1684

ORIGINAL RESEARCH—PAIN

Sexual Dysfunction in Patients with Chronic Hand Eczema in the

Turkish Population

Mahizer Ergün, MD,* Aylin Türel Ermertcan, MD,* Serap Öztürkcan, MD,* Gökhan Temeltaş, MD,†
Artuner Deveci, MD,‡ and Gönül Dinç, MD§
*Celal Bayar University, Faculty of Medicine—Dermatology, †Celal Bayar University, Faculty of Medicine—Urology,
‡
Celal Bayar University, Faculty of Medicine—Psychiatry, §Celal Bayar University, Faculty of Medicine—Public Health,
Manisa, Turkey

DOI: 10.1111/j.1743-6109.2007.00465.x

[Correction added after online publication 6-Apr-2007: Order of author fore- and surnames has been modified]

ABSTRACT

Introduction. Hand eczema can cause considerable psychosocial disorders, such as anxiety, depression, and diffi-
culties at work, and it may also cause sexual dysfunction.
Aim. The aim of this study was to investigate sexual function in patients with hand eczema and to find out whether
concomitant depression has an additional negative effect on sexual function in these patients.
Main Outcome Measures. Sexual functions were evaluated in hand eczema patients.
Methods. Ninety-one female (43 patients vs. 48 controls) and 79 male (45 patients vs. 34 controls) subjects were
enrolled in the study. Hand eczema severity index was used to determine severity of hand eczema. The Female Sexual
Function Index (FSFI) and the International Index of Erectile Function (IIEF) were used to assess sexual function.
Quality of life was assessed with the Dermatology Life Quality Index. Diagnosis of depression was made based on
the Structured Clinical Interview for the DSM-IV, while the Hamilton Depression Rate Scale was used for grading
depression.
Results. Among 43 female subjects with hand eczema, 26 had depression (60.46%); of the 45 male patients, 11 had
depression (24.44%). FSFI total score was found to be significantly decreased in female patients with both eczema and
depression compared with controls (20.84 ⫾ 9.19 vs. 24.04 ⫾ 3.40, P < 0.05). FSFI total score was found to be
significantly decreased in female patients with both eczema and depression compared with those without depression
(20.84 ⫾ 9.19 vs. 22.23 ⫾ 5.82, P < 0.05). IIEF total score was also found to be significantly decreased in male patients
with or without depression compared with controls (52.36 ⫾ 14.83 vs. 59.88 ⫾ 5.65 vs. 62.03 ⫾ 11.04, P < 0.05).
Conclusions. The results of the study demonstrated that patients with hand eczema had sexual dysfunction, and
concomitant depression had an additional negative effect on sexual dysfunction. Patients with hand eczema should
be evaluated with regard to sexual function and depression to provide a better quality of life. Ergün M, Türel
Ermertcan A, Öztürkcan S, Temeltaş G, Deveci A, and Dinç G. Sexual dysfunction in patients with chronic
hand eczema in the Turkish population. J Sex Med 2007;4:1684–1690.
Key Words. Eczema; Chronic Hand Eczema; Sexual Dysfunction; Quality of Life; Female Sexual Function Index;
International Index of Erectile Function

Introduction eczema is associated with a variety of psychological

problems, including poor self-esteem, depression,

H and eczema is one of the most common der-

matological diseases, with a 1-year preva-
lence of 7–9% in the general population [1]. Hand
and impaired functioning in social and profes-
sional arenas [2,3]. Apart from the clinical severity
of affected areas, hand eczema can also have a

