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

Management of Pompholyx (Dyshidrotic Eczema)

For pompholyx, start with high-potency topical corticosteroids applied twice daily to the affected palms and soles, combined with aggressive emollient therapy and soap substitutes, as the thick horny layer of palmoplantar skin requires more potent preparations than other body sites. 1, 2

First-Line Topical Therapy

Potent to very potent topical corticosteroids are the cornerstone of pompholyx treatment:

• Apply betamethasone dipropionate 0.05% or clobetasol propionate 0.05% (very potent) twice daily to vesicular lesions on palms and soles 1, 2
• The thick stratum corneum of palmoplantar skin necessitates higher potency preparations compared to other anatomic sites 3, 4
• Continue for 2–4 weeks during acute flares, then transition to twice-weekly maintenance dosing on previously affected areas to prevent recurrence 1, 2
• If no improvement after 2 weeks of potent corticosteroid use, reassess the diagnosis and consider second-line options 2

Essential adjunctive measures:

• Apply emollients liberally after every hand wash and immediately after bathing to restore the barrier and reduce transepidermal water loss 1, 5
• Replace all soaps with soap-free cleansers or dispersible creams, as regular soaps strip natural lipids and worsen the condition 1, 5
• Keep nails short to minimize trauma from scratching and reduce secondary infection risk 1

Alternative Topical Agents

Topical calcineurin inhibitors offer a steroid-sparing option:

• Tacrolimus 0.1% ointment applied once daily can be effective, particularly for maintenance therapy or when prolonged corticosteroid use raises concerns 1, 3, 4
• These agents avoid corticosteroid-related adverse effects but may be less effective than potent steroids for acute bullous pompholyx 3, 4

Management of Secondary Bacterial Infection

Monitor for signs of superinfection during treatment:

• Increased crusting, weeping, purulent exudate, or pustules indicate secondary Staphylococcus aureus infection 1, 5
• Prescribe oral flucloxacillin as first-line antibiotic (or erythromycin for penicillin allergy) while continuing topical corticosteroids concurrently 1, 5
• Do not withhold topical steroids when appropriate systemic antibiotics are given 1, 5
• If grouped vesicles or punched-out erosions develop, suspect eczema herpeticum and initiate oral acyclovir immediately 1, 5

Second-Line Phototherapy for Refractory Disease

When topical therapy fails after 2–4 weeks, escalate to phototherapy:

• Oral PUVA (psoralen plus UVA) is the most effective phototherapy modality, achieving significant improvement or clearance in 81–86% of patients with hand and foot eczema 1
• Oral PUVA has proven superior to UVB in prospective controlled studies of hand eczema 1
• Topical PUVA shows mixed results (58–81% improvement in uncontrolled studies) but less convincing efficacy in comparative trials 1
• Narrowband UVB (312 nm) may be considered as an alternative, showing 75% reduction in severity scores with 17% clearance in one study 1
• Weigh long-term risks of premature skin aging and cutaneous malignancies, particularly with PUVA, against therapeutic benefits 6, 1

Systemic Therapy for Severe or Bullous Pompholyx

Systemic agents are reserved for severe, recalcitrant cases:

• Oral corticosteroids (e.g., prednisone) are commonly used for bullous pompholyx to achieve rapid control, though no controlled trials exist 3, 4
• Use systemic steroids only for short-term "tiding over" during acute crises after exhausting all topical and phototherapy options 6, 1
• Never use oral corticosteroids for maintenance therapy due to risks of pituitary-adrenal suppression and other adverse effects 6, 5
• Alitretinoin has demonstrated efficacy in chronic hand dermatitis including pompholyx and should be considered for recalcitrant cases 3
• For steroid-resistant disease, combine corticosteroids with immunosuppressants such as methotrexate, azathioprine, or cyclosporine 1, 3, 4

Emerging and Alternative Therapies

Additional options for selected refractory cases:

• Intradermal botulinum toxin injection is an evolving treatment that may reduce sweating and vesicle formation 3, 4
• Radiotherapy might be considered for highly selected patients not responding to conventional treatment 3

Treatment Algorithm

1. Acute vesicular phase: High-potency topical corticosteroid twice daily + aggressive emollients + soap substitutes for 2–4 weeks 1, 2
2. Maintenance phase: Same corticosteroid twice weekly to previously affected sites + continued emollients 1, 2
3. Failure at 2 weeks: Reassess diagnosis, consider tacrolimus or escalate to phototherapy 1, 2
4. Refractory disease: Oral PUVA (first choice) or narrowband UVB 1
5. Severe bullous disease: Short course oral corticosteroids, then transition to alitretinoin or immunosuppressants for maintenance 6, 1, 3

Critical Pitfalls to Avoid

• Do not use low-potency corticosteroids (e.g., hydrocortisone 1%) on palms and soles—the thick stratum corneum requires potent or very potent preparations 1, 2, 3
• Do not discontinue topical corticosteroids when bacterial infection is present; continue them with appropriate systemic antibiotics 1, 5
• Avoid prolonged continuous use of very potent corticosteroids without "steroid holidays" to minimize adverse effects 6, 1
• Do not delay escalation to phototherapy or systemic agents when adequate topical therapy fails after 2–4 weeks 1, 2