eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses
Dyshidrotic Eczema: Treatment & Medication
Updated: Aug 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Some mildly affected patients experience spontaneous resolution within 2-3 weeks. Biofeedback therapy for stress reduction has succeeded in some patients. Outpatient care is multifaceted.
- The following treatment is appropriate if bullae are present.
- Use compresses with Burow solution (10% aluminum acetate) in a 1:40 dilution until bullae resolve (usually, within a few days).
- Compresses with a 1:10.000 solution of potassium permanganate are also effective.
- Drain large bullae with a sterile syringe, and leave the roof intact.
- Prescribe systemic antibiotics that cover Staphylococcus aureus and group A streptococci.
- Topical corticosteroids are the mainstay of treatment.
- Typically, use class I steroids initially, then class II or III steroids.
- Ointments penetrate skin better than creams; patients may prefer creams during the day.
- Topical antipruritics with pramoxine are useful.
- Systemic corticosteroids can also be used.
- Either oral prednisone or intramuscular triamcinolone suspension may be used for severe episodes.
- Tapering of prednisone can follow intramuscular treatment.
- Topical calcineurin inhibitors may be helpful.
- Some patients may benefit from topical tacrolimus or pimecrolimus. Several studies have demonstrated their efficacy and tolerability in the treatment of chronic hand dermatitis,12 and long-term occlusive therapy has also been determined to be efficacious, particularly in persons with severe dyshidrotic eczema.12
- Advantages of topical calcineurin inhibitors over topical corticosteroids include the lack of development of tachyphylaxis, telangiectasias, and thinning and atrophy of the skin.13
- Personal experience of the coauthor shows effective control in several patients followed in her practice with topical calcineurin inhibitor therapy alone. Note that topical calcineurin inhibitors can exacerbate irritant hand dermatitis.
- UV-A or UV-A1 alone or with oral or topical psoralen: Hand and/or foot UV-A therapy (UV-A or UV-A1 alone or with oral or topical psoralen) improves the eruption and pruritus when administered 2-3 times per week. The dose typically starts at 0.5 J per treatment and is increased by 0.5 J at every other or every third treatment.
- 8-Methoxypsoralen (MOP) plus UV-A (bath-PUVA): Topical application of MOP and UV-A (bath-PUVA) has been demonstrated to be the preferred method for the treatment of dyshidrotic eczema compared with oral PUVA.14 Local narrow-band UV-B has been shown to be as effective as bath-PUVA in patients with chronic hand eczema of dry and dyshidrotic types.15
- Botulinum toxin A: Injections may be helpful in some patients. Botulinum toxin A intradermal injections as an adjuvant to topical corticosteroids has been tested in a study in which 6 patients who completed an 8-week trial achieved significant reductions in the Dyshidrotic Eczema Area and Severity Index (DASI) scores and faster reductions of pruritus and vesiculation.13 In another study, 7 of 10 vesicular pompholyx patients achieved good-to-very good responses after the injection of botulinum toxin A alone, with a reduction of pruritus.16
- Other therapies
- For severe refractory pompholyx, azathioprine, methotrexate mycophenolate mofetil, cyclosporine, or etanercept may be helpful.
- Etanercept has been administered subcutaneously to one patient with recalcitrant hand pompholyx at a dose of 25 mg twice a week. The patient achieved complete remission for 4 months, after which the patient had a relapse. The etanercept dose was increased to 50 mg twice a week without improvement.17
- Consider measuring thiopurine methyltransferase levels, which may help guide azathioprine therapy. Accurate dosing avoids both toxicity and underdosing.
- Nickel chelators, such as disulfiram (Antabuse), occasionally are used in nickel-sensitive patients who demonstrate a positive oral provocation test.
- Tap water iontophoresis with pulsed direct current may be helpful as adjuvant treatment.
- Khellin, a furanochromone similar to methoxypsoralen, may be used in combination with photochemotherapy (sun exposure) for recalcitrant palmoplantar cases. Khellin, unlike other psoralens, does not induce skin phototoxicity (erythema) and hyperpigmentation of healthy skin after UV-A radiation therapy.
- Alitretinoin activates the retinoid X receptor and all retinoic receptors.