J Sex Med 2007;4:1684–1690 © 2007 International Society for Sexual Medicine

Sexual Dysfunction in Chronic Hand Eczema
profound psychosocial impact on the patient’s
quality of life (QoL) [4]. When we reviewed the
literature using dermatology and sexual function
as key words, we found several reports including
sexual impotence and erectile dysfunction due
to methotrexate and etretinate treatments [5,6].
However, we did not find a comprehensive study
on sexual dysfunction and dermatological diseases
except psoriasis. In recent years, female sexual
dysfunction has especially become a common and
important health concern influenced by medical
and psychosocial factors [7–11]. In contrast to
basic and clinical research in the field of male
sexual dysfunction, the sexual problems of women
have received relatively little attention and are
often untreated [12].
In this study, we aimed to evaluate sexual func-
tion in patients with hand eczema and to compare
it with that in healthy controls. Moreover, because
individuals diagnosed as having both hand eczema
and depression may experience more severe symp-
toms compared with subjects who have hand
eczema alone, we also investigated whether con-
comitant depression has an additional negative
effect on sexual function.
Materials and Methods
Study Population
A total of 91 female (43 with hand eczema and 48
healthy volunteers as a control group) and 79 male
subjects (45 with hand eczema and 34 healthy vol-
unteers as a control group) with active sexual life
were enrolled in the study. All subjects were
married, and they all expressed to have only one
sexual partner.
Subjects were screened for depression, and diag-
nosis was established by an experienced psychiatrist
based on the Turkish version of the Structured
Clinical Interview for the fourth revision of the
Diagnostic and Statistical Manual of Mental Dis-
orders (DSM-IV), which was tested and validated
for the Turkish population [13]. The Turkish
version of the Hamilton Depression Rate Scale
(HDRS), which was previously tested for reliability
and validity, was used for grading depression [14].
All subjects volunteered to participate in this
study and gave informed consent after the objec-
tives and method of the study had been explained.
All subjects underwent a detailed and comprehen-
sive dermatological examination. Routine blood
count and chemistry, erythrocyte sedimenta-
tion rate, and urinalysis were performed for
each subject. The functional integrity of the
1685
hypothalamo–pituitary–gonadal axis was examined
in all subjects by the measurements of the
levels of follicle-stimulating hormone, luteinizing
hormone, estradiol (E2), free testosterone, prolac-
tine, and sex hormone-binding globulin. Subjects
suffering from pulmonary, hepatic, hematological,
or renal diseases, endocrine diseases such as dia-
betes mellitus, thyroid function disorders, and
inflammatory diseases such as rheumatoid arthritis
were excluded from the study. Other exclusion cri-
teria include: pregnancy; gynecologic and systemic
disorders that might affect female sexual function,
such as hormonal, muscular, neurological, or car-
diovascular diseases; and history of psychological
disorders. Subjects on antidepressants and other
drugs that are known to interfere with sexual func-
tions, and postmenopausal subjects receiving oral
or vaginal estrogen therapy for the prevention of
climacteric symptoms or vaginal dryness, were also
excluded from the study.
Measures
Severity of hand eczema was assessed by the Hand
Eczema Severity Index (HECSI). Each hand was
divided into five areas (fingertips, fingers [except
the tips], palms, backs of hands, and wrists). For
each of these areas, the intensity of the six clinical
signs (i.e., erythema, induration/papulation, vesi-
cles, fissuration, scaling, and edema) was graded on
the following scale: 0: no skin changes; 1: mild
disease; 2: moderate disease; and 3: severe disease.
For each location (total of both hands), the
affected area was given a score from 0 to 4 (0:
0%; 1: 1–25%; 2: 26–50%; 3: 51–75%, and 4:
76–100%) for the extent of clinical findings.
Finally, the score given for the extent at each loca-
tion was multiplied by the total sum of the inten-
sity of each clinical feature, and the total sum,
called the HECSI score, was calculated, and varied
from 0 to 360 points [15].
The Female Sexual Function Index (FSFI) was
used to assess female sexual function [16]. It is a
self-reported measure of sexual functioning that
has been validated on a clinically diagnosed sample
of women with female sexual arousal disorder. The
index comprised 19 items. A six-domain structure
was identified, which included desire, arousal,
lubrication, orgasm, satisfaction, and pain. Each
domain is scored on a scale of 0 (or 1) to 5 (range
for items 1, 2, 15, and 16 = 1–5), and was calcu-
lated as previously described by Rosen et al. [16].
Higher scores indicate better function, and a
domain score of zero indicates no sexual activity
during the past month. The FSFI has been shown
J Sex Med 2007;4:1684–1690
1686 Ergün et al.

