Hand eczema in a 22-year-old woman with piercings.

BUMC PROCEEDINGS 2004;17:211–213 In mid 2002, we examined a 22-year-old waitress who complained of a 5to 6-month history of painful, pruritic lesions on her hands, arms, and legs. The itch often disturbed her sleep, and her quality of life was diminished by physical discomfort and feelings of embarrassment. Lesions on both palms showed minimal vesiculation, moderate papulation and scaling, moderate to severe erythema, and severe fissuring and lichenification. Lesions on her arms and legs were less severe, showing only slight erythema and papulation. She reported a continuous course of eczematous lesions, primarily on her hands, over the previous 6 to 7 years, with the onset coinciding with a tongue piercing received in late 1995. Immediately after the piercing, she developed a significant lingual hematoma, which resolved after approximately 3 months. She received 4 subsequent piercings over the next year: one in her lip, one in her nose (transseptum) and 2 in her right pinna. Due to a persistent “raw” feeling on her tongue around the piercing site, she eventually removed her tongue stud in mid 1997, leaving a wishbone-shaped scar (Figure 1). She also reluctantly removed her facial piercings soon afterward, assuming a correlation between the jewelry and the appearance of hand eczema, which had emerged almost simultaneously. She was not significantly affected by her eczema until early 2002, when she began the process of breaking up with a long-term boyfriend. She reported frequent and excessive consumption of beer in the months following the emotional trauma. The severity of her eczema increased to an intolerable level, and her hands were continually irritated by the frequent exposure to cleaning agents at work. Over the next 5 to 6 months, her discomfort precipitated 5 visits to her primary care physician, who treated her with diflorasone diacetate ointment 0.05%, which provided temporary relief, followed by topical pimecrolimus cream, which produced little relief. She stated that she felt hopeless and defeated. The patient had a personal history of atopic dermatitis, chronic rhinitis, and allergic conjunctivitis since infancy; allergies to melons, latex, and animals since childhood; and depression since adolescence. Her surgical history included a tonsillectomy, correction of a deviated septum, and adenoid removal. She was taking loratadine for rhinitis and paroxetine HCl for depression. Her father and all of her siblings had histories of rhinitis, allergic conjunctivitis, and episodes of urticaria and contact dermatitis. Her father also had a history of asthma, both parents had drug allergies, and one sibling had atopic dermatitis as a child. What is the most likely diagnosis, and what test would confirm it? Hand eczema in a 22-year-old woman with piercings