ESSENTIALS OF DIAGNOSIS
Pruritic “tapioca” vesicles of 1–2 mm on the palms, soles, and sides of fingers.
Vesicles may coalesce to form multiloculated blisters.
Scaling and fissuring may follow drying of the blisters.
Appearance in the third decade, with lifelong recurrences.
Pompholyx, or vesiculobullous dermatitis of the palms and soles, is formerly known as dyshidrosis or dyshidrotic eczema. About half of patients have an atopic background, and many patients report flares with stress. Patients with widespread dermatitis due to any cause may develop pompholyx-like eruptions as a part of an autoeczematization response.
Small clear vesicles resembling grains of tapioca stud the skin at the sides of the fingers and on the palms (Figure 6–28) (eFigure 6–32) and may also affect the soles, albeit less frequently. They may be associated with intense itching. Later, the vesicles dry and the area becomes scaly and fissured.
Severe pompholyx. (Reproduced with permission from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.)
Unroofing the vesicles and examining the blister roof with a KOH preparation will reveal hyphae in cases of bullous tinea. Patients with inflammatory tinea pedis may have a vesicular autoeczematization of the palms. NSAIDs may produce an eruption very similar to that of vesiculobullous dermatitis on the hands.
There is no known way to prevent attacks if the condition is idiopathic. About one-third to one-half of patients with vesiculobullous hand dermatitis have a relevant contact allergen, especially nickel. Patch testing and avoidance of identified allergens can lead to improvement.
Topical and systemic corticosteroids help some patients dramatically; however systemic corticosteroids are generally not appropriate therapy. A high-potency topical corticosteroid used early may help abort the flare and ameliorate pruritus. Topical corticosteroids are also important in treating the scaling and fissuring that are seen after the vesicular phase. Oral alitretinoin may be effective. It is essential that patients avoid anything that irritates the skin; they should wear cotton gloves inside vinyl gloves when doing dishes or other wet chores and use a hand cream after washing the hands. Patients respond to PUVA therapy and injection of botulinum toxin into the palms as for hyperhidrosis.
For most patients, the disease is an inconvenience. For some, vesiculobullous hand eczema can be incapacitating.
et al. Hand eczema: epidemiology, prognosis and prevention. J Eur Acad Dermatol Venereol. 2020;34:4.