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Hand and Foot Dermatitis

(Dyshidrotic Dermatitis)

By

Thomas M. Ruenger

, MD, PhD, Georg-August University of Göttingen, Germany

Last full review/revision Feb 2021| Content last modified Feb 2021
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Hand and foot dermatitis is a dermatitis affecting the hands and/or feet. It can be due to a contact dermatitis (allergic or irritant) or atopic dermatitis. Manifestations are erythema, scaling, and skin thickening. A unique feature of hand and foot dermatitis is that it commonly first manifests with tiny vesicles and is then called dyshidrotic dermatitis (although still hand and foot dermatitis). Diagnosis is clinical. Treatment depends on the cause and may include topical drugs, phototherapy, and sometimes systemic immunosuppressants.

Pathophysiology

A hallmark histologic feature of dermatitis is edema between epidermal keratinocytes (spongiosis). When enough edema accumulates, cell-cell adhesions (desmosomes) rupture, forming microvesicles. The microvesicles become visible macroscopically only after they enlarge. In areas other than the hands and feet, these vesicles typically rupture quickly and are not noticed. However, on the hands and feet, because of their thicker stratum corneum, vesicles tend to persist longer and become visible. Visibility of these vesicles indicates dyshidrotic dermatitis (a misnomer because it has nothing to do with sweating or abnormal sweat glands). The most severe form of dyshidrotic dermatitis (pompholyx) is characterized by coalescence of vesicles, forming larger bullae (called cheiropompholyx when on the hands, podopompholyx when on the feet, and cheiropodopompholyx when on both hands and feet).

Symptoms and Signs

Erythema, scaling, and skin thickening may progress to pruritic vesicles or bullae on the palms, sides of the fingers, or soles (called dyshidrotic dermatitis), which can rupture, resulting in erosions and crusting. The vesicles may be the first symptom noticed. Depending on the etiology and exposures, symptoms can be intermittent. Frequent or prolonged water contact (eg, frequent handwashing, work involving water or wet substances), particularly with detergents, is a common trigger, particularly in patients with atopy.

Diagnosis

  • Clinical evaluation

Diagnosis of hand and foot dermatitis can usually be inferred from location and appearance of the skin lesions. 

Differential diagnosis of hand and foot dermatitis includes

  • Fungal infection

  • Palmoplantar psoriasis

Fungal infections, which have a similar skin inflammatory reaction, also cause pruritus, erythema, and scaling. Vesicles and blisters may become apparent (bullous tinea), typically visible only on the hands and feet, as with hand and foot dermatitis. The most discriminating differentiating feature, when present, is the characteristic annular shape of the fungal infection due to the centrifugal growth of dermatophytes in the skin.

Palmoplantar psoriasis may also be difficult to differentiate from hand and foot dermatitis. Features of palmoplantar psoriasis that can help in differentiation can include erythematous and scaly plaques that are very sharply demarcated, sterile pustules, and other signs of psoriasis, such as psoriatic nail changes and psoriatic plaques elsewhere. Also, vesicles are possible with hand and foot dermatitis but are not a feature of palmoplantar psoriasis. However, vesicles and pustules can both be visible, for example:

  • When dyshidrotic dermatitis and palmoplantar psoriasis coexist

  • When vesicles in dyshidrotic dermatitis become superinfected

  • When patients with palmoplantar psoriasis become sensitized (eg, to topical corticosteroids) and develop an allergic contact dermatitis

  • When palmoplantar psoriasis is triggered (koebnerized) by an allergic contact reaction

Many disorders other than dermatitis can affect the hands and feet. Among these are

Keratolysis exfoliativa (also known as lamellar dyshidrosis or dyshidrosis lamellosa sicca) is not a dermatitis but rather a dermatosis. It affects the hand and feet and is characterized by annular erythema over the volar aspects of the hands and feet with air-filled blisters, possibly followed by peeling. Small annular collarettes of white scale may affect the palms (less often the soles) but spare the dorsal hands and feet. No fluid-filled blisters are present. Keratolysis exfoliativa may be aggravated by warm weather, hyperhidrosis, friction, and water contact.

Hand-foot syndrome is known by a variety of terms, including acral erythema, palmar-plantar erythrodysesthesia, toxic erythema of the palms and soles, Burgdorf reaction, and toxic erythema of chemotherapy. It represents cutaneous toxicity caused by certain systemic chemotherapies (eg, capecitabine, cytarabine, fluorouracil, idarubicin, doxorubicin, taxanes, methotrexate, cisplatin, tegafur). Symptoms begin with tingling in the palms and/or soles, followed by edema and tender, symmetrical erythema, particularly over the fat pads of the distal phalanges. Pain, numbness, flaking, or blistering of the palms and soles can develop.

Treatment

  • Treatment of the cause when possible

  • Supportive measures

  • Topical drugs and phototherapy

  • For severe disease, sometimes systemic corticosteroids or immunosuppressants

Treatment should be directed at the cause when possible.

Patients should avoid contact allergens as well as skin irritants, particularly frequent or prolonged contact with water and detergents.

Topical corticosteroids can be used, with the potency based on dermatitis severity. Antihistamines can help control pruritus.

Phototherapy with narrowband ultraviolet B (UVB) or with soak PUVA (in which patients soak their hands and/or feet in a psoralen solution before exposure to UVA) can help.

Superinfection is treated with topical or systemic antibiotics. For severe disease, systemic corticosteroids can be used, preferably only short term. Occasionally, if long-term systemic immunosuppressive treatment is required, cyclosporine, mycophenolate, or methotrexate can be given.

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