Dyshidrotic Eczema - developinganaesthesia



DYSHIDROTIC ECZEMA

Introduction

Dyshidrotic eczema is a form of eczema characterized by intensely itchy, small discrete vesicular lesions, on the hands and/ or feet.

The condition is also known as pompholyx, which derives from the Greek cheiropompholyx, meaning “hand and bubble”.

As lesions involve the hands and can become chronic, the condition can be very disabling.

Treatment involves topical and systemic steroids as well as removal of any aggravating or precipitating factors.

Epidemiology

Dyshidrotic eczema can affect virtually all age groups, but the mean age is around 35-40 years.

The frequency tends to decrease after middle age.

Pathology

The exact etiology of dyshidrotic eczema is unknown but is probably multifactorial.

A variety of both endogenous exogenous factors are thought to be involved.

The following etiologies/ predisposing factors have been proposed:

1. Hyperhidrosis:

● This appears to be a precipitating factor in at least 40 % of cases.

2. Atopy:

● There is an association with familial atopy.

3. Exogenous factors:

● Some agents may act to cause a contact dermatitis.

● In the case of pompholyx, one theory suggests that antigens may be acting as haptens with a specific affinity for palmo-plantar proteins within the epidermis. The binding of these haptens to specific tissue receptor sites may then initiate the pompholyx.

4. Emotional stress:

● There seems to be a correlation with emotional stress possibly via an exacerbation of sweating

5. Environmental factors:

● Seasonal changes, such as hot temperatures or high humidity may be a factor in some cases, again possibly via increased sweating.

6. Fungal infection:

● In some patients, a distant fungal infection may initiate palmar pompholyx, probably via an auto-immunological mechanism. Pompholyx of the hands can be precipitated by an acute inflammatory tinea of the feet and this should be looked for and treated. 2

Clinical features

Characteristics of the lesions

1. Vesicular lesions are characteristically small clear and fluid filled. They are also desribed as “tapioca-like”.

2. Vesicles are typically “deep seated.”

3. They appear abruptly on the hands and / or feet

● Hands are involved solely in 80% of patients

● Feet are involved solely in 10% of patients

● Both hands and feet are involved in 10% of patients

.

4. Vesicles may become larger and form bullae, or become confluent.

5. Vesicles are usually intensely pruritic

6. Vesicles may become secondarily infected

7. Chronically lesions may become crusted, scaling, lichenified, and fissured.

Time course

Eruptions may be acute, chronic or episodic.

Recurrent attacks are the rule, with episodes lasting generally 2-3 weeks, but may last longer.

Intervals between attacks may range from weeks to months.

Three examples of classic pompholyx.

Investigations

When the diagnosis is clear clinically then no specific investigations are necessary.

Investigation may be warranted to rule out differential diagnoses or secondary complications

Management

1. Antihistamines

● These may be useful to help control pruritus

2. Steroids:

● High potency topical steroids should be used.

● Applications can be retained on the hand by occlusive dressings, two to three times day.

● Treatment may need to persist for 2-3 weeks

3. Prednisolone:

● More severe cases usually respond well to oral steroids

● Treatment may be required for 2-3 weeks.

See latest edition of Dermatology Therapeutic Guidelines for full prescribing details.

4. Tinea:

● Treat any associated tinea of the feet

5. Avoid precipitants/ aggravating factors:

● Avoid precipitating stress/ environmental factors, (where possible).

● Avoid any skin irritants, (soaps, detergents, chemicals etc)

6. Secondary bacterial infection:

● Look for and treat, as indicated

7. Phototherapy:

● A number of dermatological conditions (including psoriasis, dermatitis and cutaneous lymphoma) respond favourably to carefully controlled exposure to ultraviolet (UV) radiation (phototherapy).

● In its simplest from this can mean simple sunlight.

The benefit of natural sunlight exposure for various conditions is well recognized and dates back thousands of years.

● More complex phototherapy can be prescribed under the care of a dermatologist.

● Phototherapy can be beneficial in some cases of pompholyx.

8. Dermatologist referral:

● Chronic relapsing vesicular hand and foot dermatitis will need a specialist dermatologist referral.

References

1. Wolff K, Johnson A. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dematology, Mcgraw hill 6th ed 2009

2. Dermatology Therapeutic Guidelines, 3rd ed 2009.

Dr J. Hayes

September 2009

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