What is the best treatment for a patient with peeling hands, possibly due to an underlying condition like eczema or psoriasis?

Treatment of Peeling Hands

For peeling hands, immediately begin aggressive moisturization with emollients applied to damp skin after every hand wash (two fingertip units per application), avoid all harsh soaps and hot water, and apply a mid-to-high potency topical corticosteroid if inflammation is present—while simultaneously identifying and eliminating the underlying cause through patch testing if symptoms persist beyond 2 weeks. 1, 2

Immediate First-Line Management

Moisturization Protocol

• Apply emollients liberally after every hand wash using the "soak and smear" technique: soak hands in plain lukewarm water for 20 minutes, then immediately apply moisturizer to damp skin while still wet 2
• Use two fingertip units of moisturizer per application to both hands 1
• Select fragrance-free, preservative-free moisturizers with petrolatum or mineral oil as these are most effective and least allergenic 3
• Apply moisturizer at minimum twice daily, with additional applications as needed throughout the day 4

Hand Hygiene Modifications

• Wash hands only with lukewarm or cool water—never hot water above 40°C, as higher temperatures cause lipid fluidization and increased skin permeability 1
• Replace all soaps and detergents with soap-free cleansers or emollient substitutes immediately 2
• Pat hands dry gently rather than rubbing 3
• Avoid washing hands with dish detergent, disinfectant wipes, or other known irritants 1, 2

Topical Corticosteroid Therapy

When Inflammation is Present

• Apply a mid-to-high potency topical corticosteroid (such as mometasone furoate or betamethasone dipropionate) if erythema, vesiculation, or active inflammation accompanies the peeling 1
• For severe cases with significant inflammation, clobetasol propionate 0.05% foam applied for 15 days improves symptom control (RR 2.32,95% CI 1.38 to 3.91) 5
• Caution: Prolonged use of topical steroids can cause skin barrier damage, skin thinning, and perioral dermatitis—limit continuous use and taper once improvement occurs 1, 2

Identifying the Underlying Cause

Irritant Contact Dermatitis (Most Common)

• Peeling hands are most commonly caused by irritant contact dermatitis from frequent hand washing, wet work, or exposure to detergents and surfactants 1
• Identify and eliminate irritants: review all products contacting the hands including soaps, sanitizers, cleaning products, and occupational exposures 1, 2
• Pre-existing atopic dermatitis of the hands increases susceptibility 1

Allergic Contact Dermatitis

• If symptoms persist beyond 2 weeks despite conservative management, refer for patch testing to identify specific allergens 1, 3, 2
• Common allergens include nickel, fragrances, preservatives (especially isothiazolinones), rubber chemicals (thiurams), and topical antibiotics (neomycin, bacitracin) 1, 3, 2
• A small subset of patients develop allergic contact dermatitis to topical corticosteroids themselves, which explains initial improvement followed by recurrence 3, 2
• Pattern and morphology alone are unreliable in distinguishing irritant from allergic contact dermatitis—patch testing is essential 2

Protective Measures

Glove Use

• Apply moisturizer before wearing gloves to prevent occlusion-related irritation 1
• Use rubber-free neoprene or nitrile gloves for those with latex or rubber chemical allergies 1, 2
• For household tasks, use rubber or PVC gloves with cotton liners 2
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 2
• Never apply gloves when hands are still wet from washing or sanitizer application 1

Barrier Creams

• Barrier creams alone have questionable value and should not be over-relied upon—they may create false security 2
• After-work creams applied at the end of shifts have demonstrated benefit in reducing irritant contact dermatitis incidence 2

Common Pitfalls to Avoid

• Do not wash hands immediately before or after using alcohol-based sanitizer—this is unnecessary and increases dermatitis risk 1
• Avoid occluding fingers with adhesive bandages impregnated with bacitracin or benzalkonium chloride 1
• Do not apply superglue (ethyl cyanoacrylate) to seal fissures—this causes allergic contact dermatitis 1
• Avoid picking at dermatitis-induced scale, which worsens barrier disruption 1
• Do not use products containing topical antibiotics without clear indication 2

When to Escalate Treatment

Recalcitrant Cases (No Improvement After 2-4 Weeks)

• Seek dermatology consultation for patch testing with an extended standard series of allergens 1, 3, 2
• Consider topical tacrolimus 0.1% where topical steroids are unsuitable, ineffective, or when concerns about steroid-induced skin damage exist 2, 5
• For severe chronic hand eczema resistant to topical therapy, consider phototherapy (PUVA) 1, 2, 5
• Oral alitretinoin 30 mg improves investigator-rated symptom control compared to placebo (RR 2.75,95% CI 2.20 to 3.43) for severe chronic hand eczema 5
• Oral cyclosporin 3 mg/kg/day probably slightly improves symptom control compared to topical betamethasone after 6 weeks 5

Occupational Hand Dermatitis

• Arrange workplace visits to identify hidden allergens and assess procedures causing accidental exposure 2
• Review Material Safety Data Sheets for all workplace chemicals 2
• Prognosis for occupational contact dermatitis is poor: only 25% achieve complete healing over 10 years, and changing occupation does not improve prognosis in 40% of cases 2

Differential Diagnosis Considerations

Hand Psoriasis vs. Hand Eczema

• Hand psoriasis more commonly affects the dorsal hand, wrist (both sides), nail folds, and nails, with hyperkeratotic plaques as the predominant morphology 6
• Hand eczema more commonly involves the palmar area, palmar side of digits, and finger pulps, with vesicles, scales, and fissures, accompanied by significant itching 6
• If psoriasis is suspected based on distribution and morphology, treatment approach differs significantly 1

Dyshidrotic Eczema

• Presents with vesicles on palms and sides of fingers with subsequent peeling 1, 5
• Oral PUVA shows 81-86% improvement or clearance rates in uncontrolled studies 1