczema in

adolescence (1-year-period prevalence in seventh–eighth

grade) was found in 7�7%. Childhood atopic dermatitis was

found in 41�7% of those with current hand eczema compared

with 20�9% of those without, and 22�1% of those with cur-

rent hand eczema had experienced hand eczema in adoles-

cence compared with 5�4% of those without.

In eighth grade, 8�5% of the population answering the hand

eczema questionnaire in phase 3 were sensitized to nickel;

11�1% of those with current hand eczema as adults compared

with 8�1% of those without hand eczema. Wet work in ado-

lescence was reported by 34�3%, with no difference between

the two groups.

Middle (3–4 years) to long (> 4 years) vocational training

was reported with the same frequency in those with or with-

out current hand eczema (52�8% vs. 53�5%, respectively). Thesmoking history was approximately the same in those with

hand eczema during the last year (54�0%) compared with

those without (47�6%).

Exposure and occupation

The response to questions on selected exposure variables at

work and home in relation to current hand eczema is shown

in Table 3. There was no significant change in the results

when dividing the group without current hand eczema into

those with earlier hand eczema (> 1 year ago) and those who

never had hand eczema.

Table 2 Lifetime prevalence, one-year period prevalence and point prevalence of hand eczema based on questionnaire in the 891 adults

participating both in phase 1 and 3, and point prevalence of hand eczema in the 469 interviewed and examined clinically in phase 3

Questionnaire

Total populationn = 891e

% (n)

Womenn = 502

% (n)

Menn = 389

% (n)

Ever hand eczema phase 1 (0–14 years) 9�8 (87) 12�6 (63)c 6�2 (24)

Ever hand eczema phase 1 and/or 3 (lifetime 0–29 years) 23�0 (205) 29�1 (146)a 15�2 (59)Hand eczema during the last year phase 3 (1 year) 14�3 (127) 17�9 (90)b 9�5 (37)

Hand eczema at the moment phase 3 (point) 7�1 (63) 9�0 (45)d 4�6 (18)

Clinical

Total populationn = 469

%(n)

Womenn = 286

% (n)

Menn = 183

% (n)

Hand eczema at the clinical examination (point) 6�4 (30) 7�7 (22) 4�4 (8)

aP < 0�0001 for sex difference. bP < 0�0005 for sex difference. cP < 0�002 for sex difference. dP < 0�02 for sex difference. eIn total, 899

answered the questionnaire, however only 891 had answered the questions on self-reported hand eczema.



Use of gloves at present was common (n = 190), the most

commonly used types being natural rubber/latex (n = 146)

and synthetic rubber (e.g. nitrile, neoprene; n = 85). Other

types were plastic (e.g. vinyl, polyvinylchloride, polythene;

n = 45), cloth (n = 44), leather (n = 16) and other/unknown

type (n = 16). Cotton gloves beneath rubber or plastic gloves

were used by 23 respondents. Skin complaints from glove use

were common and occurred in 16�2% (70 of 433) of those

who had ever used gloves, particularly in those with hand

eczema during the last year (48�0%, 34 of 71) but only 9�9%(36 of 362) of those without hand eczema during the last

year. Natural rubber/latex gloves were the most common cul-

prit (41/70), and 33% (23/70) had changed glove type or

stopped using gloves.

The occupational status of the cohort is shown in Table 4.

In total, 13�1% worked in a risk occupation, 17�3% of those

with current hand eczema and 12�4% of those without cur-

rent hand eczema. Focusing on the occupations where more

than 20 people were placed, the highest prevalence of hand

eczema occurred in those on disability pension/rehabilitation

(10 of 28, 36�0%), on sick leave (seven of 23, 30�0%),in healthcare work (15 of 77, 19�0%) and in those

unemployed/on leave (17 of 99, 17�0%). In typical dry

work, such as office work, the prevalence was 12�4%. Veryfew cleaners, hairdressers, laboratory technicians or doctors/

dentists/midwives participated in the study, nor did people in

the food and plants industry. In the group with hand eczema

during the last year and on sick leave (n = 7), three answered

that they had been on sick leave due to hand eczema, and all

three had lost a job due to hand eczema. In the group on dis-

ability pension or rehabilitation (n = 10) none reported pen-

sion due to hand eczema. However, one had been on sick

leave owing to hand eczema and lost a job owing to hand

eczema.

