What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

The first-line treatment for dyshidrotic eczema is topical corticosteroids, with medium to high-potency formulations applied twice daily for up to 4 weeks, followed by maintenance therapy using intermittent application (1-2× weekly) to prevent flares. 1

Stepwise Treatment Approach

First-Line Therapy

• Topical corticosteroids:
  • For hands/feet (non-sensitive areas): Medium to high-potency steroids (Class 2-3)
  • Apply twice daily for initial treatment (up to 4 weeks)
  • Reassess after 2 weeks to evaluate response 1
  • High-potency steroids (Class 1-2) reserved for thick, lichenified, or treatment-resistant lesions

Maintenance Therapy

• Reduce frequency to 1-2 times weekly after improvement to prevent flares
• Apply emollients 3-8 times daily, even when skin appears normal
• Ointments provide maximum occlusion (best for very dry skin)
• Creams offer good balance of hydration and acceptability
• Apply moisturizers immediately after bathing to lock in moisture 1

For Refractory Cases

• Topical calcineurin inhibitors: Tacrolimus 0.1% ointment can be used as rotational therapy with corticosteroids for chronic cases 2
• Consider referral to specialist care for:
  • Diagnostic uncertainty
  • Failure to respond to appropriate topical steroids
  • Need for second-line treatment 1

Addressing Underlying Factors

Infection Management

• Treat clinically evident infections with appropriate antibiotics
• Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions
• Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections 1

Trigger Identification and Avoidance

• Metal allergy consideration:
  • Metal hypersensitivity (particularly nickel and cobalt) may trigger flares in some patients 3, 4
  • A low-cobalt diet may be beneficial for patients with confirmed metal hypersensitivity 4

Associated Conditions

• Hyperhidrosis management:
  • If excessive sweating is present, treating hyperhidrosis may improve dyshidrotic eczema
  • Medications like oxybutynin have shown impressive results in patients with both conditions 5

Lifestyle Modifications

• Use gentle, pH-neutral synthetic detergents instead of soap
• Avoid irritants such as perfumes, deodorants, and alcohol-based lotions
• Avoid irritant clothing and extremes of temperature
• Keep nails short to prevent secondary infections from scratching 1

Advanced Therapies for Severe Cases

• Phototherapy (narrowband UVB) for moderate to severe cases not responding to topical treatments
• Systemic agents for severe, refractory cases (under specialist supervision):
  • Dupilumab, tralokinumab (biologics)
  • Abrocitinib, baricitinib, upadacitinib (JAK inhibitors)
  • Cyclosporine, methotrexate, azathioprine, mycophenolate 1

Caution: Systemic corticosteroids are not recommended due to the risk of rebound flares and adverse events 1

Important Monitoring Considerations

• Watch for adverse effects of topical corticosteroids, including skin atrophy, striae, telangiectasia, and purpura
• Prolonged use of medium to high-potency steroids beyond 4 weeks increases the risk of skin atrophy 1
• Regular follow-up is essential to assess treatment response and adjust therapy accordingly