Vesicular Palmoplantar Eczema Clinical Presentation

  • Author: Wingfield Rehmus, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Nov 30, 2010
 

History

The severity of vesicular palmoplantar eczema symptoms varies, ranging from mild discomfort to acute severe episodes. Patients rarely require hospitalization.

  • Itching, burning, and prickling sensations of the palms and soles precede the eruption of vesicles.
  • Thereafter, small (1- to 2-mm) vesicles form, most commonly on the lateral sides of the fingers. In pompholyx, the central areas of the palms and soles may or may not be involved.
  • Large vesicles can develop on the palms and soles and may coalesce to form confluent bullae.
  • The lesions last for 2-3 weeks, after which spontaneous resolution generally occurs. Occasionally, large bullae may need to be aspirated. This phase is followed by desquamation.
  • Palmoplantar eczema typically recurs, and episodes are more frequent during the spring and summer than in the fall and winter.
  • The chronic hyperkeratotic variety results in severe itching accompanied by thickening and fissuring of the palm. This effect may decrease the mobility of the affected hand.
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Physical

Clinical signs depend on the stage of vesicular palmoplantar eczema. An absence of erythema is often an important clinical feature in the acute and chronic forms.

Pompholyx of the palms. Pompholyx of the palms.

Acute episodes are characterized by a sudden onset of small, clear vesicles or bullae that are said to be sagolike or tapiocalike in appearance (see the image above).

  • Vesicles and/or bullae are accompanied by severe, occasionally painful pruritus.
  • Small vesicles may enlarge or become more confluent and present as large bullae (especially on the palms and soles).
  • Vesicles and bullae subsequently dry out and resolve, usually without rupturing.
  • In most individuals, desquamation occurs 2-3 weeks after the onset of vesicles and bullae.
  • In some patients, a milder recurrence follows the initial severe episode.
  • Secondary infections, such as impetigo, cellulitis, or lymphangitis, are possible in patients with recurrent hand eczema.
  • Secondary nail changes (eg, dystrophic nails, irregular transverse ridging, pitting, thickening, discoloration) can also occur.

Subacute vesicular eczema tends to have a chronic relapsing course with more vesiculation and more erythema in the acute phases than in later phases.

  • Residual erythema or some dryness or scaling occurs in the less-active phases.
  • Fissures are common and painful sequelae.

A form of microvesicular palmar eczema also occurs in association with dry nummular (discoid) eczema.

Hyperkeratotic palmar eczema is characterized by highly itchy, hyperkeratotic palms. Fissures in the folds of the hands and fingers are common and painful. Fissures can limit use of the hands.

  • Typically, chronic eczema affects the central area of the palm or the palmar aspect of the hands and fingers.
  • Only occasionally are vesicles visible on clinical examination, but spongiosis is found on histology.

When they occur on the hands, id reactions typically involve the lateral sides of the fingers. These reactions often resolve when the primary infection is treated.

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Causes

The etiology of hand eczema is unknown, but most observers suggest that intrinsic changes in the skin are responsible for vesicular palmoplantar eczema. A study of an autosomal dominant form of pompholyx found a genetic linkage on chromosome 18.[1] Whether other forms have a similar genetic linkage is not clear. However, several exogenous factors have been implicated in the causation or worsening of vesicular palmoplantar eczema.[2]

  • Coexisting atopy is common in patients with palmoplantar eczema. This is by no means the only causal relationship because many patients have no history of atopy.
  • Emotional stress may also trigger episodes.
  • Seasonal changes seem to be directly related to relapses, as episodes are most common in the spring and summer months. Warm weather has been known to initiate episodes, with several cases reporting photo-induced pompholyx.
    • Although dysfunction of the sweat glands is no longer accepted as the cause of dyshidrotic eczema, increased sweating seems to exacerbate the condition and many patients with palmar hyperhidrosis also have coexisting dyshidrotic eczema.
    • Photosensitivity to ultraviolet A (UVA) has been reported as an etiologic factor in a small subset of patients with eczema.[3, 4] Therefore, worsening of the disease in summer months may be due to the increase in exposure to sunlight. Conversely, UVA therapy is a widely accepted form of treatment for palmoplantar eczema.
  • Sensitivity to certain metals, particularly nickel and cobalt, has been linked to vesicular palmoplantar eczema.
  • Exogenous factors causing allergic contact pompholyx include balsams and cosmetic and hygiene products.[5]
  • Drugs responsible for inducing episodes include oral contraceptive pills and aspirin. Palmoplantar eczema occurring after intravenous immunoglobulin (IVIG) therapy is reported.[6]
  • Fungal infections, particularly tinea pedis, are most commonly implicated in id reactions. Bacterial infections play a role in both causation and in secondarily infecting lesions.
  • Cigarette smoking may reduce the efficacy of topical therapy with psoralen and UVA (PUVA) and has been itself, linked to pompholyx.
  • HIV infection has been associated with pompholyx, with response to antiretroviral therapy; conversely, one case report describes of 2 HIV-positive patients who developed severe dyshidrotic eczema after starting antiretroviral treatment, thought to be due to an immune reconstitution inflammatory syndrome.[7, 8]
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Contributor Information and Disclosures
Author

Wingfield Rehmus, MD, MPH  Dermatologist, BC Children's Hospital, Vancouver, British Columbia

Wingfield Rehmus, MD, MPH is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Carol E Cheng  Boston University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

James J Nordlund, MD  Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine

James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD  Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

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

Disclosure: Nothing to disclose.

References

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