Predictive factors for current hand eczema in adults

A logistic regression analysis with hand eczema during the last

year as the binary outcome is shown in Table 5. The regres-

sion analysis include factors from childhood (phase 1), and

exposures (phase 3), including wet work, taking care of small

children, sick leave/disability pension/rehabilitation, educa-

tion, smoking and sex. The number inluded in the analysis

was 771 because not all questionnaire respondents in 2010

Table 3 Exposure at work and at home in relation to current hand eczema (1-year-period prevalence of hand eczema in 2010)

Total population,

n = 889aHand eczema during the

last year, n = 126

No hand eczema during

the last year, n = 763

Factors at workExposure to wet work, hours per day 352 (39�6) 64 (50�8) 288 (37�7)

< 0�5 197 29 1680�5–2 102 22 80

> 2 52 (5�8) 13 (10�3) 39 (5�1)Don’t know 1 0 1

Glove use, hours per day 190 (21�4) 31 (24�6) 159 (20�8)1 76 14 62

2 37 7 30> 2 74 (8�3) 9 (7�1) 65 (8�5)Don’t know 3 1 2

Hand washing, times per day 889 (100) 126 (100) 763 (100)

0–5 243 32 2116–10 351 43 308

11–20 200 25 175> 20 95 (10�7) 26 (20�6) 69 (9�0)

Hand disinfectant use, times per day 364 (40�9) 59 (46�8) 305 (40�0)1–5 242 32 210

6–20 76 16 60> 20 46 11 35

Moisturizer use (hands), times per day 669 (75�3) 116 (92�1) 617 (80�9)Not every day 329 43 286

1–2 215 38 177> 2 125 35 90

Factors at homeCare for children aged < 4 years, hours per day 321 (36�1) 58 (46) 263 (34�5)

< 0�5 17 3 140�5–2 17 2 15

> 2 287 (32�3) 53 (42�1) 234 (30�7)

Values are n or n (%). aIn total 899 patients answered the questionnaire, but only 891 had answered the questions on self-reported hand

eczema, and 889 on exposure.



had been patch tested in 1995. Including all patients in phase

3, and using the question on self-reported nickel dermatitis as

a marker of nickel sensitization instead of a positive nickel

patch test in 1995 did not change the outcome (data not

shown).

The model shows that factors in childhood important for

adult hand eczema were childhood atopic dermatitis and hand

eczema already in adolescence. Wet work as an adult is also a

risk factor, as is taking care of small children at home. Inter-

estingly, sick leave/disability pension/rehabilitation, already at

the age of 29 years, is associated with current hand eczema.

Clinical examination: point prevalence of hand eczema

In total, 6�4% of respondents (30 of 469) had hand eczema at

clinical examination (Table 2). It appeared on the fingers or

finger webs in 25 adults (four on the fingertips); 12 had

eczema on the back of the hands and six on the palms. The

severity score (HESCI) was mild in 22 of 30, moderate in

seven and severe in one.

The diagnosis of hand eczema was irritant contact dermatitis

(ICD) and atopic dermatitis (n = 16), ICD (n = 5), vesicular

hand eczema (n = 3), and one each with atopic hand eczema;

allergic contact dermatitis and atopic hand eczema; atopic

hand eczema and vesicular hand eczema; ICD and vesicular

hand eczema; ICD, atopic hand eczema and vesicular hand

eczema; and unspecific fungus-infected eczema. None had

hyperkeratotic hand eczema. In 10 cases the eczema was

judged to be work related. Only one had contact allergic hand

eczema.

The treatment reported was topical steroids in 19 of 30.

None used topical immunomodulators or systemic treatment.

