Pompholyx

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Pompholyx

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.

Management strategy

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.

Specific investigations

Potassium hydroxide preparation

Bacterial culture

Patch testing

Pompholyx eczema as a manifestation of HIV infection, response to antiretroviral therapy.

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.

Pompholyx and eczematous reactions associated with intravenous immunoglobulin 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.

First-line therapies

Topical corticosteroids	A
Topical calcineurin inhibitors	C
Oral antibiotics	D
Oral antihistamines	E
Emollients	D
Oral corticosteroids	D

Pompholyx: a review of clinical features, differential diagnosis, and management.

Wollina U. Am J Clin Dermatol 2010; 11: 305–14.

Acute and recurrent vesicular hand dermatitis.

Veien NK. Dermatol Clin. 2009; 27: 337–53.

Comprehensive review on chronic hand dermatitis, including pompholyx.

Topical tacrolimus (FK 506) and mometasone furoate in treatment of dyshidrotic palmar eczema: a randomized, observer-blinded trial.

Schnopp C, Remling R, Mohrenschlager M, Weigl L, Ring J, Abeck D. J Am Acad Dermatol 2002; 46: 73–7.

Topical tacrolimus 0.1% ointment was as effective as 0.1% mometasone furoate ointment after 4 weeks of twice daily application, reducing the Dyshidrotic Area and Severity Index (DASI) to approximately 50% in 16 patients.

Efficacy and safety of pimecrolimus cream 1% in mild-to-moderate chronic hand dermatitis: a randomized, double-blind trial.

Hordinsky M, Fleischer A, Rivers JK, Poulin Y, Belsito D, Hultsch T. Dermatology 2010; 221: 71–7.

Pimecrolimus 1% cream twice daily with overnight occlusion for 6 weeks, improved pruritus and skin lesions in up to 30% of 652 treated patients.

Second-line therapies

Alitretinoin (9-cis-retinoic acid)	A
UVA, PUVA, and narrowband UVB	D
Intradermal botulinum A toxin	C

Oral alitretinoin in chronic refractory hand eczema: a “real life” case-series of 12 patients.

Kubica E, Ezzedine K, Lalanne N, Dartial Y, Taieb A, Milpied B. Eur J Dermatol 2011; 21: 454–6.

Twelve patients were treated with alitretinoin 30 mg daily for 3 to 6 months. Seven out of 10 patients responded to treatment within 1 to 3 months. Three patients stayed under remission for 6 months and four patients relapsed within 10 days to 3 months after stopping the medication.

Successful retreatment with alitretinoin in patients with relapsed chronic hand eczema.

Bissonnette R, Worm M, Gerlach B, Guenther L, Cambazard F, Ruzicka T, Maares J, Brown TC, et al. Br J Dermatol 2010; 162: 420–6.

Alitretinoin 30 mg daily for 12–24 weeks showed 80% efficacy in 117 patients who were responders but relapsed within 24 weeks after a previous 24-week course of alitretinoin 30 mg daily.

Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicentre trial.

Ruzicka T, Lynde CW, Jemec GB, Diepgen T, Berth-Jones J, Coenraads PJ, et al. Br J Dermatol 2008; 158: 808–17.

Alitretinoin 30 mg daily monotherapy for 12 to 24 weeks improved symptoms and skin lesions in 48% of 409 patients. Relapse cases were observed by 6 months after stopping alitretinoin (percentage not recorded).

Acitretin may also be of value in selected cases.

Local narrowband UVB phototherapy vs. local PUVA in the treatment of chronic hand eczema.

Sezer E, Etikan I. Photodermatol Photoimmunol Photomed 2007; 23: 10–14.

Compared to PUVA, narrowband UVB was as effective in 12 patients treated three times a week, over a 9-week period. The initial dose of 150 mJ/cm² was increased by 20% until a final dose of 2000 mJ/cm² was reached.

Comparison of localized high-dose UVA1 irradiation versus topical cream psoralen–UVA for treatment of chronic vesicular dyshidrotic eczema.

Petering H, Breuer C, Herbst R, Kapp A, Werfel T. J Am Acad Dermatol 2004; 50: 68–72.

Twenty-four of 27 patients treated with UVA1 irradiation to one hand and cream psoralen–UVA (PUVA) to the other, showed a similar 50% improvement after a 3-week period of UV irradiation. One patient relapsed within the 3-week follow-up period.

Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema.

Tzaneva S, Kittler H, Thallinger C, Hönigsmann H, Tanew A. Photodermatol Photoimmunol Photomed 2009; 25: 101–5.

Oral PUVA was as effective as bath PUVA in 29 patients with dyshidrotic eczema, who received treatment three times weekly for up to 20 weeks and were followed up for up to 40 months.

Regression of relapsing dyshidrotic eczema after treatment of concomitant hyperhidrosis with botulinum toxin-A.

Kontochristopoulos G, Gregoriou S, Agiasofitou E, Nikolakis G, Rigopoulos D, Katsambas A. Dermatol Surg 2007; 33: 1289–90 [Letter].

