Treatment of Palmar Eczema
Apply potent topical corticosteroids such as clobetasol propionate 0.05% or mometasone furoate twice daily to the palms, combined with aggressive emollient use after every hand washing, as the hands tolerate higher potency steroids better than other body sites due to thicker stratum corneum. 1
First-Line Treatment: Potent Topical Corticosteroids
Start with potent corticosteroids (clobetasol propionate 0.05% or mometasone furoate) applied twice daily to affected palmar areas, as these thicker-skinned sites tolerate higher potency preparations without the atrophy risk seen on facial or flexural skin 1, 2
After achieving clearance, transition to proactive maintenance therapy with topical corticosteroids applied twice weekly to previously affected sites to prevent relapse 1, 2
Limit continuous potent corticosteroid use to six weeks maximum without careful medical supervision, and avoid application under occlusive dressings without medical oversight 2
Essential Emollient Therapy (The Cornerstone)
Apply emollients liberally and frequently throughout the day, immediately after every hand washing and bathing, to provide a surface lipid film that retards water loss 1, 2
Continue aggressive emollient use even when eczema appears controlled, as this is the cornerstone of maintenance therapy and prevents relapse 1, 2
Use soap-free cleansers exclusively and avoid hot water, as regular soap and hot water strip natural skin lipids and aggravate hand eczema 1, 2
Managing Pruritus
Prescribe sedating antihistamines (diphenhydramine or hydroxyzine) exclusively at nighttime during severe flares to help patients sleep through itching episodes, as their benefit comes from sedation rather than direct anti-pruritic effects 1, 3
Do not prescribe non-sedating antihistamines, as they have no value in eczema treatment 1, 3
Identifying and Treating Secondary Bacterial Infection
Watch for signs of secondary infection: increased crusting, weeping, or pustules on palmar skin 1, 3
Add oral flucloxacillin as first-line antibiotic for Staphylococcus aureus (the most common pathogen), while continuing topical corticosteroids—infection is not a contraindication to steroid use when appropriate antibiotics are given concurrently 1, 3
Use erythromycin in patients with penicillin allergy or flucloxacillin resistance 3
Second-Line Treatment: Phototherapy
For palmar eczema failing topical therapy, oral PUVA (psoralen plus UVA) is superior to narrow-band UVB, with 81-86% of patients achieving significant improvement or clearance 1
Local PUVA may be more effective than narrow-band UVB for hand eczema, though adverse events (mainly erythema) occur more frequently with UVB 1, 3
Be aware of long-term concerns with PUVA including premature skin aging and cutaneous malignancies, though short-term use is generally well tolerated 3, 2
Third-Line Treatment: Systemic Therapy
Oral cyclosporin 3 mg/kg/day probably slightly improves symptom control compared to topical betamethasone after six weeks, with similar adverse event profiles (mainly dizziness) 4
Alitretinoin 30 mg daily is highly effective, improving investigator-rated symptom control significantly compared to placebo (RR 2.75), though headache risk increases 4
Never use systemic corticosteroids for maintenance treatment—reserve only for acute severe flares requiring rapid control after exhausting all other options 1, 2
Critical Pitfalls to Avoid
Do not undertreat due to steroid phobia—the palms tolerate potent corticosteroids well due to thick stratum corneum, unlike facial or flexural areas 1, 2
Never delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently 1
Avoid continuous long-term potent corticosteroid use beyond six weeks without careful medical supervision 2, 5