Medication Summary
Dyshidrotic eczema treatment can be quite challenging because of the severe inflammatory process that can be involved and because of frequent recurrences. Pharmacologic treatment begins with high-strength, topical corticosteroids. In recalcitrant cases, systemic corticosteroids are the next line of treatment. Two case reports also note some success with other immunosuppressants (eg, methotrexate, mycophenolate mofetil).
The long-term efficacy of occlusive therapy with pimecrolimus (Elidel), a topical calcineurin inhibitor, was reported in patients with severe dyshidrosiform hand and foot eczema.[34] However, the authors recommend caution in the extended use of calcineurin inhibitors.
In March 2005, the US Food and Drug Administration (FDA) issued a public health advisory to inform healthcare professionals and patients about a potential cancer risk from the use of pimecrolimus. This concern is based on information from animal studies, case reports in a small number of patients, and knowledge of how drugs in this class work. Human studies of 10 years or longer may be needed to determine if pimecrolimus administration is linked to cancer. In the meantime, because this risk is uncertain, the FDA advises that pimecrolimus be used only in patients in whom other prescription treatments have failed or cannot be tolerated. This information reflects the FDA’s preliminary analysis of data concerning this drug.
Other treatment options include botulinum toxin A injections and a topical form known as bexarotene gel, as well as plant-based pharmaceuticals; new types of anti-inflammatory oral drugs, such as leukotriene inhibitors and phosphodiesterase-4 (PDE4) inhibitors; and phototherapy with high-dose UVA-1 and UV-free phototherapy.[35]
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. Topical ointments are more potent, but greasier, than creams.
Topical corticosteroids are the first-line therapy. Steroid potency choice is based on the patient's response to treatment; however, the higher-strength steroids are usually necessary for disease control.
Clobetasol (Temovate, Clobex, Cormax, Olux)
Clobetasol is for severe episodes. It is a class I superpotent topical steroid; it suppresses mitosis and increases the synthesis of proteins that decrease inflammation and cause vasoconstriction.
Fluocinonide (Vanos)
Fluocinonide is a class II steroid. It has high potency and, like all topical steroids, possesses anti-inflammatory, antipruritic, and vasoconstrictive properties.
Prednisone
This immunosuppressant is used in the treatment of autoimmune disorders. It is a potent anti-inflammatory agent that has salt-retaining properties and varied metabolic effects. Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) activity.
A glucocorticoid, prednisone is readily absorbed from gastrointestinal tract. It is used as second-line pharmacologic treatment for dyshidrotic eczema.
Betamethasone (Celestone, Diprolene, Luxiq)
Betamethasone is used for severe, acute episodes. It has a rapid onset (within 1 h) and a 72-hour duration. It can be administered for inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of PMN leukocytes and reversing capillary permeability.
Triamcinolone (Aristospan, Kenalog)
Triamcinolone is for inflammatory dermatosis that is responsive to steroids; it decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability. This agent has a long duration (4-6 wk).
Immunosuppressives
Class Summary
These agents are for the treatment of severe, acute episodes.[50, 51, 52]
Tacrolimus topical (Protopic)
Tacrolimus topical is used for short-term treatment or for intermittent, long-term treatment in unresponsive or intolerant cases. It inhibits T-lymphocyte activation. Some patients may benefit from tacrolimus topical or pimecrolimus. Patients may achieve disease control with topical calcineurin inhibitors alone. Tacrolimus topical is available in a 0.03% and a 0.1% ointment.
Pimecrolimus cream (Elidel)
Pimecrolimus cream is used for short-term treatment or for intermittent, long-term treatment in unresponsive or intolerant cases. It is available in a 1% cream.
This was the first nonsteroid cream approved in the United States for mild to moderate atopic dermatitis. It is derived from ascomycin, a natural substance produced by the fungus Streptomyces hygroscopicus var. ascomyceticus. Pimecrolimus cream selectively inhibits the production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. Pimecrolimus cream is indicated only after other treatment options have failed.
Methotrexate (Rheumatrex, Trexall)
Methotrexate has an unknown mechanism of action in the treatment of inflammatory reactions; it may affect immune function. Methotrexate ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). It is an antimetabolite that inhibits deoxyribonucleic acid (DNA) synthesis and cell reproduction in malignant cells; it may suppress immune system. A satisfactory response is seen within 3-6 weeks following the administration of methotrexate. Adjust the dose gradually to attain a satisfactory response.
Azathioprine (Imuran, Azasan)
Azathioprine antagonizes purine metabolism and inhibits the synthesis of DNA, ribonucleic acid (RNA), and proteins. It may decrease the proliferation of immune cells, thus lowering autoimmune activity.
Cyclosporine (Neoral. Gengraf, Sandimmune)
Cyclosporine is a cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions, such as delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft versus host disease for a variety of organs. For children and adults, base the dosing on ideal body weight.
Antibiotics
Class Summary
Antibiotics are used for dyshidrosis with secondary impetiginization.
Dicloxacillin
Dicloxacillin binds to 1 or more penicillin-binding proteins, which, in turn, inhibits the synthesis of bacterial cell walls. This agent is used for infections caused by penicillinase-producing staphylococci. It may be used to initiate therapy when staphylococcal infection is suspected
Cephalexin (Keflex)
Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms. The drug's primary activity is against skin flora; it is used for skin infections and for prophylaxis in minor procedures.
Erythromycin (E.E.S., Erythro RX, Ery-Tab)
Erythromycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer RNA (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. It is used for the treatment of staphylococcal and streptococcal infections.
Age, weight, and the severity of infection determine the proper dosage in children. When twice-daily dosing is desired, one half of the total daily dose may be taken every 12 hours. Double the dose for more severe infections.
Antihistamines
Class Summary
Antihistamines are used to treat pruritus associated with dyshidrosis. Desloratadine (Clarinex) is a long-acting, tricyclic histamine antagonist that is selective for the H1 receptor. It is a major metabolite of loratadine, which, after ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine. The dose for adults and children over age 12 years is 5 mg by mouth daily. Decrease the dose in hepatic impairment. Data are limited regarding drug interactions; however, erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase in clinically relevant adverse effects, including QTc, was observed. Adverse effects were similar to placebo, and it rarely causes pharyngitis or dry mouth.
Loratadine (Claritin, Alavert, Loradamed)
This is a nonsedating agent that selectively inhibits peripheral histamine H1 receptors.
Hydroxyzine (Vistaril)
Hydroxyzine antagonizes H1 receptors in the periphery. It has sedating qualities and may suppress histamine activity in the subcortical region of the central nervous system (CNS).
Pramoxine topical (Pramosone, Zypram, Epifoam)
This is a topical antihistamine and mild anti-inflammatory. It blocks nerve conduction and impulses by inhibiting the depolarization of neurons. This agent is available alone or as a 1% or 2.5% cream or ointment. It is available over the counter as Prax.
Nickel Chelators
Class Summary
These minimize the effects of nickel in eczema.
Disulfiram (Antabuse)
Disulfiram is a thiuram derivative that interferes with aldehyde dehydrogenase. It is for patients with severe, vesicular hand dermatitis who are highly allergic to nickel. The chelating effect of disulfiram helps to reduce the body's nickel burden in individuals who are allergic to nickel. Do not administer this drug if the patient has ingested alcohol within last 12 hours. Disulfiram is supplied as a 250-mg tablet.
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