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

Treatment of Recurrent Hand Eczema

For recurrent hand eczema, apply potent topical corticosteroids (such as clobetasol propionate 0.05% or mometasone furoate) twice daily as first-line treatment, combined with aggressive emollient use after every hand washing, and consider proactive maintenance therapy with twice-weekly corticosteroid application to previously affected sites once clearance is achieved. 1

First-Line Treatment Strategy

Topical Corticosteroids

• Use potent corticosteroids as the mainstay of treatment - the hands tolerate higher potency preparations better than other body sites due to thicker stratum corneum 1, 2
• Apply clobetasol propionate 0.05% foam or cream twice daily to affected areas, which probably improves symptom control compared to vehicle (NNTB 3) 3
• Alternatively, use mometasone furoate cream twice daily during active flares 1
• After achieving clearance, transition to proactive maintenance therapy with topical corticosteroids applied twice weekly to previously affected sites to prevent relapse 1
• Mometasone furoate used thrice weekly may slightly improve symptom control compared to twice weekly after remission is reached 3

Essential Emollient Therapy

• Apply emollients liberally and frequently throughout the day - this is the cornerstone of maintenance therapy even when eczema appears controlled 1, 2
• Apply immediately after every hand washing and bathing to provide a surface lipid film that retards water loss 1, 2
• Use moisturizers packaged in tubes rather than jars to prevent contamination 4
• Keep pocket-sized moisturizers available for frequent reapplication 4
• At night, apply moisturizer followed by cotton or loose plastic gloves to create an occlusive barrier 4
• Consider "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 4

Hand Hygiene Modifications

• Use soap-free cleansers exclusively and avoid hot water, as these remove natural skin lipids and aggravate hand eczema 1, 2
• Wash hands with lukewarm water (not exceeding 40°C) to avoid lipid fluidization and increased skin permeability 4
• Avoid washing hands with dish detergent or other known irritants 4
• Look for alcohol-based hand sanitizers with added moisturizers and avoid those containing irritants, preservatives, fragrances, or dyes 4

Identifying and Managing Contributing Factors

Irritant Contact Dermatitis (ICD)

• Identify and avoid irritants - awareness of wet work and exposure to surfactants and detergents is imperative 4
• Avoid frequent hand washing, use of disinfectant wipes to clean hands, and working with known irritants such as bleach 4
• Switch to less-irritating products whenever possible 4

Allergic Contact Dermatitis (ACD)

• Consider patch testing for recalcitrant hand dermatitis to identify clinically relevant allergens 4
• Patients with suspected ACD should be patch tested to at least an extended standard series of allergens 4
• For glove-related ACD, use accelerator-free gloves such as rubber-free neoprene or nitrile gloves 4
• Apply moisturizer after washing hands and before wearing gloves 4
• Avoid products containing topical antibiotics (neomycin, bacitracin) which are common allergens 4

Secondary Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating secondary Staphylococcus aureus infection 1, 2
• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids 1, 2
• Do not delay or withhold corticosteroids when infection is present - they remain the primary treatment when appropriate systemic antibiotics are given concurrently 2

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% probably improves investigator-rated symptom control compared to vehicle after three weeks of treatment 3
• Apply twice daily to affected areas; stop when signs and symptoms resolve 5
• Use only for short periods with breaks in between - continuous long-term use should be avoided 5
• Common side effects include application site burning or warmth, typically mild to moderate and occurring during the first 5 days 5
• Do not use under occlusive dressings 5
• Safety concern: A very small number of people using topical calcineurin inhibitors have had cancer (skin or lymphoma), though a causal link has not been established 5

Phototherapy

• For hand eczema failing topical therapy, local PUVA (psoralen plus UVA) may be more effective than narrow-band UVB 1, 3
• Local combination PUVA may lead to improvement compared to local narrow-band UVB after 12 weeks of treatment 3
• Adverse events (mainly erythema) occur more frequently with UVB than PUVA 1, 3
• Some concern exists about long-term adverse effects such as premature skin aging and cutaneous malignancies, particularly with PUVA 4, 2

Systemic Treatments for Severe Chronic Hand Eczema

Oral Alitretinoin (First-Line Systemic Option)

• Alitretinoin 30 mg daily significantly improves both investigator-rated (NNTB 4) and participant-rated symptom control compared to placebo 3
• Alitretinoin 10 mg daily also improves symptom control but less effectively (NNTB 11) 3
• This is high-certainty evidence from well-conducted trials 3
• The risk of headache increases with alitretinoin 30 mg (high-certainty evidence) 3
• Recommended as second-line treatment (relative to topical corticosteroids) for patients with severe chronic hand eczema 6

Oral Cyclosporin

• Cyclosporin 3 mg/kg/day probably slightly improves symptom control compared to topical betamethasone dipropionate 0.05% after six weeks 3
• The risk of adverse events such as dizziness is similar between groups 3
• Consider for recalcitrant cases when topical therapy fails 4

Other Systemic Options

• Azathioprine and methotrexate show promising results for steroid-resistant chronic hand eczema 4, 7
• Acitretin may suppress keratotic hand eczema 7
• These options have limited RCT evidence but are supported by clinical experience 6

Critical Pitfalls to Avoid

• Never use systemic corticosteroids for maintenance treatment - they should only be used for acute severe flares requiring rapid control after exhausting all other options 1, 2
• Avoid continuous long-term use of potent topical corticosteroids beyond six weeks without careful medical supervision 6
• Do not apply topical corticosteroids under occlusive dressings without medical supervision, as this may increase systemic absorption 4
• Avoid occluding hands with gloves without underlying moisturizer application, as this worsens dermatitis 4
• Do not use topical calcineurin inhibitors continuously for long periods - use only for short periods with breaks in between 5
• Avoid non-sedating antihistamines, as they have no value in eczema 1, 2

When to Refer to Dermatology

• Failure to respond to potent topical corticosteroids after 4 weeks warrants referral 1, 2
• Recalcitrant hand dermatitis requiring patch testing 4
• Need for phototherapy or systemic immunosuppressive therapy 4, 1
• Consideration of occupational modification for work-related hand eczema 4