What is dyshidrosis?

Dyshidrosis: Clinical Features and Management

Dyshidrosis is a recurrent vesicular skin condition characterized by pruritic, non-inflammatory vesicles primarily affecting the palms, soles, and lateral aspects of fingers, which may significantly impact quality of life and requires appropriate management strategies. 1

Clinical Features

Characteristic Presentation

• Small, clear, deeply embedded vesicles beneath thick stratum corneum on palms, soles, and sides of fingers
• Intense pruritus often preceding vesicle formation
• Painful distension as vesicles enlarge
• Vesicles typically resolve within 3 weeks but frequently recur 2
• May present with various clinical forms:
  • Standard vesicular form
  • Bullous dyshidrosis (larger blisters)
  • Superinfected form
  • Psoriasiform keratoderma (chronic cases) 2

Differential Diagnosis

Dyshidrosis must be distinguished from other vesicular conditions affecting palms and soles:

• Contact dermatitis (allergic or irritant)
• Tinea manuum/pedis
• Bullous pemphigoid (dyshidrosiform variant)
• Pompholyx
• Palmoplantar pustulosis 3

The dyshidrosiform variant of bullous pemphigoid is particularly important to recognize, as it typically presents in elderly patients with hemorrhagic or purpuric blisters on palms/soles before progressing to other body sites 3.

Etiology and Pathophysiology

Despite its name suggesting sweat gland dysfunction, dyshidrosis is not primarily related to hyperhidrosis or sweat gland abnormalities 4. It is considered a form of eczema with several potential triggers:

• Atopic predisposition
• Contact allergens
• Fungal infections
• Neurovegetative disturbances
• Stress factors
• Idiopathic causes 2, 4

Management Approach

First-Line Treatment

1. Topical Corticosteroids

   • Medium potency corticosteroids for maintenance therapy
   • High/very high potency corticosteroids for severe flares 1
   • Apply twice daily during acute flares

2. Skin Care and Prevention

   • Regular emollient application (at least once daily)
   • Avoid hot water, excessive soap use, and alcohol-containing products
   • Continue maintenance therapy even after resolution 1
   • Identify and eliminate triggering substances

Management of Fissures

• Apply propylene glycol 50% in water for 30 minutes under plastic occlusion nightly
• Follow with hydrocolloid dressing 1

Secondary Infection Management

• Monitor for signs of secondary infection (usually Staphylococcus aureus)
• Obtain bacterial cultures when suspected
• Consider antiseptic baths with potassium permanganate (1:10,000) 1

Second-Line Treatment Options

Phototherapy

• Oral PUVA therapy has shown superior efficacy compared to UVB for hand eczema
• Significant improvement or clearance in 81-86% of patients with hand and foot eczema 5
• Consider for cases not responding to topical treatments

Systemic Treatments

For severe, recalcitrant cases:

• Immunomodulators (cyclosporine, methotrexate, azathioprine)
• Biologics like dupilumab for severe cases 1

Special Considerations

Chronic Disease Management

• Maintenance therapy with medium potency topical corticosteroids twice weekly to prevent relapses
• Regular use of emollients is crucial for preventing recurrence 1

Occupational Impact

Dyshidrosis can cause significant occupational impairment, particularly in manual workers or those exposed to irritants 6. Consider:

• Protective measures (cotton gloves under vinyl gloves)
• Occupational modification if possible
• Addressing psychological distress that may accompany chronic skin disease

Pitfalls and Caveats

1. Misdiagnosis: Always rule out tinea infection with KOH preparation or fungal culture before initiating corticosteroid treatment
2. Overtreatment: Prolonged use of high-potency topical corticosteroids can lead to skin atrophy
3. Undertreatment: Inadequate treatment of acute flares may lead to chronicity
4. Missing underlying causes: Failure to identify and address triggers will result in continued recurrences

When dyshidrosis is refractory to standard treatments, consider patch testing to identify potential contact allergens and evaluate for underlying systemic conditions that may be contributing to recurrent episodes.