Dyshidrosis

Dyshidrosis
Specialty	Dermatology

Dyshidrosis (also known as "Acute vesiculobullous hand eczema," "Cheiropompholyx," "Dyshidrotic eczema," "Pompholyx," and "Podopompholyx") is a skin condition that is characterized by small blisters on the hands or feet. It is an acute, chronic, or recurrent dermatosis of the fingers, palms, and soles, characterized by a sudden onset of many deep-seated pruritic, clear vesicles; later, scaling, fissures and lichenification occur. Recurrence is common and for many can be chronic. Incidence/Prevalence is said to be 20/100,000 in the United States, however, many cases of eczema are diagnosed as garden-variety atopic eczema without further investigation, so it is possible this figure is misleading.

This condition is not contagious to others, but due to its unsightly nature can cause significant distress in regard to social interactions with others.

The name comes from the word "dyshidrotic," meaning "bad sweating," which was once believed to be the cause but this association is unproven; there are many cases present that have no history of excessive sweating. There are a number of different factors which may trigger the outbreak of dyshidrosis such as allergens, stress or seasonal changes. Emotional stress may also further aggravate the condition.

Symptoms

Small blisters with the following characteristics::

• Blisters are very small (3 mm or less in diameter). They appear on the tips and sides of the fingers, toes, palms, and soles.
• Blisters are opaque and deep-seated; they are either flush with the skin or slightly elevated and do not break easily. Eventually, small blisters come together and form large blisters.
• Blisters may itch, cause pain, or produce no symptoms at all. They worsen after contact with soap, water, or irritating substances.
• Scratching blisters breaks them, releasing the fluid inside, causing the skin to crust and eventually crack. This cracking is painful as well as unsightly and often takes weeks, or even months to heal. The skin is dry and scaly during this period.
• Fluid from the blisters is serum that accumulates between the irritated skin cells. It is not sweat as was previously thought.
• In some cases, as the blistering takes place in the palms or finger, lymph node swelling may accompany the outbreak. This is characterised by tingling feeling in the forearm and bumps present in the arm pits.
• Nails on affected fingers, or toes, may take on a pitted appearance.

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  Advanced stage of dyshidrosis on the palm showing cracked and peeling skin.
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  Dyshidrosis
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  Advanced stage of dyshidrosis on the foot.
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  Advanced stage of dyshidrosis on the sole.
• Rim of scale on the plantar surface of the thumb from a resolving flare of dyshidrotic eczema
  Rim of scale on the plantar surface of the thumb from a resolving flare of dyshidrotic eczema

Causes

Causes of dyshidrosis are unknown. However, a number of triggers to the condition exist:

