What treatment options are available for a 8-year-old eczema patient with chronic, severe symptoms, including dry scaling skin, deep cracks, and intense itching on hands and feet, with a persistent patch on one hand that has not fully healed in 6 years?

Why Eczema Becomes Chronic and Treatment for Severe Hand/Foot Eczema

For your chronic hand and foot eczema with deep cracks and intense itching, you need aggressive emollient therapy combined with potent topical corticosteroids, and if this fails after 6 weeks, you should be referred for systemic therapy with alitretinoin or cyclosporine.

Why Your Eczema Has Become Chronic

Your eczema persists because of a vicious cycle between skin barrier dysfunction and immune system abnormalities 1. The chronic nature occurs through:

• Barrier breakdown: Your skin has a genetically determined deficiency in maintaining its protective barrier, which allows irritants and allergens to penetrate more easily 1
• The itch-scratch cycle: Scratching damages the skin further, releasing inflammatory signals that perpetuate more inflammation and itching 1
• Chronic inflammation: The ongoing immune response prevents complete healing, especially in that 6-year-old patch on your hand 2
• Hand location vulnerability: Hands are constantly exposed to irritants (soaps, water, detergents) that strip natural skin oils, making healing nearly impossible without aggressive intervention 1, 3

Immediate Treatment for Severe Itching

First-Line: Aggressive Moisturization

• Apply emollients at least once daily to all affected areas, ideally immediately after a 10-15 minute lukewarm bath when skin is still damp 1
• Use oil-in-water creams or ointments, not alcohol-containing lotions which will worsen dryness 1, 4
• Avoid all soaps and detergents—use only dispersible cream as a soap substitute 1

Topical Corticosteroids for Active Disease

• Apply clobetasol propionate 0.05% foam or mometasone furoate 0.1% ointment twice daily to the cracked, inflamed areas 3, 5
• This should improve symptoms within 2-4 weeks 5
• Continue for up to 6 weeks maximum under medical supervision 6
• Once controlled, transition to twice-weekly maintenance application to prevent flare-ups 5

For Severe Itching Control

• Urea-containing or polidocanol-containing lotions applied regularly help soothe itching 1, 4
• Oral antihistamines with sedative properties (like clemastine) may provide short-term relief, particularly at night 1
• However, non-sedating antihistamines provide minimal benefit beyond sedation 4
• Keep nails short to minimize damage from scratching 1

When First-Line Treatment Fails

Referral Criteria

You should be referred to a dermatologist if 1:

• No improvement after 6 weeks of potent topical corticosteroids
• The persistent patch continues despite treatment
• Deep cracks are not healing

Second-Line: Systemic Therapy

Alitretinoin is the most effective systemic treatment for severe chronic hand eczema:

• Alitretinoin 30 mg daily improves symptoms in approximately 48% of patients versus 17% with placebo (high-certainty evidence) 3
• Treatment duration is typically 12-24 weeks 3
• Main side effect is headache, which occurs more frequently than placebo 3
• Alitretinoin 10 mg daily is an alternative if 30 mg causes side effects, though less effective 3

Cyclosporine 3 mg/kg/day is an alternative that probably improves symptoms compared to topical steroids alone 3:

• Assessed over 6 weeks with continuation up to 36 weeks if effective 3
• Side effects include dizziness but are generally tolerable 3

Phototherapy Option

Local PUVA (psoralen plus UVA) therapy may help if oral medications are not suitable 1, 3:

• Requires specialized equipment and multiple clinic visits
• Main side effect is skin redness 3

Critical Pitfalls to Avoid

• Never use hot water or excessive bathing—this strips protective oils and worsens dryness 1, 4
• Do not stop treatment once symptoms improve—transition to maintenance therapy to prevent relapse 5
• Avoid wool and irritating fabrics—wear cotton gloves under protective gloves when hands must be wet 1
• Do not use systemic corticosteroids for maintenance—they should only be considered for severe flares after all other options fail 1, 5
• Watch for secondary infection—if you develop crusting, weeping, or worsening despite treatment, you may need antibiotics 1, 4

Practical Daily Routine

1. Morning: Apply emollient, then mometasone furoate 0.1% ointment to active patches
2. Throughout day: Reapply emollient after any hand washing, use soap substitute only
3. Evening: Lukewarm bath/soak, pat dry, immediately apply emollient followed by corticosteroid to active areas
4. Night: Consider polidocanol cream for itch relief, keep nails short 1, 4

Long-Term Management

• Once controlled, continue emollients indefinitely to maintain barrier function 1, 5
• Apply topical corticosteroid twice weekly to previously affected areas as maintenance 5
• Identify and avoid specific triggers through careful observation of flare patterns 1, 6
• Consider patch testing if contact allergy is suspected as a perpetuating factor 1, 6