Two patients treated with 100 units of botulinum toxin A (BTX-A) to each hand showed significant improvement of their dyshidrosis 1 week later, with no relapse after 8 weeks.

Pompholyx: what’s new?

Wollina U. Expert Opin Investig Drugs 2008; 17: 897–904.

Hyperhidrosis is an aggravating factor in approximately 40% of pompholyx patients. Botulinum toxin A, 100 units administered intradermally to each hand, resulted in improvement of pruritus, lesions, and the starch-iodine test for hyperhidrosis. The major disadvantages are the cost and the need for recurrent injections.

Third-line therapies

Cyclosporine	B
Methotrexate	D
Azathioprine	C
Mycophenolate mofetil	D
Etanercept	D
Radiotherapy	D

Long-term follow-up of eczema patients treated with cyclosporine.

Granlund H, Erkko P, Reitamo S. Acta Derm Venereol 1998; 78: 40–3.

Twenty-seven patients with chronic hand eczema treated with cyclosporine 3 mg/kg/day for 6 weeks had reduced disease activity of 54% and sustained improvement for 1 year, without topical treatment.

Low-dose oral methotrexate treatment for recalcitrant palmoplantar pompholyx.

Egan CA, Rallis TM, Meadows KP, Krueger GG. J Am Acad Dermatol 1999; 40: 612–14.

In five patients with severe pompholyx 12.5–22.5 mg of methotrexate weekly resulted in a reduced dose or discontinuation of prednisone. Superpotent corticosteroids were continued topically.

Azathioprine in dermatological practice. An overview with special emphasis of its use in non-bullous inflammatory dermatoses.

Scerri L. Adv Exp Med Biol 1999; 455: 343–8.

Six patients with severe pompholyx received azathioprine monotherapy 100–150 mg daily with a mean duration of treatment of 34 months; three had excellent, one had good, and two had fair responses.

Dyshidrotic eczema treated with mycophenolate mofetil.

Pickenacker A, Luger TA, Schwarz T. Arch Dermatol 1998; 134: 378–9.

One patient with recurrent dyshidrotic eczema refractory to topical and systemic corticosteroids and UVA1 had complete resolution after 4 weeks of mycophenolate mofetil at a dose of 1.5 g twice daily and 12 months of 1 g daily.

Recalcitrant hand pompholyx: variable response to etanercept.

Ogden S, Clayton TH, Goodfield MJ. Clin Exp Dermatol 2006; 31: 145–6.

One patient responded significantly to etanercept 25 mg twice weekly for 6 weeks. The remission lasted 4 months. A subsequent flare was unresponsive to etanercept 50 mg twice weekly.

Long-term results of radiotherapy in patients with chronic palmo-plantar eczema or psoriasis.

Sumila M, Notter M, Itin P, Bodis S, Gruber G. Strahlenther Onkol 2008; 184: 218–23.

Twenty-eight patients irradiated with a single dose of either 1 Gy or 0.5 Gy twice weekly, up to a total dose of 4–5 Gy, demonstrated significant improvement that was maintained during the 20-month follow-up period.

Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e

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Pompholyx

Management strategy

Specific investigations

Pompholyx eczema as a manifestation of HIV infection, response to antiretroviral therapy.

Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy.

A 3-year causative study of pompholyx in 120 patients.

Role of contact allergens in pompholyx.

Low-cobalt diet for dyshidrotic eczema patients.

First-line therapies

Pompholyx: a review of clinical features, differential diagnosis, and management.

Acute and recurrent vesicular hand dermatitis.

Topical tacrolimus (FK 506) and mometasone furoate in treatment of dyshidrotic palmar eczema: a randomized, observer-blinded trial.

Efficacy and safety of pimecrolimus cream 1% in mild-to-moderate chronic hand dermatitis: a randomized, double-blind trial.

Second-line therapies

Oral alitretinoin in chronic refractory hand eczema: a “real life” case-series of 12 patients.

Successful retreatment with alitretinoin in patients with relapsed chronic hand eczema.

Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomized, double-blind, placebo-controlled, multicentre trial.

Local narrowband UVB phototherapy vs. local PUVA in the treatment of chronic hand eczema.

Comparison of localized high-dose UVA1 irradiation versus topical cream psoralen–UVA for treatment of chronic vesicular dyshidrotic eczema.

Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema.

Regression of relapsing dyshidrotic eczema after treatment of concomitant hyperhidrosis with botulinum toxin-A.

Pompholyx: what’s new?

Third-line therapies

Long-term follow-up of eczema patients treated with cyclosporine.

Low-dose oral methotrexate treatment for recalcitrant palmoplantar pompholyx.

Azathioprine in dermatological practice. An overview with special emphasis of its use in non-bullous inflammatory dermatoses.

Dyshidrotic eczema treated with mycophenolate mofetil.

Recalcitrant hand pompholyx: variable response to etanercept.

Long-term results of radiotherapy in patients with chronic palmo-plantar eczema or psoriasis.

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