Treatment of Dyshidrotic Eczema
The first-line treatment for dyshidrotic eczema is topical corticosteroids, with medium potency formulations for maintenance and high/very high potency for severe flares, followed by additional therapies including immunomodulators and phototherapy for refractory cases. 1
First-Line Treatments
Topical Corticosteroids
- Medium potency corticosteroids are recommended for maintenance therapy
- High/very high potency corticosteroids for severe flares
- Apply twice weekly to prevent relapses (maintenance therapy)
- Use low potency corticosteroids for sensitive areas (face, neck, intertriginous areas)
- Caution: Extended use of high-potency corticosteroids (like clobetasol propionate) beyond 2 weeks can lead to side effects and increased risk of infections 2
Emollients
- Apply multiple times daily, especially after bathing
- Ointments provide better hydration than creams for dry, irritable rashes
- Apply at least once daily to the entire body, more frequently on affected areas
- Avoid alcohol-containing products which can worsen dryness
Specific Treatments for Complications
- For fissures: Propylene glycol 50% in water for 30 minutes under plastic occlusion nightly, followed by hydrocolloid dressing
- For erythema and desquamation: Prednicarbate cream 0.02% may help
Second-Line Treatments
Topical Calcineurin Inhibitors
- Tacrolimus 0.1% ointment has shown efficacy comparable to mometasone furoate 0.1% in treating dyshidrotic palmar eczema 3
- Can be used in rotation with topical corticosteroids for long-standing cases to minimize side effects
Phototherapy
- PUVA therapy is recommended for cases not responding to topical treatments
- Superior efficacy compared to UVB, with significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
Third-Line Treatments
Systemic Immunomodulators
- For severe, refractory cases, consider:
- Cyclosporine
- Methotrexate
- Azathioprine
Biologics
- Dupilumab may be considered for severe, recalcitrant cases of dyshidrotic eczema 1
Additional Therapeutic Options
Management of Hyperhidrosis
- Oxybutynin has shown impressive results in patients with coexisting hyperhidrosis and dyshidrotic eczema 4
Radiation Therapy
- Low-dose external beam radiation therapy may be considered in extremely refractory cases
- Complete resolution has been reported in severe cases unresponsive to multiple topical and systemic agents 5
Prevention and Maintenance
- Avoid hot showers and excessive soap use
- Identify and eliminate triggering substances
- Avoid irritant clothing and extremes of temperature
- Keep nails short to prevent secondary infections from scratching
- Continue maintenance therapy even after resolution to prevent recurrence
Managing Complications
Infection Control
- Watch for signs of secondary infection (usually Staphylococcus aureus)
- If infection is suspected:
- Take bacterial swabs
- Consider appropriate antibiotics
- Antiseptic baths with potassium permanganate (1:10,000) may help accelerate wound closure
- Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections
Common Pitfalls
- Overuse of high-potency corticosteroids leading to skin atrophy and increased infection risk
- Inadequate patient education regarding proper application of treatments
- Failure to address coexisting conditions like hyperhidrosis
- Discontinuing maintenance therapy too early, leading to relapses
- Not recognizing secondary infection or contact dermatitis when eczema deteriorates