Hand and foot eczema (endogenous, dyshidrotic eczema, pompholyx)

Management Strategy

Diagnostic procedures should be performed either to exclude the common differential diagnoses of hand and foot dermatitis such as dermatomycoses and psoriasis, or to reveal potential trigger factors of irritant and allergic contact eczema. The presence of lesions on both hands and feet is associated with chronic and more severe hand eczema, as well as a hyperkeratotic subtype of hand eczema.

Before starting any treatment, avoidance strategies and measures for known irritants and allergens should be employed. This may include a nickel-free diet and complete cessation of smoking for nickel-sensitized patients. Moreover, patient education programs and adherence improving techniques are helpful components of an effective management system.

Possible treatment options include topical agents, ultraviolet (UV) phototherapy, and systemic therapy. Dry and fissured skin lesions are best treated with highly lipophilic ointments, possibly combined with occlusive or semi-occlusive dressings to increase penetration. Keratolytic agents such as urea or salicylic acid are helpful in hyperkeratotic eczema, whereas moist and oozing skin may benefit from hydrophilic creams or gels. Desiccative agents have shown value in dyshidrotic forms of eczema. Antiseptics should be considered to avoid superinfection, especially in erosive or fissured lesions.

Topical corticosteroids of medium to high potency are the mainstay of all topical therapies of hand eczema. The topical calcineurin inhibitor tacrolimus may also be effective, especially for long-term treatment, but should not be combined with UV therapy. Pimecrolimus has shown less efficacy.

Calcipotriol ointment may show beneficial effects in chronic hand eczema, especially in the hyperkeratotic subtype, and may reflect a topical steroid-sparing alternative.

Adjuvant use of oral antihistamines has demonstrated only a slight effect on pruritus. Oral antibiotics, such as first generation cephalosporins, may be added in case of severe bacterial infection.

Psoralen–UVA (PUVA) therapy is the most effective UV-light treatment option for chronic, recurrent hand and foot eczema. UVA phototherapy or narrowband UVB (NB-UVB) phototherapy may also be useful.

Systemic treatment is frequently required in severe, refractory, or persistent hand and foot eczema. Systemic corticosteroids are recommended for short-term use only. Prednisone 0.5–1.0 mg/kg/day tapered over 2 weeks is a typical regimen. Systemic retinoids such as alitretinoin or acitretin are helpful if pregnancy prevention programs are followed strictly. Classic immunosuppressants such as methotrexate, azathioprine , and mycophenolate mofetil have been tried successfully. Ciclosporin may be especially useful in atopic hand eczema, and is approved in many countries for severe atopic dermatitis. Interestingly, a case has also been reported of improvement with oral apremilast.

New emerging therapies include dupilumab , a monoclonal antibody blocking the IL-4/IL-13 pathway. Topical Janus kinase (JAK) inhibitors such as delgocitinib may improve chronic hand eczema despite its subtype, and should be useful in therapy-refractory chronic hand eczema. Oral JAK inhibitors will undoubtedly be useful for hand eczema in the future.

Intradermal localized botulinum toxin A will reduce sweating and may therefore be helpful as adjuvant therapies in dyshidrotic forms.