Treatment of Dyshidrotic Eczema

First-Line Treatment Options

The British Medical Journal recommends using topical corticosteroids as the primary treatment, applying no more than twice daily, with the least potent preparation required to control symptoms being recommended as first-line therapy 1
The British Medical Journal suggests choosing the least potent preparation that effectively controls the eczema, using more potent formulations only for limited periods 1
Applying emollients after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis is recommended by the British Medical Journal 1
Using a dispersible cream as a soap substitute to cleanse the skin, avoiding regular soaps and detergents that remove natural lipids, is advised by the British Medical Journal 1

Avoiding extremes of temperature and irritant clothing, and keeping nails short to minimize trauma and secondary infection risk, is recommended by the British Medical Journal 1

For bacterial superinfection, flucloxacillin is usually the most appropriate antibiotic for treating Staphylococcus aureus, according to the British Medical Journal and Praxis Medical Insights 1, 2
Using erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy is suggested by the British Medical Journal and Praxis Medical Insights 1, 2
For herpes simplex virus infection, administering acyclovir early in the course of disease is recommended by Praxis Medical Insights 2

For severe pruritus, sedating antihistamines may be useful as a short-term adjuvant to topical treatment during relapses, according to the British Medical Journal 1
Considering ichthammol or coal tar preparations for lichenified eczema is suggested by the British Medical Journal 1
Oral PUVA therapy has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema, according to the British Journal of Dermatology 3, 4
Topical PUVA has shown mixed results, with uncontrolled studies reporting 58-81% improvement in dyshidrotic eczema, but comparative studies showing less convincing efficacy, according to the British Journal of Dermatology 3, 4
Narrowband UVB may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate in one study, according to the British Journal of Dermatology 3

Oral PUVA has been shown to be superior to UVB in prospective controlled studies of hand eczema, according to the British Journal of Dermatology 4

Potent and very potent topical corticosteroids should be used with caution and for limited periods only due to risk of pituitary-adrenal axis suppression, as warned by the British Medical Journal 1
Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment, according to the British Medical Journal 1

The American Academy of Dermatology recommends using medium to high potency topical corticosteroids for acute flares of dyshidrotic dermatitis, applying twice daily until symptoms improve, then tapering to maintenance therapy 5
For maintenance, the American Academy of Dermatology suggests considering intermittent use (twice weekly) of medium to high potency topical corticosteroids to prevent relapses 5
High potency steroids like betamethasone dipropionate or clobetasol propionate can be effective for severe flares, as recommended by the American Academy of Dermatology 5

The British Association of Dermatologists recommends tacrolimus 0.1% ointment applied once daily to affected areas, particularly useful for areas where prolonged steroid use is concerning 6
The British Association of Dermatologists also suggests that topical calcineurin inhibitors like tacrolimus 0.1% ointment can be used as a steroid-sparing effect 7, 6

For moderate cases, the American Academy of Dermatology recommends medium to high potency topical steroids 5
The British Association of Dermatologists suggests considering tacrolimus ointment for steroid-sparing effect in moderate cases 6

The American Academy of Dermatology advises that potent and very high potency topical corticosteroids should be used with caution and for limited periods due to risk of side effects 5
The American Academy of Dermatology also states that combination therapy with antibiotics and steroids has not shown additional benefit compared to steroids alone 5

Methotrexate has been used in adult patients with palmoplantar pompholyx (dyshidrotic eczema) and reported to improve clinical symptoms, indicating potential benefit as a systemic option for refractory disease (evidence limited to case reports) 8, 9