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

Treatment of Dyshidrotic Eczema

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

• Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate) twice daily to affected areas until symptoms improve, then taper to maintenance therapy. 1
• For maintenance, use intermittent application (twice weekly) of medium to high potency topical corticosteroids to prevent relapses. 1
• Use potent and very potent corticosteroids with caution and for limited periods only due to risk of pituitary-adrenal axis suppression. 1
• Implement "steroid holidays"—short breaks from corticosteroids when symptoms improve—to minimize systemic and local side effects. 1

Essential Emollient Therapy

• Apply emollients liberally after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis. 1
• Use emollients regularly even when eczema appears controlled, as this is the cornerstone of maintenance therapy. 1
• Use a dispersible cream as a soap substitute to cleanse the skin, avoiding regular soaps and detergents that remove natural lipids. 1

Managing Triggers and Exacerbating Factors

• Avoid extremes of temperature and irritant clothing. 1
• Keep nails short to minimize trauma and secondary infection risk. 1
• Consider metal allergy as a potential trigger—nickel and cobalt hypersensitivity may play a role in some patients. 2
• For patients with suspected metal allergy, consider dietary cobalt and nickel restriction regardless of patch test results. 3

Managing Secondary Infections

Bacterial Superinfection

• Watch for signs of bacterial superinfection: increased crusting, weeping, or pustules. 1
• Prescribe oral flucloxacillin as first-line antibiotic for Staphylococcus aureus, the most common pathogen. 1
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy. 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—infection is not a contraindication to topical steroid use. 1
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment. 1

Herpes Simplex Virus Infection

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency. 4
• Administer acyclovir early in the course of disease. 1
• In ill, feverish patients, administer acyclovir intravenously. 4

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Consider tacrolimus 0.1% ointment applied once daily to affected areas, particularly useful for areas where prolonged steroid use is concerning or as a steroid-sparing agent. 1

Managing Severe Pruritus

• Sedating antihistamines may be useful as a short-term adjuvant to topical treatment during relapses for nighttime itching through their sedative properties, not through direct anti-pruritic effects. 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 4

Lichenified Eczema

• Consider ichthammol or coal tar preparations for lichenified eczema. 1

Treatment for Severe, Refractory Cases

Phototherapy Options

• 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
• Oral PUVA has been shown to be 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 uncontrolled studies reporting 58-81% improvement but comparative studies showing less convincing efficacy. 1
• Localized high-dose UVA1 irradiation is an effective and safe alternative to cream PUVA, with comparable efficacy and easier administration. 5
• Some concern exists about long-term adverse effects of PUVA such as premature skin aging and cutaneous malignancies. 4

Systemic Corticosteroids

• Systemic corticosteroids have a limited but definite role in tiding occasional patients with severe dyshidrotic eczema during acute crises after all other treatment avenues have been explored. 4
• Use oral steroids only for short-term "tiding over" during crisis periods, not for maintenance treatment or to induce stable remission. 4
• Pituitary-adrenal suppression is a significant risk, particularly with prolonged use. 4

Radiation Therapy (Last Resort)

• Low-dose external beam megavoltage radiation therapy may achieve complete remission in severe, refractory cases where all conventional therapies have failed. 6

Critical Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 1
• Do not undertreat due to steroid phobia—explain to patients that appropriate short-term use of medium to high potency steroids is safer than chronic undertreated inflammation. 1
• Combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone. 1

When to Refer to Dermatology

• Failure to respond to medium potency topical corticosteroids after 4 weeks of appropriate use. 1
• Need for systemic therapy or phototherapy. 4
• Suspected eczema herpeticum (refer emergently). 4