What is the best treatment for an adult patient with hand eczema and no significant medical history?

Best Treatment for Hand Eczema

For an adult with hand eczema, start with frequent moisturization (two fingertip units after each hand washing) combined with a mid-to-high potency topical corticosteroid such as triamcinolone 0.1% applied twice daily, while simultaneously identifying and avoiding irritants or allergens through patch testing if the condition persists beyond 2 weeks. 1, 2

First-Line Treatment Approach

Immediate Management

Begin with topical corticosteroids as the cornerstone of therapy:

• Apply triamcinolone 0.1% cream or ointment twice daily to affected areas 2, 3
• For more severe cases, escalate to clobetasol propionate 0.05% twice daily for up to 2 weeks, which achieves clear or almost clear skin in 67.2% of severe cases 2, 4
• Topical corticosteroids demonstrate high-certainty evidence for efficacy in hand eczema 1

Intensive moisturization is essential and should be maintained throughout treatment:

• Apply two fingertip units of moisturizer to hands after each washing 1, 2
• Use moisturizers packaged in tubes rather than jars to prevent contamination 1
• Consider the "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
• At night, apply moisturizer followed by cotton or loose plastic gloves to create an occlusive barrier 1

Critical Diagnostic Step

If symptoms persist beyond 2 weeks despite appropriate topical corticosteroid treatment, refer for patch testing with an extended standard series of allergens to identify allergic contact dermatitis: 1, 2, 4

• Pattern and morphology alone cannot reliably distinguish between irritant, allergic, or endogenous hand dermatitis 4
• Identifying and avoiding specific allergens offers the best chance for long-term resolution 1, 2
• Consider testing for corticosteroid allergy if dermatitis worsens with treatment 2

Irritant and Allergen Avoidance

Implement strict avoidance measures based on the type of hand eczema:

For irritant contact dermatitis:

• Avoid frequent hand washing with hot water; use lukewarm or cold water instead 1
• Avoid dish detergent, bleach, and other known irritants 1
• Limit hand washing duration to 20 seconds 1
• Apply moisturizer before wearing gloves 1

For allergic contact dermatitis:

• Avoid products containing topical antibiotics (neomycin, bacitracin) 1
• Use accelerator-free gloves such as rubber-free neoprene or nitrile gloves if glove allergy is identified 1
• Switch to plain white petrolatum for wound care if using topical antibiotics 2

Second-Line Treatment Options

Topical Calcineurin Inhibitors

For patients concerned about long-term corticosteroid use or with facial/thin-skinned involvement, consider tacrolimus 0.1% ointment twice daily: 1, 2, 4

• Tacrolimus probably improves investigator-rated symptom control compared to vehicle after 3 weeks of treatment 5
• Pimecrolimus 1% cream is FDA-approved for mild-to-moderate atopic dermatitis in adults and can be used for atopic hand eczema 1, 6
• Apply twice daily only to affected areas; use for short periods with breaks in between 6
• Common side effects include application site burning or warmth, typically mild and resolving within the first 5 days 6
• Important caveat: Do not use continuously for long periods due to theoretical cancer concerns, though a causal link has not been established 6

Phototherapy

For chronic hand eczema unresponsive to topical treatments, phototherapy is an established second-line option: 1, 4, 5

• Local PUVA (psoralen plus UVA) may lead to improvement compared to narrow-band UVB after 12 weeks, though evidence is moderate certainty 5
• Narrow-band UVB phototherapy shows efficacy in chronic atopic eczema with good evidence 1
• Topical PUVA with 8-MOP paint showed clearance or considerable improvement in 58-81% of dyshidrotic eczema cases 1
• Main adverse events include erythema and application site reactions 5

Third-Line Systemic Therapies

For Severe Chronic Hand Eczema Refractory to Topical Treatment

Alitretinoin is the only FDA-approved systemic treatment specifically for severe chronic hand eczema and should be considered for refractory cases: 1, 5, 7, 8

• Alitretinoin 30 mg daily improves investigator-rated symptom control compared to placebo (RR 2.75,95% CI 2.20-3.43; NNTB 4) with high-certainty evidence 5
• Alitretinoin 10 mg daily also improves outcomes (RR 1.58,95% CI 1.20-2.07; NNTB 11) with high-certainty evidence 5
• Headache is the most common adverse event, particularly with the 30 mg dose 5
• Treatment duration typically ranges from 48-72 weeks 5

For severe cases where alitretinoin is unavailable or contraindicated, consider oral cyclosporin 3 mg/kg/day: 1, 4, 5

• Cyclosporin probably slightly improves investigator-rated control compared to topical betamethasone after 6 weeks (moderate-certainty evidence) 5
• Adverse events such as dizziness occur at similar rates to topical corticosteroids 5
• Azathioprine is another option for steroid-resistant chronic hand dermatitis with prospective trial support 1, 4

Emerging Systemic Options

Dupilumab, approved for moderate-to-severe atopic dermatitis, can theoretically be applied for atopic hand eczema: 1, 7

• All guideline workgroup members favored dupilumab as first-line systemic agent for atopic dermatitis 1
• It has an excellent safety track record with few major safety concerns after more than 5 years in clinical practice 1
• No head-to-head studies specifically for hand eczema exist, but it may be considered for severe atopic hand eczema 1, 7

Maintenance Therapy

Once control is achieved, implement intermittent maintenance therapy to prevent flares:

• Use medium-potency topical corticosteroids twice weekly to reduce disease flares and relapse 1
• Mometasone furoate cream used thrice weekly may slightly improve symptom control compared to twice weekly after remission is reached 5
• Continue regular moisturization even when symptoms are controlled 1

Common Pitfalls to Avoid

Critical mistakes that worsen hand eczema:

• Washing hands with very hot water, which disrupts the stratum corneum through lipid fluidization 1
• Applying gloves when hands are still wet from washing or alcohol sanitizer 1
• Using topical antibiotics (neomycin, bacitracin) which are common allergens 1, 2
• Continuous long-term use of very high potency corticosteroids without medical supervision, risking skin atrophy 1
• Failing to patch test persistent cases, missing treatable allergic contact dermatitis 1, 2, 4

Prognosis and Follow-Up

Reassess patients after 2 weeks of very high potency topical corticosteroid treatment: 2, 4

• If no improvement after 6 weeks of treatment, consider alternative diagnoses such as cutaneous lymphoma or refer to dermatology 1, 6
• Long-term prognosis for occupational contact dermatitis is often poor, with only 25% achieving complete healing over 10 years 1, 2, 4
• Complete allergen avoidance after identification offers the best chance for resolution 2, 4
• Changing occupation does not necessarily improve prognosis in 40% of cases 1