In 28 of 30 moisturizers were used, in 14 twice or more a

day. In 20 of these 30 the hand eczema had started after

18 years of age. All patients were interviewed about trigger

factors, and 19 reported wet work, 16 soap, six cleaning

agents, three food stuffs and three gloves.

In addition to the patients with hand eczema (n = 30), the

most common diagnoses were atopic dermatitis (n = 29),

acne/rosacea (n = 13), psoriasis (n = 8), seborrhoeic dermati-

tis (n = 6) and vitiligo (n = 5).

Discussion

This study confirms the high prevalence of hand eczema in

young adults (28–30 years old), with a lifetime prevalence of

23�0%, a 1-year-period prevalence of 14�3% and a point prev-

alence of 7�1% evaluated by questionnaire, and a point preva-

lence of 6�4% evaluated by clinical examination (Table 2).

Significantly more women than men had hand eczema. Com-

pared with other population-based studies, our prevalence fig-

ures are higher, reflecting the different age group in this

investigation (28–30 years) compared with other studies

pooling data from different age groups, including older

Table 4 Occupational status in relation to current hand eczema (1-year-period prevalence of hand eczema in 2010)

Total population,

n = 891aHand eczema during


No hand eczema during


Wet work occupationsHealthcare worker 77 (8�6) 15 (11�8) 62 (8�2)Cleaner 4 (0�5) 0 4 (0�5)Hairdresser 5 (0�6) 0 5 (0�6)Doctor, dentist, midwife 10 (1�1) 1 (0�8) 9 (1�2)Laboratory technician 5 (0�6) 1 (0�8) 4 (0�5)

Food and plants occupationsButcher, cook, kitchen worker 13 (1�5) 3 (2�4) 10 (1�3)Greenhouse worker, florist 3 (0�3) 2 (1�6) 1 (0�1)

Risk occupations in total (wet/food/plants) 117 (13�1) 22 (17�3) 95 (12�4)Other occupationsOffice worker, level 1–5b 380 (42�6) 47 (37�0) 333 (43�6)Tradesman, level 7 50 (5�6) 2 (1�6) 48 (6�3)Other, level 6, 8, 9c 29 (3�3) 3 (2�4) 26 (3�4)Education theoretical 137 (15�4) 17 (13�4) 120 (15�7)Education practical 28 (3�2) 2 (1�6) 26 (3�4)Unemployed, on leave 99 (11�1) 17 (13�4) 82 (10�7)Sick leave 23 (2�6) 7 (5�5) 16 (2�1)Disability pension, rehabilitation 28 (3�1) 10 (7�9) 18 (2�4)

Values are n (%). aIn total, 899 participants answered the questionnaire regarding occupation, but only 891 answered the questions on self-

reported hand eczema. The occupations of the other eight were one healthcare worker, four office workers, one tradesman, one in education

and one on disability pension/rehabilitation. bOffice worker, level 1–5, refers to DISCO-08, the Danish version of the International Standard

Classification of Occupations. In this version, level 1 referes to leadership, level 2 high educational level, level 3 medium educational level,

and level 4–5 officework and sales at lower level. cOther levels (6, 8, 9) refer to work in farms, fishing, hunting and factory work, transpor-

tation and other.



people.1 Although they looked at different age groups, the

other studies also showed a peak among young women.7,40,41

The incidence from adolescence to adulthood was 8�8 per

1000 person-years (11�0 in women, 6�0 in men). Incidence

data based on prospective studies of hand eczema from adoles-

cence to young adulthood have not been reported before. In

the general adult population the incidence was reported in a

retrospective study to be 3�3 per 1000 person-years in 24

–77-year-old unselected adults from Sweden.5 Meding and

Jarvholm also found that the incidence was highest among

20–29-year-old women (11�4 per 1000 person-years),5 which

is similar to our value. A Danish twin study among adults

(aged 19–52 years) followed prospectively for 9 years also

found an incidence of 8�8 per 1000 person-years.4 Further-

more, in a cohort of car industry workers followed for a mean

of 13�3 years, about 30% had hand eczema at least once dur-

ing the study period,42 showing the burden of hand eczema

in the car industry.

