Approach Considerations

The diagnosis of palmoplantar eczema is essentially a clinical one; however, studies may be helpful in excluding other disorders. Consider the following:

KOH staining of skin scrapings to rule out fungal infection, especially in hyperkeratotic forms of the disease
Swab and culture of suspected lesions to exclude secondary bacterial infection if infection is suspected
A biopsy to distinguish eczema from psoriasis or some forms of palmoplantar hyperkeratoses
Patch testing to exclude contact dermatitis or a systemic reaction to contact allergen
Allergy testing may suggest an atopic tendency

There are no laboratory studies specific to vesicular palmoplantar eczema. However, IgE levels may be elevated in patients with atopic dermatitis.^[2]

Histologic Findings

Histologic features vary according to the stage of the evolution vesicular palmoplantar eczema. Usually, evidence suggests intracellular edema or spongiosis, lymphocytic infiltration of the epidermis, and intraepidermal vesicles or bullae in acutely affected persons. In chronically affected persons, spongiosis is present and often associated with epithelial proliferation and/or hyperkeratosis or psoriasiform epidermal hyperplasia. Dermis is often edematous, with a mixed perivascular inflammatory cell infiltrate.

Distinguishing between palmoplantar pustulosis and pompholyx can be challenging, as they share similar histological features. Recent studies have looked at differentiating the two entities and found thinning of rete ridges, foci of parakeratosis, and irregular epidermal hyperplasia to be more often associated with pompholyx.^[30]Further, a comparison of inflammatory mediator expression between pompholyx and palmoplantar pustulosis found increased mRNA expression of granzyme B in pompholyx. In contrast, interleukin (IL)–8, and IL-17α were increased in palmoplantar pustulosis.^[31]These may serve as immunologic markers in distinguishing palmoplantar pustulosis from pompholyx.

Treatment & Management

Molin S, Diepgen TL, Ruzicka T, Prinz JC. Diagnosing chronic hand eczema by an algorithm: a tool for classification in clinical practice. Clin Exp Dermatol. 2011 Aug. 36(6):595-601. [QxMD MEDLINE Link].
Doshi DN, Cheng CE, Kimball AB. Vesicular Palmoplantar Eczema. Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, eds. Fitzpatrick's Dermatology in General Medicine. 8th ed. New York, NY: McGraw-Hill; 2012.
Soler DC, Bai X, Ortega L, Pethukova T, Nedorost ST, Popkin DL, et al. The key role of aquaporin 3 and aquaporin 10 in the pathogensis of pompholyx. Med Hypotheses. 2015 05. 84(5):498-503. [QxMD MEDLINE Link].
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. 2006 Feb. 126(2):300-4. [QxMD MEDLINE Link].
Edman B. Palmar eczema: a pathogenetic role for acetylsalicylic acid, contraceptives and smoking?. Acta Derm Venereol. 1988. 68(5):402-7. [QxMD MEDLINE Link].
Handa S, Kaur I, Gupta T, Jindal R. Hand eczema: correlation of morphologic patterns, atopy, contact sensitization and disease severity. Indian J Dermatol Venereol Leprol. 2012 Mar-Apr. 78(2):153-8. [QxMD MEDLINE Link].
Pitche P, Boukari M, Tchangai-Walla K. Factors associated with palmoplantar or plantar pompholyx: a case-control study. Ann Dermatol Venereol. 2006 Feb. 133(2):139-43. [QxMD MEDLINE Link].
Nalluri R, Rhodes LE. Photoaggravated pompholyx. Photodermatol Photoimmunol Photomed. 2016 Feb 12. doi: 10.111/phpp.12237 [Epub ahead of print]:[QxMD MEDLINE Link].
Man I, Ibbotson SH, Ferguson J. Photoinduced pompholyx: a report of 5 cases. J Am Acad Dermatol. 2004 Jan. 50(1):55-60. [QxMD MEDLINE Link].
Gerstenblith MR, Antony AK, Junkins-Hopkins JM, Abuav R. Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy. J Am Acad Dermatol. 2012 Feb. 66(2):312-6. [QxMD MEDLINE Link].
Suvirya S, Thakur A, Pandey SS, Tripathi SK, Dwivedi DI. Altered levels of serum zinc and cadmium in patients with chronic vesiculobullous hand and feet dermatitis. Dermatol Res Pract. 2016 Apr 6. 2016:3284937 doi: 10.1155/2016/3284937 [Epub]:[QxMD MEDLINE Link].
Guillet MH, Wierzbicka E, Guillet S, Dagregorio G, Guillet G. A 3-year causative study of pompholyx in 120 patients. Arch Dermatol. 2007 Dec. 143(12):1504-8. [QxMD MEDLINE Link].
Schuttelaar ML, Coenraads PJ, Huizinga J, De Monchy JG, Vermeulen KM. Increase in vesicular hand eczema after house dust mite inhalation provocation: a double-blind, placebo-controlled, cross-over study. Contact Dermatitis. 2013 Feb. 68(2):76-85. [QxMD MEDLINE Link].
Uyttendaele H, Obadiah J, Grossman M. Dyshidrotic-like spongiotic dermatitis after intravenous immunoglobulin therapy. J Drugs Dermatol. 2003 Jun. 2(3):337-41. [QxMD MEDLINE Link].
Peera M, Smith A. Palmoplantar pompholyx secondary to interleukin 17A inhibitor therapy for psoriasis: A case series. JAAD Case Rep. 2021 Jul. 13:46-48. [QxMD MEDLINE Link].
Eichhoff G. Secukinumab-induced pompholyx in a psoriasis patient. Dermatol Online J. 2020 Apr 15. 26 (4):[QxMD MEDLINE Link].
Kotan D. Erdem T, Acar BA, Boluk A. Dyshidrotic eczema associated with the use of IVIg. BMJ Case Rep. 2013 Feb 15;2013. pii: bcr2012008001. doi: 10.1136/bcr-2012-008001:[QxMD MEDLINE Link].
Shiraishi T, Yamamoto T. Severe dyshidrotic eczema after intravenous immunoglobulin therapy for Kawasaki syndrome. Pediatr Dermatol. 2012 Feb 3. [QxMD MEDLINE Link].
Brazzelli V, Grassi S, Savasta S, Ruffinazzi G, Carugno A, Barbaccia V, et al. Pompholyx of the hands after intravenous immunoglobulin therapy for clinically isolated syndrome: a paediatric case. Int J Immunopathol Pharmacol. 2014 Jan-Mar. 27(1):127-30. [QxMD MEDLINE Link].
Edman B. Palmar eczema: a pathogenetic role for acetylsalicylic acid, contraceptives and smoking?. Acta Derm Venereol. 1988. 68(5):402-7. [QxMD MEDLINE Link].
Meding B, Alderling M, Wrangsjö K. Tobacco smoking and hand eczema: a population-based study. Br J Dermatol. 2010 Oct. 163(4):752-6. [QxMD MEDLINE Link].
Douwes KE, Karrer S, Abels C, Landthaler M, Szeimies RM. Does smoking influence the efficacy of bath-PUVA therapy in chronic palmoplantar eczema?. Photodermatol Photoimmunol Photomed. 2000 Feb. 16(1):25-9. [QxMD MEDLINE Link].
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 Aug 1. 11(2):31. [QxMD MEDLINE Link].
MacConnachie AA, Smith CC. Pompholyx eczema as a manifestation of HIV infection, response to antiretroviral therapy. Acta Derm Venereol. 2007. 87(4):378-9. [QxMD MEDLINE Link].
Gill J, Pratt M. A severe case of recalcitrant pompholyx. J Cutan Med Surg. 2015 Sep-Oct. 19(5):494-7. [QxMD MEDLINE Link].
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. 2004 Jan. 50(1):68-72. [QxMD MEDLINE Link].
Soloman A, Cosgarea R, Ruzicka T, Braun-Falco M. J Eur Acad Dermatol Venereol. 2015 Oct 1. doi: 10.111/jdv.13400. [Epub ahead of print]:[QxMD MEDLINE Link].
Bittencourt AL, Mota K, Oliveira RF, Farre L. A dyshidrosis-like variat of adult T-cell leukemia/lymphoma with clinicoapathological aspects of mycosis fungoides. A case report. Am J Dermatopathol. 2009 Dec. 31(8):834-7. [QxMD MEDLINE Link].
Spieth K, Grundmann-Kollmann M, Runne U, Staib G, Fellbaum C, Wolter M, et al. Mycosis-fungoides-type cutaneous T cell lymphoma of the hands and soles: a variant causing delay in diagnosis and adequate treatment of patients with palmoplantar eczema. Dermatology. 2002. 205(3):239-44. [QxMD MEDLINE Link].
Yoon SY, Park HS, Lee JH, Cho S. Histological differentiation between palmoplantar pustulosis and pompholyx. J Eur Acad Dermatol Venereol. 2013 Jul. 27(7):889-93. [QxMD MEDLINE Link].
Kim DY, Kim JY, Kim TG, Kwon JE, Sohn H, Park J, et al. A comparison of inflammatory mediator expression between palmoplantar pustulosis and pompholyx. J Eur Acad Dermatol Venereol. 2013 Dec. 27(12):1559-65. [QxMD MEDLINE Link].
Schnopp C, Remling R, Mohrenschlager M, Weigl L, Ring J, Abeck D. Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: a randomized, observer-blinded trial. J Am Acad Dermatol. 2002 Jan. 46(1):73-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Egawa K. Topical vitamin D3 derivatives in treating hyperkeratotic palmoplantar eczema: a report of five patients. J Dermatol. 2005 May. 32(5):381-6. [QxMD MEDLINE Link].
Scerri L. Azathioprine in dermatological practice. An overview with special emphasis on its use in non-bullous inflammatory dermatoses. Adv Exp Med Biol. 1999. 455:343-8. [QxMD MEDLINE Link].
Egan CA, Rallis TM, Meadows KP, Krueger GG. Low-dose oral methotrexate treatment for recalcitrant palmoplantar pompholyx. J Am Acad Dermatol. 1999 Apr. 40(4):612-4. [QxMD MEDLINE Link].
Pickenacker A, Luger TA, Schwarz T. Dyshidrotic eczema treated with mycophenolate mofetil. Arch Dermatol. 1998 Mar. 134(3):378-9. [QxMD MEDLINE Link].
Diepgen TL, Pfarr E, Zimmermann T. Efficacy and tolerability of alitretinoin for chronic hand eczema under daily practice conditions: results of the TOCCATA open study comprising 680 patients. Acta Derm Venereol. 2012 May. 92(3):251-5. [QxMD MEDLINE Link].
Lakshmi C, Srinivas CR. Hand eczema: an update. Indian J Dermatol Venereol Leprol. 2012 Sep-Oct. 78(5):569-82. [QxMD MEDLINE Link].
Ruzicka T, Lynde CW, Jemec GB, et al. Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicentre trial. Br J Dermatol. 2008 Apr. 158(4):808-17. [QxMD MEDLINE Link].
Diepgen TL, Pfarr E, Zimmermann T. Efficacy and Tolerability of Alitretinoin for Chronic Hand Eczema Under Daily Practice Conditions: Results of the TOCCATA Open Study Comprising 680 Patients. Acta Derm Venereol. 2012 Jun 8. 92(3):251-5. [QxMD MEDLINE Link].
Tan J, Maari C, Nigen S, Bolduc C, Bissonete R. Open-label exploratory study of acitretin for the treatment of severe chronic hand dermatitis. J Dermatolog Treat. 2015. 26(4):373-5. [QxMD MEDLINE Link].
Crowley EL, Sayeau RL, Gooderham MJ. An Update on the Use of Alitretinoin for Chronic Hand Dermatitis in a Dermatology Practice Setting. J Cutan Med Surg. 2018 Jan/Feb. 22 (1):102-103. [QxMD MEDLINE Link].
Ogden S, Clayton TH, Goodfield MJ. Recalcitrant hand pompholyx: variable response to etanercept. Clin Exp Dermatol. 2006 Jan. 31(1):145-6. [QxMD MEDLINE Link].
Zirwas MJ. Dupilumab for hand eczema. J Am Acad Dermatol. 2018 Jul. 79 (1):167-169. [QxMD MEDLINE Link].
Weston GK, Hooper J, Strober BE. Dupilumab in the Treatment of Dyshidrosis: A Report of Two Cases. J Drugs Dermatol. 2018 Mar 1. 17 (3):355-356. [QxMD MEDLINE Link].
Oosterhaven JAF, Romeijn GLE, Schuttelaar MLA. Dupilumab Treatment of Very Severe Refractory Atopic Hand Eczema. JAMA Dermatol. 2018 Aug 1. 154 (8):969-970. [QxMD MEDLINE Link].
Nanda S, Nagrani N, MacQuhae F, Nichols A. A Case of Complete Resolution of Severe Plantar Dyshidrotic Eczema With Dupilumab. J Drugs Dermatol. 2019 Feb 1. 18 (2):211-212. [QxMD MEDLINE Link].
Gall RA, Peters JD, Brinker AJ. Two Cases of Recalcitrant Dyshidrotic Eczema Treated With Dupilumab. J Drugs Dermatol. 2021 May 1. 20 (5):558-559. [QxMD MEDLINE Link].
Bretterklieber A, Legat FJ, Wolf P, Hofer A. Retrospective long-term follow-up in patients with chronic palmoplantar dermatoses after good response to bath PUVA therapy. J Dtsch Dermatol Ges. 2012 Nov. 10(11):814-8. [QxMD MEDLINE Link].
Behrens S, von Kobyletzki G, Gruss C, Reuther T, Altmeyer P, Kerscher M. PUVA-bath photochemotherapy (PUVA-soak therapy) of recalcitrant dermatoses of the palms and soles. Photodermatol Photoimmunol Photomed. 1999 Apr. 15(2):47-51. [QxMD MEDLINE Link].
Tzaneva S, Kittler H, Thallinger C, Honigsmann H, Tanew A. Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema. Photodermatol Photoimmunol Photomed. 2009 Apr. 25(2):101-5. [QxMD MEDLINE Link].
Sezer E, Etikan I. Local narrowband UVB phototherapy vs. local PUVA in the treatment of chronic hand eczema. Photodermatol Photoimmunol Photomed. 2007 Feb. 23(1):10-4. [QxMD MEDLINE Link].
Letic M. Use of sunlight to treat dyshidrotic eczema. JAMA Dermatol. 2013 May. 149(5):634-5. [QxMD MEDLINE Link].
Sezer E, Erbil AH, Kurumlu Z, Taştan HB, Etikan I. Comparison of the efficacy of local narrowband ultraviolet B (NB-UVB) phototherapy versus psoralen plus ultraviolet A (PUVA) paint for palmoplantar psoriasis. J Dermatol. 2007 Jul. 34(7):435-40. [QxMD MEDLINE Link].
Robertson L. New and existing therapeutic options for hand eczema. Skin Therapy Lett. 2009 Mar. 14(3):1-5. [QxMD MEDLINE Link].
Swartling C, Naver H, Lindberg M, Anveden I. Treatment of dyshidrotic hand dermatitis with intradermal botulinum toxin. J Am Acad Dermatol. 2002 Nov. 47(5):667-71. [QxMD MEDLINE Link].
Kontochristopoulos G, Gregoriou S, Agiasofitou E, Nikolakis G, Rigopoulos D, Katsambas A. Letter: regression of relapsing dyshidrotic eczema after treatment of concomitant hyperhidrosis with botulinum toxin-A. Dermatol Surg. 2007 Oct. 33(10):1289-90. [QxMD MEDLINE Link].
Wollina U, Karamfilov T. Adjuvant botulinum toxin A in dyshidrotic hand eczema: a controlled prospective pilot study with left-right comparison. J Eur Acad Dermatol Venereol. 2002 Jan. 16(1):40-2. [QxMD MEDLINE Link].
Markantoni V, Kouris A, Armyra K, Vavouli C, Kontochristopoulous G. Remarkable improvement of relapsing dyshidrotic eczema after treatment of coexistant hyperhidrosis with oxybutynin. Dermatol Ther. 2014 Nov-Dec. 27(6):365-8. [QxMD MEDLINE Link].
Fairris GM, Jones DH, Mack DP, Rowell NR. Conventional superficial X-ray versus Grenz ray therapy in the treatment of constitutional eczema of the hands. Br J Dermatol. 1985 Mar. 112(3):339-41. [QxMD MEDLINE Link].
Cartwright PH, Rowell NR. Comparison of Grenz rays versus placebo in the treatment of chronic hand eczema. Br J Dermatol. 1987 Jul. 117(1):73-6. [QxMD MEDLINE Link].
Lindelof B, Wrangsjo K, Liden S. A double-blind study of Grenz ray therapy in chronic eczema of the hands. Br J Dermatol. 1987 Jul. 117(1):77-80. [QxMD MEDLINE Link].
Matin A, Bliwise DL, Wellman JJ, Ewing HA, Rasmuson P. Resolution of dyshidrotic dermatitis of the hand after treatment with continuous positive airway pressure for obstructive sleep apnea. South Med J. 2002 Feb. 95(2):253-4. [QxMD MEDLINE Link].
Paller AS, Tom WL, Lebwohl MG, Blumenthal RL, Boguniewicz M, Call RS, et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol. 2016 Sep. 75 (3):494-503.e6. [QxMD MEDLINE Link].
Stuckert J, Nedorost S. Low-cobalt diet for dyshidrotic eczema patients. Contact Dermatitis. 2008 Dec. 59(6):361-5. [QxMD MEDLINE Link].
[Guideline] Diepgen TL, Andersen KE, Chosidow O, Coenraads PJ, Elsner P, English J, et al. Guidelines for diagnosis, prevention and treatment of hand eczema. J Dtsch Dermatol Ges. 2015 Jan. 13 (1):e1-22. [QxMD MEDLINE Link].
Vocks E, Plotz SG, Ring J. The Dyshidrotic Eczema Area and Severity Index - A score developed for the assessment of dyshidrotic eczema. Dermatology. 1999. 198(3):265-9. [QxMD MEDLINE Link].

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 Workup

Approach Considerations

Histologic Findings

References

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Contributor Information and Disclosures

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