What is the treatment for dyshidrotic eczema?

Treatment for Dyshidrotic Eczema

For dyshidrotic eczema, high-potency topical corticosteroids are the first-line treatment, applied twice daily for up to 2 consecutive weeks, with liberal use of emollients and identification/elimination of triggers. 1

Treatment Algorithm

First-Line Treatment

1. Topical Corticosteroids

   • Use high-potency topical corticosteroids for severe or thickened areas 1
   • Apply a thin layer twice daily and rub in gently 2
   • Limit treatment to 2 consecutive weeks 2
   • Do not exceed 50g per week 2
   • Do not use with occlusive dressings 2
   • Medium-potency corticosteroids may be appropriate for mild to moderate cases 1

2. Emollients and Moisturizers

   • Apply liberally and frequently 1
   • Use immediately after bathing to lock in moisture 1
   • Choose fragrance-free, hypoallergenic formulations 1
   • Continue daily use even when skin appears normal 1

3. Trigger Identification and Avoidance

   • Identify and eliminate triggering substances 1
   • Consider using after-work protective creams if occupational exposure is suspected 1

Treatment Monitoring and Adjustment

• Reassess after 2 weeks of treatment 1
• If no improvement is seen within 2 weeks, reassessment of diagnosis may be necessary 2
• Consider changing treatment approach or referral to dermatologist if inadequate response 1

Maintenance and Prevention

• Proactive maintenance therapy with twice-weekly application of topical corticosteroids to previously affected areas can help prevent relapse 1
• Weekend or proactive therapy is generally recommended to prevent flares 1

Second-Line and Refractory Treatment Options

For cases that don't respond to first-line therapy:

1. Topical Calcineurin Inhibitors

   • Tacrolimus 0.1% ointment has shown efficacy similar to mometasone furoate in dyshidrotic palmar eczema 3
   • Can be used in rotation with topical corticosteroids for long-standing cases 3

2. Systemic Treatments for Moderate to Severe Cases

   • Phototherapy 1
   • Immunosuppressants (cyclosporin, methotrexate, azathioprine) 1
   • Biologics including dupilumab 1

3. Adjunctive Treatments

   • For patients with coexisting hyperhidrosis, oxybutynin may provide impressive improvement in dyshidrotic eczema symptoms 4

Important Considerations and Pitfalls

• Avoid prolonged use of potent corticosteroids, especially on the face, to prevent skin atrophy 1
• Avoid topical antihistamines and long-term use of topical antibiotics due to increased risk of resistance and sensitization 1
• Be alert for eczema herpeticum, a potentially serious complication characterized by sudden onset of monomorphic vesicles, often with systemic symptoms 1
• Most patients will experience recurrence within 3 weeks after stopping active treatment, highlighting the importance of maintenance therapy 3
• Undertreatment with inadequate potency or duration of corticosteroids can lead to inadequate response 1
• Genetic factors may influence response to standard therapy, with some patients showing resistance to topical corticosteroids 5

Dyshidrotic eczema presents as characteristic vesicular eruptions that can look similar to "tapioca pudding" on the palms and/or soles 6, and requires prompt, appropriate treatment to manage symptoms and prevent chronic, relapsing disease.