Which physical findings are characteristic of vesicular palmoplantar eczema?

Updated: Aug 23, 2019
  • Author: Jessica Dunkley, MD, MHSc, CCFP; Chief Editor: Dirk M Elston, MD  more...
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Clinical signs depend on the stage and form of palmoplantar eczema. 

Pompholyx of the palms. Pompholyx of the palms.

Acute episodes of vesicular eczema are characterized by a sudden onset of small, clear vesicles or bullae that are said to be "sago grain‒like" or "tapiocalike" in appearance (see the image above). Vesicles and/or bullae are accompanied by severe, occasionally painful pruritus. Small vesicles may enlarge or become more confluent and present as large bullae (especially on the palms and soles). Vesicles and bullae subsequently dry out and resolve, usually without rupturing. In most individuals, desquamation occurs 2-3 weeks after the onset of vesicles and bullae. In some patients, a milder recurrence follows the initial severe episode. Secondary infections, such as impetigo, cellulitis, or lymphangitis, are possible in patients with recurrent hand eczema. Secondary nail changes (eg, dystrophic nails, irregular transverse ridging, pitting, thickening, discoloration) can also occur.

Subacute vesicular eczema tends to have a chronic relapsing course with more vesiculation and more erythema in the acute phases than in later phases. Residual erythema or some dryness or scaling occurs in the less-active phases. Fissures are common and painful sequelae.

The chronic hyperkeratotic variety results in severe itching accompanied by thickening and fissuring of the palm. This effect may decrease the mobility of the affected hand.

When they occur on the hands, id reactions typically involve the fingers and the palms. These reactions often resolve when the primary infection is treated.

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