Pompolyx is an algorithm showing the approach to the patient with vesicular palmoplantar eczema.

the
severity of pompholyx can range from the inconvenient to the severe and can even be serious enough to
necessitate hospitalization. in true acute pompholyx, there is an explosive outbreak of deep-seated
vesicles on palms, the lateral aspects of the fingers, and sometimes the soles, usually in a symmetric
pattern. discomfort and itching usually precede the development of the blisters, which have been
described as having a "tapioca" appearance. blister may coalesce then desiccate and resolve without
rupture. intact, large blisters can be drained, but should not be unroofed. however, large blistres may
rupture spontaneously, leaving oozing or dried up erosions.
the acute phase is generally followed by desquamation of the affected areas. individual outbreaks are
usually self-limited over 2 to 3 weeks, although they may recur. secondary bacterial infection is common,
often resulting in a local cellulitis, and can sometimes potentiate the development of lymphatic damage,
resulting in lymphaedema. attacks are most common among adolescents and young adults and seem to
be more common in the spring and summer months.

chronic vesiculobullous dermatitis

Chronic vesiculobullous hand dermatitis is more common than true pompholyx and more difficult to
manage because of its relapsing course. the clinical presentation includes small 1- to 2-mm vesicles filled
with clear fluid localizing to the lateral aspects of the fingers, palms, and soles as in pompholyx. as the
condition becomes more chronic, the clinical appearance may evolve and subsequently appear more
fissured and hyperceratotic. a clear history of vesicles or exacerbations characterized by blistering may
help to narrow the classification of a given presentation of hand dermatitis.

hyperkeratotic hand dermatitis

patinets with hyperkeratotic hand dermatits are usually male and generally present with chronic
keratotic pruritic plaques, sometimes with fissures on the central palm. this condition may be the end
result of contact allergy, exacerbation, and irritation, but generally the cause is not identifiable, and
contact allergy does not seem to play an important role. this hand dermatitis commonly occurs in
middle-aged to elderly men and is normally very refractory to treatment. frictional factors of lichen
simplex chronicus may be an important factor in some cases. plantar involvement is present in a
minority of cases.

in an id reaction, erythematous vesicles usually are seen in then lateral aspects of then fingers and then
plams and are typically pruritic. this eruption of vesicles is usually sudden and classically occurs in
response to an intense inflamatory process, especially fungal infections, taking place somewhere else on
the body. the id reaction is thought to be an allergic reaction to fungi or to some antigen created during
the inflamatory process. treatment of the underlying infection results in resolution of the vesicular
eruption.
Laboratory finding

there are no distinctive laboratory finding characteristic of vesicular palmoplantar eczema, although
immunoglobulin E levels may be elevated in atopic patients.

DD
allergy contact dermatitis may be clinically indistinguishable from constitutional forms of hand eczema,
and patch testing should always be considered for those with recurrent atipical or persistent forms of
the disease. common allergen include nickel thimerosal, neomycin sulfate, formaldehyde, pphenylenediamine, quaternium-15, colophony potasium dichromate,benzoyl peroxide fragrances,
rubber,and lanolin. although frequently considered laundry detergent are a rare cause of allergy contact
dermatitis. irritan contact dermatitias is by far the most common hand dermatitis and is often
exacerbated by occupational exposure. it is usually symmetric, chronic and affect the dorsal fingertips
and web spaces.
atopic hand dermatitis is associated with a number of factor : hand dermatitis before age 15 years,
persistent eczema on the body, dry or itchy skin in adult life, and widespread atopic dermatitis in
childhood. the backs of the hands, particularly the fingers, are affected of eritema, vesiculation crusting
excoriation, and scale.
infection, most commonly from tinea, can mimic endogenous hand dermatitis. in cases of asymmetric or
atipical cases, or in case of small vesicles confined to the feet, a potassioum hydroxide examination may
be useful in ruling out primary tinea infaction. in chronic cases of hand dermatits, fungal and bacterial.
infactions may be superimposed, and treatment may result in improvement of clinical symptoms.
Herpes simplex may, in unusual cases, present as blisters on the hands.
Psoriasis and psoriasiform hand dermatitis are most prominent over pressure points. psoriasis can
normally be distinguished by its sharply marginated, nummular, or circinate scaly plagues, relative lack
of itching, silvery scales, and the presence of psoriaisis elsewhere. psoriasiform hand dermatitis can
occur without a family or personal history of psoriasis. it is a diagnosis made primarily on clinical and
histologic presentation. at times, however it appears as though eczematous, hyperkeratotic, and
psoriatic diatheses co-exist. repeated pressure or friction may cause hyperkeratotic,in same individuals.

pustular eruptions of palms and soles is generally easy is distinguish because, unlike the presentation of
clear fluid-filled blisters and bullae of hand dermatitis, pustuls are the primary lession. for example, in
pustularpsoriasis, the vesicles are cloudy and painful. keratolisis exfoliativa (recurrent focal palmar
peeling) is a chronic, asymptomatic, non inflammatory peeling of the palms and soles, most commonly
seen during the summer months. it is though to occur mor frequently in people with hyperhidrosis in
these areas. scaling usually star from 1 to 2 fine points and expands outward to larger circular areas. the
condition is usually self-limited and asymptomatic requiring only emollients.
bazex acrokeratosis paraneoplastica is a rare, acute, eritemous, scaling, vesicubullous hand dermatitis
with nail dystrophy associated with neoplasia, usually squamosa carsinoma of the upper disgestive and
respiratory tracts, althought therehave been some reports of similar findings in patient with colon
cancer and genitourinary tumors.
other blistering disease such as pemphigoid, pemphigus, or epidermolysis bullous, may affects the hands
and feet, but usually do so in the setting of blister elsewhere on the body.
complication
secondary bacterial infection of the vesicles can result in cellulitis, lymphangitis, and in rare instances,
septicemia.

