What are the treatment options for dyshidrotic eczema?

Treatment Options for Dyshidrotic Eczema

Topical corticosteroids are the mainstay of treatment for dyshidrotic eczema, using the least potent preparation required to control symptoms. 1, 2

First-Line Treatment

• Apply topical corticosteroids to affected areas twice daily for acute flares, using the least potent preparation required to control symptoms 3, 1, 2
• Use moisturizers (emollients) at least once daily, preferably oil-in-water creams or ointments rather than alcohol-containing lotions 1, 2
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1, 2
• Use dispersible cream as a soap substitute for cleansing, avoiding regular soaps and detergents that remove natural lipids 1, 2
• Keep nails short to minimize trauma and secondary infection risk 1, 2

Important Precautions with Topical Corticosteroids

• Use potent and very potent topical corticosteroids with caution and for limited periods only due to risk of hypothalamic-pituitary-adrenal (HPA) axis suppression 3, 4
• Monitor for signs of systemic absorption such as HPA axis suppression, manifestations of Cushing's syndrome, hyperglycemia, and glucosuria, especially when using more potent steroids over large surface areas or under occlusive dressings 4
• Children may absorb proportionally larger amounts of topical corticosteroids and thus be more susceptible to systemic toxicity 4

Management of Specific Symptoms

• For severe itching, consider oral antihistamines with sedative properties (such as diphenhydramine) as short-term adjuvant therapy, particularly for sleep disturbance 3, 2
• Non-sedating antihistamines have little value in controlling pruritus associated with dyshidrotic eczema 3, 2
• Avoid extremes of temperature and irritant clothing; wear cotton clothing instead 1, 2

Second-Line Treatments

• Consider ichthammol (1% in zinc ointment) or coal tar preparations for recalcitrant cases, which can be particularly useful for lichenified eczema 3, 2
• Topical calcineurin inhibitors such as pimecrolimus cream 1% may be considered as an alternative to topical corticosteroids 5, 6
• Tacrolimus 0.1% ointment has shown efficacy similar to mometasone furoate 0.1% ointment in treating dyshidrotic palmar eczema, offering a possibility for rotational therapy in chronic cases 6

Management of Complications

• For secondary bacterial infection, use appropriate antibiotics such as flucloxacillin for Staphylococcus aureus, which is the most common pathogen 3, 1, 2
• For penicillin-allergic patients, erythromycin is an appropriate alternative 3, 1, 2
• For herpes simplex infection (eczema herpeticum), administer oral acyclovir early in the course of disease; use intravenous acyclovir for ill, febrile patients 3, 2

Third-Line Treatments for Refractory Cases

• Consider PUVA therapy (oral or topical) for severe, refractory cases, with oral PUVA showing significant improvement or clearance in 81-86% of patients with hand and foot eczema 1, 2
• Narrowband UVB may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate in one study 1
• For patients with coexisting hyperhidrosis, oxybutynin has shown impressive results in treating both conditions 7
• Low-dose external beam radiation therapy has been reported to achieve complete remission in severe cases refractory to conventional therapies 8
• Systemic corticosteroids have a limited but definite role for severe cases, but should not be used for maintenance treatment 2

Special Considerations

• Investigate potential metal allergies as they may be an important etiologic factor for dyshidrotic eczema 9
• Most patients will respond well to first-line management and do not require referral to a specialist 2
• Consider referral to a dermatologist if there is failure to respond to treatment, development of contact dermatitis, or need for second-line therapies 2

Common Pitfalls to Avoid

• Undertreatment due to fear of topical steroid side effects - use the appropriate potency for the shortest effective duration 3
• Prolonged use of potent topical corticosteroids without monitoring for systemic absorption 4
• Failure to address secondary infections which can exacerbate the condition 3, 2
• Neglecting to investigate potential triggers such as metal allergies or hyperhidrosis 7, 9
• Using non-sedating antihistamines which have little value in controlling pruritus 3, 2