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Dyshidrosis

Overview

Dyshidrosis, also termed Dyshidrotic Eczema, Pompholyx, Acute vesiculobullous hand eczema, and Dyshidrotic Dermatitis, is a skin condition that is characterized by small blister

Blister

A blister is a small pocket of fluid within the upper layers of the skin, typically caused by forceful rubbing , burning, freezing, chemical exposure or infection. Most blisters are filled with a clear fluid called serum or plasma...

s on the hands or feet. It is an acute, chronic, or recurrent dermatosis of the fingers, palms, and soles, characterized by a sudden onset of many deep-seated pruritic

Itch

Itch is an unpleasant sensation that evokes the desire or reflex to scratch. Itch has resisted many attempts to classify it as any one type of sensory experience. Modern science has shown that itch has many similarities to pain, and while both are unpleasant sensory experiences, their behavioral...

, clear vesicles

Vesicle (dermatology)

A vesicle is a circumscribed, fluid-containing, epidermal elevation 1–10 mm in size.With regard to the quote "...elevation 1–10 mm in size," depending on which text is referenced, some authors state the cutoff between a vesicle and a bulla as 0.5 cm, not...

; later, scaling, fissures and lichenification

Lichenification

Lichenification is epidermal thickening characterized by visible and palpable thickening of the skin with accentuated skin markings, and is the hallmark of chronic eczematous dermatitis....

occur.

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Encyclopedia

Dyshidrosis, also termed Dyshidrotic Eczema, Pompholyx, Acute vesiculobullous hand eczema, and Dyshidrotic Dermatitis, is a skin condition that is characterized by small blister

Blister

s on the hands or feet. It is an acute, chronic, or recurrent dermatosis of the fingers, palms, and soles, characterized by a sudden onset of many deep-seated pruritic

Itch

, clear vesicles

Vesicle (dermatology)

; later, scaling, fissures and lichenification

Lichenification

Lichenification is epidermal thickening characterized by visible and palpable thickening of the skin with accentuated skin markings, and is the hallmark of chronic eczematous dermatitis....

occur. Recurrence is common and for many can be chronic. Incidence/Prevalence is said to be 20/100,000 in the United States

United States

The United States of America is a federal constitutional republic comprising fifty states and a federal district...

, however, many cases of eczema are diagnosed as garden-variety atopic eczema without further investigation, so it is possible this figure is misleading.

This condition is not contagious to others, but due to its unsightly nature can cause significant distress in regards to social interactions with others.

The name comes from the word "dyshidrotic," meaning "bad sweating," which was once believed to be the cause but this association is unproven; there are many cases present that have no history of excessive sweating. There are a number of different factors which may trigger the outbreak of dyshidrosis such as allergens, stress or seasonal changes. Emotional stress may also further aggravate the condition.

Symptoms

Small blisters with the following characteristics:

Blisters are very small (3 mm or less in diameter). They appear on the tips and sides of the fingers, toes, palms, and soles.
Blisters are opaque and deep-seated; they are either flush with the skin or slightly elevated and do not break easily. Eventually, small blisters come together and form large blisters.
Blisters may itch, cause pain, or produce no symptoms at all. They worsen after contact with soap, water, or irritating substances.
Scratching blisters breaks them, releasing the fluid inside, causing the skin to crust and eventually crack. This cracking is painful as well as unsightly and often takes weeks, or even months to heal. The skin is dry and scaly during this period.
Fluid from the blisters is serum that accumulates between the irritated skin cells. It is not sweat as was previously thought.
In some cases, as the blistering takes place in the palms or finger, lymph node swelling may accompany the outbreak. This is characterised by tingling feeling in the forearm and bumps present in the arm pits.
Nails on affected fingers, or toes, may take on a pitted appearance.

