- A skin rash (dermatitis) of which there are several different classes within the family “dyshidrosis” and strict definitions are disputed.
- Dyshidrotic eczema:
- Common, chronic, or recurrent, nonerythematous, vesicular eruption primarily of the palms, soles, and interdigital areas
- Associated with burning, itching, and pain
- Pompholyx (from Greek, “bubble”):
- Rare condition characterized by abrupt onset of large bullae, primarily on hands
- Sometimes used interchangeably with dyshidrosis, although many believe them to be discrete entities
- Lamellar dyshidrosis:
- Fine, spreading exfoliation of the superficial epidermis in the same distribution as described above
- System(s) affected: Dermatologic; Exocrine; Immunologic
- Synonym(s): Pompholyx; Cheiropompholyx; Keratolysis exfoliativa; Dyshidrotic eczema; Vesicular palmoplantar eczema; Desquamation of interdigital spaces; Palmar pompholyx reaction
- Incidence is 0.5%.
- Mean age of onset is <40 years.
- Male = Female
- Comprises 5–20% of hand eczema cases
20 cases per 100,000
- Many risk factors are disputed in the literature, with none being consistently associated
- Other dermatologic conditions:
- Atopic dermatitis (early in life)
- Contact dermatitis (later in life)
- Sensitivity to
- Drugs: neomycin, quinolones, acetaminophen, and oral contraceptives
- Nickel (seen in patients treated with disulfiram, which causes a high serum level of nickel)
- Smoking in males
- Atopy: 50% of patients with dyshidrotic eczema have atopic dermatitis.
- Rare autosomal dominant form of pompholyx found in Chinese population maps to chromosome 18q22.1–18q22.3
- Control emotional stress.
- Avoid excessive sweating.
- Avoid exposure to irritants.
- Avoid diet high in metal salts (chromium, cobalt, nickel).
- Exact mechanism unknown; thought to be multifactorial
- On dermatopathology, vesicles are found in spongiotic dermatitis
- Thick stratum corneum of palmar and plantar skin keeps the vesicles intact
- Exact cause not known
- Aggravating factors (debated):
- Hyperhidrosis (in 40% of patients with the condition)
- Climate: Hot or cold weather; humidity
- Nickel sensitivity
- Irritating compounds and solutions
- Dermatophyte infection
- Prolonged wear of occlusive gloves
- Intravenous immunoglobulin therapy
Commonly Associated Conditions
- Atopic dermatitis
- Allergic contact dermatitis
- Parkinson disease
- Episodes of pruritic rash alternating with periods that are symptom free
- Recent emotional stress
- Familial or personal history of atopy
- Exposure to allergens or irritants (1):
- Occupational, dietary, or household
- Cosmetic and personal hygiene products
- Costume jewelry use
- IV immunoglobulin therapy
- Symmetric distribution on the palms and soles; also may affect the dorsal aspects of hands and feet
- Early findings:
- 1–2 mm, clear nonerythematous deep-seated vesicles
- Late findings:
- Unroofed vesicles with inflamed bases
- Peeling, rings of scale, or lichenification common
Diagnostic Tests & Interpretation
Initial lab tests
Skin culture in suspected secondary infection (most commonly staph aureus) (2)
Follow-Up & Special Considerations
Consider antibiotics based on culture results and severity of symptoms.
- Diagnosis is based on clinical exam
- Patch test (to elicit allergic cause)
- KOH wet mount (if concerned about dermatophyte infection)
- Fine 1–2-mm spongiotic vesicles intraepidermally with little to no inflammatory changes
- No eccrine glandular involvement
- Vesicular tinea pedis/manus
- Vesicular id reaction
- Contact dermatitis (allergic or irritant)
- Chronic vesicular hand dermatitis
- Drug reaction
- Bullous disorders: Dyshidrosiform bullous pemphigoid, pemphigous, bullous impetigo, epidermolysis bullosa
- Pustular psoriasis
- Acrodermatitis continua
- Erythema multiforme
- Herpes infection
- Pityriasis rubra pilaris
- Vesicular mycosis fungoides
Identification and avoidance of aggravating factors.
