What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema

Start with medium to high potency topical corticosteroids applied twice daily as first-line therapy, using the least potent preparation that effectively controls symptoms. 1

First-Line Treatment Approach

Topical corticosteroids form the cornerstone of treatment:

• Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate for severe flares) no more than twice daily to affected areas 1
• Once symptoms improve, taper to maintenance therapy with intermittent use (twice weekly) of medium to high potency topical corticosteroids to prevent relapses 1
• Use the least potent preparation that effectively controls the eczema, reserving more potent formulations for limited periods only 1
• Very potent and potent corticosteroids carry risk of pituitary-adrenal axis suppression and should be used cautiously for limited periods 1

Essential supportive measures must accompany steroid therapy:

• Apply emollients liberally after bathing to create a surface lipid film that prevents evaporative water loss 1
• Use dispersible cream as a soap substitute instead of regular soaps and detergents that strip natural skin lipids 1
• Avoid extremes of temperature and irritant clothing 1
• Keep nails short to minimize trauma and reduce secondary infection risk 1

Second-Line Treatment for Steroid-Sparing Effect

For areas where prolonged steroid use is concerning or for maintenance therapy:

• Tacrolimus 0.1% ointment applied once daily to affected areas provides a steroid-sparing effect and is particularly useful for long-term management 1
• The British Association of Dermatologists specifically recommends topical calcineurin inhibitors like tacrolimus for their steroid-sparing properties in moderate cases 1

Managing Secondary Infections

Bacterial superinfection requires prompt antibiotic therapy while continuing topical corticosteroids:

• Flucloxacillin is the first-line antibiotic for Staphylococcus aureus, the most common pathogen 1
• Use erythromycin when flucloxacillin resistance exists or in patients with penicillin allergy 1
• Bacteriological swabs are not routinely indicated but may be necessary if patients fail to respond to treatment 1

Herpes simplex virus infection (eczema herpeticum) is a medical emergency:

• Administer oral acyclovir early in the disease course 1
• Look for grouped vesicles, punched-out erosions, or sudden deterioration with fever as warning signs 1

Treatment for Severe Pruritus

Sedating antihistamines have a limited but specific role:

• Use sedating antihistamines as short-term adjuvants during relapses with severe itching, primarily at night for their sedative properties 1
• Non-sedating antihistamines have little to no value in dyshidrotic eczema and should not be used 1

Refractory Disease Management

For cases resistant to topical therapy, phototherapy is the next step:

• Oral PUVA therapy shows significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
• Oral PUVA has proven superior to UVB in prospective controlled studies of hand eczema 1
• Narrowband UVB may be considered as an alternative, showing 75% reduction in mean severity scores with 17% clearance rate 1
• Topical PUVA has shown mixed results with less convincing efficacy compared to oral PUVA 1

For lichenified eczema specifically:

• Consider ichthammol (1% in zinc ointment) or coal tar preparations, which do not cause systemic side effects unless used extravagantly 1

Special Considerations for Hyperhidrosis

When hyperhidrosis coexists with dyshidrotic eczema:

• Oxybutynin treatment for hyperhidrosis has shown impressive results in improving coexistent dyshidrotic eczema, as hyperhidrosis plays a significant role in the pathogenesis 2

Critical Pitfalls to Avoid

• Do not use systemic corticosteroids for maintenance treatment—they should only be considered after all other treatments have been explored and only for short-term crisis management 1
• Do not apply topical corticosteroids more than twice daily, as this provides no additional benefit 1
• Do not withhold topical corticosteroids when bacterial infection is present—continue them while administering appropriate systemic antibiotics 1
• Combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone 1