What are the next steps for a patient with chronic eczema on the hands and face who has not responded to topical steroid (corticosteroid) ointment for 10 months?

Management of Steroid-Refractory Eczema on Hands and Face After 10 Months

After 10 months of failed topical steroid treatment for facial and hand eczema, you must immediately discontinue the steroids and transition to topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as first-line therapy, with dupilumab as the definitive second-line option if no improvement occurs within 6-8 weeks. 1

Immediate Action: Stop Steroids and Switch to Calcineurin Inhibitors

• Discontinue all topical corticosteroids immediately, especially on the face, as prolonged use beyond 4-6 weeks risks irreversible skin atrophy, telangiectasia, and tachyphylaxis 1, 2

• Initiate tacrolimus 0.1% ointment twice daily to both hands and face as the primary steroid-sparing agent 1, 3

  • Tacrolimus 0.1% is ranked among the most effective topical anti-inflammatory treatments for eczema in network meta-analysis 3
  • Apply thin layer to affected areas only, not to normal skin 4
  • Warn patients about transient burning/stinging during first few days of application, which typically resolves as inflammation improves 4

• Alternative option: pimecrolimus 1% cream if tacrolimus is not tolerated, though tacrolimus 0.1% shows superior efficacy 1, 4

Essential Concurrent Supportive Measures

• Apply emollients liberally and frequently (minimum once daily, ideally after every hand washing) to restore barrier function 1

  • Use fragrance-free moisturizers containing petrolatum or mineral oil 5
  • Apply to damp skin immediately after bathing using two-fingertip-unit method 2, 5

• Implement strict hand hygiene modifications to prevent irritant contact dermatitis 2

  • Use mild, pH-neutral non-soap cleansers instead of regular soap 5
  • Apply moisturizer before wearing gloves if occupational exposure is involved 2
  • Avoid hot water; use tepid water only 5

• Avoid all alcohol-containing preparations on the face, as these significantly worsen dryness and trigger flares 5

Timeline for Escalation to Systemic Therapy

If no improvement after 6-8 weeks of topical calcineurin inhibitors, escalate to dupilumab 1

• Dupilumab (Dupixent) dosing regimen 1:

  • Loading dose: 600 mg (two 300 mg subcutaneous injections) on day 1
  • Maintenance: 300 mg subcutaneous injection every 2 weeks

• This is the FDA-approved biologic specifically indicated for severe atopic dermatitis refractory to conventional topical treatment 1

Alternative Second-Line Options

If dupilumab is contraindicated or unavailable, consider 1, 6:

• Alitretinoin 30 mg daily for hand eczema specifically (high-certainty evidence; RR 2.75 for symptom control vs placebo; NNTB 4) 6

  • Most effective systemic option for severe chronic hand eczema 7
  • Expect headache as common adverse effect 6

• Oral cyclosporin 3 mg/kg/day may provide modest benefit (RR 1.88 for investigator-rated improvement vs topical betamethasone) 6

• Azathioprine or methotrexate as steroid-sparing immunosuppressives 1, 2

Phototherapy Consideration

• Narrowband UVB phototherapy can be considered for recalcitrant cases, particularly for hand eczema 2
  • Shown effective in chronic atopic eczema with 68% reduction in severity scores 2
  • Requires 2-3 treatments per week 2
  • Local PUVA may be superior to narrowband UVB for hand eczema specifically 6

Critical Pitfalls to Avoid

• Never use medium-to-high potency steroids on the face, even if low-potency steroids failed—this will worsen atrophy 1

  • Only hydrocortisone 2.5% or Class V/VI steroids should ever be used facially, and even these should be limited to 2-4 weeks maximum 1, 5

• Do not continue ineffective treatments beyond 4-6 weeks; escalate therapy promptly 1

• Avoid long-term continuous use of topical calcineurin inhibitors without monitoring, as safety beyond 12 months is not established 4

  • Use only on areas with active eczema, not as prophylaxis on normal skin 4
  • Not approved for children under 2 years 4

• Rule out contact dermatitis through patch testing if not already done, as allergic contact dermatitis requires allergen avoidance rather than escalating immunosuppression 2

When to Refer to Dermatology

Immediate dermatology referral is indicated for 5:

• Diagnostic uncertainty or atypical presentation
• Failure to respond after 4 weeks of appropriate first-line topical calcineurin inhibitor therapy
• Need for systemic immunosuppressive therapy or biologics
• Suspected allergic contact dermatitis requiring patch testing