Pompholyx
What is pompholyx?
Pompholyx is a form of hand/foot eczema characterised by vesicles or bullae (blisters). It is a form of vesicular dermatitis of hands and feet, also called vesicular endogenous eczema, and may be the same condition as dyshidrotic eczema. It is sometimes subclassified as cheiropompholyx (hands) and pedopompholyx (feet).
Who gets pompholyx?
Pompholyx most often affects young adults.
- It is more common in females than males.
- Many of them report palmoplantar hyperhidrosis.
- There is a personal or family history of atopic eczema in 50%.
What causes pompholyx?
Pompholyx is multifactorial. In many cases it appears to be related to sweating, as flares often occur during hot weather, humid conditions, or following emotional upset. Other contributing factors include:
- Genetics
- Contact with irritants such as water, detergents, solvents and friction
- Association with contact allergy to nickel and other allergens
- Inflammatory dermatophyte (tinea) infections (when it is known as a dermatophytid)
- Adverse reaction to drugs, most often immunoglobulin therapy
What are the clinical features of pompholyx?
Pompholyx presents as recurrent crops of deep-seated blisters on the palms and soles. They cause intense itch and/or a burning sensation. The blisters peel off and the skin then appears red, dry and has painful fissures (cracks).
When involving the distal finger adjacent or proximal to the nail fold, it can result in paronychia (nail fold swelling) and nail dystrophy with irregular pitting and ridges.
Pompholyx
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What are the complications of pompholyx?
Secondary bacterial infection with Staphylococcus aureus and/or Streptococcus pyogenes is common in pompholyx, and results in pain, swelling and pustules on the hands and feet.
Infected pompholyx
How is pompholyx diagnosed?
The clinical presentation is typical.
- If suspicious of a fungal infection (tinea pedis), skin scrapings should be taken for mycology.
- Patch testing is indicated in chronic or atypical cases.
- Skin biopsy is rarely necessary. It shows spongiotic eczema.
Aggravating factors
As in other forms of hand dermatitis, pompholyx is aggravated by contact with irritants such as water, detergents and solvents. Contact with them must be avoided as much as possible and protective gloves worn to prevent additional irritant contact dermatitis.
People with pompholyx that are found to be allergic to nickel must try to avoid touching nickel items.
What is the treatment for pompholyx?
Pompholyx is challenging to treat. Topical therapy is relatively ineffective because of the thick horny layer of skin of palms and soles.
General measures
- Wet dressings to dry up blisters, using dilute potassium permanganate, aluminium acetate or acetic acid
- Cold packs
- Soothing emollient lotions and creams
- Potent antiperspirants applied to palms and soles at night
- Protective gloves should be worn when doing wet or dirty work
- Well-fitting footwear, with 2 pairs of socks to absorb sweat and reduce friction
Prescription medicines
- Ultrapotent topical corticosteroid creams applied to new blisters under occlusion, and ointments applied during the inflamed dry phase
- Short courses of systemic corticosteroids, eg prednisone or prednisolone, for flare-ups
- Oral antistaphylococcal antibiotics for secondary infection
- Topical and oral antifungal agents for confirmed dermatophyte infection
- In patients with hyperhidrosis, probanthine or oxybutynin is worth trying.
- In severe cases, immune modulating medicines are indicated. These include: methotrexate, mycophenolate mofetil, azathioprine and ciclosporin.
- Where available, alitretinoin is used for resistant chronic disease.
Other options
- Superficial radiotherapy
- Botulinum toxin injections (to prevent sweating)
- Phototherapy and photochemotherapy (PUVA) therapy
What is the outlook for pompholyx?
Pompholyx generally gradually subsides and resolves spontaneously. It may recur in hot weather or after a period of stress, and in some patients is recalcitrant.
