By Gary M. White, MD
Tapioca-like vesicles on a finger. Itchy!
Pompholyx is a form of hand dermatitis where vesicles are prominent. The cause is thought to be allergic in nature and a variety of things can trigger it including contact with allergens, e.g. soluble oils, perfumes, balsum.
Tapioca-like vesicles on the hands and/or feet are typical. Flares with lesions coming in crops are common. Coalescence into large blisters may rarely occur. Itching may be intense and may precede the vesicles. Scratching may alter the appearance and expose the skin to secondary infection. Sometimes, the red, scaly, eczematous areas of irritant hand dermatitis are present as well. Both conditions may occur and overlap.
Inquiry into potential allergens should be done. Does anything trigger a flare? Is there a personal or family history of eczema, hay fever, asthma? Allergic contact dermatitis? Id reaction from a rash elsewhere, e.g., the feet? Any new medications or supplements?
The patient should be educated that this condition is usually chronic and recurrent and may be aggravated by frequent water contact, hot weather, irritants and chemicals or friction. A high potency topical steroid is appropriate, e.g. clobetasol, betamethasone dipropionate, given BID. Hand creams (not lotions) during the day may help. Fissures often signal infection and a topical antibacterial ointment overnight or Krazy glue (see hand dermatitis handout) is often helpful. Patch testing may be indicated to exclude allergic contact dermatitis, although the yield is low. If excessive sweating seems related, a topical antiperspirant (e.g. aluminum chloride 20%) may be tried. Tacrolimus 0.1% BID ointment may be tried [JAAD 2002;46;73].
Recalcitrant disease may be treated empirically with an oral antistaphylococcal antibiotic. Hand UVB or soak PUVA may be tried. A potent topical steroid occluded overnight with gloves may be recommended. For severe disease, IM kenalog, e.g. 40 mg may be needed, or even low dose prednisone, e.g. 5 mg po QAM. Low dose methotrexate (e.g. 12.5-15 mg/week) combined with a topical class I steroid prn may be very effective in controlling recalcitrant pompholyx [JAAD 1999;40;612]. Azathioprine or mycophenolate mofetil are alternatives and can do well.
One might consider nickel as a contributing factor if the following are true: positive patch test to nickel, a flare within 3 days of an oral challenge to nickel (e.g. 2.5 mg), and a negative challenge to placebo. If nickel allergy is a possibility, the patients should avoid foods high in nickel for 6 weeks as a trial and follow long term if beneficial. For additional information, see systemic contact dermatitis.
Botox intralesional helped in a case of pompholyx of the palms aggravated by sweat in the summer.
Look for multiple tiny vesicles on the fingers.
A severe case of pompholyx with larger vesicles and bulla. This often presents as an acute allergic reaction.
Pompholyx on the sole.
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