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Dyshidrosis
Cara Marshall, MD
image BASICS
DESCRIPTION
  • A skin rash (dermatitis) within the “dyshidrosis” family. Literature supports the presence of several different classes within the family dyshidrosis but no general agreement about a strict definition of these classes.
  • Dyshidrotic eczema
    • Common, chronic, or recurrent; nonerythematous; symmetric 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.
    • Sometimes used interchangeably with dyshidrotic eczema (small vesicles). Some believe these 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): cheiropompholyx, keratolysis exfoliativa, vesicular palmoplantar eczema, desquamation of interdigital spaces, palmar pompholyx reaction, acute and recurrent hand dermatitis (1)
EPIDEMIOLOGY
Incidence
  • Mean age of onset is 40 years and younger
  • Male = female
  • Comprises 5-20% of hand eczema cases
Prevalence
20 cases/100,000 populations
ETIOLOGY AND PATHOPHYSIOLOGY
  • Exact mechanism unknown; thought to be multifactorial
  • Dermatopathology: spongiosis with intraepidermal vesicles
  • Despite the name, sweat glands are not altered/affected (2)
  • Vesicles remain intact due to thickness of stratum corneum of palmar/plantar skin (1).
  • Exact cause not known.
  • Aggravating factors (debated)
    • Hyperhidrosis (in 40% of patients with the condition)
    • Climate: hot/cold weather; humidity
    • Contact sensitivity (in 30-67% of patients with the condition) (2)
    • Nickel, cobalt, and chromate sensitivity (may include implanted orthopedic or orthodontic metals) (1)
    • Irritating compounds and solutions
    • Stress
    • Dermatophyte infection (present in 10% of patients with the condition) (2)
    • Prolonged wear of occlusive gloves
    • IV immunoglobulin therapy
    • Smoking
Genetics
  • Atopy: 50% of patients with dyshidrotic eczema have atopic dermatitis (1)
  • Rare autosomal dominant form of pompholyx found in Chinese population maps to chromosome 18q22.1-18q22.3 (2).
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
    • Contact and dietary: nickel (more common in young women), chromate (more common in men), and cobalt (1)
    • Smoking in males
GENERAL PREVENTION
  • Control emotional stress.
  • Avoid excessive sweating.
  • Avoid exposure to irritants.
  • Avoid diet high in metal salts (chromium, cobalt, nickel).
  • Avoid smoking.
COMMONLY ASSOCIATED CONDITIONS
  • Atopic dermatitis
  • Allergic contact dermatitis
  • Parkinson disease
  • HIV (2)
image DIAGNOSIS
PHYSICAL EXAM
  • Symmetric distribution on the palms and soles; also may affect the dorsal aspects of hands and feet
  • Lesions may not heal completely between flares (1).
  • Early findings
    • 1 to 2 mm, clear, nonerythematous, deep-seated vesicles
  • Late findings
    • Unroofed vesicles with inflamed bases
    • Desquamation
    • Peeling, rings of scale, or lichenification common
DIFFERENTIAL DIAGNOSIS
  • Vesicular tinea pedis/manuum
  • Vesicular id reaction
  • Contact dermatitis (allergic or irritant)
  • Scabies
  • Chronic vesicular hand dermatitis
  • Drug reaction
  • Dermatophytid
  • Bullous disorders: dyshidrosiform bullous pemphigoid, pemphigus, bullous impetigo, epidermolysis bullosa
  • Pustular psoriasis
  • Acrodermatitis continua
  • Erythema multiforme
  • Herpes infection
  • Pityriasis rubra pilaris
  • Vesicular mycosis fungoides
DIAGNOSTIC TESTS & INTERPRETATION
Follow-Up Tests & Special Considerations
  • Skin culture in suspected secondary infection (most commonly, Staphylococcus aureus) (4)
  • Consider antibiotics based on culture results and severity of symptoms.
Diagnostic Procedures/Other
  • Diagnosis is based on clinical exam.
  • Potassium hydroxide (KOH) wet mount (if concerned about dermatophyte infection)
  • Patch test (if suspecting allergic cause)
Test Interpretation
  • Fine, 1- to 2-mm spongiotic intraepidermal vesicles with little to no inflammatory change
  • No eccrine glandular involvement
  • Thickened stratum corneum
image TREATMENT
GENERAL MEASURES
  • Avoid possible causative factors: stress, direct skin contact with irritants, nickel, occlusive gloves, household cleaning products, smoking, sweating
  • Use moisturizers/emollients for symptomatic relief and to maintain effective skin barrier.
  • Skin care
    • Wear shoes with leather rather than rubber soles (e.g., sneakers).
    • Wear socks and gloves made of cotton and change frequently.
    • Wash infrequently, carefully dry, then apply emollient.
    • Avoid direct contact with fresh fruit (5)[C].
