How to manage a patient with skin peeling on feet and fingers, considering potential underlying conditions such as eczema or psoriasis?

Management of Skin Peeling on Feet and Fingers

Begin with frequent application of bland emollients and hypoallergenic moisturizers multiple times daily to restore barrier function, combined with identification and avoidance of irritants, while reserving topical corticosteroids for inflammatory presentations that fail conservative measures. 1

Initial Assessment and Differential Diagnosis

The key is distinguishing between the major causes of acral peeling:

• Irritant contact dermatitis (ICD) from excessive hand washing, detergents, or occupational exposures—the most common cause in clinical practice 1
• Eczema/atopic dermatitis with characteristic flexural involvement, personal/family history of atopy, and generalized dry skin 1
• Psoriasis presenting with well-demarcated erythematous plaques with silvery scale, particularly on palms/soles 1
• Keratolysis exfoliativa showing air-filled bullae and superficial collarettes of scale without inflammation 2, 3
• Fungal infection (tinea pedis/manuum) requiring KOH preparation or culture for diagnosis 4

Look for crusting, weeping, or pustules suggesting secondary bacterial infection requiring different management 1

First-Line Conservative Management

Barrier Restoration and Moisturization

• Apply emollients liberally and frequently—at minimum once daily, but ideally multiple times throughout the day after each hand washing 1, 5
• Use approximately 100g per 2 weeks for adequate coverage of affected areas 6
• Apply moisturizer immediately after bathing while skin is still hydrated to trap moisture 1
• The American Academy of Dermatology recommends hypoallergenic moisturizing creams or ointments over lotions 5

Irritant Avoidance

• Identify and eliminate irritants—this is imperative for ICD management 1
• Replace harsh soaps with mild, pH-neutral, non-soap cleansers 1, 5
• Use lukewarm (not hot) water for washing, as temperatures above 40°C disrupt the stratum corneum lipid structure 1
• Avoid washing with dish detergent or other known irritants 1
• Never use alcohol-containing lotions, which significantly worsen dryness 5

Hand Protection

• Wear rubber-free gloves (neoprene or nitrile) when exposed to water or irritants 1
• Apply moisturizer before wearing gloves to prevent occlusive irritation 1
• Consider cotton glove liners under protective gloves 1
• Avoid applying gloves to wet hands from washing or sanitizer 1

When to Add Topical Corticosteroids

Reserve corticosteroids for inflammatory presentations (erythema, pruritus) that persist despite 1-2 weeks of aggressive moisturization and irritant avoidance. 1, 6

For Eczematous Dermatitis

• Start with hydrocortisone 1-2.5% (mild potency) applied 2-4 times daily for hands and feet 1, 7
• The FDA approves hydrocortisone for eczema, psoriasis, and dermatitis-related itching 7
• For more severe inflammation, consider betamethasone valerate 0.1% or mometasone 0.1% (potent corticosteroids) 6
• Limit use to 2-4 weeks maximum to avoid skin atrophy and tachyphylaxis 5, 6

Application Guidelines

• Apply topical steroids not more than 3-4 times daily per FDA labeling 7
• Use no more than 100g monthly of moderately potent preparations 1
• Require regular clinical review with no unsupervised repeat prescriptions 1
• Plan periods each year when alternative non-steroid treatments are employed 1

Management of Suspected Psoriasis

If well-demarcated plaques with silvery scale suggest psoriasis:

• Start with topical coal tar (0.5-1% crude coal tar in petroleum jelly, increasing to maximum 10%) or dithranol 0.1-0.25% in doubling concentrations 1
• These agents are extremely safe and can be used long-term unlike corticosteroids 1
• Topical corticosteroids may be used under the same guidelines as eczema, but tar/dithranol are preferred for chronic management 1
• For palmoplantar psoriasis unresponsive to topicals, oral PUVA has shown 81-86% clearance rates 1

Monitoring for Complications

Secondary Bacterial Infection

• Watch for increased crusting, weeping, purulent drainage, or pustule formation 1, 6
• Staphylococcus aureus is the most common pathogen requiring oral antibiotics 5, 6
• Obtain wound cultures before initiating antimicrobial therapy 6
• Do NOT use prophylactic antibiotics without clear infection signs 6

Herpes Simplex Superinfection

• Look for grouped, punched-out erosions or vesiculation 1, 5
• This requires immediate antiviral therapy 5
• Send viral swabs and electron microscopy if suspected 1

Critical Pitfalls to Avoid

• Never use greasy or occlusive creams as they may facilitate folliculitis development 5, 6
• Avoid topical acne medications (retinoids, benzoyl peroxide) which worsen dryness and irritation 5, 6
• Do not manipulate or pick at peeling skin, increasing infection risk 5, 6
• Avoid inadequate quantities of topical treatment leading to under-application and failure 6
• Do not use topical corticosteroid-antimicrobial combinations unless clinically infected eczema is confirmed 6

When to Refer to Dermatology

Refer patients who fail to respond after 4 weeks of appropriate first-line therapy (moisturizers, irritant avoidance, and if indicated, topical corticosteroids). 1, 5

Additional referral indications include:

• Diagnostic uncertainty or atypical presentation 5
• Recurrent severe flares despite optimal supportive care 5
• Need for prolonged topical corticosteroid use beyond 2-4 weeks 5
• Suspected allergic contact dermatitis requiring patch testing 1
• Consideration of phototherapy or systemic therapy for severe disease 1