What is the recommended topical steroid for eczema of the hand?

Recommended Topical Steroid for Hand Eczema

For hand eczema, start with a mid-potency topical corticosteroid such as triamcinolone 0.1% applied twice daily, and escalate to a very potent steroid like clobetasol propionate 0.05% for severe or recalcitrant cases (limited to 2 weeks maximum). 1, 2

Initial Treatment Approach

Mid-potency steroids are the first-line choice:

• Apply triamcinolone 0.1% twice daily to affected areas for 1-2 weeks as initial therapy 2
• This potency balances efficacy with safety for the thicker skin of the hands 2
• Rub in gently and completely with each application 1

Essential adjunctive measures must be implemented simultaneously:

• Apply moisturizer immediately after washing hands and before wearing gloves 1
• 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, 2
• Replace soap with soap substitutes devoid of allergenic surfactants, preservatives, fragrances, or dyes 2

Escalation for Severe or Recalcitrant Cases

When mid-potency steroids fail after 1-2 weeks, escalate to very potent steroids:

• Use clobetasol propionate 0.05% (foam, cream, or ointment) twice daily 1, 2, 3
• Clobetasol foam probably improves patient-rated symptom control compared to vehicle (RR 2.32,95% CI 1.38 to 3.91; NNTB 3) when assessed at 15 days 4
• Strict limitation: maximum 2 consecutive weeks of treatment 3
• Do not exceed 50 grams per week 3
• Discontinue when control is achieved 3

Critical Safety Precautions

Avoid common pitfalls with potent steroids:

• Never use occlusive dressings with high-potency steroids 1, 3
• Monitor for paradoxical worsening—this may indicate topical steroid allergy 1, 2
• Watch for skin atrophy, striae, or secondary infection during treatment 2
• Application site burning or pruritus may occur (occurred in 11/62 patients with clobetasol versus 5/63 with vehicle) 4

When First-Line Treatment Fails

If no improvement after 2 weeks of appropriate topical steroid therapy:

• Perform patch testing to identify clinically relevant allergens causing allergic contact dermatitis 5, 2
• Evaluate for secondary bacterial infection and treat if present 1
• Consider second-line treatments: phototherapy (PUVA), topical tacrolimus 0.1%, or systemic agents (alitretinoin, cyclosporin, azathioprine) 5, 1

Alternative Topical Anti-Inflammatory Agents

For cases where steroids are unsuitable or ineffective:

• Tacrolimus 0.1% applied twice daily over 2 weeks probably improves investigator-rated symptom control (14/14 tacrolimus versus 0/14 vehicle) 4
• Tacrolimus 0.1% is ranked among the most effective treatments in network meta-analysis alongside potent steroids 6
• Application site burning/itching occurs in approximately 4/14 patients but is generally well-tolerated 4
• Consider tacrolimus when topical steroids are contraindicated or have caused adverse effects 5

Maintenance After Remission

For preventing relapse once control is achieved:

• Step down to mometasone furoate cream applied three times weekly after remission is reached 4
• This may slightly improve investigator-rated symptom control compared to twice weekly application (RR 1.23,95% CI 0.94 to 1.61) when assessed at 36 weeks 4
• Continue aggressive emollient use indefinitely 1, 2