Dyshidrotic eczema

Dyshidrotic eczema on a patient's palm: The tiny, deep-seated blisters are often very itchy.

Dyshidrotic eczema: Overview

What is dyshidrotic eczema?

Dyshidrotic (dis-hi-drah- tic) eczema (DE) is a common group of skin conditions in which the skin cannot protect itself as well as it should, so the person often gets itchy, dry skin).

DE causes itchy, dry skin. People also develop small, deep-seated blisters, usually on their hands. It’s also possible to develop blisters on your feet.

Whether on your hands, feet, of both, the blisters are often very itchy and painful.

When the blisters clear (usually in 2 or 3 weeks), the skin tends to be red, dry, and cracked.

There is no cure for DE, so people can have flares. For many people, DE flares when they’re under a lot of stress, temperatures rise (such as in spring or summer), or their hands stay wet for long periods of time.

DE flares range from mild to debilitating. A severe flare on your feet can make walking difficult. Having many blisters on your hands can make it difficult to work and perform everyday tasks like shampooing your hair and washing dishes. 
This common skin disease has many names, including:

• Cheiropompholyx (affects the hands)
• Dyshidrosis
• Dyshidrotic dermatitis
• Foot-and-hand eczema
• Pedopompholyx (affects the feet)
• Pompholyx
• Vesicular eczema
• Vesicular palmoplantar eczema

Image used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.

References:
Habif TP, Campbell JL, et al. “Pompholyx” (card #16). In: Dermatology DDxDeck. Mosby 2006.
Miller JL, Hurley HJ. “Diseases of the eccrine and apocrine sweat glands.” In: Bolognia JL, Jorizzo JL, et al, eds. Dermatology. Mosby Elsevier 2008. p. 543.

Severe dyshidrotic eczema: As the blisters dry, the skin often starts to peel.

Dyshidrotic eczema: Signs and symptoms

How dyshidrotic eczema begins

This skin disease appears suddenly. For most people, the first sign is deep-seated blisters on their hands. Some people feel an itchy or burning sensation before the blisters appear.

​Signs and symptoms

If you have dyshidrotic eczema (DE), you’ll likely notice:

• Small blisters that vary in size on your palms and sides of your fingers (and/or soles)
• A rash and scaly skin where blisters appear
• Excessive sweating where you have blisters
• An tching or burning feeling on blistered skin (and sometimes before the blisters appear)
• Pain where you have blisters

The blisters usually clear in 2 to 3 weeks — or sooner with treatment. As the blisters clear, the skin is often dry and cracked. It may peel.

If you have frequent DE flares, the skin can start to thicken, feel scaly, and develop deep, painful cracks.

Signs of infection

An infection can develop where you have DE. A staph infection is most common. Signs of a staph infection include:

• Pain
• Swelling
• Crusting
• Pus-filled blisters

Image used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.

References:
Habif TP, Campbell JL, et al. “Pompholyx” (card #16). Dermatology DDxDeck. Mosby 2006.
Miller JL, Hurley HJ. “Diseases of the eccrine and apocrine sweat glands.” In: Bolognia JL, Jorizzo JL, et al, eds. Dermatology. Mosby Elsevier 2008. p. 543.

Working with cement: People who frequently work with cement have a higher risk of developing dyshidrotic eczema.

Dyshidrotic eczema: Who gets and causes

Who gets dyshidrotic eczema?

The people most likely to get dyshidrotic eczema (DE) are adults aged 20 to 40, who often have one or more of the following:
Certain medical condition: You have a higher risk of developing DE if you have any of the following:

• Atopic dermatitis (eczema) or blood relatives who have eczema
• Contact dermatitis, especially an allergy to nickel
• Dyshidrotic eczema in your family
• Hay fever

Sweaty or moist hands: Some people have flares every spring or summer when the temperature rises.

Wet hands throughout the day or work with certain substances: DE is more common in people who:

• Immerse their hands in water frequently during the day, such as healthcare workers, hair stylists, and florists
• Work with cement
• Work with chromium, cobalt, or nickel

Patients receiving immunoglobulin therapy may get DE

If you are receiving intravenous (IV) immunoglobulin and develop blisters on your hands or feet after an infusion, be sure to tell your doctor. This is likely DE. A few patients develop this eczema after receiving immunoglobulin therapy.
The eczema can worsen with each infusion, so early diagnosis is important. With treatment, most cases of DE due to this therapy are treated successfully. This will allow you to continue receiving immunoglobulin therapy.

Common triggers

Some people find that their DE flares at certain times, such as periods of:

• Intense stress or worrying
• Warm weather, when heat and humidity rise
• Wet work (having wet hands frequently throughout the day)

What causes dyshidrotic eczema?

