What is the treatment for dyshidrotic eczema?

Treatment for Dyshidrotic Eczema

The treatment for dyshidrotic eczema should follow a stepwise approach, starting with liberal emollient use and topical corticosteroids as first-line therapy, progressing to topical calcineurin inhibitors, phototherapy, and systemic immunosuppressants for refractory cases. 1

First-Line Treatment

Emollients

• Apply emollients 3-8 times daily, even when skin appears normal 1
• Use ointments rather than creams for better hydration of 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

Topical Corticosteroids

• Medium potency corticosteroids for maintenance therapy and high/very high potency corticosteroids for severe flares 1
• For mild to moderate cases:
  • Apply a mild potency corticosteroid such as 1% hydrocortisone twice daily for 7-14 days 1
• For moderate to severe cases:
  • Apply a medium to high potency corticosteroid twice daily
  • Super-high potency options like clobetasol propionate should be limited to 2 consecutive weeks, with amounts not exceeding 50g per week 2
  • Once-daily application of potent corticosteroids is likely as effective as twice-daily application 3

Important Precautions

• Limit continuous use of topical corticosteroids to 2 weeks maximum 1, 2
• Avoid occlusive dressings unless directed by a specialist 1, 2, 4
• For moderate flares not responding to mild steroids, a short burst (3 days) of moderate potency steroid like 0.05% clobetasone butyrate may be used 1
• Monitor for signs of skin thinning, which occurs more frequently with higher potency corticosteroids 3
• Consider weekend therapy with mild steroids to prevent relapses after flare resolution 1

Second-Line Treatment

Topical Calcineurin Inhibitors

• Consider for cases not responding adequately to topical corticosteroids
• Particularly useful for sensitive areas where corticosteroids may cause adverse effects

Phototherapy

• For cases not responding to topical treatments 1
• Options include:
  • Narrow-band UVB
  • Broadband UVB
  • UVA1
  • PUVA therapy (showing significant improvement in 81-86% of patients with hand eczema) 1
• Note: Potential risks include premature skin aging and cutaneous malignancies

Third-Line Treatment (Severe/Refractory Cases)

Systemic Treatments

• Systemic corticosteroids have a limited role in treating occasional patients with severe dyshidrotic eczema 1
  • Should not be considered for maintenance treatment
• Consider immunomodulators for severe cases:
  • Cyclosporine
  • Methotrexate
  • Azathioprine
  • Mycophenolate mofetil 1
• Biologics like dupilumab for severe, recalcitrant cases 1

Additional Management Strategies

Trigger Identification and Avoidance

• Identify and eliminate triggering substances 1
• Consider metal hypersensitivity (nickel/cobalt) as potential triggers 5
  • A low-cobalt diet may be beneficial for some patients with dyshidrotic eczema 5
• Avoid irritant clothing and extremes of temperature 1
• Keep nails short to prevent secondary infection from scratching 1

Infection Prevention and Management

• Monitor for signs of secondary infection 1
• Consider antiseptics on erosive lesions (e.g., aqueous chlorhexidine 0.05%) 1
• Use antifungal creams on macerated skin areas 1
• Consider bleach baths with 0.005% sodium hypochlorite twice weekly to prevent infections 1
• Use systemic antibiotics only when there is clear evidence of infection 1

Management of Associated Hyperhidrosis

• For patients with coexisting hyperhidrosis, treatment with anticholinergics like oxybutynin may significantly improve dyshidrotic eczema 6

Special Considerations

Pediatric Patients

• Children may absorb proportionally larger amounts of topical corticosteroids and be more susceptible to systemic toxicity 4
• Use the lowest potency corticosteroid effective for the shortest duration possible
• Monitor for potential adverse effects:
  • HPA axis suppression
  • Growth retardation
  • Cushing's syndrome 4

Maintenance and Relapse Prevention

• Weekend (proactive) therapy with topical corticosteroids significantly reduces relapse rates (from 58% to 25%) 3
• Continue liberal emollient use 3-8 times daily for maintenance after flare resolution 1

When to Refer to a Specialist

• Cases with diagnostic doubt
• Failure to respond to maintenance treatment with appropriate topical steroids
• When second-line treatment is required 1
• For counseling patients and family about long-term management

Remember that "steroid phobia" often leads to insufficient treatment and prolonged suffering, while using potent steroids unnecessarily increases the risk of side effects 1. Adequate patient education regarding proper application of treatments is essential for successful management.