Dyshidrosis

Dyshidrosis
Classification and external resources
Late stage of dyshidrosis on the hands
ICD-10	L30.1
ICD-9	705.81
DiseasesDB	10373
MedlinePlus	000832
eMedicine	derm/110 ped/1867
MeSH	D011146

Dyshidrosis (also known as "Acute vesiculobullous hand eczema,"^[1] "Cheiropompholyx,"^[2] "Dyshidrotic eczema,"^[2] "Pompholyx,"^[2] and "Podopompholyx"^[2]) 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 1/5,000 in the United States. However, many cases of eczema are diagnosed as garden-variety atopic eczema without further investigation, so it is possible that this figure is misleading.

This condition is not contagious to others, but its unsightly nature can lend to awkward social interaction. The compromised integument can increase susceptibility to infection, and the accompanying itching can be a source of psychological duress.

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 many different factors that 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.

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  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.
• Allergic reactions of various kinds, including allergies to nickel which is present in many foods and vitamins (i.e. oatmeal, canned foods).^[3]
• Ingestion of alcohol; the dehydrating effects of alcohol may exacerbate the severity of the fissures and cracking.
• 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^{[citation needed]} (or alternatively, it can be the cause of secondary effects of problems in the gut^[4][5]). Some sufferers claim diet can ease symptoms (relieving internal condition of IBS or intestinal yeast infection).^{[citation needed]} Also Inflammatory bowel diseases of Ulcerative colitis and Crohn's disease.^{[citation needed]}
• 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 (the softening and whitening of skin that is kept constantly wet) of the palms should be avoided.
• Multiple chemical sensitivity

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. However, others believe that, with conditions like dyshidrosis, the suspect substances must be applied to the affected area to induce a reaction.

It is often seen in people 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.

• Topical steroids^[6] - 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.
• Potassium permanganate dilute solution soaks - also popular, and used to 'dry out' the vesicles,^[7] and kill off superficial staphylococcus aureus,^[8] but it can also be very painful. Undiluted it may cause significant burning.^[9]
• Dapsone (diamino-diphenyl sulfone) is an antibacterial sulfonamide. It has been recommended for the treatment of dyshidrosis in some chronic cases.^[10]
• Anti-histamines: fexofenadine up to 180 mg per day.^[11]
• "Toctino" alitretinoin 9-cis-retinoic acid has been approved for prescription in the UK. It is specifically used for chronic hand and foot eczema.^[12] It is made by Basilea of Switzerland (BAL 4079).
• In the case of a nickel allergy or sensitivity a low nickel diet may lead to improvement. This includes avoiding high nickel foods like oatmeal and chocolate, canned foods (especially acidic foods like pineapple and tomato that leach metal from the can), and using vitamins the do not contain nickel. In this situation avoiding excessive exposure to environmental nickel may also be helpful, such as not using stainless steel pots and silverware.^[13]