The power of this study is that the participants were ques-

tioned and clinically examined prospectively over 15 years by

the same investigative team, giving the best obtainable infor-

mation about incidence together with risk factors in child-

hood, and also including information on education and

occupation. Recall bias is eliminated. The limitations include

only 39�0% participating in the clinical examination, while

75�0% answered the questionnaire. Comparing baseline char-

acteristics in 1995 and 2010, the participants constitute a rep-

resentative sample (Table 1), except that more with atopic

dermatitis in childhood participated in the follow-up.

The severity of hand eczema at the time of examination

was moderate to very severe in 22�0%, as judged by the pho-

tographic guide, and 76�0% reported moderate-to-very-severe

hand eczema when they were asked how severe the hand

eczema was when it was worst during the last year. This is

important and points to the fact that when chronic intermit-

tent diseases are evaluated it is useful to evaluate the range of

Table 5 Results of logistic regression on current hand eczema in adults (1-year-period prevalence of hand eczema in 2010)

Hand eczema during the

last year, phase 3 (2010),n = 116

No hand eczema during the

last year, phase 3 (2010),n = 655 OR (95% CI) P-value

Phase 1 (1995)

Atopic dermatitis (age 0–14 years)No 66 503

Yes 50 (43�1) 152 (23�2) 1�9 (1�2–3�0) < 0�01Nickel sensitization (age 14 years)

No 103 602Yes 13 (11�2) 53 (8�1) 1�0 (0�5–2�1) 0�93

Wet work after school (age 14 years)No 76 420

Yes 40 (34�5) 235 (35�9) 1�0 (0�6–1�5) 0�89Hand eczema (age 13–14 years)

No 88 617Yes 28 (24�1) 38 (5�8) 4�2 (2�3–7�5) < 0�01

Phase 3 (2010)Wet worka

No 83 535Yes 33 (28�4) 120 (18�3) 1�7 (1�1–2�8) 0�03

Taking care of children aged < 4 years for > 2 h per dayNo 66 460

Yes 50 (43�1) 195 (29�8) 1�7 (1�1–2�7) 0�02Sick leave/disability pension/rehabilitation

No 101 626Yes 15 (12�9) 29 (4�4) 2�7 (1�3–5�7) < 0�01

SmokingNo 53 349

Yes 63 (54�3) 306 (46�7) 1�4 (0�9–2�1) 0�13Educational level

None/short 55 295

Middle/long 61 (52�6) 360 (55�0) 1�0 (0�7–1�6) 0�91Sex

Female 85 372Male 31 (26�7) 283 (43�2) 0�66 (0�4–1�1) 0�09

OR, odds ratio; CI, confidence interval. Statistically significant results are in bold. The regression model is based on 771 adults participating in

the questionnaire in both phases 1 and 3 and the patch test in phase 1, and thus excludes the 118 not patch tested in phase 1. aWet work was

defined as exposure to wet work > 2 h per day, use of occlusive gloves > 2 h per day or very frequent hand washing (> 20 times per day).



severity both from the day of investigation and when the dis-

ease is worst. One-third of participants reported chronic hand

eczema.

At the clinical examination 30 patients had hand eczema.

Most cases were mild as evaluated by HESCI score, and only

half had used topical corticosteroids, while none had used

more potent treatments. One-third of the cases were judged

be work related. Allergic contact dermatitis was found in only

one case, and most cases were ICD and atopic dermatitis.

Owing to a time interval between answering the questionnaire

and performing the clinical examination of up to 6 months,

the point prevalence in the questionnaire and at the clinical

examination could not be compared directly. However, the

prevalence found in the questionnaire (7�1%) and at the clini-

cal examination (6�4%) was nearly the same.

