What is the recommended topical steroid for eczema of the hands?

Recommended Topical Steroids for Hand Eczema

For hand eczema, mometasone furoate cream is recommended as the topical steroid of choice due to its demonstrated efficacy and safety in long-term, intermittent treatment regimens. 1

Initial Treatment Approach

• For mild to moderate hand eczema:

  • Start with a moderate-potency topical corticosteroid such as mometasone furoate cream applied once daily until clearance 1
  • Apply a thin layer to affected areas and rub in gently 2
  • Continue daily application until dermatitis clears or for a maximum of 9 weeks 1

• For severe or recalcitrant hand eczema:

  • Consider a potent topical corticosteroid such as clobetasol propionate 0.05% cream/ointment applied twice daily for up to 2 weeks 3
  • Limit treatment with super-high potency corticosteroids to 2 consecutive weeks, and amounts greater than 50g per week should not be used 3
  • Reassess diagnosis if no improvement is seen within 2 weeks 3

Maintenance Therapy

• After initial clearance, implement a maintenance regimen to prevent relapse:
  • Mometasone furoate cream applied three times weekly (e.g., Sunday, Tuesday, Thursday) is most effective for preventing recurrences (83% remained clear) 1
  • Twice weekly application (e.g., Saturday and Sunday) is also effective (68% remained clear) 1
  • Without maintenance therapy, only 26% of patients remain clear 1

Important Considerations

• Application frequency:

  • For potent topical corticosteroids, once-daily application is as effective as twice-daily application 4
  • Applying more frequently than recommended does not improve efficacy but may increase risk of adverse effects 4

• Potential adverse effects:

  • Risk of skin thinning is low (approximately 1%) when used appropriately 4
  • Higher potency corticosteroids carry greater risk of skin atrophy 4, 5
  • Avoid occlusive dressings with high-potency corticosteroids as this increases absorption 3

• Adjunctive measures:

  • Use soap substitutes and emollients regularly 2
  • Apply moisturizer after washing hands and before wearing gloves 2
  • Consider "soak and smear" technique: soak hands in plain water for 20 minutes and immediately apply moisturizer to damp skin nightly for up to 2 weeks 2

Treatment Algorithm

1. Assess severity of hand eczema:

   • Mild to moderate: Start with mometasone furoate cream once daily 1
   • Severe: Consider clobetasol propionate 0.05% for up to 2 weeks 3

2. After clearance (typically 3-9 weeks of daily treatment):

   • Implement maintenance therapy with mometasone furoate three times weekly 1
   • Monitor for recurrence and treat flares promptly with short courses of daily application 1

3. For recalcitrant cases:

   • Consider patch testing to identify possible allergic triggers 2
   • Evaluate for secondary bacterial infection and treat if present 6
   • Consider referral for second-line treatments such as phototherapy, azathioprine, or cyclosporin for steroid-resistant cases 2

Common Pitfalls to Avoid

• Using super-high potency corticosteroids (e.g., clobetasol) for longer than 2 weeks 3
• Failing to implement a maintenance regimen after initial clearance 1
• Neglecting to use emollients and soap substitutes alongside topical corticosteroids 2
• Not considering potential allergic contact dermatitis as a cause of persistent hand eczema 2
• Using barrier creams alone, which have questionable value in protecting against irritants 2