Pathophysiology: The etiology of pompholyx is unknown. The condition was inaccurately described in 1873 as dyshidrosis because of the clinical symptom of sweaty palms. The term dyshidrosis indicates a sweating abnormality, although histologic examination shows no evidence of eccrine glandular involvement. Histologically, the vesicles are intraepidermal and spongiotic with little to no inflammatory changes. The more appropriate term for this vesicular eruption is "pompholyx" which means "bubble." While there are strong reasons to use the term pompholyx, dyshidrotic eczema remains a commonly used term. A tiny percentage of individuals with the disorder note flares after ingesting metal salts, specifically chromium, cobalt, and nickel. Diets that eliminate these metal salts may rarely have some clinical benefit.

Frequency:

• In the US: Pompholyx accounts for 5% of all eczemas of the hand.

Mortality/Morbidity: Pompholyx has no associated mortality, although some severe cases can become debilitating.

Race: There is no reported racial predilection.

Sex: The female-to-male ratio 2:1.

History: Patients first describe several hours of itching or burning sensations in their hands and/or feet before the eruption develops. Tiny vesicles erupt first along lateral aspects of the fingers and then on the palms or soles. Palms and soles may be red and wet with perspiration. The vesicles usually persist for 3-4 weeks. Vesicle outbreaks may occur in waves.

Physical: Physical examination performed early in the course of the flare reveals small (ie, 1-2 mm), clear, deep-seated vesicles without erythema erupting on lateral aspects of fingers, central palm, and plantar surfaces. The vesicles have been described as resembling "tapioca pudding." Eruptions usually are bilateral and symmetric. Patients seen later in the course of this disorder may have unroofed vesicles with inflamed bases, possibly accompanied by peeling or rings of scale or lichenification. Transverse furrows can develop on the nail when eruptions occur in the periungual area and/or nail matrix.

Id reaction
Pustular psoriasis
Primary fungal infection
Recurrent focal palmar peeling (previously termed keratolysis exfoliativa)

Medical Care: Typical first-line treatment includes high strength topical steroids and cold compresses. Short courses of oral steroids are the second line of treatment for acute flares, and other immunosuppressants also have been tried. Variable effects have been reported using PO administration of psoralen and subsequent exposure to long-wavelength ultraviolet light (PUVA) therapy. Identification of the causes of stress and use of stress management techniques as adjuncts may be helpful in some patients.

Consultations: Consult with a dermatologist for severe or resistant cases.

Diet: Pompholyx requires no dietary restrictions, although some patients have reported improvement by avoiding foods rich in heavy metal salts.

Pompholyx treatment can be quite challenging because of the severe inflammatory process or because of frequent recurrences. Pharmacologic treatment begins with high-strength topical corticosteroids. In recalcitrant cases, systemic corticosteroids are the next line of treatment. Two recent case reports also note some success with other immunosuppressants (eg, methotrexate, mycophenolate mofetil).
 

Drug Category: Corticosteroids -- Topical corticosteroids are the first line of therapy. Steroid potency choice is based on the patient's response to treatment; however, the higher-strength steroids are usually necessary for disease control.

Further Inpatient Care:

• Inpatient care is unnecessary.

Further Outpatient Care:

• Further outpatient care includes physician follow-up for treatment options.

Deterrence/Prevention:

• Decrease stress and avoid ingesting metal salts.

Complications:

• Complications include poor response to treatment, resulting in continued rash, pruritus, and possible superinfection.

Prognosis:

• The prognosis for patients with pompholyx varies. Some individuals recover completely; some experience chronic unremitting pompholyx.

Patient Education:

• Inform individuals with this disorder about the difficulty of achieving successful treatment.