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Treatment of vesiculobullous hand dermatitis should be based on the acuity of the condition, the severity of the disease, the prominence of blisters versus chronic changes, and any relevant history that reveals possible cofactors.
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Topical steroids, typically high potency (class 1 or 2), are usually first-line agents. They are often more effective if used under occlusion, although this approach may increase the chance of infection. Topical drying agents, such as Domeboro soaks, Burow's solutions (aluminum subacetate), or dilute potassium permanganate solution (1–8,000) may be useful in acute forms with a predominance of vesicles.
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Nonsteroidal topical immunomodulating agents, such as tacrolimus and pimecrolimus, have been studied for treatment of individuals with mild to moderate chronic hand dermatitis with improvements from baseline.5 Topical tacrolimus was shown to be as effective as momethasone furoate 0.1% ointment in a randomized, blinded trial in patients with vesicular pompholyx of the palms. After 2 weeks of treatment, the Dyshidrotic Eczema Area and Severity Index (DASI) was reduced by more than 50%.14
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Hyperkeratotic palmar eczema is notoriously difficult to manage. Topical retinoids and calcipotriene, both of which act to regulate epidermal cell maturation, have anecdotally been shown to improve this category of hand dermatitis.1
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For recurrent pompholyx and chronic vesicular dermatitis, oral prednisone may be required and is often effective if treatment is initiated early, at the onset of the itching prodrome. However, because of significant side effects, systemic glucocorticoids are typically inappropriate for long-term management. Intralesional and intramuscular steroid injections can also be considered for short-term use in acute episodes when intensive topical therapy fails.
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Cyclosporine has been studied at dosing levels of 3 mg/kg/day and 5 mg/kg/day in the treatment of chronic vesicular dermatitis. Although patients showed improvement with treatment, relapses occurred shortly after discontinuation of cyclosporine.15
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Mycophenolate mofetil has been used in the treatment of chronic vesicular dermatitis at dosing levels of 2–3 g/day (in divided doses). It has been anecdotally shown to improve chronic vesicular dermatitis that has been otherwise recalcitrant to corticosteroids, iontophoresis, and phototherapy. However, it has also been anecdotally shown to induce biopsy-proven dyshidrotic eczema.
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Methotrexate has proven a useful therapy of a wide range of skin diseases. In chronic vesicular eczema, it has been reported to partially or completely clear lesions at low doses ranging from 12.5 to 22.5 mg/week.15 However, its wide spectrum of potential side effects remains a limiting factor to its use in this particular skin disease.
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Alitretinoin, (9-cis-retinoic acid) is a novel retinoid with anti-inflammatory properties and one of the newer therapies under study for palmoplantar vesicular eczema. It is the only medication specifically approved for the treatment of adults with hand eczema unresponsive to topical steroids in some countries outside of the United States.19 In a large controlled study with over 1,000 patients it was successful in the treatment of chronic hyperkeratotic hand eczema and offers another treatment option for patients refractory to treatments with corticosteroids, radiation therapy, tretinoin, isotretinoin, and acitretin.20
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UVB, systemic, topical, and bathwater psoralen and UVA light with or without PUVA have been used in severe cases of chronic vesicular hand eczema. Studies evaluating the use of UVA-1 compared localized high-dose UVA-1 irradiation against topical cream psoralen UVA for the treatment of dyshidrotic eczema demonstrated that UVA-1 irradiation and topical PUVA showed similar beneficial responses.23,24 In addition, the potential side effects noted with PUVA, such as phototoxic reactions and long-term carcinogenic risk, are theoretically reduced with UVA-1 therapy. UV therapy is thought to work by induction of apoptosis of T and B lymphocytes.
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Iontophoresis, sympathectomy, and intradermal botulinum toxin are effective therapies for hyperhidrosis and have been studied as treatments for chronic vesicular dermatitis.15 Tap water iontophoresis with pulsed direct current showed no benefit for subjects with hand dermatitis over controls in time to improvement, but those who were treated had much longer remissions, by a factor of months.6 Intradermal botulinum toxin A was shown to have a beneficial effect in patients with treatment-refractory vesicular dermatitis, especially in those patients whose condition was aggravated by hyperhidrosis.25 This therapy may also be used in conjunction with topical corticosteroids.26
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Radiation Therapy and Immunotherapy
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The use of etanercept has also been shown in a case report to be successful in treatment of recalcitrant dyshidrotic eczema for a 4-month period before relapse occurred.16
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Azathioprine has been shown to be efficacious in a study that included six patients with pompholyx; however, a separate case study of its use reported development of myelotoxicity.17,18
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Superficial radiotherapy (Grenz ray) is still sometimes used at a few centers. This condition may be one of the last indications for this treatment modality, and has been shown to be successful in some patients with resistant chronic eczema of the hand in a double-blind study.14 Megavoltage radiation therapy (1,200 cGy) has also been tried in patients with severe chronic vesicular hand dermatitis with moderate success in long-term remission.21,22
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Leuokotriene Inhibitors
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Leukotriene receptor antagonists and inhibitors are oral medications that act by inhibiting proinflammatory mediators in the 5-lipoxygenase pathway and have been shown to block the effects of leukotrienes successfully in asthma, allergic rhinitis, and recently in atopic dermatitis. No specific trial has been reported yet with these medications on pompholyx.
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Phosphodiesterases-4 (PDE4) modulate the release of inflammatory mediators and have recently been investigated as a novel therapeutic approach in the treatment of inflammation-associated diseases. Animal models of PDE4 inhibitors have displayed strong anti-inflammatory action in models of allergic contact dermatitis. The safety and efficacy in pompholyx has yet to be evaluated.
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Tumor necrosis factor inhibitors (e.g., infliximab) have been successful for treatment of psoriatic arthritis and psoriasis, among other chronic inflammatory diseases. No data is available on pompholyx.
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Two severity indices, (1) the dyshidrosis area and severity index and (2) the total sign and symptoms score, have been validated and may prove useful in clinical trials to better assess the effectiveness of these and future therapies.