Dyshidrosis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • A skin rash (dermatitis) of which there are several different classes within the family “dyshidrosis” and strict definitions are disputed.
  • Dyshidrotic eczema:
    • Common, chronic, or recurrent, nonerythematous, vesicular eruption primarily of the palms, soles, and interdigital areas
    • Associated with burning, itching, and pain
  • Pompholyx (from Greek, “bubble”):
    • Rare condition characterized by abrupt onset of large bullae, primarily on hands
    • Sometimes used interchangeably with dyshidrosis, although many believe them to be discrete entities
  • Lamellar dyshidrosis:
    • Fine, spreading exfoliation of the superficial epidermis in the same distribution as described above
  • System(s) affected: Dermatologic; Exocrine; Immunologic
  • Synonym(s): Pompholyx; Cheiropompholyx; Keratolysis exfoliativa; Dyshidrotic eczema; Vesicular palmoplantar eczema; Desquamation of interdigital spaces; Palmar pompholyx reaction

Epidemiology

Incidence

  • Incidence is 0.5%.
  • Mean age of onset is <40 years.
  • Male = Female
  • Comprises 5–20% of hand eczema cases

Prevalence

20 cases per 100,000

Risk Factors

  • Many risk factors are disputed in the literature, with none being consistently associated
  • Atopy
  • Other dermatologic conditions:
    • Atopic dermatitis (early in life)
    • Contact dermatitis (later in life)
    • Dermatophytosis
  • Sensitivity to
    • Foods
    • Drugs: neomycin, quinolones, acetaminophen, and oral contraceptives
    • Nickel (seen in patients treated with disulfiram, which causes a high serum level of nickel)
    • Smoking in males

Genetics

  • Atopy: 50% of patients with dyshidrotic eczema have atopic dermatitis.
  • Rare autosomal dominant form of pompholyx found in Chinese population maps to chromosome 18q22.1–18q22.3

General Prevention

  • Control emotional stress.
  • Avoid excessive sweating.
  • Avoid exposure to irritants.
  • Avoid diet high in metal salts (chromium, cobalt, nickel).

Pathophysiology

  • Exact mechanism unknown; thought to be multifactorial
  • On dermatopathology, vesicles are found in spongiotic dermatitis
  • Thick stratum corneum of palmar and plantar skin keeps the vesicles intact

Etiology

  • Exact cause not known
  • Aggravating factors (debated):
    • Hyperhidrosis (in 40% of patients with the condition)
    • Climate: Hot or cold weather; humidity
    • Nickel sensitivity
    • Irritating compounds and solutions
    • Stress
    • Dermatophyte infection
    • Prolonged wear of occlusive gloves
    • Intravenous immunoglobulin therapy
    • Smoking

Commonly Associated Conditions

  • Atopic dermatitis
  • Allergic contact dermatitis
  • Parkinson disease

Atopic dermatitis, Dyshidrosis, Eczema, hand eczema, dyshidrotic eczema, oral contraceptives, emotional stress,

Diagnosis

History

  • Episodes of pruritic rash alternating with periods that are symptom free
  • Recent emotional stress
  • Familial or personal history of atopy
  • Exposure to allergens or irritants (1):
    • Occupational, dietary, or household
    • Cosmetic and personal hygiene products
  • Costume jewelry use
  • IV immunoglobulin therapy
  • HIV
  • Smoking

Physical Exam

  • Symmetric distribution on the palms and soles; also may affect the dorsal aspects of hands and feet
  • Early findings:
    • 1–2 mm, clear nonerythematous deep-seated vesicles
  • Late findings:
    • Unroofed vesicles with inflamed bases
    • Desquamation
    • Peeling, rings of scale, or lichenification common

Diagnostic Tests & Interpretation

Lab

Initial lab tests

Skin culture in suspected secondary infection (most commonly staph aureus) (2)

Follow-Up & Special Considerations

Consider antibiotics based on culture results and severity of symptoms.

Diagnostic Procedures/Surgery

  • Diagnosis is based on clinical exam
  • Patch test (to elicit allergic cause)
  • KOH wet mount (if concerned about dermatophyte infection)

Pathological Findings

  • Fine 1–2-mm spongiotic vesicles intraepidermally with little to no inflammatory changes
  • No eccrine glandular involvement

Differential Diagnosis

  • Vesicular tinea pedis/manus
  • Vesicular id reaction
  • Contact dermatitis (allergic or irritant)
  • Chronic vesicular hand dermatitis
  • Drug reaction
  • Dermatophytid
  • Bullous disorders: Dyshidrosiform bullous pemphigoid, pemphigous, bullous impetigo, epidermolysis bullosa
  • Pustular psoriasis
  • Acrodermatitis continua
  • Erythema multiforme
  • Herpes infection
  • Pityriasis rubra pilaris
  • Vesicular mycosis fungoides

Treatment

Identification and avoidance of aggravating factors.

