Dyshidrotic eczema on the hands and feet

Dyshidrotic eczema (dyshidrosis or pompholyx) in dermatology refers to a reactive disorder that can affect both the hands and feet, or just one of the two. While the term ‘dyshidrotic eczema’ and the palmar-plantar location may suggest some sort of sweating disorder, this is actually not an element of dyshidrotic eczema.

What does dyshidrotic eczema look like?

Dyshidrotic eczema causes the sudden appearance of fluid-filled blisters to form under the skin in the palmar (and sometimes fingers) and/or plantar site(s). The blisters are small, shiny and form visible bumps. A few or up to several hundred blisters may appear at any one time.

Dyshidrotic eczema on the feet

As with the hands, eruptions of blisters may appear on the feet and, in particular, on the soles.
The clinical picture of dyshidrotic eczema on the feet is usually more pronounced than on the hands.

Bullous dyshidrotic eczema

In particularly aggressive cases of dyshidrotic eczema, blisters can form instead of vesicles. They are domed, contain a thick, sticky liquid and can cause a great deal of irritation and pain.

Pustular dyshidrotic eczema

In some cases of dyshidrotic eczema, painful, pus-filled pustules can form.

What causes dyshidrotic eczema?

Dyshidrotic eczema is usually a reactive disorder whereby many white blood cells (leukocytes) migrate from the blood into the skin.
Once present in the skin, these cells form the blisters or pustules that characterize dyshidrotic eczema.
Dyshidrotic eczema is in the same family as psoriasis or atopic dermatitis. These skin diseases are auto-inflammatory and have a chronic relapsing course. Therefore, if an individual is predisposed to the condition, it will reoccur many times throughout their life.
As with psoriasis or atopic dermatitis, there is no one definite cause of dyshidrotic eczema, but some common triggers include: stress, seasonal changes, contact with irritants, secondary infections from the streptococcal bacterial family, secondary infections from the dermatophyte bacterial family.

Fake news: presumed causes of dyshidrotic eczema

As with many other conditions with unknown causes, there are many supposed roots of dyshidrotic eczema but none of which are supported by scientific data.
The most common of these theories are listed and debunked below.

Nickel allergy

Individuals suffering from dyshidrotic eczema are largely atopic and, as such, sensitive to nickel. However, nickel is not a cause of dyshidrotic eczema, but is a trigger of contact eczema. Adopting a nickel-free diet does not, therefore, benefit those with dyshidrotic eczema.

Histamine

Histamine is present in many foods, while other foodstuffs contain substances that cause histamine to be released from cells. Histamine is a cause of urticaria, for which adopting a histamine-free diet may help. However, it is not a cause of dyshidrotic eczema and, therefore, following such a diet would have no benefit.

Gut dysbiosis

Many believe that the cause of chronic disease is related to intestinal flora, or imbalances within the gut. For this, probiotics and special diets are often encouraged but, again, they will not provide any improvements in cases of dyshidrotic eczema.

Candida

Recently, the theory that candida overgrowth is a cause of dyshidrotic eczema has become more widespread. Candida is a yeast found in the intestines and aids in digestion. Antifungals to treat candida overgrowth (yeast infections) are harmful and, moreover, do not tackle dyshidrotic eczema.

Allergies and autoimmunity

As with psoriasis and atopic dermatitis, there are also many theories that link dyshidrotic eczema to allergies or autoimmunity. Confirming the presence of an allergy or autoimmunity involves numerous tests that can cause great confusion and could result in immunosuppressive therapies being implemented, which can actually worsen dyshidrotic eczema.

Cortisone and dyshidrotic eczema

As with most inflammatory skin diseases with an unknown cause, dermatologists or other physicians unfortunately often end up prescribing cortisone.
Whether taken orally or locally, cortisone is an anti-inflammatory medication that will initially reduce symptoms of dyshidrotic eczema and may lead to its complete remission.

This, however, is solely an ephemeral result and, as soon as cortisone application is reduced or suspended, there is usually a “rebound” effect where dyshidrotic eczema will reappear, often more acutely than before.
If the patient continues using cortisone without interruption, there is still a risk. Over time, tachyphylaxis could occur whereby the cortisone gradually loses control over the dyshidrotic eczema and more applications/doses are needed to contain the condition.
Eventually, the patient will be completely dependent on cortisone, which can cause cortisone damage to both the skin and body, without, however, ever truly having resolved dyshidrotic eczema.

Dyshidrotic eczema: DermaClub suggests…

Treating dyshidrotic eczema is not an easy feat, but two important steps towards its resolution are to prevent irritation and reduce symptoms.

Reduce irritation

Dyshidrotic eczema is an inflammatory skin disease. This means that any stress applied to the skin will result in further inflammation and new flare-ups of dyshidrotic eczema.
However, completely avoiding stress can be difficult, as the hands and feet are constantly subjected to many, often unavoidable potential triggers, such as walking or washing the hands. The frequency and intensity of the latter is one stressor, however, that can be controlled. Washing the body with water and detergents should be considered as an aggravator for areas with dyshidrotic eczema. Instead, use nitrile gloves on the hands when washing or when touching potential irritants, including dust and household chemicals. For the feet, dry wash once a day with potassium permanganate solution.

Reduce symptoms

To avoid the detrimental effects of cortisone, the following naturally-occurring, anti-inflammatory agents can be used to treat dyshidrotic eczema: salicylic acid, sulfur, allantoin, ichthyol sulfonate and coal tar. The sulfosalicylic 2S Cream is anti-inflammatory, while PEG Ointment (polyethylene glycols ointment with allantoin) has restorative properties. Meanwhile, Dermicitol Cream (ichthyol sulfonate) reduces and counters inflammation. Apply either 2S Cream or Dermictiol Cream every evening, followed by PEG Ointment the following morning. For each cream, apply a small amount of product and massage well.

Hand and foot cleaning can be done with a Potassium permanganate solution to avoid irritating the skin.
Coal tar cream has excellent anti-inflammatory and restorative properties, but must only be used in the autumn or winter seasons due to the increased photosensitivity that it causes.
While this cream is not commercially available in Italy, it can be purchased online and, in countries such as the UK, some products containing coal tar are available in pharmacies.

Previous cortisone treatment

Those who are trying to treat, or have recently tried to treat, dyshidrotic eczema with cortisone should suspend cortisone use immediately, and wait for rebound or steroid withdrawal syndrome to occur (see here).
This phase can be particularly unpleasant, aggressive and may last for more than one month. During this time, the skin will not tolerate any products, bar the use of potassium permanganate solution compresses.

Athlete’s foot

Dyshidrotic eczema is sometimes associated with the presence of athlete’s foot, which is caused by dermatophytes (fungi) between the toes. Before starting treatment for dyshidrotic eczema, athlete’s foot must be treated first. To do so, apply 2S Cream between the toes every evening until the condition has resolved. This treatment in itself may also simultaneously resolve dyshidrotic eczema.