What causes eczema on the top of the foot?

Management of Eczema on Top of Foot

Eczema on the top of the foot is typically treated with high-potency topical corticosteroids as first-line therapy, followed by emollient maintenance therapy and identification of potential triggers. 1

Causes of Eczema on Top of Foot

Eczema on the top of the foot can be caused by several factors:

• Contact irritants: Chemical exposure from footwear, solvents, or disinfectants
• Mechanical stress: Friction from shoes or prolonged walking
• Predisposing factors: Pre-existing hyperkeratosis
• Environmental factors: Temperature extremes, dry weather
• Atopic predisposition: Personal or family history of atopic conditions

Treatment Algorithm

First-Line Treatment

1. Topical corticosteroids:

   • For non-facial, non-intertriginous areas like the top of the foot, use high-potency topical corticosteroids (e.g., clobetasol propionate 0.05%) 1
   • Apply once daily for 2-4 weeks (once-daily application is as effective as twice-daily for potent corticosteroids) 1
   • Gradually taper to every other day, then twice weekly for maintenance 1
   • Aim to discontinue within 4-12 weeks to prevent side effects 1

2. Emollient therapy:

   • Apply fragrance-free emollients 3-8 times daily, even when skin appears normal 1
   • Ointments provide maximum occlusion and are best for very dry skin 1
   • Apply immediately after bathing to lock in moisture 1

For Persistent or Severe Cases

1. Consider topical calcineurin inhibitors (TCIs) if steroids are ineffective or for long-term management 2

   • Pimecrolimus cream 1% for mild-to-moderate eczema 2
   • TCIs have fewer side effects than topical steroids and can be used for intermittent long-term therapy 2

2. For infected eczema:

   • Consider antiseptic washes with aqueous chlorhexidine 0.05% 1
   • If clinically indicated, oral antibiotics such as doxycycline 100mg twice daily or minocycline 50mg twice daily for 6 weeks 3

3. For severe, refractory cases:

   • Consider referral for phototherapy (PUVA or UVB) 3, 1
   • PUVA has shown to be superior to UVB for hand and foot eczema, with significant improvement or clearance in 81-86% of patients 3

Prevention and Lifestyle Modifications

1. Avoid mechanical stress:

   • Wear cushioned shoes and socks 3
   • Avoid long walks without proper footwear 3

2. Avoid chemical stress:

   • Minimize exposure to skin irritants, solvents, or disinfectants 3
   • Use gentle, pH-neutral synthetic detergents instead of soap 1

3. Treat predisposing factors:

   • Address apparent hyperkeratosis before it worsens 3
   • Consider podiatric evaluation for foot care 3

4. Preventive moisturization:

   • Regular use of urea 10% cream three times daily can help prevent flares 3

When to Refer to a Specialist

• If diagnosis remains uncertain after 2-3 weeks of treatment 1
• Poor response to first-line treatment 1
• If there are signs of skin atrophy, secondary infection, or contact dermatitis to the medication itself 1
• For consideration of systemic therapy in very severe cases 1

Important Caveats

• Avoid long-term uninterrupted use of high-potency steroids on the feet as this can lead to skin atrophy and tachyphylaxis
• Regular reassessment is necessary after 2 weeks of treatment to monitor for side effects and treatment response 1
• Relapse rates can be high after discontinuation of treatment, particularly with PUVA therapy 3
• Emollients should be continued even during periods of remission to maintain skin barrier function 1
• Avoid empiric antibiotics for uninfected lesions as this practice is controversial 4

By following this structured approach to managing eczema on the top of the foot, most patients will experience significant improvement in symptoms and quality of life.