prognosis and clinical course

pompholyx tends to occur as intermittent explosive outbreaks and become less frequent with middle
age. the more chronic forms of vesicular palmoplantar eczema, however, are much more persistent and
frustrating to manage and often require multiple therapeutic approaches over time.

treatment
treatment of vesiculobullous hand dermatitis should be based on the acuity of he condition, the severity
of the disease, the prominence the blister versus chronic changes and may relevan history that reveals
possible co-factors.

topical therapy
topical steroids, typically high potency are usually first line agent. there are often more effective if use
they under occlusion although this approach may increase the changes of infection. topical drying
agents such as domeboro soaks, burow's solution (aluminum subacetate), or dilute potassium
permanganate solutions maybe useful in acute forms with a predominance of vesicle.

non steroidal topical immunomodulating agents, such as tacrolimus and pimecrolimus, have been
studied for treatment of individuals with mild to majority of these however, deep not limit study subject
to those with vesicular palmoplantar eczema ; patients with atopic, allergic, and dermatitis were
included. with this in mind, statistically significant improvements from baseline were observed for
erythema, scaling, induration, fissuring, and pruritus but not for vesiculation.
hyperkeratotic palmar eczema is notoriously difficult to manage. topical retinoids and calcipotriene,
both of which act to regulate epidermal cell maturation, have anecdotally been shown to improve this
category of hand dermatitis.
systemic therapy
for recurrent pompholyx and chronic vesicular dermatitis, oral prednisone may be required and is often
effective if treatment is initiated early, at the onset of the itching prodorme. however, because of the
significant side effects, systemic glucocorticoids are typically inapropriate for long term management.
cyclosporine has been studied at dosing levels of 3 mg/kg/day and 5 mg/kg/day in the treatment of
chronic vesicular dermatitis. although patients showed improvement with treatment, relapses occurred
shortly after discontinuation of cyclosporine .
mycophenolate mofetil has been used in the treatment of chronic vesicular dermatitis at dosing levels of
2 to 3 g/day (individed dose). it has been anecdotally shown to improve chronic vesicular dermatitis that
has been otherwise recalcitrant to corticosteroids, iontophoresis, and phototerapy. however, it has also
been anecdotally shown to induce biopsy-proven dyshidrotic eczema.
methotrexate has proven a useful therapy of a wide range of skin diseases. in chronic vesicular eczema,
it has been reported to partially or completely clear lesions at low doses ranging from 12,5 to 22,5
mg/week. however, its wide spectrum of potential side effects remains a limiting factor to its use in this
particular skin disease.
alitretinoin, 9-cis-retinoic acid, in preliminary studies has been reported to be succesful in the treatment
of chronic hyperkeratotic hand eczema. patients refractory to treatments with corticosteroids, radiation
therapy, tretinoin, isotretinoin, and acitretin reported good to very good responses to alitretinoin.

Radiation Therapy

superficial radiotherapy (Grenz ray) is still sometimes used at a few centers. this condition may be one
of the last indications for this treatment modality, although it is one of the few therapies tested
successfully in a double-blind study.
UVB, systemic, topical and bath water psoralen and UVA light (PUVA) have been used in serve cases of
chronic vesicular hand eczema. recent studies have evaluated the use of UVA-1, one study compared

localized high-dose UVA1 irradiation against topical cream psoralen UVA for the treatment of
dyshidrotic eczema. this study demonstrated that PUVA-1 irradiation and topical PUVA showed similar
beneficial responses. in addition, the potential side effects noted with PUVVA, such as phototoxic
reactions and long-term carcinogenic risk, are at least theoretically reduced with UVA-1 therapy.

other therapies

iontophoresis, sympathectomy, and intradermal botulinum toxin are effective therapies for
hyperhidrosis and have been studied as treatments for chronic vesicular dermatitis. tap water ionto
phoresis with pulsed direct current showed no benefit for subjects with hand dermatitis over controls in
time to improvement, but those who were treated had much longer remissions, by a factor of months.
in one study, intradermal botulium toxin. A was shown to have good effect in treating patients with
treatment-refractory vesicular dermatitis, especially those patients whose conditon was aggravated by
hyperchidrosis and during summer months.
two severuyt indies, the dyshidrosis area and severuty index and the total sign and symptoms score,
have been validated and may prove useful in clinical trials to better assess the effectiveness of some
these approaches.

prevention

prevention is clinical part of therapy in most ceses, espectially when known exacerbating factors are
present. avoidance of commonly encounterd allergens, such asfods and plants, and irritans, such as
soaps, solvents, acids, and alkalis, can be helpful. vinyl gloves, rather than latex, are recommended
because of the risk of either having an underlying allergy or of develomping on in the setting of impaired
barrier funtion. modification of environmental exposure to exacerbating factor, such as friction and cold
air, may also help with persistent or refractory disease. for maintence, frequent use of emollients, such
as ointments, helps to preserve normal skin barrier function.