What is the treatment for dyshidrotic (dyshidrotic eczema) eczema on the face?

Treatment of Dyshidrotic Eczema on the Face

Topical corticosteroids are the mainstay of treatment for dyshidrotic eczema on the face, with low-potency preparations (Class 6-7) being most appropriate for this sensitive area. 1

First-Line Treatment

Topical Corticosteroids

• Use low-potency topical corticosteroids (Class 6-7) for facial dyshidrotic eczema 1, 2
• Apply once or twice daily for 1-2 weeks 2
• Avoid very potent or potent formulations on the face due to increased risk of skin thinning 2
• Once daily application is as effective as twice daily for potent corticosteroids 2

Emollients

• Apply emollients at least twice daily, especially after bathing 1, 3
• Use as soap substitutes for cleansing 3
• Choose fragrance-free, alcohol-free formulations 3
• Most effective when applied after bathing to lock in moisture 1

Second-Line Treatment

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment or pimecrolimus 1% cream are effective alternatives for facial application 3, 4
• Particularly useful for long-term management due to lack of skin thinning effects 4
• Can be used in rotation with topical corticosteroids for chronic cases 4
• Apply twice daily until improvement is seen 4

Antihistamines

• Sedating antihistamines at night may help control pruritus and break the itch-scratch cycle 1, 3
• Non-sedating antihistamines have little value in controlling eczema-related pruritus 1
• Antihistamine effectiveness may decrease over time due to tachyphylaxis 1

Management of Secondary Infection

• Monitor for signs of bacterial infection (crusting, exudation, sudden worsening) 1, 3
• If infection is present, use appropriate systemic antibiotics:
  • Flucloxacillin for Staphylococcus aureus (most common pathogen) 1
  • Erythromycin for penicillin-allergic patients 1
  • Phenoxymethylpenicillin for β-hemolytic streptococci 1

Refractory Cases

PUVA Therapy

• Consider PUVA (Psoralen plus UVA) for severe, refractory cases 1
• Oral PUVA has shown better efficacy than topical PUVA for hand and foot eczema 1
• Uncontrolled studies with oral PUVA have shown significant improvement or clearance in 81-86% of patients with hand and foot eczema 1

Other Options

• Tacrolimus 0.1% ointment has shown comparable efficacy to mometasone furoate 0.1% in dyshidrotic palmar eczema 4
• In extremely refractory cases, low-dose radiation therapy has been reported to achieve complete remission, though this is rarely used 5

Avoidance of Triggers

• Identify and avoid potential triggers:
  • Soaps and detergents that remove natural skin lipids 1
  • Irritant clothing (wool) - use cotton clothing instead 1
  • Extremes of temperature 1
  • Consider metal allergy evaluation, as it may be an important etiologic factor 6

Important Considerations and Pitfalls

• Keep nails short to minimize damage from scratching 1
• Be vigilant for signs of skin atrophy with prolonged corticosteroid use 2
• Topical corticosteroids should be tapered once improvement occurs, not stopped abruptly 1
• The face is particularly susceptible to steroid-induced side effects, so use the lowest effective potency 2
• Patient education about the chronic nature of the condition and importance of consistent skin hydration is crucial 3

Monitoring and Follow-up

• Reassess after 2 weeks of treatment to monitor progress 3
• Watch for signs of:
  • Skin atrophy
  • Secondary bacterial infection
  • Treatment failure 3
• Adjust treatment according to individual response and tolerability 3