Chronic hand eczema

INTRODUCTION — Hand eczema, or hand dermatitis, is a common, inflammatory disorder involving the skin of the hands [1]. The term "chronic hand eczema" is appropriate in cases that persist for more than three months or recur two or more times within a 12-month time frame [2]. Typical clinical signs include redness, thickening of the skin, scaling, edema, vesicles, areas of hyperkeratosis, cracks (fissures), and erosions (picture 1A-B).

Hand eczema is the most frequent occupational skin disease, especially among workers exposed to "wet work," such as health care workers, food handlers, and hairdressers. It can have profound economic consequences, including medical costs; costs associated with disability, workers' compensation, and rehabilitation; absence from work; and job loss [3]. Severe hand eczema can affect the patient's psychosocial functioning and general well-being.

This topic will review the clinical manifestations, diagnosis, and management of chronic hand eczema. Acute palmoplantar eczema, irritant contact dermatitis, and allergic contact dermatitis are discussed separately.

●(See "Acute palmoplantar eczema (dyshidrotic eczema)".)

●(See "Irritant contact dermatitis in adults".)

●(See "Clinical features and diagnosis of allergic contact dermatitis".)

●(See "Management of allergic contact dermatitis in adults".)

EPIDEMIOLOGY — Hand eczema is a common problem in the general population and especially in some categories of workers, including health care workers, hairdressers, and food handlers:

●Prevalence and incidence in the general population – A 2021 meta-analysis of 66 studies including nearly 570,000 individuals from the general population found an overall lifetime prevalence of 14.5 percent (95% CI 12.6-16.5 percent) [4]. The overall one-year prevalence was 9.1 percent (95% CI 8.4-9.8 percent), and the point prevalence was 4 percent (95% CI 2.6-5.7 percent). All pooled prevalences were higher among females than males. Cohort studies of adolescents and young adults followed up for approximately 15 years estimated an incidence of hand eczema of approximately 9 to 12 per 1000 person-years [5,6]. In a German study, the lifetime prevalence of hand eczema among adolescents at the age of 15 was 10.4 percent (95% CI 8.9-12.1) [7]. Based on data from 11 European studies, the overall pooled incidence of hand eczema in the general population has been estimated at 7.3 cases per 1000 person-years (95% CI 5.4-9.5) [4].

Hand eczema is also the most common occupational skin disease. The incidence of occupational hand dermatitis has been estimated between 0.7 and 1.5 cases per 1000 workers per year [8]. Estimated prevalence ranges between 2 and 30 percent [9]. Incidence is highest among workers performing "wet work" (eg, health care workers, food handlers, hairdressers). A Danish study of health care workers found a one-year prevalence of hand eczema of 21 percent and a lifetime prevalence of 35 percent [10]. A similar study of Hong Kong nurses found a prevalence rate of 22 percent [11].

A 2022 meta-analysis of 19 studies including 15,000 hairdressers found a pooled lifetime prevalence of hand eczema of 38 percent and an overall incidence rate of 51.8 cases per 1000 person-years (95% CI 42.6-61.0) [12].

Because these numbers represent only the cases reported, they are likely an underestimate of the true prevalence. Studies have shown that occupational hand dermatitis is often underreported. In one study involving over 2000 hairdressers with chronic hand eczema, only 21 percent had reported their hand eczema as occupational to the workers' compensation authority [13]. A similar study of health care workers found that only 12 percent reported their hand eczema [10].

●Risk factors – In a 2022, Finnish, population-based study that included 6830 individuals, hand eczema was reported in 900 individuals (13.3 percent) [14]. Strong risk factors for hand eczema included a personal history of atopic dermatitis (odds ratio [OR] 11.8, 95% CI 10.1-13.9), allergic rhinoconjunctivitis (OR 2.96, 95% CI 2.55-3.44), or asthma (OR 2.39, 95% CI 2.03-2.81).

A 2022 analysis of data from the Netherlands LifeLines Cohort Study that included over 58,000 participants found a positive association between chronic hand eczema and female sex, atopic dermatitis, and exposure to wet activities [15]. In addition, cigarette smoking and being overweight and obese were also positively associated with having chronic hand eczema in the past year.

In a 2022 meta-analysis of 29 observational studies, hand washing multiple times per day (8 to 10 times per day or more) was also associated with an increased risk of hand eczema (relative risk [RR] 1.48, 95% CI 1.30-1.67 for health care workers and RR 1.62, 95% CI 1.13-2.34 for non-health care workers) [16].

