What are the treatment options for dyshidrotic (also known as pompholyx) eczema?

Treatment Options for Dyshidrotic Eczema

Topical corticosteroids are the mainstay of treatment for dyshidrotic eczema, with potency selection based on severity and application once or twice daily to affected areas. 1

First-Line Treatment

Topical Therapies

• Topical corticosteroids:

  • For mild disease: Use mild potency corticosteroids
  • For moderate disease: Use moderate potency corticosteroids
  • For severe disease: Use potent corticosteroids
  • Application frequency: Once daily application is as effective as twice daily for potent corticosteroids 2
  • Duration: Apply until resolution of active lesions, then taper

• Emollients:

  • Apply regularly as soap substitutes
  • Use after bathing when skin is still damp
  • Choose cream-based formulations for dyshidrotic eczema

• Practical application tips:

  • Keep affected areas dry between treatments
  • Keep nails short to prevent secondary infection from scratching
  • Avoid irritants including soaps and detergents 1

Anti-pruritic Measures

• Antihistamines:
  • Sedating antihistamines are useful for short-term relief of severe pruritus, especially at night
  • Non-sedating antihistamines have little value for dyshidrotic eczema 1
  • May develop tachyphylaxis (reduced effect over time)

Second-Line Treatment

For Persistent or Severe Cases

• Tar preparations:

  • Ichthammol (1% in zinc ointment) is less irritating than coal tar
  • Coal tar solution (1%) can be used in combination with hydrocortisone
  • Particularly useful for lichenified (thickened) areas 1

• Phototherapy:

  • PUVA (Psoralen plus UVA) therapy:
    • Oral PUVA has shown significant improvement in 81-86% of hand and foot eczema cases 1
    • Topical PUVA has shown variable results with improvement rates of 58-81% in uncontrolled studies 1
  • Narrowband UVB may be an alternative option

Management of Complications

Infection

• Bacterial infection:

  • Signs: Crusting, weeping, or worsening symptoms
  • Treatment:
    • Flucloxacillin is first-line for Staphylococcus aureus (most common pathogen)
    • Phenoxymethylpenicillin for beta-hemolytic streptococci
    • Erythromycin for penicillin-allergic patients 1

• Viral infection (eczema herpeticum):

  • Signs: Grouped, punched-out erosions or vesicles
  • Treatment:
    • Oral acyclovir for mild cases
    • Intravenous acyclovir for severe or febrile cases 1

Third-Line Treatment

For Refractory Cases

• Systemic corticosteroids:

  • Limited role in severe, acute flares
  • Should not be used for maintenance therapy
  • Decision to use should not be taken lightly 1

• Emerging therapies:

  • Tralokinumab (IL-13 inhibitor) has shown promise in case reports for severe dyshidrotic eczema 3
  • Dietary modifications may help if metal hypersensitivity is suspected (low-cobalt/nickel diet) 4, 5

Referral Criteria

• Failure to respond to first-line treatments
• Recurrent secondary infections
• Severe impact on quality of life or occupational function
• Suspected contact or allergic component requiring patch testing

Common Pitfalls and Caveats

1. Undertreatment: Fear of topical steroid side effects often leads to inadequate treatment. Patient education about proper use is essential.

2. Skin thinning concerns: Risk of skin atrophy with topical steroids is low (only 1% in studies) when used appropriately 2.

3. Maintenance therapy: Consider weekend/proactive therapy (applying topical steroids twice weekly) to prevent relapses after clearing 2.

4. Trigger identification: Consider metal hypersensitivity (nickel, cobalt) as potential triggers even with negative patch tests 4, 5.

5. Treatment adherence: Dyshidrotic eczema is often chronic and recurrent; emphasize the importance of consistent treatment and trigger avoidance.