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The Irregular Border: Non-pharmacologic and Lifestyle-based Approaches to Managing Chronic Hand Eczema: A Narrative Review

By Sawyeh Maher, BS, and Peter A. Lio, MD

 

 

Introduction

Chronic hand eczema (CHE) is a common and debilitating condition characterized by eczematous lesions on the hands and wrists that persist for longer than three months or recur at least twice per year (Figure 1). CHE is commonly associated with pain and itch and often carries a social and economic burden.1,2,3,4 Lifetime prevalence is estimated to be about 15%, with a higher incidence in women and young adults.5 CHE is complex and multifactorial, encompassing multiple overlapping subtypes including atopic dermatitis (AD)/atopic hand eczema (AHE), irritant contact dermatitis (ICD), allergic contact dermatitis (ACD), and protein contact dermatitis/contact urticaria (PCD/CU). The condition is driven by genetic, immunologic, environmental, and occupational factors that often complicate diagnosis and management.6

Current CHE therapies range from supportive to systemic interventions. First-line management emphasizes supportive measures such as skin protection, moisturizers, and avoidance of allergens and irritants.7,8 Topical corticosteroids (TCS) and calcineurin inhibitors (TCIs) are common second-line options, though both are limited by side effects, adherence challenges, and reduced efficacy in severe disease.9,10,7,11,12 For refractory disease, systemic agents such as alitretinoin, cyclosporine, or methotrexate may be considered, though they carry the risk of potential toxicity and lack of US approval in some cases.13,14,15 More recently, therapies have emerged that more directly target the pathogenesis of CHE, including biologics and Janus kinase (JAK) inhibitors. Delgocitinib (Anzupgo, LEO Pharma), a pan-JAK inhibitor that was recently approved for CHE, is notable for its effects on the pathways relevant to CHE. Its broad mechanism makes it particularly suitable for CHE with mixed subtypes and allergic triggers, since in such cases there may be multiple immune pathways that are dysregulated.16 While it does not carry a formal boxed warning like other JAK inhibitors, adverse effects such as application-site pain, paresthesia, and bacterial skin infections have been reported.17,18

Despite these advances, no single therapy has fully addressed the multifactorial drivers of CHE. For this reason, non-pharmacologic and lifestyle-based approaches may offer viable adjunctive strategies for CHE.

In this narrative review, we highlight non-pharmacologic and lifestyle-based interventions available for CHE with the strongest evidence, safety, and practicality for clinical use. Priority was given to randomized controlled trials (RCTs), systematic reviews, and large observational studies. Study quality was appraised using established tools, including the Jadad scale for randomized trials, with complementary reference to Risk of Bias 2.0 (RoB 2), Newcastle–Ottawa, Joanna Briggs Institute (JBI), and A MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2), where appropriate. All adjunct therapies reviewed also presented little to no side effects for participants. Outcomes of interest included Hand Eczema Severity Index (HECSI) and HECSI-R, Investigator’s Global Assessment for CHE (IGA-CHE), itch/pain, quality of life, flare frequency, work-related impact, and adverse events (Table).

Barrier Protection and Moisturizer Therapy

Barrier protection and moisturizer use are foundational components of CHE management, as most subtypes involve skin barrier dysfunction and increased transepidermal water loss.19,20 Regular use of moisturizers can restore barrier integrity, reduce water loss, and alleviate symptoms such as dryness and pruritus.21 Avoidance of common irritants such as harsh and/or scented soaps, detergents, and work hazards is equally vital for barrier protection.22 Glove use should also be implemented during wet-work and exposures to occupational hazards, with a focus on limiting occlusion and irritation.23 Barrier protectants such as dimethicone-based creams can reduce irritant-induced flares, particularly when combined with use of gloves and moisturizers.24,25

The evidence supports the importance of barrier strength in managing CHE. In a randomized, open-label study of 53 patients with resolved hand eczema, use of a 5% urea-containing barrier-strengthening moisturizer significantly delayed disease relapse compared to no treatment, with median relapse-free intervals of 20 days vs. 2 days (P = 0.04).26 Another RCT of 102 CHE patients found that a ceramide-containing cream significantly improved HECSI scores at three months compared with usual care (odds ratio 2.6; 95% CI 1.3–5.2).27

Beyond product use, patient education about barrier protection improves adherence and outcomes. A prospective study of 71 patients found that integrating therapeutic patient education into routine CHE care significantly improved barrier-protective behaviors—including moisturizing, glove use, and adherence to avoidance strategies—and was associated with improvements in clinical severity (the modified Total Lesion Symptom Score, or mTLSS), quality of life (The Dermatology Life Quality Index, or DLQI), and work productivity (the Work Productivity and Activity Impairment, or WPAI) at three months.28 No serious adverse events were reported across any of these studies.