PATHOGENESIS — The pathogenesis of hand eczema is multifactorial and involves both genetic and environmental factors:

●Genetic susceptibility – There is an association between the susceptibility to hand eczema and loss-of-function mutations in the filaggrin gene (FLG), which is important for the integrity of the epidermal barrier [17]. Filaggrin is involved in terminal differentiation of the skin with appropriate keratin filament alignment and stratum corneum hydration. Loss-of-function filaggrin polymorphisms predispose to xerosis, ichthyosis vulgaris, and atopic eczema [18]. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis", section on 'Epidermal barrier dysfunction'.)

●Wet work – Repetitive wet work exposure is recognized as a predisposing factor for hand eczema. Water exposure for more than three hours per day can induce physiologic changes in the normal skin and increase the susceptibility to skin irritation [19]. Studies of occupational hand eczema in health care workers have found an association with hand-washing practices, such as the daily number of hand washes with soap at work and time working with disposable gloves [16,20]. However, the use of alcohol-based hand sanitizer does not seem to increase the risk of hand eczema [16]. Unprotected wet work for more than two hours a day in hairdressers has been shown to be a significant risk factor for the development of hand eczema [21].

●Irritants/allergens – Irritants often play an important role in both the development and persistence of hand eczema. In addition to water, important irritants include detergents, fragrances, and preservatives in hand soaps; harsh chemicals found in common household and industrial cleaners, such as ammonia and solvents; raw fruits, vegetables, spices, and plants; and physical irritants (eg, metal tools, wood, fiberglass, dust/soil). (See "Irritant contact dermatitis in adults".)

Hand eczema may also be a manifestation of allergic contact dermatitis, a specific T cell-mediated, delayed-type hypersensitivity reaction. Contact sensitization has been reported in over 60 percent of patients with hand eczema [22,23]. Common allergens include nickel, formaldehyde, quaternium-15, methylisothiazolinone, and fragrance mix. (See 'Patch testing' below and "Clinical features and diagnosis of allergic contact dermatitis".)

Chronic or recurrent hand eczema is also the most frequent clinical manifestation of contact urticaria/protein contact dermatitis (CU/PCD), a distinct type of dermatitis induced by a type I immediate hypersensitivity reaction to high molecular weight allergens, such as animal or plant proteins in previously sensitized individuals [24,25]. CU/PCD predominantly occurs in food handlers, cooks, veterinarians, or farmers [26]. Patients with CU/PCD usually have a positive prick test or specific serum immunoglobulin E (IgE) to certain foods but negative patch tests [27,28]. The reaction usually starts as an urticarial allergic response, but with repeated episodes over time, the clinical appearance is that of chronic eczema.

Frequent relapses of acute palmoplantar eczema (dyshidrotic eczema) may also result in chronic hand dermatitis lichenified. (See "Acute palmoplantar eczema (dyshidrotic eczema)".)

CLINICAL MANIFESTATIONS — In the acute stage, hand eczema typically presents with erythema, edema, weeping, and vesiculation (picture 2A-B). As lesions become subacute or chronic, the lesion morphology shifts to scaling, thickening, and fissuring of the skin (picture 3A-B).

Lesions are usually bilateral and may involve the palmar or dorsal surface or both. In long-standing disease, nail changes may be seen, including loss of the cuticle, thickening of the nail folds (chronic paronychia), and ridging and thickening of the nail plate (picture 4).

Symptoms may include itching, burning, or stinging.

●Clinical variants – Clinical variants of hand eczema include [29,30]:

•Chronic, fissured hand eczema (picture 3A)

•Recurrent, vesicular hand eczema (dyshidrotic eczema) (picture 5A-B)

•Hyperkeratotic palmar eczema, also called psoriasiform or tylotic hand dermatitis (picture 1B)

•Pulpitis (hyperkeratotic eczema of the fingertips) (picture 1A)

•Interdigital eczema (picture 6)

•Nummular hand eczema (picture 7)

●Pattern and distribution of lesions – The pattern and distribution of the hand lesions may vary depending on the etiology [31]:

•Irritant contact dermatitis – Irritant contact dermatitis is variable and can involve the dorsal hands or palms. The distal aspect of the dorsum of the fingers is often involved. (See "Irritant contact dermatitis in adults".)

•Allergic contact dermatitis – Allergic contact dermatitis often involves the dorsal aspect of the hands and fingers and the volar aspect of the wrists (picture 2B). (See "Clinical features and diagnosis of allergic contact dermatitis".)

