POMPHOLYX

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.

• It may occur acutely and severely as an allergic eruption, or it may be more low-grade and recurrent, like eczema.
  
• Some experts feel a subset of patients flare secondary to ingestion of nickel.
• One patient of mine resisted aggressive treatment for over a year. By chance, he moved out of his Condo and within three weeks he was cured. What allergen was in the condo?

Clinical

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.

Triggers

• Interdigital-plantar fungal infection. Perform a KOH and if positive, treat with oral or topical antifungal.
• Endogenous nickel (Is the patient patch test positive?). Nickel avoidance diet?
• Cosmetic and personal hygiene products. Regarding shower gel and/or shampoo, the main allergens were fragrances and preservatives.

In a series of patients with pompholyx, patch test was positive to (decreasing frequency) nickel, shower gel, chromium, fragrance, shampoo, balsam of Peru, lanolin, cobalt, thiuram, lauryl sulfate, p-phenylenediamine (PPD), fresh tobacco, formaldehyde, parabens, and octyl gallate.

Treatment

If the condition is acute and new, it may resolve, not to return. In that case treating symptomatically and avoiding any trigger is recommended. However, if recurrent, then it must be assumed the patients is continuing to be exposed to the trigger. 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?

For the acute, severe case with larger bulla, systemic steroids may be indicated.

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.

Botox or other treatments for hyperhidrosis may be helpful in patients with increased sweating.

For more suggestions on treating pompholyx, see hand dermatitis and its handout.

Dupilumb

In one study of 15 patients, all patients demonstrated at least partial response to dupilumab, with decreased erythema and pruritus, whereas 6 of 15 patients (40%) had complete clearing.

Additional Pictures

A severe case with larger vesicles and bulla shown here on the feet. This often presents as an acute allergic reaction. Systemic steroids were given.

Tiny vesicles on the fingertip.

RegionalDerm

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