While researchers have discovered that some people are more likely to get DE, the cause is still unknown. 

The cause may be a complex reaction that happens in the immune system.

If you think that you might have DE, an accurate diagnosis and proper treatment are important.

References:
Gerstenblith MR, Antony AK, et al. “Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy.” J Am Acad Dermatol. 2012;66:312-6.
Habif TP, Campbell JL, et al. “Pompholyx” (card #16). Dermatology DDxDeck. Mosby 2006.
Kotan D, Erdem T, et al. “Dyshidrotic eczema associated with the use of IVIg.” BMJ Case Rep. 2013 Feb 15.
Lee KC, Ladizinski B. “Dyshidrotic eczema following intravenous immunoglobulin treatment.” CMAJ. 2013;185(11):E530.
Schnoop C, Remling R, et. al. “Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: A randomized, observer-blinded trial.” J Am Acad Dermatol.2002; 46(1):73-7.

Dyshidrotic eczema: Diagnosis and treatment

How do dermatologists diagnose dyshidrotic eczema?

When dyshidrotic eczema (DE) flares, a dermatologist can diagnose it by looking at your skin.
Your dermatologist will also ask about your medical history, work, hobbies, and recent stress level.
If your dermatologist thinks that the DE could be due to an allergy, an allergy test called patch testing may be recommended. During patch testing, small amounts of substances that you may be allergic to are placed on your skin — often the skin on your back.

How do dermatologists treat dyshidrotic eczema?

Your treatment plan will be designed to treat your signs and symptoms. You may be responsible for doing much of the treatment at home. It is important to carefully follow your treatment plan, which may include several of the following:

• Soaks and cool compresses: Soaks or cool compresses that you apply 2 to 4 times a day can be very effective for drying blisters. You apply these for 15 minutes at a time.
  After each soak or cool compress, you’ll likely need to apply a medicated cream or ointment, such as a corticosteroid.

• Corticosteroid that you apply to your skin: This can reduce the inflammation and clear the blisters.
• Anti-itch medicine: An antihistamine pill or other anti-itch medicine can reduce scratching. Anything you can do to reduce scratching is helpful because scratching tends to worsen DE.

• Pramoxine (pra mox’ een): A cream or lotion containing this can relieve itch and pain. 

• Moisturizer or a barrier repair cream: Your dermatologist will recommend a moisturizer or barrier repair cream. These can reduce dryness and flares of DE.
  It’s important to apply the product after each shower, bath, and hand washing.
• Medicine to treat an infection: The skin with DE can get infected. Before prescribing this medicine, your dermatologist will first determine what type of infection you have.

Infection may cause dyshidrotic eczema to linger

Having an infection can stop DE from clearing.
In one study, researchers found that about 33% of patients who had DE on their hands got rid of the DE only after treating an infection on their feet. 

When treatment fails to clear DE or a patient has severe DE

If the above treatments fail to work or you have severe DE, your dermatologist may recommend one of the following:

• Botulinum toxin: These injections, which are given in a dermatologist’s office, bring some patients relief because botulinum toxin temporarily relaxes the muscles and stops excessive sweating.
  Botulinum toxin is FDA approved to treat wrinkles and excessive sweating in the underarms — but not DE. It’s legal to prescribe a medicine for a condition other than its FDA-approved use. This is called “off-label” use, which can be very helpful for some patients.

• Draining large blisters in the office. Draining blisters is safe and effective when performed in a dermatologist’s office, but you should not drain your own blisters. Attempting this at home can lead to an infection, which can worsen DE and prevent clearing.
• Corticosteroid that works throughout the body: For a severe case, a corticosteroid pill or injection may be prescribed.

• Light treatments: This treatment exposes the skin with DE to ultraviolet (UV) light for a prescribed amount of time. Under a dermatologist’s care, light treatment can be a safe and effective treatment for DE. In one study, more than 90% of patients report good to excellent results after 6 to 8 weeks of treatment.
  It’s extremely important to get these treatments at a hospital, clinic, or your dermatologist’s office. Trying to treat your skin by using a tanning bed is not recommended.
• Changing your diet: Sometimes, DE continues to flare despite all you do to treat it. If this happens, your dermatologist may recommend a change to your diet.
  Eliminating foods that contain nickel or cobalt helps some people.
  Many foods contain nickel or cobalt. If you are allergic to either, your dermatologist can tell you how to change your diet. 

Other treatments than the ones listed here can also be helpful. Your dermatologist can tell you what treatment may be best for you.

Outcome for people who have dyshidrotic eczema

Some people have one mild outbreak that clears without treatment. It’s much more common to have flares throughout your life. Treatment can help control DE, which cannot be cured.