P.319

MEDICATION
First Line
  • Mild cases: topical steroids (high potency) (2)[B]
    • Considered cornerstone of therapy but limited published evidence
  • Moderate to severe cases
    • Ultrahigh-potency topical steroids with occlusion over treated area (4)[B]
    • Prednisone 40 to 100 mg/day tapered after blister formation ceases (2)[B]
    • Psoralens plus ultraviolet (UV)-A therapy (PUVA), either systemic/topical or immersion in psoralens (2)[B]
  • Recurrent cases (4)[B]
    • Systemic steroids at onset of itching prodrome
    • Prednisone 60 mg PO for 3 to 4 days
Second Line
  • Topical calcineurin inhibitors (mitigate the long-term risks of topical steroid use)
    • Topical tacrolimus (6)[B]
    • Topical pimecrolimus (6)[B]
    • May not be as effective on plantar surface
  • Other therapies (typically with dermatology consultation)
    • Oral cyclosporine (4)[B]
    • Injections of botulinum toxin type A (BTXA) (6)[B]
      • Newer topical forms of BTXA currently being developed show promise
      • Painful, requires nerve block
    • Systemic alitretinoin (teratogenic) (5)[B]
    • Topical bexarotene (a teratogenic retinoid X receptor agonist approved for use in cutaneous T-cell lymphoma) (6)[B]
    • Methotrexate (6)[C]
    • Azathioprine (1)[C]
    • Disulfiram or sodium cromoglycate in nickel-allergic patients (1)[C]
    • Mycophenolate mofetil (2)[C]
    • Tap water iontophoresis (2)[C]
ISSUES FOR REFERRAL
  • Allergist (if allergen testing required)
  • Psychologist (if stress modification needed)
ADDITIONAL TREATMENT
  • Radiation therapy (1)[C]
  • UV-free phototherapy (5)[C]
  • Treat underlying dermatophytosis (1).
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Topical treatments to minimize pruritus (not curative) (4)[C]: Burow solution (aluminum acetate) or vinegar compresses
  • Exposure to sunlight as maintenance therapy, 12 minutes every other day, 10 to 15 exposures (5)[C]
  • Dandelion juice (avoid in atopic patients) (6)[C]
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Dyshidrotic Eczema Area and Severity Index (DASI) (1)
  • Parameters used in the DASI score
    • Number of vesicles per square centimeter
    • Erythema
    • Desquamation
    • Severity of itching
    • Surface area affected
  • Grading: mild (0 to 15), moderate (16 to 30), severe (31 to 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 (4)[B].
  • Updated recommendations for low-cobalt diet are available (1).
PATIENT EDUCATION
  • Instructions on self-care, complications, and avoidance of triggers/aggravating factors
  • PubMed Health: Dyshidrotic Eczema at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001835/
PROGNOSIS
  • Condition is benign.
  • Usually heals without scarring.
  • Lesions may spontaneously resolve.
  • Recurrence is common.
REFERENCES
1. Veien NK. Acute and recurrent vesicular hand dermatitis. Dermatol Clin. 2009;27(3):337-353.
2. Wollina U. Pompholyx: a review of clinical features, differential diagnosis, and management. Am J Clin Dermatol. 2010;11(5):305-314.
3. Guillet MH, Wierzbicka E, Guillet S, et al. A 3-year causative study of pompholyx in 120 patients. Arch Dermatol. 2007;143(12):1504-1508.
4. Lofgren SM, Warshaw EM. Dyshidrosis: epidemiology, clinical characteristics, and therapy. Dermatitis. 2006;17(4):165-181.
5. Letic' M. Use of sunlight to treat dyshidrotic eczema. JAMA Dermatol. 2013;149(5):634-635.
6. Wollina U. Pompholyx: what's new? Expert Opin Investig Drugs. 2008;17(6):897-904.
Additional Reading
&NA;
  • Chen JJ, Liang YH, Zhou FS, et al. The gene for a rare autosomal dominant form of pompholyx maps to chromosome 18q22.1-18q22.3. J Invest Dermatol. 2006;126(2):300-304.
  • Molin S, Diepgen TL, Ruzicka T, et al. Diagnosing chronic hand eczema by an algorithm: a tool for classification in clinical practice. Clin Exp Dermatol. 2011;36(6):595-601.
  • Schuttelaar ML, Coenraads PJ, Huizinga J, et al. Increase in vesicular hand eczema after house dust mite inhalation provocation: a double-blind, placebo-controlled, cross-over study. Contact Dermatitis. 2013;68(2):76-85.
  • Soler DC, Bai X, Ortega L, et al. The key role of aquaporin 3 and aquaporin 10 in the pathogenesis of pompholyx. Med Hypotheses. 2015;84(5):498-503.
  • Stuckert J, Nedorost S. Low-cobalt diet for dyshidrotic eczema patients. Contact Dermatitis. 2008;59(6):361-365.
  • Sumila M, Notter M, Itin P, et al. Long-term results of radiotherapy in patients with chronic palmoplantar eczema or psoriasis. Strahlenther Onkol. 2008;184(4):218-223.
  • Tzaneva S, Kittler H, Thallinger C, et al. Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema. Photodermatol Photoimmunol Photomed. 2009;25(2):101-105.
See Also
&NA;
Algorithm: Rash, Focal
Codes
&NA;
ICD10
L30.1 Dyshidrosis [pompholyx]
Clinical Pearls
&NA;
  • Dyshidrosis is a transient, recurrent vesicular eruption most commonly of the palms, soles, and interdigital areas.
  • Etiology and pathophysiology are unknown but are most likely related to a combination of genetic and environmental factors.
  • Best prevention is effective skin care and limiting exposure to irritating agents.
  • Treatments are based on disease severity; preferred treatments include topical steroids, oral steroids, and calcineurin inhibitors.
  • Condition is benign and usually heals spontaneously and without scarring. Medical treatment decreases healing time and risk for progression to secondary bacterial infection.