Taking a Stepwise Approach to Managing Chronic Hand Eczema

Chronic hand eczema (CHE) may affect a small body surface area, but its impact on patient quality of life can be profound. At the 2025 Society of Dermatology Physician Associates (SDPA) Annual Summer Dermatology Conference in Washington, DC, Adam Friedman, MD, FAAD, took to the podium to share practical strategies for treatment selection in his session, “Can’t HANDle It?: Tips to Optimize the Diagnosis & Management of Chronic Hand Eczema.”

In part 2 of a follow-up interview, Friedman provided his insights on how to balance disease severity, treatment tolerability, and patient adherence.

View part 1 of the discussion, "Chronic Hand Eczema or Something Else? Adam Friedman, MD, FAAD, Shares Diagnostic Tips for Differentiating," here.

Small Area, Big Consequences

“This is an interesting scenario where you have such a small BSA, but such a huge impact on quality of life,” Friedman said, highlighting how disabling CHE can be for patients both physically and psychosocially. From lost workdays to painful daily tasks, even minimal inflammation on the hands can disrupt function and well-being, he added.

There is also a historical basis for this understanding: “There’s tons of data supporting this, dating back even 10, 20 years ago.”

Topical Treatment: It Starts With the Vehicle

Treatment often begins with the basics: topical therapies. But Friedman reminded attendees that vehicle selection is not trivial, especially on the hands.

“For example, ointment or cream could possibly influence someone's ability to handwrite, to shake hands if that’s part of their work, or even opening and turning on their phone,” he explained. “It's always good to ask patients what vehicle they prefer... because if you give them something without that consideration, adherence goes way down.”

Even the most effective therapy can fall short if it is too greasy, uncomfortable, or impractical for a patient’s lifestyle.

Stepwise Escalation to Systemics

If patients have optimized topical therapy and remain symptomatic, or are already coming in with a “gallon baggie of their curled-up topicals,” as Friedman described, then it may be time to escalate to systemic treatments.

In the past, acitretin was considered a “go-to” for hyperkeratotic hand eczema, but the treatment landscape has evolved dramatically.

“We are so fortunate in today’s world... we even have an on-label option, which would be dupilumab for hand dermatitis and atopic dermatitis,” Friedman said.

Still, he noted that not all cases of CHE are purely atopic in nature: “It may be irritant or allergic contact derm... so certain systemic therapies may not influence it but still have some role.”

Biologics and JAK inhibitors (even off-label) may have promise for patients with more complex or refractory disease. While no JAK inhibitors are currently FDA-approved for CHE, Friedman said this is likely to change.

“My feeling is we’re going to start to see those label changes... like delgocitinib, which will be the first topical—or actually any medication—specifically approved for chronic hand eczema,” he highlighted.

He added that delgocitinib’s approval will likely spur more innovation. “I think [it] will open the door for more research, but also more investment in rich pipelines that will help us better take care of our patients,” he said.

Treatment Pearls: Friedman’s Practical Approach

1. Tailor the vehicle: Creams, ointments, gels, or foams. Ask what the patient prefers.
2. Maximize adherence: Patient comfort equates to better outcomes.
3. Layer topical strategies: Class 1 corticosteroids for flares; non-steroidals for maintenance; barrier repair always.
4. Know when to escalate: If optimized topicals fail, explore systemics.
5. Stay current: New therapies such as delgocitinib are on the horizon and will likely change the standard of care.

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