AUTHOR AND EDITOR INFORMATION

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

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• Introduction
• Clinical
• Differentials
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• Medication
• Follow-up
• Miscellaneous
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Background

Dyshidrotic eczema is a recurrent or chronic relapsing form of vesicular palmoplantar dermatitis of unknown etiology. Dyshidrotic eczema also is termed pompholyx, which derives from cheiropompholyx, which means "hand and bubble" in Greek.

The etiology of dyshidrotic eczema is unresolved and believed to be multifactorial. It is considered a reaction pattern caused by various endogenous conditions and exogenous factors.

Pathophysiology

Several hypotheses have been proposed for the pathophysiology of dyshidrotic eczema. The original hypothesis of sweat gland dysfunction has been disputed because vesicular lesions are not associated with sweat ducts. Patients do not usually have hyperhidrosis. However, note that patients with dyshidrotic eczema have been reported to improve and have fewer relapses after botulinum toxin A injection.

Dyshidrotic eczema may be associated with atopy and familial atopy. Of patients with dyshidrosis, 50% have atopic dermatitis.

Exogenous factors (eg, contact dermatitis to nickel, balsam, cobalt; sensitivity to ingested metals; dermatophyte infection; bacterial infection) may trigger episodes. These antigens may act as haptens with a specific affinity for palmoplantar proteins of the stratum lucidum of the epidermis. The binding of these haptens to tissue receptor sites may initiate pompholyx.

Emotional stress and environmental factors (eg, seasonal changes, hot or cold temperatures, humidity) reportedly exacerbate dyshidrosis. A similar eruption has been reported after intravenous immunoglobulin infusion.

In some patients, a distant fungal infection can cause palmar pompholyx as an id reaction. In one study, one third of pompholyx occurrences on the palms resolved after treatment for tinea pedis. Trichophyton rubrum is the most commonly identified dermatophyte.

Frequency

United States

Dyshidrotic eczema occurs in as many as 5-20% of patients with hand eczema and more commonly occurs in warmer climates and during spring and summer months.

International

Dyshidrotic eczema comprised 1% of initial consultations in a 1-year Swedish study.

Mortality/Morbidity

Dyshidrotic eczema can be severe, resulting in occupational disability and time away from work; however, disability compensation usually is not provided for this condition.

Sex

Male-to-female ratio is 1:1.

Age

Dyshidrotic eczema affects individuals aged 4-76 years; mean age is 38 years. After middle age, the frequency of episodes tends to decrease.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

Patients complain of pruritus of hands and feet with sudden onset of blisters. Burning pain or pruritus occasionally may be experienced before blisters appear. Episodes vary in frequency from once per month to once per year. Patients may report a variety of factors that possibly are related to eruptions.

• Emotional stress
• Personal or familial atopic diathesis (eg, asthma, hay fever, sinusitis)
• Certain work exposures (eg, cobalt) and/or recreational exposures
• Recent exposure to contact allergens (eg, nickel, balsams, paraphenylenediamine, chromate, sesquiterpene lactones) before condition flares
• Exposure to contact irritants before condition flares
• Recent exposure to costume jewelry (patients with palmar pompholyx and allergic to nickel)
• Recent treatment with intravenous immunoglobulin therapy
• HIV related: Two cases were reported of HIV-positive patients who developed dyshidrotic eczema as an immune reconstitution inflammatory syndrome shortly after highly active antiretroviral therapy.

Physical

Symmetric crops of clear vesicles and/or bullae on the palms and lateral aspects of fingers characterize dyshidrotic eczema (Media Files 1-2, Media Files 5-7, and Media File 9). Feet, soles, and the lateral aspects of toes also may be affected.