Medication

First Line

  • Mild cases: Topical steroids (high potency) (2)[B]
  • Moderate to severe cases:
    • Ultrahigh-potency topical steroids with occlusion over treated area (3)[B]
    • Psoralens plus UV therapy (PUVA), either oral or immersion in psoralens (4)[B]:
      • Oral 8-methoxypsoralen (8-MOP) dose: 0.6 mg/kg taken 1 h prior to UVA irradiation
      • Immersion in 8-MOP: Solution of 5 mg/L of water × 15 minutes immediately preceding UVA irradiation
  • Recurrent cases (3)[C]:
    • Systemic steroids at onset of itching prodrome
    • Single morning dose of 60 mg × 3–4 days every 2–4 months

Second Line

  • Topical calcineurin inhibitors (mitigate the long term risks of topical steroid use):
    • Topical tacrolimus (5)[A]
    • Topical pimecrolimus (5)[A]
  • Oral cyclosporine (2)[A]
  • Injections of botulinum toxin type A (BTXA) (5)[A]
    • Newer topical forms of BTXA currently being developed and show promise
  • Systemic alitretinoin (5)[A]
  • Topical bexaarotene (a retinoid X receptor agonist approved for use in cutaneous T-cell lymphoma) (5)[B]
  • Methotrexate (5)[C]

Additional Treatment

  • Radiation therapy (6)[C]
  • UV-free phototherapy (5)[C]

General Measures

  • Avoid possible causative factors: Stress, chemical irritants, nickel, occlusive gloves, smoking, sweating
  • Moisturizers/emollients for symptomatic relief
  • Foot care:
    • Wear shoes with leather rather than rubber soles (e.g., sneakers).
    • Wear socks made of cotton instead of synthetic materials.
    • Remove shoes and socks whenever possible to allow sweat evaporation and to apply lubricants.

Issues for Referral

  • Allergist (if allergen testing required)
  • Psychologist (if stress modification needed)

Complementary and Alternative Medicine

  • Topical treatments to minimize pruritus (not curative) (2)[C]: Burrow solution (aluminum acetate) or vinegar compress
  • Exposure to sunlight as maintenance therapy (7)[C]
  • Dandelion juice (avoid in atopic patients) (5)[C]

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

  • Dyshidrotic Eczema Area and Severity Index (DASI)
  • Parameters used in the DASI score:
    • Number of vesicles per square centimeter
    • Erythema
    • Desquamation
    • Severity of itching
    • Surface area affected
  • Grading: Mild (0–15), moderate (16–30), severe (31–60)
  • Monitor BP and glucose in patients receiving systemic corticosteroids.
  • Monitor for adverse effects of medications.

Diet

  • Consider diet low in metal salts if there is history of nickel sensitivity (2)[A].
  • Updated recommendations for low-cobalt diet are available (8).

Patient Education

  • Instructions on self-care, complications, and avoidance of triggers/aggravating factors
  • Suggested web site for patients: www.nlm.nih.gov

Prognosis

  • Condition is benign.
  • Usually heals without scarring
  • Lesions often resolve spontaneously but resolve more quickly with appropriate treatment (9).
  • Recurrence is common.

Complications

  • Secondary bacterial infections (staphylococcus aureus most common)
  • Dystrophic nail changes
  • Fissures
  • Skin tightening/discomfort
  • Psychological distress

References

1. Guillet MH, Wierzbicka E, Guillet S, et al. A 3-year causative study of pompholyx in 120 patients. Arch Dermatol. 2007;143:1504–8.

2. Lofgren SM. Dyshidrosis: Epidemiology, clinical characteristics, and therapy.Dermatitis. 2006;17:165–81.

3. Chen J, et al. The gene for a rare autosomal dominant form of pompholyx maps to chromosome 18q22.1–18q22.3. J Invest Dermatol. 2006;126:300–4.

4. Tzaneva S, Kittler H, Thallinger C, et al. Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema. Photodermatol Photoimmunol Photomed. 2009;25:101–5.

5. Wollina U. Pompholyx: what’s new? Expert Opinion in Investigational Drugs.2008;17:897–904.

6. Sumila M, Notter M, Itin P, et al. Long-term Results of Radiotherapy in Patients with Chronic Palmoplantar Eczema or Psoriasis. Strahlentherapie und Onkologie. 2008;184:218–223.

7. Letić M. Exposure to sunlight as adjuvant therapy for dyshidrotic eczema.Med Hypotheses. 2009.

8. Stuckert J, Nedorost S. Low-cobalt diet for dyshidrotic eczema patients.Contact Dermatitis. 2008;59:361–5.

9. Rashid RD, Salah W, Keuer EJ. Vexing Vesicles. Journal of Medicine.2007;120:589–590.

Additional Reading

Thiers BH. What’s new in dermatologic therapy. Dermatol Ther. 2008 Mar–Apr;21:142–9.

11. Veien NK. Acute and Recurrent Vesicular Hand Dermatitis. Dermatologic Clinics. 2009;27:337–353.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Rash, Focal

Codes

ICD9

705.81 Dyshidrosis

Snomed

402567004 vesicular eczema of hands and/or feet (disorder)

Clinical Pearls

  • Dyshidrosis is a transient, recurrent vesicular eruption most commonly of the palms, soles, and interdigital areas.
  • The etiology and pathophysiology are unknown but are most likely related to a combination of genetic and environmental factors.
  • The best prevention is limiting exposure to irritating agents.
  • Treatments are based on severity of disease and include topical steroids, UV therapy, botulinum toxin A, and various immunosuppressants.
  • The condition is benign and usually heals spontaneously and without scarring. Medical treatment decreases healing time and risk for progression to secondary bacterial infection.

Jean-Paul Marat

Many tips are based on recent research, while others were known in ancient times. But they have all been proven to be effective. So keep this website close at hand and make the advice it offers a part of your daily life.

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