What causes vesicular palmoplantar eczema?

Updated: Aug 23, 2019
  • Author: Jessica Dunkley, MD, MHSc, CCFP; Chief Editor: Dirk M Elston, MD  more...
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Answer

The etiology of hand eczema is unknown, but most observers suggest that intrinsic changes in the skin are responsible for vesicular palmoplantar eczema. A 2012 study of an autosomal dominant form of pompholyx found a genetic linkage on chromosome 18. [4] Whether other forms have a similar genetic linkage is not clear. However, several exogenous factors have been implicated in the causation or worsening of vesicular palmoplantar eczema. [5]

Coexisting atopy is common in patients with palmoplantar eczema. A study found a strong association between pompholyx and atopic status. [6] However, this is by no means the only causal relationship because many patients have no history of atopy. In a univariate analysis, personal and family history of atopy, history of eczema, hyperhidrosis, and tinea pedis were the main factors associated with pompholyx cases. [7]

Emotional stress may also trigger episodes.

Seasonal changes seem to be directly related to relapses, as episodes are most common in the spring and summer months. Warm weather has been known to initiate episodes, with several cases reporting photo-induced pompholyx. Although dysfunction of the sweat glands is no longer accepted as the cause of dyshidrotic eczema, increased sweating seems to exacerbate the condition and many patients with palmar hyperhidrosis also have coexisting dyshidrotic eczema. Hyperhidrosis can be an aggravating factor in up to 40% of patients with pompholyx eczema. [8] Photosensitivity to ultraviolet A (UVA) has been reported as an etiologic factor in a small subset of patients with eczema. [9] Therefore, worsening of the disease in summer months may be due to the increase in exposure to sunlight. Conversely, UVA therapy is a widely accepted form of treatment for palmoplantar eczema. [10]

Sensitivity to certain metals, particularly nickel and cobalt, has been linked to vesicular palmoplantar eczema. Low zinc levels have been proposed to play a role. A 2016 prospective case-noncase study examining serum levels of cadmium and zinc noted a significant decrease in zinc levels in patients with vesicular palmoplantar eczema compared with the noncase group. The exact role of zinc in the pathogenesis of vesicular palmoplantar eczema remains unknown but may be related to the impact of deficient states on inflammation. [11]

Exogenous factors causing allergic contact pompholyx include balsams and cosmetic and hygiene products. [12]

A 2013 study showed an increase in IgE levels and vesicular palmar eczema after house dust mite exposure. [13]

Drugs responsible for inducing episodes include oral contraceptive pills and aspirin. Palmoplantar eczema occurring after intravenous immunoglobulin (IVIG) therapy is reported. [14]

A review of eczematous reactions linked with intravenous immunoglobulin (IVIG) therapy cited pompholyx as occurring in 63.5% of the cases reported having an eczematous reaction. [10] While most cases are seen in adults, [15] there have been occurrences in the pediatric population after IVIG administration for Kawasaki syndrome. [16] The onset of palmoplantar eczema typically occurs within a few days of the first treatment and can reoccur when rechallenged. The mechanism of pompholyx induction is unknown but may be related to the dose, infusion rate, type of IVIG, and even possibly the underlying disease being treated. [17] The majority of IVIG-associated cases of vesicular eczema are observed in patients with neurologic disorders, including multiple sclerosis, Guillen-Barre syndrome, amyotrophic lateral sclerosis, motor neuron disease, and chronic inflammatory demyelinating polyradiculoneuropathy. [16]

Fungal infections, particularly tinea pedis caused by Trichophyton rubrum, are most commonly implicated in id reactions. Bacterial infections play a role in both causation and in secondarily infecting lesions.

Cigarette smoking has been suggested as a pathogenetic factor in palmar eczema [18, 19] and may also reduce the efficacy of topical therapy with psoralen and UVA (PUVA). [20]

HIV infection has been associated with pompholyx, with response to antiretroviral therapy; conversely, one case report describes of 2 HIV-positive patients who developed severe dyshidrotic eczema after starting antiretroviral treatment, thought to be due to an immune reconstitution inflammatory syndrome. [21, 22]


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