- It has been studied in 319 patients with chronic hand dermatitis (70 with pompholyx) refractory to standard therapy in a randomized, double-blind, placebo-controlled, multicenter trial in which oral alitretinoin was administered at doses of 10 mg, 20 mg, or 40 mg once daily of for 12 weeks. Although alitretinoin induced a significant clinical improvement in a dose-dependent fashion (53% improvement in disease status and 70% reduction in clinical features), no difference was noted in the group of patients with pompholyx compared with placebo.13,18
- In another randomized, double-blind, placebo-controlled, multicenter trial, oral alitretinoin showed a response rate of 33% at a dose of 30 mg/d, compared with 23% at a dose of 10 mg/d and 16% with placebo in 377 patients with pompholyx.19
- Headache and mucocutaneous adverse events, including dry skin, rash, alopecia, exfoliative dermatitis, and hyperlipidemia, were the most common adverse events in these trials.
- Alitretinoin 1% gel has been evaluated for the treatment of classic Kaposi sarcoma,20 photoaging,21 pyogenic granuloma,22 and cutaneous T-cell lymphoma.23 Currently, alitretinoin 1% gel has not been used for the topical treatment of pompholyx.
- Currently, a phase 3, randomized, double-blind (subject, investigator), placebo-controlled, parallel-assignment, safety/efficacy study is being conducted on the treatment of chronic hand dermatitis (including pompholyx) using oral alitretinoin at 30 mg/d (1 capsule) for up to 24 weeks; the estimated completion date is 2010.24 Also see Efficacy and Safety of a Retinoid in the Treatment of Severe Chronic Hand Eczema (HANDEL).
- Newer and potential agents for pompholyx, such as topical bexarotene, systemic alitretinoin, leukotriene receptor antagonists, leukotriene synthesis inhibitors, phosphodiesterase-4 inhibitors, and monoclonal antibodies, have shown to be effective for the treatment of chronic hand dermatitis and other inflammatory conditions, including atopic dermatitis. Controlled studies need to be conducted to establish their efficacy and safety for the treatment of dyshidrotic eczema (pompholyx).
- For severe refractory pompholyx, azathioprine, methotrexate mycophenolate mofetil, cyclosporine, or etanercept may be helpful.
Consultations
- Psychologist - For stress reduction using biofeedback therapy and other techniques
- Allergist - For oral provocation test for nickel, cobalt, or chromium salts
- Oral challenges occasionally are positive in patients who demonstrate negative patch tests to these metals.
- The test is considered positive if a patient's dyshidrotic eczema flares after metal is ingested.
Diet
For nickel-sensitive patients, consider a low-nickel diet for 3-4 weeks. The diet regimen is only rarely successful and is difficult for patients to follow. The diet requires avoiding foods rich in nickel, such as canned foods, foods cooked using nickel-plated utensils, herring, oysters, asparagus, beans, mushrooms, onions, corn, spinach, tomatoes, peas, whole grain flour, pears, rhubarb, tea, cocoa, chocolate, and baking powder. A list of additional nickel-containing foods has been reported by Lofgren and Warshaw.4
For cobalt-sensitive patients, consider a low-cobalt diet that avoids apricots, beans, beer, beets, cabbage, cloves, cocoa, chocolate, coffee, liver, nuts, scallops, tea, and whole grain flour. A point-based low-cobalt diet has been described by Stuckert and Nedorost.2
Activity
Bedrest may be necessary if bullae develop on the feet. Additionally, if palmar bullae develop, patients may not be able to work or perform the activities of daily living.
Medication
The goals of pharmacotherapy for dyshidrotic eczema are to reduce morbidity and prevent complications.
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Modify the body's immune response to diverse stimuli. Topical ointments are more potent but greasier than creams.
Clobetasol (Temovate)
For severe episodes. Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.
Adult
Apply cream or ointment bid to severely affected areas for up to 2 wk; not to exceed 50 g/wk
Pediatric
Not established
None reported
Documented hypersensitivity; viral or fungal skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May suppress adrenal function and result in thinning of skin in prolonged therapy
Fluocinolone (Fluonid, Synalar)
Ointment is a class II, cream is a class III steroid. High-potency; like all topical steroids, has anti-inflammatory, antipruritic, and vasoconstrictive properties.
