What is the treatment for dyshidrotic eczema on the hands?

Treatment for Dyshidrotic Eczema on the Hands

Topical corticosteroids are the mainstay of treatment for dyshidrotic eczema on the hands, with application of a topical steroid recommended to mitigate flares of dermatitis. 1

First-Line Treatment

Topical Corticosteroids

• Start with a potent topical corticosteroid (such as clobetasol propionate 0.05% foam or mometasone furoate cream)
• Apply twice daily during acute flares
• Once improvement occurs, reduce to maintenance therapy (e.g., mometasone furoate cream thrice weekly) 1
• For recalcitrant cases, consider occlusion therapy: apply corticosteroid and cover with cotton or loose plastic gloves overnight

Proper Hand Care

• Wash hands with lukewarm or cool water (avoid hot water)
• Use gentle soaps without allergenic surfactants, preservatives, fragrances, or dyes
• Pat dry gently (don't rub)
• Apply moisturizer immediately after washing 1
• Use moisturizers in tubes rather than jars to prevent contamination

Second-Line Treatments

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% can be effective when applied twice daily
• Particularly useful for maintenance therapy to reduce steroid-associated side effects 2
• May cause temporary burning/itching at application site

Moisturizing Therapy

• "Soak and smear" technique: soak hands in plain water for 20 minutes and immediately apply moisturizer to damp skin nightly for up to 2 weeks 1
• Use moisturizers with humectants
• Apply moisturizer followed by cotton or loose plastic gloves at night to create an occlusive barrier

Third-Line Treatments

Phototherapy

• PUVA (psoralen plus UVA) is effective for dyshidrotic eczema
  • Oral PUVA has shown significant improvement or clearance in 81-86% of patients with hand eczema 1
  • Topical PUVA has shown improvement in 58-81% of dyshidrotic eczema cases 1
• Narrow-band UVB is also effective but may be less effective than PUVA 1, 2

Systemic Treatments for Severe/Recalcitrant Cases

• Immunosuppressants:
  • Cyclosporine (3 mg/kg/day) 3
  • Methotrexate for severe cases 2
• Oral retinoids (alitretinoin) for chronic hand eczema 3
• Consider systemic corticosteroids for short-term management of severe flares

Novel Approaches

• Oxybutynin for cases with coexisting hyperhidrosis 4
• Botulinum toxin has shown success in treating dyshidrotic hand eczema 2

Trigger Avoidance and Prevention

• Identify and avoid allergens and irritants
• Use protective gloves for wet work
  • Consider cotton glove liners under rubber/vinyl gloves
  • For glove allergic contact dermatitis, use accelerator-free gloves 1
• Avoid frequent hand washing with irritating soaps
• Avoid very hot or very cold water exposure

Common Pitfalls to Avoid

1. Inadequate potency of topical steroids for initial treatment
2. Failure to identify and eliminate triggers
3. Discontinuing treatment too early (maintenance therapy is often needed)
4. Using water-based moisturizers under latex gloves (can break down the material)
5. Not considering patch testing for recalcitrant cases to identify potential allergens 1
6. Overuse of topical steroids leading to skin atrophy

For persistent or recalcitrant cases that don't respond to first-line treatments, dermatology consultation is strongly recommended for consideration of advanced therapies including phototherapy, systemic immunosuppressants, or other specialized treatments 1.