Table 1 Demographic features of female groups

Hand eczema Hand eczema
Control group without depression with depression
(N = 48) (N = 17) (N = 26) P
Age (years) 37.48 ⫾ 9.53 36.06 ⫾ 10.02 41.04 ⫾ 10.50 0.25
Education (%)
Elementary school 33.3 41.2 61.5
Secondary school 22.9 11.8 23.1 0.078
High school 43.8 47.1 15.4
Occupation (%)
Housewife 39.6 47.1 69.2
Retired 14.6 5.9 7.7 0.150
Employee 45.8 47.1 23.1
Student — — —
HESCI — 31.06 ⫾ 37.60 28.69 ⫾ 21.49 0.3
DLQI score — 7.35 ⫾ 5.44‡ 8.35 ⫾ 5.75 0.000
HDRS score 2.42 ⫾ 1.92†,§ 2.18 ⫾ 1.70‡ 12.46 ⫾ 2.35 0.000

Data are expressed as mean ⫾ SD.

†
Scores of control group are significantly different from those of subjects with hand eczema with depression.
‡
Scores of subjects with hand eczema without depression are significantly different from those of subjects with hand eczema and depression.
§Scores of control group are not significantly different from those of subjects with hand eczema without depression.

HESCI = Hand Eczema Severity Index; DLQI = Dermatology Life Quality Index; HDRS = Hamilton Depression Score.

to reliably discriminate each of the six domains of
sexual function as well as the full-scale score. The
International Index of Erectile Function (IIEF)
was used to assess male sexual function [17]. It is
a 15-item, self-administered questionnaire. Five
domains were identified: erectile function, orgas-
mic function, sexual desire, intercourse satisfac-
tion, and overall satisfaction. Each domain is
scored on a scale of 0 (or 1) to 5 (range for items
11, 12, 13, 14, and 15 = 1–5). Higher scores indi-
cate better function, and a domain score of zero
indicates no sexual activity during the past month.
Health status and QoL of patients with hand
eczema was assessed by the Turkish version of
the Dermatology Life Quality Index (DLQI) [18].
The DLQI is a 10-item, self-administered instru-
ment, which measures physical functioning, work
status, social and sport activities, depression,
anxiety, pain, and well-being.
Statistical Analysis
SPSS version 10.0 was used for the statistical
analysis. Data are expressed as mean ⫾ standard
deviation (SD). Chi-square test was used for com-
paring proportions. Kruskal–Wallis and Mann–
Whitney U-tests were used for comparing means.
We analyzed the relationships between DLQI,
HECSI, HDRS scores and FSFI/IIEF scores by
the Spearman correlation test. A P value of <0.05
was considered to be statistically significant.
Results
Among the 43 female subjects with hand eczema,
26 of them were found to have depression
(60.46%). Among the 45 male subjects with pso-
riasis, 11 of them were found to have depression
(24.44%). Major depression was not detected in
any patient. Subjects in the control group did not
have depression.
Demographic findings of female groups are pre-
sented in Table 1. The three groups (control, hand
eczema patients without depression, and hand
eczema patients with depression) were compar-
able with respect to age, occupation, education,
and HECSI score. Mean HECSI score was
31.06 ⫾ 37.60 for hand eczema patients without
depression and 28.69 ⫾ 21.49 for hand eczema
patients with depression. Total DLQI score was
found to be significantly higher in hand eczema
patients with depression than inhand eczema
patients without depression (8.35 ⫾ 5.75 vs.
7.35 ⫾ 5.44, P = 0.000). Hamilton depression
scores (HDRS) were 2.40 ⫾ 1.92, 2.18 ⫾ 1.70, and
12.46. ⫾ 2.35 in groups of control, hand eczema
patients without depression, and hand eczema
patients with depression, respectively (P = 0.000).
Demographic findings of male subjects are
presented in Table 2. The three groups (control,
hand eczema patients without depression, and
hand eczema patients with depression) were
comparable with respect to age, occupation,
and HECSI score. Mean HECSI score was
27.00 ⫾ 29.66 for hand eczema patients without
depression and 53.45 ⫾ 27.86 for hand eczema
patients with depression. Total DLQI scores were
6.94 ⫾ 7.21 and 15.00 ⫾ 7.72 in hand eczema
patients without depression and hand eczema
patients with depression, respectively (P = 0.007).
Hamilton depression scores (HDRS) were

