What is dyshidrotic eczema?

Dyshidrotic eczema, also known as pompholyx, is a type of eczema⁵ characterised by small, itchy vesicles (fluid-filled sacs) on the hands and feet.¹ These vesicles are usually 1-2 mm in diameter and resemble ‘tapioca pearls’.²

Dyshidrotic eczema can occur as a single episode⁸ or as a recurrent, long-term (chronic) condition, with symptoms typically lasting 2 to 3 weeks each time.¹ 

What are the signs and symptoms of dyshidrotic eczema?

The signs and symptoms of dyshidrotic eczema include:

• Blisters typically appear on the palms of the hands, the soles of the feet, and/or the sides of the fingers or toes^1,5
• Blisters are usually 1-2mm in diameter, filled with fluid, and deep-seated³
• Both the blisters and the surrounding skin may be extremely itchy
• The affected area may have a burning or prickling sensation⁸
• Once the blisters heal, the skin may become dry, cracked, and/or discoloured¹ 

How is dyshidrotic eczema diagnosed?

Dyshidrotic eczema is diagnosed based on clinical examination, personal symptoms and the patient’s medical history.⁶ The hands and feet may also be assessed for fungal infections, as they can coexist with the condition.⁸

Blood tests may be conducted to check for autoimmune causes, and patch skin testing may be performed to identify allergies. Skin scrapings may be obtained to confirm an infection or to rule out other possible causes of the condition.¹⁵ 

What are some other conditions that may be confused with dyshidrotic eczema?

Some conditions that may be confused with dyshidrotic eczema include:^1,3

• Pustular psoriasis
• Contact dermatitis
• Bullous pemphigoid
• Hand, foot and mouth disease
• Chickenpox
• Scabies
• Tinea pedis/ tinea manuum
• Herpetic whitlow

Who is more susceptible to dyshidrotic eczema?

Anyone can develop dyshidrotic eczema; however, it is more commonly seen in individuals who:^2,8,11

• Have a family or personal history of atopic dermatitis or contact dermatitis
• Have a personal history of hay fever or other allergies
• Were assigned female at birth
• Are under the age of 40
• Receive immunoglobulin infusions or UV radiation
• Frequently expose their hands to water or moisture
• Work with cement or metals, such as gold and nickel

What are the common triggers for dyshidrotic eczema?  

While the cause of dyshidrotic eczema remains unclear,² below are some known common triggers for dyshidrotic eczema::^5,15

• Exposure to certain soaps, shampoos, or detergents
• Sensitivity to metals such as nickel, cobalt, or chromate⁸
• Very hot or cold weather
• Very dry or humid air
• Sweating
• High-stress levels
• Smoking

How do you treat dyshidrotic eczema?

While there is no single cure for dyshidrotic eczema, a dermatologist can help to manage the symptoms.⁴ Depending on the individual patient, the healthcare provider may recommend topical over-the-counter creams, prescription oral medications, and/or injectable medications.

Treatment options:⁵

• Emollients (medical moisturisers)¹⁰
• Topical corticosteroids such as methotrexate⁷
• Phototherapy⁶
• Topical calcineurin inhibitors (TCIs), such as tacrolimus ointment¹⁷
• Biologics such as dupilumab⁴
• Topical Janus kinase (JAK) inhibitors such as ruxolitinib cream¹³
• Oral steroids such as prednisone

Note: Antifungals are usually prescribed when eczema is linked to a fungal infection.⁶ Individuals with sweaty palms and soles may be given botulinum toxin injections.⁵

Self-management tips:

• Opt for lukewarm water, instead of very hot or cold water, to minimise irritation of the hands and feet²
• Wash the affected area with a gentle cleanser and pat it dry.⁶ When appropriate, consider using an emollient as a substitute for soap⁹
• Use a fragrance-free, heavy moisturiser daily to repair the skin barrier⁶
• Wear cotton gloves under waterproof gloves when shampooing your hair or washing dishes
• Keep fingernails short to discourage scratching and worsening the condition⁶

What is the prognosis of dyshidrotic eczema?

The prognosis of dyshidrotic eczema varies depending on personal circumstances and symptom severity. In some instances, symptoms resolve within a few weeks without any treatment or with moisturising alone.¹⁵ However, more often, it develops into a long-term condition with recurring flare-ups, particularly common between the ages of 20 and 40, with fewer episodes occurring afterward.¹⁶ 

What are the complications of dyshidrotic eczema?

Some complications that may arise during an episode of dyshidrotic eczema include:^3,8

• Secondary bacterial infection: if the affected area develops crusting, pain, swelling or pus-filled blisters (pustules), it may indicate a secondary bacterial infection, requiring immediate treatment with oral antibiotics⁶
• Secondary infection of the skin around the nails (paronychia)
• Painful cracks in the skin (fissures)
• Severe scratching may cause the skin to thicken and become leathery (lichenification)¹²
• Skin or nail discoloration¹⁵
• Experiencing psychological disability, as the condition may become debilitating and difficult to treat
• Financial strain due to missed work and potential loss of income

How do you prevent dyshidrotic eczema?

Following are some precautionary measures to help prevent dyshidrotic eczema:

• If the skin comes into contact with a potential trigger, wash the area immediately, dry completely, and moisturise⁶
• Use mild, fragrance-free cleansers¹⁵
• Remove all jewellery, such as rings, when washing hands to prevent moisture retention⁶
• Moisturise immediately after washing your hands or feet 
• Wear appropriate gloves when washing the dishes, gardening, or going out in cold weather
• Avoid going outdoors in extreme weather conditions¹⁵
• Opt for cotton gloves and socks that allow your skin to ‘breathe’
• Avoid rubber shoes that cause sweating. Instead, choose light footwear with a cotton lining to promote air circulation⁸
• Keep stress levels under control⁶

Summary

Dyshidrotic eczema is a type of eczema characterised by small blisters on the palms of the hands, soles of the feet and edges of the fingers and toes. The blisters are typically deep-seated and 1-2mm in diameter, which causes intense itching and/or a burning sensation. Dyshidrotic eczema can occur as a single episode or as a chronic recurrent condition.

Diagnosis is usually based on clinical examination, symptoms, and the patient's medical history. It is often mistaken for fungal infections, scabies, or contact dermatitis. While the exact cause of this condition remains unknown, triggers include exposure to metals like gold or nickel, excessive sweating, extreme temperatures, stress and smoking.

Treatment is usually tailored to the individual needs of the patient, with options ranging from topical creams to injectable medications and phototherapy. Self-management tips include washing the affected area with lukewarm water, followed by moisturising with a heavy, fragrance-free moisturiser to repair the skin barrier. It is also advisable to use emollients as a substitute for soap when appropriate.

The prognosis for dyshidrotic eczema depends on the individual patient and symptom severity. Once blisters heal, the affected area may become dry, cracked or discoloured. Potential complications include secondary bacterial infections and skin infections around the nails. 

Preventative measures include wearing appropriate gloves when washing dishes, gardening or going outside in cold weather. It is also important for patients to wash and moisturise their skin immediately after exposure to potential triggers. 

Early identification of symptoms, prompt initiation of treatment, and maintaining an individualised skincare routine are crucial steps in reducing the likelihood of flare-ups.