What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

For dyshidrotic eczema, the first-line treatment is high-potency topical corticosteroids for short periods, followed by medium to low-potency options for maintenance, with PUVA therapy or alitretinoin considered for severe or recalcitrant cases. 1

First-Line Treatment Options

Topical Therapies

• Topical corticosteroids:

  • Use high-potency topical corticosteroids for short periods (2-4 weeks) on thickened areas in severe cases 1
  • Apply medium-potency topical corticosteroids once daily for mild to moderate cases 1
  • Use low-potency topical corticosteroids for sensitive areas like the face 1
  • Once-daily application of potent topical corticosteroids is as effective as twice-daily application 2

• Emollients and moisturizers:

  • Apply liberally and frequently, especially after bathing 1
  • Use the "soak and smear" technique for chronic phase 1
  • Consider occlusion with cotton gloves at night after moisturizer application 1

• Topical calcineurin inhibitors:

  • Topical tacrolimus (0.1%) is an effective alternative to corticosteroids 3
  • Can be used for rotational therapy with topical corticosteroids to minimize side effects 3

Second-Line Treatment Options

Phototherapy

• PUVA (Psoralen plus UVA) therapy:
  • Oral PUVA has been shown to be superior to UVB for hand eczema 4
  • Oral PUVA can achieve significant improvement or clearance in 81-86% of patients with hand and foot eczema 4
  • Topical PUVA has shown variable results with improvement rates of 58-81% in uncontrolled studies, but less convincing evidence in comparative studies 4

Systemic Treatments

• Alitretinoin:
  • Recommended for chronic or recalcitrant cases 1
  • Particularly effective for severe hand eczema that doesn't respond to topical treatments

Management of Secondary Complications

• Bacterial infections:

  • Obtain bacterial cultures if secondary infection is suspected (often Staphylococcus aureus) 1, 5
  • Administer appropriate antibiotics based on culture results 1
  • Be aware that prolonged use of topical corticosteroids can increase infection risk 5

• Severe itching:

  • Consider oral antihistamines such as cetirizine, loratadine, or fexofenadine 1

Prevention and Maintenance

• Trigger identification and avoidance:

  • Identify and eliminate triggering substances 1
  • Consider metal allergy as a potential trigger 6
  • Use after-work creams for protection 1

• Proactive maintenance therapy:

  • Weekend (proactive) application of topical corticosteroids significantly reduces relapse rates (from 58% to 25%) 2
  • Apply topical corticosteroids twice weekly to previously affected areas to prevent relapse 1

Treatment Algorithm for Dyshidrotic Eczema

1. Acute phase:

   • High-potency topical corticosteroids once daily for 2-4 weeks
   • Liberal use of emollients
   • Avoid identified triggers

2. If inadequate response or severe disease:

   • Consider PUVA therapy (oral PUVA preferred over topical) 4
   • Consider alitretinoin for chronic hand eczema 1

3. Maintenance phase:

   • Weekend (proactive) application of topical corticosteroids
   • Daily emollients
   • Rotational therapy with topical tacrolimus may be beneficial 3

Important Caveats and Pitfalls

• Corticosteroid-related concerns:

  • Avoid prolonged use of potent topical corticosteroids due to risk of skin thinning 2
  • Risk of developing side effects depends on potency, duration of use, and volume applied 5
  • Clobetasol propionate (very potent) should be limited to maximum 2 weeks of use 5
  • Be aware of the cumulative depot effect of potent corticosteroids 5

• Efficacy considerations:

  • Relapse rates are high after discontinuation of treatment 4, 3
  • Complete remission is difficult to achieve with conventional therapies alone 7
  • Most patients (14 of 16 in one study) experience recurring symptoms within 3 weeks after active treatment 3

• Treatment resistance:

  • For cases refractory to multiple forms of topical and systemic agents, low-dose radiation therapy has shown complete resolution in some cases, though this is not a first-line approach 7