Excerpt from Vesicular Palmoplantar Eczema

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Background

Vesicular palmoplantar eczema is a term used to describe a group of diseases characterized by vesiculobullous eruption involving mainly the hands and feet. Clinical presentations vary from acute dermatitis to more chronic relapsing and remitting disease patterns.

Although considerable overlap exists in the various forms of vesicular palmoplantar eczema, the disease can be divided into 4 distinct categories: pompholyx, subacute or chronic relapsing vesiculosquamous eczema, chronic vesiculohyperkeratotic or hyperkeratotic eczema, and id reactions.

Pompholyx may be further subdivided into vesicular and bullous forms in which patients present with acute eruptions of blisters over their palms and soles. Chronic vesiculosquamous eczema, also called dyshidrotic eczema, was initially thought to be caused by abnormal function of the sweat glands. This association has since been disproved, but the term dyshidrotic eczema is still used. Patients with this variant present with vesicles involving the inner sides of the fingers. The chronic hyperkeratotic variety involves mainly the central palms, where it causes thickening and fissures. This category is notoriously the most difficult to treat. An id reaction refers to vesicular eruption of the hands, caused by a distal focus of infection, with fungal infections being the most common.

Despite the wide range of clinical presentations, all 4 types are histologically characterized by features of dermatitis, such as spongiosis and exocytosis.

Pathophysiology

Vesicular palmoplantar eczema is often thought to have an unidentified intrinsic cause. Although many etiologic factors are described, the underlying pathology is unknown. Similarly, though certain triggers have been associated with the development or worsening of symptoms, how these triggers cause flares has not been elucidated.

The disease results in histologic evidence of dermatitis, such as spongiosis, which is often accompanied by lymphocytic infiltrates.

Frequency

United States

The frequency in the United States is unknown.

International

The true incidence is unknown, but vesicular palmoplantar eczema is probably responsible for 5-20% of all cases of eczema of the hand.

Mortality/Morbidity

Patients with mild cases of pompholyx have an excellent prognosis. The more severe chronic hyperkeratotic variety often requires lifelong treatment and results in considerable disability.

Sex

The male-to-female ratio is 1:1.

Age

Pompholyx most commonly occurs in patients aged 20-40 years, but it may occur in individuals of any age. Onset in patients younger than 10 years is unusual. The frequency of recurrent episodes of pompholyx decreases after middle age, although this is not true of chronic vesicular and hyperkeratotic variants.

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