What is the next step in managing a patient with hand eczema that does not improve with Betaderm (betamethasone) 0.1% ointment for 2 weeks?

Management of Hand Eczema Refractory to Betamethasone 0.1%

Escalate to a super-high potency topical corticosteroid such as clobetasol propionate 0.05% applied twice daily for up to 2 weeks, as betamethasone 0.1% is only a mid-potency steroid and insufficient for refractory hand eczema. 1, 2

Immediate Next Steps

Switch to Super-High Potency Topical Corticosteroid

• Apply clobetasol propionate 0.05% cream or ointment twice daily to affected areas, rubbing in gently and completely 1
• Clobetasol propionate 0.05% foam demonstrates significantly better participant-rated symptom control compared to vehicle (RR 2.32,95% CI 1.38 to 3.91; NNTB 3) when assessed after 15 days of treatment 2
• Limit treatment to 2 consecutive weeks maximum, using no more than 50 grams per week due to the super-high potency classification 1
• If no improvement is seen within 2 weeks, reassessment of diagnosis and alternative treatments are necessary 1

Add Adjunctive Barrier Restoration

• Apply urea 10% cream three times daily to restore skin barrier function and reduce pruritus 3
• Urea emollients significantly reduce the incidence and severity of hand skin reactions 4
• Use alcohol-free moisturizers and avoid mechanical stress (heavy carrying without gloves) and chemical stress (skin irritants, solvents, disinfectants) 4

Consider Oral Antihistamines for Symptom Relief

• Prescribe cetirizine 10mg daily, loratadine 10mg daily, or fexofenadine 180mg daily for moderate-to-severe pruritus 3
• Antihistamines provide itch relief within 24-48 hours without risk of topical sensitization 3

Critical Diagnostic Considerations

Rule Out Allergic Contact Dermatitis

• Betamethasone itself can cause allergic contact dermatitis, manifesting as persistent erythema, pruritus, and edema that fails to resolve with continued use 3
• Allergic reactions to topical corticosteroids present as delayed hypersensitivity with a sensitization phase of 10-14 days, followed by worsening symptoms with continued exposure 3
• Confirm complete avoidance of the original chemical irritant, as persistent exposure is the most common cause of treatment failure 3

If Steroid Allergy is Suspected

• Stop betamethasone immediately and avoid all topical preparations containing potential sensitizers including neomycin, preservatives, and fragrances 3
• Consider switching to tacrolimus 0.1% twice daily, which probably improves investigator-rated symptom control (14/14 tacrolimus versus 0/14 vehicle after 3 weeks) 2
• Application site burning/itching occurs in approximately 4/14 patients with tacrolimus but is generally well-tolerated 2

If No Improvement After 2 Weeks of Clobetasol

Systemic Treatment Options

Oral alitretinoin is the most effective systemic option with high-certainty evidence:

• Alitretinoin 30 mg daily improves investigator-rated symptom control compared to placebo (RR 2.75,95% CI 2.20 to 3.43; NNTB 4) 2
• Participant-rated symptom control also improves significantly (RR 2.75,95% CI 2.18 to 3.48) 2
• Headache is the main adverse event (RR 3.43,95% CI 2.45 to 4.81) but is generally manageable 2
• Outcomes assessed between 48-72 weeks demonstrate sustained efficacy 2

Alternative: Oral cyclosporine 3 mg/kg/day:

• Cyclosporine 3 mg/kg/day probably slightly improves investigator-rated (RR 1.88,95% CI 0.88 to 3.99) and participant-rated (RR 1.25,95% CI 0.69 to 2.27) symptom control compared to topical betamethasone after 6 weeks 2, 5
• Both cyclosporine and betamethasone-17,21-dipropionate decrease disease activity to approximately 57-58% of baseline 5
• Monitor serum creatinine during treatment; increases above 30% of baseline require dose adjustment 5
• Adverse events (dizziness, gastrointestinal symptoms) occur in approximately 68% of patients but are generally mild 2, 5

Phototherapy Option

• Local PUVA (psoralen plus UVA) therapy may lead to improvement in investigator-rated symptom control compared to narrow-band UVB after 12 weeks (RR 0.50,95% CI 0.22 to 1.16) 2
• Narrow-band UVB causes more erythema (9/30 participants) compared to PUVA (0/30 participants) 2

Common Pitfalls to Avoid

• Do not continue betamethasone beyond 2 weeks without improvement - this indicates inadequate potency or possible steroid allergy 3, 1
• Ensure strict avoidance of chemical irritants with appropriate gloves (nitrile or butyl rubber, not latex) 3
• Replace all soaps and detergents with soap-free cleansers and emollients 3
• Do not use clobetasol with occlusive dressings due to increased systemic absorption risk 1
• Up to 65% of chronic hand eczema cases do not resolve with topical treatment alone and require systemic therapy 6

Expected Timeline

• Clobetasol should show improvement within 2 weeks if the diagnosis is correct and irritant avoidance is complete 3, 1
• If no improvement after 2 weeks of clobetasol, dermatology referral is mandatory for patch testing and consideration of systemic therapy 3
• With appropriate treatment and complete allergen avoidance, improvement should occur within 2 weeks 3