Treatment of Dyshidrotic Dermatitis
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:
- Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate) twice daily for acute flares 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 effectively controls the eczema, reserving more potent formulations for limited periods only 1
- Caution: Potent and very potent topical corticosteroids carry risk of pituitary-adrenal axis suppression and should be used for limited periods 1
Essential Adjunctive Measures:
- Apply emollients immediately after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1
- Use dispersible cream as a soap substitute to cleanse the skin, avoiding regular soaps and detergents that remove natural lipids 1
- Keep nails short to minimize trauma and secondary infection risk 1
- Avoid extremes of temperature and irritant clothing 1
Treatment for Weeping Vesicular Lesions
For moderate cases with weeping vesicles or fissures:
- Add potassium permanganate soaks at 1:10,000 (0.01%) concentration as antiseptic baths or compresses 2
- This is particularly useful for cases with fissures to accelerate wound closure 2
- Apply as part of comprehensive treatment that includes addressing xerosis with emollients 2
Second-Line Treatment Options
Topical Calcineurin Inhibitors:
- Use tacrolimus 0.1% ointment applied once daily to affected areas when prolonged steroid use is concerning 1
- This provides a steroid-sparing effect and is particularly useful for maintenance therapy 1
For Severe Pruritus:
- Sedating antihistamines may be useful as a short-term adjuvant to topical treatment during relapses 1
For Lichenified Eczema:
- Consider ichthammol or coal tar preparations 1
Management of Secondary Infection
Bacterial Superinfection:
- Flucloxacillin is the most appropriate antibiotic for treating Staphylococcus aureus 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
- Important: Combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone 1
Herpes Simplex Virus Infection:
- Administer acyclovir early in the course of disease 1
Treatment for Severe, Refractory Cases
Phototherapy Options:
- Oral PUVA therapy shows 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 a 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
Dietary Considerations for Refractory Cases
Metal Hypersensitivity:
- Consider dietary cobalt and nickel restriction in patients with refractory dyshidrotic eczema, regardless of patch test results 3
- High oral ingestion of nickel and/or cobalt may trigger flares 3
- A point-based low-cobalt diet can eliminate much of the dietary cobalt and nickel, potentially reducing dyshidrotic eczema flares 3
- Metal allergy is regarded as one of the important potential etiologic factors for dyshidrotic eczema 4