What is the treatment for dyshidrotic (dishidrotic) eczema?

Treatment of Dyshidrotic (Dishidrotic) Eczema

Topical corticosteroids are the mainstay of treatment for dyshidrotic eczema, with the least potent preparation required to control symptoms being recommended as first-line therapy. 1

First-Line Treatment Options:

• Use topical corticosteroids as the primary treatment, applying no more than twice daily (some newer preparations require only once daily application) 1
• Choose the least potent preparation that effectively controls the eczema, using more potent formulations only for limited periods 1
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1
• Use a dispersible cream as a soap substitute to cleanse the skin, avoiding regular soaps and detergents that remove natural lipids 1

Management of Triggers and Exacerbating Factors:

• Avoid extremes of temperature and irritant clothing (especially wool); cotton clothing is recommended 1
• Consider metal hypersensitivity as a potential trigger; dietary cobalt and/or nickel restriction may help reduce flares in some patients 2
• Keep nails short to minimize trauma and secondary infection risk 1

Management of Secondary Infection:

• For bacterial superinfection, flucloxacillin is usually the most appropriate antibiotic for treating Staphylococcus aureus 1, 3
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy 1, 3
• For herpes simplex virus infection (eczema herpeticum), administer acyclovir early in the course of disease; use intravenous administration for ill, febrile patients 3

Second-Line and Refractory Disease Treatment:

• For severe pruritus, sedating antihistamines may be useful as a short-term adjuvant to topical treatment during relapses (non-sedating antihistamines have little value) 1
• Consider ichthammol (1% in zinc ointment) or coal tar preparations (1% in hydrocortisone ointment) for lichenified eczema 1
• For refractory cases, oral PUVA therapy has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
• Topical PUVA has shown mixed results, with uncontrolled studies reporting 58-81% improvement in dyshidrotic eczema, but comparative studies showing less convincing efficacy 1
• Narrowband UVB (NB-UVB) may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate in one study 1

Treatment Considerations for Severe, Refractory Cases:

• Oral PUVA has been shown to be superior to UVB in prospective controlled studies of hand eczema 1
• In extreme cases unresponsive to conventional therapies, low-dose external beam radiation therapy has been reported to achieve complete resolution in a refractory case, with durable response at 6 months 4

Important Caveats:

• Potent and very potent topical corticosteroids should be used with caution and for limited periods only due to risk of pituitary-adrenal axis suppression 1
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 1
• The effectiveness of treatments may be assessed using standardized tools such as the Dyshidrotic Eczema Area and Severity Index (DASI) 5
• Genetic factors may influence response to standard therapy, with certain genotypic variants of the NR3C1 gene potentially predicting treatment response to glucocorticosteroid therapy 6