Medication Summary
The goals of pharmacotherapy for vesicular palmoplantar eczema are to reduce morbidity and to prevent complications.
The dyshidrotic eczema severity index (DASI), a standardized severity scale for palmoplantar eczema, has made it easier to compare the efficacy of various therapies in controlled clinical trials. [68]
Corticosteroids
Class Summary
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the immune response of the body to diverse stimuli.
Betamethasone dipropionate topical (Diprolene)
Betamethasone dipropionate topical is for inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. It affects the production of lymphokines and has inhibitory effect on Langerhans cells.
Clobetasol (Temovate, Olux-E, Temovate E, Cormax)
Clobetasol is a class I superpotent topical steroid; it suppresses mitosis and increases the synthesis of proteins that decrease inflammation and cause vasoconstriction.
Halobetasol (Ultravate)
Halobetasol is a class 1, superpotent topical steroid. It has antiinflammatory, antipruritic, and vasoconstrictive activity.
Prednisone
Prednisone is an immunosuppressant used to treat autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. It stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.
Calcineurin Inhibitors
Class Summary
Topical immunosuppressive agents, such as tacrolimus, have been successfully used to decrease the severity of chronic palmar eczema. These drugs may be used as steroid-sparing agents.
Tacrolimus topical (Protopic)
Tacrolimus topical reduces itching and inflammation by suppressing the release of cytokines from T cells; it inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha (all involved in early T-cell activation). Tacrolimus topical may inhibit the release of preformed mediators from skin mast cells and basophils; it may down-regulate FCeRI expression on Langerhans cells. It can be used in patients as young as 2 years. Drugs of this class more expensive than topical corticosteroids. Tacrolimus is available in an ointment formulation.
Pimecrolimus (Elidel)
Pimecrolimus is a calcineurin inhibitor that has an anti-inflammatory effect through decreasing cytokine production. It leads to decreased expression of IL-3, IL-4, IL-5, and TNFα, and it inhibits mast cell and neutrophil activation. It is available in a cream formulation.
Retinoids
Class Summary
Beta-carotene derivatives have marked effects on keratinizing epithelia. Oral alitretinoin has been shown to be an effective and well-tolerated therapy for treatment of severe hand eczema.
Retinoids
Alitretinoin topical (Panretin)
Alitretinoin is a retinoic acid derivative. Its mechanism of action is thought to be through modulation of the immune system with reduction of inflammatory mediators involved in eczematous reactions. Alitretinoin is category X in pregnancy. Patients should avoid becoming pregnant for up to 2 years after drug administration.
Immunosuppressants
Class Summary
These agents are used for severe acute episodes and as steroid-sparing agents in the chronic forms of the disease.
Azathioprine (Azasan, Imuran)
Azathioprine antagonizes purine metabolism and inhibits the synthesis of DNA, RNA, and proteins. It may decrease the proliferation of immune cells, resulting in low autoimmune activity. It is used in transplant recipients and some autoimmune conditions.
Cyclosporine (Gengraf, Neoral, Sandimmune)
Cyclosporine is a calcineurin inhibitor. It is a potent immunosuppressant and is nonmyelotoxic but markedly nephrotoxic. It is widely used in organ and tissue transplantation and skin diseases (eg, psoriasis, atopic dermatitis).
Methotrexate (Rheumatrex, Trexall)
Methotrexate is an antimetabolite; it inhibits the enzyme dihydrofolate reductase, which is essential for purine and pyrimidine synthesis. It has an unknown mechanism of anti-inflammatory action. Folinic acid after methotrexate administration helps prevent methotrexate-induced mucositis or myelosuppression.
Mycophenolate (CellCept, Myfortic)
Mycophenolate is an immunosuppressant used to prevent acute rejection of renal or cardiac transplants. It inhibits inosine monophosphate dehydrogenase (IMPDH) and suppresses de novo purine synthesis by lymphocytes, inhibiting their proliferation. It inhibits antibody production.
Chelators
Class Summary
These drugs split into two molecules of sodium diethyldithiocarbamate after absorption, which, in turn, chelates divalent metal ions (eg, Ni++) and results in the increased urinary excretion of nickel. They are effective in the treatment of vesicular palmoplantar dermatitis in nickel-hypersensitive patients whose eczema is aggravated by an oral challenge with nickel.
Disulfiram (Antabuse)
Disulfiram is a thiuram derivative that interferes with aldehyde dehydrogenase. The chelating effect is helpful in reducing the nickel burden in patients allergic to nickel.
Dermatologics, Other
Class Summary
PUVA therapy is used to treat many skin conditions, including psoriasis, eczema, urticaria, mycosis fungoides, vitiligo, and palmoplantar pustular dermatoses.
The drug 8-methoxypsoralen (8-MOP) is taken 2 hours before exposure to UVA irradiation. The initial UVA irradiation dose of 0.5 J/cm2 is usually increased by 0.5 J/cm2 for approximately six treatments, then by 1 J/cm2 per treatment for a total of 25-35 treatments.
Local bath-PUVA therapy has been successful in treating palmoplantar eczema and psoriasis. Compared with systemic PUVA, local-bath therapy has several advantages, particularly the absence of phototoxicity, severe hyperpigmentation, and protracted photosensitivity. The drug 8-MOP in a 0.15% alcoholic solution is added to tap water (37°C) at a concentration of 1 mg 8-MOP/L (0.0001%). After a 15-minute bath, the palms or soles are exposed to UVA radiation.
Methoxsalen (Oxsoralen-Ultra, Uvadex, 8-MOP)
Methoxsalen inhibits mitosis by covalently binding to pyrimidine bases in DNA when photoactivated by UVA.
Interleukin Inhibitors
Dupilumab (Dupixent)
Dupilumab is a human monoclonal antibody against the IL-4 receptor alpha subunit. It is FDA approved for moderate-to-severe atopic dermatitis.
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Pompholyx of the palms.
