What is the treatment for hand dermatitis?

Treatment for Hand Dermatitis

The treatment of hand dermatitis requires a stepwise approach starting with identification and avoidance of irritants/allergens, proper hand hygiene practices, regular moisturization, and topical steroids for flares, with progression to more advanced therapies like phototherapy or systemic medications for recalcitrant cases. 1

Types of Hand Dermatitis

• Hand dermatitis can present as irritant contact dermatitis (ICD), allergic contact dermatitis (ACD), or other forms (atopic, hyperkeratotic, pompholyx) 1
• Clinical presentations include acute (erythema, edema, vesicles), subacute (crusting, scaling), and chronic (lichenification) forms 1

First-Line Treatment Approach

Identify and Avoid Triggers

• Identify and avoid irritants (detergents, frequent hand washing, hot water) and allergens 1
• Use lukewarm or cool water for hand washing (avoid hot water which damages the skin barrier) 1
• Pat dry hands gently rather than rubbing 1
• Avoid disinfectant wipes for hand cleaning 1

Hand Hygiene Practices

• Use soaps/synthetic detergents without allergenic surfactants, preservatives, fragrances, or dyes 1
• Choose products with added moisturizers 1
• For sanitizers, use alcohol-based hand sanitizers (ABHS) with at least 60% alcohol and added moisturizers 1
• Do not wash hands with soap immediately before or after using alcohol-based products (increases risk of dermatitis) 1

Moisturization

• Apply moisturizer immediately after hand washing 1
• Use two fingertip units of moisturizer for adequate hand coverage 1
• Choose moisturizers in tubes rather than jars to prevent contamination 1
• Consider pocket-sized moisturizers for frequent reapplication 1
• For severe dryness, use "soak and smear" technique: soak hands in plain water for 20 minutes followed by immediate moisturizer application nightly for up to 2 weeks 1
• At night, apply moisturizer followed by cotton or loose plastic gloves for occlusive effect 1

Topical Anti-inflammatory Treatments

For Irritant Contact Dermatitis (ICD)

• Apply topical steroids when conservative measures fail 1
• Be cautious of potential steroid-induced damage to skin barrier with prolonged use 1
• Consider barrier creams (humectants) which may be helpful but are equivalent to regular moisturizers 1

For Allergic Contact Dermatitis (ACD)

• Identify allergens through patch testing and avoid them 1
• Apply topical steroids to mitigate flares 1
• For glove-related ACD, use accelerator-free gloves (rubber-free neoprene or nitrile) 1
• Consider cotton glove liners or loose plastic gloves 1

Topical Calcineurin Inhibitors

• Pimecrolimus cream 1% (Elidel) can be used as second-line therapy for mild to moderate cases that have failed other topical prescription treatments 2
• Has shown success in treating chronic vesicular hand dermatitis resistant to steroids 3
• Not indicated for use in children under 2 years of age 2
• Should be used for short periods with breaks in between treatments 2

Advanced Therapies for Recalcitrant Cases

When to Consider Advanced Treatment

• When hand dermatitis does not improve after 6 weeks of treatment 1
• For recalcitrant cases that fail to respond to topical treatments 1

Treatment Options

• Stronger topical steroids 1
• Phototherapy 1
• Systemic therapy options may include corticosteroids, cyclosporine, methotrexate, azathioprine 4
• Alitretinoin for chronic hand dermatitis 4
• Bexarotene gel has shown 79% response rate for ≥50% clinical improvement in chronic severe hand dermatitis 5

Special Considerations

Occupational Factors

• Consider occupational modification for recalcitrant cases 1
• For healthcare workers, use water-based moisturizers under gloves (oil-based moisturizers can break down latex and rubber) 1
• Latex, vinyl, and nitrile gloves are resistant to breakdown from ethanol or isopropyl alcohol 1

Common Pitfalls to Avoid

• Applying gloves when hands are still wet from hand washing or sanitizer 1
• Using very hot water for hand washing 1
• Washing hands with dish detergent or other known irritants 1
• Applying known allergens including topical antibiotics (neomycin, bacitracin) 1
• Using superglue (ethyl cyanoacrylate) to glue inflammatory or healing fissures 1
• Increased duration of glove occlusion without underlying moisturizer 1

When to Refer to Dermatology

• For suspected allergic contact dermatitis requiring patch testing 1
• For recalcitrant hand dermatitis not responding to initial treatments 1
• When there is a change in baseline hand dermatitis 1