Clinical Insights and Emerging Therapeutic Options for Chronic Hand Eczema

Chronic hand eczema (CHE) represents a significant clinical challenge in dermatology practice, affecting approximately 5% of the population¹—a prevalence approximately twice that of psoriasis.² Defined as spongiotic dermatitis affecting the hands and/or wrists that persists for at least 3 months continuously or recurs at least twice annually,³ CHE presents unique diagnostic and therapeutic complexities that distinguish it from dermatitis affecting other anatomical sites.

MULTIFACTORIAL ETIOLOGY AND PATHOPHYSIOLOGY

The clinical presentation of CHE reflects the distinctive anatomical characteristics of the hands, including increased stratum corneum thickness, high degree of motion, minimal subcutaneous tissue, and frequent environmental exposure. These factors contribute to the characteristic findings of hyperkeratosis, fissuring, and edema that distinguish hand dermatitis from other forms of eczema.

In addition, most CHE cases involve multiple etiological factors, creating complex inflammatory profiles that complicate treatment. The three primary underlying causes include atopic dermatitis (Th2-mediated), irritant contact dermatitis (Th17-mediated), and allergic contact dermatitis (Th1-mediated).³ This multi-pathway involvement creates what can be described as a “cytokine soup,” leading to severe, chronic inflammation that is difficult to control. Importantly, morphological features do not reliably predict etiology, as the multifactorial nature of most cases prevents consistent correlation between clinical appearance and underlying cause.

SUBSTANTIAL CLINICAL IMPACT

The burden of CHE extends far beyond dermatological symptoms, creating profound impacts on patients’ personal and professional lives. More than one in five patients directly attribute their condition to occupational exposure, with nearly 10% requiring job changes or reduced work schedules.¹ Additionally, almost one-third of patients link their disease to household activities, with over one-third needing to restrict or modify their daily activities.¹

The psychological burden is equally significant, with CHE patients demonstrating nearly four times higher rates of depression, twice the likelihood of anxiety, and double the risk of suicidal ideation compared to the general population.¹ Half of all patients report that CHE has a “very large” or “extreme” impact on their interpersonal relationships.¹

TREATMENT LIMITATIONS

Current therapeutic approaches have been sorely lacking. Traditional interventions—including hand protection from irritants and allergens, frequent moisturizer use, and mild soap recommendations—show minimal efficacy, with patients improving only 1% over 12 weeks in a recent study.⁴ Topical corticosteroids, such as clobetasol, while providing short-term symptomatic relief, almost completely eliminate barrier recovery after just 3 days of use. Given that irritant contact dermatitis usually complicates CHE cases, topical steroids rarely provide effective long-term control.

Systemic treatments present their own challenges. While systemic steroids demonstrate efficacy, their toxicity profile limits utility. Systemic atopic dermatitis medications show promise but remain off-label for isolated hand involvement and may represent suboptimal resource utilization for conditions affecting less than 5% body surface area.

EMERGING TREATMENT: TOPICAL JAK INHIBITORS

Topical delgocitinib represents a promising advancement in CHE management as a pan-JAK inhibitor targeting JAK1, JAK2, JAK3, and TYK2. This broad-spectrum anti-inflammatory profile addresses the complex cytokine involvement characteristic of CHE. The formulation avoids common contact allergens such as propylene glycol, crucial when allergic contact dermatitis components remain uncertain.

Clinical trials demonstrate significant efficacy, with approximately 25% of patients with severe CHE (requiring obvious vesicles, fissures, or edema) achieving complete clearance using an extremely stringent endpoint requiring near-normal appearance. Additionally, around 75% of patients experienced meaningful quality-of-life improvements.⁵ Delgocitinib showed particular efficacy in irritant contact dermatitis cases, historically the most challenging CHE subtype to treat.

Topical ruxolitinib also has shown promise, as a recently published phase 2 trial for non-atopic CHE showed more than half of patients reaching Investigator Global Assessment (IGA) treatment success.⁶

Now, for the elephant in the room. We have two topical JAK inhibitors that can be used for hand eczema: LEO Pharma’s Anzupgo (delgocitinib), which is approved for moderate-to-severe CHE, and Incyte’s Opzelura (ruxolitinib), which is approved for atopic dermatitis (which can affect the hands) but also has now been shown to work for other types of CHE. So, we can easily agree that topical JAK inhibitors should be the go-to treatment for CHE that does not respond to simple, cheap solutions such as clobetasol and lifestyle modification. However, do we have any idea which drug works better?

