Dyshidrotic eczema is a vexing condition that causes small, fluid-filled blisters on the skin, usually on the palms of the hands, the sides of the fingers, and the soles of the feet. It causes intense itching spells, oozing, and painful fissures (cracks in the skin). These noisome symptoms often interfere with sleep, disrupt patients’ quality of life, and can occasionally lead to complications such as infection. In rare cases, it can involve more extensive areas of the skin and require sedation and administration of systemic steroids by a Board Certified dermatologist.
The term dyshidrotic eczema, or dyshidrosis, dates from 1873. Dyshidrosis literally means “abnormal sweating,” as physicians initially believed that the condition was caused by abnormalities of the sweat glands. In reality, this skin condition has nothing to do with the sweat glands.
Also known as pompholyx (“bubble” in ancient Greek), foot-and-hand eczema, palmoplantar eczema, and vesicular eczema (referring to the blisters or vesicles characteristic of the condition), the disorder is closely related to eczema, and it is associated with exposure to allergens and other irritants.
Dyshidrotic Eczema: Who Is at Risk?
While dyshidrotic eczema can affect any age group, it is most common among adults between ages 20 and 40. In the United States, women are affected at a slightly greater rate than men. In other places (Sweden, for example), the condition is distributed almost evenly between sexes. Fifty percent of those who experience dyshidrotic eczema have atopic dermatitis. People with a family history of atopic dermatitis or dyshidrotic eczema are at greater risk, as well.
Dyshidrotic eczema often affects people with food allergies. Other common triggers include metals, such as nickel or cobalt, as well as dust mites and pet dander. There is also a strong “neurogenic component” to dyshidrotic eczema; in the United States, stress is the most consistent temporal factor in flares. Stressors such as a new job, school pressures, and being overscheduled often contribute to episodes.
Symptoms of Dyshidrotic Eczema
Dyshidrotic eczema typically begins with an itchy cluster of small fluid-filled blisters called vesicles on the palm of the hands, the sides of fingers, or the soles of the feet–these vesicles often resemble clusters of tapioca pearls. The vesicles are usually between one and two millimeters wide. Quite often, intense itching precedes the formation of blisters; the vesicles and blisters form as a result of edema, or swelling, that rushes into the epidermis (this is also what causes the oozing and weeping). As the flare continues, these vesicles can grow together into red, raised patches. Larger blisters with a ragged appearance sometimes develop. Such blisters–called bullae–rupture and peel.
At this point, these outbreaks begin to ooze pus–this is called purulence. As the blisters begin to heel, the skin can begin to dry, scale, and crack. Typically, a flare lasts about four weeks. However, symptoms can be exacerbated and prolonged by bacterial infections. On occasion, a new rash begins before the previous outbreak heals completely.
Many sufferers report that symptoms worsen at night, contributing to poor sleep quality. Because the vesicles or bullae affect the palms and the soles of the feet, everyday activities can become incredibly uncomfortable. Vesicles on the hand interfere with tasks such as typing, cooking and manual labor. Footwear can aggravate dyshidrotic blisters on the feet and can cause discomfort with walking.
There is no cure for dyshidrotic eczema. A person might experience a singular, acute flare in response to a trigger; others will experience many subsequent flares. Severe cases might result in large, painful bullae that resist treatment.
Diagnosing Dyshidrotic Eczema
If you suspect that you have dyshidrotic eczema, you should see a doctor as soon as possible. Proper treatment depends upon proper diagnosis by a competent physician; you should never attempt to diagnose or treat any skin disorder on your own.
There are several conditions with symptoms similar to dyshidrotic eczema; these conditions will not respond to eczema treatments, and some of them can become dangerous if not treated appropriately.
Scabies, a reaction caused by a mite infestation, causes a raised, itchy rash similar in appearance to dyshidrotic eczema. Scabies is contagious.
Bullous impetigo, an infection caused by the staphylococcus aureus bacterium, can look similar to a severe dyshidrotic eczema flare. While impetigo occurs more frequently on the trunk, limbs, and face, it can occur on the hands. It is infectious and requires antibiotic treatment.
Bullous pemphigoid is a skin condition usually seen in elderly patients that causes blistering. While it is not infectious like impetigo, it can lead to serious problems if not treated properly.
Hand, foot and mouth disease is a viral infection that causes blistery rashes–you guessed it–on the hands, feet, and mouth, and it will not respond to eczema treatments. Fungal infections can sometimes present similarly, as can pustular psoriasis and contact dermatitis.
Identifying and Eliminating Triggers
Once dyshidrotic eczema has been diagnosed, patients should take stock of possible triggers so that they can be avoided in the future. Sometimes, triggers are relatively easy to identify. An industrial worker might have their first flare immediately after exposure to chromium, nickel, or cobalt. A person might first notice the symptoms after visiting a friend with a pet or cleaning out a dusty attic. An accountant with a crush of tax-season clients or a college student with looming exams could experience a stress-related flare.
