What is the role of topical therapy in the treatment of vesicular palmoplantar eczema?

Updated: Aug 23, 2019
  • Author: Jessica Dunkley, MD, MHSc, CCFP; Chief Editor: Dirk M Elston, MD  more...
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Answer

First-line topical therapy for vesicular palmoplantar eczema includes high-potency glucocorticoids followed by second-line topical therapy options such as topical calcineurin inhibitors, adjunctive keratolytics, calcipotriene, and/or retinoids. [2]

Topical high-potency glucocorticoids, such as betamethasone dipropionate and clobetasol propionate, are first-line therapies. Ointment preparations are less irritating and can enhance drug delivery. As well, application of these medications under plastic and vinyl occlusion enhances their efficacy. However, this method may predispose the patient to secondary infection and to both local and systemic adverse effects of corticosteroids. Therefore, it should be used only intermittently and should never be used in the presence of coexisting infection.

Patients with mild vesicular palmoplantar eczema may be controlled with the use of less potent corticosteroids such as betamethasone valerate, triamcinolone, or mometasone cream or ointment.

In the hyperkeratotic form of hand eczema, topical keratolytic agents like salicylic acid and tar agents may be useful adjunctive therapies.

Acute, severe episodes of pompholyx benefit from rest, and bland applications with wet soaks and compresses and with drying agents such as Burow solution. Occasionally, large blisters may need to be aspirated.

Topical calcineurin inhibitors, such as topical tacrolimus 0.1% ointment and pimecrolimus, have been shown to be as effective as mometasone furoate in the treatment of chronic relapsing eczema of the hands. [30] These topical immunomodulators may be used as steroid-sparing agents to treat resistant palmar eczema, with minimal systemic absorption or systemic effect. [31] Use of other agents should be considered when plantar eczema is being treated because this therapy is less effective on the soles of the feet than on the hands. The use of occlusion with these agents has also been shown to increase their efficacy.

A small open-label study demonstrated efficacy of topical vitamin D-3 derivatives (ie, calcipotriol, maxacalcitol) for the control of hyperkeratotic palmoplantar eczema. [32]


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