Treatment of Dyshidrotic Eczema
Start with medium to high potency topical corticosteroids applied twice daily as first-line therapy, combined with liberal emollient use, and reserve phototherapy or systemic agents for refractory cases. 1
First-Line Treatment Protocol
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
Use the least potent preparation that effectively controls symptoms, escalating potency only when necessary for limited periods to minimize side effects like pituitary-adrenal suppression. 1
After acute flare resolution, transition to intermittent maintenance therapy with medium to high potency topical corticosteroids applied twice weekly to prevent relapses. 1
Apply emollients liberally after bathing to create a surface lipid film that retards evaporative water loss from the epidermis—this is the cornerstone of maintenance therapy even when eczema appears controlled. 1
Replace regular soaps with dispersible cream as a soap substitute to avoid removing natural lipids from the skin. 1
Managing Triggers and Symptoms
Keep nails short to minimize trauma and reduce secondary infection risk. 1
Avoid extremes of temperature and irritant clothing. 1
For severe pruritus, use sedating antihistamines as a short-term adjuvant during relapses—these work through sedative properties rather than direct anti-pruritic effects. 1
Infection Management
Watch for increased crusting, weeping, or pustules indicating bacterial superinfection—treat with flucloxacillin as first-line antibiotic for Staphylococcus aureus. 1
Use erythromycin when flucloxacillin resistance exists or in penicillin-allergic patients. 1
If grouped vesicles, punched-out erosions, or sudden deterioration with fever develop, suspect eczema herpeticum (a medical emergency) and initiate acyclovir early in the disease course. 1
Bacteriological swabs are not routinely indicated but obtain them if patients fail to respond to treatment. 1
Second-Line Therapy for Steroid-Sparing Effect
Consider tacrolimus 0.1% ointment applied once daily to affected areas when prolonged steroid use raises concerns about adverse effects. 1
Tacrolimus provides a steroid-sparing effect and is particularly useful for maintenance therapy in moderate cases. 1
For lichenified eczema that persists despite standard therapy, consider ichthammol or coal tar preparations. 1
Phototherapy for Refractory Disease
Oral PUVA therapy is the most effective phototherapy option, showing significant improvement or clearance in 81-86% of patients with hand and foot eczema, and has proven superior to UVB in prospective controlled studies. 1
Topical PUVA shows mixed results with 58-81% improvement in uncontrolled studies, but comparative studies demonstrate less convincing efficacy. 1
Narrowband UVB may be considered as an alternative, showing 75% reduction in mean severity scores with 17% clearance rate, though it is less effective than oral PUVA. 1
Dietary Considerations for Refractory Cases
In patients with persistent dyshidrotic eczema despite standard therapy, consider high oral ingestion of nickel and/or cobalt as potential triggers, regardless of patch test results. 2
Dietary cobalt (and nickel) restriction may reduce flares in select patients, though this is a burdensome treatment option. 2
Critical Safety Warnings
Potent and very high potency topical corticosteroids carry risk of pituitary-adrenal axis suppression and should be used with caution for limited periods only, with short "steroid holidays" when possible. 1
Avoid continuous use of potent steroids without breaks to minimize systemic absorption and local adverse effects. 1
Combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone, so avoid routine combination products. 1