Dyshidrotic Eczema
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Direct answer
Dyshidrotic eczema, also called pompholyx, is a recurrent vesicular eczema of the palms, lateral fingers and soles, producing deep-seated, intensely itchy vesicles that can coalesce into bullae. Despite the older name, sweating is a trigger rather than the cause, and stress, wet work and nickel or cobalt contact are common provokers. Treatment combines potent topical steroids in courses, cool wet dressings and strict avoidance of irritants and metal allergens.
What you must remember
- Morphology: deep-seated, tapioca-like vesicles on the palms, lateral fingers and soles that may coalesce into bullae.
- Course: recurrent crops with itch and burning, settling with scaling and fissuring.
- Triggers: stress, sweating, wet work, seasonal change and contact with nickel or cobalt.
- Allergy link: nickel and cobalt sensitisation is commonly associated, and patch testing helps in recurrent disease.
- Differential diagnosis: tinea manuum, which is usually unilateral and KOH-positive, scabies, allergic contact dermatitis and palmoplantar pustulosis.
- Acute treatment: potent topical corticosteroids in courses, with cool wet dressings for oozing vesicles.
- Severe disease: short oral corticosteroid courses for extensive disease, phototherapy for chronic cases and alitretinoin for severe chronic hand eczema.
A management ladder for recurrent vesicles
Pompholyx responds to a stepwise approach that calms inflammation, limits irritant exposure and then addresses recurrence. The steps below follow standard dermatology practice and should be applied in order.
- Confirm the diagnosis: a KOH test excludes tinea, especially when the eruption is unilateral, and patch testing identifies nickel or cobalt allergy in recurrent cases.
- Control the acute phase: a potent topical steroid is applied to the palms and fingers in courses, with cool wet dressings for oozing vesicles.
- Remove the triggers: avoid nickel-containing items, wear cotton-lined gloves for wet work and limit prolonged hand washing.
- Use emollients: apply fragrance-free emollients after washing and between flares to restore the barrier.
- Escalate for severity: a short oral corticosteroid course for extensive disease, phototherapy for chronic recalcitrant disease and alitretinoin where severe chronic hand eczema persists.
- Treat infection: antibiotic cover is given when secondary impetiginisation, usually from Staphylococcus aureus, is present.
Treatment works best when the trigger is identified early, because repeated flares damage the barrier and prolong the course.
Where the exam tries to catch you
Dyshidrotic eczema questions test the mimics, the metal link and the name trap.
- Trap: labelling every palmar vesicle as pompholyx without a KOH test Correct: unilateral vesicles with scaling suggest tinea manuum, which needs antifungal treatment.
- Trap: treating the name dyshidrosis as proof of a sweat-gland disorder Correct: sweating is a trigger, not the primary cause, and the name is historical.
- Trap: ignoring nickel allergy in recurrent disease Correct: patch testing identifies the sensitiser, and avoidance prevents recurrence.
- Trap: using potent steroids continuously on the palms for months Correct: steroids are used in courses, because long-term use causes atrophy and tachyphylaxis.
Frequently asked questions
Why is dyshidrotic eczema also called pompholyx?
Pompholyx is the Greek-derived term for the bubble-like vesicles that characterise the condition. Dyshidrotic eczema is the older name, which suggested a sweat-gland disorder. Modern texts use both names, with sweating regarded as a trigger rather than the cause.
Which conditions mimic dyshidrotic eczema on the palms?
Tinea manuum, scabies, allergic contact dermatitis and palmoplantar pustulosis are the main mimics of dyshidrotic eczema. Tinea is usually unilateral and is confirmed by a potassium hydroxide preparation. Scabies should be considered when other household members are also itchy.
Which metal allergy is linked to recurrent dyshidrotic eczema?
Nickel and cobalt allergy are commonly linked to recurrent dyshidrotic eczema. Patch testing identifies the sensitiser in these patients. Avoiding contact with the identified metal is the main preventive measure.
When is systemic therapy used in dyshidrotic eczema?
Systemic corticosteroid courses are used for extensive or disabling dyshidrotic eczema that does not respond to topical measures. Phototherapy and alitretinoin are options for chronic recalcitrant disease. Systemic therapy is always weighed against the risks of prolonged use.