J Sex Med 2007;4:1684–1690

Sexual Dysfunction in Chronic Hand Eczema 1687

Table 2 Demographic features of male groups

Hand eczema Hand eczema
Control group without depression with depression
(N = 34) (N = 34) (N = 11) P
Age (years) 40.26 ⫾ 9.74 42.73 ⫾ 8.92 39.00 ⫾ 9.62 0.36
Education (%)
Elementary school 20.6 26.5 45.5
Secondary school 20.6 29.4 9.1 0.3
High school 58.8 44.1 45.5
Occupation (%)
Retired 20.6 14.7 —
Worker 5.9 23.5 54.5 0.028
Tradesmen 5.9 8.8 9.1
Employee 67.6 52.9 36.4
Student — — —
HECSI — 27.00 ⫾ 29.66 53.45 ⫾ 27.86 0.005
DLQI score — 6.94 ⫾ 7.21 15.00 ⫾ 7.72 0.007
HDRS score 3.03 ⫾ 1.73†,§ 3.20 ⫾ 2.33‡ 11.73 ⫾ 2.65 0.000

Data are expressed as mean ⫾ SD.

†
Scores of control group are significantly different from those of subjects with hand eczema and depression.
‡Scores of subjects with hand eczema without depression are significantly different from those of subjects with hand eczema and depression.
§
Scores of control group are not significantly different from those of subjects with hand eczema without depression.
HESCI = Hand Eczema Severity Index; DLQI = Dermatology Life Quality Index; HDRS = Hamilton Depression Score.

3.03 ⫾ 1.73, 3.20 ⫾ 2.33, and 11.73 ⫾ 2.65 in
control, hand eczema without depression, and
hand eczema with depression groups, respectively
(P = 0.001).
The total and individual domain scores of FSFI
measurements are given in Table 3. As clearly
seen, FSFI total score was found to be significantly
decreased in hand eczema patients with depression
compared with healthy controls (20.84 ⫾ 9.19,
24.04 ⫾ 3.40, respectively, P < 0.05). FSFI total
score was also decreased in female hand eczema
patients without depression compared with the
control group, but the differences were not statis-
tically significant (P > 0.05). FSFI total score
was significantly lower in female hand eczema
patients with depression compared with hand
eczema patients without depression (20.84 ⫾ 9.19,
22.23 ⫾ 5.82, respectively, P < 0.05). Separate
analyses of domains revealed significant decreases
in all domain scores except pain in both hand
eczema patients with and without depression.
There were no significant differences with regard
to pain domains among the three groups. Corre-
lation analysis revealed a negative correlation
between FSFI score and HDRS in female hand
eczema patients without depression (r = -0.592,
P = 0.012). FSFI score did not correlate with
HECSI and DLQI score (P > 0.005). FSFI score
was not correlated with HECSI, DLQI, and
HDRS scores in female hand eczema patients with
depression (P > 0.05).
The total and individual domain scores of IIEF
measurements are given in Table 4. IIEF total
score was found to be significantly decreased in

Table 3 Total score and scores for each domain of female sexual function
Hand eczema Hand eczema
Control group without depression with depression
(N = 48) (N = 17) (N = 26) P
FSFI
Desire 4.13 ⫾ 0.76†,‡ 3.91 ⫾ 1.44§ 3.02 ⫾ 1.06 0.000
Arousal 4.63 ⫾ 0.88†,‡ 3.93 ⫾ 1.41§ 3.43 ⫾ 1.08 0.000
Lubrication 4.90 ⫾ 0.96†,‡ 4.57 ⫾ 1.40§ 4.11 ⫾ 1.01 0.004
Orgasm 5.05 ⫾ 0.87†,‡ 4.58 ⫾ 1.24§ 4.18 ⫾ 1.21 0.006
Satisfaction 5.32 ⫾ 0.64†,‡ 5.22 ⫾ 0.89§ 6.07 ⫾ 7.96 0.012
Pain 4.77 ⫾ 0.99 5.20 ⫾ 1.05 4.96 ⫾ 1.13 0.177
FSFI total 24.04 ⫾ 3.40†,‡ 22.23 ⫾ 5.82§ 20.84 ⫾ 9.19 0.001

Data are expressed as mean ⫾ SD.

Kruskal–Wallis.
†Scores of control group are not different from those of subjects with hand eczema without depression.
‡Scores of control group are significantly different from those of subjects with hand eczema and depression.
§
Scores of hand eczema without depression are significantly different from those of subjects with hand eczema and depression.
FSFI = Female Sexual Function Index.