- Mild cases: Topical steroids (high potency) (2)[B]
- Moderate to severe cases:
- Ultrahigh-potency topical steroids with occlusion over treated area (3)[B]
- Psoralens plus UV therapy (PUVA), either oral or immersion in psoralens (4)[B]:
- Oral 8-methoxypsoralen (8-MOP) dose: 0.6 mg/kg taken 1 h prior to UVA irradiation
- Immersion in 8-MOP: Solution of 5 mg/L of water × 15 minutes immediately preceding UVA irradiation
- Recurrent cases (3)[C]:
- Systemic steroids at onset of itching prodrome
- Single morning dose of 60 mg × 3–4 days every 2–4 months
- Topical calcineurin inhibitors (mitigate the long term risks of topical steroid use):
- Topical tacrolimus (5)[A]
- Topical pimecrolimus (5)[A]
- Oral cyclosporine (2)[A]
- Injections of botulinum toxin type A (BTXA) (5)[A]
- Newer topical forms of BTXA currently being developed and show promise
- Systemic alitretinoin (5)[A]
- Topical bexaarotene (a retinoid X receptor agonist approved for use in cutaneous T-cell lymphoma) (5)[B]
- Methotrexate (5)[C]
- Radiation therapy (6)[C]
- UV-free phototherapy (5)[C]
- Avoid possible causative factors: Stress, chemical irritants, nickel, occlusive gloves, smoking, sweating
- Moisturizers/emollients for symptomatic relief
- Foot care:
- Wear shoes with leather rather than rubber soles (e.g., sneakers).
- Wear socks made of cotton instead of synthetic materials.
- Remove shoes and socks whenever possible to allow sweat evaporation and to apply lubricants.
Issues for Referral
- Allergist (if allergen testing required)
- Psychologist (if stress modification needed)
Complementary and Alternative Medicine
- Topical treatments to minimize pruritus (not curative) (2)[C]: Burrow solution (aluminum acetate) or vinegar compress
- Exposure to sunlight as maintenance therapy (7)[C]
- Dandelion juice (avoid in atopic patients) (5)[C]
- Dyshidrotic Eczema Area and Severity Index (DASI)
- Parameters used in the DASI score:
- Number of vesicles per square centimeter
- Severity of itching
- Surface area affected
- Grading: Mild (0–15), moderate (16–30), severe (31–60)
- Monitor BP and glucose in patients receiving systemic corticosteroids.
- Monitor for adverse effects of medications.
- Consider diet low in metal salts if there is history of nickel sensitivity (2)[A].
- Updated recommendations for low-cobalt diet are available (8).
- Instructions on self-care, complications, and avoidance of triggers/aggravating factors
- Suggested web site for patients: www.nlm.nih.gov
- Condition is benign.
- Usually heals without scarring
- Lesions often resolve spontaneously but resolve more quickly with appropriate treatment (9).
- Recurrence is common.
- Secondary bacterial infections (staphylococcus aureus most common)
- Dystrophic nail changes
- Skin tightening/discomfort
- Psychological distress
1. Guillet MH, Wierzbicka E, Guillet S, et al. A 3-year causative study of pompholyx in 120 patients. Arch Dermatol. 2007;143:1504–8.
2. Lofgren SM. Dyshidrosis: Epidemiology, clinical characteristics, and therapy.Dermatitis. 2006;17:165–81.
3. Chen J, et al. The gene for a rare autosomal dominant form of pompholyx maps to chromosome 18q22.1–18q22.3. J Invest Dermatol. 2006;126:300–4.
4. Tzaneva S, Kittler H, Thallinger C, et al. Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema. Photodermatol Photoimmunol Photomed. 2009;25:101–5.
5. Wollina U. Pompholyx: what’s new? Expert Opinion in Investigational Drugs.2008;17:897–904.
6. Sumila M, Notter M, Itin P, et al. Long-term Results of Radiotherapy in Patients with Chronic Palmoplantar Eczema or Psoriasis. Strahlentherapie und Onkologie. 2008;184:218–223.
7. Letić M. Exposure to sunlight as adjuvant therapy for dyshidrotic eczema.Med Hypotheses. 2009.
8. Stuckert J, Nedorost S. Low-cobalt diet for dyshidrotic eczema patients.Contact Dermatitis. 2008;59:361–5.
9. Rashid RD, Salah W, Keuer EJ. Vexing Vesicles. Journal of Medicine.2007;120:589–590.
Thiers BH. What’s new in dermatologic therapy. Dermatol Ther. 2008 Mar–Apr;21:142–9.
11. Veien NK. Acute and Recurrent Vesicular Hand Dermatitis. Dermatologic Clinics. 2009;27:337–353.
See Also (Topic, Algorithm, Electronic Media Element)
Algorithm: Rash, Focal
402567004 vesicular eczema of hands and/or feet (disorder)
- Dyshidrosis is a transient, recurrent vesicular eruption most commonly of the palms, soles, and interdigital areas.
- The etiology and pathophysiology are unknown but are most likely related to a combination of genetic and environmental factors.
- The best prevention is limiting exposure to irritating agents.
- Treatments are based on severity of disease and include topical steroids, UV therapy, botulinum toxin A, and various immunosuppressants.
- The condition is benign and usually heals spontaneously and without scarring. Medical treatment decreases healing time and risk for progression to secondary bacterial infection.