What is the recommended treatment for hand eczema?

Treatment of Hand Eczema

Start with immediate application of fragrance-free moisturizers containing petrolatum or mineral oil after every hand wash, combined with a medium-to-high potency topical corticosteroid for active inflammation, while simultaneously identifying and eliminating irritants and allergens. 1, 2

Immediate First-Line Management

Hand Hygiene Modifications

• Wash hands with lukewarm or cool water only (never hot water, which damages the lipid barrier through fluidization) for at least 20 seconds, paying special attention to commonly missed areas: fingertips, hypothenar eminence, and dorsum of hand. 1
• Use soaps completely free of allergenic surfactants, preservatives, fragrances, and dyes, preferably synthetic detergents with added moisturizers. 1, 2
• Pat dry gently without rubbing to avoid mechanical irritation. 1
• Apply moisturizer within 1-3 minutes of drying using a minimum of 2 fingertip units per hand, spreading between fingers, cuticles, and fingertips. 1, 2
• Reapply moisturizer every 3-4 hours and after each hand washing; carry pocket-sized tubes for frequent reapplication. 1, 2

Moisturization Strategy

• Choose fragrance-free moisturizers with petrolatum or mineral oil as the base—these are the most effective and least allergenic options. 1, 2
• Use tube packaging only (never jars) to prevent contamination from double-dipping. 1, 2
• For severe dryness, implement "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 gloves (or loose plastic food gloves) to create an occlusive barrier that enhances penetration. 1, 2

Topical Anti-Inflammatory Treatment

For Active Inflammation

• Apply high-potency topical corticosteroids as the cornerstone treatment for acute flares and active dermatitis. 2, 3
• Select the lowest potency that adequately controls the eczema to minimize risk of steroid-induced skin barrier damage with prolonged use. 1, 2
• Use topical calcineurin inhibitors for maintenance therapy after initial corticosteroid control, particularly for long-term management. 3, 4

Distinguishing Irritant vs. Allergic Contact Dermatitis

For Irritant Contact Dermatitis (ICD):

• Identify and eliminate irritants: wet work, detergents, hot water, and excessive hand washing are the primary culprits. 1, 2
• Switch to less-irritating products and consider barrier creams (humectants), though these are equivalent to regular moisturizers. 1, 2
• Apply topical steroids only when conservative measures fail, being cautious of barrier damage. 1, 2

For Allergic Contact Dermatitis (ACD):

• Perform patch testing to identify clinically relevant allergens—this is essential for any recalcitrant or changing hand dermatitis. 1, 2
• Eliminate identified allergens completely from both occupational and personal exposures. 1, 2
• For glove-related ACD, switch to accelerator-free gloves (rubber-free neoprene or nitrile), apply moisturizer before gloving, and consider cotton glove liners. 1, 2

Advanced Therapies for Recalcitrant Cases

When to Escalate Treatment

Escalate therapy when hand eczema fails to improve after 6 weeks of optimized topical treatment, or when there is a change in baseline dermatitis pattern. 2

Second-Line Options

• Phototherapy (narrowband UVB or PUVA) for cases unresponsive to topical measures. 2, 5
• Stronger topical corticosteroids for limited periods under close monitoring. 2

Systemic Therapy Hierarchy

For atopic hand dermatitis specifically:

• Dupilumab is the preferred first-line systemic agent for moderate-to-severe hand involvement refractory to topical therapy, with 40% achieving clear or almost clear hands at 16 weeks versus 17% with placebo. 2
• JAK inhibitors (upadacitinib or abrocitinib) are alternative systemic options. 2
• Traditional immunosuppressants (cyclosporine, methotrexate, azathioprine, mycophenolate) may be used, though prednisolone should be avoided except very infrequently. 2, 4

For chronic hand eczema (non-atopic):

• Alitretinoin is the only oral treatment specifically approved for chronic hand eczema. 3

Critical Pitfalls to Avoid

• Never apply gloves when hands are still wet from washing or sanitizer—this traps irritants and increases dermatitis risk. 1
• Never wash hands with soap immediately before or after alcohol-based hand sanitizer—this is unnecessary and doubles irritant exposure. 1
• Never use oil-based moisturizers under latex or rubber gloves—they compromise glove integrity (though latex, vinyl, and nitrile gloves resist breakdown from alcohol). 1
• Never use superglue (ethyl cyanoacrylate) to seal fissures—this causes additional allergic contact dermatitis. 1
• Never delay switching from topical treatments in recalcitrant cases—prolonged inadequate treatment leads to sensitizations, work disability, and quality of life deterioration. 3
• Never occlude hands with gloves for extended periods without underlying moisturizer—this worsens irritation. 1

When to Refer to Dermatology

Refer immediately for:

• Suspected allergic contact dermatitis requiring patch testing to identify specific allergens. 1, 2
• Recalcitrant hand dermatitis not responding to 6 weeks of optimized topical treatment. 2
• Any change in baseline hand dermatitis pattern that suggests new allergen exposure or disease evolution. 1, 2
• Consideration of phototherapy or systemic therapy for severe, chronic cases. 2

Special Occupational Considerations

For healthcare workers:

• Use water-based moisturizers under gloves (oil-based products break down latex and rubber). 1
• Apply moisturizer both after hand washing and before wearing gloves to maintain barrier function during prolonged occlusion. 1
• Consider occupational modification for truly recalcitrant cases that threaten continued employment. 1, 2