What is the treatment for weeping eczema (atopic dermatitis) on the hands?

Treatment of Weeping Eczema on the Hands

For weeping eczema on the hands, immediately start topical corticosteroids twice daily while simultaneously treating the underlying bacterial infection with oral flucloxacillin—do not delay corticosteroid therapy due to the presence of infection. 1

Immediate Management of Weeping (Infected) Eczema

The presence of weeping, crusting, or pustules indicates secondary bacterial infection, most commonly with Staphylococcus aureus. 2, 1

Dual therapy approach:

• Start oral flucloxacillin as first-line antibiotic for bacterial infection 1, 3
• Continue or initiate topical corticosteroids concurrently—infection is not a contraindication to topical steroid use when appropriate systemic antibiotics are given 1
• Use erythromycin if penicillin allergy exists 4

Critical warning: If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency requiring immediate oral or intravenous acyclovir. 1, 4

Topical Corticosteroid Selection and Application

For hand eczema, apply topical corticosteroids twice daily using the least potent preparation that achieves control. 1, 3

Potency selection:

• Start with moderate to potent corticosteroids for active hand eczema 1, 5
• Clobetasol propionate 0.05% (super-high potency) can be used for severe cases but limit to 2 consecutive weeks maximum, not exceeding 50g per week 6
• Once control is achieved, step down to lower potency preparations 1, 4

Application technique:

• Apply a thin layer and rub in gently and completely 6
• Implement "steroid holidays"—stop corticosteroids for short periods once symptoms improve to minimize side effects 1, 4
• After initial control, transition to twice-weekly application to previously affected areas for maintenance 4

Essential Emollient Therapy

Liberal emollient use is the cornerstone of treatment and must be continued even when eczema appears controlled. 1, 7

• Apply emollients immediately after bathing to create a lipid film that prevents water loss 1, 4
• Continue daily emollient use indefinitely—this reduces flare rate by 60% and prolongs time to flare from 30 to 180 days 4
• Use dispersible cream as a soap substitute instead of regular soap, which strips natural skin lipids 2, 1, 4

Hand-Specific Hygiene Measures

Keep hands as dry as possible between necessary washing:

• Avoid prolonged water exposure, as moisture promotes bacterial colonization 4
• Pat hands dry rather than rubbing, paying special attention to finger web spaces 4
• Wear cotton gloves when possible to reduce irritation 2, 4
• Keep nails trimmed short 2, 4
• Avoid irritant exposures including detergents and harsh chemicals 2

Managing Pruritus

Sedating antihistamines help only through their sedative effects, not direct anti-pruritic action—reserve for nighttime use during severe flares. 1, 4, 7

• Non-sedating antihistamines have no value in eczema and should not be used 1, 4
• Use antihistamines as short-term adjuvant therapy during relapses associated with severe itching 2

Adjunctive Treatments for Refractory Cases

If standard therapy fails after 4 weeks, consider:

• Topical calcineurin inhibitors (tacrolimus 0.1%) for steroid-sparing maintenance, particularly for sensitive areas 1, 3
• Ichthammol or coal tar preparations (1% in zinc ointment or with hydrocortisone) for lichenified hand eczema 2, 4
• Phototherapy (narrow-band UVB or PUVA) for chronic cases unresponsive to topical therapy 1, 3

Systemic Therapy for Severe Disease

For severe hand eczema unresponsive to topical therapy:

• Alitretinoin 30 mg daily is highly effective, improving investigator-rated symptom control (RR 2.75,95% CI 2.20-3.43; NNTB 4) compared to placebo, though headache is a common side effect 3
• Oral cyclosporin 3 mg/kg/day probably improves symptom control compared to topical betamethasone alone 3
• Dupilumab has recently been shown effective for chronic hand eczema 5

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently 1
• Do not undertreat due to steroid phobia—explain that appropriate short-term use of potent steroids is safer than chronic undertreated inflammation 2, 1, 4
• Do not use topical corticosteroids continuously without breaks—implement regular "steroid holidays" 1, 4
• Do not use greasy occlusive creams excessively on hands, as these can facilitate folliculitis 4

When to Refer to Dermatology

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1, 4
• Symptoms worsening despite appropriate treatment 4
• Need for systemic therapy or phototherapy 1, 4
• Suspected eczema herpeticum (refer emergently) 1, 4
• Diagnostic uncertainty distinguishing from contact dermatitis, tinea, or psoriasis 4