Adult
Apply cream or ointment sparingly bid as severity warrants
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; herpes simplex infection, fungal, viral, or tubercular skin lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause adverse systemic effects if used over large areas, denuded areas, on occlusive dressings, or during prolonged treatment periods; prolonged use may result in thinning of skin
Prednisone (Deltasone, Meticorten, Orasone)
Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation
by reversing increased capillary permeability and suppressing PMN activity.
Adult
0.5-1 mg/kg/d PO qam; taper over 2 wk
Pediatric
Administer as in adults
Ketoconazole, erythromycin, clarithromycin, estrogens, and birth control pills increase levels
Aminoglutethimide, phenytoin, phenobarbital, rifampin, cholestyramine, and ephedrine decrease levels
Levels of potassium-depleting diuretics (due to potentiation of potassium loss and digitalis toxicity) and cyclosporine may increase; levels of isoniazid, insulin (resistance is induced), and salicylates may decrease; monitor anticoagulant therapy and theophylline levels
Absolute: Systemic fungal infection, herpes simplex keratitis, hypersensitivity (usually with corticotropin, occasionally with IV preparations)
Relative: Hypertension, active TB, CHF, prior psychosis, positive intermediate purified protein derivative test result, glaucoma, severe depression, diabetes mellitus, active peptic ulcer disease, cataracts, osteoporosis, recent bowel anastomosis, and pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur
Betamethasone (Celestone, Soluspan)
For severe acute episodes. Rapid onset (within 1 h) with 72-h duration. For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability.
Adult
5-9 mg IM as single dose
Pediatric
Not advised
Aminoglutethimide, phenytoin, phenobarbital, rifampin, cholestyramine, and ephedrine decrease levels
Levels of potassium-depleting diuretics (due to potentiation of potassium loss and digitalis toxicity) and cyclosporine may increase; levels of isoniazid, insulin (resistance is induced), and salicylates may decrease; monitor anticoagulant therapy and theophylline levels
Absolute: Systemic fungal infection, herpes simplex keratitis, hypersensitivity (usually with corticotropin, occasionally with IV preparations)
Relative: Hypertension, active TB, CHF, prior psychosis, positive intermediate purified protein derivative test result, glaucoma, severe depression, diabetes mellitus, active peptic ulcer disease, cataracts, osteoporosis, recent bowel anastomosis, and pregnancy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications
If given by injection, bruising, infection, cold abscess, temporary depression in skin, and temporary discoloration of skin (usually lightened) may occur at injection site
Triamcinolone (Aristocort)
For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability. Long duration, 4-6 wk.
Adult
40-60 mg IM as single dose
Pediatric
2.5-15 mg (10 mg/mL or 40 mg/mL solutions) IM single dose; repeat prn
Aminoglutethimide, phenytoin, phenobarbital, rifampin, cholestyramine, and ephedrine decrease levels
Levels of potassium-depleting diuretics (due to potentiation of potassium loss and digitalis toxicity) and cyclosporine may increase; levels of isoniazid, insulin (resistance is induced), and salicylates may decrease; monitor anticoagulant therapy and theophylline levels
Absolute: Systemic fungal infection, herpes simplex keratitis, hypersensitivity (usually with corticotropin, occasionally with IV preparations)
Relative: Hypertension, active TB, CHF, prior psychosis, positive intermediate purified protein derivative test result, glaucoma, severe depression, diabetes mellitus, active peptic ulcer disease, cataracts, osteoporosis, recent bowel anastomosis, and pregnancy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Multiple complications may occur (eg, severe infections, hyperglycemia, myopathy, peptic ulcer disease, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression)
If given by injection, bruising, infection, cold abscess, temporary depression in skin, and temporary discoloration of skin (usually lightened) may occur at injection site
Immunosuppressives
For severe acute episodes.25,26,27
Tacrolimus, topical (Protopic)
For short-term treatment or intermittent long-term treatment in unresponsive or intolerant cases. Inhibits T-lymphocyte activation. Some patients may benefit from topical tacrolimus or pimecrolimus. Primary author follows several patients in her practice who are controlled with topical calcineurin inhibitors alone. Available at 0.03% and 0.1% ointment.
