OBJECTIVES: To estimate the direct and indirect costs of occupational severe chronic hand eczema (OSCHE) in patients refractory to topical corticosteroids from the perspective of employer’s mutual insurance companies (EMIC) in Spain. METHODS: An employer’s mutual insurance company in Spain usually covers 75% of salaries and 100% of medical treatments of patients on occupational sick leave.  A decision analytic model was developed to perform a cost analysis of OSCHE in patients refractory to topical corticosteroids from an employer’s mutual insurance company perspective over a one year time horizon. A structured questionnaire was elaborated and answered by a Spanish panel of four dermatologists and two occupational physicians, to identify the therapeutic management and estimate the use of resources associated to OSCHE. The clinical information was obtained from published literature and was complemented by physicians. The information regarding costs associated to the different types of disability was obtained from data of 156 patients from one of the main EMIC in Spain. Disabilities are classified by EMIC in three groups according to the time spent on sick leave: Partial disability (3 months), partial permanent disability (24 months) and total permanent disability (limited to current profession). RESULTS: Annual total costs of OSCHE for a Spanish EMIC were on average over €60,000 per patient. Direct costs represented 1.4% and indirect costs 98.6% of total costs. Total permanent disability was the most important cost driver, representing 69.3% of total costs, although only 18% of patients were estimated to reach this type of disability. CONCLUSIONS: Disability is the most important predictor of total costs in patients with OSCHE for the EMIC in Spain. Indirect costs are by far the most important cost driver (98.6%) for this disease. An effective therapy for OSCHE may significantly reduce the number of disabilities and therefore indirect costs.