Childhood atopic dermatitis and hand eczema in adoles-

cence were significantly associated with adult hand eczema, in

agreement with several other studies, both in retrospective

and prospective designs.4,11,28,43 We found no relationship

between nickel sensitization or wet work in adolescence and

development of adult hand eczema (Table 5). It has been sug-

gested that nickel sensitization is associated with development

of hand eczema,12 but in 2006 Josefson et al. showed that a

positive nickel patch test in childhood did not indicate

increased risk of hand eczema 20 years later in life,13 in

agreement with this study.

The importance of wet work, frequent hand washing and

use of protective gloves as trigger factors for hand eczema is

in agreement with present knowledge. Also, taking care of

small children for > 2 h daily at home was important

(Table 5), as shown previously.44 In the questionnaire, 40�2%of those with current hand eczema reported exacerbation at

work and 37�8% reported improvement during time off.

However, 43�3% also reported exacerbation factors outside

work.

Lifestyle factors such as smoking and educational level have

been suggested as risk factors for hand eczema,19–21 but no

correlation was found in this study.

Many of the 29-year-old adults are still in education or

have been working in trade for only a few years (Table 4).

Categorizing the work into risk occupations according to

Skoet et al.,32 there was a tendency that more people with

hand eczema during the last year worked in wet occupations.

However, the numbers in the different groups were small,

and in total only 117 worked in risk occupations: 17�0%among those with hand eczema and 12�0% without. There-

fore, further analysis could not be performed. Those with

jobs as healthcare workers are at high risk, as recently shown

in another Danish study.28 The high frequency of pension/

rehabilitation/sick leave among young adults with current

hand eczema emphasizes the social impact of chronic hand

eczema for the individual, as well as for society. It is alarm-

ing that hand eczema in young adults is associated with sick

leave/disability pension/rehabilitation, as 13�4% of those

with hand eczema belong to this group compared with 4�5%without hand eczema. In a 15-year follow-up in Sweden it

was also found that 5% of patients with hand eczema had

far-reaching consequences, including long sick-leave periods,

sick pension and change of occupations.45

The long-term prognosis for hand eczema is poor,45 and

hand eczema has a significant impact on quality of life.46,47

Although hand eczema in this population-based study was

mild to moderate in the majority of cases, and the DLQI

not as high as in studies including patients from dermato-

logical departments,46 one-third of the young adults were

affected in daily activities in their occupations. Most com-

monly, they reported that they had to use gloves, had been

sick listed or had even changed job. Only 6% reported some

or substantial financial loss in this age group. Recently, a

Danish study evaluated the effect of a secondary prevention

programme for hand eczema among healthcare workers. The

programme reduced disease severity and improved quality of

life and had a positive effect on self-evaluated severity and

skin protective behaviour by hand washing and the wearing

of protective gloves.48 Such programmes should be recom-

mended to all people in at-risk occupations to improve the

long-term prognosis for hand eczema and the quality of life

for patients. It will be important to follow up the TOACS

cohort again with respect to development of hand eczema

when the young adults have been working for a longer time

in their trade. Many were still in education.

In conclusion, this prospective population-based cohort

study of hand eczema from adolescence to adulthood showed

a high incidence and prevalence of hand eczema both by

questionnaire and by clinical examination, although most

cases were mild to moderate. Childhood factors of significance

for adult hand eczema were atopic dermatitis (at age 0–

14 years) and hand eczema in adolescence (age 14 years),

while the factors of importance in adulthood were wet work

and exposure to wet work at home (taking care of small chil-

dren). Association with risk occupations in this unselected

population of young adults could not be evaluated further due

to the small numbers of people in the different occupations.

Many were still in education or had worked only a few years

in their particular jobs.

Acknowledgments

We thank the adults from the TOACS cohort for their coopera-

tion, and nurses Lis Lykkegaard and Marianne Hald, and labo-

ratory technician Anni Larsen for skilful technical help. This

work used the technical facilities of OPEN (Odense Patient

data Exploratory Network), Odense University Hospital,

Odense, Denmark.

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Hand eczema in the TOACS cohort: Prevalence, incidence and risk factors from adolescence to adulthood