PCP Case Challenge: Lesions on the Hands, Palms, and Feet of a 57-Year-Old Man

Lars Grimm, MD


April 20, 2022


The diagnosis of dyshidrotic eczema, also known as pompholyx (Greek for "bubble"), was made on the basis of the patient's history and the results of the physical examination. Additional testing (described below) ruled out any alternative diagnoses. The pruritic lesions were progressive in number and size, but they were restricted to the hands and feet. The blisters were classically vesiculobullous in nature, without any surrounding erythema. Lesions in multiple stages of development, from emerging vesicles to ruptured bullae, were concurrently present.

The history did not reveal any etiologic factors, such as recent exposures to allergens, new medications, or animal-borne vectors. The patient did not have any systemic symptoms and was afebrile. No evidence of concurrent cellulitis or lymphangitis was apparent.

Dyshidrotic eczema is estimated to be present in 0.5%-1% of the population and is twice as common in women than in men. Most cases present before the patients reach age 40 years, and no racial predominance is noted. It is more commonly found in warmer, more humid climates, especially during the spring and summer. Recurrences may occur throughout a patient's lifetime, with or without treatment.

The pathophysiology of dyshidrotic eczema has not been definitively established,[1] but several hypotheses have been proposed. The term "dyshidrosis" is a misnomer that refers to the original hypothesis of sweat gland dysfunction, which has fallen out of favor. In addition, patients are not typically noted to experience hyperhidrosis. The association of the condition with atopy is interesting,[2] as approximately 20% of patients experience concomitant hand eczema, and approximately 50% of patients have a general disposition to an atopic diathesis (eg, asthma, hay fever, and sinusitis).[3]

Other exogenous factors that have been implicated and may trigger episodes include contact dermatitis to heavy metals (such as with exposure to costume jewelry, nickel,[1,3] cobalt,[1] or chromates); sensitivity to ingested metals[1]; exposure to other contact allergens such as balsam,[1] paraphenylenediamine, and sesquiterpene lactones; and infection by dermatophytes or bacteria. Emotional stress (many patients report recurrences during stressful periods of their life) and environmental factors (eg, seasonal changes, hot or cold temperatures, and humidity) are also reported to exacerbate dyshidrosis.[1,3]

Dyshidrotic eczema has also been reported in patients recently treated with intravenous immunoglobulin (IVIg) therapy; in HIV-positive patients with an immune reconstitution inflammatory syndrome shortly after starting active antiretroviral therapy[1]; with the use of aspirin or oral contraceptives; and with cigarette smoking. In most cases, the condition remains idiopathic.


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