J Sex Med 2007;4:1684–1690

1688
Table 4 Total score and scores for each domain of male sexual function
Control group
(N = 34)
IIEF
Erectile function 25.65 ⫾ 5.02
Orgasmic function 8.85 ⫾ 2.32
Sexual desire 8.11 ⫾ 1.63
Intercourse satisfaction 11.08 ⫾ 2.60
Overall satisfaction 8.32 ⫾ 2.13
IIEF total 62.03 ⫾ 11.04‡,§
Data are expressed as mean ⫾ SD.
Kruskal–Wallis and Mann–Whitney U-test with Bonferroni correction.
†Intercourse satisfaction subgroup of IIEF; hand eczema with depression < hand eczema without depression < control group.
‡
Scores of control group are significantly different from those of subjects with hand eczema without depression.
§Scores of control group are significantly different from those of subjects with hand eczema and depression.
¶Scores of hand eczema without depression are not different from those of subjects with hand eczema and depression.
IIEF = International Index of Erectile Function.
hand eczema patients with and without depres-
sion compared with the healthy controls (52.36 ⫾
14.83, 59.88 ⫾ 5.65, and 62.03 ⫾ 11.04, respec-
tively, P = 0.018). However, there were no signifi-
cant differences in IIEF measurements between
groups of subjects with hand eczema. When
domains were analyzed individually, intercourse
satisfaction was found to be significantly decreased
in hand eczema patients with and without depres-
sion. Intercourse satisfaction was found to be sig-
nificantly decreased in hand eczema patient with
depression, compared with hand eczema patients
without depression. There were no significant dif-
ferences on erectile function, orgasmic function,
sexual desire, or overall satisfaction among three
groups. Total IIEF score was not correlated with
HECSI, DLQI and HDRS scores in male patients
with hand eczema (r = 0.061, P = 0.733;
r = -0.278, P = 0.111; and r = -0.085, P = 0.633
for hand eczema patients without depression and
r = -0.924, P = 0.8; r = -0.278, P = 0.111; and
r = -0.085, P = 0.633 for hand eczema patients
with depression, respectively).
Discussion
Hand eczema is a chronic disease that evolves in
spurts, with periods of exacerbation alternating
with periods of inactive disease [19]. It is a disease
of long duration affecting individuals and their
social relationships. It may also have certain psy-
chosocial consequences, such as anxiety, depres-
sion, difficulties at work, reduction in athletic
activities, etc. [20].
Coexistence of sexual dysfunction, especially
female sexual dysfunction, with different diseases
has gained interest in recent years [7–11,21].
Numerous studies have been carried out in other
J Sex Med 2007;4:1684–1690
Ergün et al.
Hand eczema Hand eczema
without depression with depression
(N = 34) (N = 11) P
24.44 ⫾ 3.74 21.64 ⫾ 6.34 0.052
9.56 ⫾ 1.94 9.27 ⫾ 3.49 0.610
8.32 ⫾ 1.12 7.64 ⫾ 1.36 0.301
9.29 ⫾ 2.35 6.64 ⫾ 2.58 0.000†
8.38 ⫾ 1.04 7.73 ⫾ 3.58 0.502
59.88 ⫾ 5.65¶ 52.36 ⫾ 14.83 0.018
disciplines of medicine on sexual dysfunction
[22–25], but, to the best of our knowledge, there
are no comprehensive studies on the matter in
dermatology. Because hand eczema is a chronic
disease, we decided to investigate sexual dysfunc-
tion in this group of patients.
The impact of hand eczema on sexual function
is of interest, because it can limit a person’s ability
to perform essential life tasks and social roles.
Moreover, sexual dysfunction may also cause sig-
nificant personal distress and impact negatively on
QoL.
Previous studies revealing a higher prevalence
of sexual dysfunction in chronic pain patients
support our hypothesis [22,23]. The relationship
between the sexual function and physiological
measures in chronic pain patients was investigated,
and it was reported that sexual problems are
common in patients with chronic pain and in
patients with symptoms of distress and depression
[23].
Sexual status and erectile dysfunction was inves-
tigated in 53 male patients with chronic obstruc-
tive pulmonary disease by Koseoglu et al. [24].
Mean scores of all IIEF domains except sexual
desire decreased as the severity of the disease
increased. Among IIEF domains, 75.5% of
patients were found to have erectile dysfunction
with varying degrees. The researchers concluded
that chronic obstructive pulmonary disease dimin-
ishes the sexual function of patients.
Sexual function in female patients with fibro-
myalgia was investigated by Tikiz et al. [25], and
they also evaluated whether coexistent major
depression has an additional negative effect on
sexual function. Mean FSFI total score was signifi-
cantly decreased in the fibromyalgia and fibromy-
