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

Treatment of Dyshidrotic Eczema

Start with medium to high potency topical corticosteroids applied twice daily to affected areas 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 for severe flares) twice daily 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
• Limit potent and very potent corticosteroids to short courses only due to risk of pituitary-adrenal axis suppression and infectious complications 1, 2
• Clobetasol propionate has a cumulative depot effect persisting in the epidermis for 4 days after a single application, making infection risk particularly concerning with prolonged use 2

Essential Emollient Therapy

• Apply emollients liberally after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1
• Use dispersible cream as a soap substitute instead of regular soaps and detergents that remove natural lipids 1

Trigger Management

• Avoid extremes of temperature and irritant clothing 1
• Keep nails short to minimize trauma and secondary infection risk 1
• Consider dietary cobalt and nickel restriction in refractory cases, as high oral ingestion may trigger flares regardless of patch test results 3

Managing Secondary Infections

Bacterial Superinfection

• Watch for increased crusting, weeping, or pustules indicating Staphylococcus aureus infection 1
• Prescribe oral flucloxacillin as first-line antibiotic for bacterial superinfection 1
• Use erythromycin when flucloxacillin resistance exists 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

Viral Superinfection

• Administer acyclovir early in the course of herpes simplex virus infection 1

Second-Line Treatment Options

Topical Calcineurin Inhibitors

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

Adjunctive Therapies

• Use sedating antihistamines as a short-term adjuvant during severe pruritus relapses, though they work through sedative properties rather than direct anti-pruritic effects 1
• Consider ichthammol or coal tar preparations for lichenified eczema 1

Phototherapy for Refractory Disease

Oral PUVA (Most Effective)

• Oral PUVA therapy achieves significant improvement or clearance in 81-86% of patients with hand and foot eczema and has been shown superior to UVB in prospective controlled studies 1

Alternative Phototherapy Options

• Topical PUVA shows mixed results with 58-81% improvement in uncontrolled studies, but comparative studies show less convincing efficacy 1
• Narrowband UVB may be considered, showing 75% reduction in mean severity scores with 17% clearance rate 1
• Localized high-dose UVA1 irradiation is as effective as cream PUVA and appears safer with fewer potential side effects 4

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
• Avoid using potent corticosteroids like clobetasol propionate for more than 2 weeks maximum due to cumulative depot effects and infection risk 2
• Do not use combination therapy with antibiotics and steroids, as this has not shown additional benefit compared to steroids alone 1
• Implement "steroid holidays" when symptoms improve to minimize pituitary-adrenal suppression 1

Treatment Algorithm for Refractory Cases

When standard topical therapy fails after 4 weeks of appropriate use:

1. Ensure compliance with emollients and trigger avoidance 1
2. Consider tacrolimus 0.1% ointment for steroid-sparing effect 1
3. Evaluate for dietary cobalt/nickel triggers and implement restriction if indicated 3
4. Proceed to oral PUVA therapy as the most effective phototherapy option 1
5. In extremely refractory cases unresponsive to all conventional therapies, low-dose external beam radiation therapy may achieve complete remission, though this represents a last-resort option 5