Causes

Causes of dyshidrosis are unknown. However, a number of triggers to the condition exist:

Dyshidrosis has been historically linked to excessive sweating during periods of anxiety, stress, and frustration, however, many cases present that have no history of excessive sweating, and the hypothesis of dyshidrosis as a sweating disorder is largely rejected. Some patients reject this link to stress, though as a trigger of vesicular eruption it cannot be overlooked, as with other types of eczema.
Vesicular eruption of the hands may also be caused by a local infection, with fungal infections, like Tinea pedis being the most common. Sunlight is thought to bring on attacks, some patients link outbreaks to prolonged exposure to strong sunlight from late spring through to early autumn.. Others have also noted outbreaks occurring in conjunction with exposure to chlorinated pool water or highly treated city tap waters.
Antibacterial soaps, fragrances and contact with fruit juices or fresh meat also can trigger outbreaks of dyshidrosis, as with other types of eczema.
Systemic nickel allergies may be related such as foods high nickel content - cocoa, chocolate, whole grains, & nuts.
Allergic reactions may be attributed to caffeine in coffees, teas, and carbonated beverages.
Allergic reactions may be caused by ingestion of alcohol; the dehydrating effects of alcohol may exacerbate the severity of the fissures and cracking.
Keeping skin damp will trigger or worsen an outbreak. For this reason, people with dyshidrosis should wear gloves, socks, and shoes made of materials which "breathe well", such as cotton or silk. Certain fabrics may greatly irritate the condition, including wool, nylon and many synthetic fabrics.
Inherited, not contagious. Often, patients will present with other types of dermatitis, such as seborrheic dermatitis or atopic eczema. For this reason, among others, dyshidrosis is often dismissed as atopic eczema or contact dermatitis.
Can be the secondary effect of problems in the gut. Some sufferers claim diet can ease symptoms (relieving internal condition of IBS
Irritable bowel syndrome
Irritable bowel syndrome is a functional gastrointestinal disorder. Also called spastic colon, it is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms...

or intestinal yeast infection). Also Inflammatory bowel disease
Inflammatory bowel disease
In medicine, inflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn's disease and ulcerative colitis..-Forms:...

s of Ulcerative colitis
Ulcerative colitis
Ulcerative colitis is a form of inflammatory bowel disease . Ulcerative colitis is a form of colitis, a disease of the intestine, specifically the large intestine or colon, that includes characteristic ulcers, or open sores, in the colon. The main symptom of active disease is usually constant...

and Crohn's disease
Crohn's disease
Crohn's disease is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from anus to mouth, causing a wide variety of symptoms...

.
Bandages, plasters or other types of skin-tapes may be irritating to dyshidrosis and should be avoided. As the skin needs to breathe, anything that encourages maceration
Maceration
Maceration may refer to:* Maceration , the softening or breaking into pieces with liquid* Maceration, in chemistry and herbalism, the preparation of an extract by soaking material in water, vegetable oil or some organic solvent...

of the palms should be avoided. If the 'wounds' are raw enough to warrant covering, pure cotton gloves or gauze should be used. Liquid Band-Aid brand bandage may be tolerated and helpful, refer to the Treatment section, below.
Latex and vinyl gloves may increase irritation.
Multiple Chemical Sensitivity
Multiple chemical sensitivity
Multiple chemical sensitivity is a chronic medical condition characterized by symptoms that the affected person attributes to exposure to low levels of chemicals. Commonly suspected substances include smoke, pesticides, plastics, synthetic fabrics, scented products, petroleum products and paints...
Allergic reaction to Cr(6+) compounds (Potassium Dichromate
Potassium dichromate
Potassium dichromate, K₂Cr₂O₇, is a common inorganic chemical reagent, most commonly used as an oxidizing agent in various laboratory and industrial applications. As with all hexavalent chromium compounds, it is potentially harmful to health and must be handled and...

and other leather preservative)
Dyshidrosis can sometimes even be caused by dust mite allergies, with sufferers having to wash and change bedding weekly, sometimes even every 2 days or even every day, to combat symptoms.
Balsam of Peru is a common irritant among sufferers of hand eczema, more commonly, people with dyshidrotic eczema.

Treatment

There are many treatments available for dyshidrosis, however, few of them have been developed or tested specifically on the condition.

