eMedicine Specialties > Pediatrics: General Medicine > Dermatology
Dyshidrotic Eczema
Updated: Apr 9, 2009
Introduction
Background
Dyshidrotic eczema is a type of eczema (dermatitis) of unknown cause that is characterized by a pruritic vesicular eruption on the fingers, palms, and soles. The condition affects teenagers and adults and may be acute, recurrent, or chronic. A more appropriate term for this vesicular eruption is pompholyx, which means bubble. The clinical course of dyshidrotic eczema can range from self-limited to chronic, severe, or debilitating. The condition's unresponsiveness to treatment can be frustrating for the patient and physician.
The cause of dyshidrotic eczema remains enigmatic.1 Some believe the terms pompholyx and dyshidrosis are obsolete and favor a new term, such as "acute and recurrent vesicular hand dermatitis."
Multiple tense vesicles on the palm.
Palms and soles of a patient with a dyshidrosis flare. The patient unroofed a large bulla on the right sole.
Pathophysiology
The etiology of dyshidrotic eczema is unknown. The condition was inaccurately described in 1873 as dyshidrosis because of the clinical symptom of sweaty palms. The term dyshidrosis indicates a sweating abnormality, although histologic examination reveals no evidence of eccrine glandular involvement. Histologically, the vesicles are intraepidermal and spongiotic with little to no inflammatory changes. The more appropriate term for this vesicular eruption is pompholyx, which means bubble. Although strong reasons to use the term pompholyx have been noted, dyshidrotic eczema remains a commonly used term. A tiny percentage of individuals with the disorder note flares after ingesting metal salts, specifically chromium, cobalt, and nickel. Diets that eliminate these metal salts may rarely have some clinical benefit.
One causative study observed reactional pompholyx to interdigital-plantar intertrigous and endogenous reactions to metals or other allergens; however, an unexpected number of patients with so-called contact pompholyx, in which cosmetic and hygiene products play a preponderant role (compared with metals), were also reported.2
A genetic component to the development of dyshidrotic eczema may be involved in some patients. Dyshidrotic eczema has been described in few large families; no gene or locus had been identified.3 A genome-wide search in a large Chinese family identified a locus at chromosome 18q22.1-18q22.3, with a maximum 2-point logarithm of the odds (LOD) score of 3.61 at marker D18S1131 (theta = 0.00). Haplotype analyses showed the gene to be located within 12.07 cM region between markers D18S465 and D18S1362, which corresponds to 8 Mb.
Frequency
United States
Dyshidrotic eczema accounts for 5% of all cases of eczema of the hand.
International
A study in Turkey revealed a higher prevalence of dyshidrotic eczema in the summer months.4
Mortality/Morbidity
Dyshidrotic eczema has no associated mortality, although some severe cases can become debilitating.
Race
No racial predilection is reported.
Sex
The female-to-male ratio is 2:1.
Age
Peak incidence occurs in patients aged 20-40 years, although the disorder also occurs in teenagers and older patients.
Clinical
History
Patients with dyshidrotic eczema first describe several hours of itching or burning sensations in their hands, feet, or both before the eruption develops. 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.5
Physical
Physical examination performed early in the course of the flare reveals small (ie, 1-2 mm), clear, deep-seated vesicles without erythema erupting on the lateral aspects of fingers, the central palm, and plantar surfaces. The vesicles have been described as resembling tapioca pudding. Eruptions are usually bilateral and symmetric. Patients treated later in the course of dyshidrotic eczema may have unroofed vesicles with inflamed bases, possibly accompanied by peeling or rings of scale or lichenification. Transverse furrows can develop on the nail when eruptions occur in the periungual area, nail matrix, or both.
Causes
Although the etiology of dyshidrotic eczema remains undefined, suspected risk factors include stress, exposure to metal salts, allergic contact dermatitis, and female sex. Iannaccone et al cite exposure to intravenous immunoglobulin G (IVIG) as a possible risk factor.6
Exogenous factors said to trigger a flare include dermatophyte infections, contact irritants, and metal hypersensitivity. Although metal hypersensitivity does not play a role in all cases of dyshidrotic eczema, high oral ingestion of nickel and/or cobalt should be considered, regardless of patch test results.7
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| Treatment & Medication: Dyshidrotic Eczema |
| Follow-up: Dyshidrotic Eczema |
| Multimedia: Dyshidrotic Eczema |
| References |
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References
Storrs FJ. Acute and recurrent vesicular hand dermatitis not pompholyx or dyshidrosis. Arch Dermatol. Dec 2007;143(12):1578-80. [Medline].
Guillet MH, Wierzbicka E, Guillet S, Dagregorio G, Guillet G. A 3-year causative study of pompholyx in 120 patients. Arch Dermatol. Dec 2007;143(12):1504-8. [Medline].
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. Feb 2006;126(2):300-4. [Medline].
