What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

For dyshidrotic eczema, the first-line treatment is high-potency topical corticosteroids for 2-4 weeks, followed by a maintenance regimen with medium-potency corticosteroids or intermittent application to prevent recurrence. 1

First-Line Treatment Options

Topical Corticosteroids

• Acute phase (2-4 weeks):

  • High-potency corticosteroids like betamethasone dipropionate applied once or twice daily 1
  • Limit use to 2-4 weeks to avoid side effects such as skin atrophy, telangiectasias, and striae

• Maintenance phase:

  • Reduce to intermittent application (1-2 times weekly) after clinical improvement 1
  • Consider switching to medium-potency corticosteroids for longer treatment periods
  • Use with caution on face, neck, genitals, and skin folds due to higher risk of skin atrophy

Emollients

• Apply fragrance-free emollients multiple times daily, especially after bathing 1
• Helps maintain skin barrier function and reduce flare-ups

Second-Line Treatment Options

Phototherapy

• PUVA (Psoralen plus UVA) therapy has shown efficacy for dyshidrotic eczema 2
• Oral PUVA is superior to UVB for hand eczema, with significant improvement or clearance in 81-86% of patients 2
• Topical PUVA shows mixed results with some uncontrolled studies reporting 58-81% improvement in dyshidrotic eczema, but comparative studies show less convincing efficacy 2

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream or tacrolimus 0.03% ointment can be effective with lower risk of skin atrophy 1
• Particularly useful for sensitive areas where corticosteroids pose higher risks

Topical PDE-4 Inhibitors

• Crisaborole may be considered for mild to moderate cases 1

Management of Complications

Infection Control

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

Important Cautions

• Avoid prolonged use of high-potency corticosteroids like clobetasol propionate beyond the recommended 2-week period 3
• Extended use of potent corticosteroids can lead to infectious complications, particularly with Staphylococcus aureus 3
• Monitor for signs of skin atrophy and other local side effects

Severe or Refractory Cases

For severe, widespread, or treatment-resistant dyshidrotic eczema:

• Consider systemic therapies such as:
  • Biologics (e.g., dupilumab)
  • Oral JAK inhibitors
  • Traditional immunomodulators (cyclosporine, methotrexate) 1
• Referral to a dermatologist is recommended for cases that fail to respond to first-line treatments

Lifestyle Modifications

• Identify and eliminate triggering substances 1
• Reduce exposure to irritants and allergens
• Consider patch testing for persistent or recalcitrant cases to identify potential contact allergens 4
• Maintain good skin care routine with regular moisturizing

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity using standardized assessment (e.g., Dyshidrotic Eczema Area and Severity Index) 5
   • Check for signs of secondary infection

2. Mild to Moderate Disease:

   • High-potency topical corticosteroids for 2-4 weeks
   • Regular emollient use
   • Identify and avoid triggers

3. Moderate to Severe Disease:

   • High-potency topical corticosteroids
   • Consider occlusion techniques for resistant areas
   • Add phototherapy if inadequate response

4. Severe or Refractory Disease:

   • Consider systemic therapies
   • Specialist referral

5. Maintenance:

   • Intermittent application of medium-potency corticosteroids
   • Continued emollient use
   • Regular monitoring for recurrence

Remember that treatment should be adjusted based on clinical response, and prolonged use of high-potency corticosteroids should be avoided due to potential side effects.