What is the treatment for dyshidrotic eczema?

Treatment for Dyshidrotic Eczema

The first-line treatment for dyshidrotic eczema consists of topical corticosteroids of medium potency for limited periods, combined with frequent application of emollients throughout the day. 1

First-Line Treatment Approach

Topical Treatments

• Topical Corticosteroids (TCS):

  • Use medium potency TCS as first-line prescription treatment 1
  • Apply twice daily to affected areas
  • For severe flares, high/very high potency corticosteroids like clobetasol propionate may be used, but with important limitations:
    • Limited to 2 consecutive weeks of treatment
    • No more than 50g per week
    • Avoid occlusive dressings
    • Monitor for HPA axis suppression 2
  • For sensitive areas (face, neck, intertriginous areas), use low potency TCS 1

• Emollients:

  • Apply 3-8 times daily to decrease transepidermal water loss 1
  • Use water-in-oil emollients for regular maintenance
  • Use ointments rather than creams for very dry areas as they provide better hydration 1
  • Apply at least once daily to the entire body, more frequently on affected areas 1
  • Avoid alcohol-containing products which can worsen dryness 1

Infection Prevention

• Monitor for signs of cutaneous infection (especially Staphylococcus aureus) 1
• Consider bacterial swabs from affected areas if infection is suspected 1
• For erosive lesions, use antiseptics (e.g., aqueous chlorhexidine 0.05%) 1
• Consider antiseptic baths with potassium permanganate (1:10,000) to accelerate wound closure 1
• Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections 1

Second-Line Treatments

Topical Calcineurin Inhibitors

• Tacrolimus ointment (0.03% or 0.1%) or pimecrolimus cream (1%) for short-term management of flares 1
• Apply only on limited areas due to risk of systemic absorption 1
• Particularly useful for areas where prolonged steroid use is concerning

Phototherapy

• Consider for cases not responding to topical treatments 1
• PUVA therapy has shown superior efficacy compared to UVB
• Can achieve significant improvement or clearance in 81-86% of patients with hand and foot eczema 1

Treatment for Refractory Cases

Systemic Treatments

• Immunomodulators (cyclosporine, methotrexate, azathioprine) for severe cases 1
• Biologics like dupilumab for severe, recalcitrant cases 1

Specialized Treatments

• For fissures: propylene glycol 50% in water for 30 minutes under plastic occlusion nightly, followed by hydrocolloid dressing 1
• For areas with peeling: prednicarbate cream 0.02% to help with erythema and desquamation 1

Maintenance Therapy and Prevention

• Continue regular use of emollients even after resolution to prevent recurrence 1
• Apply medium potency TCS twice weekly to prevent relapses 1
• Identify and eliminate triggering factors:
  • Avoid hot showers and excessive soap use
  • Avoid alcohol-containing lotions or gels
  • Avoid irritant clothing and extremes of temperature
  • Keep nails short 1
• Consider low-cobalt diet in cases with suspected metal hypersensitivity 3

Important Caveats and Pitfalls

1. Steroid-related risks: Clobetasol and other high-potency steroids can cause HPA axis suppression, Cushing's syndrome, hyperglycemia, and glucosuria. Limit use to 2 weeks and monitor for side effects 2

2. Treatment failure: If no improvement is seen within 2 weeks of appropriate therapy, reassessment of diagnosis may be necessary 2

3. Pediatric considerations: Children may be more susceptible to systemic toxicity from topical corticosteroids due to larger skin surface to body mass ratios 2

4. Secondary infection: If concomitant skin infections develop, appropriate antifungal or antibacterial agents should be used before continuing steroid therapy 2

5. Contraindications: Do not use high-potency corticosteroids on the face, groin, or axillae, or for treating rosacea or perioral dermatitis 2

6. Pregnancy concerns: Corticosteroids have teratogenic potential; clobetasol propionate has greater teratogenic potential than less potent steroids 2