What is the treatment for hand dermatitis?

Treatment for Hand Dermatitis

Stepwise Treatment Algorithm

The American Academy of Dermatology recommends starting with identification and avoidance of triggers, proper hand hygiene, aggressive moisturization, and topical corticosteroids for flares, progressing to phototherapy or systemic therapies only for cases that fail initial management after 6 weeks. 1

Step 1: Identify the Type and Eliminate Triggers

• Determine if the dermatitis is irritant (ICD) or allergic (ACD) by clinical presentation—acute forms show erythema, edema, and vesicles; subacute forms have crusting and scaling; chronic forms demonstrate lichenification 2
• For suspected ACD, perform patch testing to identify clinically relevant allergens, particularly if there is recalcitrant disease, a change in baseline symptoms, or occupational exposure 2, 1
• Avoid all identified irritants and allergens—common culprits include frequent hand washing, hot water, dish detergent, bleach, rubber accelerators in gloves, and products containing fragrances, preservatives, or dyes 2

Step 2: Optimize Hand Hygiene Practices

• Wash hands with lukewarm or cool water (never hot) and soap for at least 20 seconds, focusing on commonly missed areas like fingertips, hypothenar eminence, and dorsum of hand 2
• Use soaps or synthetic detergents without allergenic surfactants, preservatives, fragrances, or dyes, preferably with added moisturizers 2
• For alcohol-based hand sanitizers, use products with at least 60% alcohol and added moisturizers, but never wash with soap immediately before or after using alcohol sanitizer 2
• Pat dry hands gently (do not rub) and never apply gloves when hands are still wet 2

Step 3: Aggressive Moisturization Protocol

• Apply moisturizer immediately after every hand washing using two fingertip units to ensure adequate coverage 2, 1
• Use moisturizers packaged in tubes (not jars) to prevent contamination, and carry pocket-sized versions for frequent reapplication 2, 1
• For severe dryness, use the "soak and smear" technique: soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 2, 1
• At night, apply moisturizer followed by cotton or loose plastic gloves to create an occlusive barrier 2, 1

Step 4: Topical Corticosteroids for Active Inflammation

• For ICD, apply topical corticosteroids when conservative measures fail, but use cautiously due to potential steroid-induced skin barrier damage with prolonged use 2, 1
• For ACD, apply topical corticosteroids to mitigate flares after allergen identification and avoidance 2, 1
• Clobetasol propionate 0.05% foam improves symptom control compared to vehicle when assessed at 15 days (RR 2.32,95% CI 1.38-3.91; NNTB 3), though application site burning/pruritus may occur 3
• For maintenance after remission, mometasone furoate cream thrice weekly may provide better control than twice weekly, with minimal risk of mild atrophy 3

Step 5: Alternative Topical Agents

• Topical calcineurin inhibitors (tacrolimus 0.1%) probably improve investigator-rated symptom control compared to vehicle after 2-3 weeks, with well-tolerated application site burning/itching 3
• Tacrolimus may be particularly useful for steroid-resistant chronic vesicular hand dermatitis 4

Step 6: Phototherapy for Recalcitrant Cases

• Local PUVA therapy may improve symptom control compared to narrow-band UVB after 12 weeks, though erythema is more common with UVB 3
• Consider phototherapy when topical treatments fail after 6 weeks of appropriate management 1

Step 7: Systemic Therapies for Severe Recalcitrant Disease

• Oral alitretinoin is highly effective for recalcitrant hand dermatitis: 30 mg daily improves both investigator-rated (RR 2.75,95% CI 2.20-3.43; NNTB 4) and participant-rated (RR 2.75,95% CI 2.18-3.48) symptom control compared to placebo, though headache risk increases (RR 3.43) 3
• Alitretinoin 10 mg daily is also effective with similar symptom improvement (RR 1.58 for investigator-rated; RR 1.73 for participant-rated) and no significant increase in adverse events compared to placebo 3
• Oral cyclosporin 3 mg/kg/day probably slightly improves symptom control compared to topical betamethasone dipropionate 0.05% after 6 weeks, with similar adverse event rates including dizziness 3

Special Considerations for Glove-Related Dermatitis

• For glove ACD, use accelerator-free gloves such as rubber-free neoprene or nitrile gloves 2, 1
• Apply moisturizer before wearing gloves, using water-based moisturizers under all glove types (oil-based moisturizers can break down latex and rubber) 2, 1
• Consider cotton glove liners or loose plastic gloves for additional protection 2, 1
• Note that latex, vinyl, and nitrile gloves are resistant to breakdown from ethanol or isopropyl alcohol 2, 1

Critical Pitfalls to Avoid

• Never wash hands with very hot or very cold water, as temperatures above 40°C cause lipid fluidization and increased skin permeability 2
• Never use disinfectant wipes to clean hands or wash with dish detergent 2
• Never apply topical antibiotics like neomycin or bacitracin, or use superglue on inflammatory fissures, as these are common allergens 2
• Never occlude hands with gloves for prolonged periods without underlying moisturizer application 2
• Never pick at dermatitis-induced scale, as this worsens the condition 2

When to Refer to Dermatology

• Refer for patch testing when ACD is suspected or when there is new hand dermatitis requiring allergen identification 2, 1
• Refer for recalcitrant cases that fail to improve after 6 weeks of appropriate topical treatment 1
• Refer when considering phototherapy, systemic therapy, or occupational modification for severe disease 2, 1