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 to affected areas as first-line therapy, using the least potent preparation that effectively controls symptoms. 1

First-Line Treatment Approach

Topical corticosteroids form the cornerstone of dyshidrotic eczema management:

• Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate for severe flares) no more than twice daily until symptoms improve 1
• Once acute symptoms resolve, 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 alongside corticosteroids:

• Apply emollients liberally after bathing to create a surface lipid film that retards evaporative water loss 1
• Use dispersible cream as a soap substitute rather than regular soaps and detergents that strip natural lipids 1
• Keep nails short to minimize trauma and reduce secondary infection risk 1
• Avoid extremes of temperature and irritant clothing 1

Managing Triggers and Exacerbating Factors

Consider metal hypersensitivity as a potential trigger, particularly cobalt and nickel:

• High oral ingestion of nickel and/or cobalt should be considered regardless of patch test results 2
• Dietary cobalt restriction may reduce dyshidrotic eczema flares, though this is a burdensome treatment option 2
• Metal allergy is regarded as one of the important potential etiologic factors, and removing metal allergen can improve symptoms 3

Second-Line Treatment Options

When first-line therapy proves insufficient or steroid-sparing is needed:

• Tacrolimus 0.1% ointment applied once daily to affected areas is particularly useful where prolonged steroid use raises concerns about side effects 1
• Topical calcineurin inhibitors like tacrolimus provide a steroid-sparing effect in moderate cases 1
• Sedating antihistamines may be useful as a short-term adjuvant during relapses for severe pruritus 1
• Ichthammol or coal tar preparations can be considered for lichenified eczema 1

Managing Secondary Infections

Watch for signs of bacterial or viral superinfection:

• Flucloxacillin is the first-line antibiotic for Staphylococcus aureus superinfection 1
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy 1
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 1
• For herpes simplex virus infection (eczema herpeticum), administer acyclovir early in the disease course 1

Phototherapy for Refractory Disease

When topical treatments fail, phototherapy represents the next escalation:

• Oral PUVA therapy shows significant improvement or clearance in 81-86% of patients with hand and foot eczema 1
• Oral PUVA has been shown 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

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
• Avoid continuous use of potent topical corticosteroids without breaks to minimize side effects 1
• Do not delay appropriate treatment escalation if patients fail to respond to moderate potency topical corticosteroids after 4 weeks 4

Extreme Refractory Cases

For severe cases unresponsive to all conventional therapies:

• Low-dose external beam megavoltage radiation therapy has achieved complete remission in refractory cases where multiple topical and systemic agents failed, with durable response at 6 months 5
• This option should only be considered after exhausting all other treatment avenues due to potential long-term risks 5