What are the common causes of hand skin peeling and the recommended initial evaluation and treatment?

Common Causes and Management of Hand Skin Peeling

Hand skin peeling is most commonly caused by irritant contact dermatitis from repetitive exposure to water, detergents, soaps, and hand sanitizers—the cornerstone of treatment is complete avoidance of irritants combined with aggressive emollient therapy and mid-potency topical corticosteroids. 1, 2

Primary Causes of Hand Peeling

Irritant Contact Dermatitis (Most Common)

• Irritant contact dermatitis accounts for approximately 80% of hand dermatitis cases and results from direct chemical or physical damage to the skin barrier. 1, 3
• Chronic cumulative irritant dermatitis develops from repetitive exposure to "wet" irritants including detergents, soaps, hand sanitizers, and frequent handwashing. 1
• Water itself is a significant irritant—transepidermal water loss increases with barrier disruption and worsens with additional water exposure. 3
• Hot water (>40°C) increases lipid fluidization and skin permeability, accelerating barrier breakdown. 2

Allergic Contact Dermatitis

• Allergic contact dermatitis requires prior sensitization to specific allergens, followed by elicitation upon re-exposure through delayed-type hypersensitivity (Type IV reaction). 1, 4
• The most common hand allergens in North America include methylisothiazolinone (MI), nickel, formaldehyde, quaternium-15, fragrance mix I, and rubber accelerators. 5
• Clinical features alone cannot reliably distinguish irritant from allergic contact dermatitis, particularly on the hands—patch testing is essential when the diagnosis remains uncertain. 1, 2

Other Causes

• Atopic hand dermatitis and endogenous eczema can present with peeling, often coexisting with irritant or allergic factors. 1, 3
• Occupational exposures contribute significantly, with hand dermatitis accounting for approximately 70% of occupational skin disease. 1

Initial Evaluation

History Taking

• Document initial location of symptoms, spread pattern, and relationship to specific products or activities. 2
• Obtain detailed occupational and recreational exposure history, including use of gloves, cleaning products, hand sanitizers, and frequency of handwashing. 1, 2
• Identify dominant hand use patterns, as unilateral involvement strongly suggests localized external exposure. 2

When to Consider Patch Testing

• Persistent dermatitis despite 2 weeks of appropriate topical therapy and irritant avoidance. 2, 6
• Suspected allergic contact dermatitis based on exposure history. 2, 6
• Recurrent or chronic dermatitis despite conservative management. 1, 2
• Patch testing should include an extended standard series of allergens, as screening series alone may miss relevant allergens. 1, 2

First-Line Treatment Protocol

Aggressive Moisturization (Critical Foundation)

• Apply 2 fingertip units of fragrance-free moisturizer containing petrolatum or mineral oil immediately after each handwashing. 2, 6
• Reapply moisturizer every 3-4 hours throughout the day. 2, 6
• Use the "soak-and-smear" technique: soak hands in plain lukewarm water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks. 2, 6
• Prefer moisturizers packaged in tubes rather than jars to prevent contamination. 1, 2
• Simple petroleum-based emollients are highly effective at restoring hydration and repairing the stratum corneum. 3

Topical Corticosteroids

• Apply triamcinolone 0.1% twice daily for localized disease as first-line therapy. 6
• For more severe involvement, escalate to clobetasol propionate 0.05% twice daily for up to 2 weeks. 2, 6
• Very high potency topical corticosteroids achieve clear or almost clear skin in 67.2% of patients with severe dermatitis over 2 weeks. 2
• Monitor for steroid-induced barrier damage with prolonged use, particularly on facial skin where absorption is increased. 2

Complete Irritant Avoidance

• Replace all soaps and detergents with soap-free cleansers or emollients immediately—these are universal irritants that perpetuate inflammation. 1, 2
• Wash hands with lukewarm or cool water only; avoid very hot or very cold water. 2
• Do not use dish detergent, disinfectant wipes designed for surfaces, or other harsh cleaning products on hands. 2
• Avoid washing hands immediately before or after using alcohol-based hand sanitizer, as this unnecessarily increases dermatitis risk. 2

Protective Measures

Glove Use Strategy

• Apply moisturizer before donning gloves to reduce occlusion-related irritation. 2
• For household tasks, use rubber or PVC gloves with cotton liners. 1, 2
• Remove gloves regularly to prevent sweat accumulation, which exacerbates dermatitis. 1, 2
• For latex allergy, select accelerator-free neoprene or nitrile gloves. 2
• Select gloves based on specific chemical exposures and check Material Safety Data Sheets for permeation times—no glove is completely impermeable. 2

Critical Pitfalls to Avoid

• Do not rely solely on barrier creams—they have questionable clinical value and may create false security, reducing implementation of appropriate preventive measures. 1, 2
• Avoid topical antibiotics (neomycin, bacitracin) without clear indication, as they are frequent contact allergens. 2
• Do not apply gloves while hands are still wet from washing or sanitizer. 2
• Avoid oil-based moisturizers under latex or rubber gloves, as these can break down glove material; water-based moisturizers are safe under all glove types. 7

Second-Line Therapies for Refractory Cases

When to Escalate (After 6 Weeks of First-Line Treatment)

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable, ineffective, or when concerns exist about steroid-induced skin damage. 1, 2
• PUVA (psoralen plus UVA) phototherapy is an established second-line treatment for chronic hand eczema resistant to topical steroids, supported by prospective clinical trials. 1, 2
• For severe chronic hand eczema specifically, offer alitretinoin (strong recommendation). 1, 2
• Consider systemic immunosuppressants including methotrexate, mycophenolate mofetil, azathioprine, or ciclosporin for steroid-resistant chronic contact dermatitis. 2

Systemic Corticosteroids

• For extensive disease, use prednisone 0.5-1 mg/kg/day, but taper over a minimum of 2-3 weeks to avoid rebound dermatitis. 6
• Monitor for mood changes, irritability, and elevated blood glucose levels, particularly in patients with pre-existing diabetes. 2

Occupational Considerations

Workplace Assessment

• Arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets. 1, 2
• Implement comprehensive educational programs, which demonstrate improvements in established hand dermatitis and prevention of new cases. 2
• Compliance with skin-protection programs is often poor, requiring ongoing reinforcement. 2

Prognosis

• The long-term prognosis for occupational contact dermatitis is poor: only 25% achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms. 1, 2, 7
• Changing occupation does not improve prognosis in 40% of cases. 1, 2
• Early identification and complete avoidance of allergens offers the best chance for resolution. 2

When to Refer to Dermatology

• No improvement after 2 weeks of appropriate topical therapy and irritant avoidance. 6
• Need for patch testing to identify specific allergens. 1, 2
• Refractory symptoms requiring second-line therapies such as phototherapy or systemic immunosuppressants. 2, 3
• Suspected drug-induced hand dermatitis (hand-foot syndrome) in patients receiving chemotherapy. 6