Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

all patients

1st line – lifestyle measures

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all patients
1st line – 

lifestyle measures

Avoidance of triggers or exacerbating factors identified for a specific patient.

Advise frequent and liberal use of emollients on the affected areas, especially after any contact with water. Use white soft paraffin-based formulations, or a cream formulation if the patient does not tolerate this.

Advise patients against prolonged wet work and suggest wearing protective gloves if necessary. Recommend use of mild cleansers only and avoidance of skin products with fragrances or dyes.

Consider – topical corticosteroid or immunomodulator

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all patients
Consider – 

topical corticosteroid or immunomodulator

Additional treatment recommended for SOME patients in selected patient group

Used in patients who are unresponsive to lifestyle measures alone.[15][33][34]​​

Potent preparations (e.g., clobetasol, fluocinonide) are used for up to two weeks a month before switching to an intermediate-potency corticosteroid (e.g., mometasone, triamcinolone) to avoid adverse effects such as skin atrophy and telangiectasia. Maintenance therapy consists of a medium-potency topical corticosteroid.[35]

Ointment-based formulations are generally considered superior to creams or lotions, as they are more effective and contain fewer preservatives and additives.[22] Occlusion with plastic wrap or hydrocolloid dressing enhances efficacy, however, it also increases the risk of adverse effects, especially with high-potency corticosteroids.[34]

Topical immunomodulators such as tacrolimus and pimecrolimus are considered for chronic management and can be used for maintenance therapy (as corticosteroid-sparing agents) when there are concerns about skin atrophy after control is gained with topical corticosteroids.[15][36][37][38]​​

These agents are less effective on thickly keratinised skin such as on the soles. A keratolytic (such as a urea cream) to improve absorption may be used.[36][37]

Primary options

clobetasol topical: (0.05%) apply sparingly to affected area(s) once daily at bedtime for up to 2 weeks, then switch to lower-potency corticosteroid

OR

fluocinonide topical: (0.05%) apply sparingly to affected area(s) twice daily for up to 2 weeks, then switch to lower-potency corticosteroid

OR

mometasone topical: (0.1%) apply sparingly to affected area(s) once daily until resolution of symptoms

OR

triamcinolone topical: (0.025% or 0.1%) apply sparingly to affected area(s) twice daily until resolution of symptoms

Secondary options

tacrolimus topical: (0.1%) apply to affected area(s) twice daily

OR

pimecrolimus topical: (1%) apply to affected area(s) twice daily

Consider – oral corticosteroid

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all patients
Consider – 

oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Reserved for short courses in severe circumstances (e.g., pompholyx). The addition of an oral corticosteroid can lead to dramatic improvement in cases unresponsive to lifestyle measures alone or topical therapy.

A short course of prednisolone is advised in these circumstances; dose tapering is not required for this treatment duration.[2] Longer treatment courses of oral corticosteroids are strongly discouraged due to their well-known adverse effects, which include hyperglycaemia, hypertension, osteoporosis, and cataracts.

Primary options

prednisolone: 60 mg orally once daily for 3-5 days

Consider – antihistamine

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all patients
Consider – 

antihistamine

Additional treatment recommended for SOME patients in selected patient group

Pruritus control may be achieved with oral antihistamines (e.g., diphenhydramine, hydroxyzine).

Primary options

diphenhydramine: 25-50 mg orally every 4-6 hours when required, maximum 300 mg/day

OR

hydroxyzine: 25 mg orally every 6-8 hours when required

Consider – nickel-directed therapy

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all patients
Consider – 

nickel-directed therapy

Additional treatment recommended for SOME patients in selected patient group

A diet low in nickel is helpful to some motivated patients with stubborn dyshidrotic dermatitis and a nickel allergy, proven by patch-test or oral challenge.[27][28]

A low-nickel diet includes avoidance of all canned foods and foods prepared with nickel-containing utensils and pots, as well as avoidance of the following foods: asparagus, beans, broccoli, carrots, corn, lettuce, mushrooms, onions, pears, peas, rhubarb, spinach, tomatoes, kale, alfalfa sprouts, leeks, lentils, pineapple, raspberries, prunes, dates, figs, herring, shellfish, tea, soy protein powder, chocolate, cocoa, baking powder, marzipan, nuts, sunflower and sesame seeds, licorice, vitamins containing nickel, whole wheat flour, bran, buckwheat, millet, multi-grain bread, oatmeal, unpolished rice, and rye bran.

