Managing chronic hand eczema

Conflicts of interest J.E. has acted as a paid consultant to Basilea, the manufacturer of alitretinoin. ORIGINAL ARTICLE, p420 In medicine making an accurate diagnosis usually helps us choose the best management. With chronic hand eczema (CHE) it is not always easy to make an accurate diagnosis as until recently there was no consensus as to how to classify CHE.1 The classification of Diepgen et al.1 facilitates making an accurate diagnosis. It is based on the pathogenesis rather than descriptive patterns of hand eczema. Unfortunately standard management strategies for CHE are not always effective. If CHE cannot be managed successfully with irritant exposure reduction or allergen avoidance, topical moisturizers and topical corticosteroids, then available treatments comprise systemic corticosteroids, off‐label immunosuppressants or ultraviolet radiation therapy, none of which is suitable for long‐term use. Therefore, treatment options for patients with severe CHE unresponsive to potent topical corticosteroids are extremely limited. However, the retinoid agent, alitretinoin (9‐cis retinoic acid), has demonstrated efficacy following oral administration in patients with severe CHE unresponsive to potent topical corticosteroids [the Benefit of Alitretinoin in Chronic Hand Eczema (BACH) study]. The findings of this study were published in an earlier issue of this Journal.2 This remains the largest randomized controlled clinical trial conducted to date for CHE, having enrolled 1032 patients. The results of a follow‐on, double‐blind clinical trial involving patients with relapsed CHE, who had previously responded to alitretinoin therapy in the BACH study and who were then retreated, are published in this issue.3 In this retreatment study, 117 relapsed patients were randomized to receive a second course of their previous therapy or placebo. The percentage of patients achieving the primary endpoint of an overall Physician’s Global Assessment rating of ‘clear’ or ‘almost clear’ hands at the end of the second course of treatment was higher in both alitretinoin groups compared with their respective placebo control group. This difference was statistically significant in the 30 mg group (80% vs. 8%). The data from both clinical trials show that a relatively short course of alitretinoin can be used to keep on top of the disease as and when symptoms arise; in the BACH study, the median time to achieve clear or almost clear hands with alitretinoin 30 mg daily was approximately 12 weeks;2 this was confirmed in the retreatment trial.3 This is borne out in clinical practice and my own experience with the drug has shown that hyperkeratotoic CHE responds extremely well to alitretinoin.

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