What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

Topical corticosteroids are the first-line treatment for dyshidrotic eczema, with medium to high-potency formulations recommended for palms and soles, applied twice daily for up to 4 weeks. 1

Diagnosis and Clinical Features

Dyshidrotic eczema (also known as pompholyx) is characterized by:

• Small, pruritic, tense vesicles primarily on palms, soles, and lateral/ventral surfaces of fingers
• Often associated with hyperhidrosis
• May have relationship with metal allergies in some patients 2
• Typically presents with acute flares followed by chronic, relapsing course

Treatment Algorithm

First-Line Treatment

1. Topical Corticosteroids

   • Medium to high-potency (Class 2-3) for palms and soles 1
   • Apply twice daily for initial treatment (up to 4 weeks)
   • Reassess after 2 weeks to evaluate response
   • Monitor for adverse effects (skin atrophy, striae, telangiectasia)
   • Avoid prolonged use beyond 4 weeks to prevent skin atrophy

2. Emollients

   • Apply fragrance-free emollients 3-8 times daily, even when skin appears normal 1
   • Best applied immediately after bathing to lock in moisture
   • Ointments provide maximum occlusion for very dry skin
   • Creams offer good balance of hydration and acceptability

Trigger Management

• Identify and eliminate triggering substances 1
• Consider metal allergy evaluation, as removal of metal allergens may improve symptoms 2
• Use gentle, pH-neutral synthetic detergents instead of soap
• Avoid irritants such as perfumes, deodorants, and alcohol-based lotions
• Keep nails short to prevent scratching and secondary infection

Second-Line Treatments

1. Topical Calcineurin Inhibitors

   • Tacrolimus 0.1% ointment can be as effective as mometasone furoate for dyshidrotic palmar eczema 3
   • Useful for rotational therapy with topical corticosteroids in chronic cases
   • Particularly valuable when concerned about skin atrophy from prolonged steroid use

2. Phototherapy

   • Consider for moderate to severe cases not responding to topical treatments 1
   • UVA1 radiation can be effective, even at lower doses for mild cases 4
   • Natural sunlight exposure may provide benefit as adjuvant therapy 4

Maintenance and Prevention

• Reduce frequency of topical corticosteroid application to 1-2 times weekly after improvement 1
• Continue daily emollient use
• Avoid identified triggers
• Consider antiseptic washes for prevention of secondary infection

Treatment for Severe, Refractory Cases

1. Systemic Therapy

   • For severe cases, consider referral for systemic agents 1
   • Options include cyclosporine, methotrexate, azathioprine, or mycophenolate
   • Systemic corticosteroids generally not recommended due to risk of rebound flares

2. Radiation Therapy

   • Low-dose external beam radiation therapy may be considered in extremely refractory cases 5
   • Can provide complete resolution in severe cases unresponsive to conventional therapies
   • May allow withdrawal of oral or topical agents

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate topical treatments after 4 weeks
• Need for second-line or systemic treatments
• Recurrent or severe disease significantly impacting quality of life

Common Pitfalls and Caveats

• Avoid prolonged use of high-potency steroids beyond 4 weeks due to risk of skin atrophy
• Don't overlook potential metal allergies as triggers for dyshidrotic eczema
• Secondary bacterial infection may complicate management and require antimicrobial treatment
• Dyshidrotic eczema is often chronic and relapsing, requiring long-term management strategies
• Patient education about trigger avoidance and consistent moisturizer use is essential for successful management