•Chronic atopic hand dermatitis – Chronic atopic hand dermatitis usually involves the dorsum of the hands and fingers (picture 8) and/or the side of the fingers. It presents with erythema, scaling, and fissuring. Chronic paronychia and nail dystrophy are often associated. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis".)

•Dyshidrotic eczema – Dyshidrotic eczema typically presents with a sudden outbreak of intensely itchy, deep-seated vesicles on the palms and lateral and dorsal aspects of the fingers (picture 9A-B). Frequent relapses may result in chronic hand dermatitis, characterized by erythematous, lichenified, and scaling patches or plaques with fissures (picture 10). (See "Acute palmoplantar eczema (dyshidrotic eczema)".)

PATHOLOGY — The histopathologic findings of hand eczema vary according to the stage of the disease:

●Acute stage – In the acute stage, a classic, spongiotic reaction pattern is seen, including intercellular edema, microvesicle formation, and a superficial dermal infiltrate of lymphocytes, with or without eosinophils.

●Chronic stage – As the dermatosis progresses to the chronic stage, the degree of spongiosis is often mild and epidermal acanthosis, parakeratosis, and hyperkeratosis predominate, with a superficial, perivascular, lymphohistiocytic, inflammatory infiltrate.

It is important to note that psoriasiform hand dermatitis is often a histologic challenge, and biopsy often provides confusion and/or contradictory information [32].

DIAGNOSIS — The diagnosis of chronic hand eczema is based upon a detailed history, physical examination, and patch testing. A skin biopsy may be necessary to exclude other dermatoses involving the hands that may mimic chronic hand eczema. (See 'Differential diagnosis' below.)

History — A detailed personal, occupational, and recreational history, focused on exposure to irritants and allergens, should be obtained from all patients presenting with hand eczema. Patients should be questioned about:

●Type of work or hobbies

●Potential exposures to irritants or allergens

●Duration and frequency of exposure

●Type of personal protective equipment used

●Personal or family history of atopy, such as asthma, hay fever, allergic rhinoconjunctivitis, or childhood eczema

A detailed assessment of exposure is of key importance to plan patch and prick testing. The results of previous allergy testing, including patch testing, prick testing, and radioallergosorbent testing (RAST), should also be recorded.

Precise information regarding the onset of dermatitis, duration, associated symptoms (burning, itching, stinging, swelling), and relieving factors should be obtained. In occupational cases, patients may have a clear history of improvement on weekends and time off work.

Physical examination — When examining the patient's hands, the clinician should assess the extent of hand involvement and whether the skin changes extend to the wrist, the finger webs are involved, and the nails are normal or abnormal [31]. In addition, a complete skin examination should be performed, looking for skin changes in other body areas that may be related to the hand disorder (eg, flexural dermatitis suggesting atopic dermatitis, erythematous plaques surmounted by silvery white scales suggesting psoriasis).

Patch testing — Patch testing should be considered in all patients with chronic hand eczema that does not respond to adequate treatment as well as in patients in whom contact allergy is suspected.

Common allergens associated with hand dermatitis include:

●Preservatives

●Fragrances

●Metals (eg, nickel, cobalt)

●Rubber

●Topical antibiotics (eg, bacitracin, neomycin)

However, the selection of substances to be tested and the relevance of positive reactions should be based on the patient's occupational or recreational exposures.

A detailed discussion of patch testing and common contact allergens is presented separately. (See "Patch testing" and "Common allergens in allergic contact dermatitis".)

Skin prick tests and specific IgE measurement — Prick/puncture skin tests and determination of serum food-specific IgE levels are indicated in patients with suspected contact urticaria/protein contact dermatitis (CU/PCD). (See "Diagnostic evaluation of IgE-mediated food allergy", section on 'Prick/puncture skin tests' and "Diagnostic evaluation of IgE-mediated food allergy", section on 'In vitro testing'.)

Other laboratory tests — Other laboratory tests include:

●A potassium hydroxide (KOH) preparation may be useful to exclude a dermatophyte infection.

●Bacterial cultures may be useful to guide treatment in patients with clinical signs of superinfected hand eczema.

●A scabies preparation may be helpful to exclude Sarcoptes scabiei infestation.

Biopsy — Skin biopsy is not routinely performed in patients with hand eczema. However, in some patients, a skin biopsy for histopathologic examination may be necessary to exclude other conditions that may mimic chronic hand eczema. (See 'Differential diagnosis' below.)

