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When A Patient Presents With A Recalcitrant, Painful, Blistering Rash
A 56-year-old female patient presented to the office with a chief concern of an ongoing rash on the soles of the bilateral feet. She noticed that the rash began approximately five months ago and initially sought treatment at a different facility. The plan at that time included the use of topical antifungals, corticosteroid creams, and oral terbinafine, with minimal results. She complained of painful, pruritic blisters which limited her ability to weight-bear. She worked at a local grocery chain, primarily standing, and was unable to perform her duties due to her skin condition and pain. She noted a secondary concern of stress resulting from the condition of her feet and her inability to work. Similar findings were noted to the palms of her bilateral hands. Occasionally the blisters opened, and the skin would become dry and scaly to the point of fissuring, which exacerbated the pain. She was unable to wear shoes, tolerating only slippers, since they were soft enough not to irritate the skin. The patient’s medical history was unremarkable other than obesity and a long history of cigarette smoking. Surgical history, allergies, family and social histories were all unremarkable, as well as the review of systems. The rash at the time of initial examination consisted of vesicles on an erythematous base in a moccasin-type distribution. The patient related active, significant itching present. In addition to the physical examination, we took photographs bilaterally at the time of the initial evaluation to monitor progress. Based on the history and findings, we then performed 4mm punch biopsies to the margins and within the rash itself, bilaterally.
Key Questions To Consider
1. Are these skin changes consistent with contact dermatitis?
2. What are the relevant differential diagnoses?
3. What are some approaches to treatment for this rash?
4. What is the prognosis for such a skin condition?
Answering The Key Diagnostic Questions
1. Potentially, if one can determine a specific exogenous cause and eliminate it.
2. Tinea, dermatitis, eczema, and psoriasis are all possibilities.
3. Conservatively, understanding the potential for recurrence.
4. The prognosis can vary. Certain cases are more severe and recur, while others are self-limiting.
What You Should Know About Vesicular Palmoplantar Eczema (VPPE)
Vesicular palmoplantar eczema (VPPE) is a dermatitis of the hands and feet characterized by small-to-large blisters clinically, and spongiotic vessels histologically. Diagnosis may be difficult, as manifestation can be acute, chronic, or both.1 VPPE is considered an endogenous dermatitis, distinct from dermatoses caused by outside factors, such as contact dermatitis. It divides into four categories: pompholyx (also known as podopompholyx on the soles of the feet); chronic vesiculobullous dermatitis, also known as dyshidrotic eczema (DE); hyperkeratotic dermatitis; and id reactions.
Pompholyx is the most acute form of VPPE, causing an explosive outbreak that occurs more often in the warmer months of spring through autumn. It creates vesicles that, on physical examination, look like “tapioca pudding,” which is the characteristic clinical feature of this disorder.2 It affects both men and women equally and is usually a self-limiting condition, resolving within two to three weeks. Pompholyx can be devastating, in that it can necessitate hospitalization due to pain when the outbreak occurs. Secondary bacterial infection may also be common, leading to cellulitis and lymphatic damage. Pompholyx usually presents on the lateral aspects of the soles and the fingers, and is usually symmetric. Blisters, when they coalesce, can dessicate and resolve without rupture. One can drain larger blisters but should not unroof them, and they can rupture spontaneously. If ruptured, they leave behind oozing or dried-up erosions.1 Aggravating factors, such as stress, can potentiate acute outbreaks, but can also associate with dermatophyte infection, contact dermatitis, and metals exposure.
