What are the latest guidelines for managing dyshydrotic eczema?

Latest Guidelines for Dyshidrotic Eczema Management

Start with liberal emollients and medium-to-high potency topical corticosteroids applied twice daily as first-line therapy, using the least potent preparation that effectively controls symptoms. 1, 2, 3

First-Line Treatment Strategy

Emollient Therapy (Foundation of Treatment)

• Apply moisturizers at least once daily to all affected areas, preferably oil-in-water creams or ointments rather than alcohol-containing lotions 1, 3
• Apply emollients immediately after bathing to provide a surface lipid film that prevents evaporative water loss 2, 3
• Use dispersible cream as a soap substitute instead of regular soaps and detergents, which strip natural lipids from the skin 2, 3

Topical Corticosteroid Therapy

• Apply medium-to-high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate) twice daily for acute flares 2, 3
• Use the least potent preparation that controls symptoms to minimize systemic absorption risk 1, 2
• For mild cases, start with low-potency steroids like hydrocortisone 1% 1
• Limit potent and very potent topical steroids to short periods only 1, 2
• Once symptoms improve, taper to maintenance therapy with intermittent use (twice weekly) of medium-to-high potency corticosteroids to prevent relapses 2

Trigger Avoidance

• Keep nails short to minimize trauma and secondary infection risk from scratching 1, 2, 3
• Avoid extremes of temperature and irritant clothing such as wool; recommend cotton clothing instead 2, 3
• Avoid mechanical stress (long walks, heavy carrying without cushioned shoes and gloves) 1

Managing Pruritus

• For severe itching with sleep disturbance, use oral antihistamines with sedative properties (such as diphenhydramine or clemastine) as short-term adjuvant therapy 1, 3
• Non-sedating antihistamines have little value in controlling pruritus and should not be used 1, 3
• Consider topical polidocanol cream for itch relief 1

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Use tacrolimus 0.1% ointment once daily to affected areas as a steroid-sparing agent, particularly useful where prolonged steroid use is concerning 2
• This is especially valuable for maintenance therapy to reduce corticosteroid exposure 2

Alternative Topical Agents

• Consider ichthammol 1% in zinc ointment or coal tar preparations for lichenified, recalcitrant cases 1, 3

Phototherapy for Refractory Disease

Oral PUVA therapy is the most effective phototherapy option, showing significant improvement or clearance in 81-86% of patients with hand and foot eczema. 1, 2, 3

• Oral PUVA is superior to UVB phototherapy for dyshidrotic eczema 1
• Topical PUVA has shown mixed results with less convincing efficacy compared to oral PUVA 2, 3
• Narrowband UVB may be considered as an alternative, showing 75% reduction in severity scores with 17% clearance rate 2
• High-dose UVA1 irradiation is equally effective as cream PUVA and may be safer with fewer side effects 4

Management of Secondary Infections

Bacterial Infection

• Obtain bacteriological swabs if bacterial infection is suspected (indicated by crusting or weeping) 1, 2
• Use flucloxacillin as first-line antibiotic for Staphylococcus aureus, the most common pathogen 1, 2, 3
• Use erythromycin for patients with penicillin allergy or flucloxacillin resistance 1, 2, 3

Viral Infection

• For herpes simplex infection (eczema herpeticum), administer oral acyclovir early in the disease course 1, 2, 3
• Use intravenous acyclovir for ill, febrile patients 3
• Look for grouped, punched-out erosions or vesiculation as signs of herpes simplex infection 1

Severe, Refractory Cases

• Systemic corticosteroids have a limited but definite role for tiding over severe disease, but should never be used for maintenance treatment 1, 3
• Consider referral to dermatology if there is failure to respond to first-line treatment, development of contact dermatitis, or need for phototherapy 3
• In extreme refractory cases, low-dose external beam radiation therapy has shown complete remission, though this remains experimental 5

Dietary Considerations

• Consider low-cobalt (and low-nickel) diet in patients with suspected metal hypersensitivity, regardless of patch test results 6
• This is a safe but burdensome treatment option that may reduce flares in select patients 6

Important Caveats

• Potent and very high potency topical corticosteroids carry risk of pituitary-adrenal axis suppression and should be used cautiously for limited periods 1, 2
• Bacteriological swabs are not routinely indicated but become necessary if patients fail to respond to treatment 1, 2
• Deterioration in previously stable eczema may indicate secondary bacterial infection or development of contact dermatitis 2
• Most patients respond well to first-line management and do not require specialist referral 3