These findings align with a Cochrane Database Systematic Review of 77 trials and observational studies, which demonstrated that regular moisturizer and barrier-supportive cream use prolongs time to flare, reduces flare frequency, and lowers corticosteroid requirements.29

Paraffin Bath

Paraffin wax baths have been explored as an adjunct treatment for CHE. Paraffin, a petroleum-derived hydrocarbon, is commonly used as an emollient in skincare products and cosmetics. Its low melting point allows for submersion that provides superficial heat, improves blood flow, enhances the skin barrier, and reduces discomfort.30,31 In an RCT of 60 patients with moderate-tosevere CHE, twice-daily paraŸn baths for 12 weeks reduced SCORing Atopic Dermatitis (SCORAD) scores by 28.6% compared to 0.41% in controls. Reported symptoms, including itch and sleep quality, improved by 47% vs. 5.5% in controls, while DLQI improved by 60% vs. 3.8% in controls. No adverse events were reported.32 A smaller prospective study of 13 patients with CHE similarly found high patient satisfaction and symptomatic improvement without adverse effects.31

Digital Self-monitoring and Education via Smartphone App

Digital health tools in dermatology have emerged as a powerful avenue for patients to connect with their providers and optimize treatment outcomes. In CHE, smartphone applications provide real-time monitoring and education, which may improve adherence, outcomes, and patient–provider communication.33

An RCT of 87 patients with chronic hand and foot eczema compared frequent in-person visits plus access to an educational app with in-person visits alone. The app allowed the ability to upload photos, track symptoms, and send messages to the dermatologist. Patients in the intervention group displayed significant reduction in HECSI scores over 60 weeks (coecient of −1.108, P ≤ 0.001). Benefits were dose-dependent, with high-frequency users with ≥20% app engagement showing additional improvements in quality of life (DLQI) and symptom control. The app also reliably assessed disease severity, with patient-submitted photos strongly correlating with physician-scored HECSI (P = 0.885, P < 0.001). No adverse events were reported.34

Phototherapy

Phototherapy has been a frequently employed treatment for refractory eczema. Various modalities exist—including psoralen plus ultraviolet A (PUVA), UVA1, broadband UVB, and narrowband UVB (NB–UVB)—with NB–UVB emerging as the most used due to its favorable balance of efficacy, safety, and practicality.35

In a randomized pilot study, CHE patients were assigned to receive either NB–UVB or PUVA twice weekly for 12 weeks. At Week 12, 23% of NB–UVB patients achieved a “Clear” or “Almost Clear” Physician’s Global Assessment response, with comparable improvements in the mTLSS and DLQI. Adverse events were minimal.36

A Cochrane systematic review further supports NB–UVB for use in atopic-driven eczema, and found that patients show significant symptomatic improvement after 12 weeks.37 The American Academy of Allergy, Asthma, and Immunology also highlights NB–UVB as effective for atopic eczema, with improvements displayed in both severity and itch. No adverse effects or increased risk of skin cancer were discovered.38

Conclusion

CHE remains a challenging and often refractory condition, with widely used conventional therapies limited by side effects, adherence challenges, and variable efficacy across subtypes. While traditional pharmacologic options are expanding, non-pharmacologic and lifestyle-based strategies—including barrier optimization, paraffin baths, digital self-monitoring tools, and phototherapy—remain safe, low-risk, and practical adjunct therapies that can enhance outcomes and patient quality of life. While the data is promising, further investigation is warranted to better define the role of these methods as adjunctive or stand-alone therapies for CHE.

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ABOUT THE AUTHORS
Sawyeh Maher, BS is a third-year medical student at Rosalind Franklin University of Medicine and Science in Chicago, IL.

Peter A. Lio, MD, is a Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University Feinberg School of Medicine and a partner at Medical Dermatology Associates of Chicago in Chicago, IL.

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