What is the recommended treatment for a patient with hand eczema, specifically regarding the use of steroid cream?

Treatment of Hand Eczema with Topical Corticosteroids

For hand eczema, apply a mid- to high-potency topical corticosteroid such as triamcinolone 0.1% or clobetasol 0.05% twice daily to affected areas for 1-2 weeks, combined with aggressive moisturization and the "soak and smear" technique. 1, 2

First-Line Treatment Algorithm

Initial Topical Steroid Selection by Severity

• For mild to moderate localized hand eczema: Start with mid-potency topical steroid (triamcinolone 0.1%) applied twice daily for 1-2 weeks 1, 2

• For severe or recalcitrant cases: Use a short course (up to 2 weeks) of very potent topical steroid like clobetasol propionate 0.05% 2

• Application frequency: Most preparations should be applied twice daily, though some newer formulations require only once-daily application 3, 2. Interestingly, research suggests once-daily application may be as effective as twice-daily use, particularly for moderate eczema 4

Critical Adjunctive Measures (Must Be Done Concurrently)

• "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

• Moisturizer application: Apply immediately after hand washing and before wearing gloves, using two fingertip units for adequate hand coverage 2, 5

• Hand hygiene modifications: Use soap substitutes without allergenic surfactants, preservatives, fragrances, or dyes; wash with lukewarm (not hot) water; pat dry gently rather than rubbing 1, 5

Duration and Monitoring

• Treatment duration: Use topical steroids for short periods only; very potent and potent preparations should be used with caution for limited periods 3

• Maximum duration: High or medium potency topical steroids can be used for up to 12 weeks 1

• When to stop: Discontinue when signs and symptoms (itching, rash, erythema) resolve, or as directed 1

• Reassessment timeline: If no improvement after 2 weeks of appropriate topical steroid therapy, perform patch testing to identify clinically relevant allergens 1

• Referral threshold: Consider referral if no improvement after 6 weeks of treatment 5

Critical Safety Precautions

Areas to Avoid

• Do not use high-potency topical steroids on the face, groin, axillae, or genital region due to increased absorption and risk of skin atrophy 1

• For these sensitive areas, consider topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus) as steroid-sparing alternatives 1, 6

Monitoring for Adverse Effects

• Watch for pituitary-adrenal axis suppression, particularly with potent steroids used over large areas or for prolonged periods—this is the main risk, especially in children where it may interfere with growth 3

• Monitor for skin atrophy, striae, or secondary infection during treatment 1

• Paradoxical worsening: Be alert for signs of topical steroid allergy, which presents as worsening dermatitis despite treatment 1, 2

Common Pitfalls to Avoid

• Do not apply occlusive dressings with high-potency steroids 2

• Do not bathe, shower, or swim immediately after applying steroid cream, as this washes off the medication 6

• Do not use oil-based moisturizers under latex or rubber gloves, as they can break down the glove material; use water-based moisturizers instead 2, 5

• Do not apply gloves when hands are still wet from hand washing or sanitizer 5

When First-Line Treatment Fails

Evaluation Steps

• Perform patch testing to identify possible allergic contact dermatitis triggers 1, 2

• Evaluate for secondary bacterial infection and treat if present (flucloxacillin for S. aureus, the most common pathogen) 3, 2

• Consider stepping up to a more potent topical steroid if inadequate response 2

Second-Line Treatment Options

• Phototherapy (PUVA) for steroid-resistant cases 1, 2, 7

• Topical tacrolimus 0.1% when topical steroids are contraindicated, have caused adverse effects, or for prolonged use (≥4 weeks) on sensitive areas 1

• Systemic agents (alitretinoin, cyclosporin, azathioprine) for recalcitrant cases 1, 2, 8

Distinguishing Treatment by Etiology

For Allergic Contact Dermatitis

• Topical steroids are the primary treatment and should be applied promptly to mitigate flares 1

• Identify and eliminate the causative allergen through patch testing and avoidance 1, 5

For Irritant Contact Dermatitis

• Use topical steroids only after conservative measures fail, as they may damage the skin barrier with prolonged use 1, 5

• Prioritize barrier protection and moisturization as first-line interventions 5