Chronic vesiculobullous dermatitis, or dyshidrotic eczema (DE), is more common than pompholyx, but more challenging to treat because of a relapsing course. Clinical presentation includes small vesicles filled with clear fluid, seen on the lateral aspects of the fingers, palms, and soles like pompholyx. A detailed history is necessary to differentiate between the two. It can involve the hands, feet, or both. The term “dyshidrosis,” first used in 1873, describes the blistering of the palms and soles, historically believed to be related to the sweat glands.3 However, DE is not related to any abnormality of the sweat glands.4 The exact cause of DE is not established, but several risk factors for its occurrence include atopic dermatitis, exposure to contact allergens and/or irritants, hyperhidrosis, smoking, exposure to ultraviolet light, and intravenous immunoglobulin use.5,6
Hyperkeratotic dermatitis usually occurs in middle-aged to elderly males, and presents with chronic pruritic plaques that fissure centrally. These are more common on the palms of the hands than the soles of the feet.1 In an id reaction, erythematous vesicles result in response to an intense inflammatory process taking place somewhere else on the body.1 The vesicles are pruritic and are usually seen on the lateral aspects of the fingers and palms. The reaction stems from an allergic reaction to fungi or some antigen created during the inflammatory process, and treatment of the underlying infection results in resolution.
Understanding The Diagnosis And Treatment
There is no distinct lab testing to rule out these disorders, however, it is important to check both the hands and the feet of the patient. A potassium hydroxide examination (KOH) can be rule out tinea, and patch testing may rule out contact dermatitis. IgE levels may also be elevated in patients with atopic dermatitis.1 One should reserve biopsy for patients with refractory disease or a suspected secondary infection.
Treatments include topical, physical, and systemic modalities. Topical treatments include high-potency corticosteroids, drying agents, retinoids, tacrolimus, and pimecrolimus. Physical treatments include ultraviolet exposures and botulinum toxin. Systemic treatments include oral prednisone, methotrexate, and leukotriene inhibitors. Prevention is a critical part of therapy, especially when one identifies aggravating factors. Modification of environmental exposure to exacerbating factors is helpful, as well as frequent use of emollients to protect normal skin barrier function. Maintaining a low cobalt diet has been suggested to decrease the number of dyshidrotic flares.1
Summarizing The Clinical Case
The punch biopsy for the patient described in this piece resulted in a diagnosis of spongiotic dermatitis, specifically dishydrotic eczema. She was treated with a prescription topical corticosteroid (triamcinolone), a prescription emollient, and a short-term low dose of alprazolam to ease the stress caused by her condition. We followed up with her closely on a weekly basis for one month, with successful resolution, but as is known to occur in such cases, she did experience recurrence. In anticipation, we did educate the patient about that possibility.
In conclusion, the identification of this condition is usually by clinical features and a detailed history. This is crucial, given that it is a clinical diagnosis. Biopsy is best for patients with refractory disease or suspected secondary infection. Timely diagnosis allows for better control of disease transmission and avoidance of unnecessary treatment.
Dr. DeLauro is a Diplomate of the American Board of Podiatric Medicine and the American Board of Foot and Ankle Surgery. She is on the Board of Directors of the American Board of Podiatric Medicine and is in practice in New Jersey.
1. Doshi DM, Cheng CE, Kimball AB. Vesicular Palmoplantar Eczema. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. (eds). Fitzpatrick’s Dermatology in General Medicine, 8th ed. New York:McGraw Hill Medical;2012:187-194.
2. Calle Sarmiento PM, Chango Azanza JJ. Dyshidrotic eczema: a common cause of palmar dermatitis. Cureus. 2020;12(10):e10839.
3. Lofgren SM, Warshaw EM. Dyshidrosis: epidemiology, clinical characteristics, and therapy. Dermatitis. 2006;17:165-181.
4. Wollina U. Pompholyx: a review of clinical features, differential diagnosis, and management. Am J Clin Dermatol. 2010;11:305-314.
5. Guillet MH, Wierzbicka E, Guillet S, Dagregorio G, Guillet G. A 3-year causative study of pompholyx in 120 patients. Arch Dermatol. 2007;143:1504-1508.
6. Kotan D, Erdem T, Acar BA, Boluk A. Dyshidrotic eczema associated with the use of IVIg. BMJ Case Rep. 2013. doi: 10.1136/bcr- 2012-008001.
