History

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

Classically, 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 also develop 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.

Chronic forms typically recur, and episodes are more frequent during the spring and summer than in the fall and winter.

Physical Examination

Clinical signs depend on the stage and form of palmoplantar eczema.

Pompholyx of the palms.

Acute episodes of vesicular eczema are characterized by a sudden onset of small, clear vesicles or bullae that are said to be "sago grain‒like" 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.

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.

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

Complications

Secondary bacterial infections can occur, such as cellulitis, lymphedema, and, more rarely, septicemia.^[26]

Differential Diagnoses

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Media Gallery

Pompholyx of the palms.

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Author

Jessica Dunkley, MD, MHSc, CCFP Resident Physician, Department of Dermatology, University of British Columbia Faculty of Medicine, Canada

Jessica Dunkley, MD, MHSc, CCFP is a member of the following medical societies: American Academy of Dermatology, Canadian Dermatology Association, Canadian Medical Association, College of Family Physicians of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

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, Society for Pediatric Dermatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie; Valeant Canada<br/> Received honoraria from Valeant Canada for advisory board; Received honoraria from Pierre Fabre for advisory board; Received honoraria from Mustella for advisory board; Received honoraria from Abbvie for advisory board.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from www.DrScore.com for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

John D Wilkinson, MD, MBBS, MRCS, FRCP Chairman, Clinical Director, Department of Dermatology, Amersham Hospital and High Wycombe Hospital, UK

John D Wilkinson, MD, MBBS, MRCS, FRCP is a member of the following medical societies: American Academy of Dermatology, Royal College of Physicians

Disclosure: Nothing to disclose.

Carol E Cheng, MD Assistant Clinical Professor of Dermatology, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

Elaine Dupuis, MD, MBA Resident Physician, Section of Dermatology, Department of Medicine, University of Calgary Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Vesicular Palmoplantar Eczema Clinical Presentation

History

Physical Examination

Complications

References

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