What are the medication treatments for moderate to severe Chronic Hand Eczema (CHE)?

Medication Treatments for Moderate to Severe Chronic Hand Eczema (CHE)

For moderate to severe chronic hand eczema, topical corticosteroids are first-line therapy, followed by systemic treatments including alitretinoin, immunosuppressants, or retinoids when topical treatments fail. When selecting treatments, consider the severity, chronicity, and previous treatment responses.

First-Line Treatments

Topical Corticosteroids

• Moderate to high-potency topical corticosteroids:
  • Apply twice daily for 2-3 weeks 1
  • Options include mometasone furoate cream once daily or prednicarbate cream 0.02% twice daily 1
  • For severe cases, clobetasol propionate 0.05% cream or ointment twice daily 1
  • Maximum 50g per week to minimize systemic absorption 1

Maintenance Therapy with Topical Corticosteroids

• After achieving control, transition to maintenance therapy:
  • Mometasone furoate cream three times weekly 1
  • Continue for 4-12 months depending on severity and chronicity 1
• Always combine with regular moisturizers, especially after hand washing 1

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment for steroid-sparing in chronic cases 1
• Particularly useful for sensitive areas prone to steroid atrophy

Second-Line Treatments

When topical treatments fail to provide adequate control after 4-8 weeks:

Phototherapy

• PUVA (Psoralen plus UVA) has shown superior efficacy to UVB in hand eczema 2
• Oral PUVA: 81-86% improvement or clearance in hand eczema 2
• Topical PUVA: 58-81% improvement in dyshidrotic eczema 2

Systemic Corticosteroids

• Short-term oral systemic steroids for severe flares 2, 1
• Not recommended for long-term maintenance due to side effects 2
• Can be used to bridge to other systemic therapies 2

Third-Line Treatments

For refractory cases not responding to first and second-line treatments:

Systemic Retinoids

• Oral alitretinoin (10-30mg daily) for chronic cases 1
• Particularly effective for hyperkeratotic hand eczema 3

Immunosuppressants

• Cyclosporine: Effective for steroid-resistant chronic hand dermatitis 2
• Azathioprine: Used for steroid-resistant chronic hand dermatitis 2
• Methotrexate: Used off-label for chronic cases 3, 4

Emerging Therapies

• JAK inhibitors (topical and systemic): Currently under investigation 3
• Dupilumab: May be effective for atopic hand eczema 1, 4

Treatment Algorithm Based on Severity

Moderate CHE:

1. Start with moderate-potency topical corticosteroids (mometasone furoate) twice daily for 2-3 weeks
2. If inadequate response, increase to high-potency corticosteroids (clobetasol)
3. If still inadequate after 4-8 weeks, consider PUVA therapy
4. For persistent cases, consider systemic therapy with alitretinoin

Severe CHE:

1. Start with high-potency topical corticosteroids (clobetasol) twice daily
2. Consider short course of systemic corticosteroids for rapid control
3. Initiate PUVA therapy or systemic therapy (alitretinoin, cyclosporine)
4. For refractory cases, consider combination therapy or emerging treatments

Important Considerations

• Monitor for side effects: Watch for skin atrophy, cracks/fissures with topical corticosteroids 1
• Treat complications: For fissures, consider propylene glycol 50% in water under occlusion at night 2
• Prevent recurrence: Use soap-free cleansers, regular moisturizers, and avoid known irritants 2, 1
• Occupational factors: Consider workplace modifications and protective measures for occupational CHE 5

Treatment Challenges

• Up to 65% of CHE cases do not resolve completely with standard treatments 6
• Moderate-to-severe cases often require systemic options 6
• Recent studies show that 62.9% of moderate-to-severe CHE patients receive systemic therapy 7
• Many treatments have limited evidence specifically for CHE 7

By following this structured approach to treatment, most patients with moderate to severe chronic hand eczema can achieve significant improvement in symptoms and quality of life.