Treatment of severe hand eczema (HE) which is resistant to topical potent corticosteroid treatment is challenging. In 2013 we surveyed 194 UK dermatologists to obtain information about usual treatment pathways to inform the choice of the comparator in a trial of alitretinoin in severe HE (ALPHA trial); the results indicate that treatment approaches differ among UK dermatologists. Psoralen combined with ultraviolet A (PUVA) and alitretinoin were identified as the most frequent first line treatment options for hyperkeratotic HE, whereas oral corticosteroids were identified as frequent first line treatment for vesicular HE, followed by PUVA and alitretinoin. In terms of potential side effects of long-term or repeated use, oral steroids and ciclosporin A were reported to cause most concerns. There is uncertainty about which treatment gives the best short and long-term outcome due to a lack of definitive randomised controlled trials evaluating the effectiveness of different treatment pathways in severe HE.
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