What is the best treatment approach for a patient with eczema (atopic dermatitis) limited to the feet?

Treatment of Foot-Only Eczema

For eczema isolated to the feet, apply potent topical corticosteroids (such as clobetasol propionate 0.05% or mometasone furoate) twice daily as first-line therapy, combined with aggressive emollient use, as the thicker skin of the feet tolerates and requires higher potency preparations than other body areas. 1

First-Line Topical Corticosteroid Strategy

• Start with potent topical corticosteroids applied twice daily to affected areas on the feet, as the American Academy of Dermatology specifically recommends this approach for hand and foot eczema due to the thicker stratum corneum in these locations 1

• The feet tolerate higher potency steroids better than thin-skinned areas (face, neck, flexures) due to their thicker skin structure, making potent preparations both safe and necessary for adequate penetration 1

• Once you achieve clearance, transition to proactive maintenance therapy with topical corticosteroids applied twice weekly (weekend therapy) to previously affected sites to prevent relapse 1

• Research confirms that once-daily application of potent topical corticosteroids is equally effective as twice-daily use for treating flare-ups, so you can reduce to once daily if twice daily causes adherence issues 2

Essential Emollient Therapy

• Apply emollients liberally and frequently throughout the day, with mandatory application immediately after bathing and after any foot washing, as this provides a critical surface lipid film that prevents water loss 1

• For foot eczema specifically, use ointments or thick creams rather than lotions, as the thick, often lichenified skin on feet requires maximum occlusion and penetration 3

• Consider urea-containing emollients (10-20%) for hyperkeratotic, scaly plaques typical of foot eczema, as these are particularly effective for thick lesions 3

• Continue aggressive emollient use even when the eczema appears controlled—this is the cornerstone of maintenance therapy and must not be discontinued 1, 4

• Use soap-free cleansers exclusively and avoid hot water, as these strip natural skin lipids and worsen the underlying condition 1, 4

Managing Pruritus

• Prescribe sedating antihistamines (diphenhydramine or hydroxyzine) exclusively at nighttime for severe itching, as their benefit comes from sedation rather than direct anti-pruritic effects 1, 4

• Do not prescribe non-sedating antihistamines—they have no value in eczema and should not be used 1, 4

Identifying and Treating Secondary Infection

• Watch for increased crusting, weeping, or pustules, which indicate secondary bacterial infection with Staphylococcus aureus 1, 4

• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids—do not delay or withhold corticosteroids when infection is present, as they remain the primary treatment when appropriate systemic antibiotics are given concurrently 1, 4

Second-Line Phototherapy for Refractory Cases

• For foot eczema failing topical therapy after 4 weeks, oral PUVA (psoralen plus UVA) is superior to UVB phototherapy, with 81-86% of patients achieving significant improvement or clearance 1

• Local PUVA may be more effective than narrow-band UVB for foot eczema, though adverse events (mainly erythema) occur more frequently with UVB 1

Alternative Topical Agents

• Pimecrolimus cream 1% (topical calcineurin inhibitor) can be used as an adjunct to topical corticosteroids, applied twice daily to affected areas 5, 6

• Stop pimecrolimus when signs and symptoms resolve, and if symptoms persist beyond 6 weeks, re-examine to confirm the diagnosis 5

• Do not use pimecrolimus continuously long-term or under occlusive dressings, and avoid on malignant or pre-malignant skin conditions 5

Critical Safety Considerations and Common Pitfalls

• The feet are among the safest locations for potent topical corticosteroids due to thick skin—abnormal skin thinning occurred in only 1% of patients across trials, with most cases from very potent (not potent) preparations 2

• Implement "steroid holidays" (short breaks) when possible to minimize side effects, but do not allow steroid phobia to lead to undertreatment 3, 4

• Systemic corticosteroids should only be used for acute severe flares requiring rapid control after exhausting all other options—never for maintenance treatment 1, 4

When to Refer

• Failure to respond to potent topical corticosteroids after 4 weeks warrants referral for consideration of systemic therapy 1, 4

• Need for phototherapy or systemic immunosuppressive therapy requires specialist management 1, 4

• Suspected eczema herpeticum (grouped vesicles, punched-out erosions, sudden deterioration with fever) is a medical emergency requiring immediate referral 4