What treatment to prescribe for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

For dyshidrotic eczema, the first-line treatment is a potent topical corticosteroid such as clobetasol propionate applied once daily for 4 weeks, then on alternate nights for 4 weeks, and finally twice weekly for the third month.

First-Line Treatment

Topical Corticosteroids

• Potent topical corticosteroids are the recommended first-line treatment for dyshidrotic eczema 1, 2
• Application regimen:
  • Initial phase: Once daily application for 4 weeks
  • Second phase: Alternate nights for 4 weeks
  • Maintenance phase: Twice weekly for the third month 3
• Potent corticosteroids are significantly more effective than mild ones (70% vs 39% treatment success) 2
• For thick, lichenified lesions, high-potency (Class 1-2) steroids are appropriate 1
• A 30g tube should last approximately 12 weeks 3

Application Technique

• Apply a thin layer to affected areas
• Rub in gently 4
• For severe cases, occlusive dressing technique may be used:
  • Apply a thin coating on lesions
  • Cover with pliable nonporous film
  • Seal edges
  • Can be applied in the evening and removed in the morning (12-hour occlusion) 4

Second-Line Treatments

Topical Calcineurin Inhibitors

• Tacrolimus ointment can be used for areas at high risk of skin atrophy or as a steroid-sparing agent 1
• Particularly useful for application to lid margins in cases with ocular involvement 3

Addressing Hyperhidrosis

• Hyperhidrosis plays a significant role in dyshidrotic eczema pathogenesis
• Consider oxybutynin for patients with coexisting hyperhidrosis 5

Management of Severe or Refractory Cases

Systemic Treatments

• For severe, refractory cases, consider:
  • Methotrexate as a second-line systemic option 1
  • Dupilumab or tralokinumab (IL-4/IL-13 inhibitors) have shown efficacy in severe cases 6, 1
  • JAK inhibitors (upadacitinib, abrocitinib, baricitinib) for severe, refractory cases 1

Important Cautions

• Avoid long-term oral corticosteroids due to risk of:
  • Rebound flares upon discontinuation
  • Adverse effects including osteoporosis, hypertension, diabetes
  • Increased infection risk (particularly concerning as patients often have Staphylococcus aureus colonization) 1

Supportive Care

Emollients and Skin Care

• Apply fragrance-free emollients 3-8 times daily, even when skin appears normal
• Best applied immediately after bathing to lock in moisture
• Ointments provide maximum occlusion for very dry skin
• Use gentle, pH-neutral synthetic detergents instead of soap 1

Infection Management

• If signs of infection are present:
  • Consider antiseptic washes with aqueous chlorhexidine 0.05%
  • For clinically evident infections, use appropriate antibiotics
  • Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections 1

Monitoring and Follow-Up

• Reassess after 2 weeks to evaluate response to initial treatment 1
• Monitor for adverse effects including skin atrophy, striae, telangiectasia, and purpura
• If symptoms return when reducing application frequency, return to the previous effective frequency 3
• Most patients require 30-60g of topical corticosteroid annually for maintenance 3

Special Considerations

• Patients with genetic variants of the NR3C1 gene may show different responses to topical corticosteroid therapy 7
• For patients with coexisting atopic dermatitis, biologics targeting IL-13 (tralokinumab) may be particularly effective 6

By following this treatment approach, most patients with dyshidrotic eczema will experience significant improvement in their symptoms and quality of life.