ASSESSMENT OF SEVERITY — For the management of the individual patient with chronic hand eczema, it is important that clinicians evaluate the extent and characteristics of the eruption and ask general questions about the impact of the disease on the patient's professional and everyday activity, psychosocial functioning, and general well-being.

Although infrequently used in clinical practice, several tools have been developed to assess the clinical severity of hand eczema and response to treatment [33]. They include the Hand Eczema Severity Index (HECSI) [34], the Physician Global Assessment (PGA) [35], the clinical photo guide [36], and several instruments measuring the health-related quality of life in patients with skin diseases, such as the Dermatology Life Quality Index (DLQI) [37].

The PGA is a relatively simple tool that involves the evaluation of the intensity of the skin changes and the extent of involvement [35]:

●Mild eczema – Mild eczema is defined by the presence of two or more mild skin changes (erythema, scaling, hyperkeratosis, lichenification, vesiculation, edema, fissures, pruritus, and pain) involving <10 percent of the hand surface (picture 1A).

●Moderate eczema – Moderate eczema is defined by the presence of two or more mild to moderate skin changes (erythema, scaling, hyperkeratosis, lichenification, vesiculation, edema, fissures, pruritus, and pain) involving 10 to 30 percent of the hand surface (picture 2B).

●Severe eczema – Severe eczema is defined by the presence of two or more moderate to severe skin changes (erythema, scaling, hyperkeratosis, lichenification, vesiculation, edema, fissures, pruritus, and pain) involving >30 percent of the hand surface (picture 3A).

DIFFERENTIAL DIAGNOSIS — The differential diagnosis for hand eczema includes:

●Palmoplantar plaque psoriasis – Palmoplantar psoriasis presents with thick, scaly papules or plaques on an erythematous base. Lesions may be present on the palmar or dorsal surface of the hand (picture 11). The presence of nail pitting and/or classic, psoriatic plaques on other body sites is a clue to the diagnosis. In patients with isolated hand involvement, a skin biopsy may be helpful in rendering the correct diagnosis. (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis".)

●Palmoplantar pustulosis – Palmoplantar pustulosis is a chronic, inflammatory dermatosis characterized by the development of recurrent crops of discrete, 1 to 10 mm, sterile pustules limited to the palms and/or soles (picture 12A-C). It is often viewed as an isolated subset of acral psoriasis. Usually, it can be differentiated from chronic hand eczema on clinical grounds. In atypical cases, a skin biopsy showing an intraepidermal pustule filled with polymorphonuclear leukocytes associated with epidermal spongiosis can clarify the diagnosis. (See "Palmoplantar pustulosis: Epidemiology, clinical features, and diagnosis".)

●Tinea manuum – Tinea manuum is a dermatophyte infection that typically involves one hand and presents with erythema and fine scaling of the palm. In most cases, patients have a concomitant infection of the feet and toenails (picture 13). A potassium hydroxide (KOH) examination of scrapings from the lesions confirms the diagnosis. (See "Dermatophyte (tinea) infections".)

●Scabies – Scabies is a common infestation of the skin caused by S. scabiei and is characterized by intense pruritus and multiple small, erythematous papules or by poorly defined, erythematous patches that develop prominent scale, crusts, and fissures (crusted scabies) (picture 14A-C). A scabies preparation can confirm the presence of scabies mites, eggs, or feces. (See "Scabies: Epidemiology, clinical features, and diagnosis".)

MANAGEMENT — The management of chronic hand eczema involves patient education about avoidance of irritants and allergens, skin protection measures, and topical or systemic anti-inflammatory therapy [38,39]. Our approach to treatment is consistent with published international guidelines [29,38-41].

General principles

Patient education — A change in behavior is an important component of the management of chronic hand eczema when irritant or allergic factors are present. Patients should be educated about the causes of hand eczema, the avoidance of potential triggers, the adoption of preventive strategies and skin protection measures, and the importance of adherence to treatment [42]. The efficacy of education programs in the prevention and management of hand eczema has been evaluated in multiple clinical trials [43-45]. In one trial, 255 health care workers with hand eczema were randomly assigned to an education program with individual counseling and usual treatment or to usual treatment alone. At follow-up, the mean score on the Hand Eczema Severity Index (HECSI) was significantly lower in the intervention group than in the control group.

