What is the recommended treatment and management plan for dyshidrotic eczema (pompholyx)?

Treatment and Management of Dyshidrotic Eczema

Start with low-to-medium potency topical corticosteroids (fluticasone or mometasone) applied twice daily to affected palmar and plantar areas, combined with liberal emollient use, as this forms the cornerstone of first-line therapy. 1

First-Line Topical Corticosteroid Strategy

• Apply fluticasone propionate or mometasone furoate twice daily to vesicular areas on palms, soles, and lateral fingers until lesions significantly improve. 1
• Use the least potent preparation that achieves control—avoid unnecessarily potent steroids that increase risk of skin atrophy. 1
• For mild cases, 1% hydrocortisone may be adequate and does not cause systemic side effects unless used extravagantly. 2, 1
• Implement "steroid holidays" by stopping corticosteroids for short periods once symptoms improve to minimize pituitary-adrenal suppression. 1, 3

Essential Emollient Therapy (Non-Negotiable)

• Apply emollients liberally immediately after bathing to all affected areas, as this provides short- and long-term steroid-sparing effects. 1
• Emollients create a surface lipid film that prevents evaporative water loss from the epidermis, which is critical in dyshidrotic eczema. 1, 3
• Use dispersible cream as a soap substitute instead of regular soap, which strips natural lipids and worsens the compromised skin barrier. 1, 3

Managing Secondary Bacterial Infection

• Continue topical corticosteroids even when secondary infection is present—infection is NOT a contraindication to steroid use when appropriate systemic antibiotics are given concurrently. 3, 4
• Prescribe oral flucloxacillin as first-line antibiotic for Staphylococcus aureus, the most common pathogen in infected eczema. 2, 3, 4
• Watch for impetiginization: honey-colored crusting, increased weeping, or pustules overlying vesicles. 4

Addressing Pruritus

• Sedating antihistamines (hydroxyzine, diphenhydramine) may help with nighttime itching through sedative properties, not direct anti-pruritic effects—reserve for nighttime use during severe flares only. 2, 3
• Large doses may be required, but avoid daytime use due to sedation. 2

Second-Line Phototherapy Options (When First-Line Fails)

• Oral PUVA is superior to UVB for hand eczema and shows 81-86% improvement or clearance rates in uncontrolled studies, though relapse rates are high. 2
• Topical PUVA has shown mixed results: uncontrolled studies report 58-81% improvement in dyshidrotic eczema, but randomized controlled trials found no difference compared to placebo. 2
• The British Association of Dermatologists recommends PUVA (oral or topical psoralen) should be considered as second-line treatment for refractory hand eczema (strength of recommendation C). 2
• Be aware of long-term risks: premature skin aging and cutaneous malignancies, particularly with PUVA. 2

Investigating Underlying Triggers

• Patch testing is the gold standard when allergic contact dermatitis is suspected—particularly important in dyshidrotic eczema given the association with metal allergy (nickel, cobalt, chromium). 2, 5
• Consider patch testing in any patient with chronic or persistent hand dermatitis, or when previously well-controlled eczema becomes difficult to manage. 2
• Metal allergy is regarded as one of the important potential etiologic factors for dyshidrotic eczema, and symptoms may improve by removing metal allergen exposure. 5

Critical Pitfalls to Avoid

• Never delay or withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently. 3, 4
• Address steroid phobia directly: 72.5% of patients worry about using topical corticosteroids—explain that appropriate short-term use of low-to-medium potency steroids is safer than chronic undertreated inflammation. 1, 3
• Do not use potent or very potent corticosteroids as first-line therapy—start with the least potent preparation that achieves control. 1

When to Refer to Dermatology

• Failure to respond to moderate potency topical corticosteroids after 4 weeks of appropriate use. 1, 3
• Need for systemic therapy or phototherapy. 1
• Diagnostic doubt or when second-line treatment is required. 2, 1
• Suspected eczema herpeticum (grouped vesicles, punched-out erosions, sudden deterioration with fever)—this requires emergent referral and immediate oral or intravenous acyclovir. 2, 4