Vesicular hand dermatitis

What is vesicular hand dermatitis?

Vesicular hand dermatitis is a form of hand eczema characterised by vesicles or bullae (blisters). A similar condition can affect the feet (vesicular foot dermatitis).

The most common variant of vesicular hand dermatitis is also called vesicular endogenous eczema, dyshidrotic eczema, and pompholyx; cheiropompholyx affects the hands and pedopompholyx affects the feet.

Pompholyx on fingers

Pompholyx on the palm

Pedopompholyx

See more images of vesicular hand/foot dermatitis.

Who gets vesicular hand/foot dermatitis?

Vesicular hand/foot dermatitis most often affects young adults.

• It is more common in females than in males.
• It is often associated with palmoplantar hyperhidrosis.
• There is a personal or family history of atopic eczema in 50%.

What causes vesicular hand/foot dermatitis?

Vesicular hand/foot dermatitis is multifactorial. In many cases, it appears to be related to sweating, as flares often occur during hot weather, humid conditions, or following an emotional upset. Other contributing factors include:

• Genetics
• Contact with irritants such as water, detergents, solvents and friction
• Association with contact allergy to nickel and other allergens
• Inflammatory dermatophyte (tinea) infections (when it is known as a dermatophytid)
• Adverse reaction to drugs, most often immunoglobulin therapy.

 Vesicles can also occur in other types of hand dermatitis.

What are the clinical features of vesicular hand/foot dermatitis?

Vesicular hand/foot dermatitis presents as recurrent crops of deep-seated blisters on the palms and soles. They cause intense itch or a burning sensation. The blisters peel off and the skin then appears red, dry and has painful fissures (cracks).

What are the complications of vesicular hand/foot dermatitis?

Secondary bacterial infection with Staphylococcus aureus and/or Streptococcus pyogenes is common in vesicular hand/foot dermatitis and results in pain, swelling, and pustules on the hands and/or feet.

When involving the distal finger adjacent or proximal to the nail fold, it can result in paronychia (nail fold swelling) and nail dystrophy with irregular pitting and ridges.

Infected pompholyx

Chronic paronychia and nail dystrophy

How is vesicular hand/foot dermatitis diagnosed?

The clinical presentation of vesicular hand/foot dermatitis is typical.

• Unilateral involvement is suspicious for a fungal infection (tinea pedis), and skin scrapings should be taken for mycology.
• Patch testing is indicated in chronic or atypical cases.
• Skin biopsy is rarely necessary. It shows spongiotic eczema.

Other forms of hand dermatitis should be considered in the differential diagnosis. 

What is the treatment for vesicular hand/foot dermatitis?

Vesicular hand/foot dermatitis is challenging to treat. Topical therapy is relatively ineffective because of the thick horny layer of skin of palms and soles.

General measures:

• Wet dressings to dry up blisters, using dilute potassium permanganate, aluminium acetate or acetic acid
• Cold packs
• Soothing emollient lotions and creams
• Potent antiperspirants applied to palms and soles at night
• Protective gloves should be worn for wet or dirty work
• Well-fitting footwear, with 2 pairs of socks to absorb sweat and reduce friction.

Contact with irritants such as water, detergents, and solvents must be avoided as much as possible and protective gloves worn to prevent irritant contact dermatitis. 

• Note that cream cleansers are not antimicrobial; soap and water or a sanitiser is needed for washing hands in order to destroy pathogens such as the SARS-CoV-2 virus responsible for COVID-19.

People with vesicular hand dermatitis found to be allergic to nickel must try to avoid touching nickel items.

Prescription medicines:

• Ultrapotent topical corticosteroid creams applied to new blisters under occlusion, and ointments applied during the inflamed dry phase.
• Short courses of systemic corticosteroids, usually prednisone or prednisolone, may be prescribed for flare-ups.
• Oral anti-staphylococcal antibiotics are prescribed for secondary bacterial infection.
• Topical and oral antifungal agents are prescribed for confirmed dermatophyte infection.
• In patients with hyperhidrosis, an anticholinergic agent such as propantheline or oxybutynin may be worth trying.
• In severe cases, immune-modulating medicines are indicated. These include methotrexate, mycophenolate mofetil, azathioprine and ciclosporin.
• Where available, alitretinoin is used for resistant chronic disease.

Other options:

• Superficial radiotherapy
• Botulinum toxin injections (to prevent sweating)
• Phototherapy and photochemotherapy (PUVA) therapy.

What is the outlook for vesicular hand/foot dermatitis?

Vesicular hand/foot dermatitis generally gradually subsides and resolves spontaneously. It may recur in hot weather or after a period of stress, and in some patients is recalcitrant.