You are in: eMedicine Specialties > Pediatrics: General Medicine > Dermatology Dyshidrotic EczemaArticle Last Updated: May 22, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Camila K Janniger, MD, Clinical Professor, Dermatology and Chief, Pediatric Dermatology, Clinical Associate Professor, Pediatrics, University Medicine and Dentistry of New Jersey, 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; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; 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; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System Author and Editor Disclosure Synonyms and related keywords: dyshidrotic eczema, pompholyx, dyshidrosis, cheiropompholyx, chiropompholyx, dyshidria, palmoplantar hyperhidrosis, dermatitis, pruritic vesicular eruption 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 pompholyx 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 pompholyx 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 shows 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. While 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. A genetic component to the development of pompholyx may be involved in some patients. Pompholyx has been described in few large families, so no gene or locus had been identified1. A genome-wide search in a large Chinese family identified a locus at chromosome 18q22.1-18q22.3, with a maximum 2-point logarithm of the odds (LOD) score of 3.61 at marker D18S1131 (theta = 0.00). Haplotype analyses showed the gene to be located within 12.07 cM region between markers D18S465 and D18S1362, which corresponds to 8.0 Mb. FrequencyUnited StatesPompholyx accounts for 5% of all cases of eczema of the hand. Mortality/MorbidityPompholyx 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 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 pompholyx has been described2. 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 this disorder 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 pompholyx remains undefined, suspected risk factors include stress, exposure to metal salts, allergic contact dermatitis, and female sex. In a recent article, Iannaccone et al (1999) cite exposure to intravenous immunoglobulin G (IVIG) as a possible risk factor3. 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 - Safety for use during pregnancy has not been established. |
| 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 pompholyx. 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 - Usually safe but benefits must outweigh the risks. |
| 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 - Safety for use during pregnancy has not been established |
| 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: May 22, 2007