• In mildly affected patients, vesicles are present only on the lateral aspects of fingers and, occasionally, involve feet and toes (Media File 9).
• Vesicles are deep seated with a tapiocalike appearance, without surrounding erythema (Media File 2).
• • May become large, form bullae, and become confluent (Media File 8)
  • Typically resolve without rupturing, followed by desquamation


• Hands are involved solely in 80% of patients, feet solely in 10% (Media File 3), and both hands and feet are involved in 10% of patients (Media File 8).
• With long-standing disease, patients' fingernails may reveal dystrophic changes (eg, irregular transverse ridging, pitting, thickening, discoloration).
• Interdigital maceration and desquamation of the interdigital spaces often are present, despite the possible absence of a dermatophyte infection.
• Vesicles and/or bullae may become infected secondarily, and pustular lesions may be present. Cellulitis and lymphangitis may develop.
• The Dyshidrotic Eczema Area and Severity Index recently was developed based on severity grades for the number of vesicles per square centimeter, erythema, desquamation, itch, and the extent of affected areas. The index was found to be a simple standardized method for assessing the condition and was used to assess disease severity and treatment effectiveness in 2 clinical studies. Further evaluation with larger patient groups is needed.

Causes

The cause of dyshidrotic eczema is unknown. The condition often appears related to other skin diseases (eg, atopic dermatitis, contact dermatitis, allergy to ingested metals, dermatophyte infection, bacterial infection, environmental or emotional stress). Several factors may participate in causing dyshidrotic eczema and pompholyx.

• Genetic factors: Monozygotic twins have been affected simultaneously by dyshidrotic eczema. The pompholyx gene has been mapped to band 18q22.1-18q22.3, in the autosomal dominant form of familial pompholyx.
• Atopy: As many as 50% of patients with dyshidrotic eczema have reportedly had personal or familial atopic diathesis (eczema, asthma, hayfever, allergic sinusitis).
• • Serum immunoglobulin E (IgE) level frequently is increased, even in patients who do not report a personal or familial history of atopy.
  • Occasionally, dyshidrotic eczema is the first manifestation of an atopic diathesis.


• Nickel sensitivity: This may be a significant factor in dyshidrotic eczema.
• • Nickel sensitivity was reportedly low in some studies of dyshidrosis patients but significantly elevated in other studies.
  • Increased nickel excretion in the urine has been reported during exacerbations of pompholyx.
  • Ingested metals have been found to provoke exacerbations of pompholyx in some patients.


• Low-nickel diets: These have reportedly decreased the frequency and severity of pompholyx flares.
• • A high palmoplantar perspiration rate has been suggested to result in a local concentration of metal salts that may provoke the vesicular reaction.
  • Contact allergy has been documented in 30% of patients with dyshidrotic eczema.


• Id reaction: Dyshidrotic eczema outbreaks are not always associated with exposure to sensitizing chemicals or metals (eg, chromium, cobalt, carba mix, fragrance mix, diaminodiphenylmethane, dichromates, benzoisothiazolones, paraphenylenediamine, perfumes, fragrances, balsam of Peru, primula plant). Controversy surrounds the possible existence of an id reaction, which is a distant dermatophyte infection (tinea pedis, kerion of scalp) triggering a palmar pompholyx reaction (also termed pompholyx dermatophytid).
• Fungal infection: Pompholyx occasionally resolves when a tinea pedis infection is treated, then relapses when the fungal infection recurs, supporting the existence of this reaction pattern. Of patients who have a vesicular reaction to intradermal trichophytin testing, less than one third have experienced a resolution of pompholyx after treatment with antifungal agents.
• Emotional stress: This is a possible factor in dyshidrotic eczema. Many patients report recurrences of pompholyx during stressful periods. Improvement of dyshidrotic eczema using biofeedback techniques for stress reduction supports this hypothesis.
• Other factors: Isolated reports of other possible causative factors exist, such as aspirin ingestion, oral contraceptives, cigarette smoking, and implanted metals.

