What is the recommended treatment for acute palmoplantar eczema?

Treatment of Acute Palmoplantar Eczema

For acute palmoplantar eczema, initiate treatment with high-potency topical corticosteroids applied twice daily, combined with emollients and avoidance of mechanical/chemical irritants to the hands and feet.

First-Line Topical Therapy

High-potency topical corticosteroids form the cornerstone of acute treatment, targeting the inflammatory component that drives symptoms 1. Apply clobetasol propionate 0.05% or equivalent high-potency steroid twice daily to affected areas 1, 2.

Key Implementation Points:

• Apply emollients liberally (urea 10% cream at least twice daily) to address the barrier dysfunction characteristic of palmoplantar eczema 1
• Avoid mechanical stress including prolonged walking, heavy carrying without cushioned shoes/gloves, and repetitive friction 1
• Eliminate chemical irritants such as solvents, disinfectants, and harsh soaps that perpetuate the inflammatory cycle 1

Occlusive Dressing Enhancement

For severe acute presentations, consider hydrocolloid occlusive dressings over medium-strength corticosteroids (triamcinolone acetonide 0.1%) applied every third day, which demonstrates superior efficacy to high-potency corticosteroids alone with 63% complete clearance rates versus 21% 2. This approach is particularly effective for pustular variants and avoids skin atrophy concerns with prolonged potent steroid use 2.

Distinguishing Eczema Subtypes for Treatment Selection

The clinical subtype significantly impacts treatment response and should guide your approach:

Dyshidrotic (Vesicular) Eczema:

• Responds better to bath PUVA if topical therapy fails after 2 weeks 3, 4
• Achieves 93% excellent/good response rates with local bath-PUVA (1 mg/L 8-methoxypsoralen, 15-minute soak, followed by UVA starting at 0.5 J/cm²) 4
• Requires lower cumulative UVA doses (21.4 J/cm²) and maintains longer remission periods 3

Hyperkeratotic Eczema:

• Responds better to oral PUVA if topical therapy inadequate 3
• Add keratolytics (salicylic acid 5%-10% or urea 10%-40%) to penetrate thick scale 1
• Consider topical vitamin D3 derivatives (calcipotriol 50 μg/g or maxacalcitol 25 μg/g) as alternative therapy, with lesion clearance in 2-8 weeks in 80% of patients 5

Treatment Algorithm for Refractory Cases

If inadequate response after 2 weeks of high-potency topical corticosteroids:

1. Reassess diagnosis - exclude fungal/bacterial superinfection, contact dermatitis, or psoriasis 4

2. For dyshidrotic type: Initiate local bath-PUVA therapy 4 times weekly for up to 25 treatments 4

   • No phototoxic reactions observed with this regimen 4
   • Avoids systemic psoralen side effects (nausea, headache) 1

3. For hyperkeratotic type: Consider oral PUVA therapy or topical vitamin D3 derivatives 3, 5

   • Oral PUVA achieves significantly better clearance (P=0.03) than bath PUVA for this subtype 3
   • Vitamin D3 derivatives offer safe alternative with no adverse effects and normal laboratory parameters 5

Common Pitfalls to Avoid

• Do not use topical PUVA alone - it shows no significant benefit over placebo for palmoplantar eczema 1
• Avoid simultaneous salicylic acid with vitamin D analogues - the acidic pH inactivates calcipotriene 1
• Monitor for skin atrophy with prolonged high-potency corticosteroid use; consider treatment breaks or rotation to medium-potency agents 1
• Distinguish from palmoplantar pustulosis - which requires different treatment approach (oral PUVA plus retinoids) 1

Maintenance Strategy

Once acute inflammation controlled (typically 2-4 weeks), transition to maintenance with lower-potency corticosteroids or vitamin D3 derivatives to prevent relapse 5. Relapses respond well to retreatment with the same regimen that achieved initial clearance 5.