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

Lars Grimm, MD


April 20, 2022

Dyshidrotic eczema is a recurrent or chronic, relapsing form of vesicular dermatitis. The classic presentation is of crops of vesicles or bullae that erupt bilaterally on the palms and the lateral aspects of the fingers. The vesicles may coalesce over time to form multiloculated bullae. Most cases involve the hands alone (cheiropompholyx), but roughly 10% of patients have lesions on both the hands and feet, and another 10% have lesions on just the feet (podopompholyx).

The lesions may be intensely pruritic, leading to secondary desquamation and erosions and ulcerations from scratching. Dyshidrotic eczema developing near the tips of the fingers or toes may lead to dystrophic changes of the nails. Cellulitis, lymphangitis, or infection of the lesions themselves may all develop with the long-standing presence of lesions and/or poor hygiene. The vesicular crops usually resolve spontaneously after 3-4 weeks, leaving behind collarettes of scale. Although self-limited, outbreaks frequently alternate with disease-free intervals of weeks to months and, if severe, may be extremely disabling.[1]

The differential diagnosis includes immunobullous disorders, such as bullous pemphigoid and pemphigus vulgaris, or other dermatoses, such as contact dermatitis, herpes simplex virus infection, bullous tinea pedis, and pustular psoriasis. The diagnosis is usually made on the basis of the clinical history, the physical examination, and the exclusion of alternative diagnoses. Bacterial culture and sensitivities may be evaluated for secondary infections.

Additionally, potassium hydroxide wet mount preparations may be useful for excluding dermatophyte infections. A skin biopsy may also be useful for confirming the clinical impression in unresponsive cases and for excluding alternative diagnoses. It can be difficult to differentiate dyshidrotic eczema from an id reaction (autoeczematization), which is a cutaneous eruption that develops in response to various infectious and inflammatory stimuli at a distant site from the primary dermatosis.[1]


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