Hand Dermatitis: A Review of Clinical Features, Diagnosis, and Management

Deborah A. Kedrowski, RN; Erin M. Warshaw, MD, MS


Dermatology Nursing. 2008;20(1):17-25. 

In This Article


Definition. Pomphylox (also known as dyshidrotic eczema or vesicular eczema) is a recurrent or chronic re_lapsing dermatitis of unknown etiology that occurs on the sides of the fingers, palms, and on the plantar surface of the feet (Veien & MennE9, 2000). The word dyshi drotic is used because it was originally thought that this condition was related to sweat glands, but this association has been disproved (Veien & MennE9, 2000; Warshaw et al., 2003). The name pomphylox comes from the Greek word for bubble (Warshaw et al., 2003), which accurately describes the clinical appearance of this disorder.

Epidemiology/risk factors. Pom phy lox is more common in women than men (Veien & MennE9, 2000). As many as 50% of patients with pomphylox have had personal or familial atopic diathesis (Veien & MennE9, 2000). About 50% of those with pomphylox are atopic, and many are smokers and/or have allergies to nickel. Emotional stress can make pomphylox worse. In the United States, pomphylox occurs in as many as 5% to 20% of patients with hand eczema and more commonly occurs in warmer climates and during spring and summer months (Burdick & Santos, 2006).

Pomphylox can be severe, re sulting in occupational disability and time away from work. As in other forms of hand dermatitis, pomphylox is aggravated by contact with irritants such as water, detergents, and solvents. Pomphylox often runs a chronic course, but may remit for long periods (Burdick & Santos, 2006). It often reappears after a period of nervous tension, worry, or stress (Schwanitz, 1994). This condition can have an unpredictable course and can be very incapacitating.

Clinical features. Symmetric crops of clear vesicles and/or bullae on the palms and lateral aspects of fingers characterize pomphylox (Veien & MennE9, 2000; Warshaw et al., 2003). The lesions appear abruptly and last for 2 to 3 weeks (Warshaw et al., 2003). Vesicles are deep seated with a tapioca-like appearance, without surrounding erythema (Burdick & Santos, 2006). Itching, as well as pinpoint size intra-epidermal vesicles, occurs primarily in the central parts of the palms (MF6ller, 2000). Epi sodes vary in frequency from a few times per year to a couple of times per month. The soles of the feet and the lateral aspects of toes also may be affected (MF6ller, 2000; Veien & MennE9, 2000). Hands are involved solely in approximately 80% of patients, feet solely in 10%, and both hands and feet are involved in 10% of patients (Burdick & Santos, 2006). Transverse ridging of the fingernails is a characteristic feature of this disorder (Veien & MennE9, 2000).

Pathophysiology. Several hypotheses have been proposed for the pathophysiology of pomphylox, al though the exact cause is not known. The original hypothesis of sweat gland dysfunction has been disputed because sweat ducts are not abnormal on histopathology. Hyper hi drosis may be an exacerbating factor (Swartling, Naver, Lindberg, & Anveden, 2002; Veien & MennE9, 2000). As stated previously, pomphylox often appears during times of stress. The association between ingestion of allergens such as chromate or nickel and pomphylox is controversial, although sweat may enhance leaching of allergens from materials such as alloys (nickel).

Diagnosis. The diagnosis is usually made clinically, based on the pa tient history and exclusion of other skin diseases. Patch testing may be helpful to exclude ACD (Burdick & Santos, 2006). Bacterial culture will ex clude secondary infection (Warshaw et al., 2003). Identi fica tion of fungal infection on the feet is necessary as pomphylox can be indistinguishable from an id reaction (Veien & MennE9, 2000). An id reaction refers to vesicular eruption of the hands caused by a distal focus of infection, with fungal infections the most common (Veien & MennE9, 2000).

Treatment/management. Treat ment varies with the stage of the disease. Com presses or soaks, antihistamines, and topical corticosteroids are the main stay of therapy (Burdick & Santos, 2006). Topical or oral PUVA can be effective (De Rie et al., 1995; Grundmann-Kollmann, Behrens, Peter, & Kerscher, 1999; Schempp, MFCller, Czech, SchF6pf, & Simon, 1997); systemic corticosteroids may be used for severe episodes. Botul inum toxin injections may be helpful in some patients, especially those with prominent hyperhidrosis (Naver, Swartling, & Aquil onius, 2000; Swartling et al., 2002). The release of acetylcholine from sudomotor nerves triggers the action of sweat glands. The botulism toxin type A, when injected intradermally into the palmar surface of the hand, paralyzes the sudomotor nerves and blocks the release of acetylcholine onto the receptors of the sweat glands which inhibits sweating (Eisenach, Atkinson, & Fealey, 2005). Antibiotics may be necessary for secondary infection of pomphylox (Warshaw et al., 2003).

For stress reduction, biofeedback therapy or other techniques may help (Veien & MennE9, 2000). Patients should avoid contact with certain allergens or irritants, and follow a hand care routine with regular use of emollients. For patch test proven, nickel-sensitive patients, a low-nickel diet may be advised (Veien & MennE9, 2000). Nickel-free diet information can be found at https://www.righthealth.com/Health/nickel%20free%20diet-s?lid= goog-ads-sb-0443110428&gclid=CLPQiMGyrZECFQa1IgodqxWWYw. Although the association of nickel allergy and pomphylox is controversial, it has been suggested that the condition improves on a diet low in nickel-containing foodstuffs and by avoiding nickel in cooking utensils (Veien & MennE9, 2000).


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