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Eczematous Changes on the Hands—Diagnosis

Eczematous Changes on the Hands—Diagnosis Diagnosis: “Mechanic’s hands” as part of the antisynthetase syndrome. Microscopic findings and clinical course Histologic examination of the biopsy specimen revealed psoriasiform acanthosis with thick parakeratosis. A heavy lymphohistiocytic infiltrate in the upper dermis was noted, along with an interface dermatitis with occasional colloid bodies. Lymphocyte exocytosis was seen. Our patient experienced little benefit from treatment with a variety of topical agents, including 0.05% clobetasol propionate and propylene glycol. However, her skin, joint, and muscle problems dramatically improved after therapy with systemic prednisolone (30 mg/d) and azathioprine (100 mg twice daily) was initiated. Discussion Mechanic’s hands is a term that was first coined by Stahl et al1 in 1979. It denotes hyperkeratotic change on the hands or feet, usually over the radial surfaces.2 The condition is reported to be similar to the calloused hands seen in manual workers. Although mechanic’s hands may beseen with polymyositis and other connective tissue diseases, such as systemic lupus erythematosus, systemic sclerosis, and overlap syndromes,3 the hyperkeratotic skin changes are most closely associated with the antisynthetase syndrome (as in our patient), which comprises arthritis, Raynaud phenomenon, mechanic’s hands, and interstitial lung disease, along with the presence of anti–Jo-1 antibody. There is a slight female preponderance in mechanic’s hands (1.7:1.0), with the diagnosis usually being made in the fourth decade of life. The mortality rate associated with the antisynthetase syndrome can be as high as 20%.4 This syndrome is caused by antibodies against histidyl–transfer ribonucleic acid synthetase (Jo-1), which is expressed in a number of organs, including the skeletal muscles, lungs, heart, liver, and kidneys. The pathophysiologic mechanisms of antisynthetase syndrome are not fully understood. The cutaneous changes are particularly difficult to explain because histidyl–transfer ribonucleic acid synthetase has not been reported as being expressed in the skin. It is also not clear why the radial surfaces of the hand should be affected preferentially. Mechanic’s hands is thought to be a specific marker for myositis and is closely linked with anti–Jo-1 antibody positivity. The main differential diagnosis of mechanic’s hands includes psoriasis and hyperkeratotic dermatitides such as contact dermatitis. The histopathologic findings are typically nonspecific but may be similar to those seen in dermatomyositis. Topical corticosteroid therapy for the cutaneous involvement may be successful, although there are very few reports in the literature. If other features of the antisynthetase syndrome are present, systemic immunosuppression with agents such as corticosteroids, azathioprine, methotrexate, or cyclophosphamide (alone or in combination) is indicated. References 1. Stahl NIKlippel JHDecker JL A cutaneous lesion associated with myositis Ann Intern Med 1979;91577- 579PubMedGoogle ScholarCrossref 2. Mitra DLovell CLMacLeod TIFTan RSMaddison PJ Clinical and histological features of “mechanic’s hands” in a patient with antibodies to Jo-1: a case report Clin Exp Dermatol 1994;19146- 148PubMedGoogle ScholarCrossref 3. Garcia-Patos VBartralot RFonollosa V et al. Childhood sclerodermatomyositis: report of a case with the anti-PM/Scl antibody and mechanic’s hands Br J Dermatol 1996;135613- 616PubMedGoogle ScholarCrossref 4. Taggart AJFinch MBCourtney PAGormley GJ Anti Jo-1 myositis: “mechanic’s hands” and interstitial lung disease Ulster Med J 2002;7168- 71PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Eczematous Changes on the Hands—Diagnosis

