Dyshidrotic Eczema Clinical Presentation

  • Author: Sadegh Amini, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Sep 15, 2011
 

History

Patients report pruritus of the hands and feet with a sudden onset of vesicles. Burning pain or pruritus occasionally may be experienced before vesicles appear. 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.[11]

Dyshidrotic eczema episodes vary in frequency from once per month to once per year. Patients with dyshidrotic eczema may report a variety of factors that possibly are related to eruptions, as follows:

  • Emotional stress
  • Personal or familial atopic diathesis (eg, asthma, hay fever, sinusitis)
  • Certain work exposures (eg, cobalt) and/or recreational exposures
  • Recent exposure to contact allergens (eg, nickel, balsams, paraphenylenediamine, chromate, sesquiterpene lactones) before condition flares
  • Exposure to contact irritants before condition flares
  • Recent exposure to costume jewelry (patients with palmar pompholyx and allergy to nickel)
  • Recent treatment with intravenous immunoglobulin therapy[15, 16, 7]
  • Human immunodeficiency virus (HIV) infection

Two cases were reported of HIV-positive patients who developed dyshidrotic eczema as an immune reconstitution inflammatory syndrome shortly after highly active antiretroviral therapy.[17] Pompholyx has also been described as a manifestation of symptomatic HIV infection, including in individuals who do not respond to topical and systemic therapies and whose condition resolves only after the initiation of combination antiretroviral therapy.[18]

A recent publication provides an algorithm for the diagnosis of chronic hand dermatitis, which offers an easy way of classifying these conditions, helping in the decision making when choosing treatment modalities.[19]

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Physical Examination

Symmetrical crops of clear vesicles and/or bullae on the palms and lateral aspects of the fingers characterize dyshidrotic eczema. The feet, the soles, and the lateral aspects of toes also may be affected. (See the images below.)

Small tense vesicles on the fingers. Small tense vesicles on the fingers. Small, discrete, coalesced vesicles on the dorsal Small, discrete, coalesced vesicles on the dorsal hand. Small, discrete, coalesced vesicles on the fingersSmall, discrete, coalesced vesicles on the fingers.

In mildly affected patients, vesicles are present only on the lateral aspects of the fingers and, occasionally, involve feet and toes. (See the image below.)

Small discrete vesicles of the lateral fingers. Small discrete vesicles of the lateral fingers.

Vesicles are deep seated and have a tapiocalike appearance, without surrounding erythema. They may become large, form bullae, and become confluent. Vesicles typically resolve without rupturing, followed by desquamation. (See the image below.)

Close-up view of tense vesicles and bullae of the Close-up view of tense vesicles and bullae of the palm. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery.

In 80% of patients, only the hands are involved, while in 10% of patients, the disease affects only the feet, and in another 10% of patients, the hands and feet are involved together. (See the images below.)

Discrete yellow pustules on the sole of the foot. Discrete yellow pustules on the sole of the foot. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery. Palms and soles of a patient with a dyshidrosis flPalms and soles of a patient with a dyshidrosis flare. The patient unroofed a large bulla on the right sole.

With long-standing disease, patients' fingernails may reveal dystrophic changes (eg, irregular, transverse ridging; pitting; thickening; discoloration). Interdigital maceration and desquamation of the interdigital spaces often are present, despite the possible absence of a dermatophyte infection. Vesicles and/or bullae may become infected secondarily, and pustular lesions may be present. Cellulitis and lymphangitis may develop.

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Contributor Information and Disclosures
Author

Sadegh Amini, MD  Dermatology Resident, Department of Dermatology and Cutaneous Surgery, Jackson Memorial Hospital, University of Miami, Leonard M Miller School of Medicine

Sadegh Amini, MD is a member of the following medical societies: American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, and International Society of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Camila K Janniger, MD  Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Anne E Burdick, MD, MPH  Professor of Dermatology, Director of Leprosy Program, Associate Dean for TeleHealth and Clinical Outreach, University of Miami, Leonard M Miller School of Medicine

Anne E Burdick, MD, MPH is a member of the following medical societies: Women's Dermatologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Kevin P Connelly, DO  Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD  Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Ivan D Camacho, MD, Julie K Keck, MD, and James D Korb, MD, to the development and writing of the source articles.

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Tense vesicles and bullae on the palm. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery.
Close-up view of tense vesicles and bullae of the palm. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery.
Discrete yellow pustules on the sole of the foot. Courtesy of Norman Minars, MD, University of Miami, Department of Dermatology & Cutaneous Surgery.
Multiple tense vesicles on the palm.
Small tense vesicles on the fingers.
Small, discrete, coalesced vesicles on the dorsal hand.
Small, discrete, coalesced vesicles on the fingers.
Palms and soles of a patient with a dyshidrosis flare. The patient unroofed a large bulla on the right sole.
Small discrete vesicles of the lateral fingers.
 
 
 
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