Dyshidrosis, pompholyx in children and adults

Diseases of the palmoplantar dermatitis group of non-infectious nature include lesions of the skin of the hands and feet, defined by such synonymous names as dyshidrosis, pompholyx, dyshidrotic eczema, endogenous vesicular (or bullous) eczema of the hands and feet, as well as acute vesiculobullous eczema (atopic dermatitis) of the hands. [ 1 ]

In ICD-10, this chronic relapsing disease is coded L30.1 in the dermatitis section.

Epidemiology

According to some data, at least 20% of cases of palmoplantar dermatitis are pompholyx (dyshidrotic eczema), which is most often detected in adults under 40 years of age, with a slight predominance of women. [ 2 ]

It has been noted that in regions with a warm climate there are more patients with dyshidrosis than in countries with moderate climate conditions.

In clinical practice, dyshidrosis of the hands is four to five times more common than dyshidrosis of the feet (plantar aspect of the feet), and in most cases symptoms appear on both hands or feet.

Causes dyshidrosis

Nowadays, the name "dyshidrosis", introduced by the British dermatologist William Tilbury Fox in the last quarter of the 19th century, is considered inaccurate, since no obvious sweating disorders were found in vesiculobullous eczema of the hands and feet, and the connection of this pathology with dysfunction of the eccrine sweat glands (i.e. their occlusion and retention of sweat) has not been proven. Nevertheless, this definition has not disappeared from dermatological terminology. [ 3 ]

Pompholyx is the most severe form of dyshidrotic dermatitis, in which vesicles (small blisters) merge to form larger blisters (bullae).

Despite numerous studies, it has not yet been possible to determine the exact causes of dyshidrosis. [ 4 ] Possible etiological factors may include:

• allergic contact dermatitis (including to some metals);
• contact eczema of the palms;
• skin sensitization associated with changes in certain genes, which increases the response of the cellular immunity of the epidermis to the effects of environmental factors, as well as to irritants and allergens.

Risk factors

Hypothetical risk factors for the development of dyshidrosis (dyshidrotic eczema or pompholyx) are considered to be: stress; genetic predisposition; increased sweating (hyperhidrosis) of the palms and soles; a history (including family history) of seasonal allergies or atopic dermatitis (eczema).

According to the latest research by foreign dermatologists and immunologists, the risk of developing dyshidrosis and pompholyx is increased in the presence of autoimmune diseases (chronic glomerulonephritis, Sjogren's syndrome, SLE, Crohn's disease, etc.), as well as Wiskott-Aldrich syndrome (WAS) and selective IgA deficiency associated with primary immunodeficiency. [5 ]

The first two factors (stress and an inherited tendency to develop allergic reactions) are most often the cause of dyshidrosis in children.

Pathogenesis

The mechanisms that determine the pathogenesis of dyshidrotic dermatoses are not entirely clear, although it is becoming increasingly obvious that the immune system of the skin is involved in its occurrence, which includes epidermal dendritic cells (Langerhans cells), keratinocytes, fibroblasts, mast cells, macrophages (phagocytes), T-lymphocytes (including T-helpers), as well as inflammatory mediators (cytokines, chemokines), antimicrobial sweat peptides, and dermicide. [ 6 ]

Today, it is known that diffuse intraepidermal bubbles (vesicles) that form in this pathology are the result of intercellular edema in the epidermis (spongiosis) - with the expansion of spaces between keratinocytes and subsequent ruptures of dermosomes (intercellular adhesions).

It should be noted that spongiosis can be acrosyringial. Acrosyringium is an epidermal section of the duct of the eccrine sweat glands, which are especially numerous on the palms and soles, the secretory part of which is located deep in the dermis, and the direct duct leads to the surface of the skin and exits into a slit-like pore. [ 7 ]

Researchers put forward the following versions of vesicle formation in dyshidrosis: a decrease in the threshold of skin irritation; distorted recognition of autologous skin antigens by immune cells; development of a secondary response to the spread of latent infection antigens; deviations in skin cells that cause an inadequate reaction of antigen-recognizing receptors and induce the activity of T-lymphocytes, etc.

Thus, dyshidrosis is a spongiotic dermatitis of an atopic nature, characteristic of the skin of the palms and soles with a thicker stratum corneum, consisting of compacted keratinocytes and containing a greater number of other immunocompetent cells. [ 8 ]

The metaphysical interpretation of the origins of the disease or psychosomatics links most skin problems with excessive self-control, unwillingness to show one's feelings and, at the same time, great dependence on the opinions of others.

Symptoms dyshidrosis

Often the first signs of dyshidrosis are sudden itching of the palms, sides of the fingers or soles of the feet.

If it is true dyshidrosis, the blisters - transparent, filled with a colorless liquid - begin to appear in groups, which causes increased itching and even some pain.

Dyshidrosis after pregnancy manifests itself as the same vesicles on the palms and feet, causing itchy skin.

Often these symptoms appear episodically: about once a month for a long time. As a result, dyshidrosis of the palms or dyshidrosis of the feet from the plantar side - especially advanced dyshidrosis - is transformed into pompholyx. This is a blistering form of palmoplantar eczema, in severe cases of which exfoliation (skin peeling), painful cracks, and sometimes lichenification (thickening of the skin) are observed.

