What is the treatment for pompholyx?

Treatment of Pompholyx (Dyshidrotic Eczema)

Topical corticosteroids are the first-line treatment for pompholyx, with calcineurin inhibitors serving as effective alternatives, particularly for maintenance therapy. 1

First-Line Treatments

Topical Therapies

• Topical corticosteroids: Cornerstone of initial treatment

  • Use potent formulations for acute flares
  • Apply to affected areas on palms and soles
  • Taper to lower potency formulations as condition improves
  • Occlusive dressings may enhance penetration through thick palmoplantar skin

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus)

  • Effective alternative to corticosteroids
  • Particularly useful for maintenance therapy
  • Avoids steroid-related side effects with prolonged use
  • Apply twice daily to affected areas

Second-Line Treatments

Phototherapy Options

• Topical PUVA (psoralen plus UVA)

  • As effective as systemic photochemotherapy 1
  • Apply methoxsalen (8-methoxypsoralen) followed by UVA exposure
  • Typically 2-3 sessions per week

• High-dose UVA-1 irradiation

  • Effective alternative phototherapy option
  • Requires specialized equipment 2

Systemic Treatments for Severe Cases

• Systemic corticosteroids

  • For severe bullous pompholyx
  • Short courses to control acute flares
  • Taper to avoid rebound flares

• Alitretinoin

  • Effective for chronic hand dermatitis including pompholyx
  • Particularly useful for resistant cases 2, 3
  • May work by regulating aquaporin expression in the skin 3

Treatment for Recalcitrant Cases

• Botulinum toxin A injections

  • Intradermal injection for treatment-resistant cases
  • Reduces hyperhidrosis which may trigger flares 1, 2, 4
  • Effect typically lasts 3-6 months

• Methotrexate

  • Low-dose oral methotrexate for severe recalcitrant cases
  • Acts as a steroid-sparing agent
  • Can lead to significant improvement or clearing 5
  • Requires monitoring for potential side effects

• Combination immunosuppressive therapy

  • For highly resistant cases
  • Corticosteroids combined with other immunosuppressants 1

Management Approach

1. Initial Assessment:

   • Identify and eliminate potential triggers (irritants, allergens)
   • Assess severity and extent of vesicles/bullae

2. Mild to Moderate Disease:

   • Start with potent topical corticosteroids
   • Consider topical calcineurin inhibitors for maintenance

3. Severe or Widespread Disease:

   • Short course of systemic corticosteroids
   • Consider phototherapy (PUVA or high-dose UVA-1)

4. Recalcitrant Disease:

   • Alitretinoin
   • Botulinum toxin injections
   • Low-dose methotrexate

Important Considerations

• The thick horny layer of palms and soles makes treatment challenging 1
• Patients often benefit most from combination therapies 1
• Maintenance therapy is important to prevent relapses
• Addressing hyperhidrosis may help prevent recurrences

Pitfalls to Avoid

• Prolonged use of high-potency topical steroids without breaks (risk of skin atrophy)
• Failure to identify and address triggers
• Inadequate patient education about chronic nature of condition
• Discontinuing treatments too quickly after improvement (leads to relapses)