What is the best treatment approach for a patient with eczema (atopic dermatitis) on their hands and feet?

Treatment of Hand and Foot Eczema

For hand and foot eczema, start with potent topical corticosteroids applied twice daily to affected areas combined with liberal emollient use, and escalate to oral alitretinoin 30 mg daily for severe chronic cases that fail to respond after 4 weeks. 1, 2, 3

First-Line Topical Corticosteroid Strategy

• Apply potent topical corticosteroids (such as clobetasol propionate 0.05% or mometasone furoate) twice daily to hands and feet—these areas have thicker skin that tolerates higher potency steroids better than facial or flexural areas 1, 4

• Potent TCS are significantly more effective than mild TCS for hand eczema, with evidence showing 5-8 times greater odds of treatment success compared to vehicle 4

• Limit continuous potent corticosteroid use to 6 weeks maximum without breaks, then implement "steroid holidays" or switch to maintenance regimens to minimize systemic absorption and side effects 2, 3

• After achieving clearance, consider proactive maintenance therapy with topical corticosteroids applied twice weekly to previously affected sites to prevent relapse 5

Essential Emollient Therapy

• Apply emollients liberally and frequently throughout the day, immediately after hand washing and bathing, to provide a surface lipid film that retards water loss 1, 5

• Continue aggressive emollient use even when eczema appears controlled—this is the cornerstone of maintenance therapy 1, 5

• Use soap-free cleansers exclusively and avoid hot water, as these remove natural skin lipids and aggravate hand eczema 5

Managing Pruritus

• Prescribe sedating antihistamines (such as diphenhydramine) exclusively at nighttime to help patients sleep through severe itching episodes—their benefit comes from sedation, not direct anti-pruritic effects 1, 5

• Non-sedating antihistamines have no value in eczema and should not be used 1

Identifying and Treating Secondary Infection

• Watch for increased crusting, weeping, or pustules—these indicate secondary bacterial infection with Staphylococcus aureus 1, 5

• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids—do not delay or withhold corticosteroids when infection is present 1, 5

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate oral acyclovir immediately (or IV if patient is febrile)—this is a medical emergency 1

Second-Line Phototherapy Option

• For hand and foot eczema failing topical therapy, oral PUVA (psoralen plus UVA) is superior to UVB phototherapy, with 81-86% of patients achieving significant improvement or clearance 6

• Local PUVA may be more effective than narrow-band UVB for hand eczema, though adverse events (mainly erythema) occur more frequently with UVB 6

• Consider the long-term risks of skin carcinogenicity and premature aging when using PUVA, particularly for maintenance therapy 6

Systemic Therapy for Severe Chronic Hand Eczema

• For severe chronic hand eczema unresponsive to potent topical corticosteroids after 4 weeks, prescribe oral alitretinoin 30 mg daily—this provides 2.75 times greater odds of investigator-rated symptom control and 2.75 times greater odds of patient-rated symptom control compared to placebo 7, 4

• Alitretinoin 30 mg is more effective than the 10 mg dose (which has an NNTB of 11 versus 4 for the 30 mg dose) 7

• The main adverse effect is headache, which occurs significantly more often with alitretinoin 30 mg (RR 3.43) compared to placebo 7

• Alitretinoin is recommended as second-line treatment relative to topical corticosteroids by the European Society of Contact Dermatitis 2, 3

• Oral cyclosporin 3 mg/kg/day is an alternative systemic option that probably slightly improves symptoms compared to topical betamethasone, with similar adverse event rates (mainly dizziness) 7

Alternative Topical Agents

• Tacrolimus 0.1% ointment applied twice daily for 2 weeks is probably as effective as potent TCS and causes well-tolerated application site burning/itching in about 29% of patients 7, 4

• Tacrolimus and other calcineurin inhibitors are ranked among the most effective treatments but cause more local application-site reactions than corticosteroids 4

• JAK inhibitors (such as ruxolitinib 1.5% or delgocitinib 0.5%) are ranked similarly effective to potent TCS in recent network meta-analyses 4

• PDE-4 inhibitors (crisaborole 2%, roflumilast 0.15%) are consistently ranked among the least effective topical anti-inflammatory treatments 4

Critical Safety Considerations

• Short-term use of potent or very potent TCS on hands and feet (median 3 weeks, up to 16 weeks) shows no evidence of increased skin thinning, though longer-term use (6-60 months) does increase this risk 4

• The hands and feet tolerate higher potency steroids better than thin-skinned areas due to thicker stratum corneum 1

• Systemic corticosteroids should only be used for acute severe flares requiring rapid control after exhausting all other options, never for maintenance treatment 1

When to Refer

• Failure to respond to potent topical corticosteroids after 4 weeks warrants referral for consideration of systemic therapy 1, 5

• Need for phototherapy or systemic immunosuppressive therapy requires specialist management 1