What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

For dyshidrotic eczema, topical corticosteroids are the first-line treatment, with high-potency formulations recommended for acute phases (2-4 weeks), medium-potency for longer treatments, and low-potency for mild cases. 1

First-Line Treatment Approach

Topical Therapies

• Topical corticosteroids:
  • Acute phase: High-potency corticosteroids for 2-4 weeks
  • Longer treatment: Medium-potency corticosteroids
  • Mild cases: Low-potency corticosteroids 1
• Emollients/Moisturizers:
  • Apply alcohol-free moisturizers frequently (3-8 times daily)
  • Use immediately after bathing to trap moisture
  • Choose fragrance-free formulations 1

Skin Care Recommendations

• Avoid excessive washing with hot water
• Do not use alcohol-based products, solvents, or disinfectants
• Apply emollients liberally and frequently, even when skin appears normal 1

Second-Line Treatment Options

Alternative Topical Agents

• Topical calcineurin inhibitors such as tacrolimus 0.1% ointment can be effective and offer an alternative for rotational therapy with corticosteroids 2
  • Studies show tacrolimus 0.1% ointment is comparable to mometasone furoate 0.1% in reducing symptoms by more than 50% after 2 weeks of treatment

Addressing Potential Triggers

• Metal allergy consideration:
  • Consider patch testing for patients with persistent or recalcitrant dyshidrotic eczema 1
  • Dietary modification may help if metal hypersensitivity is identified:
    • Low-cobalt and/or low-nickel diet can reduce flares in susceptible patients 3, 4

Treatment for Severe or Refractory Cases

Systemic Therapies

• Oral corticosteroids:
  • Consider prednisone (1 mg/kg/day) with tapering over at least 4 weeks for severe cases
  • Should not be used for maintenance treatment 1

Phototherapy

• PUVA therapy (Psoralen + UVA):
  • Shown superior efficacy to UVB for hand eczema
  • Can achieve significant improvement or clearance in 81-86% of patients with hand and foot eczema 1

Advanced Therapies for Refractory Cases

• Systemic immunomodulators for moderate-to-severe cases with inadequate response to topical therapies:
  • Biologics (e.g., dupilumab)
  • JAK inhibitors (e.g., abrocitinib, baricitinib, upadacitinib)
  • Traditional immunomodulators (e.g., cyclosporine, methotrexate, azathioprine, mycophenolate mofetil) 1
• Radiation therapy may be considered in extremely refractory cases:
  • Low-dose external beam radiation has shown complete resolution in severe cases refractory to multiple topical and systemic agents 5

When to Refer to a Specialist

• Diagnostic uncertainty
• Poor response to initial treatment with appropriate topical steroids
• Need for second-line or systemic therapy
• Suspicion of underlying autoimmune skin disease
• Need for patch testing to identify potential triggers 1

Important Considerations and Pitfalls

• Duration of treatment: Limit high-potency corticosteroids to 2-4 weeks to avoid side effects 1
• Pediatric considerations: Children are particularly at risk of developing side effects from topical corticosteroids; potent agents should be avoided 6
• Prognosis awareness: Dyshidrotic eczema often runs a chronic, relapsing course with many patients requiring ongoing management 2
• Trigger identification: Metal allergies (particularly nickel and cobalt) may be important etiologic factors in some patients 4, 3