Avoidance of irritants and allergens — Patients should be counseled on potential triggers found within the home and work environment. Common chemical irritants include water and wet work, detergents and surfactants, solvents, oxidizing agents, acids, and alkalis. Physical irritants include metal tools, wood, fiberglass, plant parts, paper, and dust or soil. Common sources of allergens include soaps and detergents, foods, industrial solvents and oils, cement, metals, topical medications, gloves, and cosmetics (table 1). (See "Irritant contact dermatitis in adults", section on 'Common irritants' and "Common allergens in allergic contact dermatitis".)

Harsh soaps should be avoided, and hand-washing habits should be modified. Patients should wash with lukewarm water using a mild, unscented and fragrance-free bar soap or a liquid nonsoap (synthetic) detergent. Drying should be a gentle pat dry with attention to removing excess moisture from the interdigital spaces.

Hand washing and drying should be followed immediately by the application of a generous amount of heavy hand cream or ointment, such as petroleum jelly. Although less effective than ointments, lotion formulations can be used by patients who feel that ointment and thick cream are greasy and interfere with work or school activities [46]. Excessive or habitual hand washing should be discouraged. Overuse of soap and water can prevent the restoration of the epidermal barrier and healing of hand eczema. If the hands are not visibly soiled, an alcohol-based hand sanitizer can be substituted to minimize overexposure to soap and wet-to-dry cycles [16,47,48].

Skin protection — Use of personal protective equipment is also paramount in the management of hand eczema:

●Gloves – Gloves should be worn during cooking, gardening, and cleaning to minimize exposure to irritants such as raw meat, vegetables, and chemicals.

Vinyl or other nonlatex gloves are suitable for many routine exposures. Vinyl gloves are generally preferred to latex or rubber gloves due to the lesser presence of potential allergens. When protective gloves are to be used for intervals longer than 10 minutes, a thin cotton glove should be worn underneath. This will provide an absorbent layer and prevent sweat from irritating the skin with longer glove use. The cotton gloves can be washed and reused.

For occupational exposures, environmental hazards need to be considered when making the choice for protective glove recommendations. The patient should be encouraged to discuss appropriate protective equipment with their employer. The material safety and data sheet (MSDS) for a given chemical can be helpful and may list appropriate glove guidelines.

Certain materials readily penetrate various glove types, and not all gloves are suitable for all tasks. For example, acrylates that may be utilized in dentistry and orthopedics can easily penetrate many rubber and vinyl gloves. Therefore, if an individual is allergic to acrylates, a foil-type 4H chemical-resistant glove may be required under vinyl or rubber gloves [49]. It is also important that protective gloves be intact without holes, clean and dry on the inside, and the appropriate size.

●"Barrier creams" – So-called "barrier creams" are formulated to mimic the intercellular lipids, which are composed of ceramides, free fatty acids, and cholesterol, with the aim to limit the penetration of hazardous chemicals into the epidermis. They can either be water repellent or oil repellent. However, their superior efficacy compared with common emollients is unproven, and they cannot be used to replace gloves and other personal protective equipment [50-54]. Nonetheless, they may be utilized to augment protection against low-grade irritants.

Mild to moderate disease

Emollients/moisturizers — We suggest frequent and liberal use of emollients and moisturizers for all patients with hand eczema. To ensure consistent use, the choice of emollients and moisturizers is based on the patient's preference and exclusion of contact sensitization to any of the components.

Moisturizers that contain humectants and emollients improve the skin barrier function of the stratum corneum. Humectants include ingredients such as glycerin, topical urea, and pyrrolidone carboxylic acid. The primary function of humectants is to attract water and hydrate the stratum corneum. Emollients smooth the dry, flaking skin and also provide some occlusion to prevent water loss. Petrolatum, dimethicone, and waxes are common emollient ingredients.

Moisturizers are available in various formulations, such as oil-in-water, water-in-oil, and gels, and may contain keratolytic ingredients (eg, urea, salicylic acid) that help reduce thickness and scaling in hyperkeratotic hand eczema.

Open-label studies have shown that the appropriate use of emollients can improve the clinical signs of hand eczema and delay relapse [52,55,56]. In a small, open-label trial, 53 patients with chronic hand eczema controlled with moisturizers only were randomized to twice-daily use of a 5% urea moisturizer cream or no treatment [55]. The median time to reappearance of eczema was 20 days in the moisturizer group versus two days in the no treatment group.

