What is the recommended treatment for a patient with dermatitis hyperhidrotica?

Treatment of Dermatitis Hyperhidrotica (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, 2

First-Line Topical Therapy

• Apply medium- to high-potency topical corticosteroids (such as triamcinolone or clobetasol propionate) twice daily to affected areas until symptoms improve, then taper to maintenance therapy 1, 2
• Use high-potency steroids like betamethasone dipropionate or clobetasol propionate for severe flares 2
• Avoid potent steroids on facial involvement—use only low-potency hydrocortisone on the face to prevent skin atrophy 1
• Once controlled, transition to intermittent use (twice weekly) of medium- to high-potency topical corticosteroids to prevent relapses 2

Essential Supportive Measures

• Apply emollients (urea 10% cream) at least twice daily after bathing to provide a surface lipid film that retards evaporative water loss 1, 2
• Replace regular soaps with dispersible cream as a soap substitute to avoid removing natural skin lipids 1
• Avoid mechanical stress (long walks, heavy carrying without gloves and cushioned shoes) and chemical irritants (solvents, disinfectants) 1
• Keep nails short to minimize trauma and secondary infection risk 1
• Treat any predisposing hyperkeratosis before initiating therapy 1

Management of Secondary Infection

Bacterial superinfection is common and requires prompt treatment:

• Use flucloxacillin as the first-choice antibiotic for Staphylococcus aureus infection (indicated by crusting or weeping) 1, 2
• Switch to erythromycin if there is flucloxacillin resistance or penicillin allergy 1, 2
• For herpes simplex virus infection (grouped, punched-out erosions or vesiculation), administer acyclovir early in the disease course 1, 2
• Bacteriological swabs are not routinely needed but obtain them if patients fail to respond to initial treatment 1

Second-Line Therapy for Steroid-Refractory Disease

If topical corticosteroids fail after 2-4 weeks, escalate therapy:

• Consider tacrolimus 0.1% ointment applied once daily to affected areas as a steroid-sparing agent, particularly useful where prolonged steroid use raises concerns 2
• For severe pruritus, add sedating antihistamines as a short-term adjuvant during relapses (non-sedating antihistamines have little value) 1
• Apply ichthammol (1% in zinc ointment) or coal tar preparations for lichenified eczema 1

Phototherapy for Refractory Cases

Oral PUVA is superior to other phototherapy modalities:

• Oral PUVA therapy achieves significant improvement or clearance in 81-86% of patients with hand and foot eczema and is superior to UVB in prospective controlled studies 1, 2
• Narrowband UVB may be considered as an alternative, showing 75% reduction in mean severity scores with 17% clearance rate 1, 2
• Topical PUVA has shown mixed results—uncontrolled studies report 58-81% improvement, but comparative studies demonstrate less convincing efficacy than oral PUVA 1, 2

Dietary Considerations for Metal Allergy

In patients with suspected metal hypersensitivity:

• Consider a low-cobalt and low-nickel diet, as high oral ingestion of these metals may trigger flares regardless of patch test results 3, 4
• Metal allergy is regarded as an important potential etiologic factor, and symptom improvement occurs with metal allergen removal 4

Treatment Algorithm Based on Severity

Mild disease (minimal skin changes):

• Medium-potency topical steroids twice daily + emollients 1, 2
• Reassess after 2 weeks 1

Moderate disease (skin changes with pain, limiting activities):

• High-potency topical steroids twice daily + emollients 2
• Add tacrolimus 0.1% ointment for steroid-sparing effect 2
• Reassess after 2 weeks; if no improvement, proceed to phototherapy 1, 2

Severe/refractory disease:

• Oral PUVA therapy as the most effective option 1, 2
• Consider systemic immunomodulators in very severe cases 5

Critical Pitfalls to Avoid

• Do not use potent or very potent topical corticosteroids for extended periods due to risk of pituitary-adrenal axis suppression and skin atrophy 1, 2
• Do not continue ineffective treatments beyond 4-6 weeks—escalate therapy promptly 5
• Combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone unless active infection is present 2
• Pyridoxine is not beneficial for prevention and is not recommended 1