DIFFERENTIALS

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Other Problems to be Considered

Dyshidrosiform pemphigoid
Inflammatory tinea pedis or tinea manus
Palmoplantar pustular psoriasis
Pustular bacterid

WORKUP

Section 5 of 11  

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• Follow-up
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• Multimedia
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Lab Studies

• Diagnosis is usually made clinically.
• Bacterial culture and sensitivity exclude secondary infection.
• Blood tests are not usually ordered; however, IgE levels are commonly elevated.

Other Tests

• Use patch testing to exclude allergic contact dermatitis.
• Measuring thiopurine methyltransferase levels allows accurate dosing of azathioprine.

Procedures

• Perform potassium hydroxide wet mount preparation to exclude dermatophyte infection.
• Punch biopsy for hematoxylin and eosin staining usually is not necessary.
• Punch biopsy for periodic acid-Schiff staining may help exclude dermatophytosis in patients with unresponsive disease.
• Use punch biopsy for direct immunofluorescence to exclude bullous pemphigoid.

Histologic Findings

Spongiosis with an epidermal lymphocytic infiltrate and intraepidermal vesicles or bullae are not associated with sweat glands.

TREATMENT

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Medical Care

Some mildly affected patients experience spontaneous resolution within 2-3 weeks. Biofeedback therapy for stress reduction has succeeded in some patients. Outpatient care is multifaceted.

• The following treatment is appropriate if bullae are present.
• • Use compresses with Burow solution (10% aluminum acetate) in a 1:40 dilution until bullae resolve (usually, within a few days).
  • Compresses with a 1:10.000 solution of potassium permanganate are also effective.
  • Drain large bullae with a sterile syringe, and leave the roof intact.
  • Prescribe systemic antibiotics that cover Staphylococcus aureus and group A streptococci.
• Topical corticosteroids are the mainstay of treatment.
• • Typically, use class I steroids initially, then class II or III steroids.
  • Ointments penetrate skin better than creams; patients may prefer creams during the day.
  • Topical antipruritics with pramoxine are useful.
• Systemic corticosteroids.
• • Either oral prednisone or intramuscular triamcinolone suspension may be used for or severe episodes.
  • Tapering of prednisone can follow intramuscular treatment.
• Some patients may benefit from topical tacrolimus or pimecrolimus. The primary author follows several patients in her practice who are controlled with topical calcineurin inhibitors alone.
• Hand and/or foot UVA therapy (UVA or UVA1 alone or with oral or topical psoralen) improves the eruption and pruritus when administered 2-3 times per week. The dose typically starts at 0.5 J per treatment and is increased by 0.5 J at every other or every third treatment.
• Botulinum toxin A injections may be helpful in some patients.
• For severe refractory pompholyx, azathioprine, methotrexate mycophenolate mofetil, cyclosporine, or etanercept may be helpful. Consider measuring thiopurine methyltransferase levels, which may help guide azathioprine therapy. Accurate dosing avoids both toxicity and underdosing.
• Nickel chelators, such as disulfiram (Antabuse), occasionally are used in nickel-sensitive patients who demonstrate a positive oral provocation test.
• Tap water iontophoresis with pulsed direct may be helpful as adjuvant treatment.
• Khellin, a furanochromone similar to methoxypsoralens, may be used in combination with photochemotherapy (sun exposure) for recalcitrant palmoplantar cases. Khellin, unlike other psoralens, does not induce skin phototoxicity (erythema) and hyperpigmentation of healthy skin after UVA radiation therapy.

Consultations

• Psychologist - For stress reduction using biofeedback therapy and other techniques
• Allergist - For oral provocation test for nickel, cobalt, or chromium salts
• • Oral challenges occasionally are positive in patients who demonstrate negative patch tests to these metals.
  • The test is considered positive if a patient's pompholyx flares after metal is ingested.

