What is the treatment for dyshidrosis?

Treatment of Dyshidrosis

Topical corticosteroids applied no more than twice daily represent the primary first-line treatment for dyshidrosis, using the least potent preparation that effectively controls symptoms. 1

First-Line Treatment Approach

Topical Corticosteroids

• Medium to high potency topical corticosteroids should be applied twice daily for acute flares until symptoms improve, then tapered to maintenance therapy. 1
• For severe flares, high potency steroids like betamethasone dipropionate or clobetasol propionate are effective. 1
• After initial control, transition to intermittent use (twice weekly) of medium to high potency topical corticosteroids to prevent relapses. 1
• Potent and very potent formulations should be used with caution and for limited periods only due to risk of pituitary-adrenal axis suppression. 1

Essential Adjunctive Measures

• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis. 1
• Use a dispersible cream as a soap substitute to cleanse the skin, avoiding regular soaps and detergents that remove natural lipids. 1
• Avoid extremes of temperature and irritant clothing, and keep nails short to minimize trauma and secondary infection risk. 1

Management of Acute Vesicular Phase

For Weeping, Vesicular Lesions

• Potassium permanganate soaks at 1:10,000 (0.01%) concentration should be used as antiseptic baths or compresses for weeping vesicular lesions. 2
• This is particularly effective for cases with fissures to accelerate wound closure. 2
• Daily lukewarm baths (30 minutes or more) can help soften and remove scales, followed by gentle rubbing with sponges or microfiber cloths. 3

Treatment Algorithm by Severity

• Mild cases with minimal vesicles: Moisturizers and topical steroids. 2
• Moderate cases with weeping vesicles: Add potassium permanganate soaks at 1:10,000 concentration plus medium to high potency topical steroids. 1, 2
• Cases with fissures: Apply potassium permanganate solution (1:10,000) as soaks. 2

Management of Secondary Infection

Bacterial Superinfection

• Flucloxacillin is the most appropriate antibiotic for treating Staphylococcus aureus superinfection. 1
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy. 1
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment. 1
• Combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone. 1

Viral Superinfection

• For herpes simplex virus infection, administer acyclovir early in the course of disease. 1

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment applied once daily to affected areas is recommended as a steroid-sparing agent, particularly useful for areas where prolonged steroid use is concerning. 1
• This can be used for maintenance therapy in moderate cases to reduce steroid exposure. 1

Symptomatic Management

• For severe pruritus, sedating antihistamines may be useful as a short-term adjuvant to topical treatment during relapses. 1
• Consider ichthammol or coal tar preparations for lichenified eczema. 1

Treatment for Refractory Disease

Phototherapy Options

• Oral PUVA therapy has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema and is superior to UVB in prospective controlled studies. 1
• Topical PUVA has shown mixed results, with uncontrolled studies reporting 58-81% improvement in dyshidrotic eczema, but comparative studies showing less convincing efficacy. 1
• Narrowband UVB may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate. 1

Dietary Considerations for Persistent Cases

• For patients with suspected metal hypersensitivity, dietary cobalt (and nickel) restriction should be considered regardless of patch test results, as high oral ingestion may trigger flares. 4

Important Clinical Caveats

• Be vigilant for signs of infection in areas of compromised skin integrity; use antiseptics if infection is suspected, but not routinely. 3
• Avoid iodine-based antiseptics due to risk of thyroid dysfunction. 3
• The diagnosis becomes obvious when a period of ferocious pruritus precedes vesicle development on the sides of fingers and palms, with vesicles embedded in the epidermis below the thick stratum corneum. 5
• Relapses are frequent in patients with atopy, sweat gland disorders, or neurovegetative disturbances. 5