Tamer E, Ilhan MN, Polat M, Lenk N, Alli N. Prevalence of skin diseases among pediatric patients in Turkey. J Dermatol. Jul 2008;35(7):413-8. [Medline].
Man I, Ibbotson SH, Ferguson J. Photoinduced pompholyx: a report of 5 cases. J Am Acad Dermatol. Jan 2004;50(1):55-60. [Medline].
Iannaccone S, Sferrazza B, Quattrini A, Smirne S, Ferini-Strambi L. Pompholyx (vesicular eczema) after i.v. immunoglobulin therapy for neurologic disease. Neurology. Sep 22 1999;53(5):1154-5. [Medline].
Stuckert J, Nedorost S. Low-cobalt diet for dyshidrotic eczema patients. Contact Dermatitis. Dec 2008;59(6):361-5. [Medline].
Yasuda M, Miyachi Y, Utani A. Two cases of dyshidrosiform pemphigoid with different presentations. Clin Exp Dermatol. Jan 23 2009;[Medline].
National Institute for Clinical Excellence. Frequency of application of topical corticosteroids for atopic eczema. London, England: National Institute for Clinical Excellence (NICE); 2004. 34.
Wollina U, Abdel Naser MB. Pharmacotherapy of pompholyx. Expert Opin Pharmacother. Jul 2004;5(7):1517-22. [Medline].
Capella GL. Topical khellin and natural sunlight in the outpatient treatment of recalcitrant palmoplantar pompholyx: report of an open pilot study. Dermatology. 2005;211(4):381-3. [Medline].
[Best Evidence] Boyle RJ, Bath-Hextall FJ, Leonardi-Bee J, Murrell DF, Tang ML. Probiotics for treating eczema. Cochrane Database Syst Rev. Oct 8 2008;CD006135. [Medline].
Schurmeyer-Horst F, Luger TA, Bohm M. Long-term efficacy of occlusive therapy with topical pimecrolimus in severe dyshidrosiform hand and foot eczema. Dermatology. 2007;214(1):99-100. [Medline].
Wollina U. Pompholyx: what's new?. Expert Opin Investig Drugs. Jun 2008;17(6):897-904. [Medline].
Colebunders R, Zolfo M, Lynen L. Severe dyshidrosis in two patients with HIV infection shortly after starting highly active antiretroviral treatment. Dermatol Online J. 2005;11(2):31. [Medline].
Egan CA, Rallis TM, Meadows KP, Krueger GG. Low-dose oral methotrexate treatment for recalcitrant palmoplantar pompholyx. J Am Acad Dermatol. Apr 1999;40(4):612-4. [Medline].
Grange-Prunier A, Bezier M, Perceau G, Bernard P. [Tobacco contact dermatitis caused by sensitivity to sorbic acid.]. Ann Dermatol Venereol. Feb 2008;135(2):135-138. [Medline].
Jain VK, Aggarwal K, Passi S, Gupta S. Role of contact allergens in pompholyx. J Dermatol. Mar 2004;31(3):188-93. [Medline].
Kim YJ, Kim MY, Kim HO, Park YM. Dyshidrosiform bullous pemphigoid. Acta Derm Venereol. 2004;84(3):253-4. [Medline].
Klein AW. Treatment of dyshidrotic hand dermatitis with intradermal botulinum toxin. J Am Acad Dermatol. Jan 2004;50(1):153-4; author reply 154. [Medline].
Landow K. Hand dermatitis. The perennial scourge. Postgrad Med. Jan 1998;103(1):141-2, 145-8, 151-2. [Medline].
Ogden S, Clayton TH, Goodfield MJ. Recalcitrant hand pompholyx: variable response to etanercept. Clin Exp Dermatol. Jan 2006;31(1):145-6. [Medline].
Petering H, Breuer C, Herbst R, Kapp A, Werfel T. Comparison of localized high-dose UVA1 irradiation versus topical cream psoralen-UVA for treatment of chronic vesicular dyshidrotic eczema. J Am Acad Dermatol. Jan 2004;50(1):68-72. [Medline].
Pickenacker A, Luger TA, Schwarz T. Dyshidrotic eczema treated with mycophenolate mofetil. Arch Dermatol. Mar 1998;134(3):378-9. [Medline].
Pitche P, Boukari M, Tchangai-Walla K. [Factors associated with palmoplantar or plantar pompholyx: a case-control study]. Ann Dermatol Venereol. Feb 2006;133(2):139-43. [Medline].
Further Reading
Keywords
dyshidrotic eczema, rash, pompholyx, dyshidrosis, cheiropompholyx, chiropompholyx, dyshidria, palmoplantar hyperhidrosis, dermatitis, pruritic vesicular eruption, acute and recurrent vesicular hand dermatitis, skin rash, treatment, diagnosis, outbreak, skin condition, metal hypersensitivity, contact dermatitis