Read more – Dyshidrotic Eczema

Dry lamellar dyshidrosis, or lamellar dyshidrosis or exfoliative keratolysis of the palms, is somewhat different from pompholyx. It is characterized by annular erythema on the palmar surface of the hands (less often on the soles of the feet) with blisters that are filled not with liquid, but with air. The rash usually occurs in the warm season, does not cause itching and quickly turns into exfoliation zones - with keratin scales on the surface of the skin, which gradually expand along the periphery, leaving a tightly fitting rim. There are no signs of inflammation.

In most cases, dry lamellar dyshidrosis in children goes away spontaneously – through gradual peeling, but in adults, cracking of the skin is possible.

Complications and consequences

The most common complications and consequences of pompholyx:

• thickening of the affected areas of the skin;
• secondary bacterial infection (usually strep and staphylococcal), which leads to swelling, increased pain, formation of pustules on the arms/legs (with possible suppuration).

If dyshidrosis and dyshidrotic eczema affect the fingertips, inflammation of the nail fold may develop – paronychia and dystrophy of the nail plates. [ 9 ]

Diagnostics dyshidrosis

Diagnosis of dyshidrotic eczema includes examination of the rash, study of the anamnesis, and examination of the skin.

Blood tests are required: general, for immunoglobulins (IgE), for leukocyte-T-lymphocyte index, for serum titer of complement. Skin scraping is done (for the presence of infection), a skin allergy test may be required.

Differential diagnosis

Differential diagnosis is carried out with scabies, pustular psoriasis, bullous pemphigoid and other dermatological conditions with similar symptoms. [ 10 ]

Treatment dyshidrosis

Treatment of dyshidrosis is usually long-term, and the main clinical recommendations of dermatologists include the use of topical agents and systemic drugs to relieve symptoms.

Ointments and creams for the treatment of dyshidrosis are widely used, these are ointments for eczema and creams for eczema. In particular, ointment, cream or emulsion with the corticosteroid methylprednisolone Advantan for dyshidrosis is applied to the affected areas of the skin for one and a half to two months.

Other dermatotropic agents are also prescribed, including zinc ointment or Desitin ointment (with zinc oxide); Akriderm, Betasalik, Belosalik, Celestoderm B or Diprosalik (with betamethasone and salicylic acid).

And for dry lamellar dyshidrosis, keratolytic creams containing urea, lactic or salicylic acid should be used.

To relieve itching, antihistamines are used - Tavegil tablets (Clemastine), Loratadine or Cetrin for dyshidrosis. [ 11 ]

In case of exacerbations, short courses of systemic corticosteroids can be prescribed - orally or in the form of injections. Thus, Prednisolone preparations are taken in the form of tablets, and treatment with injections is carried out with GCS preparations of betamethasone, as a rule, Diprospan is used for dyshidrosis

In severe cases, immunomodulatory drugs Methotrexate or Cyclosporine are indicated. And in case of skin infection, antibiotics may be prescribed.

Physiotherapy treatment is prescribed according to the condition of the skin, for example, phototherapy (controlled exposure to ultraviolet radiation). [ 12 ] Read more - Physiotherapy for dermatitis and dermatosis.

The efficacy of adjuvant botulinum toxin A in dyshidrotic eczema of the hands was investigated. [ 13 ]

Most patients undergo treatment at home, following the doctor's instructions. In addition, baths and cold compresses are recommended for the hands and/or feet, for which potassium permanganate (a pale pink solution of potassium permanganate) or table vinegar (diluted with water in a ratio of 1:10) are used.

It is also possible to carry out herbal treatment at home: make baths with cooled decoctions of horsetail, three-part succession, knotweed, chamomile flowers or calendula officinalis.

Patients are also given recommendations regarding nutrition; the diet and diet menu for dyshidrosis are discussed in more detail in the materials:

• Diet for eczema
• Diet for dermatitis

Prevention

The primary preventive measure for dyshidrosis is to avoid contact with anything that may irritate the skin, including soaps, shampoos, and other household chemicals.

Forecast

Endogenous vesicular eczema of the hands and feet - dyshidrosis - can spontaneously pass. But the prognosis regarding the impossibility of its relapse, which develops quickly and completely unexpectedly, is uncertain. In 75-85% of cases, this dermatological disease is chronic, reducing the quality of life of patients.

Most Frequently Asked Questions

Dermatologists answer patients' questions:

• How is dyshidrosis transmitted? Is it contagious or not?

This skin disease is not contagious and cannot be transmitted to others in any way.

• What to do if dyshidrosis does not go away?

It is necessary to consult a dermatologist about the use of an ointment or cream with a stronger GCS - mometasone furoate (Momederm, Avecort, Uniderm, Elokom) or, alternatively, treatment with immunomodulatory drugs. [ 14 ]

• Is it possible to go to the gym if you have dyshidrosis?

During an exacerbation it is not allowed, but during remission it is possible, but hands should be protected: wear gloves during training.

• Dyshidrosis and the army

The decision on the possibility of compulsory military service for persons with atopic dermatitis (eczema), including dyshidrotic, is made by a medical commission based on the conclusion of a dermatologist after examining the conscript.