• Dyshidrosis has been historically linked to excessive sweating during periods of anxiety, stress, and frustration, however, many cases present that have no history of excessive sweating, and the hypothesis of dyshidrosis as a sweating disorder is largely rejected. Some patients reject this link to stress, though as a trigger of vesicular eruption it cannot be overlooked, as with other types of eczema.
• Vesicular eruption of the hands may also be caused by a local infection, with fungal infections, like Athlete's foot being the most common. Sunlight is thought to bring on attacks, some patients link outbreaks to prolonged exposure to strong sunlight from late spring through to early autumn.. Others have also noted outbreaks occurring in conjunction with exposure to chlorinated pool water or highly treated city tap waters.
• Antibacterial soaps, fragrances and contact with fruit juices or fresh meat also can trigger outbreaks of dyshidrosis, as with other types of eczema.
• Systemic nickel allergies may be related such as foods high nickel content - cocoa, chocolate, whole grains, & nuts.
• Allergic reactions may be attributed to soy, caffeine in coffees, teas, and carbonated beverages.
• Allergic reactions may be attributed to the use of Dairy products - milk, butter, cheese, yoghurt, icecream.
• Allergic reactions may be caused by ingestion of alcohol; the dehydrating effects of alcohol may exacerbate the severity of the fissures and cracking.
• Keeping skin damp will trigger or worsen an outbreak. For this reason, people with dyshidrosis should wear gloves, socks, and shoes made of materials which "breathe well", such as cotton or silk. Certain fabrics may greatly irritate the condition, including wool, nylon and many synthetic fabrics.
• Inherited, not contagious. Often, patients will present with other types of dermatitis, such as Seborrhoeic dermatitis or atopic eczema. For this reason, among others, dyshidrosis is often dismissed as atopic eczema or contact dermatitis.
• Can be the secondary effect of problems in the gut. Some sufferers claim diet can ease symptoms (relieving internal condition of IBS or intestinal yeast infection). Also Inflammatory bowel diseases of Ulcerative colitis and Crohn's disease.
• Bandages, plasters or other types of skin-tapes may be irritating to dyshidrosis and should be avoided. As the skin needs to breathe, anything that encourages maceration of the palms should be avoided. If the 'wounds' are raw enough to warrant covering, pure cotton gloves or gauze should be used. Liquid Band-Aid brand bandage may be tolerated and helpful, refer to the Treatment section, below.
• Latex and vinyl gloves may increase irritation.
• Multiple chemical sensitivity
• Allergic reaction to Cr(6+) compounds (potassium dichromate and other leather preservative)
• Dyshidrosis can sometimes even be caused by dust mite allergies, with sufferers having to wash and change bedding weekly, sometimes even every 2 days or even every day, to combat symptoms.
• Balsam of Peru is a common irritant among sufferers of hand eczema, more commonly, people with dyshidrotic eczema.

Diagnosis

Allergy testing is a contested subject among eczema communities. Some dermatologists posit that if a sufferer is allergic to a substance, then a general allergy test on the forearm will suffice, yet others believe that in conditions like dyshidrosis, the suspect substances need to be applied to the affected area to induce a reaction. Whole blood allergy tests (i.e.: Alcat) can prove to be more effective at determining an allergy as the effects of an allergic reaction are often slow and cumulative, not immediate. Often seen in people who are already susceptible to allergies and/or asthma.

Treatment

There are many treatments available for dyshidrosis, however, few of them have been developed or tested specifically on the condition.

