Treatment of Dyshidrotic Eczema
Start with moderate-potency topical corticosteroids applied twice daily to affected areas, combined with liberal emollient use, as this remains the cornerstone of first-line therapy for dyshidrotic eczema. 1, 2
First-Line Treatment Protocol
Apply a moderate-potency topical corticosteroid (such as triamcinolone acetonide 0.1% or mometasone furoate 0.1%) to vesicular areas twice daily, using the least potent preparation that controls symptoms 1, 2, 3, 4
Use very potent corticosteroids with caution and only for limited periods, as the palms and soles can tolerate higher potencies than other body areas, but prolonged use increases systemic absorption risk 1, 2
Apply emollients liberally and frequently throughout the day, even when lesions appear controlled, as this provides a surface lipid film that retards water loss and is the cornerstone of maintenance therapy 2
Implement "steroid holidays" by stopping corticosteroids for short periods when possible to minimize side effects, particularly pituitary-adrenal suppression 1, 2
Adjunctive Measures
Use soap-free cleansers and avoid alcohol-containing products on affected hands and feet 5, 2
Consider occlusive dressing for recalcitrant cases to enhance corticosteroid effectiveness, though this should be discontinued if infection develops 3
Prescribe sedating antihistamines (such as diphenhydramine) for nighttime use only if severe pruritus interferes with sleep, as their value lies in sedative properties rather than direct anti-pruritic effects 1, 5, 2
Managing Secondary Infections
Watch for bacterial superinfection indicated by increased crusting, weeping, pustules, or sudden worsening 2, 6
Prescribe flucloxacillin as first-line antibiotic if Staphylococcus aureus infection is suspected, or erythromycin in penicillin-allergic patients 1, 2, 6
Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 2
Suspect eczema herpeticum immediately if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever—this is a medical emergency requiring early oral acyclovir or intravenous acyclovir in febrile patients 2, 6
Alternative and Second-Line Options
Consider tacrolimus 0.1% ointment as an alternative or for rotational therapy with corticosteroids in chronic cases, though research shows similar efficacy to mometasone furoate with potential for earlier relapse after discontinuation 4
Trial a low-cobalt/low-nickel diet in patients with suspected metal hypersensitivity or those not responding to topical therapy, as dietary restriction may reduce flares regardless of patch test results 7
Refer for phototherapy (narrow band ultraviolet B at 312 nm) if topical treatments fail after 4 weeks, though long-term risks of premature skin aging and malignancies must be considered 1, 2
Common Pitfalls to Avoid
Do not withhold corticosteroids when infection is present—they remain primary treatment when appropriate antibiotics are given concurrently 2
Do not use non-sedating antihistamines, as they have little to no value in dyshidrotic eczema 1, 2
Address patient fears about steroid use by explaining different potencies and the benefits versus risks, as steroid phobia often leads to undertreatment 1, 2
Do not apply treatments more than twice daily, as increased frequency does not improve efficacy 1, 2
When to Refer
Failure to respond to moderate-potency topical corticosteroids after 4 weeks of appropriate use 5, 2
Need for systemic corticosteroids or phototherapy, which should only be considered after all other avenues have been explored 1, 2
Suspected eczema herpeticum requires immediate treatment and possible hospitalization 2, 6