Hands On: Practical Tips for Diagnosing and Treating Chronic Hand Eczema

Despite its small body surface area involvement, chronic hand eczema (CHE) represents a significant dermatologic and socioeconomic burden. In a recent session on chronic hand eczema (CHE) Socity of Dermatology Physician Associates (SDPA) 2025 Summer Conference given by Adam Friedman, MD, FAAD, he emphasized the complex nature of the condition and provided tips for diagnosis and treatment.

 “Similar to how we look at certain chronic inflammatory skin diseases as more of a composite or spectrum, the same is true of CHE. It is not just ‘one thing,’” Dr. Friedman told Practical Dermatology. “It's often a mix of irritant and/or allergic contact and other factors, and it will vary depending on the patient, which is why it's so important to focus on asking the right questions.”

The Scope of CHE

Dr. Friedman, who is Chair of the Department of Dermatology at the George Washington University School of Medicine and Health Sciences, began the talk by calling for a unified terminology for CHE. Historically referred to variably as “hand eczema,” “hand dermatitis,” or “chronic hand dermatitis,” CHE now serves as a consolidated term that helps streamline diagnosis and facilitate research. This nomenclature, Dr. Friedman pointed out, encompasses a broad spectrum of etiologies including irritant contact dermatitis (ICD), allergic contact dermatitis (ACD), and atopic dermatitis (AD)-associated hand disease. CHE, he said, must be recurrent and persist longer than three months for formal classification.

Dr. Friedman also said the epidemiological footprint of CHE is likely underestimated. While older claims-based data suggest a prevalence of 4.7%, he said this figure underestimates the burden and pointed to global studies suggesting the true prevalence is significantly higher.

Clinical Diagnosis Remains Paramount

Like AD, CHE is a clinical diagnosis, and this fact should impact the way a practitioner approaches diagnosis.

“A biopsy is not diagnostic,” Dr. Friedman warned, adding that histologic findings such as spongiotic dermatitis lack specificity. Instead, Dr. Friedman recommended comprehensive history-taking and careful morphologic assessment. He encouraged asking questions to uncover potential contact allergens—such as nickel sensitivity (hinted by periumbilical rashes with belt wear, for example) and emphasized considering multiple overlapping diagnoses.

“AD has many flavors,” he said. “CHE being a clinical diagnosis makes defining key clinical characteristics so hugely important in terms of making the right diagnosis.”

He also discussed diagnostic confusion between CHE and other dermatoses like psoriasis, tinea manuum, or even rarer, pagetoid reticulisis and secondary syphilis, adding that making the diagnosis requires investment on practitioner end, and that it's ultimately worth it.

“A robust first visit reduces follow-up complications and improves adherence,” Dr. Friedman added.

When to Use Patch Testing

Dr. Friedman cautioned against indiscriminate patch testing, which he said should be used with intent due in part to its disruptive nature for patients, requiring them to have potentially allergic reactions to numerous substances on their skin for a period of a week in order to gather the data for the test.

“It is a big deal to get patch tested—use it wisely, use it purposefully,” he said, advocating for patient-centered decision-making rather than blanket protocols.

Optimizing Treatment and Patient Adherence

Dr. Friedman also offered a roadmap for delivering treatment for CHE that emphasized optimizing basic care, ensuring correct and sufficient use of topicals, and revisiting patients early.

“Honestly, for many chronic inflammatory diseases, have them come back in four weeks,” he urged, cautioning against assuming that previous treatments failed without assessing duration, dosage, and adherence.

He also said that emollient choice should sync with patient preference and need. Dr. Friedman noted that an ideal moisturizer should contain humectants, emollients, and for hyperkeratotic CHE, chemical exfoliants, stressing the importance of matching these to clinical needs. He also pointed to barrier repair devices like zinc-based formulations as underused but potentially effective non-pharmaceutical options.

“There’s no one right emollient,” he noted. “Pick what works for the patient, especially if you’re dealing with a hyperkeratotic phenotype.”

Steroids and Other Topical Therapies

Dr. Friedman reiterated that topical steroids remain foundational, but should be used judiciously.

“Steroids will always have a place in dermatology, but they have to be used purposefully,” Dr. Friedman said. “Don’t use something weak for something strong. You need to know your steroid classes.”

Pivoting to the future, Dr. Friedman also took the time to introduce some new therapies. Topical JAK inhibitors, such as delgocitinib (not yet approved in the U.S., but is close), have shown promise.

“We are going to see the first ever prescription product specifically designated for CHE,” Dr. Friedman added, noting with data the rapid onset of action and superior efficacy to oral treatments like alitretinoin in comparative clinical trials.

Systemic therapies including dupilumab (approved for AD with hand involvement), baricitinib, and other off-label JAK inhibitors were discussed. While safety concerns persist, Dr. Friedman cited data suggesting comparable or even favorable profiles relative to older immunosuppressives.

“We've only just started defining CHE as its own disease,” Friedman concluded. “It deserves better recognition and better tools, and that starts with us making the right diagnosis, asking the right questions, and using treatments patients can actually stick with.”  -by Eric Raible

Source: Friedman A. Presented at: SDPA 2025 Summer Conference; June 25-28, 2025; Washington, DC.