Guidelines for diagnosis, prevention, and treatment of hand eczema

Key points

• Identifying and avoiding causative exogenous factors (allergens, irritants, proteins) is the basis of treatment, together with frequent use of emollients in all patients.
• Topical corticosteroids are recommended as short-term first-line treatment (moderate quality of evidence, grade A).
• Patch testing is recommended in hand eczema lasting more than 3 months, not responding to adequate treatment, or with clinical suspicion of contact allergy.
• Alitretinoin is recommended as second-line treatment for severe chronic hand eczema (high quality of evidence, grade A); it is the only systemic drug licensed for chronic hand eczema.
• Health education and training are recommended for high-risk groups such as hairdressers, health care workers and metal workers.

Overview

The European Society of Contact Dermatitis (ESCD) guideline advises managing hand eczema by removing environmental triggers, educating patients about skin protection and prevention, and starting adequate anti-inflammatory treatment: topical corticosteroids first, alitretinoin as second line for severe chronic disease. It is based on Cochrane reviews with searches updated to April 2020 and graded with GRADE, plus consensus-based recommendations, and was approved by the ESCD executive committee in October 2021.

Definitions and burden

Acute and subacute hand eczema lasts less than three months and occurs no more than once a year; chronic hand eczema lasts more than three months or relapses twice or more per year. The 1-year prevalence is at least 9.1% in the general population (6.4% in men, 10.5% in women). Hand eczema is the most common occupational skin disease, with a prevalence up to 40% in high-risk occupations; wet work is the main cause of irritant contact dermatitis.

Prevention

The guideline recommends health education in high-risk groups, secondary prevention as early as possible in affected people, and tertiary prevention in severe or chronic disease. Exposure reduction follows the STOP hierarchy: substitution or elimination, technological measures, organisational measures and personal protective equipment. Practical advice includes cotton gloves under protective gloves worn for more than 10 minutes, and alcohol disinfection instead of soap washing when hands are not visibly dirty.

Diagnosis and classification

Work-up includes a careful history of personal and occupational exposures, examination of the hands and the entire skin, patch testing with a baseline series extended by additional series depending on exposure, and exposure assessment using ingredient labels and safety data sheets. Skin prick testing is used for suspected contact urticaria or protein contact dermatitis, and biopsy only to rule out differential diagnoses. The recommended aetiological subtypes are irritant contact dermatitis, allergic contact dermatitis, protein contact dermatitis/contact urticaria and atopic hand eczema; the clinical subtypes are hyperkeratotic palmar, acute recurrent vesicular, nummular and pulpitis (fingertip eczema).

Treatment

Long-term intermittent topical corticosteroids as maintenance may be considered (low quality of evidence, grade 0). Tacrolimus ointment is suggested for short-term treatment (moderate quality, grade B); it is off-label except in atopic hand eczema. Phototherapy is suggested for adults with chronic hand eczema refractory to topical corticosteroids (moderate quality, grade B); long-term use may increase the risk of skin malignancy. Alitretinoin should be stopped if no adequate effect is seen after 3-4 months. Short-term oral corticosteroids are suggested only for acute severe inflammation. For patients refractory or contraindicated for first- and second-line therapy, cyclosporine is suggested, and azathioprine and methotrexate may be considered; acitretin may be considered for hyperkeratotic chronic hand eczema. These systemic options are off-label (cyclosporine except in atopic hand eczema).

Frequently asked questions

When should patch testing be done?

In all patients with hand eczema lasting more than 3 months, not responding to adequate treatment, or with clinical suspicion of contact allergy.

What is the first-line treatment?

Avoidance of causative factors, frequent emollients and short-term topical corticosteroids.

Which systemic drug is licensed for chronic hand eczema?

Only alitretinoin. It is recommended as second-line treatment for severe chronic hand eczema; as a retinoid it is teratogenic, so pregnancy prevention measures are needed.

Source

Thyssen JP, Schuttelaar MLA, Alfonso JH, Andersen KE, Angelova-Fischer I, Arents BWM, et al. Guidelines for diagnosis, prevention, and treatment of hand eczema. Contact Dermatitis 2022;86(5):357-378. doi:10.1111/cod.14035. Guideline of the European Society of Contact Dermatitis. Summary prepared by Medpresso from the accepted peer-reviewed manuscript (repository copy, CC BY-NC-ND 4.0) of the original publication; it is not a substitute for the full text or medical advice.