Adult
Apply bid to affected areas; continue for 1 wk after clearing
Pediatric
<2 years: Not established
>2-15 years: Apply 0.03% ointment bid to affected areas; continue for 1 wk after clearing
>15 years: Apply as in adults
None reported
Documented hypersensitivity; local infection at treatment site; Netherton syndrome; children <2 y; immunodeficiency syndromes; caution in herpes simplex or varicella-zoster virus infections, eczema herpeticum, or erythroderma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Serious adverse reactions include varicella-zoster virus infection and eczema herpeticum; common adverse reactions include skin burning, pruritus, flulike symptoms, headache, erythema, allergic reaction, skin tingling, hyperesthesia, acne, folliculitis, rash, and urticaria; do not use with occlusive dressings; limit use to affected skin.
Product insert revised and contains boxed warning stating long-term safety of calcineurin inhibitors has not been established; although causal relationship has not been established, rare cases of malignancy (eg, skin and lymphoma) have been reported; only 0.03% ointment indicated for use in children aged 2-15 y
Pimecrolimus, topical (Elidel)
For short-term treatment or intermittent long-term treatment in unresponsive or intolerant cases. Inhibits T-lymphocyte activation. Available at 1% cream
Adult
Apply bid to affected areas; discontinue after clearing
Pediatric
<2 years: Not indicated
>2 years: Administer as in adults
None reported
Documented hypersensitivity; local infection at treatment site; Netherton syndrome; children <2 y; immunodeficiency syndromes; caution in herpes simplex or varicella-zoster virus infection, eczema herpeticum, and erythroderma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Serious adverse reactions include varicella-zoster or herpes simplex virus infection, eczema herpeticum, angioneurotic edema, and anaphylaxis; common adverse reactions include skin burning, flulike symptoms, headache, nasopharyngitis, cough, pyrexia, erythema, hypersensitivity reaction, skin infection, herpes simplex, skin papilloma, erythema, and pruritus
Do not use with occlusive dressings; limit use to affected skin; avoid continuous long-term use; reevaluate if symptoms persist >6 wk.
product insert revised and contains boxed warning stating long-term safety of calcineurin inhibitors has not been established; although causal relationship has not been established, rare cases of malignancy (eg, skin and lymphoma) have been reported; only 0.03% ointment indicated for use in children aged 2-15 y
Methotrexate (Rheumatrex, Folex)
Unknown mechanism of action in treatment of inflammatory reactions; may affect immune function. Ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). Antimetabolite that inhibits DNA synthesis and cell reproduction in malignant cells; may suppress immune system. Satisfactory response seen within 3-6 wk following administration. Adjust dose gradually to attain satisfactory response.
Adult
Administer 1. 5- to 10-mg test dose; check CBC count in 1 wk; if results are normal, continue weekly 1-time 7.5-mg doses (may split if GI upset, ie, 8 am, 8 pm, 8 am dosing); increase dose by 2.5 mg/wk each month (may taper by 2.5 mg/wk each month when decreasing dose to lowest possibility)
Pediatric
Not recommended
Salicylates, NSAIDs, dipyridamole, probenecid, retinoids, ethanol, triamterene, pyrimethamine, sulfonamides, tetracycline, chloramphenicol, penicillin or other broad-spectrum antibiotics, trimethoprim, dapsone, theophylline, phenytoin, phenothiazines, barbiturates, and nitrofurantoin (impair folic acid absorption), ascorbic acid, phenylbutazone, cyclosporin, aminoglycosides
Absolute: Pregnancy or desire to get pregnant, active peptic ulcer, alcoholism, primary/secondary immunodeficiency, blood dyscrasias, active hepatitis, cirrhosis, chronic renal failure, and active infections
Relative: History of excessive ethanol intake or substance abuse, increased LFT results, recent hepatitis, diabetes mellitus, obesity, history of heritable liver disease, unreliable patient, CrCl <50 mL/min, males contemplating conception (must discontinue for 3 mo)
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Monitor CBC counts, differentials, renal panel, urinalysis, and LFT results monthly; CrCl baseline recommended for patients >50 y; monitor more frequently during initial dosing, dose adjustments, or if risk of elevated methotrexate levels (eg, dehydration); has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood cell counts occurs; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly (possibility of increased toxicity with NSAIDs including salicylates not tested yet)
Azathioprine (Imuran)
Antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. May decrease proliferation of immune cells, which results in lower autoimmune activity.