Archives of Dermatology , Volume 141 (6) – Jun 1, 2005

Eczematous Changes on the Hands—Diagnosis

Abstract

Diagnosis: “Mechanic’s hands” as part of the antisynthetase syndrome. Microscopic findings and clinical course Histologic examination of the biopsy specimen revealed psoriasiform acanthosis with thick parakeratosis. A heavy lymphohistiocytic infiltrate in the upper dermis was noted, along with an interface dermatitis with occasional colloid bodies. Lymphocyte exocytosis was seen. Our patient experienced little benefit from treatment with a variety of topical agents,...
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Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.141.6.779-g
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: “Mechanic’s hands” as part of the antisynthetase syndrome. Microscopic findings and clinical course Histologic examination of the biopsy specimen revealed psoriasiform acanthosis with thick parakeratosis. A heavy lymphohistiocytic infiltrate in the upper dermis was noted, along with an interface dermatitis with occasional colloid bodies. Lymphocyte exocytosis was seen. Our patient experienced little benefit from treatment with a variety of topical agents, including 0.05% clobetasol propionate and propylene glycol. However, her skin, joint, and muscle problems dramatically improved after therapy with systemic prednisolone (30 mg/d) and azathioprine (100 mg twice daily) was initiated. Discussion Mechanic’s hands is a term that was first coined by Stahl et al1 in 1979. It denotes hyperkeratotic change on the hands or feet, usually over the radial surfaces.2 The condition is reported to be similar to the calloused hands seen in manual workers. Although mechanic’s hands may beseen with polymyositis and other connective tissue diseases, such as systemic lupus erythematosus, systemic sclerosis, and overlap syndromes,3 the hyperkeratotic skin changes are most closely associated with the antisynthetase syndrome (as in our patient), which comprises arthritis, Raynaud phenomenon, mechanic’s hands, and interstitial lung disease, along with the presence of anti–Jo-1 antibody. There is a slight female preponderance in mechanic’s hands (1.7:1.0), with the diagnosis usually being made in the fourth decade of life. The mortality rate associated with the antisynthetase syndrome can be as high as 20%.4 This syndrome is caused by antibodies against histidyl–transfer ribonucleic acid synthetase (Jo-1), which is expressed in a number of organs, including the skeletal muscles, lungs, heart, liver, and kidneys. The pathophysiologic mechanisms of antisynthetase syndrome are not fully understood. The cutaneous changes are particularly difficult to explain because histidyl–transfer ribonucleic acid synthetase has not been reported as being expressed in the skin. It is also not clear why the radial surfaces of the hand should be affected preferentially. Mechanic’s hands is thought to be a specific marker for myositis and is closely linked with anti–Jo-1 antibody positivity. The main differential diagnosis of mechanic’s hands includes psoriasis and hyperkeratotic dermatitides such as contact dermatitis. The histopathologic findings are typically nonspecific but may be similar to those seen in dermatomyositis. Topical corticosteroid therapy for the cutaneous involvement may be successful, although there are very few reports in the literature. If other features of the antisynthetase syndrome are present, systemic immunosuppression with agents such as corticosteroids, azathioprine, methotrexate, or cyclophosphamide (alone or in combination) is indicated. References 1. Stahl NIKlippel JHDecker JL A cutaneous lesion associated with myositis Ann Intern Med 1979;91577- 579PubMedGoogle ScholarCrossref 2. Mitra DLovell CLMacLeod TIFTan RSMaddison PJ Clinical and histological features of “mechanic’s hands” in a patient with antibodies to Jo-1: a case report Clin Exp Dermatol 1994;19146- 148PubMedGoogle ScholarCrossref 3. Garcia-Patos VBartralot RFonollosa V et al. Childhood sclerodermatomyositis: report of a case with the anti-PM/Scl antibody and mechanic’s hands Br J Dermatol 1996;135613- 616PubMedGoogle ScholarCrossref 4. Taggart AJFinch MBCourtney PAGormley GJ Anti Jo-1 myositis: “mechanic’s hands” and interstitial lung disease Ulster Med J 2002;7168- 71PubMedGoogle Scholar

Journal

Archives of DermatologyAmerican Medical Association

Published: Jun 1, 2005

Keywords: hand

References