Topical corticosteroids — We suggest topical corticosteroids as a first-line treatment for mild to moderate hand eczema in conjunction with emollients and moisturizers:

●Initial treatment – We typically use high-potency or super high-potency topical corticosteroids (groups 1 to 3 (table 2)). Topical corticosteroids are applied once or twice a day for two to four weeks or until a stable improvement is achieved. Emollients should be applied liberally multiple times per day.

●Maintenance treatment – After induction of remission, we suggest maintenance intermittent therapy with a low- to mid-potency topical corticosteroid (groups 4 to 6 (table 2)) two to three times per week (eg, every other day or during weekends) to prevent relapses. Intermittent therapy can be continued for several months.

●Management of relapses – Relapses are treated by resuming daily use of topical corticosteroids until remission. However, long-term use of topical corticosteroids (especially high- or super high-potency preparations) may induce skin atrophy, especially on the thinner skin of the dorsal hand (see "Topical corticosteroids: Use and adverse effects"). Topical tacrolimus is an alternative to topical corticosteroids for patients with frequent relapses. (See 'Topical calcineurin inhibitors' below.)

●Efficacy – Although topical corticosteroids are widely used as a first-line therapy for hand eczema, data from randomized trials supporting their use are limited [39]:

•In a randomized trial that included 125 participants with chronic hand eczema, twice-daily clobetasol foam was not more effective than vehicle in improving the eczema at 15 days as assessed by the investigator's rating scale [57]. The authors suggested that the emollient properties of the vehicle may have influenced the results.

•In an open-label, randomized trial, 120 patients with chronic hand eczema initially treated with daily mometasone furoate 0.1% fatty cream for up to nine weeks or until the dermatitis cleared were randomly assigned to a 30-week maintenance period with intermittent mometasone furoate (once daily two or three times per week) or vehicle [58]. At the end of the study, more patients were free of recurrence in the groups using mometasone furoate three or two times weekly than in the group using the vehicle (83, 68, and 26 percent, respectively).

Topical calcineurin inhibitors — Topical calcineurin inhibitors can be used as a steroid-sparing treatment option for chronic hand eczema in patients who require prolonged treatment with topical corticosteroids to maintain remission and as an alternative to topical corticosteroids in patients with contact allergy to topical corticosteroids [59,60]. Limited data support the use of tacrolimus 0.1% ointment, but not pimecrolimus 1% cream, for hand eczema:

●In a small, randomized trial of 30 patients with allergic contact hand eczema, tacrolimus 0.1% ointment appeared similarly effective as mometasone furoate 0.1% ointment in reducing erythema, infiltration, vesiculation, desquamation, fissuring, and itching at three months [60].

●In a small, uncontrolled study of 29 patients with occupational chronic hand dermatitis treated with tacrolimus 0.1% ointment for four weeks, 12 patients were clear of eczema at the end of the study [59].

●In a randomized trial, 652 patients with mild to moderate chronic hand dermatitis were treated with pimecrolimus 1% cream or vehicle twice daily with overnight occlusion for six weeks [61]. At the end of the study, the proportions of patients achieving the primary end point (Investigator Global Assessment score of 0 or 1 [clear/almost clear]) were similar in the pimecrolimus and vehicle groups (30 versus 23 percent, respectively).

Severe/recalcitrant disease — Patients with severe or recalcitrant hand eczema that does not respond to superpotent topical corticosteroids may require systemic therapies, including oral corticosteroids, immunosuppressants, and retinoids, or phototherapy with narrowband ultraviolet B (NBUVB) or psoralen plus ultraviolet A (PUVA) [62]. (See "UVB phototherapy (broadband and narrowband)" and "Psoralen plus ultraviolet A (PUVA) photochemotherapy".)

Treatment of secondary bacterial infection — Secondary bacterial infection, usually with Staphylococcus aureus, may be associated with recalcitrant disease and unexplained failure to respond to treatment. Clinical signs of bacterial superinfection include weeping, pustules, and honey-colored crusting (picture 15). A course of systemic antibiotics may be given to patients with clinical signs of bacterial superinfection. (See "Impetigo", section on 'Systemic antibiotics'.)

Systemic therapy

Short-term oral corticosteroids — For patients with severe, disabling hand eczema that does not respond to superpotent topical corticosteroids, we suggest a short course of oral corticosteroids to achieve rapid improvement while continuing regular emollient use. (See 'Emollients/moisturizers' above.)