Adult
100-150 mg/d PO initially; then 50-100 mg/d PO maintenance after improvement occurs; more accurate dosing possible with measurement of thiopurine methyltransferase level
Pediatric
Not established
Allopurinol increases risk of pancytopenia; captopril/ACE inhibitors may increase risk of anemia and leukopenia; increased dose of warfarin may be necessary; may need increased dose of pancuronium for adequate paralysis; live-virus vaccines, co-trimoxazole (increased risk of hematologic toxicity); rifampicin (transplants possibly rejected); clozapine (increased risk of agranulocytosis)
Absolute: Documented hypersensitivity, pregnancy or attempting pregnancy, and clinically significant active infection
Relative: Concurrent use of allopurinol; prior treatment with alkylating agents (cyclophosphamide, chlorambucil, melphalan, others) (high risk of neoplasia)
Pediatric: Safety and efficacy not established
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
TPMT testing is not entirely reliable; it involves testing the activity of TPMT activity in RBCs, which correlates with systemic TPMT activity; functional enzyme test has been shown to have variability between test sites, and kits may contain varying amounts of enzyme inhibitor; starting at low doses, monitoring for pancytopenia, and then increasing dose is alternative; if clinical response is not good, patient may be a homozygote for high activity and may need an increased dose
Possible increased risk of lymphoproliferative disorders with long-term therapy; increases risk of neoplasia; caution with liver disease and renal impairment; hematologic toxicities may occur
Cyclosporine (Neoral)
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 dosing on ideal body weight.
Adult
3-5 mg/kg/d PO
Pediatric
Not established
Increase levels: Erythromycin, clarithromycin, azithromycin, norfloxacin ciprofloxacin, cephalosporins, doxycycline, ketoconazole, itraconazole, fluconazole, ritonavir, indinavir, saquinavir, nelfinavir, diltiazem, verapamil, nicardipine, cimetidine, methylprednisolone, dexamethasone, thiazides, furosemide, allopurinol, bromocriptine, danazol, amphotericin B, metoclopramide, oral contraceptive pills, warfarin, and grapefruit juice.
Decrease levels: Rifampin, rifabutin, nafcillin, carbamazepine, phenobarbital, phenytoin, valproate, octreotide, and ticlopidine.
Potentiate renal toxicity: Tobramycin, gentamicin, ketoconazole, azapropazone, TMP-SMZ, vancomycin, sulindac, amphotericin B, indomethacin, naproxen, cimetidine, ranitidine, diclofenac, tacrolimus, and melphalan.
Decreased renal clearance may lead to digitalis toxicity; atorvastatin renal clearance may be decreased, leading to myositis; methylprednisolone or prednisolone renal clearance may be decreased, leading to convulsions; concurrent ACE inhibitors, potassium supplements, and potassium-sparing diuretics may increase risk of hyperkalemia
Absolute: Significantly decreased renal function, uncontrolled hypertension, documented hypersensitivity, and clinically cured or persistent malignancy (except nonmelanoma skin cancer)
Relative: Age <18 or >64 y (transplant recipients as young as 1 y have been treated with no unusual effects; however safety in patients <18 y has not been established); controlled hypertension; planning to receive a live attenuated vaccine; active infection or evidence of immunodeficiency; concurrent phototherapy, coal tar, methotrexate, or other immunosuppressive agents; pregnancy or lactation; unreliable patient; and severe hepatic dysfunction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Evaluate renal and liver functions often by measuring BUN, serum creatinine, serum bilirubin, and liver enzyme levels; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO
Antibiotics
For dyshidrosis with secondary impetiginization.
Dicloxacillin (Dynapen, Dycill)
Binds to one or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. For infections caused by penicillinase-producing staphylococci. May use to initiate therapy when staphylococcal infection is suspected
Adult
250-500 mg PO qid for 7-10 d
Pediatric
25-50 mg/kg/d PO divided qid for 7-10 d
May decrease effects of anticoagulants; probenecid and disulfiram may increase levels; with concurrent use, tetracyclines may decrease effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor PT in patients taking anticoagulant medications; toxicity may increase in patients with renal impairment
Cephalexin (Keflex)
First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures.
Adult
250-500 mg PO qid for 7-10 d
Pediatric
25-50 mg/kg/d PO divided bid for 7-10 d (125 and 250 mg/5 mL)
Coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
Age, weight, and severity of infection determine proper dosage in children. When bid dosing is desired, one half of total daily dose may be taken q12h. Double the dose for more severe infections.
