Derm Dx: A teenager presents with small, clear pruritic lesions that resemble tapioca

Pompholyx, also known as acute vesicular palmoplantar eczema and cheiropompholyx, is a type of chronic and recurring vesiculobullous eczema of unknown etiology that affects the hands and feet. Although the original purported association with sweat gland dysfunction has been ruled...

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Pompholyx, also known as acute vesicular palmoplantar eczema and cheiropompholyx, is a type of chronic and recurring vesiculobullous eczema of unknown etiology that affects the hands and feet. Although the original purported association with sweat gland dysfunction has been ruled out, the disorder is still sometimes referred to as dyshidrotic eczema.

Stress has been implicated as a cause, as well as contact sensitivity to materials including nickel, Compositae, paraphenylenediamine, benzisothiazolines and chromate. Some purport that the disorder may be a secondary response to a distant fungal infection. Many cases appear constitutional but separate from atopy or other allergic conditions, including asthma and allergic rhinitis.

The condition occurs most often in the spring and summer months and affects women more often then men. Episodes can vary in frequency from a few times per  year to a couple of times per month. Severe cases can result in occupational disability, as patients are advised to avoid irritants including water, solvents and detergents. Complications can include secondary bacterial infection.

Diagnosis

Most cases can be distinguished by physical exam, but a potassium hydroxide (KOH) test or patch testing may be necessary to rule out fungal infections and contact dermatitis.

Treatment

Mild cases of pompholyx usually resolve spontaneously within one to two weeks, but more severe cases may require wet soaks and compresses to alleviate itching. Corticosteriod creams and ointments can help improve the appearance of blisters, cracks and fissures. Other treatments include antihistamines, ultraviolet light therapy, and immune-suppressing ointments, such as tacrolimus (Protopic) and pimecrolimus (Elidel). Systemic antibiotics may be necessary if there is a secondary bacterial infection.

Clinicians should advise patients to avoid scratching the rash, limit skin exposure to water, use hand cream to moisturize after hand-washing and avoid potential irritants such as perfumed hand lotion or dish detergent.

References

1. Freedberg IM, Isin AZ, Wolff K, et al. Fitzpatrick’s Dermatology in General Medicine (5^th ed.). 1999. New York: McGraw-Hill.

2. Wollina U. Pompholyx: what’s new?. Expert Opin Investig Drugs. Jun 2008;17(6):897-904.

3. US Food and Drug Administration. FDA Public Health Advisory. Elidel (pimecrolimus) Cream and Protopic (tacrolimus) Ointment. FDA.gov. Accessed March 28, 2010.

4. Jain VK, Aggarwal K, Passi S, Gupta S. Role of contact allergens in pompholyx. J Dermatol. Mar 2004;31(3):188-93.