What is the treatment for lesions on the palms of hands with scaling and itching?

Treatment of Scaling and Itching Palmar Lesions

For scaling and itching lesions on the palms, initiate treatment with a high-potency topical corticosteroid (such as clobetasol propionate 0.05%) applied twice daily, combined with frequent application of urea 10% cream three times daily for moisturization and keratolytic effect. 1

Initial Assessment and Diagnosis

Before initiating treatment, determine the underlying cause:

• Hand eczema/dermatitis presents with vesicles, scaling, erythema, and fissuring 1, 2
• Palmoplantar psoriasis shows well-demarcated erythematous plaques with thick silvery scale and hyperkeratosis 1
• Pompholyx (dyshidrotic eczema) manifests as deep-seated vesicles with intense pruritus 3
• Irritant or allergic contact dermatitis from occupational exposures or hand hygiene products 1

First-Line Topical Treatment

High-Potency Corticosteroids

Apply clobetasol propionate 0.05% cream or ointment twice daily to affected areas. 1, 2

• Clobetasol propionate 0.05% foam demonstrates significant improvement in symptom control with a number needed to treat of 3 after 15 days 2
• Ointment formulations penetrate better than creams due to occlusion, making them more effective for thick palmar skin 4
• Common adverse effects include application site burning or pruritus (reported in approximately 18% of patients) 2

Moisturization and Barrier Repair

Apply urea 10% cream three times daily to all affected areas, including after hand washing. 1

• Urea acts as both a humectant and keratolytic, reducing hyperkeratosis while improving skin barrier function 1
• For enhanced penetration, 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 1
• At night, apply thick moisturizer followed by cotton gloves to create an occlusive barrier 1

Behavioral Modifications

Avoid mechanical and chemical irritants that perpetuate hand dermatitis. 1

• Minimize hand washing frequency and avoid very hot or cold water 1
• Use protective gloves for wet work, applying moisturizer underneath (water-based moisturizers are safe under all glove types) 1
• Avoid known irritants including dish detergent, bleach, disinfectant wipes, and harsh soaps 1
• Wear cushioned gloves when performing activities involving mechanical stress 1

Second-Line Topical Options

Calcineurin Inhibitors

If corticosteroids are contraindicated or ineffective after 2 weeks, switch to tacrolimus 0.1% ointment twice daily. 2, 5

• Tacrolimus 0.1% demonstrates investigator-rated improvement in 100% of treated participants versus 0% with vehicle after 3 weeks 2
• Application site burning or itching occurs in approximately 29% of patients but is generally well-tolerated 2
• Particularly useful for chronic maintenance therapy to avoid corticosteroid-related skin atrophy 5

Phototherapy for Refractory Cases

For cases not responding to topical therapy after 4 weeks, refer for topical PUVA (psoralen plus UVA) therapy. 1

• Topical PUVA achieves clearance or considerable improvement in 58-81% of dyshidrotic eczema and 50-67% of hyperkeratotic eczema 1
• Treatment typically requires 2-3 sessions weekly for several months 1
• Oral PUVA is superior to UVB for hand eczema but carries increased long-term skin cancer risk 1
• Cutaneous malignancy on palms or soles after topical PUVA is very rare 1

Systemic Therapy for Severe Disease

Oral Retinoids

For severe palmoplantar psoriasis with significant quality of life impairment, initiate acitretin 25 mg daily. 1, 6

• Acitretin demonstrates significant improvement in scaling, thickness, and erythema within 2 months of treatment 1, 6
• FDA-approved for severe psoriasis with proven efficacy in palmoplantar disease 6
• Monitor lipid panels as elevations in triglycerides and cholesterol are common but manageable with fibrates or statins 1
• Dosage can often be reduced to 25 mg on alternate days once improvement is achieved 1

Alitretinoin

For chronic hand eczema refractory to topical therapy, alitretinoin 30 mg daily provides superior symptom control. 2, 3

• Alitretinoin 30 mg achieves investigator-rated symptom control with RR 2.75 (95% CI 2.20-3.43) and NNTB of 4 compared to placebo 2
• Participant-rated symptom control shows similar benefit (RR 2.75,95% CI 2.18-3.48) 2
• Headache is the most common adverse event, occurring more frequently than placebo (RR 3.43) 2
• Treatment duration typically extends 48-72 weeks for sustained benefit 2

Cyclosporine

For severe cases requiring rapid control, consider cyclosporin 3 mg/kg/day. 2

• Cyclosporin probably slightly improves both investigator-rated (RR 1.88) and participant-rated (RR 1.25) symptom control compared to topical betamethasone after 6 weeks 2
• Adverse events including dizziness occur in approximately 68% of patients but are similar to topical corticosteroid comparators 2

Treatment Algorithm Summary

1. Weeks 0-2: High-potency topical corticosteroid (clobetasol 0.05%) twice daily + urea 10% cream three times daily + behavioral modifications 1, 2

2. Week 2 reassessment: If no improvement, continue current regimen or switch to tacrolimus 0.1% twice daily 2, 5

3. Week 4-6 reassessment: If inadequate response, refer for topical PUVA therapy 2-3 times weekly 1

4. Persistent severe disease: Initiate systemic therapy with acitretin 25 mg daily (for psoriasis) or alitretinoin 30 mg daily (for eczema) 1, 6, 2

Critical Pitfalls to Avoid

• Do not use low-potency corticosteroids on palmar skin - the thick stratum corneum requires high-potency preparations for adequate penetration 4
• Avoid prolonged continuous high-potency corticosteroid use - switch to intermittent dosing (every other day or weekend-only) or calcineurin inhibitors for maintenance to prevent skin atrophy 1, 7
• Do not apply oil-based moisturizers under latex or rubber gloves - they cause material breakdown; use water-based formulations instead 1
• Avoid patch testing during acute flares - defer until disease is controlled, but ensure testing is performed for recalcitrant cases to identify allergens 1
• Do not delay systemic therapy in severe disease - quality of life impairment from palmar involvement is disproportionate to body surface area affected and justifies aggressive treatment 1