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DYSHIDROTIC ECZEMA

Introduction

Dyshidrotic eczema—also known as pompholyx, dyshidrosis, vesicular eczema, foot-and-hand eczema, and palmoplantar eczema—is a common, chronic dermatitis of the fingers, palms, and soles. It’s considered a special type of eczematous reaction with pronounced spongiosis and accumulation of edema fluid in regions with a thick epidermis and an even thicker overlying horny layer. Dyshidrotic eczemacan be an acute, chronic, or recurrent dermatosis, and is characterized by the sudden onset of many deep-seated pruritic, clear “sago-like” or “tapioca pudding ball” vesicles. The condition is more common in warmer weather, with some patients flaring annually in the summer with intensely pruritic or burning eruptions, and it’s considered a diagnosis of exclusion.1-4

Pathophysiology

  • The exact cause of dyshidrotic eczemais unknown, and it likely has a multifactorial etiology. Commonly cited risk factors that may play a role in its pathogenesis include allergy to metals (particularly nickel), genetic determinants, and dermatophyte infection.2,5
    • Other possible risk factors include: exposure to ultraviolet rays, emotional stress, exposure to contact irritants, recent exposure to costume jewelry, recent treatment with intravenous immunoglobulin therapy, human immunodeficiency virus (HIV) infection.
    • Although the condition appears to run in families and is therefore thought to have a genetic component, no gene has yet been identified to confirm this theory.5
    • It appears that dyshidrotic eczema occurs primarily as a feature of atopic dermatitis during childhood and adolescence, whereas later in life, the majority of cases develop as an occupational contact dermatitis. Some authors also believe that it is a special variant of atopic dermatitis, but this theory has been questioned by others.3

Related Anatomy

  • Epidermis
  • Palmoplantar skin
  • There are two clinical types of dyshidrotic eczema: bullous and vesicular. The bullous type may be referred to as cheiropodopompholyx.6

Incidence and Related Conditions

  • Dyshidrotic eczema accounts for 5-20% of all cases of hand eczema.7
  • The mean age of occurrence is 38 years, with a peak incidence between 20-40 years. After middle age, the frequency of dyshidrotic eczema episodes tends to decrease.5
  • Although hand dermatitis in general is more common in young women, dyshidrotic eczema appears to have a fairly even male-to-female distribution ratio.2,5
  • Atopic dermatitis
  • Contact dermatitis
  • Hand eczema

Differential Diagnosis

  • Acropustulosis of infancy
  • Bullous disorders 
  • Bullous impetigo 
  • Dyshidrosiform pemphigoid
  • Dyshidrotic tinea 
  • Epidermolysis bullosa
  • Erythema multiforme
  • Herpes simplex
  • Fixed drug eruption
  • Friction blisters
  • Psoriasis pustulosa
  • Scabies 
  • Subcorneal pustular dermatosis
  • Vesicular tinea pedis and tinea manus
ICD-10 Codes

  • SKIN - COMMON HAND RASHES: DYSHYIDROTIC ECZEMA

    Diagnostic Guide Name

    SKIN - COMMON HAND RASHES: DYSHYIDROTIC ECZEMA

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DYSHYIDROTIC ECZEMAL30.1   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
pruritus out of proportion
burning pain
redness
sudden eruption of blisters
cracking of skin
Typical History

A typical patient is a 36-year-old male teacher from northern New Jersey. During the summer, the man works at an outdoor restaurant and spends much of this time in the sun. For the past few summers, he’s noticed a set of specific symptoms emerge after working this job for a few weeks. Each time, small vesicles have suddenly erupted on his palms and fingers, which is associated with redness, itching, and a burning pain. These symptoms have made it difficult for him to complete his job, which led him to seek out care from a dermatologist.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative

Conservative2-4,6

  • The management of dyshidrotic eczema is not simple, and relapses are common. The three primary goals of treatment are: suppression of blister formation and inflammation, relief from itch, and prevention or treatment of infection (when present).6
  • Topical therapy
    • Corticosteroids
      • Considered the cornerstone of treatment for dyshidrotic eczema, and frequently used as a first-line intervention.6Short courses of superpotent or potent strength agents should be considered.
    • Calcineurin inhibitors
  • Systemic therapy
    • Corticosteroids
      • Primarily indicated for bullous types of dyshidrotic eczema; treatment should be deferred to dermatology
      • An initial dosage of 40-100 mg/day is typically recommended.
      • Systemic corticosteroids are rarely advised for long-term use because of undesirable adverse effects.6
    • Immunosuppressants
    • Retinoids
    • Biologics
    • Antihistamines
Operative
  • Surgery does not appear to be indicated for any cases of dyshidrotic eczema.
Complications
  • Secondary bacterial infection of dyshidrotic eczema vesicles or bullae can result in cellulitis, lymphangitis, and septicemia.
  • Dystrophic nail changes (eg, transverse ridging, thickening, discoloration, and pitting)
  • Herpes zoster
Outcomes
  • Although dyshidrotic eczema is a fairly common condition, relatively few randomized controlled trials have been performed to evaluate the efficacy of various interventions.6
  • There is ample evidence to support the use of topical drugs such as corticosteroids, calcineurin inhibitors, and bexarotene, but no randomized study has yet been published on concomitant topical and short-term systemic corticosteroids, which is the most common treatment combination used for this condition.6
Key Educational Points
  • Dyshidrotic Eczema Area and Severity Index (DASI)
    • A standardized assessment method based on the number of vesicles/cm³, erythema, desquamation, itch, and the extension of the affected area.3
  • Another workup option may include patch testing which may be used to exclude allergic contact dermatitis.
  • It was once believed that there was an association between dyshidrotic eczema and abnormal sweating of the palms, but this has since been disproven by histological studies.5
  • Although the terms “dyshidrotic eczema” and “pompholyx” are often used interchangeably, some authors have suggested that the two actually represent discrete entities: dyshidrotic eczema—or dyshidrosis—is a common, chronic, and recurrent eruption of small (1-2 mm) vesicles on the palms, soles, and/or lateral aspects of the fingers, while pompholyx is a rare condition characterized by an explosive onset of large bullae on the hands.2
References

New and Cited Articles

  1. Abreu-Velez AM, Pinto FJ, Jr., Howard MS. Dyshidrotic eczema: relevance to the immune response in situ. N Am J Med Sci 2009;1(3):117-120.PMID: 22666682
  2. Lofgren SM, Warshaw EM. Dyshidrosis: epidemiology, clinical characteristics, and therapy. Dermatitis 2006;17(4):165-181.PMID: 17150166
  3. Wollina U, Abdel Naser MB. Pharmacotherapy of pompholyx. Expert Opin Pharmacother 2004;5(7):1517-1522. PMID: 15212602
  4. Marks JG, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. Fifth Ed. London, New York: Saunders Elsevier; 2013.
  5. Summers A. Pompholyx. Emerg Nurse 2007;15(5):18-19.PMID: 17902549
  6. Wollina U. Pompholyx: a review of clinical features, differential diagnosis, and management. Am J Clin Dermatol 2010;11(5):305-314.PMID: 20642293
  7. Agarwal US, Besarwal RK, Gupta R, Agarwal P, Napalia S. Hand eczema. Indian J Dermatol 2014;59(3):213-224. PMID: 24891648

Reviews

  1. Lofgren SM, Warshaw EM. Dyshidrosis: epidemiology, clinical characteristics, and therapy. Dermatitis 2006;17(4):165-181.PMID: 17150166
  2. Wollina U. Pompholyx: a review of clinical features, differential diagnosis, and management. Am J Clin Dermatol 2010;11(5):305-314.PMID: 20642293
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