A 43-year-old man comes to the office due to a rash. He has a 1-week history of a blistering rash on his hands associated with severe pruritus. The patient had a similar rash twice in the previous 2 months that resolved with peeling of the skin on his hands. He has had no changes in household products and no occupational chemical exposure. Medical history is unremarkable. Examination shows a vesicular rash on the hands as shown in the exhibit. Which of the following is the most likely diagnosis of this patient's skin condition?
Acute palmoplantar eczema (dyshidrotic eczema) | |
Clinical features |
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Diagnosis |
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Treatment |
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This patient has a recurrent, pruritic, vesicular rash consistent with dyshidrotic eczema (ie, acute palmoplantar eczema, pompholyx). Dyshidrotic eczema is a common, although poorly understood, disorder that primarily affects the hands and feet. The etiology is uncertain but likely multifactorial and variable; contributing factors may include irritant or allergic contact dermatitis, ultraviolet radiation, and immune reactions to remote allergens or fungi.
The diagnosis is primarily based on clinical findings. A recurrent, pruritic rash characterized by deep-seated vesicles that preferentially affect the palms, soles, and sides of the digits is typical. Biopsy can be performed for confirmation but is not usually necessary. Patients with dyshidrotic eczema should be counseled on the use of emollients, avoidance of irritants, and protection from cold and/or wet conditions. When additional intervention is needed, topical corticosteroids are the first-line treatment; high-potency and super high–potency corticosteroids (eg, betamethasone dipropionate) are preferred.
(Choice B) Herpetic whitlow presents with localized vesicles and pustules. The lesions are painful but not typically pruritic and would not likely affect both hands.
(Choice C) Nummular eczema presents with chronic, round (coin-shaped), scaly plaques in regions of dry skin, primarily on the lower extremities.
(Choice D) Psoriasis is characterized by chronic, well-demarcated scaly plaques. Vesicles and severe pruritus are not common.
(Choice E) Scabies presents with papules, vesicles, and burrows, often on the hands (eg, web spaces, flexural surfaces). Pruritus can be severe, but stereotyped recurrences are more consistent with dyshidrotic eczema.
(Choice F) Tinea manuum presents with chronic, scaly, irregular, or annular patches on the hands. It is usually unilateral and typically occurs in association with tinea pedis. It is not typically vesicular and would not be expected to cause repeated acute outbreaks.
Educational objective:
Dyshidrotic eczema (acute palmoplantar eczema) is characterized by a recurrent, pruritic, vesicular rash that primarily affects the palms, soles, and sides of the digits. The diagnosis is based on clinical features, and treatment includes high- and super high–potency topical corticosteroids.