The short answer is that we do not. While the percentage of patients achieving IGA success and the overall improvement in HECSI (Hand Eczema Severity Index) were higher in the recently published ruxolitinib trial than in the delgocitinib trials, the two drugs are very different. Key differences that preclude being able to make an indirect comparison include:

The ruxolitinib trial excluded atopic hand eczema. In the delgocitinib trial, atopic hand eczema was included and these patients were more recalcitrant to therapy than the other common types of CHE. This skewed the results in favor of ruxolitinib.

The delgocitinib trials were done only in Europe, where other trials for CHE drugs have provided investigators with more experience using HECSI and the hand eczema IGA. The ruxolitinib trial included many investigators in the United States, almost none of whom had experience with HECSI or the hand eczema IGA.

The IGA scores used in the two trials were different: In the delgocitinib trials, a score of 1 (almost clear) required only barely perceptible erythema, meaning the patient could not have a single flake. In the ruxolitinib trial, patients could have barely perceptible scaling and still be rated as almost clear.

Regardless, we now have two drugs that are excellent options for chronic hand eczema that fails simple, cheap treatments.  Given that delgocitinib is approved for all types of CHE, it will likely be my first-line agent in patients who do not have concomitant atopic dermatitis, and if they do not respond adequately to delgocitnib plus lifestyle modification, I will assume the patient has isolated atopic hand eczema and use ruxolitinib. In patients with atopic dermatitis affecting areas other than the hands or with a strong atopic diathesis and no obvious other etiology, I will likely use ruxolitinib as a first-line agent and switch to delgocitinib if the patient does not improve adequately.

If they still don’t improve adequately after trials of both, I would strongly consider comprehensive patch testing and biopsies, and if those were unrevealing, unobtainable or did not lead to adequate improvement, I would likely move to systemic agents typically used for atopic dermatitis. We have strong data for the efficacy of dupilumab, abrocitinib and upadacitinib in hand eczema. 

1. Apfelbacher C, Bewley A, et al. Prevalence of chronic hand eczema in adults: a cross-sectional survey of over 60 000 respondents from the general population of Canada, France, Germany, Italy, Spain and the UK. Br J Dermatol. 2025;192(6):1047-1054. doi: 10.1093/bjd/ljaf020.

2. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis Prevalence in Adults in the United States. JAMA Dermatol. 2021;157(8):940-946. doi: 10.1001/jamadermatol.2021.2007.

3. Ghezzi G, Falcidia C, et al. Chronic hand eczema (CHE): a narrative review. Dermatol Ther (Heidelb). 2025;15(4):771-795. doi: 10.1007/s13555-025-01365-7. Epub 2025 Mar 10.

4. Waked IS, Ibrahim ZM. Beneficial effects of paraffin bath therapy as additional treatment of chronic hand eczema: a randomized, single-blind, active-controlled, parallel-group study. J Altern Complement Med. 2020;26(12):1144-1150. doi: 10.1089/acm.2020.0356. Epub 2020 Nov 16.

5. Bissonnette R, Warren RB, et al. Efficacy and safety of delgocitinib cream in adults with moderate to severe chronic hand eczema (DELTA 1 and DELTA 2): results from multicentre, randomised, controlled, double-blind, phase 3 trials. Lancet. 2024;404(10451):461-473. doi: 10.1016/S0140-6736(24)01027-4. Epub 2024 Jul 18.

6. Zirwas M, Fowler JF Jr, et al. efficacy and safety of ruxolitinib cream for the treatment of moderate to severe chronic hand eczema: results from a 16-week, multicenter, randomized, double-blind study. J Am Acad Dermatol. 2025:S0190-9622(25)02717-3. doi: 10.1016/j.jaad.2025.08.081. Epub ahead of print.

Disclosures: Dr. Zirwas has served as an investigator, speaker, and consultant for Incyte, LEO Pharma, Sanofi, Regeneron, Eli Lilly, Galderma, AbbVie, and Pfizer, all of whom have products relevant to chronic hand eczema.

Matthew J. Zirwas, MD

• Ohio University Heritage College of Osteopathic Medicine
• DOCS Dermatology
  Columbus, OH