Recommended Corticosteroids for Hand Eczema
For hand eczema, high-potency topical corticosteroids are the first-line therapy, with clobetasol propionate recommended for severe or recalcitrant cases used for up to 2 weeks. 1, 2
Initial Treatment Approach
- Start with a high-potency topical corticosteroid applied twice daily to affected areas for acute flares 1
- Clobetasol propionate (super-high potency) is effective for severe cases but should be limited to 2 consecutive weeks of use and amounts less than 50g per week 2
- For moderate cases, consider other potent corticosteroids such as betamethasone, mometasone furoate, prednicarbate, or methylprednisolone aceponate 3
- Apply a thin layer of the corticosteroid and rub in gently and completely 2
Treatment Duration and Monitoring
- Treatment with super-high potency corticosteroids (clobetasol) should be discontinued when control is achieved, with a maximum duration of 2 consecutive weeks 2
- If no improvement is seen within 2 weeks, reassessment of the diagnosis may be necessary 2
- Monitor for signs of skin atrophy, telangiectasia, or other adverse effects of topical corticosteroids 1
- Avoid occlusive dressings with high-potency steroids as this can increase absorption and side effects 1, 2
Adjunctive Measures
- Apply moisturizer after washing hands and before wearing gloves to maintain skin barrier function 4, 1
- Consider the "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 4, 1
- Use soap substitutes and avoid irritants that can worsen hand eczema 4
- For nighttime treatment, consider applying moisturizer followed by cotton or loose plastic gloves to create an occlusive barrier 4
For Recalcitrant Cases
- For hand dermatitis that doesn't respond to first-line treatment, consider patch testing to identify possible allergic triggers 4, 1
- Evaluate for secondary bacterial infection and treat if present 4
- Consider intermittent maintenance therapy with high-potency corticosteroids (twice weekly applications) to prevent relapses in chronic hand eczema 5
- For steroid-resistant cases, refer for second-line treatments such as phototherapy, azathioprine, cyclosporine, or alitretinoin 4, 1, 6
Common Pitfalls and Caveats
- Avoid using super-high potency corticosteroids for more than 2 weeks due to risk of hypothalamic-pituitary-adrenal axis suppression 2
- Be alert for signs of topical steroid allergy (worsening dermatitis despite treatment) 1
- Not considering potential allergic contact dermatitis as a cause of persistent hand eczema can lead to inadequate treatment 1
- Using barrier creams alone has questionable value in protecting against irritants; they should be used in conjunction with corticosteroids 1
- Oil-based moisturizers can break down latex and rubber gloves; use water-based moisturizers under gloves 1