Diet

• For nickel-sensitive patients, consider a low-nickel diet for 3-4 weeks.
• • The diet regimen only rarely is successful and is difficult for patients to follow.
  • The diet requires avoiding foods rich in nickel, such as canned foods, foods cooked in nickel-plated utensils, herring, oysters, asparagus, beans, mushrooms, onions, corn, spinach, tomatoes, peas, whole grain flour, pears, rhubarb, tea, cocoa, chocolate, and baking powder.

• For cobalt-sensitive patients, consider a low-cobalt diet that avoids apricots, beans, beer, beets, cabbage, cloves, cocoa, chocolate, coffee, liver, nuts, scallops, tea, and whole grain flour.

Activity

• Bedrest may be necessary if bullae develop on the feet.
• If palmar bullae develop, patients may not be able to work or perform the activities of daily living.

MEDICATION

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• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Modify the body's immune response to diverse stimuli. Topical ointments are more potent but greasier than creams.

Drug Category: Immunosuppressives

For severe acute episodes.

Drug Category: Antibiotics

For dyshidrosis with secondary impetiginization.

Drug Category: Antihistamines

To treat pruritus associated with dyshidrosis. Desloratadine (Clarinex) is a newly approved long-acting tricyclic histamine antagonist selective for H1 receptor. Is a major metabolite of loratadine, which, after ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine. The dose for adults and children >12 y is 5 mg PO qd. Decrease dose in hepatic impairment. Limited data exist regarding drug interactions; however, erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase in clinically relevant adverse effects, including QTc, was observed. Adverse effects were similar to placebo, and it rarely causes pharyngitis or dry mouth.

Drug Category: Nickel chelators

Minimize effects of nickel in eczema.

FOLLOW-UP

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

• Schedule follow-up and check blood pressure 1 week after initiating prednisone.

Deterrence/Prevention

• Advise patients to avoid known contact irritants or allergens.
• Advise patients to reduce stress (may help some patients).
• Advise patients to follow a hand care regimen.
• Advise regular prophylactic use of emollients.

Complications

• Secondary bacterial infection of vesicles or bullae can result in cellulitis, lymphangitis, and septicemia (rare).
• Dystrophic nail changes may develop with transverse ridging, thickening, discoloration, and pitting of nails.

Prognosis

• Dyshidrotic eczema follows a chronic intermittent course. Fewer episodes occur after middle age.

Patient Education

• Instruct patients to avoid contact with certain allergens or irritants (eg, nickel).
• Instruct patients to follow a hand care routine that avoids irritants.
• Instruct patients to use emollients regularly.
• For excellent patient education resources, visit eMedicine's Skin, Hair and, Nails Center. Also, see eMedicine's patient education article Eczema.

MISCELLANEOUS

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• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to guard against or inform patients of the potential development of systemic corticosteroid side effects with prolonged use of systemic steroids (eg, hypertension, diabetes mellitus, weight gain, cataracts, osteoporosis)
• Failure to acquire an adequate history of exposure to potential allergic and irritant contactants (contactants at patient's work may be a contributing factor or cause recurrent episodes)
• Failure to consider other possible diagnoses

Special Concerns

• Substances used to systemically challenge patients with possible ingested allergens may trigger exacerbations. Vasculitis or erythema multiforme may develop during this testing.

MULTIMEDIA

Section 10 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Tense vesicles and bullae on the palm. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery.
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Media file 2:  Close-up view of tense vesicles and bullae of the palm. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery.
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Media file 3:  Discrete yellow pustules on the sole of the foot. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery.
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Media file 4:  Multiple tense vesicles on the palm.
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Media file 5:  Small tense vesicles on the fingers.
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Media file 6:  Small, discrete, coalesced vesicles on the dorsal hand.
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Media file 7:  Small, discrete, coalesced vesicles on the fingers.
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Media file 8:  Palms and soles of a patient with a dyshidrosis flare. The patient unroofed a large bulla on the right sole.
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Media file 9:  Small discrete vesicles of the lateral fingers.
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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Article Last Updated: Jun 8, 2007