What is the treatment plan for dyshidrotic eczema?

Treatment Plan for Dyshidrotic Eczema

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

First-Line Treatment

• Apply topical corticosteroids as the mainstay treatment, using the least potent preparation that effectively controls symptoms 2, 1
• Use emollients after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1
• Use dispersible creams as soap substitutes for cleansing, avoiding regular soaps and detergents that remove natural lipids 1
• Avoid potential triggers including extremes of temperature and irritant clothing 1
• Keep nails short to minimize trauma and secondary infection risk 1

Second-Line Treatment Options

• For severe pruritus, consider sedating antihistamines as a short-term adjuvant during flares (non-sedating antihistamines have little value) 2, 1
• Consider ichthammol (1% in zinc ointment) or coal tar preparations (1% in hydrocortisone ointment) for lichenified eczema 2, 1
• For persistent cases, topical calcineurin inhibitors like tacrolimus 0.1% ointment can be effective and offer an alternative for rotational therapy with corticosteroids 3

Management of Secondary Infection

• For bacterial superinfection, prescribe flucloxacillin as first-line antibiotic for Staphylococcus aureus 2, 1
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy 2, 1
• For suspected herpes simplex virus infection (eczema herpeticum), administer acyclovir early in the disease course; use intravenous administration for ill, febrile patients 2, 4

Refractory Disease Management

• For moderate to severe cases not responding to topical treatments, consider phototherapy options:
  • Oral PUVA has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema and is superior to UVB in controlled studies 2, 1
  • Narrowband UVB may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate 1
  • Topical PUVA has shown mixed results with uncontrolled studies reporting 58-81% improvement, but comparative studies show less convincing efficacy 2, 1

Additional Considerations for Persistent Cases

• For patients with coexisting hyperhidrosis, oxybutynin treatment may provide remarkable improvement in dyshidrotic eczema symptoms 5
• Consider dietary modifications in metal-sensitive patients, particularly low-cobalt and low-nickel diets, which may reduce flares in some patients 6
• In extremely refractory cases unresponsive to conventional therapies, low-dose radiation therapy has been reported to achieve complete remission, though this should be considered only after failure of other treatments 7

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 2, 1
• The relapse rate after PUVA treatment can be high, and long-term risks of skin carcinogenicity must be considered 2
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 1
• Maintenance therapy may be required for chronic cases, with rotational approaches to minimize side effects of individual treatments 3