Treatment is started with prednisone (or equivalent dose of other systemic corticosteroids (table 3)) at a dose of 0.5 to 1 mg/kg per day (maximum 60 mg per day) for seven days. The dose may be tapered and discontinued over the following two weeks. Daily treatment with superpotent topical corticosteroids should be resumed as oral corticosteroids are tapered off to avoid a rebound flare up. Topical corticosteroid treatment should be continued for a few weeks after oral corticosteroids are discontinued and then followed by maintenance intermittent therapy, as described above. (See 'Mild to moderate disease' above.)

There are no randomized trials evaluating the efficacy of oral corticosteroids for severe hand eczema. However, in clinical practice, they are beneficial in inducing rapid improvement in most patients with extensive allergic contact dermatitis or acute flares of atopic dermatitis. (See "Management of allergic contact dermatitis in adults" and "Treatment of atopic dermatitis (eczema)".)

Alitretinoin — Alitretinoin (9-cis-retinoic acid) is an oral retinoid with anti-inflammatory, immunomodulatory, antiproliferative, and apoptotic effects [63]. It is licensed in Europe and Canada for the treatment of severe chronic hand eczema that is unresponsive to potent topical corticosteroids but is not available in the United States.

Evidence from a few randomized trials supports the use of alitretinoin for hand eczema [39]. In one study, 1032 patients with severe chronic hand eczema unresponsive to topical steroids were randomized to receive alitretinoin 30 or 10 mg per day or placebo for 12 to 24 weeks [35]. All patients were given an emollient cream and instructed to apply it frequently [35]. After 24 weeks, a greater proportion of patients achieved the primary end point of clear or almost clear hands in the alitretinoin 30 and 10 mg groups than those in the placebo group (48, 28, and 17 percent, respectively). Headache was the most frequent adverse effect of alitretinoin. Serious adverse events were rare, but alitretinoin was associated with increases in both total cholesterol and triglycerides.

As are all oral retinoids, alitretinoin is teratogenic. Female patients of childbearing potential must commit to the use of at least one form of effective contraception for at least one month prior to starting alitretinoin therapy, during therapy, and for one month after therapy and have a pregnancy test each month during treatment.

Other therapies — Conventional immunosuppressants (eg, methotrexate, cyclosporin, azathioprine) have been occasionally used in the management of patients with severe hand eczema [64]. However, there is insufficient evidence of benefit from high-quality studies to suggest their use in refractory cases. In a six-week, randomized trial including 41 patients with chronic hand eczema, oral cyclosporin 3 mg/kg per day was equally effective as topical betamethasone dipropionate in reducing the baseline disease activity score (average reduction 43 and 42 percent, respectively) [64].

Dupilumab, an interleukin (IL) 4/IL-13 receptor antagonist approved for the treatment of atopic dermatitis, has been reported as effective in improving nonatopic chronic hand eczema as well as isolated atopic hand eczema in a few patients [65-69].

Phototherapy — For patients with severe or recalcitrant hand eczema for whom oral corticosteroids are contraindicated or patients who prefer not using oral corticosteroids, we suggest local NBUVB phototherapy or topical PUVA therapy. Phototherapy is administered two to three times per week for at least 12 weeks. Patients should continue using emollients liberally. (See 'Emollients/moisturizers' above.)

Adverse effects of phototherapy include erythema, pruritus, hyperpigmentation, and increased risk of skin cancer. Nausea is a potential adverse effect of oral PUVA. (See "UVB phototherapy (broadband and narrowband)" and "Psoralen plus ultraviolet A (PUVA) photochemotherapy".)

The use of phototherapy for patients with chronic hand eczema is largely supported by its use in the treatment of other inflammatory dermatoses. However, there are a few small clinical trials that have demonstrated clinical improvement with PUVA or NBUVB in patients with hand or palmoplantar eczema of various etiologies [70-72]:

●In a left-to-right comparison study, 15 patients with chronic hand eczema were treated with local NBUVB or topical PUVA [70]. Complete clearance or marked clinical improvement (defined as 75 percent improvement in the baseline severity score) occurred in the NBUVB phototherapy-treated side in 11 of 12 patients and in the PUVA-treated side in 10 of 12 patients.

●In a randomized trial, 60 patients with hand eczema unresponsive to super high-potency topical corticosteroids were treated with topical PUVA or NBUVB twice weekly for 12 weeks [73]. At the end of the study, 43 percent of patients in the PUVA group and 23 percent of patients in the NBUVB group achieved the primary outcome of a Physician Global Assessment (PGA) score of 0 or 1 (clear/almost clear).

