Hand-and-Foot Eczema

Hand-and-foot eczema, a common problem in adults, has various clinical manifestations.
Both, dyshidrotic eczema, or the “wet” type; and the scaly, patch/plaque hand-and-foot eczema, or the “dry” type, are thought to be triggered by various endogenous or exogenous factors.
Frequently, both exogenous (i.e., irritants, allergens, or microbes) and endogenous (i.e., a personal or family history of atopy) factors are at work in the same patient.

For descriptive purposes, atopic hand-and-foot eczema may be divided into two clinical types that may overlap in the same patient: a “wet” type and a “dry,” scaly type. The clinical course of both types may be acute, recurrent, or chronic.

“Wet” Type

Dyshidrotic eczema, the wet type (Figs. 13.27 and 13.28), was formerly referred to as pompholyx (the Greek word for bubble), and describes the following:

An itchy, clear, vesicular eruption on the hands and/or feet.
The vesicles are typically located on the sides of the fingers, but they can also occur on the palms and, less commonly, on the soles of the feet and the lateral aspects of the toes.
Initially, lesions are small, deep seated, clear vesicles that resemble little bubbles.
Later, as they dry and resolve without rupturing, they generally turn into a golden-brown appearance (“sago grain vesicles”) without surrounding erythema.
Secondary impetiginization may occur.

“Dry,” Scaly Type

In nondyshidrotic hand eczema—the dry, scaly type—the following are noted:

Lesions are scaly and often erythematous.
Hyperkeratotic, lichenified plaques may be apparent.
The central palm or palmar aspect of the hands and fingers are also commonly affected.
Fingertips may become dry, wrinkled, and red, with resultant painful fissures and erosions (Fig. 13.29).
As with the dyshidrotic type of hand eczema, secondary bacterial infection (“honey-crusted” skin) may occur.
With long-standing disease, patients' fingernails may reveal dystrophic changes (e.g., irregular transverse ridging, pitting, thickening, discoloration) when the nail matrix (root) becomes involved (Fig. 13.30).

Outline
“Wet” Type
“Dry,” Scaly Type

The diagnosis of atopic hand eczema is usually made on clinical grounds when other causes are excluded. A diligent history must be taken to rule in or rule out contact dermatitis.

Differential Diagnosis

Contact Dermatitis

This is suspected, particularly if the eruption is on the dorsum of the hands or feet.
Patch testing with putative allergens (see earlier in this chapter) may be performed if an exogenous cause is suspected.

Inflammatory Tinea Manuum or Pedis

Suggested by well-demarcated plaques on the palms (often on one palm only) and soles with an advancing edge of scale; or a positive KOH examination or fungal culture.

Palmoplantar Psoriasis

Often indistinguishable from hand-and-foot eczema.
The patient may have evidence of psoriasis elsewhere on the body or a personal or family history of psoriasis.

Scabies (see Chapter 29: Bites, Stings, and Infestations)

Considered if there is an acute pruritic vesicular eruption in the web spaces of the fingers.

Management

Mild Cases

Nonirritating cleansers or soap substitutes.
Protective cotton-lined gloves should be used for washing dishes or similar tasks.
Fastidious hand protection, emollient barrier creams, protective gloves, and the avoidance of irritants and allergens.
For oozing and infected lesions, compresses with Burow solution (aluminum acetate) are applied. This treatment promotes drying and has an antibacterial effect. The solution is applied in a 1:40 dilution two or three times daily until bullae resolve.
Topical corticosteroids: Ointments penetrate skin better than creams do, but patients may prefer to use creams during the day. Most patients require at least medium-potency (class 3) corticosteroids (e.g., triamcinolone 0.1%), with or without occlusion. However, higher-potency (class 2) corticosteroids (e.g., fluocinonide 0.05%) can be used on an as-needed basis. Lower-strength (class 5) corticosteroids (e.g., hydrocortisone valerate 0.2%) may sometimes be applied for long-term maintenance.
Protopic ointment (tacrolimus) 0.1% or Elidel cream (pimecrolimus) 1% may also be effective as maintenance but may be less effective for treating an acute flare.

Severe Cases

Application of potent corticosteroids applied under plastic or vinyl occlusion, as well as superpotent topical corticosteroids can be used intermittently and for short periods, because they increase the risk of skin atrophy.
Systemic antibiotics should be administered for obvious or suspected secondary infection.
Short-term use of systemic corticosteroids may be required for very severe flares.
Treatment of hyperkeratotic palmar eczema is notoriously difficult. Acitretin (Soriatane), an aromatic retinoid, may help control hyperkeratosis.
Other measures, such as oral psoralen plus topical ultraviolet A (PUVA), oral cyclosporine, azathioprine, and low-dose methotrexate are used for severe, refractory cases.
Botulinum toxin A injection may be effective, particularly in those patients in whom hyperhidrosis is considered to be an aggravating factor.

SEE PATIENT HANDOUTS “Burow Solution” and “Hand Eczema” IN THE COMPANION eBOOK EDITION.

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Basics ⬇

Clinical Manifestations ⬆ ⬇

Diagnosis ⬆