Approach

Dyshidrotic dermatitis characteristically follows a relapsing-remitting course and so will most often resolve without any treatment, however, patients will appreciate therapies to lessen the duration and prevent recurrence of uncomfortable eruptions.

Lifestyle measures

Advise patients to avoid identified triggers or exacerbating factors. Provide all patients with strategies to maintain effective skin barrier mechanisms such as frequent use of emollients, avoidance of irritants, and use of protective gloves or footwear.[23] Advise against prolonged wet work and harsh cleansers, and suggest immediately moisturizing with a heavy emollient, preferably a white soft paraffin-based product, after each exposure to water.[23] In addition to these measures, some patients require further adjunctive therapies:

Pruritus

  • Symptomatic control of pruritus may be achieved with oral antihistamines.

Hyperhidrosis

  • 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 chloride, iontophoresis, topical glycopyrronium and onabotulinumtoxinA (botulinum toxin type A), may be helpful.[24][25][26]

  • These treatments are relatively safe, although an adverse effect of onabotulinumtoxinA is temporary hand weakness.

  • OnabotulinumtoxinA is preferred over iontophoresis.

Nickel allergies

  • Several studies suggest a systemic role for nickel-related exacerbation of dyshidrotic dermatitis in nickel-allergic patients.[27][28]

  • After nickel-sensitive patients are identified through patch testing or oral challenge, they should stringently avoid contact with all nickel-containing objects. A dimethylglyoxime kit is used to test frequently encountered objects for nickel content.

  • If after these precautions the patient is still experiencing flares, some authors recommend attempting to decrease systemic nickel exposure.[28][29] A diet low in nickel is useful in some motivated patients with stubborn dyshidrotic dermatitis and a nickel allergy proven via patch-test or oral challenge.[28][29]

  • Other methods employed for decreasing the systemic effects of nickel are treatment with oral agents (such as vitamin C, iron, disulfiram and cromolyn sodium) and hyposensitization.[30][31][32]​ A metabolite of disulfiram binds divalent metals, including nickel, while cromolyn sodium inhibits mast cell degranulation. Iron deficiency anemia is understood to enhance nickel absorption (secondary to upregulation of divalent metal transporter 1 [DMT1] on enterocyte luminal surfaces) and is treated with iron supplementation. Vitamin C acts to suppress nickel absorption.[33]

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

Patients unresponsive to lifestyle measures

If the condition persists after conservative lifestyle measures are taken, topical corticosteroids are frequently used.[15][34][35]​​​​ A potent preparation may be needed for the first couple of weeks to gain control of the eruption. This is then tapered to a less-potent formulation for the remainder of the treatment course.[36]

Topical immunomodulators, such as tacrolimus and pimecrolimus, are helpful corticosteroid-sparing agents for long-term maintenance and when there are concerns about skin atrophy with topical corticosteroids.[15][37][38][39]​​​ However, topical immunomodulators do not penetrate thick skin well, so if these agents are used on thickly keratinized skin, a keratolytic (such as a cream containing urea) can be coadministered to improve absorption.[37][38]

Lifestyle measures may need to be continued in selected patients, despite escalation of therapy.

Patients unresponsive to topical therapies

A short course of oral prednisone is sometimes helpful if patients' symptoms have severely flared and cannot be controlled with skin-directed methods.[2] Long-term use of oral corticosteroids is discouraged because of the well-known range of adverse effects. Topical corticosteroids and lifestyle measures are continued if necessary.

Recalcitrant disease

Patients at this level of severity should seek consultation with a dermatology specialist. Phototherapy or immunosuppressants may be considered. Topical psoralen (e.g., methoxsalen) plus ultraviolet A (PUVA) and narrowband UVB are effective measures.[15][39]​​​​[40][41][42]​​​​​​​ Oral PUVA is a second-line option as, while effective, can carry a risk of skin cancer with repeated exposure. 

Systemic immunosuppressants are used with some success in patients with dyshidrotic dermatitis that is unresponsive to conventional therapy, and for recalcitrant disease unresponsive to phototherapy.[43][44][45][46]​ However, evidence of efficacy for dyshidrotic dermatitis is weak.[39]

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