Why Does CHE Deserve Its Own Diagnostic Framework?
Shah said the hands warrant special consideration given how frequently they are exposed to irritants, particularly amid increased hand sanitizer and handwashing use since the COVID-19 pandemic. This frequent exposure can introduce irritant contact dermatitis alongside underlying atopic dermatitis, engaging additional immunologic pathways, including Th1 and Th17 activity, beyond the traditional Th2 and Th22 pathways associated with classic atopic dermatitis. Shah noted patients treated only for atopic dermatitis of the hands, such as nurses or nail technicians with frequent chemical or water exposure, may be undertreated if clinicians target only a single immunologic pathway rather than accounting for this broader immune involvement.
What Makes CHE Difficult to Diagnose and Manage?
Shah said the central diagnostic challenge involves distinguishing between contact dermatitis, atopic dermatitis, and mixed presentations. She noted patients typically present with redness, fissuring, and scaling, requiring clinicians to piece together occupational exposures, hobbies, and potential allergens contributing to the presentation. Once a mixed picture is identified, Shah said treatment often needs to be broadened accordingly.
How Should Clinicians Weigh Quality of Life in Severity Assessment?
According to Shah, quality-of-life impact, including pain, itching, sleep disturbance, and the visible appearance of the hands, is often the most important factor in her severity assessments, sometimes outweighing objective disease severity. She noted patients place significant weight on hand appearance given how visible and functionally essential hands are in daily life and public interaction. For structured severity scoring, Shah said she uses the Investigator Global Assessment scale developed by LEO Pharma during the Anzupgo studies, which ranges from 0, indicating clear skin, to 4, indicating severe disease.
What Are the Limitations of Traditional Topical Therapies?
Shah said she generally avoids calcineurin inhibitors in her practice due to a burning sensation that reduces patient compliance, often resulting in disease flares when patients stop using prescribed treatment. While she considers topical corticosteroids highly effective, Shah noted she has observed fissuring between the fingers, dorsal hand atrophy, and dyspigmentation with prolonged high-potency steroid use, particularly among patients with skin of color who may already have pigmentary changes from chronic inflammation. She characterized topical corticosteroids as effective bridge therapy rather than a long-term solution, given the chronic, incurable nature of CHE.
How Does Shah Approach the Decision to Move to Systemic Therapy?
For patients refractory to topical treatment, Shah said the decision to pursue systemic or biologic therapy depends heavily on patient comfort and clinical history, including flare frequency, family history of eczema, and involvement of other body areas. Patients with an atopic dermatitis background are often considered for injectable biologic therapy, while those with suspected allergic contact dermatitis are referred for patch testing.
Shah described a case involving a nail technician with an acrylate allergy who could not change occupations, for whom an oral JAK inhibitor combined with other therapies achieved disease stability. For patients hesitant about long-term systemic therapy, Shah said a short prednisone course may be considered, with the caveat that repeated courses should prompt reconsideration of systemic treatment.
What Should Clinicians Change About Their Approach to CHE?
Shah's top recommendation for clinicians is to more consistently consider irritant contact dermatitis as a contributing factor rather than defaulting to atopic dermatitis or psoriasis when evaluating hand scaling, particularly in the post-COVID era. She encouraged greater clinician comfort with topical and systemic JAK inhibitors when clinically warranted. Shah also emphasized that hand-limited disease should not be viewed as lower priority simply because it represents a smaller body surface area, noting the substantial quality-of-life and compliance benefits systemic therapy can offer patients who struggle with long-term topical adherence.
Editor's Note: This transcript has been edited for grammar and clarity using artificial intelligence tools. Shah had no relevant disclosures of note.
References
Ghezzi G, Falcidia C, Valenti M, et al. Chronic Hand Eczema (CHE): A Narrative Review. Dermatol Ther (Heidelb). 2025 Apr;15(4):771-795. doi: 10.1007/s13555-025-01365-7. Epub 2025 Mar 10. PMID: 40064754; PMCID: PMC11971080.
