You are in: eMedicine Specialties > Pediatrics: General Medicine > Dermatology Dyshidrotic EczemaArticle Last Updated: Sep 29, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School Camila K Janniger is a member of the following medical societies: American Academy of Dermatology Coauthor(s): Julie K Keck, MD, Assistant Professor of Clinical Pediatrics, Neurodevelopmental Pediatrician, Department of Developmental Pediatrics, Riley Hospital for Children; James D Korb, MD, Program Director, Department of Pediatrics, Children's Hospital of Orange County Editors: Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: dyshidrotic eczema, rash, pompholyx, dyshidrosis, cheiropompholyx, chiropompholyx, dyshidria, palmoplantar hyperhidrosis, dermatitis, pruritic vesicular eruption, acute and recurrent vesicular hand dermatitis INTRODUCTIONSection 2 of 10
  BackgroundDyshidrotic eczema is a type of eczema (dermatitis) of unknown cause that is characterized by a pruritic vesicular eruption on the fingers, palms, and soles. The condition affects teenagers and adults and may be acute, recurrent, or chronic. A more appropriate term for this vesicular eruption is pompholyx, which means bubble. The clinical course of dyshidrotic eczema can range from self-limited to chronic, severe, or debilitating. The condition's unresponsiveness to treatment can be frustrating for the patient and physician. PathophysiologyThe etiology of dyshidrotic eczema is unknown. The condition was inaccurately described in 1873 as dyshidrosis because of the clinical symptom of sweaty palms. The term dyshidrosis indicates a sweating abnormality, although histologic examination reveals no evidence of eccrine glandular involvement. Histologically, the vesicles are intraepidermal and spongiotic with little to no inflammatory changes. The more appropriate term for this vesicular eruption is pompholyx, which means bubble. Although strong reasons to use the term pompholyx have been noted, dyshidrotic eczema remains a commonly used term. A tiny percentage of individuals with the disorder note flares after ingesting metal salts, specifically chromium, cobalt, and nickel. Diets that eliminate these metal salts may rarely have some clinical benefit. One causative study observed reactional pompholyx to interdigital-plantar intertrigos and endogenous reactions to metals or other allergens; however, an unexpected number of patients with so-called contact pompholyx, in which cosmetic and hygiene products play a preponderant role (compared with metals), were also reported.2 FrequencyUnited StatesDyshidrotic eczema accounts for 5% of all cases of eczema of the hand. Mortality/MorbidityDyshidrotic eczema has no associated mortality, although some severe cases can become debilitating. RaceNo racial predilection is reported. SexThe female-to-male ratio is 2:1. AgePeak incidence occurs in patients aged 20-40 years, although the disorder also occurs in teenagers and older patients. CLINICALSection 3 of 10
HistoryPatients with dyshidrotic eczema first describe several hours of itching or burning sensations in their hands, feet, or both before the eruption develops. Tiny vesicles erupt first along lateral aspects of the fingers and then on the palms or soles. Palms and soles may be red and wet with perspiration. The vesicles usually persist for 3-4 weeks. Vesicle outbreaks may occur in waves. A photo-induced form of hand dermatitis resembling dyshidrotic eczema has been described.4 PhysicalPhysical examination performed early in the course of the flare reveals small (ie, 1-2 mm), clear, deep-seated vesicles without erythema erupting on the lateral aspects of fingers, the central palm, and plantar surfaces. The vesicles have been described as resembling tapioca pudding. Eruptions are usually bilateral and symmetric. Patients treated later in the course of dyshidrotic eczema may have unroofed vesicles with inflamed bases, possibly accompanied by peeling or rings of scale or lichenification. Transverse furrows can develop on the nail when eruptions occur in the periungual area, nail matrix, or both. CausesAlthough the etiology of dyshidrotic eczema remains undefined, suspected risk factors include stress, exposure to metal salts, allergic contact dermatitis, and female sex. Iannaccone et al (1999) cite exposure to intravenous immunoglobulin G (IVIG) as a possible risk factor.5 DIFFERENTIALSSection 4 of 10
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| Drug Name | Clobetasol propionate (Temovate) |
|---|---|
| Description | A high-potency corticosteroid with anti-inflammatory, antipruritic, and vasoconstrictive properties. |
| Adult Dose | Apply to affected areas bid |
| Pediatric Dose | <12 years: Not recommended >12 years: Administer as in adults |
| Contraindications | Documented hypersensitivity; viral or fungal skin infections |
| Interactions | None reported |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | May suppress adrenal function in prolonged therapy |
| Drug Name | Prednisone (Deltasone, Meticorten) |
|---|---|
| Description | A glucocorticoid readily absorbed from GI tract. Used as second-line pharmacologic treatment of dyshidrotic eczema. It is a potent anti-inflammatory agent that has salt-retaining properties and varied metabolic effects. Can modify immune response. |
| Adult Dose | 5-60 mg PO qd |
| Pediatric Dose | 0.5-2 mg/kg/d PO qd or divided bid/qid |
| Contraindications | Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI bleeding |
| Interactions | Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use |
These agents are topical immune suppressants that block early T-cell activation, degranulation of mast cells, and multiple cytokines.
| Drug Name | Pimecrolimus (Elidel cream) |
|---|---|
| Description | First nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by the fungus Streptomyces hygroscopicus var. ascomyceticus. Selectively inhibits production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. Indicated only after other treatment options have failed. |
| Adult Dose | Apply topically to affected areas bid Short-term and intermittent use only |
| Pediatric Dose | <2 years: Not established >2 years: Administer as in adults Short-term and intermittent use only |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Potential exacerbation of existing infection at site of application; may cause burning and irritation; caution with conditions that suppress the immune system (eg, AIDS, cancer); possible risk of lymph node or skin cancer based on animal studies and a small number of patients; may increase risk of viral infections; other adverse effects include headache, sore throat, flulike symptoms, fever, and cough |
Article Last Updated: Sep 29, 2008
