What is the best treatment for eczema on the hands?

Treatment of Hand Eczema

The best treatment for hand eczema involves a stepwise approach starting with medium-potency topical corticosteroids for short-term use (2-4 weeks), followed by topical calcineurin inhibitors for maintenance therapy if needed. 1

Initial Assessment and Classification

Hand eczema can be classified into several types:

• Irritant contact dermatitis (ICD)
• Allergic contact dermatitis (ACD)
• Dyshidrotic eczema
• Atopic hand dermatitis

First-Line Treatment

1. Topical Corticosteroids

   • Medium-potency topical corticosteroids for 2-4 weeks 1
   • For acute flares, use once daily application 2
   • Mometasone furoate cream is effective and safe for long-term, intermittent treatment 3
   • After initial control, taper to intermittent use (3 times weekly) for maintenance 4, 3

2. Moisturizers

   • Apply immediately after hand washing 4
   • Use fragrance-free products in tubes (not jars) 4
   • Apply liberally and frequently (3-8 times daily) 1
   • Two fingertip units is the appropriate amount for both hands 4

Maintenance Therapy

1. Topical Calcineurin Inhibitors

   • Tacrolimus 0.1% ointment is effective for maintenance after initial control with corticosteroids 1, 5
   • Consider alternating between topical corticosteroids (weekends) and tacrolimus (weekdays) for moderate to severe cases 1
   • Pimecrolimus cream 1% is an alternative for adults and children ≥2 years old 5

2. Intermittent Corticosteroid Regimens

   • For long-term control, use mometasone furoate on Sunday, Tuesday, and Thursday (83% remained clear) or Saturday and Sunday (68% remained clear) 3
   • This approach is more effective than stopping corticosteroids completely after clearing (only 26% remained clear) 3

Specific Approaches for Different Types

For Irritant Contact Dermatitis (ICD)

• Identify and avoid irritants (detergents, frequent hand washing, hot water) 4
• Use barrier creams with humectants 4
• Switch to less-irritating products 4
• Apply topical steroids if conservative measures fail 4

For Allergic Contact Dermatitis (ACD)

• Identify allergens through patch testing 4, 1
• Avoid identified allergens 4
• For glove-related ACD, use accelerator-free gloves (rubber-free neoprene or nitrile) 4
• Consider cotton glove liners 4

Hand Washing Recommendations

• Use lukewarm or cool water (not hot) 4
• Pat dry gently (don't rub) 4
• Apply moisturizer immediately after washing 4
• Avoid products with antibacterial ingredients, fragrances, or dyes 4

For Severe or Recalcitrant Cases

1. Phototherapy

   • PUVA (Psoralen + UVA) is superior to UVB for hand eczema 1, 6
   • Significant improvement or clearance occurs in 81-86% of patients 1

2. Systemic Therapy (when topical treatments fail)

   • Alitretinoin (30 mg) is more effective than placebo for controlling symptoms 6
   • Oral cyclosporin (3 mg/kg/d) may be slightly more effective than topical betamethasone dipropionate 0.05% 6
   • Other options include methotrexate, azathioprine, and mycophenolate mofetil 1

3. Soak and Smear Technique

   • Soak hands in plain water for 20 minutes 4
   • Immediately apply moisturizer to damp skin 4
   • Do this nightly for up to 2 weeks 4

4. Occlusive Therapy

   • At night, apply moisturizer followed by cotton or loose plastic gloves 4
   • Creates an occlusive barrier to enhance penetration 4

Infection Prevention and Treatment

• Keep crusted or eroded lesions clean and covered 1
• For suspected bacterial infections, obtain cultures and use appropriate antibiotics 1
• Consider bleach baths with 0.005% sodium hypochlorite twice weekly 1

Common Pitfalls to Avoid

• Using hot water for washing (increases skin permeability and irritation) 4
• Applying gloves when hands are still wet 4
• Using moisturizers in jars (risk of contamination) 4
• Prolonged continuous use of high-potency corticosteroids (risk of skin atrophy) 1
• Washing hands immediately before or after using alcohol-based sanitizers 4
• Inadequate moisturizer application (too little or infrequent) 1

When to Refer to a Specialist

• Diagnostic uncertainty 1
• Poor response to initial treatment 1
• Need for systemic therapy 1
• Recalcitrant hand dermatitis 4, 1

Hand eczema often runs a chronic, relapsing course, but with proper treatment and maintenance therapy, most patients can achieve good symptom control and improved quality of life 6, 7.