In these cases, avoiding the triggers altogether might not be feasible, but steps could be taken to mitigate the risk of a flare. The industrial worker might request better personal protective equipment (PPE), and the person allergic to their friend's pets might decide to find an alternate venue for meet-ups.
The busy accountant and harried student could investigate stress-management techniques or more flexible schedules. While none of these steps can completely eliminate the possibility of a flare, they can go a long way towards reducing exposure to triggers or lessening the severity of a flare.
Triggers are not always so easily identified. A relatively serene person who has not changed their diet, work, or home environment could still have a flare. Keeping a journal of activities, meals, and symptoms could shed light on a trigger that has been previously overlooked. Discoveries and dead-ends should be discussed with your dermatologist.
Dyshidrotic eczema is closely associated with atopic disorders such as asthma, eczema, and atopic rhinitis. These disorders are characterized by elevated levels of immunoglobulin E (IgE). Immunoglobulin E acts upon the body’s cells, causing them to release histamines in response to foreign antigens. Histamines in turn cause many of the symptoms we associate with allergies, such as redness and itch.
For this reason, a blood test to check for elevated IgE levels might be your physician’s first step in identifying the cause of your flares. It is important to note, however, that normal levels of IgE do not mean that you have no allergy-related triggers. It’s simply one part of a process to help shed light on what’s happening in your body and to narrow down potential culprits.
Patch tests, where the skin is exposed to small amounts of specific allergens, can sometimes be helpful when dyshidrosis fails to respond to lifestyle changes.
Treatment For Dyshidrotic Eczema
All treatments for dyshidrotic eczema should be supervised by a dermatologist. Because there is no cure for dyshidrotic eczema, treatment centers upon relieving its symptoms. Part of the problem in dyshidrotic eczema is swelling; early applications of ice can help with this symptom if the patient can tolerate it.
Corticosteroids are the active ingredients in most eczema treatments; unfortunately, high doses of corticosteroids can have adverse effects on the skin’s health. SmartLotionⓇ is an over-the-counter treatment developed by board-certified dermatologist Dr. Steve Harlan, MD for the treatment of all types of chronic dermatitis, including dyshidrotic eczema.
SmartLotionⓇ uses a relatively low dose of Hydrocortisone USP–0.75%--to combat the itching and redness caused by dyshidrotic eczema. This low dosage provides relief without risk of topical steroid withdrawal, skin atrophy, or adverse interactions. In addition, its prebiotic formula encourages healthy skin flora and improved barrier function.
Dr. Harlan’s recommended treatment for most of his adult dyshidrotic eczema patients is an application of SmartLotionⓇ 3-4 times daily for up to four weeks–the average span of a flare. If a patient sees improvement after four weeks, Dr. Harlan usually has them taper down by one application per day for two weeks, proceeding incrementally until they have tapered off completely. The rash’s response to treatment determines the rate at which the patient will taper. Petrolatum can be applied to open skin and fissures to prevent moisture loss.
If there is no improvement within the first four weeks, Dr. Harlan often prescribes a stronger treatment for three weeks, after which patients resume treatment with SmartLotionⓇ.
Since broken skin is often seen during dyshidrotic eczema flares, it’s important to remember to apply SmartLotionⓇ around open wounds, not within them.
During treatment, patients should use a dermatologist-recommended moisturizer (Dr. Harlan recommends CeraVeⓇ). The moisturizer should be applied before the SmartLotionⓇ, and should be reapplied throughout the day–especially after handwashing. Unlike SmartLotionⓇ, moisturizer can be applied to wounds.
A topical calcineurin inhibitor such as tacrolimus or pimecrolimus is sometimes prescribed for stubborn flares. These medications reduce inflammation by inhibiting the release of cytokines by an overactive immune system. Topical treatment with bland hydrocarbons such as Icthammol ointment (OTC) can also be added to reduce inflammation.
An Ounce of Prevention
If you have had dyshidrotic eczema in the past or if you have associated risk factors, there are steps you can take to help prevent flares. You should wash your hands with warm water, avoiding extreme heat or cold. Use gentle cleansers, and moisturize with a dermatologist-recommended lotion after baths and hand-washing. Skin should be protected from exposure to ultraviolet (UV) radiation–sunlight or artificial–unless otherwise advised by a doctor.
Allow affected skin to “air out,” avoiding socks or gloves where possible and relying upon breathable, moisture-wicking fabrics when gloves and socks are necessary. Moisturize before the skin dries out too much from air exposure. Keep yourself hydrated, avoid known eczema triggers, and work to manage your stress.
Finally, remember that flares do not indicate that you’ve done something wrong. Even the most careful person can be exposed to triggers. Continue to follow your dermatologist’s recommendations, and remember that Dr. Harlan’s extensive knowledge base is literally at your fingertips, as well as the blog.