Treatment of Dyshidrotic Eczema
Dyshidrotic eczema should be treated with a stepwise approach starting with topical corticosteroids as first-line therapy, with consideration of additional treatments for refractory cases based on severity and response. 1
First-Line Treatment
- Apply topical corticosteroids to affected areas twice daily for acute flares, using the least potent preparation required to control symptoms 1, 2
- Use moisturizers (emollients) at least once daily to the whole body, preferably oil-in-water creams or ointments rather than alcohol-containing lotions 1, 3
- Keep nails short to prevent secondary infection from scratching 1
- Use dispersible cream as a soap substitute for cleansing to prevent further drying of the skin 1
- Avoid irritant clothing such as wool; cotton clothing is recommended 1
Management of Specific Symptoms
- For severe itching, consider oral antihistamines with sedative properties (such as diphenhydramine or clemastine) as short-term adjuvant therapy, particularly for sleep disturbance 1
- Non-sedating antihistamines have little value in controlling pruritus associated with dyshidrotic eczema 1, 3
- For dry skin, apply emollients after bathing for maximum effectiveness 1
- Topical polidocanol cream can help relieve itching 1, 3
Management of Complications
- For secondary bacterial infection (suggested by crusting or weeping), use appropriate antibiotics such as flucloxacillin for Staphylococcus aureus, which is the most common pathogen 1
- For herpes simplex infection (eczema herpeticum, characterized by grouped, punched-out erosions), administer oral acyclovir early in the course of disease; use intravenous acyclovir for ill, febrile patients 1
Second-Line Treatments
- For recalcitrant cases, consider ichthammol (1% in zinc ointment) or coal tar preparations, which can be particularly useful for lichenified eczema 1
- Topical tacrolimus (FK506) 0.1% ointment has shown efficacy similar to mometasone furoate 0.1% ointment and can be used in a rotational therapy approach for chronic cases 4
- Consider patch testing if metal allergy is suspected as a potential trigger, as removing metal allergens may improve symptoms 5
Third-Line Treatments
- For severe, refractory cases, consider oral PUVA therapy, which has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
- Topical PUVA has shown mixed results, with some uncontrolled studies reporting improvement but comparative studies showing less convincing efficacy 1
- In extremely refractory cases, low-dose radiation therapy may be considered, which has shown complete remission in some cases where other treatments have failed 6
- Systemic corticosteroids have a limited but definite role for severe cases, but should not be used for maintenance treatment 1
Important Precautions
- Monitor for systemic absorption of topical corticosteroids, especially when used over large areas or with occlusive dressings, which can lead to HPA axis suppression 2
- Children may absorb proportionally larger amounts of topical corticosteroids and require closer monitoring for systemic effects 2
- Preparations in the very potent and potent categories should be used with caution for limited periods only 1
- Genetic factors may influence response to standard therapy; some patients with specific genotypes (such as 646 CC of the NR3C1 gene) may be less responsive to topical corticosteroid treatment 7