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

Lars Grimm, MD


April 20, 2022

Treatment for dyshidrotic eczema begins with topical corticosteroid therapy; topical class I steroids are the first-line treatment regimen, with oral steroids reserved for more severe cases. Large lesions should be drained, but not unroofed, to prevent subsequent infection. The patient should make appropriate modifications to daily activities and should avoid scratching to limit unwarranted skin irritation, exacerbation, and subsequent infection.

In addition, numerous adjuvant therapies are available, such as ultraviolet light, botulinum toxin occlusive dressings, and immunosuppressive agents, which may be helpful on a case-by-case basis for refractory patients. Unfortunately, no preventive therapy is available other than avoidance in patients with well-established triggers. Untreated dyshidrotic eczema can lead to concomitant infections; therefore, prompt detection and treatment are essential.

In this case, one of the bullae, measuring approximately 3 cm x 1.5 cm, was percutaneously drained with a 10-cc syringe. Approximately 3 mL of a clear fluid was aspirated. The roof of the vesicle was left intact. To confirm the diagnosis and exclude alternative diagnoses, a punch biopsy of the skin was performed from the foot (Figures 1-3).

Figure 1.

Figure 2.

Figure 3.

Histologically, spongiotic dermatitis and an intraepidermal vesicle were present, which were consistent with the diagnosis of dyshidrotic eczema. A periodic acid-Schiff stain performed on this specimen did not reveal any fungal elements; scrapings of skin from the feet were negative for fungal infection as well.

The patient was instructed to begin a regimen of topical steroids and moisturizing emollient as well as wet compresses. An over-the-counter moisturizer was recommended, and prescriptions for Burrow's solution (10% aluminum acetate) and clobetasol propionate were written. At a follow-up visit, the patient underwent patch testing, but a causative contact allergen was not identified.


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