algia plus major depression groups, compared with
Sexual Dysfunction in Chronic Hand Eczema
that of healthy controls. All individual domain
scores were also found to be significantly de-
creased in fibromyalgia and fibromyalgia plus
major depression groups. The authors concluded
that female subjects with fibromyalgia have dis-
tinct sexual dysfunction, and major depression
has no additional negative effect on sexual
dysfunction.
Sexual function in patients with psoriasis was
assessed by Türel Ermertcan et al. [26], and they
found that FSFI total score was significantly lower
in female psoriatic patients with or without
depression than in healthy controls. However,
FSFI score was not significantly different between
psoriasis with and without depression. IIEF total
score was also significantly lower in male psoriatic
patients with or without depression than in healthy
controls. The difference between IIEF scores of
psoriasis patients with and without depression was
not statistically significant. The results of the study
demonstrated that patients with psoriasis, espe-
cially female individuals, have distinct sexual dys-
function compared with healthy controls, and
coexistent depression has no additional negative
effect on sexual dysfunction in psoriatic patients.
In the present study, FSFI total score was found
to be significantly decreased in female hand eczema
plus depression patients, compared with hand
eczema patients without depression. IIEF total
score was also found to be significantly decreased in
male hand eczema patients with or without depres-
sion compared with healthy controls. The differ-
ence between IIEF scores among hand eczema
patients with and without depression was not sta-
tistically significant. Individual analyses of domains
showed that intercourse satisfaction was signifi-
cantly decreased in hand eczema patients with
depression compared with those without depres-
sion. Correlation analysis revealed a negative cor-
relation between FSFI score and HDRS in female
hand eczema patients without depression. FSFI
score did not correlate with HECSI and DLQI
scores. FSFI score was not correlated with HECSI,
DLQI, and HDRS scores in female hand eczema
patients with depression. Similarly, IIEF score was
not correlated with HECSI, DLQI, and HDRS
scores in male patients with hand eczema.
In contrast to the studies by Tikiz et al. [25] and
Türel Ermertcan et al. [26], in the present study
we found that depression had a negative effect on
sexual function in hand eczema patients. Similar to
the finding of Türel Ermertcan et al., all domain
scores except pain were significantly lower in
female patients. In male patients, on the other
1689
hand, only intercourse satisfaction was found to be
significantly decreased in chronic hand eczema
patients.
QoL has been reported to have a prominent
effect on sexual function [12]. In our study, sexual
function was not correlated with DLQI in female
or male patients with hand eczema.
Selective serotonin reuptake inhibitor medica-
tions used to treat depression and anxiety can
affect sexual response. Women receiving these
medications often complain of decreased desire,
decreased arousal, decreased genital sensation, and
difficulty in achieving orgasm [27]. In order to
eliminate the possible drug effects on sexual dys-
function, subjects who were using these drugs
were not included in the present study. We believe
that the detected sexual dysfunction is closely
related to hand eczema.
Hand eczema is an often symptomatic skin con-
dition, and patients with hand eczema may have
clinical symptoms such as itching, pain, burning or
stinging sensation, irritation, and bleeding. Hand
eczema may also have negative effects on patients’
QoL, because it affects self-perception and social
relationships of the patients. Based on these, we
conclude that sexual dysfunction was caused by
hand eczema.
The results of the study demonstrated that
patients with chronic hand eczema have distinct
sexual dysfunction compared with healthy con-
trols, and concomitant depression has an addi-
tional negative effect on sexual dysfunction.
Patients with hand eczema should be assessed with
regard to sexual function and depression in order
to provide a better QoL.
Corresponding Author: Aylin Türel Ermertcan, MD,
Celal Bayar University, Faculty of Medicine, Depart-
ment of Dermatology, Manisa 45010, Turkey. Tel:
+90 532 2243384; Fax: +90 236 2346307; E-mail:
draylinturel@hotmail.com
Conflict of Interest: None declared.
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