What is the recommended medication for treating dyshidrotic (pompholyx) eczema in an adult?

Treatment of 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 Topical Treatment

Topical corticosteroids are the cornerstone of treatment:

• Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate) twice daily for acute flares until symptoms improve 1
• Once controlled, taper to maintenance therapy with intermittent use (twice weekly) to prevent relapses 1
• Use the least potent preparation that effectively controls the eczema, reserving more potent formulations for limited periods only 1
• Critical caveat: Potent and very potent topical corticosteroids carry risk of pituitary-adrenal axis suppression and should be used with caution for limited periods 1

Essential adjunctive measures:

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

Management of Acute Weeping Vesicular Lesions

For moderate cases with weeping vesicles or fissures:

• Add potassium permanganate soaks at 1:10,000 (0.01%) concentration as antiseptic baths or compresses 2
• This accelerates wound closure in cases with fissures 2
• Apply particularly when vesicular lesions are weeping 2

Second-Line Treatment Options

When first-line therapy is insufficient:

• Consider tacrolimus 0.1% ointment applied once daily to affected areas, particularly useful where prolonged steroid use is concerning 1
• Tacrolimus provides a steroid-sparing effect and can be used for maintenance 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

For severe, treatment-resistant cases:

• Oral PUVA is the most effective phototherapy option, showing 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 as an alternative, showing 75% reduction in mean severity scores with 17% clearance rate 1
• Topical PUVA has shown mixed results (58-81% improvement in uncontrolled studies) but less convincing efficacy in comparative studies 1

Management of Secondary Infection

Watch for signs of bacterial superinfection (crusting, weeping, increased redness):

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

Emerging Systemic Therapies

For severe refractory cases:

• Methotrexate has been used for palmoplantar pompholyx, though evidence is limited to case reports 3
• Alitretinoin has demonstrated efficacy in chronic hand dermatitis including pompholyx 4
• Intradermal injection of botulinum toxin is an evolving treatment option 4, 5, 6
• Novel biologic: Tralokinumab (IL-13 inhibitor) has shown success in a case report of severe dyshidrotic palmoplantar eczema, though this represents emerging evidence 7

Practical Treatment Algorithm

Mild cases with minimal vesicles:

• Moisturizers and low-to-medium potency topical steroids 2

Moderate cases with weeping vesicles:

• Medium to high potency topical steroids twice daily PLUS potassium permanganate soaks at 1:10,000 concentration 1, 2

Severe or refractory cases:

• Continue topical therapy AND add oral PUVA as the most effective phototherapy option 1
• Consider systemic immunosuppressants or alitretinoin for recalcitrant disease 4

Important Caveats

• Avoid extremes of temperature and irritant clothing, and keep nails short to minimize trauma and secondary infection risk 1
• Combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone 1
• In practice, patients benefit most from a combination of treatments rather than monotherapy 4