Topical steroids - while useful, can be dangerous long-term due to the skin-thinning side-effects, which are particularly troublesome in the context of hand dyshidrosis, due to the amount of toxins and bacteria the hands typically come in contact with.
Nutritional deficiencies may be related, so addressing diet and vitamin intake is helpful
Potassium permanganate
Potassium permanganate
Potassium permanganate is the inorganic chemical compound KMnO₄, a water soluble salt consisting of equal mole amounts of potassium and permanganate ions. This salt, formerly known as permanganate of potash or Condy's crystals is a strong oxidizing agent...

dilute solution soaks - also popular, and used to 'dry out' the vesicles, and kill off superficial staphylococcus aureus
Staphylococcus aureus
Staphylococcus aureus is the most common cause of staph infections. It is a spherical bacterium, frequently part of the skin flora found in the nose and on skin. About 20% of the population are long-term carriers of S. aureus. S...

, but it can also be very painful. Undiluted it may cause significant burning.
Domeboro (OTC) helps alleviate itching in the short term, and can help to quicken the natural healing process. The active ingredient in Domeboro is aluminum acetate, also found in Borow's solution, an OTC antistringent available at most drug stores. Either product is effective in helping to dry out the blisters which leads to faster healing. Affected areas should be soaked in Domeboro or Borow's solution for 20–30 minutes several times a day to be effective.
Emollients during the drying/scaling phase of the condition, to prevent cracking and itching. While petroleum jelly
Petroleum jelly
Petroleum jelly, petrolatum or soft paraffin, CAS number 8009-03-8, is a semi-solid mixture of hydrocarbons , originally promoted as a topical ointment for its healing properties...

may work well as a barrier cream, it does not absorb into the skin and or allow it to breathe, so may actually be less helpful.
Salt soaks - maintaining palms for 40 minutes to an hour immersed in a salt solution of 1/4 salt dissolved in water. Repeating treatment for 3–4 days or additionally if required. It is best to soak only the palm and avoid exposing the top of the hand to the saline solution as salt can severely dry and irritate the skin on the top of the hand.
White vinegar soaks
Avoidance of known triggers - dyshidrosis sufferers may need to abstain from washing their own hair or bodies, or wearing gloves when they do so, however waterproof gloves are often potential irritants.
Zinc oxide
Zinc oxide
Zinc oxide is an inorganic compound with the formula ZnO. It usually appears as a white powder, nearly insoluble in water. The powder is widely used as an additive into numerous materials and products including plastics, ceramics, glass, cement, rubber Zinc oxide is an inorganic compound with the...

ointment
Nickel-free diets
Alcohol and caffeine free diets
When in the scaling phase of the condition, the scales may cause deep cracks and fissures in the skin. Filing (as with an emery board) may help to minimize this.
Stress management
Stress management
Stress management is the amelioration of stress, especially chronic stress.-Historical foundations:Walter Cannon and Hans Selye used animal studies to establish the earliest scientific basis for the study of stress...

counseling
Light treatment: UVA-1, PUVA
PUVA
PUVA is a Psoralen + UVA treatment for Eczema, Psoriasis and Vitiligo, and mycosis fungoides. The Psoralen is applied or taken orally to sensitize the skin, then the skin is exposed to UVA. Long term use has been associated with higher rates of skin cancer....

, Grenz rays
Grenz Rays
Grenz Rays are a type of ultrasoft radiation waves used in the treatment of skin conditions such as dermatitis, warts, psoriasis and hand eczma. This type of treatment is usually reserved for cases that have been unresponsive to other modern chemical treatments....

, Low Level Light Therapy using a Red + NIR (LED) combination
Ciclosporin
Ciclosporin
Ciclosporin , cyclosporine , cyclosporin or cyclosporin A, is an immunosuppressant drug widely used in post-allogeneic organ transplant to reduce the activity of the patient's immune system and, so, the risk of organ rejection. It has been studied in transplants of skin, heart, kidney, liver,...

a strong immunosuppressant drug used to combat dyshidrosis caused by ulcerative colitis
Efalizumab
Efalizumab
Efalizumab is a medication designed to treat psoriasis. As its name implies, it is a recombinant humanized monoclonal antibody that binds to CD11a and acts as an immunosuppressant. It is administered once weekly by subcutaneous injection. It acts to inhibit white blood cell migration out of blood...