References:
Egan CA Rallis TM, et al. “Low-dose oral methotrexate treatment for recalcitrant palmoplantar dyshidrotic dermatitis.” J Am Acad Dermatol. 1999;40(4):612-14.
Gerstenblith MR, Antony AK, et al. “Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy.” J Am Acad Dermatol. 2012;66(2):312-6.
Habif TP, Campbell JL, et al. “Pompholyx” (card #16). Dermatology DDxDeck. Mosby 2006.
Klein AW. “Treatment of dyshidrotic hand dermatitis with intradermal botulinum toxin.” J Am Acad Dermatol. 2004:50(1):153-4.
Miller JL, Hurley HJ. “Diseases of the eccrine and apocrine sweat glands.” In: Bolognia JL, Jorizzo JL, et al, eds. Dermatology. Mosby Elsevier 2008. p. 543.
Peterling H, Breuer C, et al. “Comparison of localized high-dose UVA1 irradiation versus topical cream psoralen-UVA for treatment of chronic vesicular dyshidrotic eczema.” J Am Acad Dermatol 2003;50(1):68-72.
Schnoop C, Remling R, et. al. “Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: A randomized, observer-blinded trial.” J Am Acad Dermatol. 2002;46(1):73-7.

Wash hands gently: To prevent flares from hand washing, be sure to remove your rings, use lukewarm water, and wash with a fragrance-free cleanser.

Dyshidrotic eczema: Tips for managing

Making some simple changes to your everyday routine can help clear your skin and prevent flares. Dermatologists recommend the following to their patients who have dyshidrotic eczema (DE):

1. Wash skin with DE gently: When washing, you’ll want to: 
   Remove rings: Always remove these before washing your hands. If the skin beneath your ring gets wet and stays damp, the DE can flare.
   Use lukewarm water: Using lukewarm water every time can help prevent flares.
   Wash with mild, fragrance-free cleansers: Skip the antibacterial soaps, waterless hand sanitizers, and deodorant soaps, which can cause DE to flare.
Even when the eczema clears, you'll want to continue gently washing the skin that had eczema. This will help prevent flares.

2. Apply moisturizer frequently: You’ll want to apply moisturizer:
   • After washing
   • Throughout the day when your skin feels dry.
   Dermatologists often recommend using a product called a barrier repair cream that contains dimethicone. This product allows skin to breathe. It also helps relieve itch and creates a barrier to protect you from things that can irritate your skin.
   If you opt to use another moisturizer, make sure it is:
   • Thick and creamy
   • Fragrance free (“Fragrance free” and “unscented” are different.)
   • Something you like enough to use frequently
   Avoid moisturizer that is thin and runny as are many lotions. Lotions contain a lot of water, which can worsen DE.

3. Learn to manage stress really well: Some patients find that they can clear their skin by practicing a stress-reduction technique and treating their skin as directed.
   It can be helpful to continue finding ways to relieve your stress. Many people say that the DE returns when they feel stressed.

4. Try to avoid scratching: Anything you can do to reduce scratching is helpful because scratching tends to worsen DE.

5. Avoid dry environments and hot conditions that cause you to sweat a lot: Both heat and dryness can trigger flares.

6. Ask your dermatologist if something could be triggering your DE. If the DE won’t clear, you may:
   • Have an allergy
   • Be irritating your skin
   Your dermatologist can ask questions to find out if something is irritating your skin. Allergy testing can find out whether you have allergies.

7. Avoid what causes an allergic reaction and what irritates your skin. If either allergens or irritants are the problem, avoiding them may be necessary to clear your skin — and keep it clear.

8. Wear gloves to protect your hands: Many things that touch your skin can cause DE to flare. Water, detergents, and household cleaners are a few. 
   To protect your hands, you’ll want to put gloves on before you get your hands wet and before touching something that irritates your skin. Dermatologists recommend the following: 
   • Wear 100% cotton gloves (hands won’t get wet)
   • Wear 100% cotton gloves under waterproof gloves (wet work)

9. Remove your rings: Rings can irritate your sensitive skin. To reduce irritation, dermatologists recommend that you remove your rings BEFORE:
   • Washing your hands
   • Applying moisturizer
   • Going to sleep

10. Wear moisture-wicking socks: If you have dyshidrotic eczema on your feet, this will help keep your feet dry.

References:
Habif TP, Campbell JL, et al. “Pompholyx” (card #16). In: Dermatology DDxDeck. Mosby 2006.
Miller JL, Hurley HJ. “Diseases of the eccrine and apocrine sweat glands.” In: Bolognia JL, Jorizzo JL, et al, eds. Dermatology. Mosby Elsevier 2008. p. 543.

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