New Topical and Systemic Therapies Are Shifting the Paradigm for the Management of Chronic Hand Eczema

Emerging therapies are changing the way dermatologists think about the management of chronic hand eczema (CHE), while providing them with more options that can help achieve stable, long-term control of the disease. While CHE management traditionally centered on control of symptoms and flares, the development of novel agents that target the underlying mechanisms of CHE may provide durable improvements in symptoms and quality of life. 

CHE is a chronic eczematous process that affects the hands and wrists, defined as lasting more than 3 months a year or recurring at least two times within a year. It may present with various signs and symptoms, including erythema, cracks, fissures, vesicles, hyperkeratosis, dryness, scaling, lichenification, and debilitating pruritus and pain, which can occur in combination or in isolation. 

While patients can present with different subtypes and degrees of severity, they all have one thing in common: the significant impact of CHE on their overall health and quality of life. Improving quality of life is the ultimate goal in treating this disease that affects a significant proportion of the population. “The hands are considered this special site for a reason,” said Alexandra Golant, MD, associate professor at the Icahn School of Medicine at Mount Sinai, in New York City. “This is how you interact with the world, how you introduce yourself, how you function, do your job.” 

CHE is characterized by various etiologic subtypes, including irritant contact dermatitis, atopic hand eczema, allergic contact dermatitis, and contact urticaria. Patients often present with overlapping subtypes, making it hard to identify and avoid potential triggers. “When you consider chronic hand eczema, the rule is that you are dealing with a mixed picture,” Golant noted. “I like to tell patients that it is likely more than one thing contributing to [their] story. We want to make an accurate diagnosis, we want to exclude variables with testing when it is relevant, but we do not need to spend so much time spinning our wheels, particularly in the era of treatments that treat more than one subtype of disease.” 

When it comes to the diagnostic algorithm for CHE, different clinicians may employ different strategies, however, the suspected etiology can guide the diagnostic workup. PATCH testing should be performed if allergic contact dermatitis is suspected, and prick testing is useful if the index of suspicion points to protein contact dermatitis. Other strategies, including scraping and biopsy, may also be used when appropriate. However, the point of departure should be the patient’s history, which can provide important clues for a definitive diagnosis. Providers should ask about risk factors, such as occupational and allergen exposure, as well as a history of atopic dermatitis, co-speaker Benjamin Ehst, MD, PhD, said during a symposium at the 2025 Fall Clinical Dermatology Conference. 

Targeted therapies, including biologic therapies and small-molecule drugs, have recently taken the management of CHE beyond the realm of conventional skin care and corticosteroids, which are associated with side effects and are not typically recommended for long-term use. 

“CHE is a rather hot topic in dermatology right now, for a couple of different reasons,” Golant said. “We recently received [approval of] our first topical [therapy] that is specifically [designed] for moderate-to-severe chronic hand eczema, delgocitinib, a pan-Janus kinase (JAK) inhibitor, and we have two other topical nonsteroidal [agents], ruxolitinib and roflumilast.” Other targeted therapies for the treatment of CHE currently include oral JAK inhibitor abrocitinib and several injectable monoclonal antibodies. 

The pathogenesis of CHE relies on several inflammatory cascades involving multiple JAK-dependent cytokines. “We know there is broad activation of T cell subsets that drive this disease,” Raj Chovatiya, MD, PhD, explained during an expert therapeutic update. “It’s not simply a story of interleukin (IL)-4, IL-13, IL-31, and IL-5, or even thymic stromal lymphopoietin (TSLP). All those different cytokines can contribute to the immunologic drivers of this disease state.” Delgocitinib, a pan-JAK inhibitor, was designed to inhibit the JAK-STAT pathway, which interrupts downstream signaling and production of different pro-inflammatory cytokines implicated in CHE, thereby reducing inflammation at the site of action. The strength of a targeted therapy like delgocitinib lies in its ability to improve disease across many different subtypes, regardless of etiology, Chovatiya added. 

Results from the pivotal phase 3 clinical trials DELTA 1 and DELTA 2, enrolling nearly 1,000 individuals, showed that delgocitinib cream safely and effectively improved clinical signs and symptoms of moderate-to-severe CHE in adults who previously had suboptimal response or contraindications to topical corticosteroids (Bissonnette R et al. Lancet 2024;404:461-473). At week 16, a greater proportion of participants treated with delgocitinib cream achieved treatment success, measured by an Investigator’s Global Assessment for Chronic Hand Eczema (IGA-CHE) score of 0 (clear) or 1 (almost clear) compared with those assigned to cream vehicle in both trials. Delgocitinib cream also showed superiority compared with cream vehicle for all secondary endpoints, which included reductions in itch and pain scores. Long-term data from the extension trial showed that these improvements were sustained up to week 52. “Significantly, more patients achieved changes in itch as early as week 2 and changes in pain as early as week 4,” Ehst added. 

Data from a phase 2 open label extension trial showed that patients treated with ruxolitinib also achieved IGA-CHE treatment success by week 16, which was maintained up to week 32. Both topical therapies were well tolerated and had comparable rates of adverse events with those reported for placebo or cream vehicle across all trials, as well as low rates of discontinuation. While providers should weigh the risks of prescribing a JAK inhibitor to immunocompromised patients and those with active hepatitis infection, these topical therapies have demonstrated a favorable safety profile and do not have any known drug-drug interactions or contraindications. 

Systemic therapies such as dupilumab and tralokinumab also achieved IGA treatment success and marked reductions in itch and pain scores in significant proportions of patients with hand and foot atopic dermatitis and atopic hand eczema compared with placebo. Topical agents are typically the first-line treatment for localized eczema. However, patients who do not respond to topical medications may be eligible for systemic therapies. In the era of ever-expanding treatment options, providers should rely on individual signs and symptoms to guide them in the selection of appropriate initial therapies for their patients, Ehst concluded.