Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
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Anne E. Burdick and Ivan D. Camacho
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Pompholyx, also known as dyshidrosis or dyshidrotic eczema, is a recurrent, pruritic vesicular eruption of the palms, soles, and lateral aspects of the fingers. It is of unknown etiology and is considered a reaction pattern to various endogenous and exogenous factors, including atopy, hyperhidrosis, dermatophytosis, contact allergic dermatitis (to nickel, chromium, balsams and cobalt), irritant dermatitis, and possibly emotional stress and seasonal changes. Pompholyx has also been reported to be induced by intravenous immuneglobulin (IVIG) therapy and during the immune reconstitution inflammatory syndrome.
Although pompholyx may resolve spontaneously, treatment is aimed at controlling pruritus and the formation of vesicular lesions. Evaluation is required to exclude dermatophytosis, irritant or allergic contact dermatitis, impetigo, herpes simplex, and vesiculobullous disorders.
Topical corticosteroids are the mainstay of treatment. For mild localized disease, mid- to-high-potency corticosteroid creams or ointments are recommended. Oral antihistamines are useful for control of symptoms. Emollients are also beneficial. A course of oral antibiotics (cephalosporins or doxycycline) is recommended for secondary impetiginization.
Topical tacrolimus or pimecrolimus is useful, alone or in combination with a corticosteroid, which may be delivered under occlusion for increased penetration. For severe disease, systemic corticosteroids are indicated: daily prednisone 0.5–1.0 mg/kg/day tapered over 2 weeks, or intramuscular triamcinolone acetonide (40–60 mg). Hand and foot narrowband phototherapy and UVA, alone or with oral or topical psoralen, are also effective.
Refractory pompholyx may respond to systemic retinoids such as alitretinoin and immunosuppressive agents including azathioprine, methotrexate, cyclosporine, mycophenolate mofetil or etanercept. Radiotherapy may be an option in recalcitrant cases.
Intradermal botulinum toxin A may be helpful as adjuvant therapy. Low nickel and cobalt diets are recommended in nickel-sensitive patients who demonstrate a positive provocation test.
Potassium hydroxide preparation
Bacterial culture
Patch testing
MacConnachie AA, Smith CC. Acta Derm Venereol 2007; 87: 378–9.
Pompholyx may present as both a manifestation of symptomatic HIV infection and as part of the immune reconstitution inflammatory syndrome. Conventional treatment for pompholyx may fail but improvement may be observed with highly active antiretroviral therapy.
Gerstenblith MR, Antony AK, Junkins-Hopkins JM, Abuav R. J Am Acad Dermatol 2012; 66: 312–16.
Pompholyx is observed as an adverse effect in up to 62% of patients receiving IVIG for cutaneous disorders (chronic urticaria, Stevens–Johnson syndrome, Kawasaki syndrome) and neurologic diseases (multiple sclerosis, chronic inflammatory demyelinating polyneuropathy, Guillain-Barré syndrome). Most patients present within 1 to 2 weeks after initiation of IVIG therapy and respond to topical steroids or discontinuation of the medication.
Guillet MH, Wierzbicka E, Guillet S, Dagregorio G, Guillet G. Arch Dermatol 2007; 143: 1504–8.
A prospective survey of 120 patients reported allergic contact pompholyx in 67.5% of cases (31.7% to cosmetic and hygiene products and 16.7% to metals), 15% idiopathic, 10% secondary to dermatophytes, and 6.7% due to ingestion of drugs, food, or nickel.
Jain V, Passi S, Gupta S. J Dermatol 2004; 31: 188–93.
Patch testing with the Indian Standard Patch Test Battery was performed on 50 subjects and 40% reacted to one or more allergens. Nickel sulfate was the most common allergen, followed by potassium dichromate, phenylenediamine, nitrofurazone, fragrance mix, and cobalt.
Stuckert J, Nedorost S. Contact Dermatitis 2008; 59: 361–5.
Restriction of dietary cobalt and nickel reduces flares of dyshidrotic eczema, regardless of patch test results.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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