Vesicular Palmoplantar Eczema

Updated: Jun 21, 2016
  • Author: Elaine Dupuis, MD, MBA; Chief Editor: Dirk M Elston, MD  more...
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Overview

Background

Vesicular palmoplantar eczema is a term used to describe a group of diseases characterized by vesiculobullous eruption involving mainly the hands and feet. Clinical presentations vary from acute dermatitis to more chronic relapsing and remitting disease patterns. The diversity of presentation has created challenges in classifying hand eczema. A 2011 publication assembled an algorithm for chronic hand eczema based on etiology, morphology and clinical features. [1]

Although considerable overlap exists in the various forms of vesicular palmoplantar eczema, the disease can be roughly divided into four distinct categories: pompholyx, subacute or chronic relapsing vesiculosquamous eczema, chronic vesiculohyperkeratotic or hyperkeratotic eczema, and id reactions.

Pompholyx ("blister" or "bubble" in Greek) may be further subdivided into vesicular and bullous forms, in which patients present with acute severe eruptions of blisters over their palms and, less commonly, the soles.

Chronic vesiculosquamous eczema, also called dyshidrotic eczema, was initially thought to be caused by abnormal functioning of the sweat glands. This association has since been disproved, but the term dyshidrotic eczema is still used. Patients with this variant present with small (1-2 mm) vesicles on nonerythematous skin involving the inner sides of the fingers or on the palms and soles. The vesicles are pruritic, last 1-2 weeks, desquamate, and then recur at unpredictable intervals.

The chronic hyperkeratotic variety involves mainly the central palms, where it causes thickening and fissures. This category is notoriously the most difficult to treat.

An id reaction refers to a widespread eczematous eruption in response to a distal focus of infection. Common manifestations include a papulovesicular eruption with vesicles on the hands and feet secondary to a fungal infection (dermatophytid).

Despite the wide range of clinical presentations, all four types of vesicular palmoplantar eczema are histologically characterized by features of dermatitis, such as spongiosis and exocytosis.

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Pathophysiology

Vesicular palmoplantar eczema is often thought to have an unidentified intrinsic cause. Although many etiologic factors are described, the underlying pathology of vesicular palmoplantar eczema is unknown. One study examined the roles of aquaporin 3 and aquaporin 10, which are water/glycerol channel proteins located in the epidermis, and concluded that overexpression of these channels may play a role. [2]

Similarly, although certain triggers have been associated with the development or worsening of symptoms, how these triggers cause flares has not been elucidated.

Vesicular palmoplantar eczema results in histologic evidence of dermatitis, such as spongiosis, which is often accompanied by lymphocytic infiltrates.

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Epidemiology

Frequency

United States

The frequency of vesicular palmoplantar eczema in the United States is unknown.

International

The true incidence is unknown, but vesicular palmoplantar eczema is probably responsible for 5-20% of all cases of eczema of the hand. The dyshidrotic pattern is most common [3] ; a 2012 study found pompholyx accounted for 14% of all cases of hand eczema. [4]

Sex

The male-to-female ratio for vesicular palmoplantar eczema is 1:1.

Age

Pompholyx most commonly occurs in patients aged 20-40 years, but it may occur in individuals of any age. Onset in patients younger than 10 years is unusual. The frequency of recurrent episodes of pompholyx decreases after middle age, although this is not true of chronic vesicular and hyperkeratotic variants.

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Prognosis

Patients with mild cases of palmoplantar eczema have an excellent prognosis. The more severe chronic hyperkeratotic variety of vesicular palmoplantar eczema (eczema tyloticum) often requires lifelong treatment and results in considerable disability.

Acute vesicular eczema (pompholyx) in both major and minor forms tends to occur intermittently or sporadically and becomes less common as patients age. Episodes are less frequent from middle age onward.

The prognosis is less satisfactory for subacute and chronic forms of vesicular and hyperkeratotic eczema, which often persist for years, than for other forms.

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Patient Education

For excellent patient education resources, visit eMedicineHealth’s Skin Conditions and Beauty Center. Also, see eMedicineHealth’s patient education article Eczema.

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