What is the treatment for dyshydrotic eczema?

Treatment of Dyshidrotic Eczema

The first-line treatment for dyshidrotic eczema is topical corticosteroids, which should be used at the lowest effective potency to control symptoms, combined with regular moisturization to maintain skin barrier function. 1

First-Line Treatment Approach

Topical Therapies

• Apply emollients/moisturizers at least once daily to affected areas to maintain skin barrier function and reduce dryness 1, 2
• Use oil-in-water creams or ointments rather than alcohol-containing lotions which can worsen dryness 1, 2
• Apply topical corticosteroids of appropriate potency to affected areas 2-3 times daily depending on severity 3
• For mild cases, use low-potency steroids like hydrocortisone 1
• For moderate to severe cases, consider medium to high-potency steroids such as triamcinolone acetonide 3
• Limit use of potent and very potent topical steroids to short periods only to avoid systemic absorption 1, 3

Managing Pruritus

• For severe itching, consider oral antihistamines with sedative properties as short-term adjuvant therapy 1
• Non-sedating antihistamines have little value in controlling pruritus associated with dyshidrotic eczema 1, 2
• Topical polidocanol cream can help relieve itching 1, 2

Second-Line Treatment Options

Phototherapy

• Oral PUVA (psoralen plus UVA) therapy has shown significant improvement in 81-86% of patients with hand and foot eczema 1
• Oral PUVA is superior to UVB phototherapy for dyshidrotic 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

Immunomodulators

• Topical tacrolimus (FK506) 0.1% ointment can be as effective as mometasone furoate 0.1% ointment, offering a steroid-free alternative for rotational therapy in chronic cases 4

Management of Complications

Infection

• If bacterial infection is suspected (indicated by crusting or weeping), obtain bacteriological swabs 1
• Flucloxacillin is usually most appropriate for treating Staphylococcus aureus, the commonest pathogen 1
• Use erythromycin for patients with penicillin allergy 1
• For herpes simplex infection (eczema herpeticum), characterized by grouped, punched-out erosions, administer oral acyclovir early in the course of disease 1
• For severe cases with fever, consider intravenous acyclovir 1

Special Considerations

Potential Triggers

• Consider metal allergy as a potential etiologic factor - improvement may occur by removing metal allergen exposure 5
• Avoid irritants such as soaps and detergents that remove natural lipids from skin surface 1
• Use dispersible cream as a soap substitute for cleansing 1
• Keep nails short to minimize damage from scratching 1

Monitoring and Precautions

• Monitor for signs of systemic absorption of topical corticosteroids, especially when used on large surface areas or under occlusion 3
• Children may absorb proportionally larger amounts of topical corticosteroids and require closer monitoring 3
• For patients not responding to treatment, consider:
  • Secondary bacterial or viral infection 1
  • Development of contact dermatitis 1
  • Genetic factors affecting response to glucocorticoid therapy 6

Refractory Cases

• For severe cases unresponsive to conventional therapy, consider referral to a dermatologist 2
• Systemic corticosteroids have a limited but definite role in tiding over occasional patients with severe disease, but should not be used for maintenance treatment 1
• In extremely refractory cases, low-dose radiation therapy has shown complete remission in case reports, though this is not standard practice 7

Treatment Algorithm

1. Start with emollients and low to medium potency topical corticosteroids
2. If inadequate response after 2 weeks, increase to higher potency topical steroids for limited periods
3. For persistent severe itching, add oral antihistamines with sedative properties
4. If infection is present, add appropriate antibiotics
5. For cases unresponsive after 4-6 weeks, consider:
   • Phototherapy (preferably oral PUVA)
   • Topical immunomodulators (tacrolimus)
   • Referral to dermatologist for consideration of systemic therapy