What is the best treatment approach for Dyshidrotic Eczema (Pompholyx)?

Treatment Approach for Dyshidrotic Eczema (Pompholyx)

Topical corticosteroids are the mainstay of treatment for dyshidrotic eczema, with potent formulations being more effective than mild ones for moderate to severe cases. 1

First-Line Treatment

Topical Therapy

• Topical corticosteroids:

  • Use potent or moderate potency for active flares 1, 2
  • Apply once or twice daily (once daily application is equally effective as twice daily for potent steroids) 2
  • Basic principle: Use the least potent preparation required to control the eczema 1
  • For resistant cases: Consider clobetasol propionate with hydrocolloid occlusive dressing once weekly 3

• Emollients:

  • Apply after bathing when skin is still damp 1
  • Use as soap substitutes (dispersible creams) 1

Addressing Triggers

• Avoid soaps and detergents that remove natural skin lipids 1
• Avoid extreme temperatures 1
• Wear cotton clothing rather than wool or synthetic materials 1
• Consider metal allergy evaluation, particularly for cobalt and nickel 4, 5
  • Low-cobalt/nickel diet may help in cases with confirmed metal hypersensitivity 5

Second-Line Treatment

For Persistent Cases

• Antihistamines:

  • Primarily useful for their sedative properties to control severe pruritus 1
  • Non-sedating antihistamines have little value in dyshidrotic eczema 1

• Phototherapy:

  • Oral PUVA has shown effectiveness in hand eczema, superior to UVB 1
  • Oral PUVA resulted in significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
  • Topical PUVA has shown mixed results in controlled studies 1

For Secondary Infection

• Antibiotics when bacterial infection is present:

  • Flucloxacillin for Staphylococcus aureus (most common pathogen) 1
  • Phenoxymethylpenicillin for β-hemolytic streptococci 1
  • Erythromycin for penicillin-allergic patients 1

• Antivirals for suspected herpes simplex infection (eczema herpeticum):

  • Oral acyclovir early in the course of disease 1
  • Intravenous acyclovir for ill, febrile patients 1

Third-Line Treatment

For Severe, Refractory Cases

• Systemic corticosteroids:
  • Limited but definite role in severe cases 1
  • Should not be considered for maintenance treatment 1
  • Decision to use systemic steroids should never be taken lightly 1

Important Considerations

Potential Complications

• Risk of pituitary-adrenal suppression with prolonged use of potent topical steroids 1
• Skin thinning occurs in approximately 1% of patients using topical corticosteroids, with higher risk in very potent formulations 2

When to Refer to a Specialist

• Failure to respond to first-line management 1
• Suspected contact dermatitis as a complicating factor 1
• Need for phototherapy or systemic treatments 1

Treatment Application Tips

• Apply treatments no more than twice daily 1
• Some newer corticosteroid preparations require only once daily application 1
• Consider weekend therapy (proactive approach) to prevent relapses after clearing 2

By following this stepwise approach, most patients with dyshidrotic eczema can achieve significant improvement in symptoms and quality of life.