
Train it over 15 and you're good to punch down rats. It just feels more pronounced with hand-to-hand because even when you do hit your enemy with it you don't see damage. Hand-to-hand only sucks when your skill is super low.

This will lower the block rate and hit rate massively, letting you punch them down the rest of the way.
If you run up on particularly tough melee enemies (especially with shields), hit them with a few hard drain fatigue effects first, enchants or just spells. Hand-to-hand has a high stagger rate, so if you just swing away your enemy is stuck taking those hits. I'd recommend not "charging" your punches, except every fourth or fifth hit for the sake of letting some of your own stamina come back. In the late game with Tribunal/Bloodmoon, using fortify skill hand-to-hand as an enchant is a great way to make a low-maintenance super character. There's also no need to repair your fists. You can beat ghosts and dagoths to death. I think it also bypasses armor for the fatigue damage (but armor will make it take longer to actually beat the unconscious to death). They'll pop back up a couple of times, possibly, but each time that happens, the next punch will put them down again. Once they've hit the ground, you've won, you just have to hit them for a while.

4-5 punches means your enemy won't be hitting you much anymore, and for most enemies by (successful) punch 12-15 they're on the ground. So at 50 h2h, you're hitting most of the time and knocking off 20 fatigue per punch. Their strikes miss, their spells fail, and they become easier to hit themselves. But fatigue damage makes your opponent less successful in combat, the same way you are if you let your fatigue run down. It looks terrible at first because you're swinging away, doing no damage. Once you get your hand to hand to around 50, it's one of the most effective ways to win one-on-one combat.
