Pompholyx (Dyshidrotic Eczema)

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis | Management and Treatment | Prevention | When to Refer | References

Introduction

Pompholyx, also known as dyshidrotic eczema or dyshidrosis, is a type of eczema characterised by the sudden onset of intensely itchy, fluid-filled blisters (vesicles) on the palms of the hands, sides of the fingers, and soles of the feet. The condition can be recurrent and is more common in adults, particularly those with a history of atopic eczema. The exact cause of pompholyx is unknown, but it can be triggered by stress, allergens, or moisture.

Aetiology and Risk Factors

The exact cause of pompholyx is not fully understood, but several factors have been identified as potential triggers:

• Atopic Eczema: Individuals with a history of atopic eczema are at higher risk of developing pompholyx.
• Stress: Emotional stress is a well-known trigger for flare-ups of pompholyx.
• Allergens: Exposure to allergens, such as nickel, cobalt, or other contact allergens, can precipitate an outbreak.
• Moisture: Excessive sweating or exposure to water can exacerbate the condition, particularly in individuals with hyperhidrosis.
• Environmental Factors: Warm weather and humidity are often associated with increased incidence of pompholyx.

Clinical Presentation

Pompholyx presents with characteristic symptoms that can help in its identification:

• Itchy Vesicles: The hallmark of pompholyx is the sudden appearance of small, intensely itchy vesicles on the palms, sides of the fingers, and soles. These vesicles are typically deep-seated and may be accompanied by a burning sensation.
• Blisters: In more severe cases, the vesicles can coalesce to form larger blisters, which may become painful.
• Crusting and Peeling: As the vesicles heal, they may burst, leading to crusting, peeling, and scaling of the skin.
• Recurrent Nature: Pompholyx often follows a relapsing-remitting course, with periods of flare-ups followed by remission.
• Associated Symptoms: In some cases, pompholyx may be associated with hyperhidrosis (excessive sweating), particularly of the hands and feet.

Diagnosis

The diagnosis of pompholyx is primarily clinical, based on the characteristic appearance and patient history:

• History: A thorough history should be taken, focusing on the onset of symptoms, potential triggers (such as stress or allergens), and any history of atopic eczema.
• Physical Examination: The diagnosis is often made based on the appearance of the small, deep-seated vesicles on the hands and/or feet, along with the typical distribution and symptoms.
• Differential Diagnosis: It is important to differentiate pompholyx from other conditions such as contact dermatitis, tinea pedis (athlete's foot), or pustular psoriasis. A fungal culture may be performed to rule out tinea pedis if necessary.
• Patch Testing: In cases where contact allergens are suspected as a trigger, patch testing may be useful to identify specific allergens.

Management and Treatment

The management of pompholyx aims to relieve symptoms, reduce flare-ups, and prevent complications:

1. Topical Treatments

• Topical Corticosteroids:
  • Potent topical corticosteroids (e.g., Dermovate) are often the first line of treatment to reduce inflammation and itching. Apply once or twice daily during flare-ups. For example, a common treatment in primary care could be: Mometasone 0.1% 1000g OD for 4 weeks, then twice a week (for maintenance)
  • For maintenance, milder corticosteroids may be used to control symptoms and prevent relapses (ie eumovate).
• Topical Emollients:
  • Regular application of emollients can help to maintain skin hydration, reduce dryness, and prevent flare-ups.
• Topical Calcineurin Inhibitors:
  • For sensitive areas or long-term use, topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) may be considered as an alternative to corticosteroids (often initiated by a dermatologist).
• Aluminium Chloride Solution:
  • For patients with hyperhidrosis, topical aluminium chloride solution can be used to reduce sweating and thereby decrease the frequency of flare-ups.

2. Systemic Treatments

• Oral Antihistamines:
  • Sedating antihistamines (e.g., hydroxyzine) can help manage itching and improve sleep, particularly during flare-ups.
• Oral Corticosteroids:
  • Short courses of oral corticosteroids (e.g., prednisolone) may be considered in severe cases to quickly control symptoms (mostly done in secondary care).
• Immunosuppressants:
  • For refractory cases, systemic immunosuppressants such as methotrexate or cyclosporine may be considered under specialist supervision.

3. Lifestyle Modifications

• Avoidance of Triggers:
  • Identify and avoid potential triggers, such as stress, allergens (e.g., nickel, cobalt), and excessive moisture.
• Protective Measures:
  • Advise patients to wear cotton gloves or socks to protect the skin and absorb sweat. Avoid prolonged exposure to water or irritants, such as harsh soaps or detergents.

Prevention

Preventing pompholyx primarily involves avoiding known triggers and maintaining proper skin care:

• Stress Management: Encourage patients to manage stress through relaxation techniques, exercise, or counselling, as stress is a common trigger for pompholyx.
• Skin Care Routine: Regular use of emollients and avoidance of irritants can help prevent flare-ups.
• Avoidance of Allergens: If specific contact allergens are identified, patients should avoid exposure to these substances.

When to Refer

Referral to a specialist may be necessary in the following situations:

• Refractory Cases: If the pompholyx does not respond to standard treatment, referral to a dermatologist is advised for further evaluation and management.
• Severe or Widespread Disease: In cases of severe or widespread pompholyx, particularly if systemic treatment is being considered, specialist input is recommended.
• Diagnostic Uncertainty: If there is uncertainty about the diagnosis or if the condition does not follow the typical course, referral for a skin biopsy or further investigation may be necessary.
• Associated Hyperhidrosis: For patients with significant hyperhidrosis contributing to pompholyx, referral to a specialist for further management options, such as botulinum toxin injections, may be appropriate.

References

1. British Association of Dermatologists (2024) Guidelines for the Management of Pompholyx. Available at: https://www.bad.org.uk (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Dyshidrotic Eczema: Diagnosis and Treatment. Available at: https://www.nice.org.uk/guidance/ng205 (Accessed: 26 August 2024).
3. British National Formulary (2024) Topical and Systemic Treatments for Eczema. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).