What is the role of systemic medications 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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Systemic therapy includes steroids, immunosuppressive agents (eg, azathioprine, [33] cyclosporine), retinoids (eg, acitretin, alitretinoin), and PUVA.

Consider the use of systemic glucocorticoids or intralesional steroids in acute episodes of vesicular palmoplantar eczema when local therapy fails. These agents are not helpful for long-term treatment because of a potential for severe adverse effects.

Cyclosporine, mycophenolate mofetil, and methotrexate either alone or in combination with steroids may be used for severe, recalcitrant cases of vesicular palmoplantar eczema. [34, 35] These therapies have also been tried as steroid-sparing agents in chronic relapsing eczema.

For hyperkeratotic eczema, consider the use of aromatic retinoids, such as acitretin, which help control hyperkeratosis. These agents are best used in relatively low doses because of adverse effects. Therapy may need to be continued indefinitely in cases of hyperkeratotic eczema and is often accompanied by topical occlusive therapy, with combined or alternating steroids and keratolytics (5-20% salicylic acid) or tar preparations.

Increasingly, the retinoid alitretinoin has been shown to be a favorable option for severe hand eczema. Oral alitretinoin has been shown to be an effective and well-tolerated therapy for treatment of severe hand eczema. [36, 37] One randomized, double-blind, placebo-controlled multicenter trial examining severe chronic hand eczema found alitretinoin superior to placebo, with 48% of patients achieving full or almost full resolution of signs and symptoms. [38] A 2012 observational study noted alitretinoin improved vesicular eczema in 47.9% of patients. [39] An open-label study showed significant improvement with alitretinoin at doses starting at 10 mg daily (increased to 30 mg daily as tolerated). [40] A more recent chart review showed alitretinoin to be a safe and tolerated medication in real-world practice for chronic hand dermatitis, which included hyperkeratotic and dyshidrotic hand eczema. [41]

The use of etanercept in a case study achieved a 4-month remission of vesicular palmoplantar eczema, which was followed by relapse. [42]

Dupilumab, a novel monoclonal antibody therapy for moderate-to-severe atopic dermatitis, has shown positive results in case reports for dyshidrosis as well as hand dermatitis. [43, 44, 45, 46]

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