Other methods employed for decreasing the systemic effects of nickel are treatment with oral agents (such as vitamin C, iron, disulfiram and sodium cromoglicate) and hyposensitisation.[29][30][31]

However, nickel-directed therapies, as a whole, lack large, randomised, controlled studies.

Primary options

disulfiram: consult specialist for guidance on dose

OR

sodium cromoglicate: 200-400 mg orally four times daily

Consider – therapy for hyperhidrosis

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all patients
Consider – 

therapy for hyperhidrosis

Additional treatment recommended for SOME patients in selected patient group

Hyperhidrosis is an exacerbating factor for some patients with dyshidrotic dermatitis.

In this subset of patients, modalities that interrupt eccrine sweat function, such as topical aluminium chloride, iontophoresis, topical glycopyrronium, and botulinum toxin type A, may be helpful.[23][24][25]

Botulinum toxin type A treatment is associated with pain at the time of injections, and the adverse effect of temporary hand weakness. Careful dilution and injection techniques are necessary to prevent complications.[25]

Botulinum toxin type A is preferred over iontophoresis.

Primary options

aluminium chloride topical: (20% solution) apply to the affected area(s) once daily at bedtime for 2-3 days or until anhidrosis, followed by once or twice weekly at bedtime when required

OR

glycopyrronium topical: (2.4% pad) apply one pad to the affected area(s) once daily

OR

botulinum toxin type A: consult specialist for guidance on dose

Consider – hand/foot phototherapy

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all patients
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with recalcitrant disease
Consider – 

hand/foot phototherapy

Additional treatment recommended for SOME patients in selected patient group

Phototherapy can be a useful adjunctive treatment in patients who are partially responding to conventional therapy.

Topical psoralen (e.g., methoxsalen) plus ultraviolet A (PUVA) is an effective treatment.[15][38]​​[39][40][41]​​​​ Numerous regimens exist, but an 8-week regimen is often used. Topical PUVA has local adverse effects of blistering and hyperpigmentation, but the systemic adverse effects of nausea or vomiting and persistent whole-body photosensitivity seen with oral PUVA treatment are rare.[46]

Oral PUVA is a second-line option; however, it carries a risk of ocular damage and skin cancer.[47]UV-A-1 does not require the use of psoralens (which increase the risk of carcinogenesis), but it is not widely available.[48].

The major risk of PUVA is carcinogenesis, which is dose-dependent. Narrowband UVB is another effective option.[15][38]​​ In the active management phase, patients are treated three times a week. Patients are given an 8-week trial of active management ,after which treatments can be tapered down in the maintenance phase.

Consider – systemic immunosuppressant therapy

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all patients
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with recalcitrant disease
Consider – 

systemic immunosuppressant therapy

Additional treatment recommended for SOME patients in selected patient group

Systemic immunosuppressants are used with some success in patients who are unresponsive both to conventional therapy and to phototherapy.[42][43][44][45]​ However, evidence of efficacy for dyshidrotic dermatitis is weak.[38]

These agents are only employed in treatment-resistant disease as their adverse effects can be serious. These include: hepatotoxicity, renal toxicity, pneumonitis, pancytopenia, increased risk of malignancy or infection, teratogenicity, hypertension, hyperlipidaemia, and oligospermia.

Folic acid supplementation reduces the likelihood of haematological adverse effects of methotrexate.

Patients at this level of severity should seek consultation with a dermatology speciality clinic.

Primary options

methotrexate: 12.5 to 20 mg orally once weekly, taken on the same day of each week

-- AND --

folic acid: 1 mg orally once daily

OR

azathioprine: 100-150 mg/day orally initially; reduce to 50-100 mg/day for maintenance dose

OR

ciclosporin: 2.5 mg/kg/day orally given in 2 divided doses

OR

mycophenolate mofetil: 1.5 g orally twice daily initially and taper dose gradually according to response

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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