Basics

Description

• 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

Epidemiology

Incidence

• Incidence is 0.5%.
• Mean age of onset is <40 years.
• Male = Female
• Comprises 5–20% of hand eczema cases

Prevalence

20 cases per 100,000

Risk Factors

• Many risk factors are disputed in the literature, with none being consistently associated
• Atopy
• Other dermatologic conditions:
  • Atopic dermatitis (early in life)
  • Contact dermatitis (later in life)
  • Dermatophytosis
• Sensitivity to
  • Foods
  • 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

Genetics

• 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

General Prevention

• Control emotional stress.
• Avoid excessive sweating.
• Avoid exposure to irritants.
• Avoid diet high in metal salts (chromium, cobalt, nickel).

Pathophysiology

• 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

Etiology

• 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
  • Stress
  • Dermatophyte infection
  • Prolonged wear of occlusive gloves
  • Intravenous immunoglobulin therapy
  • Smoking

Commonly Associated Conditions

• Atopic dermatitis
• Allergic contact dermatitis
• Parkinson disease

Diagnosis

History

• 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
• HIV
• Smoking

Physical Exam

• 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
  • Desquamation
  • Peeling, rings of scale, or lichenification common

Diagnostic Tests & Interpretation

Lab

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.

Diagnostic Procedures/Surgery

• Diagnosis is based on clinical exam
• Patch test (to elicit allergic cause)
• KOH wet mount (if concerned about dermatophyte infection)

Pathological Findings

• Fine 1–2-mm spongiotic vesicles intraepidermally with little to no inflammatory changes
• No eccrine glandular involvement

Differential Diagnosis

• Vesicular tinea pedis/manus
• Vesicular id reaction
• Contact dermatitis (allergic or irritant)
• Chronic vesicular hand dermatitis
• Drug reaction
• Dermatophytid
• Bullous disorders: Dyshidrosiform bullous pemphigoid, pemphigous, bullous impetigo, epidermolysis bullosa
• Pustular psoriasis
• Acrodermatitis continua
• Erythema multiforme
• Herpes infection
• Pityriasis rubra pilaris
• Vesicular mycosis fungoides

Treatment

Identification and avoidance of aggravating factors.

Medication

First Line

• 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

Second Line

• 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]

Additional Treatment

• Radiation therapy (6)[C]
• UV-free phototherapy (5)[C]

General Measures

• 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]

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

• Dyshidrotic Eczema Area and Severity Index (DASI)
• Parameters used in the DASI score:
  • Number of vesicles per square centimeter
  • Erythema
  • Desquamation
  • 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.

Diet

• Consider diet low in metal salts if there is history of nickel sensitivity (2)[A].
• Updated recommendations for low-cobalt diet are available (8).

Patient Education

• Instructions on self-care, complications, and avoidance of triggers/aggravating factors
• Suggested web site for patients: www.nlm.nih.gov

Prognosis

• Condition is benign.
• Usually heals without scarring
• Lesions often resolve spontaneously but resolve more quickly with appropriate treatment (9).
• Recurrence is common.

Complications

• Secondary bacterial infections (staphylococcus aureus most common)
• Dystrophic nail changes
• Fissures
• Skin tightening/discomfort
• Psychological distress

References

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.

Additional Reading

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

Codes

ICD9

705.81 Dyshidrosis

Snomed

402567004 vesicular eczema of hands and/or feet (disorder)

Clinical Pearls

• 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.