What is the best treatment for a skin problem on the hands?

Treatment for Hand Skin Problems

Start with frequent moisturization (two fingertip units per hand after each washing), identify and avoid irritants, and apply a medium-potency topical corticosteroid like clobetasol propionate 0.05% foam twice daily for active inflammation. 1, 2, 3

Immediate First Steps

Identify and Eliminate Triggers

• Stop all harsh soaps, detergents, hot water, and potential allergens immediately 1, 2, 4
• Use only lukewarm or cool water for hand washing—hot water (>40°C) damages the skin barrier through lipid disruption 1
• Avoid dish detergent, disinfectant wipes on skin, and washing hands immediately before/after alcohol sanitizer use 1
• Pat hands dry gently with clean towels rather than rubbing 1, 2

Optimize Hand Hygiene

• Switch to pH-neutral, fragrance-free soaps without allergenic preservatives 1, 2
• Use alcohol-based hand sanitizers (≥60% alcohol) with added moisturizers when appropriate 2
• Wash hands for 15-20 seconds, focusing on commonly missed areas (fingertips, hypothenar eminence, dorsum) 1

Core Treatment Protocol

Aggressive Moisturization (Critical Foundation)

• Apply two fingertip units of moisturizer to each hand immediately after every hand washing 1, 2
• Use tube-packaged moisturizers (not jars) to prevent contamination 1, 2
• Keep pocket-sized moisturizers available for frequent reapplication throughout the day 1, 2
• For severe dryness: perform "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, 2
• At night, apply moisturizer followed by cotton or loose plastic gloves to create occlusive barrier 1, 2

Topical Anti-Inflammatory Treatment

For Active Inflammation (Irritant or Allergic Contact Dermatitis):

• Apply clobetasol propionate 0.05% foam twice to three times daily to affected areas, which provides superior symptom control compared to vehicle (RR 2.32, NNTB 3) 2, 3, 5
• Alternative: triamcinolone acetonide 0.1% cream two to three times daily, rubbed in gently 3
• For maintenance after initial improvement: switch to mometasone furoate cream three times weekly to prevent relapse 1, 2

Important Corticosteroid Considerations:

• Monitor for skin atrophy with prolonged use—use lowest effective potency once control achieved 1
• Consider occlusive dressing technique for recalcitrant areas: apply thin layer, cover with nonporous film for 12 hours overnight, then reapply without occlusion during day 3
• If infection develops during occlusive therapy, discontinue immediately and start antimicrobial treatment 3

Alternative Topical Agents

• Tacrolimus 0.1% ointment twice daily is probably effective for investigator-rated improvement and may be preferred for facial/thin skin involvement or steroid-refractory cases 2, 5
• Expect mild, well-tolerated burning/itching at application site in approximately 30% of patients 2

When Conservative Measures Fail (After 6 Weeks)

Phototherapy Option

• Local PUVA (psoralen plus UVA) may improve symptoms compared to narrow-band UVB after 12 weeks, though evidence shows wide confidence intervals 2, 5
• Expect erythema as common adverse effect with UVB 2

Systemic Therapy for Recalcitrant Cases

Oral Alitretinoin (First-Line Systemic):

• Alitretinoin 30 mg daily provides superior symptom control (RR 2.75 for investigator-rated improvement, NNTB 4) compared to placebo, with high-certainty evidence 2, 5
• Alitretinoin 10 mg daily is less effective but still beneficial (RR 1.58, NNTB 11) 2, 5
• Expect headache as common adverse effect with 30 mg dose (RR 3.43) 2, 5
• Assess response at 48-72 weeks 2, 5

Oral Cyclosporine (Alternative):

• Cyclosporin 3 mg/kg/day probably slightly improves symptoms compared to topical betamethasone after 6 weeks (RR 1.88 for investigator-rated control) 2, 5
• Monitor for dizziness and other systemic effects 2

Oral Tetracyclines (For Grade ≥2 Dermatitis):

• Doxycycline or minocycline reduce severity through anti-inflammatory effects, not antimicrobial action 1
• Minocycline carries risk of vestibular symptoms and hyperpigmentation; doxycycline causes more photosensitivity 1

Special Considerations

For Suspected Allergic Contact Dermatitis

• Refer for patch testing to identify specific allergens (common culprits: preservatives, fragrances, rubber accelerators in gloves, nickel, propylene glycol) 1, 2, 4
• Use accelerator-free gloves (neoprene or nitrile) if glove allergy confirmed 1, 2
• Apply moisturizer before wearing gloves 1, 2

For Healthcare Workers and Occupational Exposure

• Use water-based moisturizers under gloves—oil-based products degrade latex and rubber 1, 2
• Latex, vinyl, and nitrile gloves resist breakdown from alcohol-based sanitizers 1, 2
• Consider cotton glove liners under work gloves 1, 2
• Never apply gloves to wet hands from washing or sanitizer 1

Sun Protection

• Apply hypoallergenic sunscreen (SPF ≥30, PABA-free, UVA/UVB protection with zinc oxide or titanium dioxide) daily to hands 1
• Wear protective clothing and avoid direct sun exposure 1

Critical Pitfalls to Avoid

• Do not use greasy/occlusive creams for basic care—these facilitate folliculitis 1
• Avoid topical acne medications and retinoids—they worsen dryness and irritation 1
• Do not apply topical antibiotics (neomycin, bacitracin) routinely—these are common allergens 1
• Never use superglue on fissures—this is a known allergen 1
• Avoid prolonged glove occlusion without underlying moisturizer—increases irritation risk 1

When to Refer to Dermatology

Mandatory referral criteria:

• No improvement after 6 weeks of appropriate topical treatment 2, 4
• Suspected allergic contact dermatitis requiring patch testing 1, 2, 4
• Recalcitrant disease requiring phototherapy or systemic therapy 1, 2
• Change in baseline dermatitis pattern 2, 4