See also

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

References

1. ^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology (10th ed.). Saunders. ISBN 0-7216-2921-0.
2. ^ ^{a b c d} Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0. 
3. ^ Menne T, Borgan O, Green A. Nickel allergy and handdermatitis in a stratified sample of the Danish female39. Gawkrodger DJ, Vestey JP, Wong W-K, Buxton PK.Contact clinic survey of nickel-sensitive subjects. Contactpopulation: an epidemiological study including a statisticappendix. Acta Derm Venereol 1982; 62: 35–41.
   Gawkrodger DJ, Vestey JP, Wong W-K, Buxton PK.Contact clinic survey of nickel-sensitive subjects. Contactpopulation: an epidemiological study including a statisticappendix. Acta Derm Venereol 1982; 62: 35–41.Dermatitis 1986; 14: 165–169
   Christensen OB, Moller H. Nickel allergy and handitis, and hand and contact dermatitis in adolescents. TheOdense Adolescence Cohort Study on Atopic Diseaseseczema. Contact Dermatitis 1975; 1: 129–135.
   Menne T, Holm NV.
   Hand eczema in nickel-sensitiveand Dermatitis. Br J Dermatol 2001; 144: 523–532.24. Mortz CG, Lauritsen JM, Bindslev-Jensen C, Andersenfemale twins. Genetic predisposition and environmentalfactors. Contact Dermatitis 1983; 9: 289–296.
   Flyholm MA, Nielson GD, Andersen A. Zeitschrift für Lebensmitteluntersuchung und -Forschung. 1984. p. 427-31.
4. ^ Dermatology 1999;199:308-312 (DOI: 10.1159/000018280)
5. ^ Vol. 140 No. 12, December 2004 Archives of Dermatology Oral Al1itretinoin (9-cis-Retinoic Acid) Therapy for Chronic Hand Dermatitis in Patients Refractory to Standard Therapy Results of a Randomized, Double-blind, Placebo-Controlled, Multicenter Trial Thomas Ruzicka, MD; Frederik Grønhøj Larsen, MD, PhD; Dorota Galewicz, MD; Attila Horváth, MD; Peter Jan Coenraads, MD; Kristian Thestrup-Pedersen, MD; Jean Paul Ortonne, MD; Christos C. Zouboulis, MD; Martin Harsch, PhD; Thomas C. Brown, PhD; Maurice Zultak
6. ^ "eMedicine - Dyshidrotic Eczema : Article by Camila K Janniger". http://www.emedicine.com/ped/topic1867.htm. Retrieved 2007-07-10. 
7. ^ BIRT AR (March 1964). "Drugs for Eczema of Children". Can Med Assoc J 90 (11): 693–4. PMC 1922428. PMID 14127384. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1922428. 
8. ^ Stalder JF, Fleury M, Sourisse M et al. (1992). "Comparative effects of two topical antiseptics (chlorhexidine vs KMn04) on bacterial skin flora in atopic dermatitis". Acta Derm Venereol Suppl (Stockh) 176: 132–4. PMID 1476027. 
9. ^ Baron S, Moss C (February 2003). "Caustic burn caused by potassium permanganate". Arch. Dis. Child. 88 (2): 96. doi:10.1136/adc.88.2.96. PMC 1719457. PMID 12538301. http://adc.bmj.com/cgi/pmidlookup?view=long&pmid=12538301. 
10. ^ http://www.dermnet.org.nz/dermatitis/pompholyx.html
11. ^ MDContact Dermatitis 2007: 57: 203–210 Journal compilation # 2007 Blackwell Munksgaard CONTACT DERMATITIS Management of chronic hand eczema THOMAS L. DIEPGEN, TOVE AGNER, WERNER ABERER, JOHN BERTH-JONES, FRE´ DE´ RIC CAMBAZARD, PETER ELSNER, JOHN MCFADDEN AND PIETER JAN COENRAADS 1Department of Clinical Social Medicine, Occupational & Environmental Dermatology, University Hospital Heidelberg, Heidelberg 69115, Germany, 2Department of Dermatology, University of Copenhagen, Roskilde Sygehus, 4000 Roskilde, Denmark, 3Department of Dermatology, University of Graz, 8036 Graz, Austria, 4Department of Dermatology, University Hospitals Coventry and Warkwickshire NHS Trust, Coventry CV2 2DX, UK, 5Department of Dermatology, 42055 St Etienne, France, 6Department of Dermatology and Allergology, Friedrich Schiller University Jena, 07740 Jena, Germany, 7St Thomas Hospital, St Johns Institute of Dermatology, London, UK, and 8Department of Dermatology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
12. ^ Ruzicka T, Lynde C, Jemec G et al. Efficacy and safety of oral alitretinoin in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomised, double-blind, placebo-controlled, multicentre trial. British Journal of Dermatology April 2008; 158(4): 808-817.
13. ^ KAABER, K., VEIEN, N. K. and TJELL, J. C. (1978), Low nickel diet in the treatment of patients with chronic nickel dermatitis. British Journal of Dermatology, 98: 197–201. doi: 10.1111/j.1365-2133.1978.tb01622.x

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