How to treat dyshidrotic eczema on hands during the second trimester of pregnancy?

Treatment of Dyshidrotic Eczema on Hands During Second Trimester of Pregnancy

Start with aggressive moisturization and low-to-medium potency topical corticosteroids, which are safe and effective during the second trimester of pregnancy.

First-Line Approach: Skin Barrier Protection and Topical Therapy

Immediate Skin Care Modifications

• Avoid all irritants including harsh soaps, detergents, frequent hand washing with hot water, and disinfectant wipes 1
• Use lukewarm or cool water for hand washing rather than hot water to prevent further skin barrier damage 1
• Pat hands dry gently rather than rubbing to minimize trauma to vesicular lesions 1
• Choose fragrance-free, dye-free cleansers without allergenic surfactants or preservatives 1

Aggressive Moisturization Protocol

• Apply moisturizer immediately after every hand washing using two fingertip units for adequate coverage 1
• Use fragrance-free moisturizers containing petrolatum or mineral oil, which are most effective and least allergenic 1
• Implement the "soak and smear" technique nightly: soak hands in plain water for 20 minutes, then immediately apply thick moisturizer to damp skin for up to 2 weeks 1
• Reapply moisturizer frequently throughout the day using pocket-sized tubes to prevent contamination 1

Topical Corticosteroid Therapy

Topical corticosteroids are the mainstay of treatment and are safe during pregnancy. 2, 3

• Apply low-to-medium potency topical corticosteroids (such as hydrocortisone) to affected areas 3-4 times daily as needed 4, 5
• Prednisolone is 90% inactivated by the placenta, making topical and systemic corticosteroids relatively safe during the second trimester 6
• Limit prolonged use to avoid steroid-induced skin barrier damage, but do not hesitate to use them for active flares 1

Alternative Topical Options

• Topical tacrolimus (calcineurin inhibitor) is a safe alternative to corticosteroids during pregnancy and can be used in combination to reduce steroid exposure 2, 3
• Consider alternating between topical corticosteroids and tacrolimus to minimize side effects while maintaining disease control 5

When Conservative Measures Fail After 6 Weeks

Phototherapy

• UV light therapy (UVB or PUVA) can be considered if topical treatments are insufficient, as it is safe during pregnancy 2, 3
• Bath-PUVA treatment has shown effectiveness specifically for hand eczema 5

Systemic Therapy (Requires Dermatology Consultation)

If systemic therapy becomes necessary, cyclosporine A is the first-line systemic option during pregnancy. 2, 3

• Cyclosporine A is the preferred systemic agent for severe cases unresponsive to topical therapy 2, 3
• Azathioprine may be considered if already being used prior to pregnancy, though risks of teratogenicity exist (albeit low) 6, 2
• Systemic corticosteroids (prednisolone) can be used if needed, as there is no significant increased risk of stillbirth, preterm delivery, or congenital malformations, though intrauterine growth retardation has been linked to their use 6

Contraindicated Medications

• Avoid methotrexate, mycophenolate mofetil, cyclophosphamide, and JAK inhibitors due to known fetal risks 6, 2
• Dupilumab is not generally recommended due to lack of safety data in human pregnancies 2

Occupational and Protective Measures

• Use cotton glove liners under protective gloves if occupational exposure is unavoidable 1
• Choose accelerator-free gloves (neoprene or nitrile) if glove-related allergic contact dermatitis is suspected 1
• Apply water-based moisturizers under gloves (oil-based products can break down latex and rubber) 1
• Never apply gloves when hands are still wet from washing or sanitizer 1

Critical Pitfalls to Avoid

• Do not use superglue to seal fissures or vesicles 1
• Avoid washing hands with dish detergent or other known irritants 1
• Do not increase glove occlusion duration without underlying moisturizer application 1
• Avoid betamethasone and dexamethasone systemically if corticosteroids are needed, as these are far less inactivated by the placenta compared to prednisolone 6

When to Refer to Dermatology

• Refer immediately if no improvement after 6 weeks of conservative treatment 1
• Refer for patch testing if allergic contact dermatitis is suspected 1
• Refer for consideration of phototherapy or systemic therapy in recalcitrant cases 1, 2
• Refer if there is any change in the baseline pattern of the dermatitis 1