What is the recommended treatment for a patient with dyshidrotic eczema?

Dyshidrotic Eczema Treatment

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 Strategy

Topical corticosteroids are the cornerstone of dyshidrotic eczema management:

• Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate for severe flares) twice daily to affected areas until symptoms improve 1
• Once controlled, 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 maintains control—avoid continuous use of very potent corticosteroids due to risk of pituitary-adrenal axis suppression 1
• Implement "steroid holidays" when possible to minimize side effects 2

Essential Adjunctive Measures

Emollients and skin protection are critical for maintenance:

• Apply emollients liberally and regularly after bathing to provide a surface lipid film that retards water loss, even when eczema appears controlled 1
• Use dispersible cream as a soap substitute instead of regular soaps and detergents that remove natural lipids 1
• Avoid extremes of temperature and irritant clothing 1
• Keep nails short to minimize trauma and secondary infection risk 1

Managing Pruritus

• Sedating antihistamines (such as diphenhydramine) may help with nighttime itching through their sedative properties, not direct anti-pruritic effects 1
• Use only as short-term adjuvant during relapses 1

Managing Secondary Infections

Watch for infection complications that require prompt treatment:

• Monitor for signs of bacterial superinfection: increased crusting, weeping, or pustules 1
• Flucloxacillin is first-line for Staphylococcus aureus infection 1
• Use erythromycin when there is flucloxacillin resistance or penicillin allergy 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 2
• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency requiring immediate acyclovir 1

Second-Line Treatment for Refractory Disease

When first-line therapy fails after 4 weeks, escalate to alternative treatments:

• Tacrolimus 0.1% ointment applied once daily offers a steroid-sparing effect, particularly useful where prolonged steroid use is concerning 1
• Consider ichthammol or coal tar preparations for lichenified eczema 1

Phototherapy for Severe Cases

Phototherapy is highly effective for refractory dyshidrotic eczema:

• Oral PUVA therapy achieves significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
• Oral PUVA is superior to UVB in prospective controlled studies of hand eczema 1
• Narrowband UVB may be considered, showing 75% reduction in mean severity scores with 17% clearance rate 1
• Topical PUVA has shown mixed results (58-81% improvement in uncontrolled studies, but less convincing in comparative studies) 1
• Be aware of long-term concerns including premature skin aging and cutaneous malignancies, particularly with PUVA 2

Treatment Hierarchy Based on Recent Evidence

The 2024 Cochrane network meta-analysis provides important comparative data: potent TCS, JAK inhibitors, and tacrolimus 0.1% were consistently ranked among the most effective topical anti-inflammatory treatments, while PDE-4 inhibitors were among the least effective 3. Tacrolimus 0.1% and potent TCI are more likely to cause application-site reactions compared to TCS 3.

Critical Pitfalls to Avoid

• Do not delay topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given 2
• Avoid very potent corticosteroids on palmar skin for extended periods without breaks 1
• Do not use combination therapy with antibiotics and steroids routinely—it has not shown additional benefit compared to steroids alone 1
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 1

When to Refer or Escalate

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 2, 1
• Need for systemic therapy or phototherapy 2
• Suspected eczema herpeticum (medical emergency) 2