Investigational therapies — Delgocitinib is a small molecule pan-Janus kinase (JAK) inhibitor that inhibits the activation of innate and adaptive immune cells and inhibits T helper (Th)1-, Th2-, Th17-, and Th22-type inflammatory responses [74]. In a small, randomized, eight-week, phase 2a trial, topical delgocitinib 30 mg/g cream showed efficacy in improving chronic hand eczema [75]. In a subsequent phase 2b, randomized trial that included 258 patients with chronic hand eczema, more patients in the delgocitinib cream 8 mg/g and 20 mg/g groups achieved an Investigator Global Assessment score of clear/almost clear at 16 weeks compared with patients in the vehicle group (37 and 38 percent versus 8 percent, respectively) [76]. Treatment was generally well tolerated. Adverse events, including nasopharyngitis, eczema worsening, and headache, occurred with similar frequency in the active treatment and placebo groups (68 and 60 percent, respectively); were in most cases mild or moderate; and considered unrelated to treatment. No adverse event was suggestive of systemic exposure.

PROGNOSIS — Hand eczema often has a very prolonged course. The reported average duration is approximately 12 years [77,78]. Moderate to severe eczema at initial examination, history of childhood eczema, and age younger than 20 years at diagnosis are the strong predictors of persistent disease [79,80]. Cigarette smoking also appears to be an unfavorable prognostic factor [81,82].

Chronic hand eczema may have significant psychosocial consequences, such as social stigma, long-term sick leaves, involuntary job rotation, and early retirement, and a profound impact on quality of life [83-87].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contact dermatitis".)

SUMMARY AND RECOMMENDATIONS

●Epidemiology – Hand eczema, or hand dermatitis, is a common, inflammatory disorder involving skin of the hands that affects approximately 4 percent of the general population. It is also the most frequent occupational skin disease, with an incidence of 0.7 to 1.5 cases per 1000 workers per year. Hand eczema is especially common among workers exposed to "wet work," such as health care workers, food handlers, and hairdressers. (See 'Introduction' above and 'Epidemiology' above.)

●Clinical presentation – In the acute stage, hand eczema typically presents with erythema, edema, weeping, and vesiculation (picture 2A-B). As lesions become subacute or chronic, scaling, thickening, and fissuring of the skin become the predominant clinical signs (picture 3A). (See 'Clinical manifestations' above.)

●Diagnosis – The diagnosis of hand eczema is based upon a detailed history, physical examination, and patch testing. (See 'Diagnosis' above.)

●Management – The management of chronic hand eczema involves patient education about avoidance of irritants and allergens, skin protection measures, and anti-inflammatory therapy (see 'General principles' above):

•Mild to moderate disease – For patients with mild to moderate chronic hand eczema, we suggest high-potency or super high-potency topical corticosteroids (groups 1 to 3 (table 2)) as a first-line treatment rather than lower-potency topical corticosteroids or topical calcineurin inhibitors (Grade 2C). For all patients with chronic hand eczema, we suggest the use of emollients (Grade 2C). These should be applied liberally multiple times per day. After induction of remission, we suggest maintenance intermittent therapy with a super high-potency or high-potency topical corticosteroid (Grade 2C). Topical tacrolimus can be used as a steroid-sparing treatment option for chronic hand eczema and as an alternative to topical corticosteroids in patients with contact allergy to topical corticosteroids. (See 'Mild to moderate disease' above.)

•Severe, recalcitrant disease – For patients with severe, recalcitrant hand eczema that does not respond to superpotent topical corticosteroids, we suggest a short course of oral corticosteroids (Grade 2C). Alternative treatments include phototherapy, alitretinoin, or oral immunosuppressants (eg, methotrexate, cyclosporin, azathioprine). Alitretinoin is licensed in Europe and Canada for the treatment of severe chronic hand eczema unresponsive to potent topical corticosteroids but is not available in the United States. Because secondary bacterial infection, usually with Staphylococcus aureus, may be associated with recalcitrant disease and unexplained failure to respond to treatment, a course of systemic antibiotics may be given to patients with clinical signs of bacterial superinfection (eg, weeping, pustules, honey-colored crusting). (See 'Severe/recalcitrant disease' above.)

●Prognosis – Hand eczema often has a very prolonged course and may have significant psychosocial consequences, such as social stigma, long-term sick leaves, and job loss. (See 'Prognosis' above.)