Resident Rounds: Part III – Case Report: Betel Quid Induced Irritant Contact Dermatitis of the Hand

A 35-year-old Bengali male with no significant past medical history presented to the dermatology clinic with a rash on the first 3 digits of the right hand that had been present for several years. He complained of itchiness and peeling associated with the rash. The patient was a baker and his hands were frequently submerged in water. Physical examination of the hands revealed erythematous and hyperpigmented plaques with cracking on the first 3 distal fingertips of the right hand (Figure 1). No lesions were present on the left hand.

Initially, the diagnosis of hand irritant contact dermatitis due to frequent water exposure was suspected. Because the distribution involving only the first 3 digits on one hand was unusual, other etiologies that would explain the peculiar distribution were explored. Further examination of the patient revealed that his lips were slightly tinted with a faint red pigment. After inquiry, the patient revealed that he had chewed betel nut and betel leaf for many years. In fact, the patient brought his betel chewing components with him to the clinic and described the process of rolling the betel nut mixed with lime paste into the betel leaf and inserting this betel quid between his gum and cheek using the first 3 digits of his right hand (Figure 2). After the patient washed out the betel quid residue from his mouth, an extensive examination of the oropharynx revealed thick adherent black calculus on the teeth with attrition of many of the teeth and severe gingivitis and gum recession (Figure 3).

The diagnosis of an irritant contact dermatitis to the betel quid components, specifically lime paste, was made. Cessation of betel quid chewing was extensively recommended and the patient was referred to dentistry. The hand dermatitis was treated with clobetasol 0.05% ointment without significant improvement as the patient continued to chew betel quid.

Betel nut, or areca nut, is a seed derived from the areca palm tree, which natively grows in Far East Asia, India, and the South Pacific.¹ In these areas, it is widely used as a natural drug that is chewed for its psychoactive and cholinergic effects.² The preparation, known as betel quid, is commonly a mix of the areca nut, alkaline slaked lime (calcium hydroxide), and tobacco wrapped in betel leaf.³

Many adverse oral manifestations of betel quid chewing have been reported, including oral lichen planus, submucous fibrosis, angular cheilitis, and squamous cell carcinomas involving the oral cavity, larynx, and esophagus.^3-7 Betel nut also produces deep red staining of the oral mucosa, as was evident in our case.

Cutaneous manifestations of this habit are widely underreported, but can include hand irritant contact dermatitis due to the alkalinity of the slaked lime.⁸ Interestingly, this dermatitis along with hyperpigmentation is most commonly seen involving the first 3 fingers of the dominant hand as those are the fingers that assemble the betel quid, as was seen in our case. This is rarely seen in the United States as betel nut chewing is primarily limited to East Asian immigrants.⁹ Allergic contact dermatitis of the hand to Piper betle L. inflorescence (the flower component of the betel plant) confirmed by patch testing has