Treatment for 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 Approach
Topical corticosteroids form the cornerstone of treatment:
- Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate for severe flares) no more than twice daily to affected areas 1
- Once symptoms improve, taper to maintenance therapy with intermittent use (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
Essential adjunctive measures must be implemented concurrently:
- Apply emollients liberally after bathing to provide a surface lipid film that retards evaporative water loss 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
Managing Secondary Infections
Watch for signs of bacterial superinfection (increased crusting, weeping, or pustules):
- Flucloxacillin is the first-line oral 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 2
For herpes simplex virus infection:
- Administer acyclovir early in the disease course if you observe grouped vesicles, punched-out erosions, or sudden deterioration 1
Second-Line Treatment Options
When first-line therapy is insufficient after 4 weeks:
- Consider tacrolimus 0.1% ointment applied once daily to affected areas, particularly useful for areas where prolonged steroid use is concerning 1
- Tacrolimus provides a steroid-sparing effect and can be used for maintenance therapy 1
For severe pruritus:
- Sedating antihistamines may be useful as a short-term adjuvant during relapses 1
- Consider ichthammol or coal tar preparations for lichenified eczema 1
Phototherapy for Refractory Disease
Oral PUVA therapy is the most effective phototherapy option:
- Oral PUVA has shown 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
Alternative phototherapy options:
- Topical PUVA has shown mixed results, with uncontrolled studies reporting 58-81% improvement, but comparative studies showing less convincing efficacy 1
- Narrowband UVB may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate 1
- High-dose UVA1 irradiation appears to be as effective as cream PUVA and is easier to perform 3
Addressing Potential Triggers
Consider metal hypersensitivity as a contributing factor:
- High oral ingestion of nickel and/or cobalt should be considered, regardless of patch test results 4
- Dietary cobalt (and nickel) restriction may reduce dyshidrotic eczema flares in susceptible patients 4
- Metal allergy is regarded as one of the important potential etiologic factors for dyshidrotic eczema 5
Critical Pitfalls to Avoid
- Do not use combination therapy with antibiotics and steroids routinely, as it has not shown additional benefit compared to steroids alone 1
- Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 2
- Avoid very potent corticosteroids in thin-skinned areas where risk of atrophy is higher 2
- Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given 2
When to Escalate Treatment
Refer or consider advanced therapies when: