Vesicular Palmoplantar Eczema Workup

Updated: Oct 08, 2021
  • Author: Jessica Dunkley, MD, MHSc, CCFP; Chief Editor: Dirk M Elston, MD  more...
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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.