What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

Topical corticosteroids are the mainstay of treatment for dyshidrotic eczema, using the least potent preparation required to control symptoms, applied no more than twice daily. 1

First-Line Treatment Approach

• Apply topical corticosteroids as primary treatment, using the least potent preparation that effectively controls symptoms 2, 1
• Use emollients after bathing to provide a surface lipid film that prevents water loss from the epidermis 2, 1
• Replace regular soaps with dispersible creams as soap substitutes to prevent removal of natural skin lipids 1
• Avoid extremes of temperature and irritant clothing that may exacerbate symptoms 2
• Keep nails short to minimize trauma and reduce risk of secondary infection 2, 1

Management of Severe Symptoms

• For severe pruritus, sedating antihistamines can be used as a short-term adjuvant to topical treatment during acute flares 2, 1
• Non-sedating antihistamines have little to no value in treating dyshidrotic eczema 2
• Be aware that antihistamine effectiveness may decrease over time due to tachyphylaxis 2

Treatment for Lichenified Eczema

• Consider ichthammol (1% in zinc ointment) or coal tar preparations for lichenified areas 2
• Ichthammol paste bandages can be particularly useful for healing lichenified eczema 2
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar 2

Managing Secondary Infections

• For bacterial superinfection, flucloxacillin is usually the most appropriate antibiotic for treating Staphylococcus aureus 2, 1
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy 2, 1
• For herpes simplex virus infection (eczema herpeticum), administer acyclovir early in the course of disease 2
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 2

Second-Line Therapies for Refractory Cases

• 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 3
• Consider phototherapy options for severe, refractory cases:
  • Oral PUVA therapy has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
  • Narrowband UVB may be considered, with studies showing a 75% reduction in mean severity scores 1

Important Precautions

• Potent and very potent topical corticosteroids should be used with caution and for limited periods only due to risk of pituitary-adrenal axis suppression 2, 1
• Monitor for signs of tachyphylaxis with long-term antihistamine use 2
• Be aware that contact sensitization is commonly involved in dyshidrotic eczema, with positive patch test reactions found in up to 72.8% of patients 4
• Consider genetic factors that may influence response to standard therapy, as some patients with specific genotypes may be less responsive to topical corticosteroids 5

Treatment Algorithm

1. Start with mild to moderate potency topical corticosteroids twice daily
2. Add emollients after bathing
3. Eliminate irritants and potential allergens
4. If severe pruritus, add short-term sedating antihistamines
5. If no improvement or signs of infection, consider bacterial culture and appropriate antibiotics
6. For persistent cases, consider:
   • Topical tacrolimus as a steroid-sparing agent
   • Ichthammol or coal tar preparations for lichenified areas
   • Phototherapy (PUVA or narrowband UVB) for severe refractory cases