Adult
250-500 mg PO qid for 7-10 d
Pediatric
25-50 mg/kg/d PO divided qid
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (administer pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Antihistamines
To treat pruritus associated with dyshidrosis. Desloratadine (Clarinex) is a long-acting tricyclic histamine antagonist selective for H1 receptor. Is a major metabolite of loratadine, which, after ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine. The dose for adults and children >12 y is 5 mg PO daily. Decrease dose in hepatic impairment. Data 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)
Nonsedating; selectively inhibits peripheral histamine H1 receptors.
Adult
10 mg PO, usually in morning
Pediatric
<6 years: Not established
6-11 years: 10 mg Redi-Tab or 10 mL syr daily (1 mg/mL)
Ketoconazole, erythromycin, procarbazine, and alcohol may increase levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Initiate therapy at lower dose in liver impairment
Hydroxyzine (Atarax)
Antagonizes H1 receptors in periphery. Sedating; may suppress histamine activity in subcortical region of CNS.
Adult
10-50 mg PO q4-6h, often at bedtime
Pediatric
0.5 mg/kg PO q4-6h or 10 mg/5 mL
CNS depression may increase with alcohol or other CNS depressants when coadministered
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Associated with clinical exacerbations of porphyria (may not be safe for porphyric patients); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness
Pramoxine (Pramosone)
Topical antihistamine and mild anti-inflammatory. Blocks nerve conduction and impulses by inhibiting depolarization of neurons. Available alone or as 1% or 2.5% cream or ointment. Available OTC as Prax.
Adult
Topically apply cream or ointment bid/tid to affected area
Pediatric
Apply as in adults
<12 years: Not indicated
None reported
Documented hypersensitivity; do not apply over large areas and avoid contact with eyes and nose
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Serious adverse reactions include anaphylactic reactions and skin sloughing (rare); common adverse reactions include contact dermatitis, edema, burning, stinging, and tenderness; caution in patients with trauma in area to be treated
Nickel chelators
Minimize effects of nickel in eczema.
Disulfiram (Antabuse)
Thiuram derivative that interferes with aldehyde dehydrogenase. For patients highly allergic to nickel with severe vesicular hand dermatitis. Chelating effect of disulfiram helps reduce the body's nickel burden in individuals allergic to nickel. Do not administer if patient has ingested alcohol within last 12 h. Supplied as a 250-mg tab.
Adult
250-500 mg/d PO (range 125-500 mg); not to exceed 500 mg/d
Pediatric
Not established
Increases effects of diazepam and chlordiazepoxide; metronidazole, isoniazid, and phenytoin may increase toxicity of disulfiram; coadministration with warfarin may increase PT; coadministration with alcohol may cause disulfiram reaction
Documented hypersensitivity; severe myocardial disease and coronary occlusion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypothyroidism, hepatic cirrhosis, hepatic disease or insufficiency, seizure disorders, diabetes mellitus, cerebral damage, and nephritis
More on Dyshidrotic Eczema |
| Overview: Dyshidrotic Eczema |
| Differential Diagnoses & Workup: Dyshidrotic Eczema |
 Treatment & Medication: Dyshidrotic Eczema |
| Follow-up: Dyshidrotic Eczema |
| Multimedia: Dyshidrotic Eczema |
| References |
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References
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Stuckert J, Nedorost S. Low-cobalt diet for dyshidrotic eczema patients. Contact Dermatitis. Dec 2008;59(6):361-5. [Medline].
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Lofgren SM, Warshaw EM. Dyshidrosis: epidemiology, clinical characteristics, and therapy. Dermatitis. Dec 2006;17(4):165-81. [Medline].
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Further Reading
Keywords
dyshidrotic eczema, pompholyx, vesicular palmoplantar eczema, atopic dermatitis, contact dermatitis, hand eczema, atopic diathesis, asthma, hay fever, allergic sinusitis, contact allergens, intravenous immunoglobulin therapy, interdigital maceration, desquamation of interdigital spaces
cellulitis, lymphangitis, Dyshidrotic Eczema Area and Severity Index, allergy to ingested metals, dermatophyte infection, emotional stress, nickel sensitivity, id reaction, tinea pedis infection, pompholyx dermatophytid, palmar pompholyx reaction, implanted metals.
