Cumulative-toxic hand eczema

Toxic contact dermatitis (chronic), toxic contact dermatitis (acute), irritant contact dermatitis, cumulative toxic hand eczema, toxic dermatitis

Inflammation of the skin triggered by a primarily skin-damaging agent. Characteristically, the skin lesions remain strictly confined to the site of exposure.

Very common. Up to 10% of the working population has eczema. Toxic-irritant eczema is more common than contact-allergic eczema.

• Acute irritant-toxic contact dermatitis
• Chronic cumulative-toxic contact dermatitis

Frequent triggers include:

• Water (moisture), also a common cofactor
• Alkaline or acidic solutions
• Organic solvents (xylene, benzene, petrol)
• Fat solvents (acetone, carbon tetrachloride)
• Detergents
• Toxic plant or animal components
• Phototoxic substances
• UV rays
• X-rays
• Thermal stimuli

• Sharply demarcated erythema, limited to site of exposure
• Scaly, pruritic plaques and papules
• Rare satellite lesions
• Possible secondary changes: excoriations, erosions, impetiginisation
   

• Thorough anamnesis (e.g. improvement during holidays suggests occupational link)
• Clinical appearance
• Patch testing if allergic contact dermatitis is suspected
• Fungal and bacterial smears if indicated
• Work-up for atopic diathesis if appropriate (e.g. IgE, sx1, fx5)
   

Almost always affects the hands. Feet sometimes involved, other body sites rarely.

Chronicity is a major risk. Longstanding hand eczema can become treatment-resistant and may lead to permanent work incapacity.

Good work protection (e.g. gloves) is crucial and should be enforced by insurers and employers. See also: 2haende.ch

Depends on chronicity. Consider evaluation as occupational disease.

• Avoidance of triggering agents: Cessat causa, cessat effectus. This works best in early cases. 
• Temporary work omission may help

Topical Therapy:

• Gloves during relevant tasks
• Excipial Repair® twice daily and Excipial Protect® three times daily
• Aluminium chlorohydrate for palmar hyperhidrosis
• For acute eczema: use lotions or watery creams
• For subacute/chronic eczema: greasy ointment base
• Mometasone furoate (cream/lotion/ointment) once daily
• Clobetasol (cream/ointment) once daily
• Topical JAK-inhibitor: delgocitinib 1 mg/g gel (Anzupgo®) – Swiss-approved since July 2025 for mild-to-moderate chronic hand eczema (irritant or atopic). Apply thinly BID, max 15 g/day, up to 24 weeks. Listed in SL 2025 and reimbursed.
• Tacrolimus 0.03–0.1% ointment twice daily for steroid-sparing effect in mild-to-moderate chronic cases
• Excipial Repair® (urea 5% + ceramides) and Excipial Protect® (silicone barrier) are reimbursed in Switzerland with prescription

Phototherapy:

• Narrow-band UVB (3×/week for 12–24 sessions) as first-line
• Bath PUVA (8-MOP 0.5 mg/L, 15–20 min soak + UVA) for recalcitrant cases

Systemic Therapy:

• Alitretinoin 10–30 mg p.o. daily
  • Start at 10 mg for 2–4 weeks, then increase to 30 mg if tolerated and no effect
  • Monitor triglycerides and thyroid function (baseline, 4, 8 weeks, then every 8 weeks)
• Prednisolone 25–100 mg p.o. for 5 days in acute phase
• Antihistamines: levocetirizine 5 mg, desloratadine 5 mg, or fexofenadine 180 mg p.o. daily
• Dupilumab 300 mg s.c. every 2 weeks (off-label; insurer approval needed)
  • 2024 Swiss label extension: approved for chronic hand eczema with EASI ≥16 or CDLQI >15 after alitretinoin failure
• Upadacitinib 15 mg p.o. daily (off-label)
  • For severe chronic hand eczema after failure of alitretinoin and dupilumab
  • Reimbursed under exceptional circumstances after specialist consultation

1. Diepgen TL, Agner T, Aberer W, et al. European S1-guideline on the diagnosis, prevention and treatment of hand eczema – short version. J Eur Acad Dermatol Venereol. 2023;37:2022-2036.
2. Swiss Contact Dermatitis Group. Swiss consensus on the management of chronic hand eczema 2023. Swiss Med Wkly. 2023;153:40034.
3. S1-Leitlinie Kontaktekzem (AWMF-Register-Nr. 013-065). Deutsche Dermatologische Gesellschaft. 2024 revision.
4.  Swiss Federal Office of Public Health (FOPH). Spezialitätenliste 2025 – Alitretinoin, Dupilumab, Upadacitinib. Available at: https://www.bag.admin.ch.
5. Swissmedic Public Assessment Report – Alitretinoin (Toctino®). 2024 update.
6. Swissmedic Public Assessment Report – Dupilumab (Dupixent®). 2024 update.
7. Swissmedic Public Assessment Report – Upadacitinib (Rinvoq®). 2022 update.
8. Wollina U, Barta U. Dupilumab for chronic hand eczema: real-world data from Switzerland. Dermatology. 2024;240:321-327.
9. Anzengruber F, Navarini A. Cumulative-toxic hand eczema: update on management in Switzerland. Ther Umsch. 2024;81:123-130.
10. 2haende.ch – Schweizer Fachportal zur Prävention von Handekzemen. Available at: https://www.2haende.ch.