(Raptiva) a medication used to treat psoriasis
Psoriasis
Psoriasis is a chronic, non-contagious autoimmune disease that affects the skin and joints. It commonly causes red, scaly patches to appear on the skin. The scaly patches caused by psoriasis, called psoriatic plaques, are areas of inflammation and excessive skin production. Skin rapidly...
Clobetasol Propionate
Clobetasol propionate
Clobetasol propionate is a corticosteroid used to treat various skin disorders including eczema and psoriasis. Clobetasol belongs to Class I of the corticosteroids, making it one of the most potent available. It comes in ointment and emollient cream presentations...

(0.05%) (potent corticosteroid cream or ointment ) has been an effective treatment.
Tacrolimus
Tacrolimus
Tacrolimus is an immunosuppressive drug whose main use is after allogeneic organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection. It reduces T-cell and interleukin-2 activity...

and Pimecrolimus
Pimecrolimus
Pimecrolimus is an immunomodulating agent used in the treatment of atopic dermatitis . It is currently available as a topical cream, once marketed by Novartis under the trade name Elidel.-Pharmacology:Pimecrolimus is an ascomycin macrolactam derivative...

, immunomodulators often used to prevent organ rejection in topical, ointment form, may be used in severe cases.
Unbleached cotton gloves may be used to cover the hands to prevent scratching and vulnerability of the skin to bacteria
Plantain (Plantago major) infused in olive or other oil can be soothing.
Band-Aid brand liquid bandage regularly applied during the (often painful) peeling stage allows the skin to breathe while protecting it from further irritation. Some suffers have found that with regular application the skin will close and reform within 1 to 2 days. Protection is sufficient that the user can (gently) wash their hands with no irritation, however additional application after each hand wash is suggested. It does not cure the condition and only aids healing during the peeling stage. Other spray-on or brush-on liquid topical coatings can contain irritating ingredients and have not been found to be helpful, some will aggravate the condition significantly.
Avoid metal computer keyboards and track pads which contain nickel.

Many sufferers of dyshidrosis will find that treatments that were previously suitable for them no longer work or have induced sensitive reactions, which is common in most types of eczema.

It may be prudent to wear light cotton gloves while reading newspapers, books and magazines. The inks and paper may irritate the condition.
Avoid Purell and other hand sanitizing products which contain alcohol. These may aggravate the condition.
Wash affected hands and feet with cool water and apply a moisturizer as soon as possible. While hot water seems to kill the itch it may aggravate the condition.
Avoid moisturizers that contain water (cremes and lotions). Stick with ointments. Use only thin applications of ointments as excessive amounts of ointment may restrict breathing of the skin and aggravate the condition.
Aloe Vera may be applied after cleaning hands
When itchy or inflamed 100% lavender oil can be applied occasionally to soothe and reduce irritation for those who are not sensitive to the oil making sure to pat excess oil with a tissue. A patch test on the wrist is recommended before application to the palms.
Saline solution for washing hands may be very useful.
Avoid soaps with Sodium Laureth Sulfate (SLS). Many pump style soaps and common shampoos contain SLS.

'Toctino' alitretinoin 9-cis-retinoic acid has been approved for prescription in the UK. (08/09/2008) This is specifically for chronic hand eczema. It is made by Basilea of Switzerland (BAL 4079)

Rinsing the affected areas briefly in surgical spirit is very effective. It will work to clear up the blisters within hours if they have been pricked open first.

Allergy testing

Allergy testing is a contested subject among eczema communities. Some dermatologists posit that if a sufferer is allergic to a substance, then a general allergy test on the forearm will suffice, yet others believe that in conditions like dyshidrosis, the suspect substances need to be applied to the affected area to induce a reaction. Whole blood allergy tests (ie: Alcat) can prove to be more effective at determining an allergy as the effects of an allergic reaction are often slow and cumulative, not immediate.
Often seen in people who are already susceptible to allergies and/or asthma.

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