• Cut nails as short as possible cleaning under and around them daily with baking soda. Apply a paste of baking soda and water to the affected areas, twice a day for three days. After 5 minutes rinse and carefully pat dry paying special attention to the area in between the fingers or other possible places moisture may remain. If rash spreads to a new area recommence applying to both old and new areas leaving a large border around effected areas. Continue to clean hands daily with baking soda for a week paying special attention to the areas around and under the nails. Avoid itching as this will cause rash to spread.
• Topical steroids - while useful, can be dangerous long-term due to the skin-thinning side-effects, which are particularly troublesome in the context of hand dyshidrosis, due to the amount of toxins and bacteria the hands typically come in contact with.
• Nutritional deficiencies may be related, so addressing diet and vitamin intake is helpful.
• Potassium permanganate dilute solution soaks - also popular, and used to 'dry out' the vesicles, and kill off superficial staphylococcus aureus, but it can also be very painful. Undiluted it may cause significant burning.
• Domeboro (OTC) helps alleviate itching in the short term, and can help to quicken the natural healing process. The active ingredient in Domeboro is aluminum acetate, also found in Burow's solution, an OTC antistringent available at most drug stores. Either product is effective in helping to dry out the blisters which leads to faster healing. Affected areas should be soaked in Domeboro or Borow's solution for 20–30 minutes several times a day to be effective.
• Emollients during the drying/scaling phase of the condition, to prevent cracking and itching. While petroleum jelly may work well as a barrier cream, it does not absorb into the skin or allow it to breathe, so may actually be less helpful.
• Salt soaks - maintaining palms for 40 minutes to an hour immersed in a salt solution of 1/4 salt dissolved in water. Repeating treatment for 3–4 days or additionally if required. It is best to soak only the palm and avoid exposing the top of the hand to the saline solution as salt can severely dry and irritate the skin on the top of the hand.
• White vinegar soaks
• Avoidance of known triggers - dyshidrosis sufferers may need to abstain from washing their own hair or bodies, or wearing gloves when they do so, however waterproof gloves are often potential irritants.
• Zinc oxide ointment
• Nickel-free diets
• no sugar, no flour and no fruit diet
• Alcohol and caffeine free diets
• When in the scaling phase of the condition, the scales may cause deep cracks and fissures in the skin. Filing (as with an emery board) may help to minimize this.
• Stress management counseling
• Light treatment: UVA-1, PUVA, Grenz rays, Low Level Light Therapy using a Red + NIR (LED) combination
• Ciclosporin a strong immunosuppressant drug used to combat dyshidrosis caused by ulcerative colitis
• Efalizumab (Raptiva) a medication used to treat psoriasis
• Clobetasol Propionate (0.05%) (potent corticosteroid cream or ointment ) has been an effective treatment.
• Tacrolimus and Pimecrolimus, immunomodulators often used to prevent organ rejection in topical, ointment form, may be used in severe cases.
• Betamethasone Dipropionate, and creams that contain it such as Lotrisone (which also contains an antifungal Clotrimazole) has worked in some cases.
• Dapsone (diamino-diphenyl sulfone) is an antibacterial sulfonamide. It has been recommended for the treatment of dyshidrosis in some chronic cases.
• Unbleached cotton gloves may be used to cover the hands to prevent scratching and vulnerability of the skin to bacteria
• Plantain (Plantago major) infused in olive or other oil can be soothing.
• Frequent application of a barrier cream can protect against irritants while allowing the skin to breathe.
• Avoid metal computer keyboards and track pads which contain nickel.
• When affect area is itchy, apply a mixture of hemp oil and vaseline, cover with finger condom. Replace every two hours and leave uncovered for a half-hour between applications.
• Ingest 1-4 tablespoons of hemp oil daily. Use straight or mixed with other substances, like a smoothie.

Many sufferers of dyshidrosis will find that treatments that were previously suitable for them no longer work or have induced sensitive reactions, which is common in most types of eczema.

• It may be prudent to wear light cotton gloves while reading newspapers, books and magazines. The inks and paper may irritate the condition.
• Wash affected hands and feet with cool water and apply a moisturizer as soon as possible. While hot water seems to kill the itch it may aggravate the condition.
• Avoid moisturizers that contain water (cremes and lotions). Stick with ointments. Use only thin applications of ointments as excessive amounts of ointment may restrict breathing of the skin and aggravate the condition.
• Aloe Vera may be applied after cleaning hands
• When itchy or inflamed 100% lavender oil can be applied occasionally to soothe and reduce irritation for those who are not sensitive to the oil making sure to pat excess oil with a tissue. A patch test on the wrist is recommended before application to the palms.
• Saline solution for washing hands may be very useful.
• Avoid soaps with Sodium Laureth Sulfate (SLS). Many pump style soaps and common shampoos contain SLS.
• 'Toctino' alitretinoin 9-cis-retinoic acid has been approved for prescription in the UK. (08/09/2008) This is specifically for chronic hand eczema. It is made by Basilea of Switzerland (BAL 4079)
• Rinsing the affected areas briefly in surgical spirit is very effective. It will work to clear up the blisters within hours if they have been pricked open first.

See also

• List of skin diseases
• Dermatology
• Epidermolysis bullosa - a genetic disorder that causes similar, but more severe, symptoms to dyshidrosis

External links

• Dyshidrotic eczema at MedlinePlus
• Images of dyshidrotic eczema at Skinsight
• MedAdvice.com
• Pompholyx at DermNet NZ (New Zealand Dermatological Society Incorporated)
• Information, advice and shared experiences for Pompholyx sufferers